Rehabilitation of traumatised refugees and survivors of torture
BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.39036.739236.43 (Published 14 December 2006) Cite this as: BMJ 2006;333:1230
All rapid responses
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
Conclusion - Need for concerted action
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
Competing interests: No competing interests