'I was lost in my life and they helped me find my way again': Befriendee and befriender experiences of the Spirasi Befriending Programme for survivors of torture in Ireland.

INTRODUCTION: Befriending is one of the rehabilitative services embedded in the holistic approach adopted by Spirasi, the Irish National Centre for the Rehabilitation of Survivors of Torture. Their befriending programme offers survivors one-to-one companionship from trained volunteer befrienders. The literature suggests that befriending programmes can improve quality of life, provide emotional support and combat loneliness. However, there is little empirical research of the effectiveness of befriending programmes for torture survivors. OBJECTIVE: The main objective was to explore, in complementary ways, the impact of the Spirasi befriending programme on befrienders and befriendees and to incorporate their voices into recommendations for optimising the service. METHODS: The methodology consisted of five focus groups (two with befriendees, two with befrienders and one with both) and a portrait workshop facilitated by two community artists, where each befriending pair member created a portrait of their partner to express and visually explore the befriending relationship. Data comprised the focus group transcripts and written feedback on the portrait-creation process. RESULTS: The themes identified in both data sets firmly ground the befriending programme in Spirasi's holistic approach to recovery. For the focus group participants, befriending promotes integration; models trusting, kind and reciprocal relationships; combats loneliness and protects against suicide. They also highlighted the importance of regular befriender training, increasing the programme's reach and developing a befriender community of practice. The portrait workshop was found to strengthen relationships and provide a context of normality, acceptance and shared humanity through compassionate and creative exchanges. CONCLUSIONS: This paper highlights the benefits of the befriending programme within Spirasi's holistic approach and the importance of collaborative expressive arts activities in building befriending relationships. It provides recommendations for good befriending practice which are relevant to all organisations working with survivors of torture as well as those working with people seeking international protection more broadly.

The Impact of Parent Torture and Family Functioning on Youth Adjustment in War-Affected Families: A Path Analysis Describing Intergenerational Trauma and the Family System.

The direct exposure to physical or psychological trauma from torture or war leads to well-documented individual health consequences. Less understood are the inclusive and intergenerational effects of war trauma on family systems and youth adjustment. The purpose was to examine mechanisms in war-affected families that explained the significant emotional and behavioral consequences of intergenerational trauma in youth through the use of multiple methods. Quantitative assessments of maternal and paternal caregivers and youth characterized associations between parent torture, parent mental health distress, parent physical health problems, family functioning, and youth adjustment. Narrative statements further contextualized processes through which the trauma of a parent impacted youth and family systems. The research was conducted in partnership with local, refugee-serving community-based organizations. The study sample included parents and youth in 96 Karen families, originating from Burma in Southeast Asia, who had been resettled to the United States through the U.S. Refugee Admissions Program. Path analysis results indicated that parent torture (ß = -0.173) had statistically significant negative direct effects on youth adjustment. Parent torture had a negative indirect effect on youth adjustment through the mental health (ß = -0.345) and physical health problems of parents (ß = -0.305), and youth gender (ß = 0.126) and trauma exposure of youth (ß = -0.048). Family functioning type demonstrated a positive direct effect on youth adjustment (ß = 0.449). Family type had an indirect effect on youth adjustment through youth gender (ß = 0.142), youth trauma exposure (ß = -0.165), parent physical health problems (ß = -0.202), and parent mental health (ß = 0.509). The current study developed and tested the first model of intergenerational trauma's effects on the adjustment of Karen refugee youth. Results emphasize that individual recovery from torture must be accompanied by adjunct interventions focused on family systems and youth adjustment, to holistically address intergenerational sequala of trauma.

Atendimento psicossocial à mulher que comete ofensa sexual / Psychosocial attention for women that commit sexual offenses / Atención psicosocial para mujeres que cometen delitos sexuales

Objetivamos apresentar uma proposta de atendimento psicossocial grupal oferecida para mulheres adultas que cometeram ofensa sexual, cuidadoras e mães. A experiência está sendo desenvolvida no Distrito Federal, Brasil, com pessoas do gênero feminino provenientes de encaminhamento judicial. Carece que os profissionais das áreas da justiça, saúde, serviço social e psicologia avancem no estudo e na compreensão desta temática, de modo a pensarem a atuação e o apoio terapêutico a essas mulheres. O modo de atendimento é focal e breve, com ênfase na criação de um ambiente lúdico como facilitador das interações grupais e da discussão sobre os temas: identidade; confiança nas relações afetivas e sociais; vivência pessoal com violência física e sexual; configuração de gênero; e expressão da sexualidade e futuro. A abordagem individual também se baseia no enfoque dos temas mencionados. O oferecimento de ajuda à mulher cuidadora ou à mãe tem participação ativa na interrupção do circuito abusivo sexual, pois essa violência é extremamente ocultada, ocasionando uma prolongada vulnerabilidade para as vítimas. Ressalta-se o valor do texto indicando a descrição de ação voltada para uma população permanentemente não estudada e evitada em seu reconhecimento. Os limites desta proposta encontram-se na falta de outras iniciativas que possibilitem uma discussão sobre essa experiência.(AU)

We aim to present a proposal of a group psychosocial intervention offered for adult female sexual offenders, caregivers, and mothers. The intervention is being developed at Federal District, Brazil, with female people coming from judicial referrals. Professionals in the areas of justice, health, social work, and psychology need to advance in the study and understanding this theme to think about action and therapeutic support for these women. The intervention is a focal and brief approach, with emphasis on the creation of a ludic environment as a facilitator of group interactions and discussion about the themes: identity; trust in affective and social relationships; personal experience with physical and sexual violence; gender configuration; and sexuality expression and future. The individual approach is also based on focusing on these themes. The offering of help to the female caregiver or the mother has an active participation in the interruption of the sexual offense circuit, since this violence is extremely hidden, bringing a prolonged condition of vulnerability to the victims. The value of this text is highlighted indicating the description of an action directed to a population that is permanently not studied and whose recognition is avoided. The limits of this proposal are found in the absence of other initiatives that would allow a discussion about this experience.(AU)

Este texto presenta una propuesta de atención psicosocial grupal destinada a mujeres adultas que han cometido delito sexual, a cuidadoras y madres. La intervención se está desarrollando en el Distrito Federal (Brasil), con personas del género femenino provenientes de remisiones judiciales. Es necesario que los profesionales de las áreas de justicia, salud, trabajo social y psicología avancen en el estudio y comprensión de esta temática para pensar en el desempeño y apoyo terapéutico de estas mujeres. El servicio es enfocado y breve, con énfasis en la creación de un ambiente lúdico como facilitador de interacciones grupales y discusión sobre los temas: identidad; confianza en las relaciones afectivas y sociales; experiencia personal con violencia física y sexual; configuración de género; y expresión de la sexualidad y el futuro. El enfoque individual también se centra en estos temas. La oferta de ayuda a la mujer cuidadora o a la madre es importante para la interrupción del circuito de abuso sexual, ya que esta violencia es extremadamente oculta y provoca una vulnerabilidad prolongada a las víctimas. Se destaca el valor del texto con la descripción de la acción dirigida a una población que no es objeto de estudios ni reconocida. Los límites de esta propuesta se encuentran en la ausencia de otras iniciativas que permitan un debate sobre esta experiencia.(AU)

Percepção sobre o cuidado à perda gestacional: estudo qualitativo com casais brasileiros / Perceptions on pregnancy loss care: a qualitative study with brazilian couples / Percepción sobre la atención a la pérdida del embarazo: estudio cualitativo con parejas brasileñas

Este artigo analisou a percepção e os sentimentos de casais sobre o atendimento recebido nos serviços de saúde acessados em função de perda gestacional (óbito fetal ante e intraparto). O convite para a pesquisa foi divulgado em mídias sociais (Instagram e Facebook). Dos 66 casais que contataram a equipe, 12 participaram do estudo, cuja coleta de dados ocorreu em 2018. Os casais responderam conjuntamente a uma ficha de dados sociodemográficos e uma entrevista semiestruturada, realizada presencialmente (n=4) ou por videochamada (n=8). Os dados foram gravados em áudio e posteriormente transcritos. A Análise Temática indutiva das entrevistas identificou cinco temas: sentimento de impotência, iatrogenia vivida nos serviços, falta de cuidado em saúde mental, não reconhecimento da perda como evento com consequências emocionais negativas, e características do bom atendimento. Os achados demonstraram situações de violência, comunicação deficitária, desvalorização das perdas precoces, falta de suporte para contato com o bebê falecido e rotinas pouco humanizadas, especialmente durante a internação após a perda. Para aprimorar a assistência às famílias enlutadas, sugere-se qualificação profissional, ampliação da visibilidade do tema entre diferentes atores e reorganização dos serviços, considerando uma diretriz clínica para atenção ao luto perinatal, com destaque para o fortalecimento da inserção de equipes de saúde mental no contexto hospitalar.(AU)

This study analyzed couples' perceptions and feelings about pregnancy loss care (ante and intrapartum fetal death). A research invitation was published on social media (Instagram and Facebook) and data collection took place in 2018. Of the 66 couples who contacted the research team, 12 participated in the study by filling a sociodemographic questionnaire and answering a semi-structured interview in person (n=04) or by video call (n=08). All interviews were audio recorded, transcribed, and examined by Inductive Thematic Analysis, which identified five themes: feelings of impotence, iatrogenic experiences in health services, lack of mental health care, not recognizing pregnancy loss as an emotionally overwhelming event, and aspects of good healthcare. Analysis showed experiences of violence, poor communication, devaluation of early losses, lack of support for contact with the deceased baby, and dehumanizing routines, especially during hospitalization after loss. Professional qualification, extended pregnancy loss visibility among different stakeholders, and reorganization of health services are needed to improve the care offered to grieving families, considering a clinical guideline for perinatal grief care with emphasis on strengthening the insertion of mental health teams in the hospital context.(AU)

Este estudio analizó las percepciones y sentimientos de parejas sobre la atención recibida en los servicios de salud a los que accedieron debido a la pérdida del embarazo (muerte fetal ante e intraparto). La invitación al estudio se publicó en las redes sociales (Instagram y Facebook). De las 66 parejas que se contactaron con el equipo, 12 participaron en el estudio, cuya recolección de datos se realizó en 2018. Las parejas respondieron un formulario de datos sociodemográficos y realizaron una entrevista semiestructurada presencialmente (n=4) o por videollamada (n=08). Los datos se grabaron en audio para su posterior transcripción. El análisis temático inductivo identificó cinco temas: Sentimiento de impotencia, experiencias iatrogénicas en los servicios, falta de atención a la salud mental, falta de reconocimiento de la pérdida como un evento con consecuencias emocionales negativas y características de buena atención. Los hallazgos evidenciaron situaciones de violencia, comunicación deficiente, desvalorización de las pérdidas tempranas, falta de apoyo para el contacto con el bebé fallecido y rutinas poco humanizadas, especialmente durante la hospitalización tras la pérdida. Para mejorar la atención a las familias en duelo, se sugiere capacitación profesional, ampliación de la visibilidad del tema entre los diferentes actores y reorganización de los servicios, teniendo en cuenta una guía clínica para la atención del duelo perinatal, enfocada en fortalecer la inserción de los equipos de salud mental en el contexto hospitalario.(AU)

Reflections on healing and recovery from the legacies of trauma and violence.

With the arrival in Denmark of torture sur-vivors from Latin America in the nineteen seventies and eighties, therapists faced the challenge of how best to accompany the sur-vivors in their healing processes. The New Left and Feminism were important political movements which influenced the therapeu-tic approaches discussed at that time. In the author's meeting with Latin American col-leagues a dialogue about therapeutic methods was further developed with emphasis on the connection between "Human Rights and Mental Health". The civil war in the Balkans in the nineties brought new challenges: the development of psychosocial community in-terventions as well as an intensification of the debate between the "medical" and psycho-social approaches to trauma healing. Coop-eration during the last decade with NGOs in e.g., India, Cambodia, and Honduras brought new and more holistic perspectives on therapy represented by a brief version of Testimonial Therapy that sought to integrate cultural and spiritual traditions as well as "third wave" cognitive methods.

Seeing the person before the teeth: A realist evaluation of a dental anxiety service in Norway.

Patients with a trauma history, whether sexual abuse or torture, or dental phobia, tend to avoid dental services due to severe dental anxiety. Subsequently, they experience poor oral health, lower quality of life, and poorer general health. In Norway, a specific service (torture, abuse, and dental anxiety [TADA]) targets these patients' dental anxiety through cognitive behavioural therapy (CBT) prior to dental restoration. By exploring patients' experiences with TADA services using a realist evaluation approach, this paper aims to increase our understanding of how this type of service addresses patients' dental anxiety in terms of its mechanisms and contextual factors. Interviews with TADA patients (n = 15) were analysed through a template analysis driven by context-mechanism-outcome heuristics. The analysis revealed that patients value a dental practitioner who provides a calm and holistic approach, positive judgements and predictability elements that lean towards a person-centred care approach. Provided this, patients felt understood and cared for, their shame was reduced, self-esteem emerged, and control was gained, which led to alleviation of dental anxiety. Therefore, our findings suggest that combining CBT with a person-centred care approach helps alleviate patients' dental anxiety. This provides insights into how dental services could be executed for these patients.

Assessing signs of torture: A review of clinical forensic dermatology.

BACKGROUND: It is important for dermatologists and other physicians in refugee-receiving countries to acquire knowledge of forensic dermatology to identify lesions from torture. OBJECTIVE: Review forensic dermatology in cases of torture. RESULTS: In provision of medical assessment and care to refugees and migrants, chronic skin lesions will be the most readily identifiable signs of torture. Beatings are common, with blunt force trauma resulting in postinflammatory hyperpigmentation. Torture burns can be thermal, chemical, or electrothermal, causing distinct lesions determined by the method, duration, and intensity of exposure, and area of skin affected. Sharp instruments inflict a wide range of lesions arising from stabbing/perforation or cuts from knives. Wound healing without medical attention and in unsanitary conditions will affect the scarring process. Lesions from suspension and ligatures may occur alongside scars from other forms of torture. Differential diagnoses include self-inflicted wounds, ethnic scarification, and scars from traditional healing practices. CONCLUSION: Physicians who may encounter survivors of torture in community or specialist practice would benefit from basic training in forensic dermatology, whereas knowledge of common forms of torture and cultural practices in refugees' countries of origin is important when considering differential diagnoses of skin lesions.

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.

Statement of the Independent Forensic Expert Group on Conversion Therapy.

Conversion therapy is a set of practices that aim to change or alter an individual's sexual orientation or gender identity. It is premised on a belief that an individual's sexual orientation or gender identity can be changed and that doing so is a desirable outcome for the individual, family, or community. Other terms used to describe this practice include sexual orientation change effort (SOCE), reparative therapy, reintegrative therapy, reorientation therapy, ex-gay therapy, and gay cure. Conversion therapy is practiced in every region of the world. We have identified sources confirming or indicating that conversion therapy is performed in over 60 countries. In those countries where it is performed, a wide and variable range of practices are believed to create change in an individual's sexual orientation or gender identity. Some examples of these include: talk therapy or psychotherapy (e.g., exploring life events to identify the cause); group therapy; medication (including anti-psychotics, anti- depressants, anti-anxiety, and psychoactive drugs, and hormone injections); Eye Movement Desensitization and Reprocessing (where an individual focuses on a traumatic memory while simultaneously experiencing bilateral stimulation); electroshock or electroconvulsive therapy (ECT) (where electrodes are attached to the head and electric current is passed between them to induce seizure); aversive treatments (including electric shock to the hands and/or genitals or nausea-inducing medication administered with presentation of homoerotic stimuli); exorcism or ritual cleansing (e.g., beating the individual with a broomstick while reading holy verses or burning the individual's head, back, and palms); force-feeding or food deprivation; forced nudity; behavioural conditioning (e.g., being forced to dress or walk in a particular way); isolation (sometimes for long periods of time, which may include solitary confinement or being kept from interacting with the outside world); verbal abuse; humiliation; hypnosis; hospital confinement; beatings; and "corrective" rape. Conversion therapy appears to be performed widely by health professionals, including medical doctors, psychiatrists, psychologists, sexologists, and therapists. It is also conducted by spiritual leaders, religious practitioners, traditional healers, and community or family members. Conversion therapy is undertaken both in contexts under state control, e.g., hospitals, schools, and juvenile detention facilities, as well as in private settings like homes, religious institutions, or youth camps and retreats. In some countries, conversion therapy is imposed by the order or instructions of public officials, judges, or the police. The practice is undertaken with both adults and minors who may be lesbian, gay, bisexual, trans, or gender diverse. Parents are also known to send their children back to their country of origin to receive it. The practice supports the belief that non-heterosexual orientations are deviations from the norm, reflecting a disease, disorder, or sin. The practitioner conveys the message that heterosexuality is the normal and healthy sexual orientation and gender identity. The purpose of this medico-legal statement is to provide legal experts, adjudicators, health care professionals, and policy makers, among others, with an understanding of: 1) the lack of medical and scientific validity of conversion therapy; 2) the likely physical and psychological consequences of undergoing conversion therapy; and 3) whether, based on these effects, conversion therapy constitutes cruel, inhuman, or degrading treatment or torture when individuals are subjected to it forcibly2 or without their consent. This medico-legal statement also addresses the responsibility of states in regulating this practice, the ethical implications of offering or performing it, and the role that health professionals and medical and mental health organisations should play with regards to this practice. Definitions of conversion therapy vary. Some include any attempt to change, suppress, or divert an individual's sexual orientation, gender identity, or gender expression. This medico-legal statement only addresses those practices that practitioners believe can effect a genuine change in an individual's sexual orientation or gender identity. Acts of physical and psychological violence or discrimination that aim solely to inflict pain and suffering or punish individuals due to their sexual orientation or gender identity, are not addressed, but are wholly condemned. This medico-legal statement follows along the lines of our previous publications on Anal Examinations in Cases of Alleged Homosexuality1 and on Forced Virginity Testing.2 In those statements, we opposed attempts to minimise the severity of physical and psychological pain and suffering caused by these examinations by qualifying them as medical in nature. There is no medical justification for inflicting on individuals torture or other cruel, inhuman, or degrading treatment or punishment. In addition, these statements reaffirmed that health professionals should take no role in attempting to control sexuality and knowingly or unknowingly supporting state-sponsored policing and punishing of individuals based on their sexual orientation or gender identity.

Mental Health of Refugees and Torture Survivors: A Critical Review of Prevalence, Predictors, and Integrated Care.

Civilian war trauma and torture rank among the most traumatic life experiences; exposure to such experiences is pervasive in nations experiencing both internal and external conflict. This has led to a high volume of refugees resettling throughout the world with mental health needs that primary care physicians may not be screening for and prepared to effectively address. In this article, we review the literature on demographics, predictors, mental health outcomes of torture, and integrated care for the mental health needs of refugees. We searched PubMed and PSYCINFO databases for original research articles on refugees and mental health published in the English language between 2010 and present. Nine percent of 720 adults in conflict areas in Nepal, with predominance of literate married males, met the threshold for Post-Traumatic Stress Disorder (PTSD), 27.5% for depression, and 22.9% for anxiety. While, PTSD rate has been documented as high as 88.3% among torture survivors from Middle East (ME), Central Africa (CA), South Asia (SA), Southeast Europe (SE). Depression was recorded as high as 94.7% among 131 African torture survivors and anxiety as high as 91% among 55 South African torture survivors. Torture severity, post-migration difficulties, and wait time to receive clinical services were significantly associated with higher rate of mental health symptoms. Mental health screening is not a standard component of initial physical exams for refugees, yet these individuals have had high trauma exposure that should inform clinical care. Integrated care models are lacking but would greatly benefit this community to prevent progression to greater severity of mental health symptoms.

Fanon's Police Inspector.

Frantz Fanon practiced psychiatry in a colonized Algeria during its struggle for independence. In his 1961 work The Wretched of the Earth, Fanon described cases from his treatment of Algerian nationalists and French colonists. I present one of Fanon's cases as an ethical inquiry into posttraumatic stress disorder (PTSD). A French police inspector, who is employed in torture, visits Fanon with symptoms of PTSD after escalating domestic violence. The patient asks Fanon "to help him torture … with a total peace of mind." Is it possible to treat the inspector in a meaningful way? More broadly, how might researchers and clinicians balance collective responsibilities to individual symptoms and social conditions? The answer depends on how trauma is framed: as disorder of meaning-making or circuit dysfunction, as individual illness or social rupture, as potentially gendered and racialized. These framings can reveal different views on the allocation of responsibility for the causation, expression and management of PTSD. I do not propose that it is inherently immoral to modify traumatic memories; nor do I question the efficacy of individual interventions. Rather, I ask whether PTSD has a social meaning that transcends individual comfort in decision making about erasure. What do individual interventions accomplish in the absence of concurrent political and social transformations? I argue that a holistic understanding of PTSD entails a set of social obligations: to address at its root political, gendered, and racialized violence, to repudiate occupations centered on exploitative manipulation of individuals and cultures, and to social change that prioritizes these commitments.

Skin lesions, differential diagnosis and practical approach to potential survivors of torture.

As the international refugee crisis has reached new proportions (BMJ, 355, 2016 and i5412), survivors of torture increasingly present in treating physicians with an array of acute or chronic skin lesions. Physicians should be aware of common presentations and likely differential diagnoses in order to avoid mislabelling or under-recognizing torture. Survivors of torture also frequently suffer from psychological sequelae, such as post-traumatic stress disorder, and appropriate referrals are essential in order to improve recovery trajectory. Skin sequelae are the most common physical findings of torture. Not all skin lesions seen in tortured survivors are due to perpetrator inflicted injuries, and many dermatological conditions can mimic lesions typical of torture, as can scars as a result of folk remedies or cultural practices specific to geographical regions. Medical documentation of torture includes injury and lesion description. While forensic dermatology and other forensic specialties use an injury description taxonomy, and the standard dermatologic taxonomy uses an anatomic description, they are complementary sciences for lesions inflicted by torture. This results in an opportunity for learning across disciplines in order to improve evidence documentation for survivors of torture. This article describes features of common skin lesions consistent with torture, including their clinical appearances, differential diagnoses, patterns of injury and appropriate clinical descriptions.

Indicators likely to contribute to clinical and functional improvement among survivors of politically-sanctioned torture.

INTRODUCTION: Heartland Alliance Marjorie Kovler Center (Kovler Center) is a torture treatment program located in Chicago, Illinois. Established in 1987, Kovler Center provides medical, mental health, and social services, as well as coordination with legal services, to a diverse population of survivors. Historically, Kovler Center used clinical measurement instruments to assess depression, anxiety and posttraumatic stress, but staff was challenged with finding the best way to assess and ultimately measure changes in functional domains. The purpose of this paper is to describe (1) the Kovler Center framework, philosophical pillars, and model of treatment; (2) the comprehensive outcome evaluation program, including the Marjorie Kovler Center Well-Being Questionnaire (MKC WBQ); and (3) the results and implications to date. METHODS: Kovler Center measured outcome data utilizing three instruments including a well-being tool and supplemented the data with a satisfaction survey. These instruments were administered at intake and re-administered at six-month intervals up to 24 months. RESULTS/DISCUSSION: With nine years of data, Kovler Center can now provide valid and reliable findings in diagnostic and functional changes, with 86.6% of its clients reporting fewer symptoms of anxiety and depression, 83.1% reporting fewer symptoms of trauma, and significant improvement in employment status, housing status, and physical health after receiving services for 24 months. Indicators significantly correlated with clinical improvement at 24 months include stable housing, stable employment, region from where survivors came, number of days between initial assessment and program admittance, number of services (medical, psychological, social) received while in the program, number of medical problems diagnosed with while in the program, and number of psychological problems diagnosed with while in the program. From the Generalized Linear Mixed Models (GLMM) analysis, the total number of psychological problems and whether or not the participant had a secure legal status while in the program were demonstrated to explain the variance in anxiety, depression, and PTSD. Females were more likely to experience depression while in the program compared to males, and participants from the Middle East were more likely to experience symptoms of depression and PTSD compared to participants from Africa. CONCLUSIONS: Since, medical, psychological, and social indicators are demonstrated to correlate with or predict clinical outcomes, this highlights the need for comprehensive and holistic treatment programs for survivors of torture.

Showers: from a violent treatment to an agent of cleansing.

In the early nineteenth century, physicians designed the first manufactured showers for the purpose of curing the insane. Sustained falls of cold water were prescribed to cool hot, inflamed brains, and to instil fear to tame impetuous wills. By the middle of the century showers had appeared in both asylums and prisons, but shower-related deaths led to their decline. Rather than being abandoned, however, the shower was transformed by the use of warm water to economically wash the skins of prison and asylum populations. In stark contrast to an involuntary, deliberately unpleasant treatment, by the end of the century the shower was a desirable product for the improvement of personal hygiene and population health.

"In the Sport I Am Here": Therapeutic Processes and Health Effects of Sport and Exercise on PTSD.

Current evidence suggests positive effects of exercise on posttraumatic stress symptoms; however, knowledge about how these effects are achieved is limited. Thus, this study aims to contribute to a more holistic understanding of these effects. We performed a single case study of a war and torture survivor, who was diagnosed with posttraumatic stress disorder (PTSD) and depression, and who was participant of the sport and exercise therapy program Movi Kune. Participant observation was conducted as well as semi-structured interviews with the participant and his psychotherapist. Data analysis resulted in the proposal of different processes: The focus on bodily sensations related to an exposure effect, contributing to improvements in body awareness, coping behavior, and affect regulation, whereas the focus on playing related to an improved performance, presence, enjoyment, and mastery experiences, pointing toward distraction and motivational-restorative effects. The findings also advice to be cautious as participants may be exposed to negative sensations and trauma-related triggers.

The efficacy of traditional cultural practices in the rehabilitation of victims of torture in Nigeria's Niger Delta.

INTRODUCTION: Traditional methods of purification and healing carried out by healers and priests are of utmost importance for the mental and spiritual rehabilitation of victims of torture and perpetrators. The efficacy of traditional practices in the rehabilitation of victims of torture in Nigeria is examined. METHODS: Data is derived from 60 interviews with key informants and eight Focus Group Discussions (FGDs) conducted with victims of torture, youth militias, priests, secret cults, community leaders, women leaders, youth leaders, security agencies, and others, in local communities in the Niger Delta states of Bayelsa and Ilaje, Ondo. RESULTS: By means of reconciliation rituals, both the perpetrators and the victims are re-integrated into the community. The mental healing of victims, who were deeply traumatized by the experiences of torture during violent conflict, is an aspect of community peacebuilding that is at least as important as material reconstruction. Traditional forms of justice and reconciliation that can address the psychosocial trauma of victims of torture may be helpful in the rehabilitation process. CONCLUSIONS: This paper suggests that healing and reconciliation rituals have been an essential component of rehabilitation processes in many local communities in the Niger Delta region. International, regional and national actors and institutions must recognize the cultural importance of such rituals and their potential relevance and significance for victims of torture, but their complex dynamics need to be better understood in order to safely and effectively apply them programmatically to achieve reconciliation and rehabilitation outcomes.

Interventions for treating persistent pain in survivors of torture.

BACKGROUND: Persistent (chronic) pain is a frequent complaint in survivors of torture, particularly but not exclusively pain in the musculoskeletal system. Torture survivors may have no access to health care; where they do, they may not be recognised when they present, and the care available often falls short of their needs. There is a tendency in state and non-governmental organisations' services to focus on mental health, with poor understanding of persistent pain, while survivors may have many other legal, welfare, and social problems that take precedence over health care. OBJECTIVES: To assess the efficacy of interventions for treating persistent pain and associated problems in survivors of torture. SEARCH METHODS: We searched for randomised controlled trials (RCTs) published in any language in CENTRAL, MEDLINE, Embase, Web of Science, CINAHL, LILACS, and PsycINFO, from database inception to 1 February 2017. We also searched trials registers and grey literature databases. SELECTION CRITERIA: RCTs of interventions of any type (medical, physical, psychological) compared with any alternative intervention or no intervention, and with a pain outcome. Studies needed to have at least 10 participants in each arm for inclusion. DATA COLLECTION AND ANALYSIS: We identified 3578 titles in total after deduplication; we selected 24 full papers to assess for eligibility. We requested data from two completed trials without published results.We used standard methodological procedures expected by Cochrane. We assessed risk of bias and extracted data. We calculated standardised mean difference (SMD) and effect sizes with 95% confidence intervals (CI). We assessed the evidence using GRADE and created a 'Summary of findings' table. MAIN RESULTS: Three small published studies (88 participants) met the inclusion criteria, but one had been retracted from publication because of ethical problems concerned with confidentiality and financial irregularities. Since these did not affect the data, the study was retained in this review. Despite the search including any intervention, only two types were represented in the eligible studies: two trials used cognitive behavioural therapy (CBT) with biofeedback versus waiting list on unspecified persistent pain (58 participants completed treatment), and one examined the effect of complex manual therapy versus self-treatment on low back pain (30 participants completed treatment). Excluded studies were largely either not RCTs or did not report pain as an outcome.There was no difference for the outcome of pain relief at the end of treatment between CBT and waiting list (two trials, 58 participants; SMD -0.05, 95% CI -1.23 to 1.12) (very low quality evidence); one of these reported a three-month follow-up with no difference between intervention and comparison (28 participants; SMD -0.03, 95% CI -0.28 to 0.23) (very low quality evidence). The manual therapy trial also reported no difference between complex manual therapy and self-treatment (30 participants; SMD -0.48, 95% CI -9.95 to 0.35) (very low quality evidence). Two studies reported dropouts, one with partial information on reasons; none of the studies reported adverse effects.There was no information from any study on the outcomes of use of analgesics or quality of life.Reduction in disability showed no difference at the end of treatment between CBT and waiting list (two trials, 57 participants; SMD -0.39, 95% CI -1.17 to 0.39) (very low quality evidence); one of these reported a three-month follow-up with no difference between intervention and comparison (28 participants; SMD 0, 95% CI -0.74 to 0.74) (very low quality evidence). The manual therapy trial reported superiority of complex manual therapy over self-treatment for reducing disability (30 participants; SMD -1.10, 95% CI - 1.88 to -0.33) (very low quality evidence).Reduction in distress showed no difference at the end of treatment between CBT and waiting list (two trials, 58 participants; SMD 0.07, 95% CI -0.46 to 0.60) (very low quality evidence); one of these reported a three-month follow-up with no difference between intervention and comparison (28 participants; SMD -0.24, 95% CI -0.50 to 0.99) (very low quality evidence). The manual therapy trial reported superiority of complex manual therapy over self-treatment for reducing distress (30 participants; SMD -1.26, 95% CI - 2.06 to -0.47) (very low quality evidence).The risk of bias was considered high given the small number of trials, small size of trials, and the likelihood that each was underpowered for the comparisons it reported. We primarily downgraded the quality of the evidence due to small numbers in trials, lack of intention-to-treat analyses, high unaccounted dropout, lack of detail on study methods, and CIs around effect sizes that included no effect, benefit, and harm. AUTHORS' CONCLUSIONS: There is insufficient evidence to support or refute the use of any intervention for persistent pain in survivors of torture.

Neurofeedback as an adjunct therapy for treatment of chronic posttraumatic stress disorder related to refugee trauma and torture experiences: two case studies.

OBJECTIVE: The objective of this study was to describe the use of neurofeedback for refugee-related chronic posttraumatic stress disorder (PTSD) in two case studies. METHODS: We describe the assessment and application of neurofeedback integrated into the treatment of two clients with chronic PTSD. We include details of our treatment schedule, symptoms and quantitative electrophysiological data for each case. Results All clients achieved significant reduction in symptoms of PTSD and improvement in daily functioning post-neurofeedback therapy. Quantitative electroencephalogric (EEG) measures indicate a normalisation of EEG markers relating to trauma, including overarousal at rest and working memory function. Conclusions Neurofeedback as an adjunct to trauma-informed therapy may help to remediate chronic PTSD relating to refugee experiences. If replicated then improvements demonstrated in this population would be generalisable to all chronic PTSD.

Reviewing outcomes of psychological interventions with torture survivors: Conceptual, methodological and ethical Issues.

BACKGROUND: Torture survivors face multiple problems, including psychological difficulties, whether they are refugees or remain in the country where they were tortured. Provision of rehabilitation varies not only with the needs of survivors and resources available, but also with service models, service provider preferences and the local and country context. Despite increasing efforts in research on effectiveness of psychological interventions with torture survivors, results are inconclusive. METHODS: We undertook a Cochrane systematic review of psychological, social and welfare provision, with meta-analysis to best estimate efficacy. The process raised conceptual, methodological and ethical issues of relevance to the wider field. FINDINGS: We searched very widely, but rejected hundreds of papers which recommended treatment without providing evidence. We found nine randomised controlled trials, from developed and under-resourced settings. All conceptualised survivors' problems in psychiatric terms, using outcomes of post-traumatic stress symptoms, distress, and quality of life, by self-report, with or without translation or unstandardised interpretation, and with little mention of cultural or language issues. None used social or welfare interventions. Four related studies used narrative exposure therapy (NET) in a brief form, and without ensuring a safe setting as recommended. Five used mixed methods, including exposure, cognitive behavioural therapy, and eye movement desensitisation. Combined, the studies showed no immediate improvement in PTSD, distress, or quality of life; at six months follow-up, a minority showed some improvement in PTSD and distress, although participants remained severely affected. CONCLUSIONS: While applauding researchers' commitment in running these trials, we raise ethical issues about exposure in particular, and about the effects of shortcomings in methodology, particularly around assessment using unfamiliar cultural frameworks and language, and the lack of concern about dropout which may indicate harm. The issues addressed aid interpretation of existing research, and guide clinical practice as well as future studies evaluating its effectiveness.