Rehabilitation for Survivors of Torture: Observations from Humanity and Inclusion
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Top Contributors - Naomi O'Reilly, Wanda van Niekerk, Kim Jackson and Kirenga Bamurange Liliane
Value Added Practice and Considerations for Enhancement in Migrant Care[edit | edit source]
Physiotherapy services are being used to support the recovery of survivors of torture within an interdisciplinary setting. As the contexts of the victims are changing and new ways are needed to increase access to physiotherapy for the users, it is important to back up these needs with more evidence based practice allowing smooth integration of physiotherapy practice in the mental health driven care models currently. This situation presents a significant challenge to the activity set up and needs attention and consideration from the field actors and stakeholders making the care possible and involved in it. Evidence based practices available so far suggest that they need to be scaled up and proposed as complete activities, either as standalone or in a care chain as difficulties in context allow, for patients and the care team monitored by clinical practice scaling, with use of common outcome measures, operational research and capacity building of the workforce involved. Techniques applied and their modalities should pay attention to the specific background and particular ‘ history of the patients' traumatic experiences to withhold trust and therapeutic connexion with the patient. As there is a need to continue developing research and translate this research into practice for the field, it should also be backed up by adapting the methods of delivery of the services to constant changing environments. The ultimate goal for the physiotherapy is to ensure that the patient can integrate the acquired skills from the treatment into their recovery and reconstruction process. This should not be limited to the therapeutic compliance only face to face, but should be put in perspective with minimum conditions of safety, protection and benefit of basic needs. The shift of care as recovery advances and its follow-up and ultimately discharge from treatment should also be taken into account in the care model of physiotherapy, be it to equip the patient with skills that can use to increase their resilience as well as promote elements of an inclusive immediate living environment the recovered person can return too at community level.
Rational for Enhancing the Role of Physiotherapy[edit | edit source]
Physiotherapy services are considered as a significant care component for enhancing parts and phases of the recovery of survivors of torture, especially when the first intake of these patients shows lesions and injuries requiring physical rehabilitation in order to recover from injury and regain normal function again. It is known that the effects of Violence and Torture, having a devastating impact on the individual and their environment, are not only physical but of a psychological nature as well. It is crucial therefore to have all necessary services (medical, psychological, legal, social) aligned in the most appropriate and relevant way for the benefit to the patient in order to maximise a recovery that should make sense to them and their surroundings .
More recent development in the humanitarian space relating to increased migration of populations that are exposed to a higher risk of contact with violence / injury events and effects, service provision for this population got more attention from a small number of experienced health providers in physical and psychological rehabilitation attempting to raise more attention to the needs for these victims beyond the classical medical and psychological approach and its available evidence base .
Alongside the pool of health professionals working with this population, physiotherapist staff working in these conditions/environments face important challenges on how to combine functional recovery with the special and unique needs these patients have when it comes to managing the symptoms and complaints the patients present with once the first wave of physical impairments (muscular skeletal, neurological,…) have been addressed and should answer to the widely accepted holistic recovery path when possible.
At this point, physiotherapist and/or rehabilitation workers are confronted with an additional therapeutic questioning that, at times, is addressed by a range of approaches such as specialised and dedicated treatment techniques combining other care elements beyond the classical body systems and structures ’ observation that physiotherapy uses. They include managing the clinical signs of persistent pain, for example altered body perception by the patient, reactions towards flashbacks relating to traumatic events leading to a continuing search for solutions and self-care options to help the patient manage the signs, live with them, insert them in the patient's own resilience pattern and daily life struggles that they are trying to overcome .
Taking this into consideration, it is inconceivable that physiotherapy is being able to address these issues alone, and there is a need to integrate these issues through the wider circle of health care workers that need to offer and share their specialties (mental health professionals, medical specialties, social workers, legal experts ,… ) in the holistic care program of the patient that was formulated during of the initial intake into the care program .
Barriers and difficulties to consider for physiotherapist treating VoT/ SoT The practice space and clinical environment of the physiotherapy integration contributing to access to services for SOT/ VOT and more particularly for physiotherapy must face a certain number of barriers. To mention a few , is the access to physiotherapy put in competition with other services ( medical , social , legal , psychological ) on the basis of prioritizing financial means to these other services be it on the local level but also on the more global level of allocating finances to care for VOT / SOT . Although being part of a multi-disciplinary approach for VOT/SOT , physiotherapy might not always be included systematically in the care set up of VOT programs / service points referring to the competition for financial means between the medical and mental health providers , the difficulties in integrating physiotherapy in the care model have also their reasoning in not using the already ( and if no so )available evidence-based physiotherapy in existing and functioning care systems to patients that could benefit from it . This has an impact on the interest to pursue more research in this field that would feed into the need for better and consistent indicators used by all care stakeholders around the patient in order to share the same focus and goals on the recovery of the patients and answering to his needs and expectation in one voice shared by the team . When these issues are compounded, this might lead to the actual reality leading to limited tools, approaches, treatment techniques for the physiotherapy stakeholders to handle. Moreover the geographical spread of the physiotherapy workforce in the areas where the VOT/SOT population meets most of the needs is unevenly distributed and compounded by the lack of skills development either at entry level practice but also at post graduate education level , leaving few offers for specialized physiotherapy training in the field of VoT / SOT skills management . A small number of stakeholders have developed specialized models of care in physiotherapy for VOT/ SOT and lead to substantial proof of impact and changes in terms of outcomes for patients as a standalone input or integrated with other services. Their practice record and subsequent publication of their results have lead to results and impact that can be reproduced in a variety of settings. Environment of care accessibility, its modalities and impact on care and caretakers Next to the contend and position of physiotherapy within models of care , they should also be put in perspective with the environment as to where the care is provided and the living conditions that patients are returning too after their treatment . Examples of these challenges and approaches within a constant changing environment the author for this writing has witnessed were related to the choice of offering the best care possible within an unsecure setting not conducive to ensuring a holistic approach for VOT care . This seems to reflect the situation of an increasing number of settings where delivery of physiotherapy is being either considered or ongoing . How can physiotherapy find its place in order to ensure its fullest range of known impact and changes in the lives of VOT/SOT ? Elements of answers could be located in the operational capacity of the structures where the care is provided either under a mandate of government health care provision , private care institutions , charity based providers and so called ‘informal spaces ‘’ where the care is offered in order to ensure protection and confidentiality for users and providers alike . The latter might have seen an evolution more recently in being able to capture an even more ‘’invisible ‘’ cohort of service users that is aspiring to access the care in very unstable conditions be it to access the services , become a user of the service and being a user of services going back to an environment that could expose him to new or additional trauma that he was seeking care for in the first place . It is clear that organizations , structures and providers of physiotherapy services ( either as a relative standalone or integrated in a multidisciplinary service offer ) do not chose the context of the VOT/SoT especially in the humanitarian space made up of a mixture of , conflict , migration , violence – torture exposure and sustained insecure environment . The dimensions of protection, basic needs ( food , shelter , education ) delivered in a safe environment need also to be considered in order to create minimum care conditions for the victims and providers alike. This leads us to the crucial reflection on how physiotherapy providers and their immediate network should be sufficiently prepared, briefed and trained in additional skills to function in such environments either adapting themselves to a changing context locally and/or fulfilling their roles in technical expertise provision when not familiar with the environment . Self care , psychological resilience , mental health hygiene should also play an important part in the training of physiotherapist when dealing with VOT/SOt in these environments supplemented with a constant follow-up and staff care component during the active clinical exposure to the patients and briefing opportunities during breaks or end of assignments .
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