Psychosocial needs of torture survivors

The impact of experiencing severe physical abuse in childhood on adolescent refugees' emotional distress and integration during the COVID-19 pandemic

Background

Accumulating evidence highlights the importance of pre- and post- migration stressors on refugees' mental health and integration. In addition to migration-associated stressors, experiences earlier in life such as physical abuse in childhood as well as current life stress as produced by the COVID-19-pandemic may impair mental health and successful integration - yet evidence on these further risks is still limited. The present study explicitly focused on the impact of severe physical abuse in childhood during the COVID-19 pandemic and evaluated the impact of these additional stressors on emotional distress and integration of refugees in Germany.

Methods

The sample included 80 refugees, 88.8% male, mean age 19.7 years. In a semi-structured interview, trained psychologists screened for emotional distress, using the Refugee Health Screener, and integration status, using the Integration Index. The experience of severe physical abuse in childhood was quantified as a yes/no response to the question: "Have you been hit so badly before the age of 15 that you had to go to hospital or needed medical attention?" Multiple hierarchical regression analyses further included gender, age, residence status, months since the start of the COVID-19 pandemic and length of stay in Germany to predict emotional distress and integration.

Results

Two regression analyses determined significant predictors of (1) emotional distress (adjusted R ² = 0.23): duration of being in the pandemic (ß = 0.38, p < 0.001) and severe physical abuse in childhood (ß = 0.31, p = 0.005), and significant predictors of (2) integration (adjusted R ² = 0.53): length of stay in Germany (ß = 0.62, p < 0.001), severe physical abuse in childhood (ß = 0.21, p = 0.019) and emotional distress (ß = -0.28, p = 0.002).

Conclusion

In addition to migration-associated stressors, severe physical abuse in childhood constitutes a pre-migration risk, which crucially affects the well-being, emotional distress and integration of refugees in Germany.

The longitudinal association between moral injury appraisals and psychological outcomes in refugees

BACKGROUND

Refugees report a diverse array of psychological responses following persecution and displacement. Little is known, however, regarding the mechanisms that underlie differential psychological reactions in refugees. This study investigated the longitudinal impact of negative moral appraisals about one's own actions [i.e. moral injury-self (MI-self) appraisals] and others' actions [i.e. moral injury-other (MI-others) appraisals] on a variety of psychological symptoms over a period of 6 months.

METHODS

Participants were 1085 Arabic, Farsi, Tamil, or English-speaking refugees who completed a survey at baseline and 6 months later either on-line or via pen-and-paper. The survey indexed demographic factors, exposure to potentially traumatic events (PTEs), exposure to ongoing stressors, MI-other appraisals, MI-self appraisals, re-experiencing and arousal symptoms, and feelings of sadness, anger and shame.

RESULTS

Findings indicated that, after controlling for demographics, PTE exposure and ongoing stressors, MI-other appraisals predicted increased re-experiencing and hyperarousal symptoms, and feelings of sadness and shame. MI-self appraisals predicted decreased feelings of shame, and decreased re-experiencing symptoms. In contrast, psychological symptoms at baseline did not as strongly influence MI appraisals 6 months later.

CONCLUSIONS

These findings highlight the important role that cognitive appraisals of adverse events play in the longitudinal course of psychological symptoms. These results thus have important implications for the development of tailored psychological interventions to alleviate the mental health burden held by refugees.

Uncovering re-traumatization experiences of torture survivors in somatic health care: A qualitative systematic review

Little research has focused on torture survivors' re-traumatization experiences in health and hospital units that treat somatic diseases, though any medical procedure can re-traumatize survivors. This study's purpose was to summarize qualitative research evidence on torture survivors' somatic healthcare experiences and to identify "triggers" or "reminders" that can lead to re-traumatization. The study's search strategies identified 6,326 citations and eight studies, comprising data from 290 participants, exploring encounters with healthcare providers from torture survivors' perspectives, which were included in the present research. Dallam's Healthcare Retraumatization Model was used as a framework for data extraction and analysis. Five main themes were elicited from the findings: (1) invisibility, silence, and mistrust; (2) healthcare providers' attitudes and a lack of perceived quality in healthcare; (3) disempowerment; (4) avoidance; and (5) satisfaction and gratitude. An analysis of the study's findings revealed that torture survivors do not receive adequate healthcare and may experience challenges during treatment that can result in re-traumatization. The findings of this literature review provide a basis for understanding the difficulties that survivors experience in receiving somatic healthcare, as well as an explanation of the re-traumatization process.

Prevalence of torture and trauma history among immigrants in primary care in Denmark: do general practitioners ask?

Background

Torture survivors typically present with varied and complex symptoms, which may challenge assessment by general practitioners (GPs). This study explored the prevalence of torture and trauma history among immigrants born in non-Western countries presenting to GPs in Denmark and the extent to which GPs ask this population about torture or trauma history.

Methods

Based on a self-reported questionnaire among non-western immigrant patients, we used bivariate analyses to determine the prevalence of torture and trauma history and the proportion of patients being asked by their GP about this. Data were analysed using multivariate logistic regression.

Results

From 46 GP clinics, 300 questionnaires were finalized by immigrant patients. Twenty-eight percent of the patients had a history of torture. Of these, significantly more were men (70%) than women (29%). About half of the torture survivors (55%) had been asked by their GP about torture history. The odds ratio (OR, 95% confidence interval) for being asked about torture history by the GP was 1.28 (0.46–3.53) among women compared with men. Compared with Southeast Europe, OR for being a torture survivor among male immigrants from Middle East-North African region and South and East Asia was 1.83 (0.81–4.15) and 0.25 (0.08–0.82), respectively.

Conclusions

Our results suggest that torture and trauma are widespread among immigrants presenting to GPs. In our study, the GPs had managed to detect half of the torture survivors. A more systematic approach to detection in General Practice is advisable, and more knowledge on how and when to ask is needed.

Resilience and anxiety or depression among resettled Bhutanese adults in the United States

BACKGROUND

Resilience, or an individual's positive response in managing life's adversities, is of increasing interest in addressing the mental health disparities in refugees. Although the link between stressful life events and poor mental health is established, research on the role of resilience on the mental health of refugees is limited.

AIMS

This study assessed the association between resilience and anxiety or depression in resettled Bhutanese adults in Western Massachusetts.

METHODS

A cross-sectional survey was conducted among 225 Bhutanese (men: 113, women: 112) refugees aged 20-65 residing in Massachusetts. Resilience was measured with the 25-item Wagnild and Young's Resilience Scale including two constructs as follows: a 17-item 'personal competence' that measures self-reliance, independence, determination, resourcefulness, mastery and perseverance and an 8-item 'acceptance of self and life' that measures adaptability, flexibility and a balanced perspective of life. Higher total scores indicate greater resilience. The Hopkins Symptom Checklist-25 was used to measure anxiety (10-item) and depression (15-item) with a cutoff mean score of ⩾1.75 for moderate to severe symptoms. Associations of resilience with anxiety or depression scores were assessed using multiple-linear and logistic regression analyses.

RESULTS

The proportion of participants with above threshold anxiety and depression were 34.2% and 24%, respectively. Resilience was inversely associated with both anxiety (beta for 1 unit change in resilience scores: β = -0.026; p = .037) and depression (β = -0.036, p = .041). 'Personal competence' resilience was inversely associated with both anxiety (β = -0.041 p = .017) and depression (β = -0.058, p = .019), but 'acceptance of self and life' resilience was not. Participants with the highest tertile of resilience scores had a significantly decreased risk of anxiety (ORs (95% CI): 0.13 (0.04-0.40)) and depression (0.16 (0.04-0.60)).

CONCLUSION

Higher resilience was associated with reduced anxiety and depression among Bhutanese with personal competence resilience accounting for most of the effects. These findings suggest the potential targets for mental-health intervention to improve resilience in refugees.

The effects of perceived torture controllability on symptom severity of posttraumatic stress, depression and anger in refugees and asylum seekers: A path analysis

Torture is associated with greater psychopathology, however, the specific mechanisms underlying the effects of torture remain unclear. Research suggests that the perceived uncontrollable nature of, rather than the exposure to, torture, influences the development of psychological disorders. Perceived distress during torture has also been shown to influence psychological outcomes. This cross-sectional study explored the relationship between perceived torture controllability, emotions (i.e., anger and fear) during torture, and current posttraumatic stress (PTS), depression and anger symptoms, controlling for the effects of post-migration living difficulties. Data were collected from 108 refugees and asylum seekers in treatment at two psychiatric clinics in Zurich, Switzerland. Path analyses revealed negative correlations between PTS, depression and anger symptoms, and perceived torture controllability, and positive correlations with anger and fear during torture. Furthermore, the effects of perceived torture controllability on PTS and depression symptoms were mediated by fear during torture, and on anger symptoms via anger during torture. This was over and above the effects of post-migration living difficulties on psychological symptoms. The study provides preliminary evidence that perceived uncontrollability and distress during torture might be significant risk factors for current mental health of torture survivors. These findings may have implications for informing interventions for torture survivors.

Difficult to treat? A comparison of the effectiveness of treatment as usual in refugees and non-refugees

Aims and method To examine treatment response in traumatised refugees, we compared routine outcome monitoring data (Harvard Trauma Questionnaire) of two refugee populations with those of individuals experiencing profession-related trauma who were treated at a specialised psychotrauma institute. Results Asylum seekers/temporary refugees (n = 21) and resettled refugees (n = 169) showed significantly lower post-traumatic stress disorder (PTSD) symptom reduction between intake and 1 year after intake than did a comparison group of non-refugees (n = 37), but the interaction effect was clinically small (partial η(2) = 0.03). Refugees who had more severe symptoms at intake showed significantly greater symptom reduction after 1 year. Clinical implications Therapists and refugee patients should have realistic expectations about response to treatment as usual. Additional treatment focusing on improving quality of life may be needed for refugees whose PTSD symptom severity remains high. At the same time, novel approaches may be developed to boost treatment response in refugee patients with low responsiveness.

Challenges and Successes in Dissemination of Evidence-Based Treatments for Posttraumatic Stress: Lessons Learned From Prolonged Exposure Therapy for PTSD

Posttraumatic stress disorder (PTSD) poses monumental public health challenges because of its contribution to mental health, physical health, and both interpersonal and social problems. Recent military engagements in Iraq and Afghanistan and the multitude of resulting cases of PTSD have highlighted the public health significance of these conditions. There are now psychological treatments that can effectively treat most individuals with PTSD, including active duty military personnel, veterans, and civilians. We begin by reviewing the effectiveness of these treatments, with a focus on prolonged exposure (PE), a cognitive-behavioral therapy (CBT) for PTSD. Many studies conducted in independent research labs have demonstrated that PE is highly efficacious in treating PTSD across a wide range of trauma types, survivor characteristics, and cultures. Furthermore, therapists without prior CBT experience can readily learn and implement the treatment successfully. Despite the existence of highly effective treatments like PE, the majority of individuals with PTSD receive treatments of unknown efficacy. Thus, it is crucial to identify the barriers and challenges that must be addressed in order to promote the widespread dissemination of effective treatments for PTSD. In this review, we first discuss some of the major challenges, such as a professional culture that often is antagonistic to evidence-based treatments (EBTs), a lack of clinician training in EBTs, limited effectiveness of commonly used dissemination techniques, and the significant cost associated with effective dissemination models. Next, we review local, national, and international efforts to disseminate PE and similar treatments and illustrate the challenges and successes involved in promoting the adoption of EBTs in mental health systems. We then consider ways in which the barriers discussed earlier can be overcome, as well as the difficulties involved in effecting sustained organizational change in mental health systems. We also present examples of efforts to disseminate PE in developing countries and the attendant challenges when mental health systems are severely underdeveloped. Finally, we present future directions for the dissemination of EBTs for PTSD, including the use of newer technologies such as web-based therapy and telemedicine. We conclude by discussing the need for concerted action among multiple interacting systems in order to overcome existing barriers to dissemination and promote widespread access to effective treatment for PTSD. These systems include graduate training programs, government agencies, health insurers, professional organizations, healthcare delivery systems, clinical researchers, and public education systems like the media. Each of these entities can play a major role in reducing the personal suffering and public health burden associated with posttraumatic stress.

From pioneers to scientists: challenges in establishing evidence-gathering models in torture and trauma mental health services for refugees

Outcome studies on treatment of trauma-affected refugees have been published but are limited in design and quality. In this article, we discuss possible impediments to pursuing research aimed at gathering evidence to support the efficacy of treatments in the field and the challenges in carrying out such inquiries. We then present a working model that demonstrates the feasibility of integrating outcome research into clinical settings. The aim of this model is to involve all personnel in generating research of high quality with minimal additional costs and time commitment. We conclude that although challenges remain in carrying out treatment outcome studies, they can be overcome by careful consultation and negotiation in a setting with an established ethos of commitment to the scientific endeavor. Ultimately, identifying the most effective interventions will provide better treatment and quality of life for the large number of traumatized refugees seeking assistance for mental health problems.

EMDR With Traumatized Refugees: From Experience-Based to Evidence-Based Practice

Many refugees resettled in Western countries suffer from an accumulation of traumatic and current stressors that contribute to mental health problems and may complicate trauma-focused treatment. Consequently, the acceptability, safety, and efficacy of trauma-focused treatment with refugees have been a matter of clinical and scientific interest. In recent years, the evidence has accumulated for narrative exposure therapy and culturally adapted cognitive behavioral therapy. Although eye movement desensitization and reprocessing (EMDR) is practiced with resettled refugees, only five small studies of limited quality have been conducted on EMDR with this population. In the absence of strong evidence, therapists practising EMDR with refugees may be aided by transcultural psychiatric principles, especially matching of explanatory models. In addition, high-quality research is needed to reliably determine acceptability, safety, and efficacy of EMDR with traumatized refugees.

Trauma exposure, PTSD and psychotic-like symptoms in post-conflict Timor Leste: an epidemiological survey

BACKGROUND

Studies in developed countries indicate that psychotic-like symptoms are prevalent in the community and are related to trauma exposure and PTSD. No comparable studies have been undertaken in low-income, post-conflict countries. This study aimed to assess the prevalence of psychotic-like symptoms in conflict-affected Timor Leste and to examine whether symptoms were associated with trauma and PTSD.

METHODS

The Psychosis Screening Questionnaire and the Harvard Trauma Questionnaire (assessing trauma exposure and PTSD) were administered in an epidemiological survey of 1245 adults (response rate 80.6%) in a rural and an urban setting in Timor Leste. We defined PSQ screen-positive cases as those people reporting at least one psychotic-like symptom (paranoia, hallucinations, strange experiences, thought interference, hypomania).

RESULTS

The prevalence of PSQ screen-positive cases was 12 percent and these persons were more disabled. PSQ cases were more likely to reside in the urban area, experienced higher levels of trauma exposure and a greater prevalence of PTSD. PTSD only partially mediated the relationship between trauma exposure and psychotic-like symptoms.

CONCLUSIONS

Psychotic-like symptoms may be prevalent in countries exposed to mass conflict. The cultural and contextual meaning of psychotic-like symptoms requires further inquiry in low-income, post-conflict settings such as Timor Leste.

Change in visa status amongst Mandaean refugees: relationship to psychological symptoms and living difficulties

Policies of deterrence, including the use of detention and temporary visas, have been widely implemented to dissuade asylum seekers from seeking protection in Western countries. The present study examined the impact of visa status change on the mental health of 97 Mandaean refugees resettled in Australia. At the time of the first survey (2004), 68 (70%) participants held temporary protection visas (TPVs) and 29 (30%) held permanent residency (PR) status, whereas by the second survey (2007), 97 (100%) participants held PR status. We tested a meditational model to determine whether the relationship between change in visa status and change in psychological symptoms was mediated by change in living difficulties associated with the visa categories. The conversion of visa status from TPV to PR status was associated with significant improvements in PTSD and depression symptoms, and increases in mental health-related quality of life (MHR-QOL). The relationship between change in visa status and reduced PTSD and depression symptoms was mediated by reductions in living difficulties. In contrast, the relationship between change in visa status and increased MHR-QOL was not mediated by changes in living difficulties. These results suggest that restriction of rights and access to services related to visa status negatively affect the mental health of refugees. Implications for government policies regarding refugees are discussed.

Is torture reliably assessed and a valid indicator of poor mental health?

Torture is thought to confer worse mental health than other war-related traumatic events. However, reliability of torture assessment and validity of torture constructs as indicators of poor mental health have not been systematically evaluated. Study aims were to assess the psychometric properties of 2 common torture constructs. Refugees were assessed for having experienced torture by 1 subjective and 1 objective criterion. A subset was interviewed about definitions and effects of torture. Reliability and validity of torture constructs were assessed with general linear models. Interview data were analyzed for consistency of themes. Reliability of torture constructs was moderate, which paralleled inconsistencies in interview themes. Both torture criteria had similar dose-dependent relationships to mental health. Multivariate analyses showed that torture was not an independent predictor of poor mental health when controlling for the number of war-related events. Further work is needed to define torture from distinct medical and legal perspectives to improve reliability and validity.

EMDR versus stabilisation in traumatised asylum seekers and refugees: results of a pilot study

BACKGROUND

Traumatised asylum seekers and refugees are clinically considered a complex population. Discussion exists on whether with this population treatment guidelines for post-traumatic stress disorder (PTSD) should be followed and Trauma-Focused Cognitive-Behavioural Therapy (TF-CBT) or Eye Movement Desensitisation and Reprocessing (EMDR) should be applied, or whether a phased model starting with stabilisation is preferable. Some clinicians fear that trauma-focused interventions may lead to unmanageable distress or may be ineffective. While cognitive-behavioural interventions have been found to be effective with traumatised refugees, no studies concerning the efficacy of EMDR with this population have been conducted as yet.

OBJECTIVE

In preparation for a randomised trial comparing EMDR and stabilisation with traumatised refugees, a pilot study with 20 participants was conducted. The objective was to examine feasibility of participation in a randomised trial for this complex population and to examine acceptability and preliminary efficacy of EMDR.

DESIGN

Participants were randomly allocated to 11 sessions of either EMDR or stabilisation. Symptoms of PTSD (SCID-I, HTQ), depression and anxiety (HSCL-25), and quality of life (WHOQOL-BREF) were assessed at pre- and post-treatment and 3-month follow-up.

RESULTS

Participation of traumatised refugees in the study was found feasible, although issues associated with complex traumatisation led to a high pre-treatment attrition and challenges in assessments. Acceptability of EMDR was found equal to that of stabilisation with a high drop-out for both conditions. No participants dropped out of the EMDR condition because of unmanageable distress. While improvement for EMDR participants was small, EMDR was found to be no less efficacious than stabilisation. Different symptom courses between the two conditions, with EMDR showing some improvement and stabilisation showing some deterioration between pre-treatment and post-treatment, justify the conduct of a full trial.

CONCLUSION

With some adaptations in study design, inclusion of a greater sample is justifiable to determine which treatment is more suitable for this complex population.

A critical review of psychological treatments of posttraumatic stress disorder in refugees

Despite much research evidence that refugees suffer from elevated rates of posttraumatic stress disorder (PTSD), relatively few studies have examined the effectiveness of psychological treatments for PTSD in refugees. The field of refugee mental health intervention is dominated by two contrasting approaches, namely trauma-focused therapy and multimodal interventions. This article firstly defines these two approaches, then provides a critical review of 19 research studies that have been undertaken to investigate the efficacy of these treatments. Preliminary research evidence suggests that trauma-focused approaches may have some efficacy in treating PTSD in refugees, but limitations in the methodologies of studies caution against drawing definitive inferences. It is clear that research assessing the treatment of PTSD in refugees is lagging behind that available for other traumatized populations. The review examines important considerations in the treatment of refugees. A theoretical framework is offered that outlines contextual issues, maintaining factors, change mechanisms and the distinctive challenges to traditional trauma-focused treatments posed by the needs of refugees with PTSD.

Human rights and the trauma model: genuine partners or uneasy allies?

Since World War II, a comprehensive body of international law has developed to protect and promote human rights. Three generations of rights can be delineated: civil and political; economic, social and cultural; and collective rights. The convergence of a medical rights-based campaign in the late 1970s with the emergence of the new trauma model resulted in mental health professionals playing a prominent role in documenting and protecting civil and political rights. Economic, social, and cultural rights also emerged as being pivotal, particularly in the Australian context as mental health professionals began to work with excluded populations such as asylum seekers. Consideration of third-generation rights raises important questions about the responsibilities facing mental health professionals applying the trauma model to non-Western settings.

Culture, power, and practice in a psychosocial program for survivors of torture and refugee trauma

Based on a case study of anthropological fieldwork at a small program located in the north-eastern USA, this article critically examines the development of culturally sensitive psychosocial models of care for survivors of torture and refugee trauma in western countries of resettlement. Fieldwork identified several unresolved tensions in the bicultural model of counseling, psychosocial models of care, and the field of refugee mental health. Despite efforts to develop an innovative treatment model, the culturalization of care and the emphasis placed on meeting social needs in interventions resulted in maintaining conventional relations of power within the mental health professions.

Trauma, post-migration living difficulties, and social support as predictors of psychological adjustment in resettled Sudanese refugees

OBJECTIVE

This paper explores the impact of pre-migration trauma, post-migration living difficulties and social support on the current mental health of 63 resettled Sudanese refugees.

METHOD

A semistructured interview including questionnaires assessing sociodemographic information, pre-migration trauma, anxiety, depression and posttraumatic stress, post-migration living difficulties and perceived social support were administered assisted by a bilingual community worker.

RESULTS

Resettled refugees from Sudan evidenced a history of trauma. Less than 5% met criteria for posttraumatic stress but 25% reported clinically high levels of psychological distress. The results indicate that social support--particularly perceived social support from the migrant's ethnic community--play a significant role in predicting mental health outcomes. Pre-migration trauma, family status and gender were also associated with mental health outcomes.

CONCLUSIONS

Refugees in Australia may constitute a particularly vulnerable group in terms of mental health outcomes. Culturally specific sequelae in terms of social isolation and acculturation may be particularly problematic for these migrants.

Mental health issues in Tamil refugees and displaced persons. Counselling implications

Fifty-one Sri Lankan Tamil refugees/displaced persons living in South India completed the Hopkins Symptom Checklist-58. In addition, in interviews they answered open-ended questions about personal loss, personal traumatic experiences, negative feelings, living in camps, and the availability of support. The health of the respondents was poor. Moreover, experiences such as watching the killing of family members and being wounded were mentioned as reasons to flee. Many respondents said they experienced negative feelings. Social support was reasonably available although family members were often not situated in the same camp.

Listening for the sounds of silence: a nursing consideration of caring for the politically tortured

In 1997 Amnesty International reported that 115 out of 251 countries surveyed practised torture on their citizens. Many of these victims have been forced to flee their country of origin and become refugees in the West, in countries such as Australia, Canada, the UK and the United States. However, torture itself remains an unspoken and covert problem. In addition to the obvious traumatic effects, it may induce shame and dread on the part of the victim. It may be too terrifying and too painful to talk about, and yet may affect every aspect of a person's life (Forrest 1996). All too commonly a victim of torture may pass unnoticed or unrecognised because health care providers do not know how, or may be unwilling to engage with the issue. This paper will examine the implications for nurses of caring for the tortured. It will explore the nature of torture itself, who might be the perpetrators and who might be the victims (always acknowledging that nurses and other health care staff are often both), how victims of torture may present for health care, and the possible subjective perceptions of a torture victim when faced with a Western health care process and understanding. Finally, it will argue for an increase in awareness and sensitivity on the part of all nurses in all health care settings to the needs and sensibilities of victims of torture, and suggest that caring for them is the distillation of everything good nursing practice should be.

Expert opinions about the ICD-10 category of enduring personality change after catastrophic experience

The inclusion of enduring personality change after catastrophic experience (EPCACE) as a diagnostic category in the ICD-10 represents a turning point in the evolution of the nosology of traumatic stress syndromes, yet many aspects of the diagnosis remain contentious. Given the absence of published research concerning this category, an exploratory survey of international experts was conducted using a questionnaire focusing on key aspects of the category, namely whether respondents used the diagnosis of EPCACE in their practice; which features were most salient in making a diagnosis of posttraumatic personality change; the types and characteristics of traumatic events that were judged to be most likely to cause EPCACE; and the possible limitations of the ICD-10 diagnosis. A response rate of 56.3% was obtained. A substantial portion of trauma experts working in the field of human-engendered violence recognize the possibility that certain traumas can result in personality change. However, questions were raised about the specificity of the criteria proposed for the category of EPCACE in ICD-10. A composite profile of proposed additional features suggests that a more comprehensive array of adaptational changes are recognized than are encompassed by EPCACE.

The psychosocial effects of torture, mass human rights violations, and refugee trauma: toward an integrated conceptual framework

Torture is a complex trauma that often occurs within the context of widespread persecution and human rights violations. In addition, the nature of modern warfare is such that whole populations are at risk of suffering extensive trauma, injustices, loss, and displacement. Refugees, in particular, experience sequential stresses that may compound each other over prolonged periods of time. The present overview examines whether contemporary notions of trauma, and especially a focus on the category of posttraumatic stress disorder (PTSD), are adequate in assessing the multiple effects of such experiences. Recent studies are reviewed to indicate the strengths and limitations of current research approaches. Rates of PTSD in such studies have varied with relatively low rates being found in recent epidemiologic studies undertaken on refugee populations. It is suggested that a focus on intervening psychosocial adaptive systems may assist in delineating more clearly the pathways that determine whether traumatized persons achieve psychosocial restitution or are at risk of ongoing psychiatric disability. A model is proposed which suggests that torture and related abuses may challenge five core adaptive systems subserving the functions of "safety," "attachment," "justice," "identity-role," and "existential-meaning." It is argued that a clearer delineation of such adaptive systems may provide a point of convergence that may link research endeavors more closely to the subjective experience of survivors and to the types of clinical interventions offered by trauma treatment services.

Methodological issues in the use of survey questionnaires to assess the health effects of torture

It has become increasingly important to identify torture survivors among subgroups of the American population and to assess the continuing health effects of torture experience. To determine whether survey questionnaires can be effectively used to make such assessments, we reviewed the recent literature on refugee health, on the measurement and treatment of trauma, and in the related areas of survey methodology and cognitive psychology. We conclude that, if properly conducted, the survey approach represents an effective method, and we propose specific recommendations concerning procedures that may be used in surveys of torture survivors to maximize study validity.

Short-term treatment of a Central American torture survivor

The short-term treatment of a Honduran torture survivor is recounted. Torture--the "counter-therapy of the State" (Ritterman 1987, p. 43)--involves intentional physical and psychological destruction of human beings. The socio-political context in which the traumatic events occurred is described, as are the theoretical and ethical assumptions underlying the work. Treatment of victims of organized violence is a formidable challenge. Obstacles and advantages of short-term psychotherapy and use of the therapist's emotional reactions to understand survivors' experiences are emphasized.

Anxiety, depression and PTSD in asylum-seekers: assocations with pre-migration trauma and post-migration stressors

BACKGROUND

Research into the mental health of refugees has burgeoned in recent times, but there is a dearth of studies focusing specifically on the factors associated with psychiatric distress in asylum-seekers who have not been accorded residency status.

METHOD

Forty consecutive asylum-seekers attending a community resource centre in Sydney, Australia, were interviewed using structured instruments and questionnaires.

RESULTS

Anxiety scores were associated with female gender, poverty, and conflict with immigration officials, while loneliness and boredom were linked with both anxiety and depression. Thirty subjects (79%) had experienced a traumatic event such as witnessing killings, being assaulted, or suffering torture and captivity, and 14 subjects (37%) met full criteria for PTSD. A diagnosis of PTSD was associated with greater exposure to pre-migration trauma, delays in processing refugee applications, difficulties in dealing with immigration officials, obstacles to employment, racial discrimination, and loneliness and boredom.

CONCLUSIONS

Although based on correlational data derived from'a convenient' sample, our findings raise the possibility that current procedures for dealing with asylum-seekers may contribute to high levels of stress and psychiatric symptoms in those who have been previously traumatised.

Homeless, helpless and hospitalised: the travails of a Chinese refugee

OBJECTIVE

To report the case of a Chinese refugee who presented with a brief reactive psychosis in the presence of significant stressors.

CLINICAL PICTURE

A 30-year-old Chinese refugee, who fled alleged torture and persecution in China, presented with an acute, severe, paranoid psychosis.

TREATMENT AND OUTCOME

This patient's psychosis was exacerbated by involuntary hospitalisation and treatment. The withdrawal of restrictive measures, cessation of medications and attention to his social needs led to an improvement in his condition.

CONCLUSIONS

Involuntary treatment of a brief reactive psychosis in those who have been previously tortured may exacerbate the psychosis. Withdrawal of restrictions and advocacy for the patient may generate a therapeutic alliance with a positive outcome.

Narrative constructions of historical realities in testimony with Bosnian survivors of "ethnic cleansing"

Mental health care for traumatized refugees includes practices common to mainstream mental health care but also modifications and innovations in technique and approach. One such innovation, the testimony method, was first described by a group of Chilean psychiatrists working with Chilean survivors of torture from political repression (Cienfuego and Monelli 1983). The testimony method has been used as a time-limited psychotherapeutic intervention, often within the context of an extended, supportive psychotherapy. This method consists of asking individuals to tell in detail the story of their experiences of victimization from state-sponsored violence and recording their narrative accounts verbatim. Agger and Jensen's account of this method depicts testimony as a universal practice, appearing in multiple cultures and at different points in history (Agger and Jensen 1990). They also note that testimony simultaneously functions in both the private and public domains; and as confession embodying the person's spiritual, ethical, aesthetic, and philosophical values, and as evidence documenting the occurrence of evil events to the world.

Risk of retraumatisation of asylum-seekers in Australia

Australia has a long legacy of providing asylum to refugees who, it is now well established, suffer high rates of psychological and psychiatric problems requiring specialised treatment. In this paper we outline the special stressors faced by asylum-seekers who have not obtained formal refugee status and who are at risk of being forcibly repatriated. We suggest that the experiences they undergo in Australia, particularly that of prolonged detention, risk retraumatising an already vulnerable group. The implications for policy formulation are considered.

Somatisation as a presentation in depression and post-traumatic stress disorder among Cambodian refugees

Three Cambodian patients with Depression and Post-traumatic Stress Disorder (PTSD) presenting with somatic complaints are described. Their case histories support previous observations that somatisation is the most common presentation of Cambodian patients with Depression and PTSD. The probable reasons why depressed, traumatised Cambodian patients somatise their psychiatric problems are discussed. These cases illustrate the difficulties involved in engaging such patients in Western style psychotherapy, but show the effectiveness of small doses of antidepressants in treating the depressive and post-traumatic stress symptoms.

Variations in therapeutic interventions for Cambodian and Chilean refugee survivors of torture and trauma: a pilot study

The treatment of refugee survivors of torture and trauma has attracted increasing clinical attention. The present study surveyed therapists concerning the emphasis that was placed on disclosure of previous traumatic experiences in therapy with refugees from Chile and Cambodia. Significant differences were found between the two groups with trauma story discussion being judged by therapists to be more important to treatment outcome in Chilean patients. The problem of potential therapist bias limits definitive conclusions, however we suggest that differences in cultural preparedness for psychotherapy aimed at uncovering previous traumatic experiences may be the main reason for variations in styles of therapy offered to these distinctive ethnic groups. Other possible explanations are differences in diagnostic profiles and types of previous traumatic experiences.