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PTSD and retraumatisation in asylum seekers
- Frank W Arnold, Reading RG6 1QB (15 April 2007)
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Preventing the disorder
- Woody Caan (16 April 2007)
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PTSD Management and Maslow's hierarchy of needs
- Mehraj Uddin Shah, Akeem Sule, Jan Farida (20 April 2007)
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Frank W Arnold, Independent Doctor 14 College Road, Reading RG6 1QB
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Sir, Perhaps for reasons of space, Bisson’s review (1) does not mention torture, a depressingly common cause of Post Traumatic Stress Disorder (PTSD), or the risk of re-traumatisation in such patients. UK doctors are most likely to encounter these problems among asylum seekers, especially those who have been detained in removal centres after being “failed” by the Home Office and Immigration Judges. The number of such cases probably exceeds 5000 per annum. It was accepted in the drafting of the Detention Centre Rules (2) and underlying statutory instruments that detention of torture survivors was unduly likely to cause severe psychological harm and should only occur under “exceptional circumstances.” Indeed doctors working in detention centres are required to report to the Immigration and Nationality Department(IND)about anyone whose health is likely to be harmed by detention, which can be of indefinite duration, exceeding one year without any conviction in some cases. Sadly, receipt of such reports (when sent) has heretofore resulted in inaction and significant misrepresentation by IND: 1) In a report on Harmondsworth DC, Her Majesty’s Chief Inspector of Prisons identified 57 such “torture reports” sent to IND over the first half of 2006 (3). Not one of these is known to have resulted in any action by IND to investigate the accuracy of such reports. 2) In a recent statement to the House of Lords (4), Baroness Scotland alleged that all suitable cases where an immigration detainee is reported to have suffered torture are referred by IND to the Medical Foundation for the Care of Victims of Torture for assessment. This is wholly untrue. I have worked at the Foundation and recently checked with their management. NO such case has ever been referred to the Foundation. 3) In the past 18 months, colleagues in the Medical Justice Network and I have seen at least 25 detained asylum seekers with strong physical evidence of torture (including cigarette burn scars and stigmata of falaka) as well as fulfilling all necessary criteria for a diagnosis of PTSD. In some cases, we have been able to provide medico-legal reports which have assisted their release by judicial decision. This has usually been resisted by the Home Office. Doctors, especially general practitioners, whose asylum seeking patients have evidence they were tortured before coming to the UK, who have PTSD as a result, and who are at risk of detention, may wish to supply them with a letter (or full medico-legal report) outlining evidence to that detention would be unduly harmful. This would go some way to reducing the very substantial numbers who suffer retraumatisation while seeking refuge. Frank Arnold For the Medical Justice Network www.medicaljustice.org.uk References: 1) Bisson JI. Post-traumatic stress disorder. BMJ 2007; 334: 789-93. 2) Detention Centre Rules 2001 (item 35). http://www.aviddetention.org.uk/aviddefault.htm 3) HM Chief Inspector of Prisons. Report on an unannounced inspection of Harmondsworth Immigration Removal Centre 17–21 July 2006. http://inspectorates.homeoffice.gov.uk/hmiprisons/inspect_reports/irc- inspections.html/Harmondsworth1.pdf?view=Binary 4) Baroness Scotland of Asthal. [HL982], Hansard. January 8, 2007. All internet references accessed 15 April 2007. Competing interests: FWA helped to found the Medical Justice Network. For assisting detained hunger strikers to obtain adequate medical care, he was reported to the GMC by the management of a detention centre, against the wishes of the patients concerned. He is occasionally paid, under legal aid, for medico-legal reports. |
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Woody Caan, Professor of public health Anglia Ruskin University, Cambridge CB1 1PT, UK.
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Bisson has produced a very practical overview of managing post- traumatic stress disorder (PTSD), even years after the distressing symptoms [1] have emerged. PTSD was originally characterised in terms of two extreme types of violence, warfare and rape, but we now recognise that a variety of nasty experiences can produce prolonged psychological disorder (from premature delivery of a sick baby, to imprisonment in camps designed to break the human spirit [2]). I was bemused to read one section of Bisson's review [3], 'Preventing the disorder'. This dealt only with clinical interventions after a horrific experience. From a public health perspective, 'Preventing' PTSD would involve reducing exposure to violence and abuse, or else promoting safer practices in high-risk environments like neonatal units or youth custody. Doctors may not feel competent to prevent wars, but many professionals have to engage with potentially violent individuals (including rapists) or have practical experience with areas like road safety or fire prevention. Given the will and wherewithall, how much trauma could we prevent? The pathetic failure, of the UK Government's 'zero tolerance' spin, to protect health service staff from violence suggests that clinicians will themselves have to take the lead, even for their own safety. Thought for the Day: Tough on Trauma, Tough on the Causes of Trauma ? 1 Caan W. Post traumatic shrapnel dreams. Psychiatry Research Trust Newsletter 2000; 22: 7. 2 Frankl VE. Man's search for meaning: an introduction to logotherapy. (English edition of 1946 German original). New York: Pocket Books, 1963. 3 Bisson JI. Post-traumatic stress disorder. BMJ 2007; 334: 789-93. Competing interests: In the past, I have investigated traumatic incidents involving health professionals. |
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Mehraj Uddin Shah, Locum Consultant Spring House, Biggleswade Hospital,Potton road, Biggleswade, SG18 0EL, Akeem Sule, Jan Farida
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Bisson's review (1) raises interesting discussions on PTSD management. With the number of conflicts in the developing world resulting in an increase in Asylum seekers and refugees flocking to developed countries, PTSD management becomes even more important. We believe more focus should be placed on basic needs provision for Asylum seekers such as food, water, shelter and security. Maslow's hierarchy of needs could represent a good framework to determine appropriate policies to be implemented for the prevention and treatment of PTSD in the above group. Articles by Drennan and colleague (2)as well as Toscani et al (3) add weight to ths point, but this appears to be sadly ignored in most research and management of PTSD. References 1 Bisson JI. Post-traumatic stress disorder. BMJ 2007;334: 789-93 2 Drennan V.M and Joseph J. Health visiting and refugee families: issues in professional practice. Journal of Advanced Nursing 2005;49(2),155-163. 3 Toscani L. et al Health status of returnees to Kosovo: Do living conditions during asylum make a difference? Public Health 2007; Jan;121(1):34-44. Competing interests: None declared |
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