Working with suffering

Patient Education and Counseling 48 (2002) 43±50

Working with suffering Lucy M. Candib* Family Health Center, 26 Queen Street, Worcester, MA 01610, USA and University of Massachusetts Medical School, MA, USA Received 20 July 2001; received in revised form 20 January 2002; accepted 28 April 2002

Abstract The past century has shown that human beings are capable of genocidal destruction of millions of other humans based on ethnicity or race. Clinicians today are likely to encounter patients who are survivors of in¯icted atrocities and abuse. People ¯eeing horrendous circumstances bring persisting memories that produce symptoms even for the next generation. Families carry the knowledgeÐpersonal, cultural, familial, and sometimes individualÐof the depths of destruction that human beings can do to one another. Suffering derives from the memory, both physical and mental, of what other persons in¯icted; it has multiple dimensions that patients may not express explicitly; instead they may frame their experience of suffering in terms of pain. Diagnostic labels such as post-traumatic stress disorder or somatization are inadequate to convey human comprehension of suffering. Clinicians around the world need to be willing and able to acknowledge and witness the profound sources of experiential pain in the lives of their patients. # 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Suffering; PTSD; Communication; Somatization

1. Introduction Medicine usually interprets suffering in terms of pain, loss of function, dying, loss of hope, fear of future pain. Those of us who are physicians tend to think that people come to us with their suffering for us to heal them. We tend to think that their pain is their suffering, and that their pain is a manifestation of disease. We work hard to learn about and implement new international initiatives for the better control of pain. Another kind of suffering that is familiar in the medical setting has to do with loss: a couple has a miscarriage of a much-wanted pregnancy; a baby dies in utero; an imperfect child is born and the possibility of the perfect child is lost; a child drowns; a teenager is killed in an accident; a wife dies in childbirth; a husband ®re ®ghter dies in a ®re; mother and father die; grandparents die. All losses, some anticipated, others not. All these cause a kind of suffering we know as griefÐthe loss of the precious, the irreplaceable in the form of another human being. Sometimes natural catastrophes cause the losses of whole families and communities: to earthquakes, ¯oods, and volcanoes. These take away often the poorest and most marginal of our citizens and destroy communities leaving hardly a person who has a recollection of the past. * Tel.: ‡1-508-860-770; fax: ‡1-508-860-7855. E-mail address: [email protected] (L.M. Candib).

People also suffer grief from the loss of family and community through migration or marriage. A young woman moves away from her family and her village to follow her husband; she is lost, alone, adrift. An immigrant comes to the new country hoping for the better life and leaves behind all the familiar values, language, community. The new world is cold, hostile, inhospitable. This dislocation represents a different kind of loss, the loss of the proud connection of place and community. This article will address these kinds of losses only tangentially. This article will focus not on either on disease-related pain or on grief, two common and understandable and predictable kinds of human suffering. Instead, I will address that kind of suffering that is the most opaque to us: when patients bring us their pain which is the result of their sufferingÐin other words, after people have experienced some awfulness in their lives, they may come to us with a pain, dizziness, fatigue, distress, problems removed from what they experienced, revealing that they continue to suffer. This is the legacy of pain caused by what human beings do to one another, which Freud thought was the worst suffering of all [1]. After human beings do outrageous things to one another, the suffering derives from the memory, both physical and mental, of what happened. I have chosen to talk about this kind of suffering because it is common in medical practice yet we avoid talking about it.

0738-3991/02/$ ± see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 7 3 8 - 3 9 9 1 ( 0 2 ) 0 0 0 9 8 - 8

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2. Inflicted suffering The kind of suffering from what human beings do to one another is the most destructive and the least open to resolution. Empirical research comparing survivors of natural disasters with those who have experienced severe interpersonal violence shows the persistence and intensity of symptoms caused by in¯icted harm [2]. Its very reality, the fact that the events really did happen, robs the person of his or her ability to believe that human beings are fundamentally good. This kind of suffering destroys hope. Here the doctor's role involves not only witnessing what cannot be looked at, but also trying to understand where, or what, if anything, can be the basis of hope for this person. Unlike childbirth, suffering does not just hurt during the time that it is happening. We intuitively understand that, for many, the experience of suffering comes to dominate life afterward, and that this, in fact, is often the reality of sufferingÐthe life after, living with the memory, and sometimes having to encounter again and again the face of that memory in daily life or in night time terrors. In English, the word ``to suffer'' has two meanings: the ®rst, and most common meaning, is to experience deep pain, often in the soul. The second, more subtle and perhaps older meaning, has to do with ``to tolerate'' or allow: as in ``suffer the little children to come unto me'' or ``I couldn't suffer him any longer.'' This meaning has some element of endurance in it. So we understand that to suffer means to endure the pain across time. Suffering is not brief or momentary. All adults are familiar with sufferingÐwe may have experienced it in a national or ethnic form, or as a community, as a family, or as an individual. We cannot pick up the newspaper without becoming aware that human beings continue to in¯ict suffering on each other over ethnic, religious, or racial differences. At present about 40 violent con¯icts are going on around the world resulting in 1% of the people in the world being a displaced person or a refugee. Four million of these persons have come to Europe in the last decade [3], while 3.5 million have sought safety in the United States since 1975 [4]. Nations, religious groups, and ethnic groups today continue to in¯ict these kinds of suffering on those whom they perceive as their enemy. We have come to understand that we as humans have the capacity to kill, torture, and maim huge numbers of other humans who we think are different from us, and who we are prepared to believe will cause us harm when our leaders, political or religious, tell us so. As physicians, we see and will continue to see patients who are living through the current versions of genocidal suffering that dominated the 20th century. Suffering may take place at a national level: My country poisoned the soil of Vietnam with Agent Orange and left so many chemicals in the soil that children continue to be born with phocomelia as a result of a war that ended 25 years ago. Because of modern technology, this suffering is guaranteed to continue: Over 20 million land mines persist (in Angola, Afghanistan, and Cambodia alone) which will destroy kill and

maim innocent people for generations [3]. Whole communities in Vietnam and in Guatemala have been forcibly destroyed or moved by armies funded by the US government in the last 35 years because we believed that those communities would choose our enemies if we did not control them. The killing and displacement of so many people around the world means the loss of whole cultures, the destruction of the fabrics of communities and even complete societies. Families are the medium through which national and ethnic suffering are mediated. Refugees may survive with some portion of their families, yet lose everything else. Christa Wolff says, ``Exile, that means one is saved, yet connected to nothing'' (cited in Wiehlputz [5], p. 172). With migration also comes the loss of status and power; in the move to a new land, formerly respected parents become the lowliest street cleaners, janitors and maids because they do not speak the language. Their children learn more of the new land's language and may treat the parents badly for seeming ignorant of the new country that they struggled so hard to reachÐfor their children. Family suffering includes not being able to talk to one's own children about living in concentration camps and that child's resulting suffering for not ever feeling able to share the burden or know how bad it felt [6]. And now family suffering comes from children lost to a generation of drugs, of pointless killing of youth in our inner cities. As physicians often the suffering we see played out in families is the much larger re¯ection of social and political forces, yet we ®nd it hard to look beyond the individuals in front of us. Suffering most obviously occurs at an individual level. A father beats a mother while small children cower in the next room. A stepfather repeatedly enters the 10-year-old girl's room at night and touches her all over threatening to kill her or her mother if she tells. He escalates to intercourse when she enters puberty. A convicted rapist gets out of jail and goes to the home of his ex-girlfriend and proceeds to abduct and rape her at knifepoint. In intact societies, even intact families, we see violence against women and children, including sexual abuse and incest, practiced against daughters by fathers, stepfathers, uncles, grandfathers, cousins, and older brothers. About 10% of girls experience genital sexual abuse before age 12; up to 40% experience other forms of contact abuse [7]. Girls grow up and live with this legacy of sexual abuse and then as women come to physicians with myriad problems that initially do not in any way appear connected with their past experience that often is hidden form their consciousness [8]. This is the suffering in¯icted on individuals in families; those of us who care for families are aware that current and former abuse lies in the background of much of the misery that our patients bring us. 3. Social memory Suffering crosses generations through social memory. Even those who did not themselves experience genocidal

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suffering such as concentration camps may ®nd their lives dominated by the experiences of their parents, who did survive the camps. Children carry the pain of their parents. Whether it is Holocaust survivors' children who cannot feel safe in the world [6], or the children of an abusive Vietnam veteran who have lived under his impulsive violence against them [9], suffering does not just stop with the generation upon which it is in¯icted. Thus we cannot just look into an individual's single life experience to understand about the experience of sufferingÐwe need to look beyond to the experiences of their parents and sometimes grandparents, and at times we need to consider the experience of an entire ethnic group or nation. As with slavery, the legacy of those kinds of genocidal tidal waves do not heal for hundreds of years. Eighty years later, Armenians cannot abide Turks; Jews still fear the intentions of Aryan Germans; and 135 years after emancipation in the United States, blacks are still distrustful of the intentions of white Americans and ®nd anger to be an incapacitating emotion [10]. Groups are not unanimous in how they deal with the past. Some members want to look to the future and forget the abuses and atrocities of the past; others will want to remember and commemorate. Some will seek retribution and others reparations. Revenge and sorrow underlie the issues of separatism and exclusion. National healing must address these. How is ethnic suffering passed down across generations? How is it that members of an ethnic group suffer because of what was done to their people years before? Partly we know because of what is said, what the elders say, the family stories, the written documents. For instance, every Jew has a migration story; most the result of oppression towards Jews in one country or another. In my family, my immigrant Jewish grandparents who ¯ed the pogroms in Russia 100 years ago passed their suffering down to their children by expecting them to put up with hardship because nothing was as bad as what they had ¯ed from. Or imagine my friend from Argentina whose father, a professor at the medical school in Buenos Aires, had to burn his books, because just having books was enough to get a Jew or a professor arrested and ``disappeared.'' And this was in 1976. These stories pass the suffering down. But for other families what is passed down is not verbal; these families do not want their children to know and remember the stories because they are too awful. For children of concentration camp survivors, the silence, the unknowable, unbearable suffering that their parents endured, becomes a burden, a form of wordless suffering that is passed down in another form. So a legacy is passed down, in families, in communities, and in the environment, of the suffering persons in¯ict on each other. Suffering is also passed down through the impact the outrageous acts had on the society that performed themÐthe silence. In homeopathic medicine, the active ingredient is thought to leave an impact on the surrounding substrate, even when the substance is diluted to in®nity. Similarly, the vestiges of prior oppressive and violent relationships live on in the collective consciousness, and unconsciousness of both

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groupsÐGermans with what they did, Jews with what fragments remain [11]. The silence becomes an issue preventing recovery and integration of the whole. No wonder that blacks demand apologies for slavery in the US, and Aboriginal peoples in Australia are insulted by the failure of the government to apologize for wrongs done to Aboriginal children. The silence condones the past. 4. Perpetuated suffering The suffering that is experienced across generations may also continue to be in¯icted across generations. Attempts at racial destruction seem to have had a high rate of transmission over time. English settlers to North America systematically displaced and destroyed native American communities, stealing land shamelessly out of a belief in racial superiority and white entitlement. Spanish colonizers likewise slaughtered and enslaved native peoples in the Americas in the search for riches and conquest. Millions died. Even today, North America sequesters native Americans on ``reservations,'' and the US funds the military destruction of Mayan communities in Guatemala. Though not a race, Jews have experienced cross-generational suffering for millennia. In Europe, anti-Semitism raised its head in Spain by the seventh century; it returned throughout the Middle Ages with the Expulsion, the Inquisition, and persisted in Europe until the 20th century Holocaust. Today skinheads paint swastikas on walls and murder an occasional Jew as an initiation rite. Jews in Israel experience the surrounding Arab hostility as a perpetuation of the same genocidal intent. Moses advised Pharaoh, and a Jew can run for vice-president of the US, but anti-Semitism lives and at times comes into ascendance around the world. Because anti-Semitism does not go away, the experience of suffering by Jews who hold past suffering in individual and collective memory, does not go away either. Ethnic and racial suffering is passed down because the original racism that led to the atrocities does not disappear. It lives on in silent or indirect prejudices, affronts, and discriminations, that leave the affected group still wondering if this is the beginning of the repeat of that past. For these reasons, Jews fear the rise of Haider in Austria. The repeat of episodes like the Tuskegee Experiment, in which black men with syphilis were left untreated from 1932 to 1972 in a US government research project, keep African Americans suspicious of deliberate white persecution [12]. People of color in the US have higher infant and maternal mortality, poorer access to health care, and shorter life spans; they know that while part of this systematic disadvantage is the result of poverty, part is due to overt racism [13]. The net result is ongoing harm against those who suffered the harm in the ®rst place. Oppression is passed down, now in more indirect ways. In families, suffering is passed down when the brutal behaviors are repeated in the next generation and the next.

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A father beats his wife and children; some of his sons grow up to beat their wives and children in the next generation. Likewise, incest practiced by the father on the daughter gets reenacted by a stepfather on that woman's own daughter. Boys of abusive fathers are more likely to beat their own wives; for girls, sexual victimization seems to result in vulnerability to later revictimization and inability to protect their own children from abuse as well [7]. Patriarchal oppressive relations replicate themselves in the next generation. Silence is also toxic in families. A mother's abuse at the hands of her stepfather may never be disclosed to her children, but it affects every family reunion when the abuser smiles and waves his cigar at her own children and she cringes in the recollection and the shame. 5. Religion It is not possible to talk about suffering without at least touching on the role of religion. The strife incited by religion, and the human institutions that stand for religious authorities, are now and have been for thousands of years, the causes of so many waves of persecution and genocide in all parts of the world that it is impossible to extricate religion with all its political power from the causes of massive human suffering. We know that human beings in groups do their worst to others out of belief systemsÐ systems adopted because they provide identity and stability. These beliefs are ancient and entrenched; they seem immutable. This form of suffering is as old as recorded history. On every continent, nations have experienced both the destruction wrought by expelling or torturing those different who live within and the pain of living with that history. In every part of the world today, religious hatred fuels the atrocities that will not be unraveled in human terms for generations. In the face of the suffering in¯icted on humans by each other, in the name of religion or against speci®c religions, many human beings abandon religious faith after looking at the horror. Could any kind of god want this? 6. Suffering and oppression The experience of suffering is tightly linked with the practice of oppression. Just because an individual, an ethnic group, or a racial group experiences victimization or suffering does not mean that their own later conduct is moral. In fact, the rage against past suffering may lead to reciprocal victimization, not necessarily in the same person or in the exact same era or generation. So Israelis whose parents and grandparents were victimized in Europe rob Palestinians of their lands and torture Palestinian prisoners; Hutsis and Tutus retaliate against each other; Serbs recall Croat collaboration with Nazis and now engage in ``ethnic cleansing'' against Muslims; afterwards, Kosovars retaliate against

Serbs. Being oppressed creates oppressors. We are all tied together. At the individual level, we know that the boy who witnesses his mother being beaten and who experiences physical abuse at the hands of his parents is more likely to beat his own wife and children. The boy who is sexually abused is more likely to later victimize other boys. Studies of the most hideous murderers reveals a history of sadistic abuse in their childhoods leading them to shut off all feelings except rage [14]. So common is such a reaction that victimizing of others is now included as one of the criteria for the diagnosis of Disorders of Extreme Stress [2]. While not all victims become oppressors, the personal history of those who do in¯ict pain, shame, and humiliation on others often contains a history of victimization. At a group level, all of us have in our collective national, ethnic and religious memories both what They have done to Us, and what We did to Them. Because suffering and oppression are linked, none of us are free of these dynamics. 7. Suffering is gendered Suffering is genderedÐwithin families and within cultures. Girls who are sexually abused are less able to protect themselves later from subsequent unrelated rape and abuse and they are less able to protect their own daughters from sexual abuseÐthe vulnerability is passed down [7]. Likewise, the inability to feel another's sufferingÐwhat Lisak calls ``empathic disconnection''Ðis beaten into boys as a form of macho socialization and results in their lack of feeling toward those that they later abuse [14]. In ethnic strife, degradation takes a gendered form: rape becomes a deliberate weapon to contaminate women and destroy the heart and healthiness of a people by rendering them de®led in their own terms. Shame is likewise genderedÐthe rape of a Bangladeshi or Kosovar woman invalidates her life and her womanhoodÐthis was in fact the goal of the rapist. The warring rapist uses the rape to negate his opponent's manhoodÐrendering him unable to protect his wife and daughters. Likewise slave owners made a point of rape and sexual ownership of their women slaves, emasculating the enslaved black man. When these individuals survive, each lives in a gendered hell of suffering. Oppressors use gender to in¯ict suffering. 8. Wordless suffering Suffering may not be put into words. Survivors of concentration camps may never tell their own children of their experiencesÐin fact three quarters of the adult children of Nazi concentration camps have never heard their own parents' stories [15]. Seventy-®ve percent of elderly Armenian survivors of the Turkish genocide in 1919 never told their families what they went through [16]. Survivors of rape

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and witnesses to family murders may never put their experiences into words. Depending on the age that the terrifying experience or even ongoing abuses are sustained, many children may repress the explicit memories of what they witnessed or experienced. Children disappear from their own minds while hurting and go to other spacesÐsometimes to imaginary spaces or to places outside their bodies. We have come to understand that this kind of dissociation is protective. It allows the child to go on functioning at other times. Likewise perpetrators of atrocities deny and repress what they participated in, and even their children's generation may respond with denial to the knowledge of their parents' participation in genocidal activities [17]. Listeners as well prefer silence to explicit details of past hideous experience. Because of shared collective histories, potential confessors of perpetrators (priests, doctors, therapists) may be unable to handle the emotions that might arise. Together they erect a ``double wall'' against witnessing the past [17]. But what cannot be said is still experienced. We as physicians often become the receivers of the stories of the pain, now described in the body. 9. Suffering causes symptoms Suffering cannot be sustained in the mind, cannot be kept in consciousness. There is no way to make sense of it, and make sense of the world. Humans make use of every mechanism to push it from consciousness. The body becomes the repository of the memories of starvation and deprivation, degradation and torture, physical and sexual abuse. Suffering goes into the body, and comes out, translated, as pain, as symptoms. The symptoms are in the bodyÐthey have become embodied [18]. We understand the connection between in¯icted abuse and later bodily suffering from many sources. We know that girls who experienced physical and sexual abuse have far more physical and emotional symptoms as adults [19]; that women who are battered by their partners are polysymptomatic [20]; that women who are raped or assaulted have more symptoms in the years subsequent to the victimization [21]. Immigrants, torture survivors, concentration camp survivors have multiple physical symptoms that we call ``unexplained.'' Population studies likewise support the connection between a past history of sexual assault and multiple explained and unexplained symptoms as well as poor health perception and chronic disease [22]. Survivors of trauma whose main symptoms fall within the diagnostic label of PTSD also carry a burden of poorer physical health [23,24]. But physical suffering cannot be subsumed within the category of PTSD or somatization. To do so is to deny the reality of the pain. When we do it cross-culturally, we are also assigning Western psychiatric categories to experiences of people emerging from very different cultures with completely diverging assumptions about the individual and

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society. When Ugandan rape survivors present with multiple somatic symptoms, these are not the same as PTSD, ``not just `epiphenomena,' but the way in which these women actually experienced their distress'' [25]. When a person has lived through intense, unspeakable awfulness (like a Bosnian rape camp experience, perhaps with a resulting contaminated pregnancy), she might experience intrusive memories, ¯ashbacks to the events, nightmares. She might alternate between overwhelming memories or attempts to block it all out by feeling numb. She ®nds herself hypervigilant, distrustful, and incapacitated by fear [26]. This is suffering. In the Western biomedical psychiatric approach, we call this PTSD. But what is the effect of this label? First, the problem becomes individualized. Although the pills we use may induce sleep or control some aspects of symptoms, the use of diagnostic labels and pills functions to locate the problem within the individual rather than within the family or society or strife which caused the suffering. Because we as doctors may see patients as individuals or at best as families, we cannot fathom what her village experienced, or the women in her prison cell, or even the women in her family. We see only the person before us with her often wordless suffering. The person is pathologizedÐnot the people who tortured or raped her, nor the society that permitted the atrocities, the ones who looked on, the ones who felt it was not their problem. Instead, she has the problem. In the face of multiple symptoms, medicine pathologizes the sufferer. What is more, if we call the physical response to in¯icted suffering a psychiatric diagnosis, we are rede®ning her body symptoms as mental disease. Making an equivalence between her physical symptoms and a psychiatric diagnosis implies that ``the expression of emotion in bodily symptoms is abnormal'' ([27], p. 749). Instead of a true integration of mind and body, the use of the diagnostic label further separates what the patient so desperately is trying to integrate: the suffering of body and mind that she previously experienced and the ongoing body experiences that currently de®ne her suffering. Using psychiatric diagnoses moves us away from understanding pain as the normal human response to in¯icted human suffering. 10. The physician's role What should be the physician's response in the face of symptoms induced by suffering? First, to prepare ourselves, we must learn about the national, regional and ethnic history that led up to the events that our patients have experienced. Then we can understand not only the internal family story, but the way that story ®ts into the local and regional history. We must be watchful of relying on the media for this history as they are likely to oversimplify the facts to provide news snippets. Next, we can take an immigration history. While some people happily immigrate for a better economic position, many are ¯eeing for their lives. Often in the course of

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relating this history the immense suffering and loss in¯icted on the immigrant will become apparent. Finally, we can ask for the individual story. Many women who were sexually abused as children by family members have never told anyone, much less a physician. We must ask about battering. The majority of doctors never ask women about the experience of battering and rape that may still be happening. Patients want to know why their bodies hurt. The answer has many levels and goes on over an extended period of time. I use the following strategies to answer their question. First, I remind patients that the body can hang on to physical memories like how to ride a bicycle, swim, or play a tune on the piano, even though those muscles and sensations have not been activated in years. Similarly, the body retains a memory of physical and emotional pains from previous experience. We can enhance patients' understanding through the practice of ``bodily empathy''Ðtouching the painful place, touching oneself in the same place where the patient hurts, and sharing verbal metaphors ([28], p. 220). Secondly, I talk about how these past events made their bodies sensitive and vulnerable. Bodies that have been hurt and not protected stay sensitive, just like the bruised elbow that just seems to ``bump into everything.'' My third strategy is to talk about hypervigilance. When, as abused children or as battered wives or as persecuted minority group members, they did not know what was going to happen next, they had to be on guard all the time to ®gure out how to protect themselves. The result was a constant state of watchfulness. Even though that abuse may no longer be happening (and it is essential to make sure that it is not), they remain on guard for the next assault, even from within their own bodies. Such vigilance means that they become aware of all the sensations that otherwise they might accept as routine discomforts of life. Finally, we can explain that some biochemical pathways in the mind and body actually get programmed by past injury and trauma to repeat their responses even after the events have stopped happening [29]. For example, I talk about how our bodies get into patterns of releasing chemicals that make us feel scared, prevent us from sleeping, and make our intestines cramp in painful ways. If patients understand why their bodies hurt so much and why their bodies keep calling their attention to pain, it allows them to refocus on the fact that real harm was done to those bodies and psyches at the time when they were more vulnerable. 11. Testimony But what about those histories that I have alluded to that cannot be put into words? Those who silently well up with tears when the ®rst question is asked, who say nothing. To address the patient's suffering, does the doctor need to know the details of the events that happened? Does the patient need to say it all explicitly? Can there be healing if the worst traumas and atrocities are not discussed, not made real

through speech, not shared by another? We have evidence that giving testimony and witnessing that testimony within psychotherapy can be therapeutic for survivors of atrocities [30±32]. Such interpersonal testimony may enable survivors of political violence to begin the process of integrating their experience, to put their story into the larger historical framework, and to engage in a ritual that begins a healing process [33]. Testimonies are a way to not let the world forget [34]. If we forget, we must wonder, did it happen? Howard Stein wrote this line of poetry to just this point [35]: If none will see Atrocity, Does the survivor Have a wound? However, testimony may be more appropriate for members of some cultures and less for others. African and Southeast Asian survivors may not ®nd narrative documentation to be relevant and may instead require other socially and culturally appropriate rituals directed at healing such as ritual cleansings and ceremonies to bury the dead [26]. Just as we cannot superimpose Western diagnoses of posttraumatic stress on unimaginable suffering, strategies for healing must come out of the survivors' own understanding about what happenedÐwhat can be called ``cultural bereavement'' [36]. 12. When words are inadequate When a patient cannot give us a narrative of suffering because it is too awful, because such things cannot be put into words, because it is too awful to say out loud what was done, what was seen, I do something that I call spinning a web. I try to create a space of acknowledgment. This is parallel to the ``holding environment'' that some therapists create. It is necessary to have knowledge of the historical conditions which are likely to have contributed to this patient's suffering in doing the work of spinning the web. A Vietnamese woman who ¯ed by boat and lived 4 years in camps before migrating has one set of experiences; an Albanian immigrant woman with anxiety has another; a Liberian another. We are obligated to learn the recent history of our patients' political and ethnic experience if we are to be able to do this work of creating a space of acknowledgment. And then I say, ``I do not know what you saw, or what they did to you and to your family. I know it is too awful to talk about or to tell me right now. I know that it is terrible to live with this pain that does not go away. It was not right what happened to you. It is not fair to have to live with this pain. In this of®ce you can just sit for a while. If you ever want to tell me what happened, I will listen.'' Because we know that those who survive often feel guilty, guilty for having lived when others died, guilty for having done things to survive like stealing others' food or submitting to the oppressor or becoming their servant or even becoming one of the guards

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of the others, or guilty for having responded to the sexual acts of a father or stepfather, it is important to recognize that guilt is a frequent accompaniment to suffering. I say out loud, ``You may feel that it was your fault. You may have done things or said things or felt things in order to survive, to make it, to grow up, to get here, to get free, but you are not responsible for what happened there. You did not cause that situation or make that history happen. You know what you did and did not do, and that is part of the terrible suffering that those times did to you and others.'' It is, of course, not possible to absolve a person's sense of guilt for their own actions, but it is possible to recognize that he or she did not create the situation itself and its awful dynamics. 13. Communities of healing Sometimes in the medical setting individual work is enoughÐenough that the headaches and pains and fatigue and sadness can ease. Sometimes more is needed. It is important to understand in what way the patient before us belongs to a community, and how that community is a source of healing for him or her. Be it a Vietnamese boat woman, an American Vietnam veteran, a Jewish concentration camp survivor, a Bosnian refugee, an incest survivorÐthere is a community of fellowship, brotherhood, or sisterhood, or community identity, that is part of the context of healing. Within that community, a variety of informal, formal and even clinical groupings can sustain healing. The refugee who was professor in the ``old country'' but here is a factory worker meets on weekends with his countrymen and is given the respect and honor that his station deserves; the incest survivor meets with a self-help group of sexual abuse survivors and begins to unravel her story. The Vietnam vet attends rap groups at the veteran's club and ®nds a place where others share his memories of the past and discomfort with the present. And art therapy groups help children who have lost an arm or leg and their parents to a bomb. Psychiatrists run narrative therapy groups for Bosnian refugees to let the stories out in safe and supportive settings and ultimately provide testimony for the world to witness. Sometimes an artist or a journalist witnesses for a country, a community, a people: this person documents what was real with sounds, words, or images and makes it last, makes it real to the larger world. These are the broader spaces of acknowledgment so crucial to recovery. We can encourage patients to enter these spaces and help them create them when they do not yet exist. For communities as well there are forms of collective healing. Ceremonies serve a function of remembrance and closure. Young German activists held a memorial night for the Jews who had died in the Holocaust from a small town. They showed slides of individual people who had been herded on to trains to death camps 50 years earlier, and helped townspeople talk about this lost part of their community. They dedicated a stone and plaque at the center of

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their village to the memory of those who had been killed, those that they had identi®ed, ostracized, and expelled. Healing takes creativity. We have to work at an individual level, a family level, and sometimes at a community level. When oppression is lifted, it takes years for communities to recover from the losses and humiliations they experienced, and sometimes the efforts to repair and recover from the oppression result in excesses in reaction. Recovery does not occur in one generation or even two or three. Citizens are uneasy that the forces that created that particular oppression could resurface again from the same wellsprings of history. These histories and the repetitions of the old dynamics in current times keep Jews, Blacks, and war-torn immigrants of all kinds from all countries from recovery. 14. Conclusion: never again So we also have a job called, ``Not letting it happen again.'' This means helping women to teach their daughters about sexual abuse, even inside the family. It means raising boys not to see sex as a weapon. It means raising boys in such a way that they can feel pain so they are not hardened to the pain of others, nor taught to in¯ict it. It means training our children for peace. Not letting it happen again means challenging and opposing chauvinistic, nationalistic, racial and religious divisiveness of all sorts. It means not getting stuck in maintaining the fantasy of professional neutrality, but instead recognizing that we as physicians must take political stands, even at risk to ourselves. Even now physicians are in prison in Turkey for not collaborating in torture. Working with suffering requires that we stay with the symptoms in their intolerability. Patients who are survivors of terrible things are painful to be with. They may in¯ict their symptoms on us and make us feel responsible for their pain or for not relieving their suffering. Insofar as we take on their pain, we re-experience it as well and carry it around with us too. Clinicians need spaces of our own where we can recuperate from the secondary or vicarious trauma that happens to us from hearing the stories and empathizing with the symptoms. Healing has to occur among clinicians as well to do this work. Working with suffering means witnessing explicitly the awful nature of what human beings have done to each other and continue to do today. It means opening ourselves to our own sources of suffering in our families and our communities, and committing ourselves to preventing repetitions of the past. Clinicians working in communities all over the world are privileged to know these histories of suffering. We are trusted with the pain of our patients every day. We have the skills and humanity to create spaces of acknowledgment for their suffering; we have the wisdom to spin a web of safety in which secrets can be told. We need courage to do this work. Let us hope that health workers coming together around the world can ®nd a way to build that courage together.

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L.M. Candib / Patient Education and Counseling 48 (2002) 43±50

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