Healing Invisible Wounds: Paths to Hope and Recovery in a Violent World

Healing Invisible Wounds: Paths to Hope and Recovery in a Violent World

by Richard F. Mollica


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In these personal reflections on his thirty years of clinical work with victims of genocide, torture, and abuse in the United States, Cambodia, Bosnia, and other parts of the world, Richard Mollica describes the surprising capacity of traumatized people to heal themselves.

Healing Invisible Wounds reveals how trauma survivors, through the telling of their stories, teach all of us how to deal with the tragic events of everyday life. Mollica's important discovery that humiliation—an instrument of violence that also leads to anger and despair—can be transformed through his therapeutic project into solace and redemption is a remarkable new contribution to survivors and clinicians.

This book reveals how in every society we have to move away from viewing trauma survivors as "broken people" and "outcasts" to seeing them as courageous people actively contributing to larger social goals. When violence occurs, there is damage not only to individuals but to entire societies, and to the world. Through the journey of self-healing that survivors make, they enable the rest of us not only as individuals but as entire communities to recover from injury in a violent world.

Product Details

ISBN-13: 9780826516411
Publisher: Vanderbilt University Press
Publication date: 12/29/2008
Pages: 288
Sales rank: 801,506
Product dimensions: 5.90(w) x 8.90(h) x 0.80(d)

About the Author

Richard F. Mollica, MD, Professor of Psychiatry at Harvard Medical School, directs the Harvard Program in Refugee Trauma. He is the recipient of the Human Rights Award from the American Psychiatric Association.

Read an Excerpt

Healing Invisible Wounds

Paths to Hope and Recovery in a Violent World

By Richard F. Mollica

Vanderbilt University Press

Copyright © 2006 Richard F. Mollica
All rights reserved.
ISBN: 978-0-8265-1642-8


Striking Out on a New Pathway

Although we all know that suffering is a universal human experience, the modern world still does not know how to speak about and understand the terrible experiences that human beings inflict on each other every day. Because of the horror and disbelief associated with human-on-human violence, it is easy to slide into a cynical attitude that nothing can be done to prevent this violence or to recover from it. One reason for this is that the major harms caused by human aggression are invisible wounds. While physical scars can be identified and accounted for by medical science, psychological, spiritual, and existential injuries remain hidden.

I have spent the past twenty-five years caring for people who have experienced human aggression on a societal scale, as refugees, victims of torture or terrorism, and survivors of war. My experiences reveal a new way of thinking about human aggression and the healing of the physical and emotional damage caused by violence. Major insights, which I call scientific epiphanies or revelations, occurred as I interacted with my patients. I proceeded to investigate these conclusions scientifically and, when they were proven valid, to integrate them into my clinical care. These revelations form the basis for the healing practices advocated in this book.

My pathway to this work was a circuitous one. Educated in a technical high school with an engineering curriculum of physics, chemistry, and math, I discovered early on that science does not address the moral and humanistic issues of society. These matters are better addressed by the humanities and arts. Although I had never met a doctor except during routine physical examinations, in college I majored in chemistry and religion, fantasizing that in medicine I could apply my interests in science, religion, philosophy, and the arts to better the human condition. While in medical school in New Mexico, I worked in the remote Hispanic villages of northern New Mexico and the Indian reservations of Zuni and Jemez Pueblo, serving poor patients within a rich cultural and natural environment. Subsequently I undertook residency training in psychiatry while simultaneously pursuing an advanced degree in religion and philosophy. Divinity school provided the moral compass for my medical and scientific skills, as well as for my future work with survivors of extreme violence. My interests in the arts and literature have also informed my work, yielding metaphorical insights to mysteries that are beyond the abilities of science and medicine to explain.


When I arrived at Harvard as a young doctor in the early 1980s, I knew that I wanted to provide the highest quality of medical and psychiatric care to the poorest people in my community, in spite of financial and political barriers. Looking around the Greater Boston area for those who most needed help, I found that newly arrived refugees from Southeast Asia were both extremely poor and almost totally excluded from the existing public, private, and academic medical systems. With the help of James Lavelle, a young idealistic social worker already working for the refugee community, we decided to set up a small free clinic for them in the Brighton section of Boston, initially called the Indochinese Psychiatry Clinic, later the Harvard Program in Refugee Trauma. Our little group unknowingly became one of the first refugee mental health clinics in America.

During this time, medicine and psychiatry were still color- and gender-biased, in spite of the work of individuals such as my mentor, Fritz Redlich, a Yale professor of psychiatry. Redlich showed in a study in the early 1950s that although mental illness was more prevalent in the poor, they received a radically different type of psychiatric care than middle-class and rich patients. Poor patients were often given drugs and rarely psychotherapy because they were considered incapable of psychological insights into their mental health problems. Psychiatrists rarely treated these patients; instead they received treatment primarily from paraprofessionals, that is, mental health workers with limited clinical training. Twenty-five years later, I revealed in a follow-up study that treatment biases toward the poor and African Americans remained unchanged, in spite of enormous efforts by the federal government to rectify the situation by providing easy access to community mental health centers. Newly arrived Southeast Asian refugees were still thrown into a large group of low-status patients receiving a low level of health care and mental health care, because they were poor, overwhelmed by social problems, nonwhite, and unfamiliar with American mental health practices, especially psychotherapy.

All refugees entering America have a basic health screening in a government-funded primary health care center. Tens of thousands of Southeast Asian refugees, victims from the war in Vietnam, were flooding through these centers to start their new lives in America. Our team of medical pioneers was waiting in the Brighton clinic to help them with their emotional distress, which was often readily apparent to the primary care doctors who referred them to our clinic. Our staff included Jim Lavelle; Ter Yang, a Hmong chief from the animistic tribes of Laos; Binh Tu, a Vietnamese ex-soldier who had been the "Frank Sinatra" of the Vietnamese army; and Rosa Lek, a young Cambodian woman whose job was drawing blood in a medical laboratory.

The mental health clinic was initially open one half-day a week. Our services were free and none of us were paid. Referrals came flooding in from our medical colleagues at the rate of sometimes twenty refugee patients in a single afternoon. The refugees did not have to be convinced of the value of the clinic; they immediately felt comfortable being greeted by a medical doctor, a social worker, and respected members of their own communities. Our Indo-Chinese colleagues were never used as interpreters; they always functioned as integral elements of our treatment team, in a bicultural partnership that was key to our clinical success.

As I listened to the story of Leakana, an elderly Cambodian woman who was one of the first patients in our clinic, I realized that the conventional psychiatric tools I had been taught would not be sufficient to help her:

During the year of the snake, the God of the Sun came to stay in my body. It made my body shaky all over—and I fainted. Upon awakening, I can remember as I opened my eyes that it was very dark. I then went to the rice fields to find someone to ask them what time it was. A voice shouted 10 o'clock. Suddenly, the owls began to cry and all the animals that represented death were howling all around me. I could also barely see a small group of people whispering to each other in the forest. I became so frightened that I tried to calm myself by praying to all the Gods and the angels in heaven to protect me from danger. I was so paralyzed with fear that I was unable to walk either backward or forward.

I came to settle in east Boston near the ocean. Now when I dream, I always see an American who dresses in black walking along the sea. One day when I was in my sponsor's house, I had this vision. This year, the year of the cow, I would like the American people to help me build a temple near the seashore. Since the Pol Pot soldiers killed my children, I am so depressed that all I can think about is just to build a temple—that is all. God appeared to me again the other day, and he told me to build a temple. Please help me make my dream come true. If not, I do not think I can live any more.

Leakana had survived the Khmer Rouge labor camps that killed five daughters and four of her ten grandchildren. After fleeing Cambodia into the Thai refugee camps, she and a remaining son and daughter were resettled in America. Psychologically, she was full of fear, anxiety, and despair. Her main medical complaint was that she was dizzy and chronically on the verge of fainting.

At that time I was unfamiliar with Leakana's culture and language and the extent of the atrocities committed by the Khmer Rouge. Few Americans were then fully aware of the genocide in Cambodia between 1975 and 1979, when more than two million people, out of approximately eight million, died of starvation and murder in the labor camps.

In order to help Leakana, I worked very closely with the Indo-Chinese members of my group. Although they were not medically trained, they were able to contextualize for me the past history and suffering of these patients. They also provided insights into the cultural manifestations of suffering in different Southeast Asian societies. My elderly Cambodian patient was a deeply religious Buddhist widow. She believed her spirit was possessed by the god of the sun, who caused her to faint and accompanied her to a place with animals and people who represented death. Spirit possession is common in Cambodian culture and can, as in this patient's case, be dangerous. Once the spirit has entered a person's body and mind, it can cause serious illness and even death if it is not quickly eliminated. This patient was extremely depressed because the Khmer Rouge had killed most of her children and grandchildren. Through her request for help in building a temple, she was telling us that the solution to her extraordinary grief and despair was not to be found in the counseling and medication we offered her. Her pain was so great that it could only be relieved by building a Buddhist temple.

In a conventional psychiatric setting Leakana would have been diagnosed as having a psychotic illness because it seemed that she was out of touch with reality by claiming to be possessed by the god of the sun, hearing voices, and having hallucinations. She would have been given drugs and denied access to psychotherapy. Her request for help in building a temple by the sea would have been interpreted as grandiose and delusional. But this assessment would have been inaccurate. In her understanding of my role as a doctor to keep her healthy, it was legitimate for her to ask me to help build this temple, because she felt she was going to die. I agreed to her request, having no idea how I could honor it. The solution we came upon was to speak to local Cambodian authorities, who allowed Leakana to enter the local monastery as a Buddhist nun. Although she was never able to build a temple herself, she could still devote her life to Buddhism. Leakana visited me every month for the next fifteen years until she died, never indicating to me any disappointment in not being able to achieve her dream.

In the early 1980s American psychiatrists and psychologists had little capacity for identifying and treating psychological problems in non–English speaking populations such as Leakana's. Furthermore, a deep belief existed in medicine and psychiatry that patients who had experienced horrific atrocities, including rape and other forms of criminally inflicted traumas, could not be rehabilitated. It was generally thought that Holocaust survivors in particular expressed their upset through physical and bodily complaints and illnesses. Medicine believed that these traumatized patients were not "psychologically minded" and their capacity to resolve their trauma-related problems was therefore limited.

These beliefs were found to be wrong as our clinic successfully treated more than ten thousand survivors of mass violence and torture over the next two decades.


From the beginning of our clinical experiment I was concerned with correcting the trend that our Indo-Chinese patients were either neglected or primarily given drugs because of their low status in the health care system. We had to come up with an effective alternative. The English psychiatrist Douglas Bennett offered us a different way of treating these patients. After serving as a glider pilot in World War II, Dr. Bennett began working in the infamous Bedlam Hospital in London, where he struggled with rehabilitating the seriously mentally ill. These patients had been abandoned by medicine and psychiatry and were now warehoused in a mental hospital. They were called the "objecting" and "objectionable" patients of English society, because they fiercely resisted psychiatric treatment and often were physically unattractive as a result of poor living conditions and personal hygiene. Dr. Bennett looked for "gold in other people's dustbins." His approach, a commonsense philosophy of clinical care, rejected and transformed traditional psychiatric practices that forced drugs upon patients and demanded their dependency upon the psychiatric system, thereby hindering their successful integration into society. He labeled his approach "upside-down psychiatry," and believed that no patients were hopeless—all could have socially productive work that provided them with an income, no matter how serious their psychiatric impairment. Focusing on the concrete realities of everyday life, Bennett was a pioneer who moved mentally ill people—previously abandoned in the horrible idleness of the mental hospital—to community living and factories where they worked for a living, sometimes achieving self-employment.

Like Bennett's patients, the Harvard clinic refugee patients were the poorest members of the local communities. If they sought help in an emergency room for serious emotional distress, they ended up being committed to a mental hospital against their will, and were strongly advised to take psychotropic drugs without counseling or social rehabilitation. During the first few years of the clinic, we rescued hundreds of refugees from the mental hospital. At our clinic we provided them with all of the material (for example, housing) and emotional support (such as counseling in their own language) they needed to obtain a job, live independent lives, and care for their families. Similar to Douglas Bennett's experience in London, most succeeded in being self-sufficient; few ever needed psychiatric hospitalization.

The Phenomenological Method

After the clinic was established and started attracting Indo-Chinese patients, we had to discover the true nature of their clinical problems and the best way of helping them cope with their emotional upset. The answer came from the phenomenological method, which had been developed and widely applied in Europe and embraced by America's greatest psychologist, William James. The basic principle of this method is that a fresh approach to human behavior and relationships can be obtained by the psychologist or doctor by abandoning all currently held theories, opinions, prejudices, and biases. To best help patients, the healing professional has to let go of all of his or her assumptions and "see" what is actually present. It is extremely difficult for practitioners to reject everything they have learned because they've come to depend on conventional labels and diagnostic pigeonholes. But when I began treating Indo-Chinese patients, I wanted to make my own discoveries about how best to help them without being blinded by the observations of previous medical providers.

We therefore made a list of conventional psychological beliefs, then proceeded to intentionally disregard them when they were proved not to be valid over time. The beliefs we abandoned included the views, posited by conventional psychiatry, that torture survivors and other patients who had suffered extreme violence were untreatable; that traumatized people would not readily talk about their traumatic life experiences; and that patients from non-Western countries primarily expressed their depressed feelings through physical complaints. Over the past twenty years, many such standard assumptions have been proven false. The capacity of persons to recover from violent events and to engage in self-healing is, in fact, the major discovery celebrated in this book.

Exegesis: The Meaning of Words

Another major breakthrough in our approach was an intentional focus on culture and history as revealed in the words that our patients used to describe their traumatic life experiences. We could not take the words of these traumatized persons for granted, because language can hide their true experiences. When refugees say they became "homeless," they may mean fleeing their village before armed men arrived, or they could mean watching aggressors rape and murder their daughters in their own home before it is burnt to the ground and they are forced to leave their village. The phrase "sexual abuse" can have many different implications in different societies, from rape or standing naked in front of others to different degrees of societal stigma and ostracism, such as divorce or the killing of the raped women.

Divinity students learn a critical approach to interpreting texts called the exegetical method or exegesis. An exegesis is an explanation or critical interpretation of a text, aiming to make as explicit as possible the precise meaning of a passage, usually in the Bible. Connotations of the words and concepts in the passage are explored and placed into the author's historical context. Using this method, biblical scholars try to get closer to the original meaning of the words and phrases used by God and Jesus in the Old and New Testament.

As an example, in the following passage in the Gospel of St. Mark (7:24–30) a Syro-Phoenician woman begs Jesus to heal her daughter, who is possessed by a demon:

And he said to her, "Let the children first be fed, for it is not right to take the children's bread and throw it to the dogs." But she answered him, "Yes, Lord; yet even the dogs under the table eat the children's crumbs." And he said to her, "For this saying you may go your way; the demon has left your daughter." And she went home, and found the child lying in bed, and the demon gone.


Excerpted from Healing Invisible Wounds by Richard F. Mollica. Copyright © 2006 Richard F. Mollica. Excerpted by permission of Vanderbilt University Press.
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