Special Considerations for the Treatment of Pain from Torture and War

Torture survivors' experiences of receiving surgical treatment indicating re- traumatization

Due to the invasive nature of surgical procedures and the involvement of medical personnel, torture survivors may experience re-traumatization during surgical treatment. This study aimed to explore torture survivors' experiences of re-traumatization during surgical treatment as well as the process by which trauma-related emotions and responses are evoked during surgical treatment for torture survivors. Eight men, aged 45 to 72, from four different countries, who have lived in Norway for 6-40 years, were recruited. We assessed torture and surgical care experiences through in-depth interviews, and the data were analyzed using thematic analysis, resulting in five themes: (1) Interactions with healthcare providers, (2) Reactions during treatment, (3) Triggers causing re-experiences, (4) Avoidance, and (5) Suggestions to healthcare providers. In this study, survivors reported challenges receiving surgical treatment, indicating re-traumatization and difficulty returning to daily life following treatment. Participants reported little collaboration in care-related decision-making processes, lack of recognition of torture by healthcare providers involved in surgical care and experiencing healthcare professionals' attitudes as a source of perplexity, frustration, and despair. Exacerbation of torture memories throughout treatment and re-experiencing of trauma symptoms aggravated these difficulties. Our findings suggest that surgical treatment can remind torture survivors of the traumatic aspects of torture, eliciting strong reactions and feelings like those experienced during torture.

Torture Survivors and Asylum: Legal, Medical, and Psychological Perspectives

Torture occurs worldwide. Survivors seeking asylum are detained and must complete a complicated legal process to prove a "well-founded fear of persecution" if returned to their home countries. Forensic evaluations guided by the United Nations Istanbul Protocol increase asylum grant rates. Medical evaluation emphasizes skin examination, which can provide strong evidence of torture. Female genital mutilation and cutting, a basis for asylum, is classified according to the World Health Organization. Many resettled refugees and foreign-born immigrants at urban health care facilities have been tortured, but few report it to physicians due to factors affecting both survivors and physicians. Specific torture methods can cause characteristic long-term sequelae. Painful somatic disorders of mind-body interaction and psychological disorders are common. Practices derived from cultural factors and traumatized individuals' feedback enhance management of survivors. Individual and group psychotherapy provide modest proven benefit, but assessment is limited. Physicians and psychotherapists should coordinate care.

The association between chronic pain and pre-and-post migration experiences in resettled humanitarian refugee women residing in Australia

Background

Refugee women are potentially at increased risk for chronic pain due to circumstances both in the pre-migration and post-settlement setting. However, this relationship between refugee-related challenges introduced along their migration trajectories and chronic pain remains unclear. This study will therefore examine the association between pre- and post-migration factors and chronic pain in refugee women five years into resettlement in Australia.

Methods

The first five waves of data from the ‘Building a New Life in Australia’ longitudinal study of humanitarian refugees living in Australia was analysed using logistic regression models to investigate the association between predictor variables and chronic pain. The study outcome was chronic pain and predictors were migration process and resettlement factors in both the pre-and post-settlement setting.

Results

Chronic pain was reported in 45% (n = 139) of women, and among these a further 66% (n = 120) also reported having a long-term disability or health condition that had lasted 12 months. Pre- migration factors such as increasing age (OR 1.08; 95% CI 1.05, 1.11) and women who migrated under the Women at Risk Visa category (OR 2.40; 95% CI 1.26, 4.56) had greater odds of experiencing chronic pain. Interestingly, post migration factors such as women with better general health (OR 0.04; 95% CI 0.01, 0.11) or those who settled within metropolitan cities (OR 0.29; 95% CI 0.13, 0.68) had lower odds of experiencing chronic pain, and those who experience discrimination (OR 11.23; 95% CI 1.76, 71.51) had greater odds of experiencing chronic pain.

Conclusion

Our results show that there is a high prevalence of chronic pain in refugee women across the initial years of resettlement in Australia. This may be in part due to pre-migration factors such as age and migration pathway, but more significantly the post migration context that these women settle into such as rurality of settlement, poorer general health and perceived discriminatory experiences. These findings suggest that there may be many unmet health needs which are compounded by the challenges of resettlement in a new society, highlighting the need for increased clinical awareness to help inform refugee health care and settlement service providers managing chronic pain.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13226-5.

Torture-survivors' experiences of healthcare services for pain: a qualitative study

Background:

Increasing numbers of torture-survivors are presenting to UK healthcare services with persistent pain. However, there is a paucity of evidence surrounding the management of persistent pain among torture-survivors and their experience of healthcare services for pain is currently unknown. This qualitative study explores their experiences of services for managing pain, to inform clinical practice and service provision.

Methods:

Thirteen participants were recruited from a specialist pain clinic for torture-survivors in the United Kingdom. Utilising an ethnographic approach, data were collected via clinic appointment observations, interviews and medical records and analysed using inductive thematic analysis.

Results:

Three themes emerged in relation to torture-survivors’ experiences of healthcare services for pain: the patient–clinician relationship; multiplicity of diagnoses and treatments; lack of service integration. Participants described limited engagement in decision-making processes regarding their care. Lack of recognition of torture experience when diagnosing and treating pain, alongside multiple unsuccessful treatments, led to confusion, frustration and hopelessness. These issues were exacerbated by the disconnect between physical and mental health services.

Conclusion:

This study provides new insight into the challenges faced by torture-survivors when accessing healthcare services for pain. Our findings suggest current service provision is not meeting their complex needs. Clinical implications include the need for integrated care systems and better recognition of the influence of torture experience on persistent pain. Strategies to engage and empower torture-survivors in the management of their pain are suggested.

Two Patient Cases Illustrating the Importance of Addressing Physical and Mental Trauma as a Cause of Pain in Refugee Women

Refugees, and more so women than men, are often seeking medical care for a wide range of health-related problems, among which persistent pain has long been recognized as a defining feature. When treating refugee women for any condition, pain and its consequences need to be addressed in the rehabilitation efforts. It is therefore essential that health professionals engaged in the care of refugee women are familiar with the physiology of pain mechanisms, including the biopsychosocial model of pain, as well as the best evidence-based practice in managing pain, acute as well as chronic. Persistent or chronic pain not only causes disability and restricted functioning but also produces psychological impairments, compounding the impact on overall personal and social functioning. Yet, the research literature on health regarding refugees is predominantly targeted at mental health problems without specific reference to pain and pain as a significant cause of distress and disability due to migration (pre-and post). Pain as a consequence of torture is also an issue that is under-assessed when refugees are seeking medical aid for pain-related problems. When aiming at treating refugee women with disabling pain, one can use the same intervention methods that are being used for other chronic pain states. Professionals need, however, to be able to work with less written information and in close co-operation with interpreters. Reviews of the rehabilitation literature have noted a lack of scientifically rigorous studies of multicomponent interventions for refugees. Only few studies have evaluated outcomes of pain management, and the quality of the evidence they provide is very low. The small number of randomized controlled trials and the resulting paucity of information means that recommendations amounting to good clinical practice for refugee women with persistent pain are lacking. The aim of this article, illustrated by two patient cases, is to point out important areas that need to be addressed within the health care system in order to improve health care for refugee women. Pain is a common reason for refugee women to seek medical aid, is a costly burden for the society, and decreases quality of life for these women.

Post-migration treatment targets associated with reductions in depression and PTSD among survivors of torture seeking asylum in the USA

Mental health research among asylum seekers and refugees has largely focused on effects of pre-migration trauma on post-migration wellbeing. While emerging literature highlights the importance of post-migration factors, we do not yet understand how addressing these factors may influence change in psychological distress. This study uses archival clinical data to identify post-migration correlates of reductions in distress among torture survivors, after accounting for pre-migration trauma. Depression (Patient Health Questionnaire-9) and Post Traumatic Stress Disorder (PTSD; Harvard Trauma Questionnaire) were measured among torture survivors following 6 months of interdisciplinary treatment (N = 323). Relationships between pre-, post-migration factors, and changes in symptom levels from intake to six months follow-up, were evaluated using regression analyses. Average levels of depression and PTSD significantly reduced after six months of treatment. Higher exposure to pre-migration trauma, female gender, and change to a more secure visa status were associated with reduced distress. Accessing more social services and not reporting chronic pain were associated with reduced PTSD. Stable housing and employment significantly moderated the relationship between lower chronic pain and reduced PTSD. Although effect sizes were small, results emphasize the importance of post-migration factors on wellbeing among torture survivors and are a first step towards identifying key treatment targets.