Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Treating torture survivors - there is no 'quick fix'
- Abigail Seltzer, Alex Sklan, Director of Clinical Services, Nimisha Patel, Consultant Psychologist (19 December 2006)
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Brief treatment of torture trauma is possible – Dismissing evidence as ‘quick fix’ will not help torture survivors
- Metin Basoglu (21 December 2006)
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Rehabilitation and PTSD
- Abraham Rudnick (23 December 2006)
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Rehabilitating torture survivors – Social support is not enough
- Metin Basoglu (26 December 2006)
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Disability and PTSD
- Abraham Rudnick (28 December 2006)
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Defining priorities: treat PTSD or related disability first?
- Metin Basoglu (29 December 2006)
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The practical difficulties of providing CBT for torture survivors in the UK
- Gervase Vernon (2 January 2007)
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Refugee status with its potential for torture should be a ‘yellow flag’ in the management of back or neck pain
- Andrew O. Frank (3 January 2007)
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Torture Survivors need services
- Joanna H Newell (4 January 2007)
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Putting things in perspective - Facts and myths about torture trauma
- Metin Basoglu (6 January 2007)
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What evidence base?
- Juliet R Cohen (8 January 2007)
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Putting things in perspective - facts and myths about torture treatment centres
- Abigail Seltzer, Alex Sklan, Director of Clinical Services, Nimisha Patel, Consultant Psychologist (9 January 2007)
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Evidence base of exposure-based treatments in PTSD – Do we need more evidence?
- Metin Basoglu (9 January 2007)
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Facts and myths about torture trauma - II
- Metin Basoglu (10 January 2007)
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Evidence regarding usefulness of torture rehabilitation programmes– What do we mean by evidence?
- Metin Basoglu (12 January 2007)
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Re: Facts and myths about torture trauma - II
- Sophie Durieux-Paillard (13 January 2007)
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Clarifying misconceptions about brief behavioural treatment – It is no magic!
- Metin Basoglu (14 January 2007)
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Treating refugees with PTSD: what should come first, evidence base or ethics?
- Ariel Eytan, Jessica M. Carlsson, MD, PhD, Rehabilitation and Research Centre for Torture Victims, Copenhagen, Denmark (15 January 2007)
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Hiding the truth and ethics – Are they compatible?
- Metin Basoglu (16 January 2007)
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Re: Hiding the truth and ethics – Are they compatible?
- Bengt H. Sjölund (19 January 2007)
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Encouraging changes in thinking – Have we learned from past mistakes?
- Metin Basoglu (20 January 2007)
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Torture survivors- a complex subject
- Thomas Wenzel (21 January 2007)
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Final response to the argument about torture trauma being different
- Metin Basoglu (23 January 2007)
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Standard Therapy for All Torture Survivors?: A Reply to Metin Basoglu
- James M Jaranson, Uwe Jacobs, PhD, J David Kinzie, MD, Jose Quiroga, MD (30 January 2007)
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More of the same – Reply to Jaranson et al
- Metin Basoglu (31 January 2007)
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Research, Therapy and Rehabilitation with Torture Survivors.
- Peter Berliner, Stine Amris, MD, Specialist in Internal Medicine and Rheumatology, and Julio Arenas, Psychologist, University of Copenhagen (23 February 2007)
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Treatment of torture survivors: Some observations on the current debate.
- Thomas Maier, MD (24 February 2007)
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Conclusion - Need for concerted action
- Metin Basoglu (26 February 2007)
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Abigail Seltzer, Consultant Psychiatrist Medical Foundation for the Care of Victims of Torture, Alex Sklan, Director of Clinical Services, Nimisha Patel, Consultant Psychologist
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We welcome and support Basoglu’s analysis of the need for better evaluations, more effective use of evidence based interventions and accountability in the treatment of survivors of torture.1 The Medical Foundation for the Care of Victims of Torture, as the only treatment centre in the UK providing care specifically for survivors of torture, is committed to evaluation of its work; the results of its own audit and evaluation programme are routinely disseminated to funders. In common with most reputable centres, we do not hold that advocacy and redress are sufficient as treatments. However, unlike trauma treatment clinics within the statutory sector, we are a human rights organisation. Advocacy and redress are core components of our work; we therefore know their importance as supplementary therapeutic tools. We question Basoglu’s claim that there are ‘very brief and highly effective interventions available for survivors’, and the implication that rapid, cost effective treatments are being wilfully ignored by specialist treatment centres for political reasons. We are not aware of a significant body of work to support his view on the efficacy of such treatments. There exist only a handful of small scale, short term studies, which are promising but neither conclusive nor comprehensive. Carlsson et al note ‘the complexity of torture as a trauma may imply a gradual response to treatment’ and acknowledge that ‘nine months might be too short a time to expect any changes in mental health’.2 Many torture survivors must deal with not only the physical and psychological consequences of deliberately inflicted harm but with multiple losses – of livelihood, status, family, country and even bodily integrity. Many have endured numerous episodes of torture during prolonged detention. Further, most must contend with a harsh asylum process along with hostility, poverty and extreme isolation in exile. There is no robust evidence that for such people there is a ‘quick fix’. We are not convinced that it is valid to generalise from work with other populations, such as earthquake survivors or war veterans, to torture survivors. PTSD diagnostic criteria were not developed with trauma of this nature in mind. It is therefore hard to see how ‘standard’ PTSD treatments can be confidently recommended. Indeed, many leaders in the field of PTSD now recognise the limitations of this diagnosis and the need for new treatment approaches.3 We would argue that a normative model of recovery from torture which takes into account all of the above factors is needed. Without this, we are left with confusing and ultimately unhelpful debates about who is not ‘scientifically rigorous enough’ and who ‘medicalises’. References: 1. Basoglu M. Rehabilitation of traumatised refugees and survivors of torture. BMJ 2006; 333: 1230-1231 2. Carlsson JM, Mortensen EK, Kastrup M. A Follow-Up Study of Mental Health and Health-Related Quality of Life in Tortured Refugees in Multidisciplinary Treatment. J Nerv Ment Dis 2005;193: 651–657 3. Van der Kolk BA et al. Disorders of extreme stress: The empirical foundation of a complex adaptation to trauma. J Traum Stress 2005; 18: 389-399 Competing interests: None declared |
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Metin Basoglu, Head of Trauma Studies Unit, Institute of Psychiatry, King's College London Institute of Psychiatry, Box PO91, DeCrespigny Park, Denmark Hill, London SE5 8AF
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Seltzer et al’s1 response to my comments2 about rehabilitation of survivors of torture clearly illustrates the thinking behind the problem reviewed in my article. The argument about the validity of Posttraumatic Stress Disorder (PTSD) is an ideological position, which is not supported by any evidence. Our 20 years of work with torture, war, and earthquake survivors in different countries show that fear and helplessness responses to life-threatening events are the primary mediating factors in traumatic stress. Fear is a universal human response, though its manifestations might show some variance across cultures. Whether such responses are defined as PTSD or given some other name is irrelevant to the issue of treatment. The fact remains that some people develop chronic traumatic stress as a result, which can be reversed by simple and brief interventions. The authors state that they are not aware of a significant body of work to support the efficacy of cognitive-behavioural treatment, despite the evidence cited in my article. The literature review conducted by the National Institute for Clinical Excellence3 in the U.K. was based on a review of 24 controlled studies of cognitive-behavioural treatment. The authors can also refer to a recent meta-analysis4 of 19 controlled studies of cognitive-behavioural treatment. The evidence base for a modified version of behavioural treatment that we used with more than 5,000 earthquake survivors includes two open and two randomised controlled studies, involving altogether 229 cases. It is ironical that the authors dismiss such evidence as ‘small scale…neither conclusive nor comprehensive” when they are unable to cite a single controlled study supporting their own approach. The authors single out torture from other traumas, without citing any evidence to justify their position. Our studies5 show that natural disasters, for example, lead to just as complex traumatic stress problems (and cognitive effects) as traumas of human design, such as war and torture. I cited evidence in my article suggesting that torture trauma is just as responsive to behavioural interventions as earthquake trauma. Thus, the notion that human-made trauma is more complex and difficult to treat simply reflects a misconception. Complex problems need not necessarily require complex solutions. Such arguments can no longer justify the status quo in the field. Any comments on my article are more than welcome, provided they are substantiated by evidence. Use of euphemisms, such as ‘quick fix,’ to dismiss evidence on brief interventions or merely citing views of ‘leaders in the field of PTSD’ does not promote progress in this field. I am prepared to stand corrected by any evidence on the usefulness of lengthy rehabilitation programs and urge anyone with such evidence to make it public. It is encouraging to hear that the authors are committed to evaluation of their work, which implies that they have evidence on the effectiveness of their approach based on ‘normative model of recovery.’ Perhaps they might care to share such information with the public. If, however, they are unable to this after decades of work, is it not about time they made room for others with alternative and evidence-based ideas? References: 1.Seltzer A, Sklan A, Patel N. Treating torture survivors – there is no ‘quick fix.’ British Medical Journal (19 December 2006). 2.Basoglu M. Rehabilitation of traumatised refugees and survivors of torture – After almost two decades we still do not use evidence based treatments. BMJ 2006; 333:1230-1231. 3.National Institute for Clinical Excellence. Posttraumatic stress disorder: the management of PTSD in adults and children in primary and secondary care. National Clinical Practice Guideline Number 26, London: Gaskel and the British Psychological Society, 2005. 4.Bradley R, Greene J, Russ, E, Dutra L, Westen D. A multidimensional meta-analysis of psychotherapy for PTSD. Am J Psychiatry, 2005; 162: 214- 227. 5.Salcioglu E. The effect of beliefs, attribution of responsibility, redress and compensation on posttraumatic stress disorder in earthquake survivors in Turkey. PhD thesis. University of London, 2004. Competing interests: None declared |
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Abraham Rudnick, Associate Professor, Departments of Psychiatry and Philosophy, University of Western Ontario Regional Mental Health Care, 850 Highbury Avenue, London, Ontario N6A4H1, Canada. arudnic2@uwo.ca
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In a recent BMJ editorial, Basoglu laments the sorry state of treatment for torture survivors, as compared to survivors of other types of trauma.1 Specifically, Basoglu suggests that cognitive behavioural therapy (CBT) could be helpful for torture survivors, particularly those who present with related post-traumatic stress disorder (PTSD), and that this could be an important part of their rehabilitation (loosely defined). I would like to point to an important and rich domain of mental health theory and practice that could be of help in the care of such individuals with PTSD. This is the field of psychiatric rehabilitation (PSR), which includes an evidence-based set of practices, mainly focused on helping people who are disabled by their mental illnesses recover by enhancing their living skills and their social supports so as to be successful and satisfied with their lives.2 PSR was orginally established to address serious mental illnesses (narrowly defined as psychotic disorders and major mood disorders), particularly schizophrenia. Yet PSR has promise for any mental illness that disables a person afflicted with it, partly because it directly addresses domains such as functioning, which could sometimes be more amenable to direct intervention and improvement than refractory symptoms. Although some subgroups of individuals with PTSD may not be disabled by it,3 others may be severely disabled by PTSD.4 Torture survivors may be among the latter. For a while now, PTSD research has suggested that treatment, in the sense of attempts to alleviate symptoms, may not be effective for individuals with severe and prolonged PTSD,5 and that PSR may be an effective set of interventions for this subgroup.6 Yet not much research has been published on PSR for individuals with severe and prolonged PTSD, and the scant research that has been published has either used outdated PSR interventions (which, not surprisingly, demonstrated poor outcomes),7 or has been published in langauges other than English such as Croatian,8 which would account for the low profile of PSR in clinical research related to PTSD. It may be time to consider PSR as a high priority for clinical research related to PTSD, particularly for severe and prolonged PTSD. This may require clinical researchers to target daily functioning,2 experience of self,9 leisure activity,10 and other disability-relevant and PSR- related outcomes, no less and perhaps more, than symptom severity. This, in its turn, may require an educational and cultural transformation in the field of PTSD and possibly in clinical psychiatric research and practice in general. If so, implementation and study of systemic interventions attempting to transform psychiatry may be required. This could perhaps be done cost-effectively via post-graduate (resident/registrar) education, among other things. Although achieving such transformation is expected to be a formidable task, it may be well worth pursing. 1 Basoglu M. Rehabilitation of traumatised regufees and survivors of torture. BMJ 2006;333:1230-1. 2 Anthony WA, Cohen M, Farkas M, Gagne C. Psychiatric rehabilitation, 2nd ed. Boston: Center for Psychiatric Rehabilitation, 2002. 3 Neal LA, Green G, Turner MA. Post-traumatic stress and disability. Br J Psychiatry 2004;184:247-250. 4 Bleich A, Solomon Z. Evaluation of psychiatric disability in PTSD of military origin. Isr J Psychiatry Relat Sci 2004;41:268-76. 5 Johnson DR, Rosenheck R, Fontana A, Lubin H, Charney D, Southwick S. Outcome of intensive inpatient treatment for combat-related posttraumatic stress disorder. Am J Psychiatry 1996;153:771-7. 6 Shalev A, Bonne O, Eth S. Treatment of posttraumatic stress disorder: a review. Psychosom Med 1996;58:165-82. 7 Rosenheck R, Stolar M, Fontana A. Outcomes monitoring and resting of new psychiatric treatments: work therapy in the treatment of chronic post-traumatic stress disorder. Health Serv Res 2000;35:133-51. 8 Koic E, Filakovic P, Muzinic L, Vondracek S, Nad S. [The club of Croatian war veterans treated for PTSD as a form of psychosocial rehabilitation]. Lijec Vjesn 2005;127:44-7. 9 Roe D, Chopra M, Rudnick A. Persons with psychosis as active agents interacting with their disorder. Psych Rehab J 2004;28:122-8. 10 Rudnick A. Psychiatric leisure rehabilitation: conceptualization and illustration. Psych Rehab J 2005;29:63-5. Competing interests: None declared |
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Metin Basoglu, Head of Trauma Studies Unit, Institute of Psychiatry, King's College London Institute of Psychiatry, Box PO91, DeCrespigny Park, Denmark Hill, London SE5 8AF
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Rudnick’s proposed approach based on ‘enhancing living skills and social supports’ overlooks the psychological mechanisms underlying traumatic stress. Several points concerning this issue deserve further comment. In choosing a treatment for any medical illness, mental or physical, one needs to consider how closely its mechanisms of action match the pathogenetic mechanisms that underlie the illness. To use an analogy, we use antibiotics rather than salicylates to treat infections, because the latter drugs do not remove the causal agent. As noted in my article, the causal process in traumatic stress is loss of control over stressors during the traumatic event. Following the trauma, helplessness is perpetuated and reinforced by re-experiencing symptoms and fear induced by perceived (or sometimes real) threat of further exposure to trauma.1 Depression that often accompanies posttraumatic stress disorder (PTSD) is secondary to the helplessness and hopelessness effects of chronic anxiety and fear associated with traumatic stress.2 This formulation implies that interventions can be effective in reducing traumatic stress to the extent that they enhance sense of control over (and thereby increase resilience against) traumatic stressors. Our work shows that this is most effectively achieved by behavioural interventions. On the other hand, studies3 of stressor-response associations in torture trauma show that lack of social support contributes to depression but not to PTSD. This implies that social support is likely to reduce depression but not PTSD. Indeed, this is supported by other studies4 showing that non-refugee torture survivors who enjoy strong emotional support are less likely to get depressed but such support does not prevent them from developing full-blown PTSD. Such differential stressor-response associations might well explain why current rehabilitation programmes do not reduce survivors’ traumatic stress problems, despite all the support they provide. Second, a control enhancing behavioural intervention has a ‘patholytic’ effect, improving all traumatic stress and depressive symptoms.5 Functional impairment or disability is secondary to such symptoms and thus removing the symptoms leads to marked improvement in social, work, and family functioning and quality of life. Thus, why focus on ‘living skills’ to facilitate coping with disability when disability itself can be effectively removed? Furthermore, the treatment studies cited in my article (among others) show that severity and chronicity of PTSD do not impede improvement, provided that survivors comply with treatment. As is the case with other life-threatening events, torture- induced PTSD is characterised by fear-related stress symptoms, which are highly responsive to a potent fear-reducing intervention, such a behavioural treatment. To conclude, it is worth noting that the techniques used by torturers in breaking resistance and inducing total helplessness in a person are also behavioural in nature (see Basoglu and Mineka6 for a detailed review of torture methods), which explains why torture is such a potent traumatic stressor for psychologically unprepared people.7 Fortunately, however, behavioural strategies are equally effective in reversing the traumatic impact of torture. The sad irony is that we are still debating how best to treat torture survivors, while torturers, fully aware of the potency of such strategies, have long been exploiting them to the full. References: 1. Basoglu M, Livanou M, Crnobaric C. Torture versus other cruel, inhuman and degrading treatment: Is the distinction real or apparent? Arch Gen Psychiatry, in press. 2. Mineka S, Watson D, Clark LA. Comorbidity of anxiety and unipolar mood disorders. Annu Rev Psychol 1998; 49:377-412. 3. Basoglu M, Paker M, Tasdemir O, Ozmen E, Sahin D. Factors related to long-term traumatic stress responses in survivors of torture in Turkey. JAMA 1994; 272(5): 357-363. 4. Basoglu M, Paker M, Paker O, Ozmen E, Marks IM, Incesu C, Sahin D, Sarimurat N. A comparison of tortured with matched non-tortured political activists in Turkey. Am J Psychiatry 1994; 151: 76-81. 5. Basoglu M, Salcioglu E, Livanou M. A randomized controlled study of single-session behavioral treatment of earthquake-related posttraumatic stress disorder using an earthquake simulator. Psychol Med 2007; 37(2): 203-214. 6. Basoglu M, Mineka S. The role of uncontrollability and unpredictability of stress in the development of post-torture stress symptoms. In M. Basoglu (Ed.) Torture and Its Consequences: Current Treatment Approaches. Cambridge University Press, 1992, p.182-225. 7. Basoglu M, Mineka S, Paker M, Aker T, Livanou M, Gok S. Psychological preparedness for trauma as a protective factor in survivors of torture. Psychol Med 1997; 27:1421-1433. Competing interests: None declared |
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Abraham Rudnick, Associate Professor, University of Western Ontario, Departments of Psychiatry and Philosophy Regional Mental Health Care, 850 Highbury Avenue, London, Ontario N6A4H1, Canada. arudnic2@uwo.ca
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I appreciate the opportunity given to me by the BMJ to respond to Dr. Basoglu's reply to my commentary addressing Basoglu's paper.1 I would like to address a few key points in response. Psychiatric rehabilitation (PSR) does not overlook psychological mechanisms such as loss of sense of control that may underly traumatic stress and post-traumatic stress disorder (PTSD). Rather, typical PSR does not address such psychological mechanisms directly, but targets their adverse outcomes, such as dysfunction, the improvement of which can be beneficial in itself and can also result in enhanced sense of control. Using infection as an analogy for PTSD is misleading, as it implies an acute disease model of PTSD. PTSD, like many other psychiatric disorders (including anxiety disorders as well as mood disorders and psychotic disorders), has many similarities to chronic disease and can clearly result in disability. At the very least, a subgroup of patients with PTSD are disabled, temporarily or permanently, and hence may require rehabilitation as a central intervention. Sadly, many torture victims may be included in that disabled group, not only because of unattempted or unsuccessful treatment, but also because of the pervasive adverse effects of torture, such as general mistrust, sense of guilt and more. Disability is not caused by symptoms alone but rather by symptoms in conjunction with background factors, such as available support and coping skills, as well as by the afflicted person's life course since the onset of the disorder, which itself is determined by many factors related to the disorder, the person and the environment. Hence, attempting to remove or reduce symptoms, even if successful, is not sufficient in some cases, and then intervention directly addressing other factors contributing to disability, i.e., PSR, is required. This is even more so when treatment attempts to remove or reduce symptoms are not successful, as can happen even with cognitive behavioural therapy (CBT). An approach that individualizes the integration of treatment and rehabilitation is in keeping with sound and established general medical theory, findings and practice for many, if not most, health-related disorders. A consideration of the notion of disability, as formulated by the World Health Organization (WHO),2 and as analyzed in detail more recently,3 could be very helpful in this context, e.g., where symptoms - and impairments in general - are considered necessary but not sufficient for disability. I remain hopeful that Basoglu and others will seriously consider the potential benefits of PSR for disabled torture victims and for other psychiatrically disabled patient populations. 1 Basoglu M. Rehabilitation of traumatised refugees and survivors of torture. BMJ 2006;333:1230-1. 2 World Health Organization (WHO). International classification of functioning, disability and health. Geneva: WHO, 2001. 3 Edwards SD. Disability: definitions, value and identity. Abingdon: Radcliffe, 2005. Competing interests: None declared |
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Metin Basoglu, Head of Trauma Studies Unit, Institute of Psychiatry, King's College London Institute of Psychiatry, Box PO91, DeCrespigny Park, Denmark Hill, London SE5 8AF
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A final comment on Rudnick’s points will hopefully put things in perspective and finalise the discussion on social support and skills training. It is important to make a distinction between sense of control over trauma-related stressors and sense of control over general psychosocial stressors, because they seem to relate differentially to posttraumatic stress disorder (PTSD) and depression. As noted in my earlier response, enhancing the latter by improving skills and social support is likely to reduce depression but not PTSD, unless skills training also involves effective strategies (e.g. self-exposure to trauma cues) to overcome fear and related stress problems. But then this means incorporating a behavioural intervention in this approach, which is precisely what I am recommending for rehabilitation programs for torture survivors. A focus on dysfunction makes sense only after all other treatments have failed. The important point to remember is the fact that such cases constitute a relatively small minority, given the ample evidence showing that anxiety disorders, including PTSD, are treatable in 80%-90% of the cases, with generalized improvement in all life areas. Torture-related PTSD is no exception. Evidence suggests that cognitive effects of trauma, such as guilt, blame, sense of injustice, etc, are not associated with PTSD in war and torture survivors,1 do not impede response to treatment,2 and improve with exposure treatment.3,4 It is worth avoiding sidetracking from the main issue in this discussion. The main purpose of my article was to draw attention to recent evidence showing that PTSD is treatable using brief interventions. Our studies5,6 show that a single session of control-focused behavioural treatment is effective in over 80% of the cases, achieving effect sizes (mean 2.40) substantially larger than those obtained by other currently available treatments for PTSD (including the traditional 10-session cognitive-behavioural treatment). However unlikely or hard to believe these findings might seem, they are some food for thought. Our findings by no means imply that all cases can be treated in a single session. What they suggest, however, is that cost-effective care of millions of people exposed to mass trauma events, such as political violence, torture, wars, natural disasters, and terrorism is possible. This is particularly important in view of the fact that there are no other such brief interventions for traumatic stress available to us. Thus, let us first concentrate on how best to help the majority of those people and then we can consider what to do for a relatively small group of non-responders. References: 1.Basoglu M, Livanou M, Crnobaric C, Franciskovic T, Suljic E, Duric D, et al. Psychiatric and cognitive effects of war in former Yugoslavia - The relationship between lack of redress for trauma and posttraumatic stress reactions. JAMA 2005; 294:580–590. 2. Livanou M, Basoglu M, Marks IM, De Silva P, Noshirvani H, Lovell K, Thrasher S. Beliefs, sense of control, and treatment outcome in post- traumatic stress disorder. Psychol Med 2002; 32,157-165. 3.Paunovic N, Ost LG. Cognitive-behavior therapy vs exposure therapy in the treatment of PTSD in refugees. Behav Res Ther 2002; 39:1183-1197. 4.Foa EB, Rauch SAM. Cognitive Changes During Prolonged Exposure Versus Prolonged Exposure Plus Cognitive Restructuring in Female Assault Survivors With Posttraumatic Stress Disorder. J Consult Clin Psychol 2004; 72: 879-884. 5.Basoglu M, Salcioglu E, Livanou M, Kalender D, Acar G. Single- session behavioral treatment of earthquake-related posttraumatic stress disorder: a randomized waiting list controlled trial. J Trauma Stress 2005; 18:1-11. 6.Basoglu M, Salcioglu E, Livanou M. A randomized controlled study of single-session behavioral treatment of earthquake-related posttraumatic stress disorder using an earthquake simulator. Psychol Med 2007; 37(2): 203-214. Competing interests: None declared |
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Gervase Vernon, Medical report writer Medicalfoundation for the care of victims of tortue,N7 7JW
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Dear editor, even accepting the value of CBT for torture survivors there are practical difficulties in accessing CBT in the UK. Most obviously CBT in any form is not avaible even to my NHS patients and that in a prosperous part of Essex. Small wonder then that it is difficult to provide for an immigrant group, many with irregular legal status. The greater problem arises when clients have not yet recieved an asylum decision. At this stage they are tightly focussed on obtaining this status and acutely aware that they may be sent back to countries where they believe they will be tortured again. In this situation, where at least three quaters are refused asylum, it is impractical to "increase the sense of control" as Dr Basoglu tells us CBT aims to do. At a later stage in the asylum process, when legal status has been gained, CBT is surely appropriate in those troubled by PTSD symptoms, Yours Sincerely,
Competing interests: None declared |
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Andrew O. Frank, Consultant Physician in Rehabilitation Medicine & Rheumatology Arthritis Centre, Northwick Park Hospital, Harrow, HA1 3UJ
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The migration of refugees from central London to the outer London suburbs exposes clinicians to the problems of refugees that they may have no experience of, or training in. The recent fascinating discussion following the editorial by Basoglu [1] presupposes that an appreciation that torture has taken place is understood in primary care and the details made available in any referral to the secondary sector. We have recently reported that only 50% of referral letters to a rheumatology service for refugees complaining of back or neck pain had this information provided [2]. Consequently a small number were ‘triaged’ to the physiotherapy service, where, following unsuccessful standard back treatment, they were referred on to the rheumatology service. As a physician, I would not be so bold as to comment on the diagnosis of post-traumatic stress disorder (PTSD, but when the sleep history clearly identifies nightmares regularly disturbing sleep [3], the need for tricyclic antidepressant medication seems appropriate for their sedatory, as well as their pain modulating, benefits. As commented by Seltzer et al [4], we have noted that there are usually multiple losses contributing to the clinical picture and that the effects of torture may also affect other family members. I have seen at least two patients whose experience of spinal pain has clearly been affected by their spouses’ torture and PTSD, again elicited via the sleep history – a crucial element in managing chronic pain [5;6]. As well as evaluating the best ways of helping refugees, we must put more emphasis on training health professionals to diagnose their problems (health or social) speedily, and then provide effective medical, psychological and social interventions. Reference List (1) Basoglu M. Rehabilitation of traumatised refugees and survivers of torture. BMJ 2006; 333(16 December):1230-1231. (2) Retrospective study of refugees presenting to a rheumatological service with spinal pain: afraid to go to sleep? Proceedings of the 11th World Congress on Pain, Sydney, August 2005, pp 1457-8. (3) McCarthy J, Frank A. Post-traumatic psychological distress may present in rheumatology clinics. BMJ 2002; 325(27 July):221. (4) Seltzer A, Skian A, Patel N. Treating torture survivors - there is no quick fix. eBMJ 2006; 333/781/1230. (5) De Souza LH, Frank AO. Experiences of living with chronic back pain: the physical disabilities. Disabil Rehabil - in press. (6) McCracken LM, Iverson GL. Disrupted sleep patterns and daily functioning in patients with chronic pain. Pain Research & Management 2002; 7(2):75-79. Competing interests: Andrew Frank is Medical Director of Kynixa, a vocational rehabilitation company |
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Joanna H Newell, GP Health Access Team for Asylum Seekers, Sycamore Lodge, 7a Woodhouse Cliff, Leeds, LS6 2HF
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Basoglu suggests that brief behavioural interventions are as effective as traditional cognitive behavioural traetment for post- traumatic stress disorder sufferers and implies that these should be the only approaches to the treatment of torture survivors (1) . Torture is a very different pattern of trauma compared to a single natural event, and most torture survivors who arrive in the UK also have a number of other stressors, eg family separation, bereavement, loss of social status, poverty and uncertainty about the future. Torture survivors may be a very different cohort to that in which brief behavioural interventions were so helpful. We know that 40% of newly arrived asylum seekers seen by our team in Leeds disclose a history of physical abuse and that 15% disclose a history of rape or sexual abuse (2) . So there are a lot of people in our city for whom this is not just an academic argument. In Leeds, as in many parts of the UK, there is almost no provision of rehabilitation services for the hundreds (3) of survivors of torture who are living here. Well designed trials of different approaches to the rehabilitation of torture survivors can only be a good thing. But it would be a disgrace if the scarcity of relevant evidence was used as an excuse to prolong the deplorable lack of services for these patients 1. Basoglu. BMJ 2006;333:1230-1 2. Audit of recorded health issues February – May 2005, Health Access Team for Asylum Seekers in Leeds, unpublished 3. Asylum Newsletter Issue 32 – July/August 2006. can be accessed at www.refugeeaccess.info Competing interests: None declared |
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Metin Basoglu, Head of Trauma Studies Unit, Institute of Psychiatry, King's College London Institute of Psychiatry, Box PO91, DeCrespigny Park, Denmark Hill, London SE5 8AF
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Vernon (BMJ, 2 January 2007) is certainly right in pointing to the problem of access to treatment facilities in parts of the UK. Clearly, we need to consider how to make such services available to all refugees, once we agree on what type of interventions such services should involve. Asylum-seeking status is no contraindication for behavioural treatment. Quite the opposite, this treatment is particularly appropriate for asylum-seekers, given the evidence suggesting that control-enhancing behavioural interventions have resilience-building effects against traumatic stressors.1 Resilience is indeed what an asylum-seeker needs most, whether granted refugee status or repatriated to the country of origin later. Furthermore, we have demonstrated in two case studies that it is possible to treat effectively non-refugee torture survivors2 who are at risk of further torture in their own country or asylum-seekers3 facing the risk of repatriation from a host country. Thus, the notion that a person cannot be treated when facing threat of further torture is a myth and not supported by any evidence. I completely agree with Frank’s statement (BMJ, 3 January 2007) that all health professionals dealing with refugees’ need to be aware of posttraumatic stress problems and their possible connection with certain medical problems. Given the well-known connection between stress and physical health, interventions focusing on traumatic stress might also be helpful with some medical problems. For example, Frank’s patient with spinal pain might well benefit from a behavioural intervention designed to reduce anxiety, fear, and related traumatic stress symptoms. This issue is certainly worth exploring in future research. In response to Newell (BMJ, 4 January, 2007), I never said or implied that behavioural treatment should be the only approach in rehabilitation of torture survivors. I clearly indicated that it should be incorporated into existing rehabilitation programmes. To be more precise, existing rehabilitation programmes could be reformulated along behavioural lines to maximise their therapeutic impact on traumatic stress problems. For example, various components of such programmes (e.g. assessment of trauma history and psychiatric status, medical examinations and treatments, physiotherapy, etc.) often cause anxiety, fear, and even panic responses in survivors, because they evoke memories of certain procedures in a torture setting (e.g. interrogation, authority figures, use of various instruments in torture, etc). Such procedures, when conducted within the framework of control-focused exposure treatment, are very likely to reduce survivors’ conditioned anxiety and fear responses and lead to generalised improvement in all posttraumatic stress symptoms.1 Physiotherapy, for example, could also be used as an exposure treatment procedure, if it is presented to the patient as a means of overcoming trauma-related distress and fear. Such an approach, however, requires a reconceptualisation of the whole rehabilitation programme (including psychotherapy) in behavioural terms and retraining of all staff to ensure a unified and consistent approach to survivors’ problems. Without such an orientation, some care providers tend to adopt anti-therapeutic notions, attitudes or approaches in treatment (e.g. most commonly “whatever you do, do not remind the survivors of their torture experiences”).4 Such approaches (although reflecting well meaning, humanitarian concerns) essentially reinforce avoidance and helplessness (e.g. the ‘victim’ role), thereby perpetuating the problem in survivors. A more detailed discussion of this problem can be found in a book chapter4 published 14 years ago. Regarding torture being a different traumatic event, this is simply another myth. Family separation, bereavement, loss of social status, poverty, uncertainty about the future, and cognitive effects (and much more) apply equally to natural disaster survivors (see my reply to Rudnick, 29 December 2006 where I cited research that examined this very issue). This is not to dispute the fact that torture is a severe trauma with serious psychosocial consequences but it is important to view things in perspective so that effective treatment prospects are not overlooked. It should be clear from this reply that I am not against providing rehabilitation services for torture survivors. I completely agree with the view that specialised care services for refugees are grossly inadequate, not only in western countries but also in the rest of the world. My only argument is that they can be made more effective. If existing programmes are not effective, then we need to examine our approach first before blaming torture trauma for being so difficult to treat. References: 1.Basoglu M, Salcioglu E, Livanou M. A randomized controlled study of single-session behavioral treatment of earthquake-related posttraumatic stress disorder using an earthquake simulator. Psychol Med 2007; 37(2): 203-214. 2.Basoglu M, Aker T. Cognitive-behavioural treatment of torture survivors: A case study. Torture 1996; 6:61-65. 3.Basoglu M, Ekblad S, Baarnhielm S, Livanou M. Cognitive-behavioral treatment of tortured asylum seekers: A case study. J Anxiety Disord 2004; 18(3): 357-369. 4.Basoglu M. Behavioural and cognitive treatment of PTSD in torture survivors. In M. Basoglu (Ed.) Torture and Its Consequences: Current Treatment Approaches. Cambridge University Press, 1992 p. 402-429. Competing interests: None declared |
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Juliet R Cohen, GP and Forensic Physician Warborough, Oxfordshire, OX10 7DA
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I am interested to read M Basoglu's insistence on the use of evidence based medicine in determining treatment for victims of torture with PTSD. The evidence he cites in support of using 'brief' exposure based therapy seems to refer to two case studies published in 1996 and 2004. Each is on a single patient. 16 sessions of CBT are referred to. I do not see how this constitutes either a sound foundation of evidence or brief therapy. In Oxford the PCT had to halt referrals of asylum seekers and refugees with PTSD symptoms to the CBT service because of both the high number of referrals and the high DNA rate, which created an impossibly long waiting list and breached too many targets. Asylum seekers in particular were found to be living in too chaotic a situation with too many other competing pressures and anxieties to focus on the demanding nature of CBT sessions. Since changing the referral pathway for such cases to a triaged system with the majority receiving psycho-social supportive counselling and only a selected minority reaching the CBT service (an expensive and skill-limited resource), more patients have been helped more effectively. Competing interests: None declared |
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Abigail Seltzer, Consultant Psychiatrist Medical Foundation for the Care of Victims of Torture, Alex Sklan, Director of Clinical Services, Nimisha Patel, Consultant Psychologist
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We are surprised at Basoglu’s response to the points we raised. Nowhere do we suggest abandoning the diagnosis of PTSD on ideological grounds, and do not see how he infers this from our response. We are merely mindful - as are others - of its limitations as well as its genesis, and continue to question its utility in certain populations. As Turner states, ‘Although PTSD represents a useful diagnostic entity, it does not go far enough in explaining the wide range of symptomatology seen in torture survivors.’ 1. Indeed, the NICE PTSD guidelines (cited by Basoglu) recognise that: ‘Clinicians working with refugees should…. have knowledge of the complexity of the emotional reaction that many experience (going well beyond PTSD in many cases)’ 2 Basoglu also seems to infer that we dismiss the utility of CBT out of hand, again on ideological grounds, and that we offer only ‘lengthy rehabilitation’. This suggests that he is unfamiliar with the work of the Medical Foundation: our Early Intervention Team’s mandate is to undertake short term work. As to treatment methodology, we use trauma focussed CBT in our own centre when it is appropriate to do so, usually as part of a multidisciplinary programme incorporating other interventions such as case work to address practical issues which impact on health, eg homelessness, destitution or difficulties in accessing health care. We also use group and family therapies, physical and somatic therapies, as well as other trauma focussed evidence based techniques such as EMDR. We also use medication for which there is a acceptable evidence base in the treatment of PTSD in torture survivors. As for Basoglu’s own two case studies of CBT with torture survivors (each of a single individual and with rigid exclusion criteria, including willingness to receive CBT), they are hopeful pointers, although hardly grounds for abandoning all other approaches. Torture survivors are not a homogeneous group, and many of our clients take months to build up sufficient trust to tackle trauma work, if that is their need. We stand by our view that single session or even brief CBT is not a panacea, and await further trials with interest, as there is indeed a dearth of good evidence. We consider that our views and his on PTSD and its treatment are not so far apart, and resent the implication in both his editorial and his response that we are ideologically driven and neglectful of current evidence and practice. As for sharing our work with the public, we refer him to the bibliography on our website www.torturecare.org.uk. 1. Turner S. Psychiatric help for survivors of torture. Adv. Psychiatr. Treat., Jul 2000; 6: 295 – 303 2. National Institute for Clinical Excellence. Posttraumatic stress disorder: the management of PTSD in adults and children in primary and secondary care. National Clinical Practice Guideline Number 26, London: Gaskell and the British Psychological Society, 2005. Competing interests: None declared |
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Metin Basoglu, Head of Trauma Studies Unit, Institute of Psychiatry, King's College London Institute of Psychiatry, Box PO91, DeCrespigny Park, Denmark Hill, London SE5 8AF
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The evidence base to which I referred in my original article and subsequent correspondence relates to randomised controlled studies of cognitive-behavioural treatment (CBT) in post-traumatic stress disorder (PTSD) in general. I clarified the evidence for a control-focused behavioural treatment (BT) in my BMJ editorial and also in my reply to Seltzer et al (BMJ, 21 December 2006). The only reference I made to torture survivors in this regard was, quoting from my original BMJ editorial, “Preliminary evidence suggests that exposure-based interventions are also useful in refugees and survivors of torture.” To qualify this statement, I cited two clinical trials1,2 involving exposure- based treatments and our two case studies. These studies certainly provided at least preliminary evidence of the usefulness of exposure-based treatments in torture survivors. I never referred to an 'evidence base' with respect to BT of torture survivors. The two case studies were published simply to illustrate the fact that torture trauma is treatable in different socio-political contexts. Surely, I would know better than referring to two single case studies as ‘evidence base’ for a particular treatment. Our experience with earthquake survivors in Turkey after the 1999 earthquakes might be quite informative regarding how treatment can be effectively delivered to survivors under difficult circumstances. The problems we faced in delivering care to survivors after a devastating natural disaster were no less serious than those described by Cohen (BMJ, 8 January 2007) in Oxford. In fact, the extremely high DNA rate (due to daily survival problems and increased demographic mobility in the disaster region) was the primary reason why we were compelled to develop and use a single-session BT. We developed this treatment by modifying and shortening an existing treatment (i.e. 10-session CBT) and testing it in a clinical trial3 to find out the minimum number of sessions required for significant improvement. We were indeed quite surprised to find out that it required 1 session to achieve significant improvement in 76% and 2 sessions in 88% of the cases. Later we tested a single-session version of BT in two randomised controlled studies (cited in my original BMJ editorial) and found, again to our surprise, substantial improvement in over 80% of the cases. We were then able to deliver this treatment confidently to more than 5,000 survivors in 3 years. This shows that it is possible to tailor a treatment according to the particular circumstances in which it has to be delivered, provided, of course, the right choice of treatment is made. We would have never been able to develop a single-session intervention, had it not been for the difficult post-disaster circumstances. These findings do not necessarily imply that torture survivors can be treated in a single session but operational research of the kind we conducted could well identify the optimum number of sessions and an effective modality of treatment delivery. It is because of lack of such research with torture survivors that we have not made much progress in treating them in the last 20 years. It is also worth noting in this connection that the control-focused BT to which I keep referring is quite different from traditional CBT in its theory and practice. It is a fairly simple intervention, involving mainly instructions for self-exposure to distress- or fear-evoking trauma cues and no systematic cognitive interventions (which is why I refer to it as BT rather than CBT). It is based on learning theory formulations4 of anxiety and fear, which point to the important role of unpredictable and uncontrollable stressors in traumatic stress. Accordingly, the primary aim in treatment is to enhance sense of control over trauma-related stressors or cues rather than achieve habituation to them. This has important implications in the way the intervention is actually delivered in clinical practice. Unlike traditional BT, it does not involve (a) prolonged and extensive exposure to trauma cues and (b) certain time-consuming practices, such as setting of homework exposure tasks, review of progress on these tasks, diary keeping, etc. It is essentially a self-help treatment with minimal involvement on the part of the therapist. Such features make it much easier to administer than traditional CBT. The cognitive restructuring component of the latter (which our work has shown to be redundant) is certainly difficult to administer with refugees, particularly those with language difficulties. There is even some preliminary evidence5 from our work with earthquake survivors that control -focused BT can be effectively disseminated through a highly structured self-help manual with minimal or no therapist contact. These findings certainly point to prospects of similar results with torture survivors, as available evidence suggests. I should also note that it was our observations4 of human behaviour (and mechanisms of traumatic stress) under torture that eventually led to the development of a control-focused BT for earthquake survivors. To summarise my main point, given (a) the evidence base for CBT in PTSD in general, (b) the evidence base for control-focused BT in earthquake survivors, and (c) preliminary evidence suggesting the effectiveness of exposure-based treatments in refugees and torture survivors (all cited in my BMJ editorial), the usefulness of these interventions is well worth exploring further in tortured asylum-seekers and refugees, before we conclude in desperation that they are a difficult group to treat. Who knows, there may be more surprises ahead of us! References: 1.Neuner F, Schauer M, Klaschik C, Karunakara U, Elbert T. A comparison of narrative exposure therapy, supportive counselling and psychoeducation. J Consult Clin Psychol 2004;72:579-87. 2.Paunovic N, Öst GL. Cognitive-behaviour therapy versus exposure therapy in the treatment of PTSD in refugees. Beh Res Ther 2001;39:1183- 97. 3.Basoglu M, Livanou M, Salcioglu E, Kalender D (2003). A brief behavioural treatment of chronic post-traumatic stress disorder in earthquake survivors: Results from an open clinical trial. Psychol Med, 33(4), 647-654. 4.Basoglu M, Mineka S. The role of uncontrollability and unpredictability of stress in the development of post-torture stress symptoms. In M. Baþoðlu (Ed.) Torture and Its Consequences: Current Treatment Approaches. Cambridge University Press, 1992, p. 182-225. 5.Basoglu M, Salcioglu E, Livanou M. Single-case experimental studies of a self-help manual for traumatic stress in earthquake survivors (submitted for publication). Competing interests: None declared |
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Metin Basoglu, Head of Trauma Studies Unit, Institute of Psychiatry, King's College London Institute of Psychiatry, Box PO91, DeCrespigny Park, Denmark Hill, London SE5 8AF
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First of all, I should note that I am not an ardent defender of posttraumatic stress disorder (PTSD) myself. It certainly has various deficiencies and how it applies to torture trauma (or various other traumas, for that matter) is not adequately investigated. We even reported that PTSD, as it is presently defined, fails to capture fully the phenomenology of traumatic stress in earthquake survivors.1 However, the argument that the ‘complexity of the emotional reaction’ associated with torture distinguishes it from other traumas is not substantiated by any evidence. This requires a comparative study examining the phenomenology of PTSD, cognitive and emotional responses to trauma, complex stressor- response relationships, and mechanisms of traumatic stress in different trauma groups. To the best of my knowledge, such a study has been undertaken only by our research group. We examined this issue with respect to different types of trauma, including torture (in political activists and war survivors), combat, refugee status, internal displacement, aerial bombardment, and natural disaster (earthquakes). The sample includes altogether about 2,000 survivors. Using an Emotions and Beliefs After Trauma Questionnaire we obtained detailed data on a wide range of cognitive and emotional responses to trauma. Using a semi-structured Redress for Trauma Survivors Questionnaire, we also examined survivors’ appraisal of redress and compensation and how such appraisal relates to psychological functioning. These studies allowed direct comparisons between various trauma groups. There was no evidence suggesting that torture survivors substantially differed from the other groups. Indeed, earthquake survivors’2 cognitive and emotional response profile showed striking similarities to that of war and torture survivors.3 This is because earthquake trauma (defined as the initial devastating shock and all the other stressor events that follow, including numerous aftershocks that often last for months) also has a strong human element. More importantly, cognitive and emotional responses to trauma were not associated with PTSD, which was very strongly associated with fear and loss of control associated with perceived threat to safety.2,3 This means that one develops PTSD not because of sense of injustice, for example, but because of fear-related helplessness. This was true for all trauma groups, suggesting that torture, war trauma, and natural disasters all share the same mechanisms of traumatic stress. This means that ‘complex emotional reactions’ have no bearing on PTSD and (though highly important from a moral, social, and political perspective) are merely psychological epiphenomena secondary to traumatic stress. These findings also imply that restoring sense of control over trauma-related stressors, cues or reminders is likely to reverse trauma-induced stress (and its effects on cognitions and emotions). We tested and confirmed this hypothesis in four clinical trials (cited in my original BMJ editorial) involving altogether 229 earthquake survivors (and in more than 5,000 survivors in routine outreach treatment delivery work). Given that earthquake and torture traumas share the same underlying mechanisms, a similar response to control-enhancing interventions in torture survivors is highly likely. In fact, this is supported by available evidence on the effectiveness of a potent fear-reducing intervention, such as exposure treatment, in torture survivors. These findings also imply that whether torture survivors have PTSD or something else beyond PTSD is irrelevant to the issue of treatment. Perhaps we should not even be talking about PTSD here. The important issue is what causes traumatic stress (however it might manifest itself) and how it can be reversed. Our work with earthquake survivors shed some light on this important question. I also noted in earlier correspondence that ‘complex emotional reactions’ are likely to respond to fear-reducing interventions, citing evidence suggesting that such interventions lead to cognitive change. If Seltzer et al have any evidence contrary to these findings, I would be happy discuss this issue further. I would also like to know in which ways torture survivors differ from each other, the evidence showing these differences, and how this is relevant to treatment. I did not comment on the current status of rehabilitation programmes with specifically the Medical Foundation in mind. There are more than hundred such programmes around the world and they might well show some variation in their approach. I am glad to hear that Seltzer et al do not have an ideological position on any of these issues and that they also have a trauma-focused approach in their work. The main point of my original BMJ editorial was the lack of evidence on the usefulness of these approaches. I checked the Medical Foundation website, as suggested, and could not find any publication reporting the results of an outcome evaluation. If I missed it, perhaps they might provide the reference for it. Seltzer et al state that they also use CBT in their programme, presumably for a good reason. Yet, in the same paragraph they refer to our two cases studies as inadequate evidence (which is certainly true but also see my previous reply, BMJ, 9 January 2007, regarding evidence base for CBT). One wonders why they are using this approach when they believe that there is no evidence to support its usefulness in torture survivors. As regards ‘abandoning all other approaches,’ see my earlier reply (BMJ, 6 January 2007) to Newell (BMJ, 4 January 2007) on this issue. To clarify one important point, I made a distinction between traditional cognitive-behavioural treatment (CBT) and control-focused behavioural treatment in a recent reply (BMJ, 9 January 2007). I am not advocating the use of traditional CBT with torture survivors, because our work shows that its cognitive restructuring component is redundant (and also because of some other theoretical reasons). I am also glad to hear that Seltzer et al are not neglectful of current evidence and practice. Once they overcome their notions about torture trauma being different and have a better understanding of how various types of trauma share the same mechanisms by which they exert their impact on people and what this implies for effective treatment, they will see the relevance of our findings to their work. References: 1.Basoglu M, Salcioglu E, Livanou M. Traumatic stress responses in survivors of earthquake in Turkey. J Traumatic Stress 2002; 15:269-276. 2.Salcioglu E. The effect of beliefs, attribution of responsibility, redress and compensation on posttraumatic stress disorder in earthquake survivors in Turkey. PhD thesis. University of London, 2004. 3.Basoglu M, Livanou M, Crnobaric C, Franciskovic T, Suljic E, Duric D, et al. Psychiatric and cognitive effects of war in former Yugoslavia - The relationship between lack of redress for trauma and posttraumatic stress reactions. JAMA 2005; 294:580–590. Competing interests: None declared |
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Metin Basoglu, Head of Trauma Studies Unit, Institute of Psychiatry, King's College London Institute of Psychiatry, Box PO91, DeCrespigny Park, Denmark Hill, London SE5 8AF
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In an earlier letter (BMJ, 19 December 2006) Seltzer et al noted that “the Medical Foundation for the Care of Victims of Torture, as the only centre in the UK providing care specifically for survivors of torture, is committed to evaluation of its work; the results of its own audit and evaluation programme are routinely disseminated to funders.” They also argued for a “normative model of recovery from torture” that goes beyond the concept of posttraumatic stress disorder. In my reply (BMJ, 21 December 2006) I invited them to share the evidence on the usefulness of their approach with the public. In response (BMJ, 9 January, 2007) they referred me to their website. In my reply (BMJ, 10 January 2007) I noted that I checked their website and could not find any publication on evaluation of their work. This is curious since they have already stated that they regularly make such evidence available to their funders. In the meantime, I thought I should clarify what I mean by “evidence.” In their last letter (BMJ, 9 January 2007) they note that they provide (a) help with respect to social and medical problems, (b) group and family therapies, (c) physical and somatic therapies, (d) trauma focused treatments, such as EMDR and CBT, and (e) drug treatment. Such a multi-disciplinary approach would be expected to have an impact on (a) posttraumatic stress symptoms, (b) depression, (c) other psychiatric problems associated with torture, (e) social, work, and family functioning, and (f) problem areas included in their “normative model of recovery from torture.” If Seltzer et al are considering a response to my request for evidence, they need to answer the following questions: 1) Outcome evaluation requires validated and standardized assessment measures. What measures have they developed or used to assess the above problem areas? 2) Have they operationalised their ‘normative model of recovery from torture” and developed measures to assess this construct? 3) Given that they serve survivors from different national and cultural backgrounds, have they validated these measures in different languages and published their psychometric properties? 4) Have they conducted any outcome evaluation work to examine the overall usefulness of their rehabilitation model (e.g. its cumulative impact of psychosocial functioning), obtaining baseline data with post- treatment and long-term follow-up assessments? 5) Have they conducted any research to examine the relative contribution of each component of their rehabilitation model listed above? How do they know if any of these components is essential? For example, do group and family therapies really help? If so, in which problem domains? Does EMDR or CBT help, etc? 6) Have they conducted controlled studies to demonstrate that their model has a cumulative therapeutic impact on psychological functioning? Any controlled studies of the usefulness of the individual components of their model? After all, any observed improvement in the survivors’ condition might reflect non-specific effects of therapist contact, psychological placebo effects or natural recovery processes. Does their model overall (and its components individually) contribute anything over and above these effects? 7) Have they published any of these studies in peer-reviewed respectable journals? 8) Based on findings from such studies, have they attempted to refine their model, retaining effective elements and getting rid of redundant ones so as to increase the cost-effectiveness of their model? If such work has not been conducted, then Seltzer et al need to explain the reasons. Is it because they did not have the necessary funds or the know-how or the time? Or is it because they do not support the idea of such crucial operational research because they think it is unethical? They need to declare their position (as all other rehabilitation centres) on this issue so that the public knows about this. I should once again stress the fact that I have never singled out the Medical Foundation in my criticism of rehabilitation work with torture survivors. I am directing these questions to them in this letter because they were the only rehabilitation centre that responded to my original BMJ article. These questions are actually meant for all rehabilitation programmes. I should also stress the point that the responsibility for lack of progress in this field does not lie squarely on rehabilitation programmes. Increasingly unfavourable refugee policies in western countries, lack of interest in or attention to refugees’ needs, difficulties in raising funding for research in this field have all contributed to this problem. It is worth noting that the major funders of work with refugees and torture survivors (including the United Nations agencies concerned with this problem) have given priority to funding rehabilitation work without any consideration whether the relatively meagre resources made available have been put to good use. Scientific research, the only vehicle for addressing this issue, has often been regarded as unethical (or even almost a 'sacrilege' by some human rights workers). While such moral and ethical considerations (reflecting in part the horror in the western mind evoked by gruesome torture stories) are without doubt based on well- meaning, humanitarian concerns, they remind me of my favourite English saying: “The path to hell is paved with good intentions.” Competing interests: None declared |
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Sophie Durieux-Paillard, MD, MPH Department of community medicine, University hospital of Geneva, 1211 Geneva 24. Switzerland
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CBT or not CBT : that is the question If the subject was not so dramatic, the polemic about the treatment of PTSD among asylum seekers and refugees following the first article of Basoglu(1)would be laughable. PTSD as such, has been a part of organized psychiatry for only the past twenty years. The concept of PTSD, however, has been well known for over a hundred years under a variety of names. It is probably as old as the war (and earthquake)are. I am sure that all the authors of the quick responses remember that, 6 years before, a same quarrel perturbed advocates and opponents of Psychological Debriefing as a treatment of PTSD (2,3). More recently, Eye Movement Desensitization and Reprocessing (EMDR) method to treat PTSD which was first considered as the new panacea (4) has been much debated (5). Actually, the determinants of PTSD are so multifactorial that it is not possible to considered the treatment of this disease on an “evidence based” point of view. Many authors considered that recovery after exposure to extreme trauma like torture or organised violence is not a question of months but years (6) : use of CBT as a universal “quick fix” treatment of PTSD will be probably considered as an n-ieme myth in some years... or weeks. Clemenceau, a French politician said during the first World War: “War is too serious a matter to be entrusted to the military”. I am not a psychiatrist, but specialist in public health, and reading some of my colleagues and their auto quotations, I would like to write “PTSD among refugees is too serious a matter to be entrusted by psychiatrists, only”. It is surprising, indeed disrespectful to compare victims of natural disasters like earthquake and victims of torture. Indeed, both had been exposed to a trauma and should be helped and treated, but I don’t see where is the “strong human element” of the trauma linked to earthquake, other than the symptoms of PTSD. On the other hand, as many of the authors, I meet patients who have been exposed to torture in my daily practice in our primary care facility for asylum seekers (7 : auto quotation!) and I think that the intentional and man-made nature of the torture trauma is an essential element of the particularity of PTSD among torture victims. Moreover, the socio-political context of asylum is an other trauma factor(8). If it could be possible to treat efficiently victims of torture in a few days or weeks, every body would know that… References 1- Basoglu M. Rehabilitation of traumatised refugees and survivors of torture. BMJ 2006; 33:1230-31. 2- Deahl M. Psychological debriefing : controversy and challenge. Australian and New Zealand Journal of psychiatry. 200; 34:929-39. 3- Mayor S. Psychological therapy is better than debriefing for PTSD, BMJ. 2005;330:689. 4- Shapiro F., Maxfield L Eye Movement Desensitization and Reprocessing (EMDR) : information processing in the treatment of trauma. J Clin Psychol 2002, 58(8) 933-46. 5- Hembree EA, Foa EB, Dorfan NM et al : Do patients drop out prematurely from exposure therapy for PTSD? J Trauma Stress, 2003, 16(6) 555-62. 6- Steel Z, Silove DM, Phan T Bauman A. The long term impact of trauma on the mental health of Vietnamese refugees resettled in Australia : a population based study. Lancet 2002, 360:1056-62. 7- Durieux-Paillard S, Whitaker-Clinch B, Bovier PA, Eytan A. Screening for major depression and PTSD among asylum seekers : adapting a standardized intrument to the social and cultural context. Can J Psychiatry, 2006, 51:9.587-97. 8- Laban CJ, Gernaat HB, Komproe IH, Schreuders BA,De Jong JT. Impact of a long asylum procedure on the prevalence of psychiatric disorders in Iraqi asylum seekers in The Netherlands. J Nerv Ment Dis, 2004,192, 843- 51. Competing interests: None declared |
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Metin Basoglu, Head of Trauma Studies Unit, Institute of Psychiatry, King's College London Institute of Psychiatry, Box PO91, DeCrespigny Park, Denmark Hill, London SE5 8AF
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It appears that the issue of brief treatment needs to be clarified further so that this discussion does not go off the track. First of all, as I indicated in two previous letters (9 and 10 January, 2007), it is important to make a distinction between traditional cognitive-behavioural treatment (CBT) and control-focused behavioural treatment (BT). The two are quite different in their theoretical and practical aspects. It is well known that a substantial proportion of people exposed to a trauma recovers from the psychological impact of the event and do not develop chronic stress problems. How they recover is an issue that is not adequately investigated. In our fieldwork with torture, war, and natural disaster survivors, we had an opportunity to observe some of the factors associated with natural recovery processes in survivors. A commonly used strategy was to overcome fear (and related traumatic stress problems) by confronting situations that evoke trauma-related distress and fear. For example, we have seen torture survivors who made a point of going to the local police station with an excuse, just to spend some time there chatting with the police officers so that they could overcome their (conditioned) fear of police officers and police stations. Some survivors who were arrested during a political demonstration later made a point of participating in such demonstrations for the same purpose. This is similar to the behaviour of some road traffic accident survivors who get on the road and start driving again at the earliest opportunity so that they do not allow fear to take control over their lives. Similarly, many earthquake survivors, who had taken refuge in survivor shelters because of fear of further earthquakes, eventually started entering concrete buildings, often in a systematic and graduated fashion (in pretty much the same way it would be prescribed by a behaviour therapist), just to overcome their fear and normalise their lives. Many similar examples can be given for war survivors. The common element in such coping behaviours is to overcome pervasive conditioned fear and related helplessness responses (which our work shows to be the mediating factor in PTSD). We actually followed up such cases in our fieldwork (without any interference) and observed them recover from traumatic stress without any external help. Such coping behaviours might well be an evolutionarily determined response to life-threatening events, which naturally evoke intense fear and lead to extensive conditioned fear and avoidance responses. Such responses can become incompatible with survival (interfering with functioning in all aspects of life) and thus eventually need to be countered by risk-taking behaviours (e.g. confronting situations perceived as dangerous). Control-focused BT is based on such naturalistic observations. It is designed to mobilise, facilitate, and reinforce natural coping processes. Some survivors are unable to utilize their naturally existing capacity to overcome fear, mainly because of overwhelming feelings of helplessness. The therapist simply removes this obstacle by conveying a sense of control, instilling hope, courage, and self-confidence in the person. Our work has shown that 90% of survivors comply with instructions for self- exposure, because they can intuitively relate to the rationale of the treatment. When the treatment involves multiple sessions, improvement takes about 3 months to reach a maximum.1 When it involves a single session, this process takes about 6 months.2 When the intervention also involves one session of therapist-guided live exposure to fear cues, treatment effects are 20% stronger.3 In the latter case, the effect of treatment on trauma-related distress and fear (and sense of control) is quite rapid, dramatic, and observable immediately after the session. Even then, however, it takes about 3 months for such treatment impact to generalise to PTSD, depression, and work, social, and family disability. Thus, it is important to understand that a single-session treatment is not a magic wand that makes the problem disappear in one swing. Improvement depends largely on the personal efforts of the person after the session. This is why control-focused BT is largely a self-help intervention. It is also important to remember that a single-session intervention was developed as a means of cost-effective treatment delivery after major disasters affecting millions of people. It is not yet clear whether torture survivors would respond to a single session but future research might well show that a few (if not a single) sessions is sufficient. The fact that much of the improvement achieved by a full-course (e.g. 10 sessions) BT programme occurs during the first few weeks of treatment supports this point. In any event, even a 10-session BT is brief, relative to lengthy rehabilitation programmes that take 9 months or more (and with no demonstrable effects). More importantly, such lengthy programmes, particularly when they do not mobilise or reinforce the survivors’ own natural capacity in dealing with traumatic stress, may achieve not much more than reinforcing a helpless ‘victim’ role. To appreciate the relevance of our recent treatment studies to torture survivors, it is important to have an adequate understanding of the mechanisms by which human beings develop anxiety and fear responses and how these mechanisms apply to all anxiety disorders, including posttraumatic stress. In this connection, I would recommend a recent paper by Mineka and Zinbarg4 to those who might be thinking of putting up the same argument regarding torture trauma being different. Western mental health professionals concerned with torture survivors also need to remember that they see only a small minority of such cases in the world. The majority of survivors of torture (or other traumas, for that matter) are left to their own devices in coping with traumatic stress. This indeed explains why we found (moderately severe) PTSD in only 18% of severely tortured political activists4 and that a high level of psychological preparedness (a measure of sense of control) was the primary factor in recovery.5 The challenging question to tackle here is: how do these survivors recover without the kind of ‘sophisticated’ rehabilitation programmes available in western countries, despite continued threat of re- arrest, torture, and even death? It is interesting to see such strong opposition to the idea of brief treatment for torture survivors, which I am sure is shared by many in the field. The irony is that I had met with similar opposition, criticism, and anger (and even insults) from various colleagues when I first introduced the idea of single-session treatment in earthquake survivors after the 1999 disaster in Turkey. History has certainly a way of repeating itself! References: 1. Basoglu M, Livanou M, Salcioglu E, Kalender D (2003). A brief behavioural treatment of chronic post-traumatic stress disorder in earthquake survivors: Results from an open clinical trial. Psychol Med, 33(4), 647-654. 2. Basoglu M, Salcioglu E, Livanou M, Kalender D, Acar G. Single- session behavioral treatment of earthquake-related posttraumatic stress disorder: a randomized waiting list controlled trial. J Trauma Stress 2005; 18:1-11. 3. Basoglu M, Salcioglu E, Livanou M. A randomized controlled study of single-session behavioral treatment of earthquake-related posttraumatic stress disorder using an earthquake simulator. Psychol Med 2007; 37(2): 203-214. 4. Basoglu M, Paker M, Paker Ö, Özmen E, Marks IM, Incesu C, Sahin D, Sarimurat N. A comparison of tortured with matched non-tortured political activists in Turkey. Am J Psychiatry, 1994; 151:76-81. 5. Basoglu M, Mineka S, Paker M, Aker T, Livanou M, Gök S.Psychological preparedness for trauma as a protective factor in survivors of torture. Psychol Med 1997; 27:1421-1433. 6. Mineka S, Zinbarg R. A contemporary learning theory perspective on the etiology of anxiety disorders – It is not what you thought it was. Am Psychol 2006; 61(1): 10-26. Competing interests: None declared |
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Ariel Eytan, MD Department of Psychiatry, University hospital of Geneva, 1211 Geneva 24. Switzerland, Jessica M. Carlsson, MD, PhD, Rehabilitation and Research Centre for Torture Victims, Copenhagen, Denmark
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Following his recent BMJ editorial, a debate engaged between Basoglu and other authors taking care of traumatized refugees. Basically, the question is: can brief interventions for torture survivors (such as CBT) be efficient or not? Our study 1., reporting no improvement in post-traumatic stress disorder, depression, anxiety, or health-related quality of life after nine months' treatment at the Rehabilitation and Research Centre for Torture Victims in Denmark was quoted by both Basoglu 2. and by Selzer in her rapid response and thus fed the polemic. In another study 3., we found a positive association between length of stay in country of asylum and poor mental health among Kosovar returnees from Switzerland. More specifically, duration of stay longer than 26 weeks was associated with lower mental health scores, particularly among people with PTSD. Consequently, our experience indicates that there is indeed no “quick fix” for such serious mental health problems. However, we argue that, given the current political context in most West European countries (including Denmark and Switzerland), health professionals may be reluctant to admit and publish negative results regarding outcomes of PTSD treatment among refugees by fear of “undesirable side effects” or unethical consequences. This ethical dilemma was present when we published our research: with the Danish study, the risk was to see the absence of clinical improvement interpreted, although this was not a treatment effect study, as a justification for reducing refugees’ mental health care services. Similarly, the risk with the results of the Swiss survey was to provide the Swiss government with arguments for sending asylum seekers back to their home country more rapidly. We firmly believe that such concerns should not lead us to self- censorship, nor to stop us from trying to study the efficiency of different treatment modalities, but rather to a more thorough discussion about the complexity of treating traumatized refugees, without neglecting the ethical implications of such difficulties. 1.Carlsson JM, Mortensen EL, Kastrup M. A follow-up study of mental health and health-related quality of life in tortured refugees in multidisciplinary treatment. J Nerv Ment Dis 2005;193:651-7. 2.Basoglu M. Rehabilitation of traumatised refugees and survivors of torture. BMJ 2006; 333: 1230-1231. 3.Toscani L, Deroo LA, Eytan A, Gex-Fabry M, Avramovski V, Loutan L, Bovier P. Health status of returnees to Kosovo: Do living conditions during asylum make a difference? Public Health. 2007 Jan;121(1):34-44. Epub 2006 Dec 19. Competing interests: None declared |
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Metin Basoglu, Head of Trauma Studies Unit, Institute of Psychiatry, King's College London Institute of Psychiatry, Box PO91, DeCrespigny Park, Denmark Hill, London SE5 8AF
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First of all, I would like to congratulate Carlsson and her associates for their courage in conducting their study1 and publishing the results. In my view, they have done a great service to this field. Such work indeed takes courage, not only because of the potential problems mentioned in Eytan and Carlsson’s letter (BMJ, 15 January 2007), but also because of the (potentially embarrassing) risk of not being able to demonstrate any positive outcomes of a rehabilitation model that has been in existence and consumed so much resources for 30 years. I completely agree with them that there should be more studies of this kind. Moreover, as I noted in my editorial, funding of these programmes should be conditional on the results of such studies. Self-censorship would achieve nothing more than perpetuating the problem. If studies of the kind Carlsson et al published had been conducted 20 years ago, we might not have been discussing this problem now. As I have repeatedly emphasised in the correspondence following my editorial, we are now at a stage where we can at least consider treating torture survivors more effectively. Available evidence certainly warrants controlled studies of interventions with potential efficacy. Leading groups in the field, such as the Rehabilitation Centre for Torture Victims (RCT) in Denmark have the necessary means to undertake such studies. If their rehabilitation model does not achieve any positive psychological outcomes, then it is difficult to see the rationale of establishing more than 100 similar programmes throughout the world. Advocacy alone may not justify their existence, if they also claim to be a “rehabilitation centre for torture victims.” In anticipation of ethical objections to this suggestion, I should note that controlled studies need not necessarily raise any ethical issues. Given that the RCT model is not demonstrated to be effective, there cannot be an ethical question of withholding effective treatment from survivors (with the exception of treatment for physical sequelae of torture, of course). In any case, it is possible to allocate survivors randomly to two groups, both receiving the usual ‘multi-disciplinary approach’ (e.g. an ineffective condition), while only one receiving active treatment (e.g. an alternative evidence-based intervention). If active treatment is found to be effective, then the other group could be crossed- over (e.g. after 3 months) to receive the same treatment. Then both groups could be followed up for 1 year or more to examine long-term outcome. Furthermore, an open trial involving multidisciplinary approach plus alternative active treatment (with flexible treatment duration) could be conducted to examine the minimum number of sessions required for significant improvement. Such a study would reveal the optimum number of sessions and time required for improvement. Until such studies are conducted there is no point in talking further about the difficulties in treating torture trauma or whether brief treatment is possible or not (regarding the issue of “quick fix” see my letter of 14 January 2007). The ethical issues alluded to in Eytan and Carlsson’s letter are unfortunately a direct result of using ineffective rehabilitation models for survivors. If the rehabilitation centres cannot demonstrate the usefulness of their work, then this will of course play into the hands of governments that are eager to promote unfavourable refugee policies. Where does the responsibility lie: the governments or rehabilitation centres or both? References: 1. Carlsson JM, Mortensen EL, Kastrup M. A follow-up study of mental health and health-related quality of life in tortured refugees in multidisciplinary treatment. J Nerv Ment Dis 2005;193:651-7. Competing interests: None declared |
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Bengt H. Sjölund, Professor of Rehabilitation, Director General RCT, Rehabilitation and Research Centre for Torture Victims, PO Box 2107 , DK-1014 Copenhagen K, Den
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RE Rehabilitation of traumatised refugees and survivors of torture/Hiding the truth and ethics – Are they compatible? I thank Dr Basoglu for endorsing the decision taken in our organization in 2000 to conduct the follow-up study igniting the present debate (1) with my predecessor, Dr Marianne Kastrup, as one of the senior authors. As Dr Carlsson already pointed out, it is a follow up study, not a controlled trial, and therefore, firm conclusions about the treatment effects cannot be drawn as easily as done by Dr Basoglu. However, I fully agree with the need for controlled studies (e g 2) and for evidence-based interventions in rehabilitation of torture survivors. But when conducting such studies, especially among torture survivors with long standing problems like those of our patients, it is important to consider the domains of the outcome measures employed (with a program aimed at increasing activity and participation, assessments of changes in anxiety or in mood do not give the whole answer). At RCT, we are therefore currently implementing the ICF concept (WHO; 3) to routinely assess outcomes not only at the body function level but also at individual and contextual levels. The core matter concerns the content of the rehabilitation program in relation to the problems of our patients. Since 2006, our programs have an increased focus on CBT, have been shortened and use an interdisciplinary approach. Another recent study from our centre by Reff-Olsen et al. (4) points out that almost all patients referred to RCT suffer from chronic pain, not only from PTSD-like or DESNOS conditions. The pain characteristics speak firmly against it being mainly of psychogenic origin. Hence, we have additionally included evidence based components for rehabilitation of patients disabled by chronic pain (e g 5) in the programs at RCT. It is our assumption that the outlined measures at RCT will contribute to a more effective rehabilitation of torture survivors with chronic problems and we hope to demonstrate the results in scientific studies in the years to come. I welcome the participation of Dr Basoglu and others in this work, not only for persons with post-acute but also for those with longstanding problems related to the exposure to torture. References 1. Carlsson JM, Mortensen EL, Kastrup M. A follow-up study of mental health and health-related quality of life in tortured refugees in multidisciplinary treatment. J Nerv Ment Dis 2005;193:651-657. 2. Hinton D., Chhean D., Pich V., Safren S., Hofman S., Pollack M. A randomized controlled trial of cognitive-behavior therapy for cambodian refugees with treatment-resistant PTSD and panic-attacks: a cross-over design. Journal of Traumatic Stress 18, 617-629, 2005 3. WHO: International Classification of Functioning, Disability and Health. Geneva 2001, pp 1–299. 4. Olsen DR, Montgomery E, Bojholm S, Foldspang A. Prevalent musculoskeletal pain as a correlate of previous exposure to torture. Scand J Public Health. 2006;34:496-503. 5. Morley S, Eccleston C, Williams A. Systematic review and meta- analysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain 1999:80:1-13. Competing interests: None declared |
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Metin Basoglu, Head of Trauma Studies Unit, Institute of Psychiatry, King's College London Institute of Psychiatry, Box PO91, DeCrespigny Park, Denmark Hill, London SE5 8AF
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It is encouraging to hear that the Rehabilitation Centre for Torture Victims (RCT) has now adopted an evidence-based approach in their work. I will wait in hope for the outcome of their scientific studies in the future. I do hope they choose their outcome measures carefully, based on an evidence-based theoretical formulation of torture trauma, before embarking on a long journey of scientific research. They will need to clarify, specify, and operationalise constructs, such as ‘increasing activity and participation,’ ‘body function level’ or ‘outcomes …at individual and contextual levels’) and empirically validate their connection with torture trauma and related stressors. A long journey indeed! To clarify one point, I do not see why conclusions cannot be drawn from an uncontrolled study when it is reporting negative results. Its uncontrolled design would have been a problem if it had reported positive outcomes, in which case we would not have been certain as to whether the improvement is attributable to the treatment or non-specific effects of time and therapist contact or merely placebo effects of treatment. Unless there is a compelling reason to think that survivors who do not get treatment from the RCT get worse over time, we can conclude fairly safely that the treated cases have not shown any significant improvement from pre - to post-treatment. With regard to Sjölund’s comment (BMJ, 19 January 2007) about my participation in scientific research in this field, I should note that I have always been willing to contribute to the RCT’s work. I have even taken the initiative in the 1990s to offer them collaboration in a long- term extensive research programme involving a series of projects designed to explore the mental health effects of torture, related factors, mechanisms of traumatic stress, and effective methods of treating torture survivors. We even convened a consortium of researchers in this area and held meetings at the RCT to discuss the details of this programme. I also visited the RCT on other occasions (or sent my team) to give them information about our work on treatment of torture survivors. Unfortunately, however, such collaboration never materialised, mainly because of two factors: (a) resistance to novel approaches in treatment (at least in some staff members) and (b) a view of research as a low priority issue, almost as something that can be done on the side in one’s spare time. Research is a serious and costly business, requiring substantial amount of expertise, effort, time, and funding. The RCT at the time was not prepared to make such an investment and thus the idea of collaboration quickly fizzled out. Their rehabilitation programme might have been quite different now if such collaborative work had taken place. This story is of course more than 15 years old now and the ‘new’ RCT might perhaps have a different view of things. I do hope past mistakes are not repeated and scientific research is given the attention and emphasis it deserves in the rehabilitation programmes they have established. Competing interests: None declared |
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Thomas Wenzel, Prof. Chair, WPA Section on Section on Psychological Consequences of Torture CRISE/UQAM, 305 rue Christin,Montréal, Québec, H2X 1M5, Canada
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I am very grateful to Metin Basoglu to have started this very important and stimulating discussion hosted by the BMJ, which I belief is important to the further development of services, especially as it raises the question of how homogenous torture, survivors, and applied rehabilitation or treatment strategies are- and if generalisations are possible. Obviously sequels are not limited to Posttraumatic Stress Disorder alone, but can include a large range of reactions, or symptoms of disorders already described - though probably not completely covered - by the ICD 10 and other standards (1). The issue of impact in the psychosocial network have been noted above. Co-morbidity appears to be common, complicating treatment, and must therefore must be taken seriously, as for example reports on suicidality (2)) and high rates of mood disorders (3,4)- have demonstrated. Focusing solely on PTSD and its treatment therefore is not an option, as suicide or similar clinical problems like the probably under diagnosed brain trauma (5) or culture specific reactions should receive adequate attention This issue was obviously not put in question by Basoglu’s comments, but should be stressed. Heterogeneity applies also to who is submitted to torture, and what he experiences in torture. While torture is targeted in some countries mainly at political activists, that could be seen as a very specific group, the use of torture is indiscriminate and common against many groups in the population in other countries (6), and duration of detention and forms of torture applied vary greatly, as do potentially other traumatic experiences related to persecution independent from torture. Torture survivors in consequence are a very heterogeneous population, in regard to all aspects such as pre-torture stress and exposure, torture, general stress, post-trauma conditions, and sequels. A highly relevant question in this context is also the question if approaches that have been proven to be effective in other patients with the same defined disorder- such as PTSD and mood disorders – must again be proven to be effective in survivors of torture, which is partly implied in the above discussion. While torture trauma might not be different from other trauma, culture and specific experiences in different places where torture takes place might be considered in any form of Psychotherapy. While an earlier discussion postulating a specific “torture” syndrome has been largely abandoned, most authors agree that torture survivors must be treated as potentially, but not necessarily highly vulnerable and with special care, which also certainly does not lead to the conclusion that all survivors must be chronically disabled. It is also important, as noted by several commentators, that service capacities are usually not available in sufficient number even in relatively “rich” countries, such as the UK and that the situation might be much worse in regions with high morbidity and a complete lack of resources as Sudan or Afghanistan. Alleviation and effective approaches with proven transcultural applicability would therefore be extremely important, but require further careful research, though the usual care in treating a person as a being with complex needs and individuality should remain the target standard. To clarify one misunderstanding that might be implied by Basoglu’s last comment: The Rehabilitation Council for Torture Survivors (RCT) (see http://www.rct.dk is a rehabilitation centre based in Denmark, and a member of the international umbrella organisation of centres, the International Rehabilitation Council for Torture Survivors (IRCT, see www.irct.org). While RCT is pioneering important research in several areas related to torture with a limited group of collaborating centres, it is not “establishing more than 100 similar programmes” worldwide, based on the generalisation of a simple model. The IRCT, with a common office in Copenhagen, has indeed more then 100 member centres, but is an umbrella organisation of equal members, most of which have been established by dedicated and often very courageous local initiatives developing their own programs. Umbrella organisations such as the WMA or IRCT are not primarily research organisations, but have mainly other tasks, which does not at all indicate that research in the centres is not taken seriously, or that centres are all based on the same model. After having visited and collaborated with many of the centres for years, I am in fact impressed by the range of very different problems faced and solutions found, and by the research projects developed. It is to be hoped that Basoglus adaptation of CBT (7) can become an important “brick” in the many different “houses” of rehabilitation programmes for torture survivors, if used with care. 1. World Health Organization, International Statistical Classification of Diseases and Health Related Problems, ICD-10, Second Edition, WHO, 2004. 2. Ferrada-Noli M, Asberg M, Ormstad K. Suicidal behavior after severe trauma. Part 2: The association between methods of torture and of suicidal ideation in posttraumatic stress disorder. J Trauma Stress 1998; 11(1):113-124. 3. Ekblad S, Prochazka H, Roth G. Psychological impact of torture: a 3-month follow-up of mass-evacuated Kosovan adults in Sweden. Lessons learnt for prevention. Acta Psychiatr Scand Suppl 2002;(412):30-36. 4. Wenzel T, Griengl H, Stompe T, Mirzaei S, Kieffer W. Psychological disorders in survivors of torture: exhaustion, impairment and depression. Psychopathology 2000; 33(6):292-296. 5. Weinstein CS, Fucetola R, Mollica R. Neuropsychological issues in the assessment of refugees and victims of mass violence. Neuropsychol Rev 2001; 11(3):131-141. 6. Amnesty International, Torture Worldwide: An Affront to Human Dignity. Amnesty International, 2000. 7. Basoglu M, Livanou M, Salcioglu E, Kalender D. A brief behavioural treatment of chronic post-traumatic stress disorder in earthquake survivors: Results from an open clinical trial. Psychol Med, 2003, 33(4), 647-654. Competing interests: None declared |
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Metin Basoglu, Head of Trauma Studies Unit, Institute of Psychiatry, King's College London Institute of Psychiatry, Box PO91, DeCrespigny Park, Denmark Hill, London SE5 8AF
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Many of the points raised in Wenzel’s letter (BMJ, 21 January 2007) about torture being a different and complex trauma were dealt with in my previous letters so I will not repeat them here. Available evidence does not support this position and no one participating in this discussion has yet come up with any evidence to the contrary. As to the relative importance of posttraumatic stress disorder (PTSD) with respect to other psychiatric problems, it might be worth presenting some data from our studies. Using the Structured Clinical Interview for DSM-IV1 (SCID) we examined the whole range of psychiatric disorders in war, torture, and earthquake survivors. Below is a summary of some of the results. In our study2 of 230 torture survivors in former Yugoslavia countries, the rates of SCID diagnoses were as follows: current PTSD 55.7%, current depression 17%, anxiety disorders 14.8%, drug / alcohol abuse or dependence 9.6%, mood disorders 8.2%, somatoform disorders 2.2%, eating disorders 1.3%, minor depressive disorder / mixed anxiety –depressive disorder 1.8%. Note that most of these cases also had additional exposure to a wide range of war stressors, such as active combat, forced displacement, refugee experience, aerial bombardment, etc. This response pattern also applied to other non-tortured war survivors. The respective findings from another study3 of 55 (highly resilient) tortured political activists were: current PTSD 18%, current depression 4%, dysthymia 4%, bipolar affective disorder 5%, panic disorder 2%, social phobia 2%, specific phobia 7%, obsessive-compulsive disorder 5%, generalized anxiety disorder 7%, and adjustment disorder 2%. The findings from our study4 of 387 earthquake survivors were: current PTSD 41.3%, anxiety disorders 36.2%, current depression 31.5%, somatoform disorders 9%, mood disorders 5.2%, adjustment disorder 4.1%, drug / alcohol abuse or dependence 3.9%, and eating disorders 0.3%. This study involved 199 treatment seeking and 188 non-treatment-seeking survivors, the two groups differing only in the prevalence of these conditions and not in their response patterns. Note that the outcome patterns are by and large similar across all groups. The three most common psychiatric conditions after war, torture, and natural disaster are PTSD, depression, and anxiety disorders. The rates of PTSD are an underestimation of traumatic stress problems, because they exclude many cases that do not meet the criteria for PTSD but nevertheless have many PTSD symptoms or sub-threshold PTSD (similarly for depression and anxiety disorders). As noted in an earlier letter (BMJ, 10 January 2007) the cognitive and emotional response profiles were also very similar across war, torture and earthquake survivors. The fact that torture survivors are ‘heterogenous’ in their traumatic experiences does not mean much. So were the survivors in our studies (information captured by a structured Exposure to Torture Scale). The important issue is how these stressors exert their impact and what type of mental health problems they cause. The above figures reflect the CUMULATIVE impact of a wide range of traumatic stressors. Traumatic stress might not only lead to various conditions that did not exist before the trauma (e.g. PTSD, depression, anxiety disorders) but also exacerbate previously existing ones. Thus, whatever the outcome might be, traumatic stress is by definition the principal causal and mediating factor. Our work also shows that the three most common conditions of PTSD, depression, and anxiety disorder share the same psychological mechanisms (i.e. loss of control). When I talk about behavioural approach to torture-related problems, the most common objection is “yes but PTSD is only one of the many outcomes of torture.” This reflects a lack of understanding of mechanisms of traumatic stress and how the latter relates to various psychiatric (and even certain medical) conditions. (This is why I made a distinction between traumatic stress and PTSD in my BMJ letter of 10 January 2007). It also reflects a misconception about behavioural treatment. Control-focused behavioural interventions ultimately target all torture-related psychological problems by targeting and reversing the traumatic stress processes that lead to these problems in the first place (only one of which is PTSD). Thus, one would expect an improvement in not only PTSD but also depression, anxiety disorders, behavioural disturbances, suicidal tendencies, drug / alcohol abuse, psychosomatic problems (e.g. pain, among others), or any other psychiatric or medical condition that is mediated by traumatic stress. Data from our treatment studies support this hypothesis. For example, depression improves alongside PTSD, without any additional intervention, simply because it reflects the helplessness and hopelessness effects of trauma (and perhaps to some extent also the secondary helplessness effects of PTSD symptoms). We have seen obsessive-compulsive disorder and panic disorder (precipitated by the trauma) improving with reduction in traumatic stress and WITHOUT a behavioural intervention specifically targeting these conditions. We have even seen various psychosomatic skin reactions improving with treatment. Furthermore, all psychiatric conditions listed above can also be DIRECTLY targeted with behavioural interventions. The three most common conditions, PTSD, depression, and anxiety disorders are particularly responsive to such treatment, as evidence shows. Once a rehabilitation programme is reconceptualised and reformulated along behavioural lines (as discussed in my letter of 6 January 2007), all of its components become in essence behavioural interventions. Recall the example I gave regarding the use of physiotherapy as a behavioural technique in that letter. One can formulate and implement even social support as a means of enhancing sense of control over various traumatic and other ordinary psychosocial stressors and reducing helplessness associated with them. Without such a formulation, indiscriminate social support might simply make a survivor dependent on it and reinforce his / her helplessness. Thus, a behavioural approach to the problem is not merely an important “brick” in the “house” of rehabilitation programmes. It needs to be the entire “supporting structure,” including its “foundation,” determining the shape, size, and colour of every other component of the house. The rehabilitation centres supported by the International Rehabilitation Council for Torture Victims (IRCT) might have some variations in their modus operandi and without doubt involve courageous and dedicated people. Whatever the inner workings of the IRCT and the Rehabilitation Centre for Torture Victims (RCT) might be, the fact remains that more than 100 centre around the world are largely modelled after the RCT in their so-called multi-disciplinary approach and indeed quite understandably so, given that the RCT did the standard-setting work in this field. I have also visited over the years quite a few of those centres and, though admiring their courage and dedication, I must admit the standard of their (psychological) treatment work left much to be desired. If research had been given the proper attention it required, we would have seen published evidence on the outcome of their work and an improvement in their standard over the years. Wenzel’s comment about the IRCT not being a primarily research organisation unfortunately sounds to me not much more than an apologetic excuse for the present state of affairs. If the IRCT has set out to spearhead rehabilitation work in the field, supporting the establishment of rehabilitation centres around the world and setting an example for them, then they also have a responsibility to find out what effective rehabilitation is about. Such knowledge, unfortunately, does not all of a sudden drop from the sky or one does not wake up with it one morning. I have argued endlessly over the years (indeed at the expense of making myself quite unpopular in the field) that this calls for proper systematic research. (Nevertheless, it took the RCT 30 years to come up with the outcome data reported by Carlsson et al5). If the IRCT (or the RCT) prefers to define its function as mainly advocacy, then they should replace the word “rehabilitation” in their title with “advocacy” and limit their work to the latter. I would then take my hat off to them and become the most ardent supporter of their work. If the IRCT or the RCT are taking research seriously, as Wenzel seems to contend, then we should see the evidence for it. After all, to cite another English saying, the proof of the pudding is in the eating! In my view, as a matter of priority, the RCT needs to (a) reformulate its rehabilitation programme fairly radically (rather than merely 'increasing focus on CBT' in the same existing structure - as noted by Sjölund, BMJ, 17 January 2007 - which may not be enough), adopting an evidence-based approach in both theory and practice, (b) undertake the 8-step research programme outlined in my BMJ letter of the 12th of January 2007, (c) launch a controlled study with sound methodology, and (d) publish the results in a peer reviewed respectable journal to prove to the world that their rehabilitation model works. Until then, sorry, no apologetic excuses accepted! References: 1. First MB, Spitzer RL, Gibbon M, Williams JBW. Structured clinical interview for DSM-IV axis I disorders - Non-patient ed. (SCID-I/NP, Version 2). New York: Biometrics Research Department, New York State Psychiatric Institute, 1996. 2. Basoglu M, Livanou M, Crnobaric C, Franciskovic T, Suljic E, Duric D, et al. Psychiatric and cognitive effects of war in former Yugoslavia - The relationship between lack of redress for trauma and posttraumatic stress reactions. JAMA 2005; 294:580–590. 3. Basoglu M, Paker M, Paker Ö, Özmen E, Marks IM, Incesu C, Sahin D, Sarimurat N. A comparison of tortured with matched non-tortured political activists in Turkey. Am J Psychiatry, 1994; 151:76-81. 4. Salcioglu E. The effect of beliefs, attribution of responsibility, redress and compensation on posttraumatic stress disorder in earthquake survivors in Turkey. PhD thesis. University of London, 2004. 5. Carlsson JM, Mortensen EL, Kastrup M. A follow-up study of mental health and health-related quality of life in tortured refugees in multidisciplinary treatment. J Nerv Ment Dis 2005;193:651-7. Competing interests: None declared |
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James M Jaranson, Psychiatrist 1950 Upas St.,, #405, San Diego, CA 92104, Uwe Jacobs, PhD, J David Kinzie, MD, Jose Quiroga, MD
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As health professionals with extensive experience treating torture survivors, we would like to respond to the editorial by Dr. Metin Basoglu in the BMJ 2006;333:1230-1. We agree with Basoglu’s assertion that it is important to identify common factors in the development of trauma symptoms and treatment and that the knowledge accumulated by researchers should be disseminated to clinicians who help survivors. For example, the proper understanding of fear and loss of control as powerful determinants is such knowledge, and we readily agree that more is needed. Dissemination of research results to mental health clinicians and implementation of research into practice is often lacking. The observation that evidence-based treatments are not used as frequently as desirable is true for mental health treatment in general and is not specific to the treatment of torture victims. Moreover, evidence-based treatments exist only for isolated symptom clusters rather than for the complex problems that often result from persecution and torture. For example, an elderly refugee who was tortured and is also widowed, uprooted, does not speak the language of the host country, and has lost multiple family members, suffered a head injury, and has serious depression//PTSD requires something much more than brief exposure. As health professionals we cannot depend entirely upon evidence-based treatments and ignore our clinical skills and relationship with the patient.(1) One cannot also expect the poorly funded area of torture rehabilitation to do better than general mental health practice and suggest that the situation will improve by dismissing all other forms of treatment besides cognitive behavioural therapy (CBT). We agree with Basoglu that there has been a tendency in some quarters to resist innovation and to dismiss sound approaches as “medicalising.” However, one must recognize that rehabilitation of torture survivors is not equivalent to treating PTSD or depression. A brief course of exposure treatment for PTSD in a conflict zone does not work as effectively as might a course of antibiotics for cholera. Partly due to the fact that CBT is more readily accessible to scientific study than many other approaches, there is better evidence for its effectiveness. This does not mean that other approaches are necessarily ineffective. Throughout the world, patients receive differing psychological treatments for all kinds of conditions. In many settings, practitioners offer help to torture survivors for little or no compensation. If practitioners’ training and practice is not CBT, should we discourage them from continuing with their work? We believe that disseminating knowledge and offering additional training is more desirable than limiting practice to a single modality. We share the desire for more outcome research in torture rehabilitation.(2) In the US we participated in a task force of senior clinicians funded by the Langeloth Foundation to recommend outcome evaluation approaches for torture rehabilitation programmes. We concluded that not only are there serious methodological difficulties to consider, but that we must first avoid errors of categorization. The category of torture survivors is extremely diverse and not homogeneous. To say that treatment for the consequences of torture ought to be CBT is akin to prescribing treatment for a group of patients defined by their experiences rather than by their particular diseases, conditions, or symptoms. Outcome studies as traditionally conceived require homogeneous populations and control groups. These conditions cannot typically be met in psychological outcome studies, even in situations with well-defined populations, minimal confounding factors, etc. Torture survivors are not homogeneous nor is it ethically appropriate to put them in a control group, even if that were feasible. There are places in the world where torture victims are never seen with the acute signs and symptoms of PTSD but only with the late signs and chronic symptoms remaining after a long period of emigration and exile. Often torture victims are not interested in therapy of any kind and will not accept psychological treatment, be it CBT or any other form of therapy. Rehabilitation centers for torture victims typically offer multi- modal approaches that aim to improve the lives of torture survivors in many ways, including obtaining political asylum protection, employment, general medical care, housing and much more. Hence, there are very powerful confounding factors that cannot be separated from specialized psychological treatment. The single focus on specific psychological symptoms recommended by Basoglu is most applicable in situations where people who have similar characteristics were subjected to a common and limited traumatic stressor, such as an earthquake. Torture survivors do not usually fall into this category. The sadistic interpersonal violence experienced by many torture survivors destroys fundamental trust in other human beings, raises deeply disturbing existential questions, and results in despair that cannot be compared with the consequences of natural disasters. Often torture occurs in the context of genocide, and we do not believe that it would be appropriate to offer a brief course of exposure treatment to these survivors. We frequently find that survivors of genocide have long-term sequelae often called Complex PTSD,(3) as well as exacerbations of depression and PTSD symptoms, requiring a long-term commitment to treatment.(4,5) It is possible that clinicians treating torture survivors avoid brief treatments out of sensitivity to the enormity of survivors’ experiences and the resulting consequences. Measurement of outcome in torture rehabilitation must occur, but it would be erroneous to focus narrowly on studying psychological treatment. The consensus among our study group was that, given the heterogeneity of torture survivors treated in rehabilitation programmes and all the confounding factors, beginning this research with measures of overall rehabilitation outcome rather than of psychological treatment is more promising. (1) Kinzie JD. Psychotherapy for massively traumatized refugees: The therapist variable. Amer J Psychotherapy 2001;55:474-90. (2) Quiroga J, Jaranson, JM. Politically-motivated torture and its survivors: A desk study review of the literature. Torture 2005;15(2-3):1-111. (3) Herman JL. Trauma and Recovery. New York: Basic Books, 1992. (4) Boehnlien JK, Kinzie JD, Sekiya,U, Riley C, Pou K, Rosborough B. A ten-year treatment outcome study of traumatized Cambodian refugees. J Nerv Ment Dis 2004;192:658-63. (5) Kinzie JD. PTSD and traumatized refugees. In: Kirmayer L, Lemelson R and Barad M, eds. Understanding Trauma: Integrating Biological Clinical, and Cultural Perspectives. New York: Cambridge University Press, 2007. Competing interests: None declared |
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Metin Basoglu, Head of Trauma Studies Unit, Institute of Psychiatry, King's College London Institute of Psychiatry, Box PO91, DeCrespigny Park, Denmark Hill, London SE5 8AF
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I have addressed almost every point raised by Jaranson et al several times in previous correspondence so I will not repeat myself again. A distinct pattern of arguments has emerged throughout this discussion. Most participants appear to converge on the same self-fulfilling prophecy: torture trauma is different, more difficult to treat, and therefore requires lengthy rehabilitation. Not only they have merely stated personal opinions not substantiated by any evidence but they also appear to be resistant to and dismissive of contrary evidence. After having taken the trouble of 20 years of research in this field just so that I am able to qualify any statement that I may want to make on these issues, I must admit I find this rather frustrating. Such is the nature of the problem in this field. I will leave it to BMJ readers to judge for themselves the likely reasons for such resistance. Competing interests: None declared |
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Peter Berliner, Associate Professor, Head of the University of Copenhagen Centre for International Traumatic Stress University of Copehagen, 22 Linnesgade, DK-1361 Copenhagen K, Denmark, Stine Amris, MD, Specialist in Internal Medicine and Rheumatology, and Julio Arenas, Psychologist, University of Copenhagen
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Over the years it has become incumbent on health care providers to provide evidence supporting the effectiveness of their treatment. Thus, we welcome the debate on the lack of outcome research within the field of rehabilitation of torture survivors. And we fully agree with Basoglu that there is an urgent need for the advancement of evidence based practice, which is based on a theoretical framework which has a sound theoretical rationale to ensure quality assured rehabilitation services. In spite of significant available funding for decades here in Denmark and the strong potential for a link between research and clinical practice at Rehabilitation Treatment Centres claiming to be at the vanguard of rehabilitation work, attention to the systematic description and evaluation of practice have not been prioritized. On the contrary, rehabilitation has been prone to the vagaries of eclecticism in clinical practice. There has been no consensus on measurable outcome indicators or conceptual basis for multidisciplinary approaches to the therapy and rehabilitation of torture survivors. Basoglu’s recent observations and comments have been both needed as well as timely because a similar – both in the public domain and later in the academic sphere - debate to the one initiated by Basoglu emerged last year in Denmark (informed primarily by the research of Basoglu 1 and Staub 2). Focal points in the discussion have been that (1) Danish Rehabilitation Centres specializing in therapy, rehabilitation and research have not been able to advance the development of theory and practice nor to provide the evidence-based practice information and (2) as of today, no clear and scientifically valid recommendations on the organization and functioning of rehabilitation services, and the interventions they offer in different socio-cultural contexts have been put forward. As a solution to this dearth of "state of the art" evidence based practice, the following actions are recommended: 1. National funding of research in this field is put out for tenders from academic institutions, agencies and Rehabilitation Treatment Centres, being subject to rigorous and robust peer review processes. So far standard practice is to give substantial funding automatically to the Rehabilitation Treatment Centres only. 2. Research should be conducted in collaboration with the above to ensure a coordinated knowledge base grounded in sound theoretical principles based on identified and prioritized need. 3. Global networks of therapy and rehabilitation centres, universities, other institutions and agencies are established as a base for the advancement of international evidence based practice. We welcome and support Basoglu’s commentary, adding the above recommendations as a means of ensuring that this important and neglected field of practice with a vulnerable, politically contentious population is subjected to the research recognition it warrants. References 1.Basoglu M, Salcioglu E, Livanou M, Kalender D, Acar G. Single- Session Behavioural Treatment of Earthquake-Related Posttraumatic Stress Disorder: A Randomized Waiting List Controlled Trial. J of Traumatic Stress, 2005; 18:1-11. 2. Staub E, Pearlman A L, Gubin A, Hagengimana A. (). Healing, reconciliation, forgiving and the prevention of violence after genocide or mass killing: an intervention and its experimental evaluation in Rwanda. Journal of Social and Clinical Psychology, 2005; 24: 297-334. Competing interests: None declared |
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Thomas Maier, MD, Assistant medical director Outpatient Clinic for Victims of War and Torture, Zurich University Hospital, CH-8091 Zurich
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With a mixture of bewilderment and amusement the unprejudiced reader may have followed the protracted debate raised by M Basoglu’s recent editorial in BMJ (1). It is easily identifiable, however, that the controversy is mainly fuelled by Basoglu himself, who is given vast opportunity to repeat his well known arguments several times. Most of the contributors obviously have not recognised the polemic and provocative intention of Basoglu’s assertions. One after the other willingly grabs for his decoys, just to be polished off in return by predictable arguments. As a consequence, there is no convergence of standpoints anymore in this debate and no constructive struggle for more clarity in a clinical problem. In times of evidence-based medicine it has become very easy to advance a position in a medical debate and to refute another. One has just to put forth his/her empirical evidence and then claim for the opponents’ evidence. Like in a boxing match, the points are added up finally and the one who scores more points is the winner, while the loser has to remain silent henceforth. Owing to this type of argument, more and more medical debates are in danger to degenerate into cockfights, especially when predominantly based on auto quotations (as subtly commented by Durieux- Paillard (2)). Medicine, however, is neither a boxing match nor a cockfight, less than ever when it comes to the treatment of chronic and complex disorders. In real medical practice, there is no high-quality evidence anyway for the majority of treatments and interventions. The reason for this lies in the fact that real medical problems are of necessity more complex than the ones amenable to statistical evaluation (3, auto quotation!). Fortunately many interventions and therapies lacking the consecrations of EBM are applied successfully millions of times all over the world. From a slightly distant position to this polemic debate it appears evident to me, that CBT (or control-focused BT) plays an extremely important role in the treatment of torture survivors. It is undisputed, that excellent results can be achieved even in such patients. On the other hand, it is equally evident to sensible clinicians, that there is only a rather small (positive) selection of torture survivors who can be significantly improved by just a few sessions of CBT. Many will need additional and continued treatment of various nature. Any kind of polemic like M Basoglu is igniting in this context seems inappropriate to me, because it distracts from the seriousness of the issue. I can’t help interpreting the ferocity of the controversy also from a psychological perspective (without empirical evidence): Both Basoglu and his opponents are obviously overwhelmed by the unsettling brutality and violence of torture as it is conveyed to therapists when treating torture survivors. In order to cope with this, some trauma therapists are warding off feelings of helplessness by making themselves believe that there is a quick and effective remedy to the devastating consequences of torture. Apparently also M Basoglu’s fervour in defending what he thinks is best for torture survivors is nourished by his worry and anger facing the reality of torture. Different therapists may alleviate their distressed minds by putting forward intensive long-term treatments. Anyway therapists should rather become aware of their feelings of helplessness and anger than acting them out in fruitless cantankerousness. To avoid misunderstandings: I greatly appreciate for a long time already M Basoglu’s important and excellent scientific contributions. They have helped us a lot to better understand the mechanisms of traumatisation (and of resiliency) in torture survivors. Yet I feel, that this debate is not really on an appropriate level of considerateness anymore. References: 1. Basoglu M. Rehabilitation of traumatised refugees and survivors of torture. BMJ 2006; 333: 1230-1231 2. Durieux-Paillard S. Re: Facts and myths about torture trauma – II. BMJ 13 January 2007 3. Maier T. Evidence based psychiatry: Understanding the limits of a method. J Eval Clin Pract 2006; 12(3): 325-329 Competing interests: None declared |
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Metin Basoglu, Head of Trauma Studies Unit, Institute of Psychiatry, King's College London Institute of Psychiatry, Box PO91, DeCrespigny Park, Denmark Hill, London SE5 8AF
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Berliner et al’s recommendations made me think that it is perhaps time to bring this discussion to a useful conclusion. I believe we have reached a point in this debate where not much more can be said before testing various hypotheses by further research. In my view this discussion has been useful on several accounts. Most importantly, it highlighted where we stand in rehabilitation of torture survivors after more than 30 years of work. This will hopefully be useful for independent observers, policy makers, funding bodies, and the public in general. While opinions diverged on treatment issues, at least we seemed to agree on the need for an evidence-based approach in rehabilitation of torture survivors. On an optimistic note, this marks an encouraging change in thinking in this field since the 1980s. After all, once we agree on this fundamental point, other differences in opinion could be resolved by future research. I agree with Berliner et al’s recommendations regarding future course of action. Their idea of establishing global networks of rehabilitation centres, universities, and other institutions concerned with survivor care is in fact very similar to my proposal to the Rehabilitation Centre for Torture Victims in Denmark in the 1990s (mentioned in my reply to Sjölund, 20 January 2007) for a European Union Concerted Action project. The primary aim of this project was defined at the time as “the establishment of a consortium of European mental health scientists concerned with torture survivors with a view to organising international collaborative research into psychological effects of torture and effective ways of treatment.” Perhaps the time is now ripe for reconsidering such an idea. This debate might be brought to a useful conclusion by comments, suggestions or expressions of interest from colleagues to help develop this idea further. Competing interests: None declared |
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