Kathleen Allden: Drawing hope from despair
By Jennifer Durgin
Ande was an African businessman, not a political dissident. Yet his tribal identity and frequent travel to other countries caused him to be detained on two occasions by local militants. They tortured and nearly beat him to death, and Ande (not his real name) was certain they'd kill him the next time. So he fled his homeland for the United States. He arrived with no home, no job, no legal status, and only the clothes on his back. Like most asylum seekers, he had left his family behind. Days and nights blended together as he wandered the streets of Boston, surviving off handouts from soup kitchens and homeless shelters while he tried to develop a plan.
But Ande was having trouble organizing his thoughts and remembering basic information. He felt like he was losing his mind. Beset by worry for his wife and many children, Ande, a deeply spiritual man, was filled with despair. He even thought of ending his life.
Ande is a typical patient for DMS psychiatrist Kathleen Allden, M.D., who is the medical director of the International Survivors Center (ISC) in Boston. The center is a multidisciplinary mental-health program that was established by the International Institute of Boston (IIB) in 1999. Together, the organizations provide comprehensive legal, social, and mental-health services to refugees and asylum seekers who have been victims of torture, mass violence, and other humanrights abuses.
"We start out with the very basic necessities," Allden explains. Do the individuals have a safe place to live? No? Connect them with local shelters or a network of volunteer homes. Do they have legal refugee status? No? Make an appointment with the IIB legal department. Do they speak English? No? Enroll them in a language course. The ISC staffsocial workers, psychiatrists, nurse clinicians, and psychologists also assesses each individual's psychological state to determine if mental-health intervention is needed.
"It takes a whole, broad array of assistance to help [them] find meaning again in their life," says Allden. "How do you develop a will to live again when you've been betrayed by your own country, sometimes your own family or your own community?"
From an early age, Allden, who grew up in Hanover, N.H., envisioned helping the world's poor through the practice of medicine. But it wasn't until years after she'd graduated from the University of Cincinnati College of Medicine in 1980 and finished her residency in psychiatry at DHMC that she realized her vision. Allden was already married and had a toddler when she entered medical school, so she learned to balance family and career early in her professional life. When she missed her psychiatry rotation due to the birth of her second child, she sought out a clerkship at Dartmouth so her parents, who still lived in Hanover, could help with child care. Gary Tucker, M.D., then chair of psychiatry at DMS, arranged for Allden to do a rotation in child psychiatry, since she was considering pediatrics.
Dartmouth's approach to psychiatry appealed to Allden because it embraced biochemical, neurological, and pharmacological issues, as well as the psychosocial and cultural factors that contribute to an individual's mental health. Not long into her rotation, she decided psychiatry would be her specialty. "I had finally found a place where you could address all aspects of the human being," she says. And she was so impressed with Dartmouth that it was the only place she applied for residency.
As a resident, from 1980 to 1984, Allden worked with Vietnam veterans at the VA Medical Center in White River Junction, Vt. For the first time, she saw the kinds of psychiatric damage that war and trauma inflict on people. Later, in the late 1980s, she began practicing general psychiatry at Lakes Region General Hospital in Laconia, N.H. There, she encountered refugees, mostly from Southeast Asia, who'd settled in the area. "These people were suffering from emotional and mental problems unlike any I had ever been trained to deal with," she recalls.
Few people in the world are more in need of mental-health care than the victims of mass violence, slavery, torture, and genocide. But until recently, the only humanitarian assistance provided to such people was in the form of food, water, shelter, and basic medicine.
Integrating mental-health care into primary-health care for refugees and individuals in post-conflict communities has been an important theme in Allden's work. In 1991, she began working in Thailand as a fellow with the Indochinese Psychiatry Clinic at what is now Beth Israel-Deaconess Medical Center and with the Harvard Program in Refugee Trauma. Within two years, she was the director of the Beth Israel clinic and medical director of the Harvard program.
One of the goals of the Indochinese initiative was to address the psychosocial and emotional suffering of Burmese and Cambodian refugees still in Thailand. Allden and her colleagues trained indigenous health-care providers to interview and identify patients who seemed to have mental-health problems.
The other focus of the Thailand project was to document the health and mental-health consequences of war, mass violence, and torture among the refugees. "Governments, including our own," says Allden, "don't like to be accused of abusing human rights. But if you draw attention to a health problem, it's a very acceptable, face-saving way for a government to say, 'Oh, well, we care about people's health. Therefore, we can intervene in such a way to help people.' And so it's a way of advocating for human rights."
Allden has also worked in the former Yugoslavia and, in 1999, was asked to participate in a United Nations working group to develop guidelines for medicolegal investigations of torture and other human-rights abuses. She chaired a subcommittee on psychological evidence of torture and coauthored the Istanbul Protocol, a manual that is now the gold standard by which such investigations are conducted.
Photo by Jon Gilbert Fox
The serenity Allden looks out on in the Upper Valley is something that eludes many of her patientsvictims of violence, abuse, and torture from all around the world.
The project was exciting for Allden, but the timing was bittersweet. The Indochinese Psychiatry Clinic was in "a state of chaos and collapse" due to funding problems, and Allden was trying to find a way to continue her clinical and academic work. Yet the closing of the clinic, though tragic, was the impetus for Allden to cofound the International Survivors Center and to accept an assistant professorship at DMS. At Dartmouth, she has found the flexibility she was seeking and has also been recognized for her expertise: in 2003, Dartmouth honored her and her work with its Martin Luther King, Jr., Social Justice Award.
Allden is adept at building consensus and cooperation among human rights activists, social workers, and medical professionals, who often disagree as to the best way to provide humanitarian relief and assistance to refugee populations. Nonphysicians, for instance, don't like to treat refugees as if they are "sick" and need medical treatment.
"It can be very difficult to navigate these waters effectively," observes Matthew Friedman, M.D., a professor of psychiatry at DMS and the executive director of the VA's National Center for Post-Traumatic Stress Disorder. "I think Kathy has done a marvelous job navigating those waters, providing a quality intervention and doing it in a way that has engendered support from people who occupy different places within this continuum."
Allden is also admired for her ability to juggle a lot of projects. "I love the breadth of her involvement," says Westy Egmont, M.D., executive director of IIB, which has established Boston as a national leader in addressing the complex needs of refugees and asylum seekers. "She's off to Thailand, working on the Burma Border Projects," he says. "Then she'll bounce back from that and come into the institute, where she will help us take on a very difficult asylum case. With grace and tenderness and medical attention, [she'll] help the person to tell their story, to document their story, to do the forensics that are necessary to be able to give the court evidence. And then she'll turn around intellectually and contribute in a paper and participate with the [United Nations] High Commission to be sure the field is advancing." Egmont laughs, adding, "She puts together more pieces than most of us would tolerate."
Allden admits that her chosen path has been extraordinarily challenging. "I don't want to be misleading. It's taken a lot of sacrifice for me and my family," says Allden, who became a single mother of four in 1993 when she divorced. Her work can also be emotionally draining. The stories she routinely hears and documents are of destroyed villages, forced migrations, slave labor, bondage, rape, torture, and genocide. These are the stories of an estimated 30 million refugees worldwide. How then do Allden and her patients resist despair?
"If there is any one theme to my individual work with patients and my training and teaching of doctors and paramedics and social workers, it has been the issue of hope," Allden says. "It's very hard to find hope, and the struggle to find hope is something we work withI have to work withall the time." She says the principles of compassion and sacrifice that are common to most major religions have helped her understand how to talk with her patients "far more than any kind of psychoanalytic theory ever has."
Allden has found her work to be gratifying, but she is now ready to be more selective about the projects she takes on. She will continue her clinical work at the ISC and remain on the DMS faculty but is also building a private practice. In the international realm, she is helping the International Committee for the Red Cross evaluate the consequences of psychological torture on prisoners of war and political prisoners, including those held in Guantanamo Bay. "When I began my work with survivors of political torture, I never envisioned that I would be asked to help evaluate the behavior of my own government," she comments. As she reflects on what she's learned, she is trying to develop a unifying message to inspire others to use their expertise to assist the most marginalized and disenfranchised people of the world. "It's easy to be seduced by the material benefits [of] one's own lifestyle, one's own career, promotion," she says, noting that she is still an assistant professor. "I'm not getting the kind of funding that gets you promoted to full professor," she adds.
Yet, she insists, it's been worth it. Being an international physicianhumanitarian has its rewards, not the least of which is the feeling that you've made a real difference in someone's life. Last spring, Allden received some thrilling news. Having won political asylum, Ande was no longer alone. His wife and children had joined him in the U.S., thanks in part to assistance from Allden and the IIB and ISC.
Jennifer Durgin is Dartmouth Medicine magazine's newly named senior writer.
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