COMMENTARY

Evaluation and Treatment of Survivors of Torture and Refugee Trauma

Allen S. Keller, MD

Disclosures

May 13, 2009

In This Article

Mental Health Treatment for Torture Survivors

Effective means for evaluating and treating the mental health costs of torture and refugee trauma is a rich and complex subject that merits extensive discussion. For the purposes of this article, however, several points are important to note.

The health consequences of torture and refugee trauma are multifaceted, and include physical, psychological, and social dimensions. At the Bellevue/NYU Program for Survivors of Torture (PSOT) in New York City, we have found it extremely beneficial to address health concerns, including mental health problems, with a multidisciplinary treatment approach.[11] This is true whether an individual is referred for specialized mental health services or mental health treatment is provided in the primary care setting.

Similar to other populations, refugees and torture survivors may resist psychiatric or psychological referral and treatment. The perceived stigma of mental health services and unfamiliarity with such care can be significant impediments. Psychoeducation, including information about the high frequency and effects of psychological symptoms, as well as the benefits of treatment, can significantly improve referral and treatment. Primary care providers have an important role to play in addressing questions or concerns about mental health treatment and normalizing such care as a central component of achieving well-being.

At PSOT, we have found the use of supportive group treatment to be very important, both for improving symptoms and providing a social support network.[11,24] Group membership is often determined by language or culture. For example, PSOT has a French-speaking African torture survivors group, an English-speaking African group, and a Tibetan group. We also develop groups around shared experiences, such as a group for individuals persecuted because of their sexual orientation/gender identification and a women's group. We have found that groups facilitate a sense of community and social reconnection -- something that torture and refugee trauma significantly undermines. Close collaboration between medical and mental health professionals also facilitates referrals and their acceptance by patients.

Psychopharmacologic treatment can be prescribed by the primary care provider or mental health specialist. Psychopharmacologic treatment options are numerous and should be tailored to an individual's symptoms and diagnosis. Selective serotonin reuptake inhibitors are commonly used in treating both depression and anxiety disorders. Given the significant length of time for antidepressant medications to reach stable therapeutic levels, one should consider using additional medication (at least initially), such as a benzodiazepine, to manage substantial and potentially disabling symptoms, including sleep difficulties and profound anxiety.

Social and Legal Concerns

Survivors of torture and refugee trauma face a myriad of difficulties for which social and legal services are crucial. These individuals need assistance with housing, food, school placement, and language competency.[11] Legal status, including work authorization, applications for political asylum, and family reunification, are common concerns. Although effective social and legal services are essential for navigating the complex labyrinth of the US immigration system, clinicians have a central role to play in providing appropriate referrals for social and legal services as well as providing necessary documentation and other information.

Immigrants fleeing persecution who arrive in the United States without formal refugee status may apply for political asylum, which, if granted, gives them permission to remain in the United States. After several years, political asylees become eligible for US citizenship. For torture survivors and others who have a genuine fear of persecution, being forced to return to their native countries can result in imprisonment, further torture, or death. Health professionals have the opportunity to play a crucial role in the asylum process by providing medical affidavits in which credible evidence of the physical and/or psychological consequences of the alleged torture or mistreatment is documented. Such forensic documentation can provide important corroborating information for the asylum applicant. National organizations, such as Physicians for Human Rights and HealthRight International (formerly Doctors of the World-USA), coordinate networks of health professional volunteers who conduct evaluations and prepare medical affidavits. Both organizations provide training and mentorship for volunteers.

The Istanbul Protocol[11] provides international guidelines for the assessment of persons who allege torture and ill treatment, and for reporting findings to the judiciary and any other investigative body. Physicians for Human Rights has developed a manual that is based on the Istanbul Protocol, "Examining Asylum Seekers,[11]" intended to provide medical professionals with the information necessary to conduct these potentially lifesaving evaluations.

Health Professional Participation in Torture

It is a gross breach of professional ethics for health professionals to countenance, condone, or participate in torture, or other cruel, inhuman, or degrading treatment or punishment of prisoners. This is clearly stated in the ethical principles of health professional organizations, including the American Medical Association, the American College of Physicians, the American Nurses Association, the American Public Health Association, the American Psychiatric Association, and the American Psychological Association. Health professionals who participate in torture are not fit to practice in their professions. Federal authorities, state licensing boards, and health professional organizations should take action again health professionals who participate in torture.

Substantial documentation shows that US health professionals have participated in developing, monitoring, and implementing torture in US detention facilities, such as Guantanamo Bay, as well as falsifying medical reports about allegations of torture.[25,26,27,28,29,30] To date, no health professionals have been held accountable for these actions. In 2008, California's state legislature became the first to pass a resolution, the aim of which is to prevent health professionals from engaging in torture and coercive interrogations at US military detention facilities.[31] Recently, legislation was introduced in New York State[32] that, if enacted, would facilitate New York State medical licensing boards in removing the licenses of health professionals who participate in torture.

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