The complex care of a torture survivor in the United States: The case of Joshua.

INTRODUCTION: Torture is an assault on the physical and mental health of an individual, impacting the lives of survivors and their families.The survivor's interpersonal relationships, social life, and vocational functioning may be affected, and spiritual and other existential questions may intrude. Cultural and historical context will shape the meaning of torture experiences and the aftermath. To effectively treat torture survivors, providers must understand and address these factors. The Complex Care Model (CCM) aims to transform daily care for those with chronic illnesses and improve health outcomes through effective team care. METHODS: We conduct a literature review of the CCM and present an adapted Complex Care Approach (CCA) that draws on the Harvard Program in Refugee Trauma's five-domain model covering the Trauma Story, Bio-medical, Psychological, Social, and Spiritual domains.We apply the CCA to the case of "Joshua," a former tortured child soldier, and discuss the diagnosis and treatment across the five domains of care. FINDINGS: The CCA is described as an effective approach for working with torture survivors. We articulate how a CCA can be adapted to the unique historical and cultural contexts experienced by torture survivors and how its five domains serve to integrate the approach to diagnosis and treatment. The benefits of communication and coordination of care among treatment providers is emphasized. Discussion / Conclusions: Torture survivors' needs are well suited to the application of a CCA delivered by a team of providers who effectively communicate and integrate care holistically across all domains of the survivor's life.

Testimony ceremonies in Asia: integrating spirituality in testimonial therapy for torture survivors in India, Sri Lanka, Cambodia, and the Philippines.

This study explores the therapeutic implications of including culturally adapted spiritual ceremonies in the process of testimonial therapy for torture survivors in India, Sri Lanka, Cambodia, and the Philippines. Data were collected through an action research process with Asian mental health and human rights organizations, during which the testimonial method was reconceptualized and modified to include four sessions. In the first two sessions, community workers assist survivors in the writing of their testimony, which is their narrative about the human rights violations they have suffered. In the third session, survivors participate in an honour ceremony in which they are presented with their testimony documents. In the fourth session, the community workers meet with the survivors for a reevaluation of their well-being. The honour ceremonies developed during the action research process came to employ different kinds of symbolic language at each site: human rights (India), religious/Catholic (Sri Lanka), religious/Buddhist (Cambodia), and religious/Moslem (Philippines). They all used embodied spirituality in various forms, incorporating singing, dancing, and religious purification rituals in a collective gathering. We suggest that these types of ceremonies may facilitate an individual's capacity to contain and integrate traumatic memories, promote restorative self-awareness, and engage community support. Additional research is needed to determine the method's applicability in other sociopolitical contexts governed by more Western-oriented medical traditions.

The land of milk and honey: a picture of refugee torture survivors presenting for treatment in a South African trauma centre.

Intake data obtained from 55 refugee torture survivors accessing trauma treatment services at a centre in Johannesburg, South Africa, paints a picture of suffering beyond the torture experience. The intake forms part of a more comprehensive monitoring and evaluation system developed for the work done with torture survivors accessing psychosocial services. The diverse sample with different nationalities highlights that torture occurs in many countries on the African continent. It also highlights South Africa's role as a major destination for refugee and asylum seekers. However, "the land of milk and honey" and the process of arriving here, often poses additional challenges for survivors of torture. This is reflected in the high levels of Post Traumatic Stress Disorder (69%), anxiety (91%), and depression (74%) for our sample, all of which were significantly correlated. The loss of employment status from before the torture experience until the time of intake was great for this sample, impacting on their recovery. In addition the presence of medical conditions (44%), disabilities (19%), and pain (74%) raise serious questions regarding interventions that focus mainly on psychosocial needs. No significant gender differences were found. The paper begins to paint a clearer picture of the bio-psycho-social state of torture survivors accessing services in South Africa, as well as highlighting many of the contextual challenges which impact on recovery.

Testimonial therapy. A pilot project to improve psychological wellbeing among survivors of torture in India.

INTRODUCTION: In developing countries where torture is perpetrated, there are few resources for the provision of therapeutic assistance to the survivors. The testimonial method represents a brief cross-cultural psychosocial approach to trauma, which is relatively easy to master. The method was first described in Chile in 1983 and has since been used in many variations in different cultural contexts. In this project the method has been supplemented by culture-specific coping strategies (meditation and a delivery ceremony). METHODS: A pilot training project was undertaken between Rehabilitation and Research Centre for Torture victims (RCT) in Copenhagen, Denmark, and People's Vigilance Committee for Human Rights (PVCHR) in Varanasi, India, to investigate the usefulness of the testimonial method. The project involved the development of a community-based testimonial method, training of twelve PVCHR community workers, the development of a manual, and a monitoring and evaluation (M&E) system comparing results of measures before the intervention and two to three months after the intervention. Twenty-three victims gave their testimonies under supervision. In the two first sessions the testimony was written and in the third session survivors participated in a delivery ceremony. The human rights activists and community workers interviewed the survivors about how they felt after the intervention. FINDINGS: After testimonial therapy, almost all survivors demonstrated significant improvements in overall WHO-five Well-being Index (WHO-5) score. Four out of the five individual items improved by at least 40%. Items from the International Classification of Functioning, Disability and Health (ICF) showed less significant change, possibly because the M&E questionnaire had not been well understood by the community workers, or due to poor wording, formulation and/or validation of the questions. All survivors expressed satisfaction with the process, especially the public delivery ceremony, which apparently became a "turning point" in the healing process. Seemingly, the ceremonial element represented the social recognition needed and that it re-connected the survivors with their community and ensured that their private truth becomes part of social memory. DISCUSSION: Although this small pilot study without control groups or prior validation of the questionnaire does not provide high-ranking quantitative evidence or statistically significant results for the effectiveness of our version of the testimonial method, we do find it likely that it helps improve the well being in survivors of torture in this particular context. However, a more extensive study is needed to verify these results, and better measures of ICF activities and participation (A&P) functions should be used. Interviews with human rights activists reveal that it is easier for survivors who have gone through testimonial therapy to give coherent legal testimony.