COMMENTARY

Evaluation and Treatment of Survivors of Torture and Refugee Trauma

Allen S. Keller, MD

Disclosures

May 13, 2009

In This Article

BT (Part III)

BT finally goes to a walk-in clinic at a nearby hospital. Speaking in French and broken English, he tries to explain that he has been coughing and his stomach hurts. The clinician who sees him attempts to communicate in very limited French. BT is afebrile, and an examination of his heart, lungs, and abdomen is unremarkable. The clinician orders a chest x-ray, and it is normal except for an old healed left rib fracture. Routine lab tests, including hemogram, electrolytes, and liver function tests, are also normal. The clinician prescribes acetaminophen for BT's headaches and musculoskeletal pain, and ranitidine for abdominal discomfort. Two weeks later, BT again presents to the walk-in clinic with similar complaints.

Clinical Assessment of Survivors of Torture and Refugee Trauma

Approach to the Patient

Despite the prevalence and health consequences of torture and refugee trauma among immigrant patients, health professionals rarely, if ever, inquire or learn about such events. BT, similar to many patients, does not volunteer this information to a healthcare provider who doesn't specifically ask about it. BT is haunted by shame and humiliation. Furthermore, it doesn't occur to him that his current medical complaints have anything to do with this past trauma, which he wants to put behind him.

Clinicians may not be aware of the prevalence or health consequences of torture and refugee trauma. They may feel quite uncomfortable requesting such information and uncertain of its clinical utility. However, as BT's story demonstrates, the trauma history (the patient's narrative of the severe human suffering s/he has endured) is an important component of the medical interview and enables clinicians to better understand such patients and their health concerns.[11,12,18]

For example, identifying a history of head trauma, beatings to a particular part of the body, or sexual assault can further guide clinical evaluation. Patients may not offer this information unless specifically asked. In the case of BT, the clinician failed to ask about or identify BT's prior trauma, which is clearly salient. This clinician never asked about the old rib fracture. BT's musculoskeletal and psychological symptoms are likely linked to his torture and abuse. His gastrointestinal symptoms may have resulted from parasitic infections caused by poor prison conditions or the squalor of a refugee camp.

Although potential risks for retraumatizing individuals should not be minimized, the utility of screening all immigrant patients for traumatic events is not clearly established. Clinicians should at least maintain a low threshold for asking, given the prevalence and health consequences of torture and refugee trauma. This is particularly true for immigrants presenting with multiple complaints of unclear etiology, and immigrants who come from war-torn countries or areas known to have political violence. Furthermore, rather than viewing such questions as an infringement on privacy, patients may consider such probing as a sign of empathy and desire to better understand them.

Simple questions that may be helpful in eliciting a trauma history include:

  • "Tell me about why you left your country"; and

  • "Have you ever been seriously hurt physically or emotionally by someone or something that happened in your country or after leaving?"

For immigrants coming from countries, such as Cambodia, the former Yugoslavia, or Sudan, asking a question that both inquires about and acknowledges potential past suffering may be appropriate: "I understand that many individuals from your country experienced or witnessed very terrifying things. Did this ever happen to you?"

Health professionals should be sensitive to whether patients are willing to discuss such events. For example: "I appreciate how difficult talking about disturbing past events can be, and respect that it is your decision regarding what you tell me. I am asking because such information is important in helping me to provide the best care for you."

Working With Interpreters

Good interpreting services are essential for effective communication, including proper diagnosis and treatment. The first clinician who evaluated BT tried to "get by" with his broken French and BT's limited English. This contributed to not eliciting relevant clinical information about BT's imprisonment and beatings.

Healthcare providers should try to ensure that a patient is comfortable with the interpreter. Consideration must be paid to issues, such as gender and ethnicity. As a general rule, family members or friends should not serve as interpreters, given issues of privacy and interpersonal dynamics. When using interpreters, clinicians should look at and talk directly with the patient rather than the interpreter.

Ancillary Testing

The utility of ancillary tests,[11,12,13,14,15,16] including blood tests and radiographic studies, must be considered and appropriately explained to patients. Patients from certain cultures may have particular concerns about the amount of blood taken from them, and healthcare providers need to be sensitive to this. Patients who were subjected to electric shocks or confined in small spaces as part of their abuse may find an electrocardiogram or magnetic resonance imaging (MRI) terrifying. Adequate explanation of the procedure should be provided, and the need for pre-procedure sedation considered.

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