Rehabilitation of traumatised refugees and survivors of torture

In a 1988 BMJ editorial,1 Marks and I reviewed the available knowledge on the mental health effects of torture and their treatment and presented a critical look at rehabilitation programmes for survivors. Eighteen years later, it is time to cast another look at the advances in our understanding of torture and its treatment and how this progress has translated into rehabilitation work with survivors. Such an update is timely: given the political developments of the last two decades, torture has become an ever more serious problem.

An important advance in the 1990s was the demonstration of an association between torture and post-traumatic stress disorder through controlled studies using standardised assessment instruments.2 Further work provided insight into the psychological mechanisms that played a part in torture-induced post-traumatic stress. In a controlled study survivors who felt that those they held responsible for the torture did not receive the punishment they deserved were more likely to have a sense of injustice, anger, rage, distress, loss of meaning in life, demoralisation, desire for revenge, pessimism, fear, and loss of control over life.3 Among these responses, however, only fear and loss of control were associated with post-traumatic stress disorder and depression. This implied that post-traumatic stress and depression could be effectively treated by psychological interventions designed to reduce fear and enhance the sense of control and that the sense of injustice associated with impunity would not necessarily impede recovery.

The 1990s also saw considerable progress in treating post-traumatic stress disorder. Controlled studies showed that it could be effectively treated with cognitive behavioural treatment, essentially a potent fear-reducing intervention. A consensus emerged among experts that cognitive behavioural treatment is the treatment of choice in post-traumatic stress disorder.4 Recently, the National Institute for Clinical Excellence in the UK recommended cognitive behavioural treatment as an effective treatment for trauma survivors.5 Such treatment is usually delivered in 8-10 weekly sessions, but a much briefer behavioural intervention has been developed in recent years. Randomised controlled studies with earthquake survivors showed that a single session of exposure treatment designed to enhance a sense of control over trauma-induced fear and distress is highly effective in reducing post-traumatic stress disorder and depression in over 85% of the cases.6 7 Preliminary evidence suggests that exposure-based interventions are also useful in refugees8 9 and survivors of torture.10 11

Such progress, however, appears to have had little impact on work with survivors of torture. Most psychological treatments used in rehabilitation programmes still appear to be a mixture of various psychotherapeutic elements, not based on a consistent theory, and lack evidence on their effectiveness. In 1988 we noted that lack of outcome evaluation makes it impossible to judge the effectiveness of these rehabilitation programmes in facilitating recovery from the trauma of torture. Unfortunately, evidence is still lacking. A recent report based on the work of the Rehabilitation and Research Centre for Torture Victims in Denmark is a sobering reminder of where we stand after two decades. The Danish centre is a pioneering organisation, serving as a model for more than 90 similar centres around the world. An outcome evaluation study based on 55 people admitted to the centre in 2001 and 2002 showed no improvement in post-traumatic stress disorder, depression, anxiety, or health-related quality of life after nine months' treatment.12 These findings led the authors to conclude that future studies are needed to explore effective interventions for traumatised refugees, including cognitive behavioural therapy. This is indeed what we had recommended in1988.1

Lack of progress among torture survivors partly stems from the fact that scientific approaches to the problem are often dismissed as reductionist “medicalising.” Many of those working with torture survivors advocate a solely political approach to the problem in the belief that recovery from trauma is only possible through eradicating impunity for the perpetrators of torture. Research evidence does not support this view.3 Although advocacy against torture is certainly important, as long as the problem lasts rehabilitation centres also have a moral obligation to provide effective psychological treatment for their clients. After more than 30 years of work, those working with torture survivors need to confront the uneasy but important question of whether their approach is helpful. This issue can be addressed only by proper outcome evaluation. Given that there are now very brief and highly effective interventions available for survivors, the public have a right to know the justification behind lengthy and expensive rehabilitation programmes without demonstrable beneficial effects.

Funders of rehabilitation programmes are in an excellent position to promote progress here. They also need to adopt an evidence-based approach and consider the following questions in their review of funding applications: (a) is the proposed intervention based on sound theory; (b) is there is sufficient evidence on its effectiveness; and (c) does the work involve outcome evaluation? Making grant support conditional on such requirements would certainly enhance the quality of work in the field. Given the painfully slow progress this appears to be the only hope for change.