When the Treatment Room Becomes Another Closed Door: Why Western Mental Health Care Fails Survivors of Torture and State Violence
A woman sits in a therapist’s office in a Western city. He fled his home country after months of being imprisoned, interrogated and tortured by a government that wanted to silence him. He succeeded. By all external measures, you are safe now.
The therapist is kind. You are educated. Good intention. They asked him to rate his anxiety on a scale of one to ten. They suggest breathing exercises. They provide a mental distortion worksheet.
He is not coming back.
Each time, I feel the same silent grief—not because of the therapist’s failure of compassion, but because of the failure of imagination.
I have heard this story, in different ways, in different details, more times than I can count. And each time, I feel the same silent grief—not because of the therapist’s failure of compassion, but because of the failure of imagination.
Traditional Western medicine was not designed for him. And until we speak the truth about that, we will continue to lose people who have already survived the inevitable, not because of their injuries, but because of our lack of it.
Examining Our Assumptions About Safety and Treatment
Western psychotherapy and mental health care depend on a set of basic assumptions so embedded in the model that most practitioners never think to question it.
Western psychotherapy relies on a set of basic assumptions so embedded in the model that most practitioners don’t think to question it.
It thinks that healing is an internal process, something that happens within one person, in a private room, between two people who meet a week for fifty minutes. It assumes that language is a vehicle for processing trauma. There is an understanding that feelings can and should be named, explored, and reorganized. In this framework, security is a feeling, which can be cultivated through the use of strategies.
For those who have survived abuse and state violence, almost all of these ideas fail.
When a person is systematically targeted by the government, arrested, interrogated, beaten, defamed, sexually abused, mocked, and stripped of their humanity, the wound is not primarily psychological in the Western sense. It gets to the bottom of that.
The perpetrator was not human. It was a system, often still in power, still persecuting those left behind, still present in the world that the survivors must inhabit and define themselves within.
When Betrayal Revisits the Place That Was Said to Be Safe
For many survivors of state violence, the deepest wound is the destruction of trust—in institutions, in strangers, and in the basic security of the world. That wound begins in their own countries, where the very governments that were meant to protect them become the source of persecution, imprisonment, torture, and fear. But for some survivors, the trauma doesn’t stop when they run away.
I have worked with survivors of the Islamic Republic of Iran, the Taliban, and other oppressive regimes, and I believe that if they can come to the United States, they will be safe. They believed they had reached a world built on democracy, due process, and human rights—a place where the rules would finally be different.
Instead, some found themselves behind another locked door.
For survivors who have already endured torture, the greatest trauma is often not just re-traumatization—the realization that the environment they believed would protect them has become another source of fear.
Survivors described being held in cells under the conditions they experienced as extremely abusive. There were many reports of physical abuse, psychological abuse, prolonged isolation, humiliation, threats, and treatment that echoed the very tactics they had fled.
What made this experience uniquely painful was not just the suffering itself, but the betrayal. They expected cruelty from authoritarian regimes. They never expected torture in a country they believed stood for freedom, justice and law.
Many have asked me, “If this can happen here, where is it safe?”
For survivors who have already endured torture, the greatest trauma is often not just re-traumatization—the realization that the environment they believed would protect them has become another source of fear. That second betrayal can destroy any fragile trust that is left, making them feel that nowhere in the world is truly safe.
Providing an Anchor in Participatory Mental Health Care
When a person survives persecution by the government, they don’t just feel anxious or depressed. They lose their basic sense that the world is safe, that it matters, that life has meaning, that justice is real. They have been told, plainly and clearly, by their governments, their communities, and sometimes even their own minds, that their suffering was meaningless. It destroys the ground a person stands on. No breathing exercise addresses that fact. No mental re-framing is involved.
For this reason, I place great emphasis on rebuilding trust, restoring agency, providing evidence, and creating relational safety before launching any approach that requires ongoing internal attention.
I can see that trauma-sensitive thinking has been helpful to other survivors. However, in my clinical work with survivors of domestic abuse and violence, I often do not use mindfulness-based interventions that ask clients to focus on their bodies or sit in silence for long periods of time.
People who survive the inevitable do not wait to be saved. They expect to believe.
Here’s why: Many of the people I work with have learned that paying attention to their bodies means expecting pain. Their bodies are not places of safety, but places where unimaginable violence takes place. Directing the attention inward can trigger flashbacks, panic, dissociation, or physical arousal. Similarly, prolonged silence and silence can be very similar to solitary confinement, arrest, or interrogation, making these actions feel threatening rather than controlling.
For many survivors, healing begins not with looking within, but with discovering that another person can always be there without hurting.
People who survive the inevitable do not wait to be saved. They are waiting to believe, that there will be someone who will stay with them in their truth – not to correct it, not to re-establish it, not to rush them to be firm, but to say, simply and firmly: What happened to you was real. I believe you. And there is still a future for you.
Through my work with former political prisoners and survivors of torture, I had to learn many principles and tools that I had been trained in. When we ask survivors to sit still, make eye contact, and express what they are feeling in accurate language, we are often asking them to do things that their bodies experience as a threat. The clinical environment itself—fenced, formal, dysfunctional—can unknowingly reveal the very areas of injury.
Often the very words of Western mental health care—PTSD, trauma, motivation, self-care—often don’t translate. Not just linguistically, but conceptually. Most of my clients don’t say they’ve been hurt. They identify as survivors, as opponents, as people who did what they had to do.
In Western medicine, language is everything. Talk therapy is built on the premise that talking about suffering heals. But for many of the survivors I work with—Iranians, Afghans, people from communities where there is no cultural tradition of discussing psychological pain with a stranger—language is already a place of violence. They were interrogated. Their words are used against them. They learn, the hard way, that talking is dangerous. Then we ask them to come into the room and talk.
Besides this, it is the very vocabulary of Western mental health care-like PTSD, trauma, causes, self care—usually doesn’t translate. Not just linguistically, but conceptually. Most of my clients don’t say they’ve been hurt. They identify as survivors, as opponents, as people who did what they had to do. Disrupting their experience, framing it in terms of diagnosis, may sound like another form of resignation, another institution telling them who they are.
Perhaps the least important skill in this job is being able to hear what happened and not look away.
Now Is it Are you really working?
For many survivors of state violence, the deepest wound is the destruction of trust—in institutions, in strangers, in the basic security of the world. Healing does not begin in the treatment center but in the gradual, careful rebuilding of society: peer support, cultural spaces, shared traditions, the knowledge of being among people who will not cause pain, and where trust can begin to be rebuilt.
Each culture has its own frameworks for understanding suffering and recovery. For my Iranian clients, poetry, Hafez, Rumi, the great Persian literary tradition, holds a healing power that no DSM classification can touch. For my Afghan clients, community prayer, collective mourning, the presence of older women—these are not additions to therapy. See there is treatment. Our role as workers is to make room for them, not to replace them.
Supporting, unwavering evidence is very healing, because it is the exact opposite of what the perpetrators wanted. They wanted peace. They wanted the world to look away. If we don’t, we become part of the survivor’s resistance.
Perhaps the least important skill in mental health care is being able to hear what has happened and not look away. Not an analysis or reformulation. Don’t rush to hope. Staying true to what is shared. This act of constant, unwavering testimony is very healing, because it is the complete opposite of what the perpetrators wanted. They wanted peace. They wanted the world to look away. If we don’t, we become part of the survivor’s resistance.
The mental health field is not cruel. Most of the workers who fail with this number do so because they have never been taught otherwise. Our training programs, our diagnostic frameworks—were built for a different kind of suffering, in a different world.
