Rehabilitation for Survivors of Torture
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Introduction[edit | edit source]
Individuals who have experienced torture and severe trauma are found throughout the international community. Among the most vulnerable are persons who have been forcibly displaced from their homes. According to the UNHCR, this includes 25.4 million refugees, 40 million internally displaced persons, and 3.1 million asylum-seekers. (UNHCR) Before and during flight, many forcibly displaced individuals experience traumatic events such as imprisonment, torture, loss of property & livelihood, physical abuse, separation from family, and malnutrition.(Refugee Health) These conditions can result in serious physical and psychological harm.
As the population of forcibly displaced persons continues to grow,(UNHCR) so does the reach of its social, physical, and psychological consequences. As a result, physical therapists are increasingly likely to work with patients who have experienced severe trauma or torture. In order to meet the comprehensive rehabilitation needs of this population, it's imperative that physical therapists be aware of and address special considerations for patient care.
The Physical and Mental Impact of Trauma and Torture[edit | edit source]
Trauma encompasses any event in which an individual experiences extreme distress or emotional disturbance. Torture is a specific type of trauma in which mental or physical suffering is purposely inflicted to punish, coerce, or intimidate a person or third party.(UN convention) Methods of torture include beatings, suspension, forced positions, strapping, electroshock, and sexual violence. The nature of these methods make injury to the musculoskeletal, neurological, and integumentary systems common.(Gueron) Post-traumatic stress disorder (PTSD), depression, and anxiety are psychological sequelae that may persist well after physical wounds have healed. Moreover, ongoing psychological stress can manifest in the form of chronic somatic pain.
General Considerations[edit | edit source]
In light of the physical consequences of trauma and torture, physical therapy is an important part of recovery for survivors. A trauma-informed approach to patient care can promote healing by establishing an environment characterized by safety, empowerment, trust, collaboration, and cultural competence.(SAMHSA) The table below outlines a list of considerations and strategies for establishing a therapeutic treatment environment:
Strategies to Avoid Client Re-traumatization (Franklin, Gueron)
Language and Culture
Consideration | Strategies |
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English may not be the client's first language. |
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Sensitivity to working with individuals of the opposite sex. |
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Trust
Consideration | Strategies |
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Fear of being let down. |
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Safety
Consideration | Strategies |
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Certain positions, settings, uniforms, equipment, or treatment interventions can provoke discomfort and flashbacks. |
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Sensitivity to prolonged questioning and interrogation. |
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Assessment[edit | edit source]
While there is no limit to the impairments and functional limitations that trauma can cause, patterns in symptoms may exist. The following is a collection of common findings that may be noted during the history taking and examination process:
- Headaches
- Chronic pain of the joints and muscles
- Changes in vision
- Dizziness
- Postural impairments
- Sleep disturbances
- Muscle tension and weakness
- Muscular imbalances
- Decreased mobility
- Inability to perform activities of daily living
- Impaired self-regulation (breathing rate & pattern, relaxation)
- Impaired sensation and body awareness
Further insight into client presentation can be gleaned from injury context and comorbidities. In particular, psychological conditions and maladaptive coping strategies can modulate how clients experience pain and other symptoms impacting function. For instance, while dissociation can be an effective mechanism for surviving torture, afterwards it can lead to difficulties in localizing pain and coordinating body movement.(Gueron) Thus, screening for psychiatric symptoms and affective barriers, like depression and avoidance behavior respectively, should be part of the physical therapy evaluation. If positive, referral for psychological support (ex. counseling, psychotherapy) is warranted.
Treatment[edit | edit source]
Physical therapy intervention should emphasize empowerment and collaboration. Clients should be partners in determining the acceptability and progression of techniques, especially in the case of electrical equipment and hands-on techniques that may trigger re-traumatization. When in doubt, the use of potential triggers should be deferred to maintain client trust and safety. Group sessions, self-regulation, and relaxation training are interventions that may complement traditional PT sessions well.(Gueron, Gamble, Franklin)
Ongoing education and home exercise programs are instrumental in promoting self-efficacy. For those experiencing chronic pain, pain science is key for re-framing clients' understanding of movement and pain.(Gamble) However, in teaching self-management strategies, physical therapists must account for psychosocial factors that influence adherence.(Franklin) Outside of physical and psychological recovery, many forcibly displaced persons are also dealing with financial and legal problems, unsatisfactory living conditions, adaptation to a new culture, family separation, and religious, racial and/or ethnic hostilities. Complex clinical and social needs can make the rehabilitation process take longer average. These conditions may necessitate more modest goal setting and criteria for client progress.
Conclusion[edit | edit source]
System or organization wide measures should be implemented to give physical therapists the flexibility and support needed to effectively work with forcibly displaced persons and survivors of torture. Client-centered care is the foundation to promote healing.
Resources[edit | edit source]
- healingtorture.org- Physical Therapy/Physiotherapy
- The Center for Victims of Torture