Treatment of Torture Survivors in a Global Environment of Refugees Seeking Asylum

Effective rehabilitation of torture survivors remains a complex issue worldwide, particularly in the landscape of more than 63 million people forcibly displaced, creating 21 million refugees (approximately half of them children), 3 million of whom seek asylum in foreign countries.¹ During their journeys these people are exposed to various forms of torture, a pattern that often persists in different ways in their new home countries.

In a study recently published in The Lancet Psychiatry, researchers reported that more than 140 countries continue to practice torture, with profound and lasting consequences for survivors.² Posttraumatic stress disorder (PTSD) is a frequent symptom in torture survivors, occurring in refugees at 10 times the rate of the general population, and usually directly related to war.³ Some studies have identified PTSD in as many as 67% of people who were tortured.⁴

Although PTSD is a significant component of the ongoing trauma from torture, it is far from representative of the whole spectrum of physical, mental, and psychological distress survivors experience. A 2017 review reported that “trauma experienced by refugees is different in character, severity and duration than that seen in other populations, leading to the expression of psychopathology with a long-term fluctuating course and a high comorbidity with other disorders, particularly depression.”¹ The investigators cited cultural and language barriers, lack of trust about the intent of healthcare professionals, and the high risk for social marginalization as obstacles to effective treatment.

“Trauma-focused treatments typically focus on reducing traumatic stress symptoms, but torture survivors experience a range of other psychological symptoms — including depression, anger, and grief,” Belinda Liddell, PhD, a research fellow in the school of psychology and neuroimaging, and program director at the Refugee Trauma and Recovery Program (RTRP) at the University of New South Wales, Australia, told Psychiatry Advisor. In a 2016 position paper for the International Society for Traumatic Stress Studies (ISTSS), Dr Liddell and her colleagues reported that the trauma of displacement compounds other issues, with torture and repeated trauma in the home country and other locations leading to poor mental health outcomes, particularly in children and adolescents, who are at high risk for exploitation and human trafficking.⁵

Types of Torture

Torture falls into 3 main categories — physical, mental, and sexual — and the majority of victims suffer all 3 in a single torture event:⁴

• Physical torture often includes beatings; being crushed, choked or asphyxiated; being burned or electrocuted, suspended, hung or subjected to ice baths or drowning; being stabbed, cut, or shot; or being deprived of food and water.
• Mental torture involves mock executions; threats of death to an individual or their family; sensory deprivation or overstimulation; or solitary confinement.
• Sexual torture involves humiliation through being disrobed, forced to stay nude, and having derogatory remarks made about an individual’s anatomy; physical trauma to the genitals; or rape.

The combination of physical types of abuse may result in long-term bone displacement or growths, and nerve dysfunction and numbness that can affect an individual’s ability to walk, talk, or have the strength and ability to grasp and manipulate objects. Frequently, blunt-force trauma, asphyxiation, and sleep-deprivation result in cognitive disorders affecting memory, executive function, and comprehension. Restraints and suspension tortures often cause peripheral nerve damage and permanent motor dysfunction. Mental torture can produce a range of psychoses and at mimimum a widespread mistrust of health professionals.

These issues all contribute to the difficulties in being able to sort through the multilayered traumas and effect any kind of relief and recovery. All healthcare professionals working with patients who have undergone torture need to be critically sensitive about the possibility of retraumatization.

Treatment Approaches

A wide range of psychological treatment strategies employed for PTSD and other psychiatric disorders are likely to be of limited benefit in torture rehabilitation because of the uniquely personal nature of the trauma. Unlike other causes of PTSD, which tend to be general and often random, torture is designed to humiliate and dehumanize an individual and to erode their social and familial ties so that trust is deliberately broken.

“Overall, the evidence-base is very scant in terms of specific treatment approaches for torture survivors,” remarked Dr Liddell, “as the majority of individual and group-based interventions have not been well-evaluated in torture victims, and their efficacy is not known.” She pointed out that there is often a significant gap between torture exposure and treatment. In many patients, it may be months or even years before they come to the attention of a mental health professional — or even seek treatment for physical complaints. “It appears it is not uncommon for symptoms to have a delayed onset as well,” she said, adding, “we don’t fully understand these longitudinal pathways to different mental health outcomes in torture victims, because there’s been no research.”

Recommendations for Improving Treatment Strategies

A systematic protocol known as the Istanbul Protocol for Document Exposure to Torture on Individuals is an important tool to help physicians and healthcare professionals recognize and treat cases of torture or institutional violence.⁵

In their ISTSS position statement, Dr Liddell and her colleagues pointed to a number of features unique to torture that should be considered in order to provide effective psychological treatment for individual patients. They note that in their new environments, adult and child refugees and asylum-seekers continue to experience many of the same stressors and traumas they experienced before being dispossessed, including the fear of being forcibly displaced again in the future. While trauma-focused interventions have the strongest evidence base in reducing PTSD symptoms, these approaches are much less effective in managing other symptoms associated with torture, including ongoing pain and cognitive disorders resulting from physical abuse.

Special attention needs to be given to each individual’s cultural background. In a 2002 review, researchers suggested that treating professionals should familiarize themselves with the particulars of the person’s country of origin and other influencing cultures.⁶ They encouraged empathy about the potential fear of reprisal if an individual shares information with healthcare staff, and emphasized the importance of using an adult, impartial translator for patients who cannot communicate on their own. They also pointed out the importance of communication about all aspects of the examination and obtaining patient consent in order to give patients a sense of control over everything that occurs during the healthcare visit.

References

1. Nosè M, Ballette F, Bighelli I, et al. Psychosocial interventions for post-traumatic stress disorder in refugees and asylum seekers resettled in high-income countries: Systematic review and meta-analysis. PLoS One. 2017;12:e0171030.
2. Liddell BJ, Nickerson A, Bryant RA. Clinical science and torture survivors’ rights to rehabilitation [published online October 25, 2017].  Lancet Psych. doi:10.1016/S2215-0366(17)30332-2
3. Ibramin H, Hassan CQ. Post-traumatic stress disorder symptoms resulting from torture and other traumatic events among Syrian Kurdish refugees in Kurdistan region, Iraq. Front Psychol. 2017;8:241.
4. Moreno A, Grodin MA.  Torture and its neurologic al sequelae. Spinal Cord 2002;40:213-223.
5. Akar FA, Arbel R, Benninga Z, Dia MA, Steiner-Birmanns B. The Istanbul protocol (manual on the effective investigation and documentation of torture and other cruel, inhuman or degrading treatment or punishment): implementation and education in Israel. Isr Med Assoc J 2014;16:137-141.
6. Nickerson A, Liddell B, Asnaani A, et al. Trauma and mental health in forcibly displaced populations.  2016, International Society for Traumatic Stress Studies (ISTSS). www.istss.org/education-research/briefing-papers/trauma-and-mental-health-in-forcibly-displaced-pop.aspx. Accessed November 27, 2017.