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This is FRESH AIR. I'm Terry Gross. Tibetan monks who have post-traumatic stress disorder from being tortured, Holocaust survivors who have dementia and believe their nursing home is a concentration camp, these are some of the problems that my guest, Dr. Michael Grodin, deals with. He's co-director of the Boston Center for Refugee Health and Human Rights, where he works with people who have survived imprisonment and torture.

He's also a professor of psychiatry, bioethics and human rights at Boston University's School of Public Health and the director of the Program for the Study of Medicine and the Holocaust at the Elie Wiesel Center for Judaic Studies.

Dr. Grodin's work is part of a growing field of cross-cultural medicine, which tries to offer health care that's more culturally sensitive to immigrants.

Dr. Michael Grodin, welcome to FRESH AIR. I want to start with something that I've read about your work that I just found fascinating, which is you've been treating Tibetan monks who were tortured for opposing Chinese rule. And these monks practice meditation, but for these monks who survived imprisonment and torture, meditation was leading to flashbacks. How did you find that out?

Dr. MICHAEL GRODIN (School of Public Health, Boston University): Well, obviously meditation is the essence of being a monk.

It's part of their life and part of who they are. And so one of the things I talked to them about was when they came to see me was how has their life been and how has their meditation practice been, and as part of that discussion, they were somewhat embarrassed, but they started to tell me that they were having difficulty with their meditation.

Now, usually meditation is comforting, obviously, to someone, but in this case, it was something quite disturbing because as they would start to meditate, in certain states they would have flashbacks and images coming into their mind, and this would be quite distressing to them, causing them to have to stop their meditation practice.

GROSS: Do you have any idea why that was happening?

Dr. GRODIN: Well, that's a terrific question. I wish I did know. I spent many years working with Holocaust survivors, and the Holocaust survivors as they age are starting to have dementia and starting to have strokes, and they get disinhibited and start to think they're back in the concentration camps.

And my hypothesis is, is that something in the meditation practice is equally disinhibiting the monks. So the repression of the memories and the horrible things that happened to them starts to come to the surface, and then they start to have flashbacks.

GROSS: So how widespread was this meditation problem among the Tibetan monks that you were treating?

Dr. GRODIN: Well, I've treated seven monks, and this seemed to be a problem to some degree with all of them.

GROSS: So what kind of advice were you able to give them? It must have been so upsetting to them because their spiritual lives are based on meditation.

Dr. GRODIN: Absolutely. But I think it's not just the meditation practice that was a problem. They were obviously in a new land. They were away from their monasteries. They were away from their families, and they had a lot of problems.

I think they missed their mothers. Many of these monks were put into the monastery at a very young age. Some of them I think were homesick. They had heartache, and they felt a longing for Tibet, for their homeland. And so, there was a lot of guilt because they were here in this country, and their family or other monks were back in Tibet.

They had problems concentrating and often would ruminate on these issues, and I tried to tell him to try not to do that which was bothering them, but I tried to teach them a different type of meditation, a more body kind of meditation, more breathing kind of meditation, and I would actually teach them a qigong, which is simple exercises, coming in contact with their body.

One of the other things that happened to many of them was, is that when they were imprisoned, they were beaten every day and electrocuted, and so they started to separate from their bodies and just live in their minds, if you will.

And I was trying to reconnect them to the calmness and relaxation of their body through the qigong exercises, through tai chi, through chanting, which we did in my office, and through singing bowls, which I have many in my office, which are very calming and relaxing and cause them to resonate with the sound, which causes them to calm down their hyper-vigilance.

GROSS: Dr. Grodin, I know you brought one of those singing bowls, one of those meditations bowls, with you. Before you strike it for us or play it for us, so to speak, tell us how it's used in meditative practice.

Dr. GRODIN: It's a way of separating the kind of space of every day to the sacred space of the monks in the Tibetan tradition, and the bowl is played usually three times, three gongs, before the start of a meditation practice, and then the monks meditate, and then someone rings it at the end, which gives a sign that the meditation practice is over.

So I use it in many ways to resonate, calm the monks, but I use it at the beginning and end of a meditation practice.

GROSS: Let us hear how it sounds.

Dr. GRODIN: Okay.

(Soundbite of singing bowl)

GROSS: It has beautiful overtones.

Dr. GRODIN: I often hold it above their heads and around their body and bathe them in the sound, if you will.

GROSS: Mm hmm.

Dr. GRODIN: Which is really very relaxing - It's kind of like a waterfall, a shower of sound coming over their body.

GROSS: Now is this from Tibetan practice, or is this from another culture, and you brought it in for the Tibetan monks who were tortured?

Dr. GRODIN: Well, I think it's used by many people who have practiced meditation, but these bowls come from Nepal and Tibet. So they're quite familiar to the Tibetan monks.

GROSS: Mm hmm. So tell us more about what you've done to help the monks be able to meditate without suffering flashbacks.

Dr. GRODIN: Well, we also often chant together in my office. Om Mani Padme Hum, which is a meditation chant, mantra, which is about compassion.

One of the things that's most remarkable about these men is this ability to still maintain compassion. They've gone through this incredible ordeal, and yet they meditate on compassion. They meditate on compassion for their captors. They meditate on compassion for their perpetrators, and it's really a remarkable thing.

So we often chant Om Mani Padme Hum.

(Chanting) Om Mani Padme Hum. Om Mani Padme Hum. Om Mani Padme Hum. Om Mani Padme Hum. Om Mani Padme Hum.

And that's meditative. Again, these are all ways to get back to re-experiencing the calm relaxation that they've had and trying to rekindle that type of calmness and special state that they've learned so much from their time in the monastery.

GROSS: So has this been effective?

Dr. GRODIN: It has. Again, what exactly it is that's been effective - I think there are many things. One is, is that they come to my office, and my office is full of Tibetan flags and Tibetan pictures of monks, and I know a number of monks from all over the world.

And so I think they have trust, and they have a sense of security and safety in my office. And then of course the fact that I know a fair amount about Tibetan Buddhism and have been involved with the Tibetan community for over 15 years. They have trust in being able to come and talk to me and talk to me about their worries and their fears and their difficulties.

Many of them are doing kind of manual labor here in this country. One of my Tibetan monks works in a restaurant at night, cleaning the floors, and he asked me, you know, do I do a good job? Do I do a good enough job?

Here's a very famous, venerable reincarnated monk who's world-renowned, and he wants to know if he's doing a good enough job cleaning the floors in the restaurant.

Another one of my monks was a baker and another one a gardener. And so they're involved in all kinds of activities, simple activities, which is quite different than what they did, obviously, in their tradition in Tibet.

GROSS: Do you think the people who work at the restaurant, where the monk who you mentioned cleans the floors, know who he is and what he's been through?

(Soundbite of laughter)

Dr. GRODIN: I'm sure they have no idea. I'm sure they have no idea. But he's this very, very kind, warm, caring person who is committed to being a certain type of person, a certain venerable Tibetan, and I think that he is an example of the incredible sincerity and honesty and forthrightness of these Tibetan monks.

GROSS: Is post-traumatic stress disorder a concept in Tibetan medicine, or have you had to find ways of translating this Western diagnosis into Eastern medicine?

Dr. GRODIN: Well, that required some learning, also. I've used Tibetan doctors. There's a Tibetan doctor here in Boston. But the Dalai Lama's physician was here visiting - I've met the Dalai Lama on a couple of occasions. And the Tibetan doctor would diagnose these problems that the monks are having as rLung, R-L-U-N-G, which is a type of wind, Tsa-rLung, which is life-wind problems.

And it's a variation on what I would call post-traumatic stress disorder, but it really relates to a sense of being kind of vigilant, re-experiencing things but also something that we don't see in Western times, this kind of homesickness, this heartache.

They describe heartache, but they're not talking about their heart being in pain. They're talking about kind of a longing, and over the years, I've been able to kind of see this, and I can see when a monk comes in that he has a diagnoses of Tsa-rLung.

The Tibetan amchi - amchi is the Tibetan word for doctor - prescribed certain pills that they take. And actually when I first began working with the amchi, I was concerned that the antidepressants that I was prescribing might interact with the Tibetan medicines. And only in Boston, you know, we have such this great institution - there's somebody at McLean, which is this famous psychiatric hospital, who only studies the interaction of herbs and antidepressants and said that there probably wasn't going to be a problem.

GROSS: How effective do you think antidepressants have been for the Tibetan monks who were imprisoned?

Dr. GRODIN: You know, that's a good question. I'm not sure, you know, because I use all different methods to treat these men, and so it's hard to know what exactly is helping them.

And I must say that I'm not sure that all the monks take the medicine that I prescribe to them. So sometimes I write a prescription and ask them if they need a refill, and they no, they have enough, but it's been beyond the time when their prescriptions ran out.

So I'm not sure if they always take the medicine. But insofar as they get better, whether it be from my medicine, from the amchi's medicine, from the meditation practice, the breathing practice, the qigong, the singing bowls, the chanting is less concern to me as long as they get better and they feel better.

GROSS: I'm wondering how your experience with the Tibetan monks has affected your recommendations about whether, say, American soldiers who are suffering from post-traumatic stress disorder should use meditation as a way of helping them through it or if you fear that meditation would open their minds more to reliving the traumatic moments.

Dr. GRODIN: Well you know, I think that it's a good idea. The question is what kind of meditation to teach. And I think these monks have been meditating their whole lives, and so obviously, they're very, very - at a high level of meditation, and they do different kinds of meditation practice.

But kind of calming relaxation - meditation can be divided up into three types of meditation. One is called concentration, which is when you concentrate on a mantra, a sound, an image, a visual object.

And then there's mindfulness, which is once your mind starts to go away from that concentration, you gently recognize it and say that your mind has gone away and bring it back.

And then a third type is contemplative meditation, which I think is somewhat what the Tibetan monks are doing. But the simple kind of concentration meditation, which a lot of people do these days - breathing, relaxation, yoga -is a pretty simple technique to calm one's body and to calm one's mind and to ground one.

One of the things that happens with these vets that come back is that they're hyper-vigilant. They've kind of always on guard. They're ready to snap when they hear a sound, a siren, and so one of the - any way you can calm them and relax them I think is very, very helpful.

So I often make audiotapes of relaxation exercises and breathing exercises and give it to them to take with them. One, they hear my voice, which is a contact with me and is calming and relaxing, but also it gives them a way to meditate and follow a methodology which I think is helpful.

Another thing I do sometimes is hypnosis. Well, they wouldn't call it hypnosis, but a certain type of almost trance where I have the monks and/or my other patients sit and breathe and imagine sitting on the side of a river, and whenever a thought comes into their mind, taking the thought and putting it on a lotus blossom and imagining the lotus blossom floating down the river.

And so they can continue to stay in their breath, and when a new thought comes up, they gently put it on a lotus blossom and let it go away so that they come back to the present.

One of the things that people have a hard time doing is staying in the present. They are constantly either in the past with flashbacks and with re-experiencing, or they're fearful of the future. They're hyper-vigilant. They don't want to go out. They don't want to interact with people for fear of being triggered. And so they have a hard time being in the present, and that's one of the things that meditative practice can be very helpful with.

GROSS: My guest is Dr. Michael Grodin, co-director of the Boston Center for Refugee Health and Human Rights. We'll talk more after a break. This is FRESH AIR.

(Soundbite of music)

GROSS: My guest is Dr. Michael Grodin, co-director of the Boston Center for Refugee Health and Human Rights. He works with torture victims from around the world, including Tibetan monks, sub-Saharan Africans and Holocaust survivors.

Now in working with Holocaust survivors, you've been learning that some Holocaust survivors, when they get dementia - and many Holocaust survivors now are quite elderly and have dementia - that the dementia can make them think that they are back in the concentration camps again.

And that's so tragic to think that Holocaust survivors at the end of their lives would actually believe that they're back in the camps, that they'd be spending their final days believing that they were in the camps.

Dr. GRODIN: It's incredibly distressing and disturbing. I've done several consults to nursing homes, you know, where the Holocaust survivor smells urine in the bathroom or lines up to get food and flashes back to Auschwitz and thinks they're back in the camps.

And this is obviously not only disturbing to the family and the staff - it depends on how demented the patient is as to how much they really appreciate what's going on - but incredibly frightening. And you can see it in their eyes.

You know, the patients that I see have what we call complex post-traumatic stress disorder, which is more than just, you know, the hyper-vigilance, being on guard and the re-experience, the nightmares and the avoidance.

It's really a much deeper problem because these are people who have been traumatized but are entrapped, and they can't leave. So you know, when you have a hurricane, or you have a horrible disaster, that's a single-event trauma, but when you're imprisoned and tortured or in a concentration camp, you're traumatized, but you're unable to escape.

And so you have to try to somehow develop a mechanism to survive, and when they come out, it was described that many of them have kind of lost their sense of self. They've lost their soul.

I've often called it soul death, and you can see it in their eyes, and this is a much, much more complex problem and much more difficult to deal with, to kind of reconstruct their sense of self, their sense of who they are and what the meaning of life is.

GROSS: Can you talk a little bit about what approach you've taken to try to reconstruct that sense of self?

Dr. GRODIN: Well, it takes - first of all, it takes a long time, and the most important thing one needs to remember is that the patient has to be in control.

The one thing that was taken away from them when they were in camps or when they were in prison is their control of their lives and their ability to make their own decisions. And so the one thing you don't want to do is force anything on them.

And so it takes time, and you have to listen, and you have to be prepared to listen. You know, there was a conspiracy, a silence, where people came out of the camps and out of the torture chambers, that we've seen patients where the patient doesn't want to talk for fear of hurting you.

The person doesn't want to hear because they're scared of what they're going to hear, and this is incredibly distressing because it's almost as if it's taboo, that it's unacceptable to talk about, and people don't want to hear it.

So what you have to learn to do is to sit, to sit with these patients and to listen and to be connected with and be open to hearing anything. So one of the things that I tell my patients is that, sadly, over the last 30 years, I've heard all kinds of stories, and so I know what's happened to them.

And so I can reassure them that what they tell me is not going to hurt me and that I will be with them, and I won't abandon them, but they're in control. They have to decide what they want to talk about, what they don't want to talk about.

The last thing you want to do is tell someone how they're supposed to feel or how they're supposed to think or what they're supposed to do.

GROSS: Let me just stop you here. I think it's interesting you have to reassure them that they're not going to hurt you by telling you the horrors that they experienced.

Dr. GRODIN: Yeah.

GROSS: Why do you need to do that? Why do they need to know that?

Dr. GRODIN: Because they're very frightened about telling their story because it's like letting it out, and once it lets out, the evil will consume everybody around them. And some of the things that have happened to them - the beatings, the rapes - about 70 percent of the women patients that we see, including the Tibetan nuns which I've seen, have been raped. About 25 percent of the men have been raped.

This is a very, very distressing trauma, and there's embarrassment, and there's disbelief. There's concern that people won't believe what happened to them, and it's a horrible, horrible experience that they've gone through.

And they're frightened to talk about it because they don't think anybody will believe it or everybody will understand or be able to listen and tolerate their trauma.

GROSS: Let's get back to the idea that some elderly Holocaust survivors with dementia believe that they're back in the concentration camps. So how do you convince somebody who has dementia and thinks they're back in the concentration camp that they're not, that yes, they're in an institution, but they're safe?

Dr. GRODIN: Well, that's a real challenge. You know, one of the things you need to do is to ground them. But insofar as you can bring people from their contemporary life, their family, people that they know, people they recognize, and bring the things that they are familiar with, that will be very much helpful in terms of grounding them as to - they're here, you're here. You're now - let's feel the floor. Let's step on the floor. Let's bang on the chair. Let's experience what's going on here and that it's today, that we're no longer back there.

But it's very, very hard, and it's an international problem. I spent - last summer - I spent about six, seven weeks in Yad Vashem in Israel, and I met with not only Holocaust survivors but people who care for Holocaust survivors.

Obviously, the largest number of Holocaust survivors are in Israel, and this is a known phenomenon.

GROSS: You know, one of the things I just find so disturbing about this is that you would like to think that when you've been through an unimaginably horrible experience, that when it ends, you get to appreciate life again. You can put it behind you.

But the fact that no matter what, it keeps coming back to haunt you and that even in your dying days, you might think that you are back there again, it's just - the thought that it doesn't stop, it doesn't go away, it doesn't end, is so disheartening and upsetting and frightening.

Dr. GRODIN: Well, I think you're right. One of the things that I try to do while they still have capacity is try to get them so that they can remember without reliving. I think there's an important distinction.

GROSS: Absolutely, yeah.

Dr. GRODIN: They can't - you know, they can't get rid of the memory. Often they come to my office and say, I want to get rid of the memory. I'm trying to get rid of the memory. But the problem is when you try to put out the memory, which you can't do, you become numb because you don't have any memories then, and you can't just isolate some memories and not other memories.

So what we try to do is have the past be in the past and the present be the present. So they have memories of what happened, but it doesn't have the reliving experience, the effect that they are there. And that can be done through time and through talk and through vigilance.

GROSS: Dr. Michael Grodin will be back in the second half of the show. He co-directs the Boston Center for Refugee Health and Human Rights and is a professor of health law, bioethics and human rights at Boston University's School of Public Health. I'm Terry Gross, and this is FRESH AIR.

(Soundbite of music)

GROSS: This is FRESH AIR. I'm Terry Gross back with Dr. Michael Grodin. He is a psychiatrist who has spent 25 years working with torture victims from around the world, helping those who have survived imprisonment and torture also live with their traumatic memories. He co-directs the Boston Center for Refugee Health and Human Rights and is a professor of health law, bioethics and human rights at Boston University's School of Public Health. His work is part of a growing field of cross-cultural medicine, which tries to offer health care that is culturally sensitive and in tune with immigrants and refugee patients.

Torture is probably as old as mankind, but have you found that in the years you've been doing this work that the techniques that have been used to torture people most commonly have changed or that there are techniques that seem to be specific to different regions?

Dr. GRODIN: That's a great question. Sadly, the perpetrators, which I have also done some writing and work on perpetrators - I interviewed some of the Nazi doctors and I wrote a book on the Nazi doctors in the Nuremberg trials - but the perpetrators actually read the literature that we write and try to develop new techniques.

They try to develop techniques that cause harm but don't leave scars, because after the fact we're going to document - and that's one of the important things that we do, is document the torture, use it to present to not only their asylum case, because most of our patients are seeking asylum because they can't go back to their country where they were tortured - so we develop evidence which is used in the court, but also hopefully evidence at some point to prosecute the perpetrators.

But the perpetrators get more and more sophisticated in using various techniques of electrocution, banging on the bottom of the feet. And we know that certain types of torture occur in certain areas. We know that there's certain types of suspension that's done in Latin America. In Africa it's very common to hit the bottom of the feet. And in various areas of Tibet they use electrocution devices. So you can get the history and we see the type of torture that was used.

The other thing that's very, very disturbing is, is that in many places physicians have been involved or are involved in the torture. If not in the actual carrying out the torture, they're there after the fact to say that, you know, you can't continue because you might kill the person or it's okay to continue, or after the fact they examine the patient and see the scars and the wounds and don't document it or even change the death certificates.

And so medicine is often complicit around the world, which is incredibly horrible, you know, and it causes people not to be able to trust. Who can they trust when they come to this country? So it's really a horrible thing.

GROSS: What are some of the torture techniques that you've always described as torture that you subsequently learned the United States had used in secret CIA prisons?

Dr. GRODIN: Well, actually, I've been a consultant to lawyers representing the detainees in Guantanamo and I actually read the medical records of some of those detainees. And I never thought it would be the day that I would say that the same kind of tortures are used by the U.S. in black sites as well as in Guantanamo itself. It's just unconscionable. You know, waterboarding, which is a technique that's used in many countries and Arabic countries - to think that the U.S. would carry out these kinds of things is unconscionable.

And I've read the medical records - you know, the force-feeding of the detainees is a violation of international medical ethics. And of course the depriving of food or banging loud sounds or preventing people from sleeping is used around the world, but I never thought I'd see that it would be done by the U.S. under U.S. auspices.

GROSS: Now, I know you've been studying cross-cultural medicine so that you can understand the medical practices of the people from different cultures who you deal with. But does it work to use one country's medical practice on somebody from another culture? Like if you take what you've learned from patients around the world and kind of mix it up and…

Dr. GRODIN: Well, I think that, you know, the idea of grounding people and causing them to - calm and relaxation is true universally, but how one goes about doing that I think has to be culturally bound.

GROSS: So you've dealt with a lot of people from Sub-Saharan Africa. What are some of the medical practices that you've learned from their cultures that you've applied?

Dr. GRODIN: Well, one of the things that's quite interesting is, is that many people from Sub-Saharan Africa hear voices. They hear the voices of their ancestors. And so, you know, in our chronomonology(ph) we might say that they are psychotic. And I think that there are some people that hear the voices of their ancestors and some people that literally hear voices, and so it's a little hard to tell sometimes. And so we have to try to understand within their culture. The other thing is, is that in many African cultures people who hear voices are special.

So in this country we would say that they have schizophrenia or they would have psychosis, whereas in their country they're chosen by the gods to hear these voices. And so, you know, the value judgment as to what's good about the voices or what's bad about the voices is fairly culturally contextual. So that requires a lot of experience, and the patients teach - teach you. You don't want to stereotype, you don't want to assume.

One of the dangers in doing cross-cultural medicine is to assume that everybody follows the culture that - that they come from, or you learn a little bit and then you assume that everybody has that. So each person should be treated individually, and each person needs to be understood in their own sense of their sense of self.

GROSS: Can you tell us about one of the people you work with, one of the torture survivors from Sub-Saharan Africa who heard voices and how - how you learned about those voices and how you address that therapeutically?

Dr. GRODIN: Well, one of my patient's hears voices quite a bit. And sometime she hears voices of her ancestors talking to her about, you know, her life, and I think that's normal. But when she hears voices, they tell her that she is a bad person, or when she hears voices that say that she's going to be harmed or that maybe she should harm someone else, then that moves into a dangerous area where whatever we want to call it, it's not going to be helpful for her. And so we've used antipsychotic medications, which have been helpful.

But you know, sometimes they work and sometimes they don't, and I'm convinced that sometimes when they work, it's somebody who has real psychosis and when they don't, it's this cultural-bound notion of hearing voices.

GROSS: So say they don't work. Then what?

Dr. GRODIN: Well, at least one patient that I had we had hospitalized. And that was a horrible thing, you know, what we call counter-transference, which is the therapist's feeling about the patient coming from their background. I just felt horrible in having to commit this person. But they were unsafe and they were not going to be able to function. They were flashing back and they were dissociating, meaning that they were not there, and we had to hospitalize her. But I felt like I was a torturer, putting her in a prison essentially. But I think that was the right thing because she was not safe.

But afterwards she agreed that she was not in a good way and kind of gave me permission to say that it was okay what I did.

GROSS: I know you've heard stories from so many people from around the world who you've treated for post-traumatic stress, people who have been victims of torture. And you've heard it before. You were there to help them. You have to reassure them that they are not going to hurt you by telling you their story. At the same time, do you feel affected by those stories in a way that can be very troubling? Do you have nightmares from those stories? Do you feel like they are having an effect on you that - that is unsettling?

Dr. GRODIN: They can't help but have an effect on you. And this is the constant challenge, which is not shutting down and defending so much that you don't hear, but not taking it in so much that you become traumatized by what you hear also. So this is a constant balancing of how far to go and what kind of boundaries to set up. But we know that what people have, what's call them vicarious traumatization, which is that people who do this kind of work and listen to these stories become traumatized themselves and they start to take on the same symptoms that their patients have, and they start to have flashbacks and they start to have nightmares.

And I'm very cognizant of that with our staff, which we monitor, and we have a social worker come from outside the institution to talk to us and to be with us. Nobody sees patients for more than, you know, 15, 20 hours a week - these kind of patients. And even that's probably too much. But it can be incredibly rewarding work, because people can get better and do get better. And when someone comes back who's gone through this ordeal, gotten asylum, we've found their family and reunited them and they've gotten a job and the kids are going to school and they pull their life back together, it's a remarkable thing.

GROSS: Well, Doctor Michael Grodin, thank you so much for talking with us.

Dr. GRODIN: My pleasure. (Foreign language spoken) - that's what they say in Tibetan, which is peace be with you.

GROSS: Dr. Michael Grodin is the co-director of the Boston Center for Refugee Health and Human Rights. Coming up, actor Colin Hanks, co-star of the new film, "The Great Buck Howard." This is FRESH AIR.

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