Rehabilitation for Survivors of Torture

Introduction[edit | edit source]

Figure.1 Source: Pixabay, License: CC0

Individuals who have experienced torture are found throughout the international community. Among the most vulnerable, are persons who have been forcibly displaced from their homes. According to the UNHCR,[1] this includes 27.1 million refugees, 53.2 million internally displaced persons, and 4.6 million asylum-seekers. Before and during flight, many displaced persons experience torture,[2] which can result in serious physical and psychological harm. As the population of displaced persons continues to grow,[1] so does the reach of its social, physical, and psychological consequences. As a result, rehabilitation professionals are increasingly likely to work with individuals who have experienced torture. In order to meet the comprehensive rehabilitation needs of this population, it's imperative that rehabilitation professionals be aware of and address special considerations for patient care.

What is Torture?[edit | edit source]

Trauma refers to any event that is experienced as being emotionally harmful and has a lasting negative impact on an individual's well-being.[3] Torture is a specific type of trauma and is clearly defined by the ‘United Nations Convention against Torture and Other Cruel, Inhuman or Degrading Treatment and Punishment’, known as the UNCAT, which came into force in 1987. Article 1 of the UNCAT states:[4]

"Torture means any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining from him or a third person information or a confession, punishing him for an act he or a third person has committed or is suspected of having committed, or intimidating or coercing him or a third person, or for any reason based on discrimination of any kind, when such pain or suffering is inflicted by or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity. It does not include pain or suffering arising only from, inherent in or incidental to lawful sanctions."[4]

In simple terms, this definition means that to be classified as torture, an act must inflict severe suffering, and be carried out intentionally and for a specific purpose, by a person acting in an official capacity.

Surviving torture can result in long-term physical impairments, and may also cause survivors to question their basic trust in the world and other people. [5] [6] Survivors of torture (SoT) are frequently classified as primary or secondary. Primary SoT are people who were directly tortured or forced to witness or participate in the torture of another person. Secondary SoT are close family members or relationships to the primary survivor. Secondary survivors can be vicariously traumatised, meaning they may experience secondary traumatic stress from second-hand exposure to their loved ones' trauma, resulting in their own trauma reaction, including physical symptoms. [7][8]

Epidemiology[edit | edit source]

According to the United Nations High Commission on Refugees (UNHCR), in 2019 there were 22.5 million refugees worldwide, of whom up to 35% report being survivors of torture.[9] Despite the UNCAT and the ban on torture in 2009, the number of countries worldwide that continue to practise systematic torture was estimated as 50% of all countries[10] or as many as 141 countries.[11] The use of torture remains a global public health problem among displaced persons and has been shown to have a long-standing impact on individuals, their families, and communities.[12]

Rehabilitation Response to Torture[edit | edit source]

Dignity (Danish Institute Against Torture), founded in 1982, was the first European centre for the rehabilitation of survivors of torture that included multidisciplinary care including physiotherapy; the evidence base for physiotherapy as part of the rehabilitation of SoT has been growing steadily since then.[13][14][15] Currently, over 200 centres for the medical treatment and rehabilitation of SoT exist worldwide. Advice for rehabilitation professionals working with this patient group for the first time readily acknowledges the apprehension rehabilitation professionals might feel working with such a sensitive patient group. However, given the increasing focus within the profession on skills such as management of chronic pain, patient education and self-management, the modern rehabilitation ‘tool-box’ is well equipped with knowledge and skills that can be adapted to work with this group.

Types of Torture[edit | edit source]

The Istanbul Protocol [16], revised in 2022, which builds upon the previous 2004 edition[17], is the official United Nations Guideline for documenting torture and its effects, considers torture as a process that can involve both physical and psychological methods, producing both physical and psychological effects.

Methods of Torture[edit | edit source]

The Istanbul Protocol outlines a number of commonly recognised methods of torture. The list is extensive and includes blunt trauma such as whipping or beating, positional torture, burns, electric shocks, sexual violence, conditions of detention such as solitary confinement, deprivation of sleep, water, food, threats of death or harm to themselves or family members, forcing the victim to witness or cause harm to others, acts of humiliation verbally or physically.[16][17]

Understanding the method of torture used can aid the physiotherapist in understanding the injuries and managing the assessment and treatment appropriately and sensitively. There may be national and regional patterns in the types of torture that are carried out. Some methods, such as forcing someone to maintain a cramped position in a small cage or box, may be selected because they are less likely to leave incriminating marks or wounds on the body. The lack of physical scars should not be taken as an indication that the person did not experience torture. Understanding the types of torture employed is important for rehabilitation professionals documenting alleged torture and can support the validity of the survivor's statement. [16]

Impact of Torture[edit | edit source]

Pre-, Peri- and Post-Migration Factors and the Social Impact[edit | edit source]

At its root, torture aims to destroy the integrity of a person and eviscerate their sense of self. Torture seeks to “break” its victim through the intentional use of intolerable pain to destroy and/or damage the physical and psychological integrity of the individual and, by extension, the integrity of the family and community. [20]

Torture is an intimate, interpersonal trauma that often occurs in secrecy or seclusion and renders its victims silent and ashamed. This is particularly true for sexual torture or torture which breaks cultural taboos. It may instil intense and overwhelming feelings of distrust, betrayal, and isolation. In the patient-therapist relationship, this can impact disclosure and trust.

As torture is, by definition, carried out by persons acting in an official capacity, it may mean that the survivor has to flee their country in search of safety. However, displaced persons fleeing torture, encounter many barriers to resettlement in Europe, or their country of refuge. While rehabilitation professionals may focus on the outcomes of the torture experience itself (e.g. scar tissue, fracture malunion, chronic pain), SoT have likely experienced many additional stressors that impact their health status and well-being. [21] [22] During flight, SoT may experience significant physical and psychological hardships, making unsafe journeys or dealing with exploitation from attempted human traffickers or kidnappers. Upon resettlement, SoT experience many losses (e.g., status, identity, family, employment, property, etc.), and often live with uncertainty about their immigration status and their safety in their country of arrival. [23] These experiences interact with and compound their distress related to their torture.

This continuum of potentially traumatising experiences, also known as the ‘Triple Trauma Paradigm’, [24] occurs at the pre-, peri- and post-displacement phase for displaced persons,[25] meaning;

  1. The traumatic experiences that disrupt life and cause the person to flee.
  2. The uncertainties and trauma experienced during the flight to safety.
  3. The adjustment and uncertainties confronted in a new country, often without an understanding of the language or culture, or the ability to work [25]

Physical Assaults[edit | edit source]

Physical torture is in most cases directed toward the musculoskeletal system. It is aimed at producing soft tissue lesions and pain and usually leaves no visible evidence after the acute stage. Some studies have shown that pain in the musculoskeletal system (prevalence up to 48%); headache (38 - 50%); pain in the back (up to 43%); pain in the feet (19 - 28%); and joint pain (19 - 43%) are examples of frequently reported somatic symptoms among previously tortured displaced persons.[26]

The impact of physical assaults on the body varies depending upon which type of torture method(s) have been used. The impact of some methods has been more widely documented than others.

For example; victims of Falanga, which is the repeated application of blunt trauma to the feet, typically present with persistent pain of burning, stinging and/or cramping nature, sensory disturbances, walking difficulties including alterations in gait pattern, reduced stride and walking speed.[27] Clinical findings include reduced elasticity in the footpads, skin changes, damage to the plantar aponeurosis and myofascial changes in the lower limb including compartment syndrome. Palestinian hanging can cause major damage to the shoulder joint complex and creation of brachial plexus damage.[28]

More broadly, fractures, dislocations, muscular contusions, lacerations, amputation of digits, peripheral nerve lesions, pelvic floor trauma, neurological damage, hearing loss, visual problems, pain, scars and headaches are just a handful of the direct physical effects seen on the body as a result of torture. In addition to these assaults, a number of factors may have affected the healing and chronicity such as lack of access to proper medical treatment or rehabilitation during the time of healing.

Torture as a ‘Traumatic Event’[edit | edit source]

In order for a method to be classified as torture, it must cause ‘severe pain and suffering'.[17] This can be very difficult to classify as it is a largely subjective measure and can be impacted by factors such as age, gender, health, cultural background or religious conviction of the victim.

Clients who have experienced the same methods of torture can present in very different ways. As a treating rehabilitation professional, it is important to keep in mind that as with any other experience, the physical and psychological impact of torture is subjective and a person who has an isolated experience of torture may have lesser, equal or greater needs for rehabilitation than a survivor of prolonged or severe torture. When treating a torture survivor, it’s important to not only treat the impact that the physical assaults have had on the body but also to recognise and treat the impact that experiencing a traumatic event has on the body.

Trauma can be defined as ‘a shock to your system’, physically or mentally. Defining characteristics are that it is:

  • Outside the range of normal experience
  • The event threatens the person’s life or physical integrity, or the life or physical integrity of a close other
  • The event makes the person feel helpless and out of control
  • The event exceeds a person’s ability to cope

When you have experienced trauma, you realise it can happen again. As a result of this, your brain and your body can start to function in ‘survival mode’. This affects the way the brain and body communicate and affects our normal homeostatic mechanisms.

Essentially, trauma dysregulates the autonomic nervous system. The results of this are that multiple body systems are affected.

Symptoms of Trauma[edit | edit source]

Table.1 Symptoms of Trauma
Psychological Physical Social
  • Intense anxiety/fear
  • Anger or irritability
  • Feeling sad or hopeless
  • Poor memory
  • Confusion/difficulty concentrating
  • Loss of meaning or purpose
  • Feeling of guilt or shame
  • Shock/denial or feeling numb
  • Easily startled
  • Wanting to avoid places/people
  • Insomnia or nightmares
  • Feeling tired
  • Racing heartbeat
  • Sweating
  • Breathing difficulties
  • Muscle tension
  • Chronic pain
  • Coordination/balance problems
  • Nausea/vomiting
  • Dizziness or fainting
  • Weight change
  • Upset stomach, cramps
  • Isolation
  • Not being able to trust others
  • Loss of interest in others
  • Insecurity
  • Avoidance of intimacy
  • Family problems
  • Loss of interest in work/hobbies
  • Overprotective behaviour
  • Aggressive behaviour towards others
  • Being overly critical of others
Long Term Psychological Effects:[edit | edit source]

Include difficulty concentrating, nightmares, insomnia, memory loss, fatigue, anxiety, depression and post-traumatic stress disorder.

Long Term Physical Effects: [edit | edit source]

The effects of these physical symptoms in the body chronically cause a number of conditions and disorders that rehabilitation professionals commonly treat.

Common ‘Trauma' conditions treated by rehabilitation professionals:

  • Anxiety - Decreased balance, faintness, dizziness, headaches, muscle tension panic attacks
  • Depression - Low energy, fatigue
  • Post Traumatic Stress Disorder - Avoidance of certain movements related to torture experience, cardiorespiratory symptoms such as heart racing, shortness of breath, chest heaviness, difficulty breathing
  • Chronic Stress - Musculoskeletal changes as a result of pain, tension and decreased core stability
  • Pelvic Dysfunction - Pelvic floor weakness, dyspareunia, avoidance of intimacy, incontinence
  • Sleep Difficulties - Falling asleep, frequent night waking
  • Persistent Pain - Widespread and generalised pain
  • Decreased Body Awareness - Numbing of sensations, difficulty identifying sensations, changes in posture, decreased flow and vitality to movement
  • Self-regulation Problems - Unable to control the escalation of disturbing sensations such as heart racing, breathing, dizziness
  • Gastrointestinal Problems - Irritable Bowel Syndrome (IBS) symptoms including nausea, pain and constipation

These conditions may be worsened by prison or camp conditions where there may have been a lack of access to water, food, medicine and general sanitary conditions. Infections and poor health amplify these existing conditions.

Role of Physiotherapy with Survivors of Torture[edit | edit source]

In light of the physical consequences of trauma and torture, physiotherapy is an important part of recovery for survivors. As a result of the complex interplay between psychological, physical and social factors, physiotherapists should use a Biopsychosocial Approach with survivors of torture. Torture survivors struggle to manage both the injuries sustained as a result of the physical assaults and the disturbing physical symptoms of trauma and subsequently cope with activities of daily living. The overall goal of physiotherapy is therefore to enable them to manage these symptoms in order to improve their functional ability. The key goals of rehabilitation can be summarised as follows:

  • Treat the direct effects of physical assaults of torture
  • Treat the physical effects of trauma on the body

In doing so, the primary impacts on their health can be summarised as:

  • Improved functional ability
  • Decreased pain levels
  • Improved management of specific conditions e.g. incontinence, stress and sleep
  • Improved social participation and functioning
  • Improved coping and outlook
  • Improved body awareness and self-regulation

Due to the complex needs of torture survivors, an interdisciplinary approach to rehabilitation ensures that an individual can be treated holistically. Interventions are effective if delivered through individual or group settings alongside other disciplines, especially counselling. Where appropriate, combined interdisciplinary sessions can be delivered to facilitate shared goals and enhance the biopsychosocial response to the conditions being treated.

The Interdisciplinary Team[edit | edit source]

When working as an interdisciplinary team, a deep understanding of each other’s goals and treatment approaches enables the team to work together on shared and realistic goals and recognise those areas of overlap between the disciplines and maximise them. Examples of this overlap include consistency in delivering pain neuroscience education, reinforcement and practise of the same mind-body approaches such as breathing and relaxation, and providing psychoeducation on trauma and its symptoms.

Interdisciplinary team members typically include:

  • Physiotherapists
  • Psychosocial Counsellors
  • Social Workers
  • Medical Doctors
  • Nurses
  • Interpreters or Cultural Mediators
  • Specialist referral to psychiatrists and surgeons may be necessary.

Providing Rehabilitation to Survivors of Torture[edit | edit source]

In this section, we will discuss the Principles of Trauma Informed Care, recommendations for a successful assessment, which helps to build a relationship of trust with your patient/client. We will also explore Judith Herman’s mental health model of trauma recovery and how it can be adapted to physiotherapy, including treatment approaches to different symptom presentations that are common among survivors of torture.

Trauma-Informed Care[edit | edit source]

Sometimes your patient will come to you with a known background of torture, but given the high prevalence of torture among displaced persons, and the multiple reasons why they may be reluctant to disclose (e.g. fear, shame, lack of trust) you may or may not be aware of your patient's torture history. Therefore, we advocate using a trauma-informed approach with all patients/clients, irrespective of known torture status. Of course, trauma-informed care is also helpful for persons with a non-torture background of trauma, such as sexual assault, domestic violence etc. Trauma-informed care is relevant across all rehabilitation practices, not only with displaced persons or SoT.

Applying the principles of trauma-informed care to your treatment approach is about recognising the many ways in which a traumatic experience can impact all aspects of care, from communication to clinical reasoning. The basic principles of trauma-informed care can be summarised as follows:

  • Establish an environment where the client feels safe, connected, valued, informed, empowered and hopeful of recovery.
  • Apply the knowledge of trauma and paths to recovery to practices, policies and procedures.
  • Recognise the signs and symptoms of trauma in clients, families, staff and others involved in the system.
  • Work purposefully with individuals, family, friends and other social service agencies to promote and protect the autonomy of the client
  • Understand the concept of re-traumatisation and apply that knowledge to your services at the level of practices, policies and procedures.
  • Practise culturally competent and non-discriminatory policies, procedures and practices.

Assessment[edit | edit source]

Below are some guiding tips for your first assessment with your patient. Remember, that most of your ‘usual’ therapy skills such as taking a thorough history, observing range of movement etc. are still relevant. You just need extra care in how you interact with your patient/client. Assessment may take multiple sessions with SoT due to a complicated history and the need to build trust. If you feel that the patient is uncomfortable, give them an opportunity to ask a question or offer feedback, and then move on. A good physio-to-patient relationship is most important!

Simple Tips for a Successful Assessment[edit | edit source]

Interpreter / Translator[edit | edit source]

Remember that if you will be working through a translator, you should familiarise yourself with some considerations for doing that well here. Reassure your patient/client that the translator is also bound by strict confidentiality. Try to use the same translator for every session and be sensitive to potential issues of the translator and patient/client speaking the same language but being from different ethnic groups or tribes (e.g. if there is a background of civil unrest in their home country).

Greetings[edit | edit source]

Spending a little time familiarising yourself with some basic social customs from your patient's home country or learning how to say hello in their language can help to set the patient at ease and break the ice.

Trust[edit | edit source]

Experiencing torture fundamentally affects a person's ability to trust others. Unfortunately, health professionals have also historically been involved in administering torture - if your patient has experienced this, they may naturally be fearful of your role. Know that building a therapeutic relationship may take longer than usual, and remain patient.

Environment[edit | edit source]

SoT will likely feel more comfortable in a quiet, private space. If there is a door, do not lock or fully close it without their permission. Offer some time for the patient to explore the space and ask any questions about the room. Be aware that some equipment, such as pulleys or electrotherapy machines may trigger unpleasant memories for the patient (being bound or gagged, electrical torture). A ‘Do no disturb’ sign outside the treatment space can help your patient/client to relax.

Body Language[edit | edit source]

Non-threatening body language such as smiling, resting with your palms face up, sitting or standing at the same level or lower than the patient, and not ‘squaring’ your shoulders or torso toward the patient can help to set them at ease.

Explanations[edit | edit source]

Offer your patient an explanation of what will happen before it does, and check in frequently to ensure you have their consent to continue or to address any new fears or concerns that may arise as the session proceeds. Never touch a patient unexpectedly or without their explicit consent, e.g. "I’d like to take a look at your shoulder now, and to do that I will stand beside you and put one hand on your shoulder and one on your ribcage. Is that ok for you?"

Social[edit | edit source]

Understanding the social environment of the patient forms part of any biopsychosocial assessment but is particularly key with this patient group. Some considerations to keep in mind involve both the impact of displacement and your patient/client’s altered identity as a ‘displaced person’ and the impact of torture itself. These impacts are diverse and wide-ranging, and part of the reason why SoT are best treated using an interdisciplinary approach. This section is limited to practical examples of the implications for your approach and treatment.

Family and Interpersonal Dynamics[edit | edit source]

Torture is a form of interpersonal trauma that is purposefully used to create shame and destroy social bonds. Family members and close friends may or may not be aware that the person has experienced torture or its extent. This isolation may have practical implications for your treatment such as your patient/client trying to keep appointments (or their purpose) secret, or not feeling comfortable carrying out home exercise programmes in a shared space.

Community Standing[edit | edit source]

People may have been targeted for torture because of their prominent position in the community, for example as a public intellectual, political opponent or community organiser. Their new displaced person status leaves them open to anti-immigrant sentiment, and they often struggle to (re)attain stable socio-economic standing in a new country. Being aware of different power dynamics across your cultures, e.g. with regard to gender or age, and ways to demonstrate respect e.g. using a more formal address such as Dr. or Mrs., ensuring punctuality, can be a way to treat your patient/client in a way that respects their inherent dignity.

Livelihoods[edit | edit source]

Be aware that many displaced persons live in precarious financial situations. If they rely on public transportation to reach your appointments try to allow some flexibility on the appointment time, know that securing childcare may affect their ability to attend sessions and if you need to contact them about an appointment etc., make sure to call them directly and not leave a message that necessitates them having to initiate a new call.

Religious and Cultural Practices[edit | edit source]

This might impact whether your patient/client feels comfortable alone in the treatment room/cubicle with a therapist, working with a therapist of the opposite gender, or the level of undress or movement they feel comfortable with. Culturally specific holidays may affect their ability to attend sessions. An advance phone call before your first session where you give the client/patient time to express their preferences and anything that might help them to comfortably engage in their session can help.

Vulnerability[edit | edit source]

Displaced persons SoT may be in a vulnerable position - removed from their usual home, culture, language, and social support network and dealing with the physical and psychological impact of their experience. If you have concerns about the well-being of the patient (e.g. domestic violence, food insecurity) working with other members of the interdisciplinary team, such as the social worker, is helpful.

Strategies to Avoid Client Re-traumatisation[edit | edit source]
Table.2 Strategies to Avoid Re-traumatisation
Considerations Strategies
Language and Culture English may not be the client's first language.
  • Use of an interpreter to facilitate clear communication and the expression of subtle experiences and feelings.[29]
Sensitivity to working with individuals of the opposite sex.
  • Assess client comfort and sensitivity.
  • Arrange for treatment with a same-sex therapist, if necessary.
Trust Fear of being let down.
  • Be consistent and on time to therapy sessions.[30]
  • Encourage realistic client expectations.[29]
Fear of loss of privacy.
  • Respect client confidentiality.
  • Make sure interpreters know that rules regarding respect for client confidentiality extend to them as well.[29]
Safety Certain positions, settings, equipment, or treatment interventions can provoke discomfort and flashbacks.
  • Explain all procedures to clients beforehand.[29][30]
  • Ask for permission before touching a client. Check ongoing tolerance to physical touch.[30]
  • Give clients choices related to treatment (ex. treatment positions, speed of progression, intervention focus, choice of modalities) [29][30]
  • Caution with mirrors, bright lights, and uniforms.[29]
Sensitivity to prolonged questioning and interrogation.
  • Gather history using an open listening/discussion approach.[29]
  • Avoid excessive questioning.[29][30]
  • Break up initial evaluations over several sessions.[29][30]

Treatment Model[edit | edit source]

Judith Herman is an American psychiatrist whose mental health-based model of trauma recovery is employed in many torture treatment centres globally, and can be adapted by rehabilitation professionals for treatment with SoT. Herman’s approach emphasises the empowerment of the survivor and rebuilding their interpersonal relationships. [31] For this reason, if appropriate for your patient/client, treatment in a group setting can support rehabilitation. The model has three stages;

i) establishing safety

ii) reconstruction and

iii) reconnection.

As already outlined, it is vital to holistically address the needs of the SoT through an inter or multi-disciplinary approach. When adapting the Herman model to rehabilitation treatment, it is highly recommended to work closely with the psychologist or other mental health care colleague.

1. Safety and Stabilisation[edit | edit source]

People affected by trauma tend to feel unsafe in their bodies and in their relationships with others. This stage is the starting point and is necessary for all healing and engagement that follows. This occurs across many domains (psychological, behavioural, physiological, legal, environmental, social) and involves creating a safe space and stabilising the individual’s reaction to the preceding trauma.

In establishing Safety and Stabilisation, rehabilitation professionals should work towards:

  1. Empower the client as much as possible in all aspects of the decision-making and help them adapt to a pace that is tolerable for them.
  2. Provide interventions that help control the body’s symptoms of emotional distress.
  3. Consider how the treatment environment feels safe and not re-traumatising.

Specifically, tips for this stage include:

  • Allow the client to decide on the gender of their therapist as this will vary with cultural norms and trauma history.
  • Reinforce issues of confidentiality and maximise informed consent.
  • Consider using a translator or cultural mediator will help understanding of cultural norms and assist in building trust.

Treatment modalities typically used in this phase include:

Pain Education and Education about Trauma Symptoms[edit | edit source]

Allows cognitive restructuring of irrational thoughts, reduces fear, and reduces catastrophisation.

Diaphragmatic Breathing[edit | edit source]

This teaches clients to stimulate the vagal nerve to generate a parasympathetic response of the body which helps down-regulate symptoms of hyper-arousal (heart racing, shallow fast breathing, sweating, feelings of nervousness).

Relaxation Techniques[edit | edit source]

Physical relaxation techniques work on principles of progressive muscular relaxation, hold relax or reciprocal inhibition to help create a state of physical and in turn mental calm.

Sleep Hygiene Advice and Education[edit | edit source]

Advice and education around factors that encourage and prevent sleep are important in enabling an individual to modify their behaviours during the day and create a ‘bedtime routine’ which optimises the potential for better sleep.

Grounding Techniques[edit | edit source]

Help bring your focus to what is happening to you physically, either in your body or in your surroundings, instead of being trapped by the thoughts in your mind that are causing you to feel anxious. Having the client bring their focus to an object or feel the sensation in their feet in contact with the ground are examples of grounding and can help if the client is dissociating.

Mindfulness of Breath and Movement including Yoga Based Practices[edit | edit source]

These practices provide an opportunity for ‘interoceptive exposure’. Gradually the client learns to notice the sensations in their body associated with different emotions and different movements. Teaching them to pendulate back and forth between sensations that are disturbing to them and those that are not, helps them gradually recognise and normalise symptoms and learn how they can control them. [32]

Posture and Emotion (The ‘Somatic Narrative’)[edit | edit source]

Posture is linked to emotion. Helping a client identify the changes in their posture when their emotions change such as a slumped, rounded posture when sad and an open expansive posture when happy or confident enables them to recognise patterns of movement and posture and actively use this as a strategy to support positive emotions during their day. [33]

Self-Massage[edit | edit source]

Using available props they have at home and teaching self-massage is a way to bring pain relief especially if the client is not yet ready to be touched by the therapist.

2. Process of Reconstruction[edit | edit source]

Once a basic sense of safety is restored and the survivor is stabilised to the extent that the effects of the trauma no longer overwhelm his/her capacity to function, the focus is now on coming to terms with the trauma and its effect on one’s life. [34]

In this phase, rehabilitation professionals should work towards:

  • Reinforcing methods of stabilisation as an exploration into more challenging movements continue.
  • Empowering individuals to work towards goals with a focus on pacing
  • Acknowledging the loss of prior physical abilities and working together to regain or compensate for the impairments.

Treatment modalities typically used in this phase include:

Continuation of Mindfulness Activities[edit | edit source]

Enables individuals to increase awareness of their body’s sensations during previously avoided movements which may ‘trigger’ traumatic memories and subsequent body reactions. Working through these sensations as before to enable self-regulation is crucial in being able to restore normal movement. For example, hip abduction in supine is often avoided in survivors of rape.

Aerobic Exercise[edit | edit source]

In an educational context, individuals will understand the benefits both for their general health and in alleviating symptoms of depression. Practising different forms of aerobic exercise during treatment sessions enables individuals to feel an immediate sense of well-being and consider which types may work for them in their home context. A consistent programme of aerobic activity also helps alter levels of arousal and energy combating fatigue, and lethargy and better enabling individuals to engage in other activities of daily life. Consideration should be given to access resources and the home setting where there may be limitations of space, safety and confidentiality.

Strength Work[edit | edit source]

Is typically focused both on general body conditioning and more specifically on a particular area of weakness. There should be a focus on core stability to mitigate the effects of the body’s chronic fight or flight response following a traumatic experience where energy is directed more to the global muscles. Strengthening of the pelvic floor and lumbosacral muscles are often incorporated into programmes. Working alongside a counsellor to teach ‘protective’ movements that empower an individual to move through their trauma memories can be a very powerful strategy in trauma recovery.

Flexibility[edit | edit source]

Stretching helps recover movement and also has a dual effect of relaxing the body. Trauma dysregulates the autonomic nervous system and one impact of this is on constriction of fascia. Targeted myofascial stretches are a key part of the programme.[35][36]

Balance[edit | edit source]

Decreased balance may present as a co-morbidity of anxiety[37] and so improving balance can improve anxiety, while decreased anxiety may be accompanied by improved balance. Challenging yoga-based practices have the added benefit of recovering strength, and body awareness in addition to balance.

Pacing and Goal Setting Education[edit | edit source]

A decreased ability to self-regulate symptoms in the body following trauma means that individuals often need support around gauging realistic amounts of activity towards their determined goals. Starting slowly and setting modest steps towards their goals helps clients feel successful. Progress should be highlighted for even small changes. To acknowledge the cognitive changes that impact memory and concentration following trauma, keep the information short and simple without too much detail. Limit the number of prescribed exercises to 4 or 5. Provide written and illustrated instructions. Consider additional support for appointment reminders: written, phone calls, etc. Helping individuals avoid ‘boom and bust’ cycles of activity or addressing issues of fear and avoidance on the opposite end is key in helping them self-regulate and return to functional levels of activity.

Manual or ‘Hands On’  Approaches[edit | edit source]

Manual treatments such as massage or joint mobilisations or ‘hands on’ referring to assisted movement or physical prompts can be important to restore safety in ‘touch’, something that may have been violated as part of their torture experience. These approaches should be applied cautiously to avoid re-traumatising the client and acknowledging usually heightened levels of sensitivity to pain. The therapist should provide a full explanation of the intervention along with the expected sensations in order to empower the individual to provide full consent. During these interventions, the therapist should observe for physical reactions such as facial expressions or withdrawing, physiological reactions such as sweating, fast shallow breathing, or psychological reactions such as emotional outbursts to the treatment. Providing gradual exposure to these interventions and stopping to help the individuals ground themselves will better enable success in progressing such interventions.

3. Reconnection[edit | edit source]

In this stage, assisting the survivor in rebuilding and re-engaging in their current life becomes a primary focus of rehabilitation. The focus should be on cultivating empowerment and reconnection. Herman suggests that the essence of this stage can be captured by the phrase, “I know I have myself.”  It is during this stage that torture survivors no longer feel held captive by their past and are often filled with insight into the positive aspects of themselves.

In this phase, rehabilitation professionals should work towards:

  • Facilitating a continued reconnection of the body through graded exercise, body awareness and self-regulation exercises.
  • Facilitate safe physical interactions with others.
  • Facilitate activities which promote a sense of joy to movement.
  • Achieving functional goals by continuing to facilitate goal-setting, pacing and tailoring of home exercise programmes.
  • Facilitate independent management of symptoms including management of exacerbations.
  • Supporting the survivor to seek external resources that promote reintegration into the community and social support networks.

Treatment modalities typically used in this phase include:

Pacing and Goal Setting[edit | edit source]

Continuing to help survivors identify the coping strategies and interventions that they will continue to use after discharge to continue working towards sustaining progress, meeting unmet goals and managing any future exacerbations.

Partner Activities[edit | edit source]

If working in a group setting or partnering with the therapist. Physical interaction to facilitate, for example, stretches or balance positions can be utilised as a way to encourage safe physical connection with others.

Dancing and Games[edit | edit source]

Depending upon what is culturally appropriate and the mode of delivery, specific cultural dances are effective in enhancing social bonding and reconnection through physical touch. Competitive games or exercise circuits promote a sense of joy in teams and the achievement of challenging activities renews a sense of confidence in their bodies.

Ergonomics and Preventative Advice[edit | edit source]

General education about ergonomic principles and practice of relevant activities or postures ensures healthy habits moving forward but also acknowledges that SoT often have an overly sensitised nervous system with higher co-morbidities or conditions such as chronic pain. Preventative advice and education ergonomically and in understanding how to manage acute injuries as they arise can help mitigate the descent into chronic pain states.

Outcome Measures[edit | edit source]

A variety of measures for functional ability,  pain levels, management of specific conditions such as incontinence, stress and sleep, improved social participation and functioning, improved coping and outlook and improved body awareness and self-regulation should be considered.

Outcome measures do not need to be specific to torture as a mechanism of injury. Using a Trauma Informed Approach, the most appropriate outcome measure for assessing the progress of an agreed goal or outcome can be applied, as with most other patient groups, for example, a Visual Analogue Scale, the Patient Specific Functional Scale, etc.

Clinical Guidelines[edit | edit source]

  1. World Physiotherapy Policy Statement: Torture
    • WCPT supports the United Nations Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment and encourages its member organisations to call on their national governments to sign and comply with the convention. WCPT will support and encourage the international community, its member organisations and physical therapists to support fellow physical therapists and physical therapists’ families in the face of threats or reprisals resulting from a refusal to condone the use of torture or other forms of cruel, inhuman or degrading treatment.
  2. UNCAT Implementation Tool 5/2018 Providing Rehabilitation to Victims of Torture and other Ill Treatment
    • This tool provides an overview of how states have implemented the right to rehabilitation through a collection of practices, supplemented with experiences from non-state rehabilitation providers. The practices included in this tool are intended to inspire states to learn from each other and thereby improve implementation at the national level, within the OSCE region and beyond. Promising practice examples from the OSCE region and from other parts of the world have been collected to illustrate possible approaches and steps on the way to ensuring torture victims’ rights to the fullest possible level of rehabilitation.
  3. Istanbul Protocol; Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment
    • The Istanbul Protocol: Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment is intended to serve as international guidelines for the assessment of persons who allege torture and ill-treatment, for investigating cases of alleged torture and for reporting findings to the judiciary or any other investigative body. This manual includes principles for the effective investigation and documentation of torture, and other cruel, inhuman or degrading treatment or punishment. These principles outline minimum standards for States in order to ensure the effective documentation of torture.
  4. DIGNITY Facts about the Health Consequences of Torture and Other Il- Treatment Methods
    • This is a series of one-page fact sheets each defining a method of torture or ill-treatment, recapping related international standards and outlining the health consequences. They use the torture definition of the UN Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment (UNCAT). The purpose of the fact sheet series is to empower partners with information; to raise awareness of professional staff who encounter survivors, and to initiate dialogue on the use of these methods.

Optional Resources[edit | edit source]

Video Series[edit | edit source]

You can watch the following video series developed by The Bellevue Program for Survivors of Torture’s. Their mission is to assist individuals and families subjected to torture and other human rights abuses to rebuild healthy, self-sufficient lives, and to contribute to global efforts to end torture.

You can also view survivors' stories through their Seeking Refuge Documentary, which follows four survivors who were forced to flee dire circumstances in their homes, as they work to reclaim their lives in the United States.

Physiotherapy[edit | edit source]

  1. Interventions for Physiotherapists working with Torture Survivors: With Special Focus on Chronic Pain, PTSD, and Sleep Disturbances
    • This publication provides practical guidelines to assist the rehabilitation professional working with survivors of torture in identifying the most pressing issues, and which physiotherapeutic tools are most useful for each individual client.
  2. Rehabilitation of Torture Survivors Resource Kit for Service Providers
    • This resource kit, produced by the IRCT, explores options for providers along a continuum of services they might choose to provide, from implementing a survivor service component in their ongoing practice to developing a full-service torture rehabilitation program.  
  3. Heal Torture
    • The HealTorture webpage provides support for rehabilitation professionals treating torture survivors.

Sleep[edit | edit source]

Blog Posts[edit | edit source]

References[edit | edit source]

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  2. Refugee Health Technical Assistance Center. Traumatic Experiences of Refugees [Internet]. [Cited September 29, 2018]. Available from:
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