TORTURE 3 2020 Journal on Rehabilitation of Torture Victims and Prevention of Torture

Physiotherapy for torture survivors: Is there evidence of its utility in torture rehabilitation? - Part II

VOLUME 30, NO 3, 2020, ISSN 1018-8185 TORTURE

Journal on Rehabilitation of Torture Victims and Prevention of Torture Content Published by the International Rehabilitation Council for Hunger: Deprivation and manipulation of food as a torture method. State ­Torture Victims (IRCT), Copenhagen, Denmark. of the art in research and ways forward TORTURE is indexed and included in MEDLINE. Citations from the articles indexed, the indexing terms and the Pau Pérez-Sales 3 English abstracts printed in the journal will be included in the databases. Special Section. Physiotherapy for torture survivors - Part 2

Volume 30, No 3, 2020 Guest Editor: Eric Weerts ISBN 1018-8185 International survey of the utilization of physiotherapy in treatment The Journal has been published since 1991 as Torture centers for survivors of torture – Quarterly Journal on Rehabilitation of Torture Victims and Prevention of Torture, and was relaunched as Torture Laura Pizer Gueron and MaryAnn de Ruiter 20 from 2004, as an inter­national scientific core field journal on torture.­ Group physiotherapy with survivors of torture in urban and camp settings in Jordan and Kenya Editor in Chief Pau Pérez-Sales, MD, PhD Laura Pizer Gueron, Arobogust Amoyi, Winnie Chao, Justine Chepngetich,

Editorial Assistant Jepkemoi Joanne Kibet, Stephen Nyambok and Joseph Wesonga 27 Chris Dominey, LL.M Acceptability of a physiotherapeutic pain school treatment in trauma- Editorial advisory board affected populations in the Middle Eastern & Northern African region Bernard L. Duhaime, B.C.L., LL.B., LL.M. Gavin Oxsburgh, PhD Anne-Mette Karrer, Ane Kirstine Viller Hansen, Marie Louise D. Hans Draminsky Petersen, MD Oestergaard and Linda Nordin 43 Jens Modvig, MD, PhD Jim Jaranson, MD, MA, MPH Perspectives John W. Schiemann, PhD, MA José Quiroga, MD Collaborative effort to increase the physiotherapist’s competence in Lenin Raghuvanshi, BAMS rehabilitation of survivors of torture Mariana Castilla, MSc Nora Sveaass, PhD Maria Nordheim Alme, Rolf Vårdal, Djenana Jalovcic, Ilona Fricker, Sarah S. Megan Berthold, PhD, LCSW Peters, Patricia Rocca, William Hale, Esra Alagöz, Nika Leskovsek, Aicha Steven H. Miles, MD Benyaich, Emer McGowan, Anna Pettersson, Line M. Giusti, Michel Landry, Tania Herbert, DClinPsy Carina Boström, Rachael Lowe, Kjersti Wilhelmsen and Joost van Wijchen 61 Guest editor - Physiotherapy for torture survivors Eric Weerts Scientific Articles

Editorial support in this issue Violence and torture against migrants and refugees attempting to reach Naila Kosar the European Union through the Western Balkans Correspondence to Marta Guarch-Rubio, Steven Byrne and Antonio Manzanero 67 IRCT Vesterbrogade 149, building 4, 3rd floor, “A random system”: The organisation and practice of torture rehabilitation 1620 Copenhagen V, Denmark services in Norway Telephone: +45 44 40 18 30 Email: [email protected] Moa Nyamwathi Lønning, Anette Bringedal Houge, Inga Laupstad and Ann Evy Aasnes 84 Subscription http://irct.org/media-and-resources/publications#torture-journal Looking for stability: Experiences of rehabilitation for Congolese survivors The Journal is free of charge. of torture in Athens and the role of the Congolese community in their The views expressed herein are those of the authors and support can therefore in no way be taken to reflect the official opinion of the IRCT. Maria-Angeliki Psyrraki, Emilie Venables, Christos Eleftherakos, Nathalie Front page: Mogens Andersen, Denmark Severy, Declan Barry, Nikos Gionakis, Maria Episkopou, Aikaterini Layout by Pedro López Andradas Komita and Gianfranco De Maio 101 Printed in Lithuania by KOPA. Book Review The torture doctors. Human rights crimes and the road to justice by Steven Miles. Pau Pérez-Sales 113 Letter to the editor EMDR as an evidence-based therapy for trauma – A reply to the Independent Forensic Expert Group’s statement on conversion therapy. Oliver Piedfort Marin, Isabel Fernandez and Carol Miles 117 Response to EMDR Association letter on conversion therapy. Asger Kjaerum 120 Call for papers 122 3 TORTURE Volume 30, Number 3, 2020 ------is , a term referred, to Food deprivation Food is the specific effect specific the is . Refers deficiencya to in . Food manipulation Food objective measures. measures. objective the dietary below defined as a food intake There energy level. required minimum reviewed to measure it, are different ways is often combined deprivation Food below. with taste or contamina aspect, the quality, individual to an tion of the food provided 2016). (DIGNITY, Starvation enough to be below caloric intake severe needed to maintain an organism’s the level While the purpose of a reduction in life. food supply can be to temporarily debili and psycho individual physically the tate the purpose is to in starvation, logically, produce unbearable pain and eventually, death. slow as a consequence, Malnutrition a deficiency of having of one or more essential nutritional (ie. components iron deficiency produc thiamine deficit, ing anemia) without necessarily receiv ing an insufficient daily energy intake. Food and Agriculture of the Organization and Food Objective measures of food deprivation. deprivation. of food measures Objective food Defining and measuring an individual’s in rela needs is a challenge given variations and level health status age, tion to gender, Based on reports by the activity. of physical the and (WHO) Organization Health World 3. 4.

- - - - - hunger . Hunger is an . subjective sensation sensation subjective Provided that that Provided

. Refers the to . Correspondence to: [email protected] Correspondence to: threat (Al-Shawaf, 2016). 2016). (Al-Shawaf, threat Deprivation. Food human rights in sensation, subjective is a with research sometimes is better to work Hunger or needing food of wanting signal essential for evolutionary adaptive survival towards directs attention that pain that food acquisition in a similar way is a signal of bodily harm and a signal of International Rehabilitation Council for Torture Victims. All rights reserved. Victims. Torture International Council for Rehabilitation *) Editor-in-Chief. https://doi.org/10.7146/torture.v30i3.123318 2. 1. Definitions and conceptual map 1. a torturea suggest some tentative and method furtherfor research. avenues and conclusions (UNHCR, 1999). In this Editorial, we would would we Editorial, this In 1999). (UNHCR, psychologiand medical the to update like cal research on the impacts of starvation as (i.e. Rejali, 2009) nor in the Istanbul Pro 2009) nor in the Istanbul Rejali, (i.e. marginallyit mentions which con tocol, cerning conditions of detention without any pages other mention or guidance within its academic research on the subject is unusually academic research on the subject is unusually mentioned neither It is 2019). (Rubin, low. as a torture method in source handbooks hunger or starvation in places of detention Sur camps worldwide. and concentration the quantity and quality of however, prisingly, are described in the Bible as a way of retriare described in the Bible as a way There are offended. when God was bution of accounts of the use of forced imposition Deprivation of food is one of, if not the oldest the not if of, one is food of Deprivation Hunger and famine method of punishment. in research and ways forward in research Editor-in-Chief* Pau Pérez-Sales, Hunger: Deprivation and manipulation of manipulation and Deprivation Hunger: the art method. State of torture food as a EDITORIAL 4 TORTURE Volume 30, Number 3, 2020 when intakeisbelow 30 kcal/kg/day and0.9 g that food-deprivation producesstarvation below), Wischmeyer, (2017)hassuggested is ~0.75g/kg/day. (FAO & WHO, 2005). toavoidprotein delivery inhumans starvation women. The recommended WHO baseline men and 2500 kcal/ day (36 kcal/kg/day) for (TEE)) is3000kcal/day (44kcal/kg/day) for (or approximate Total EnergyExpenditure of 30and60, thedailyenergyrequirement kg individual(1.75×BMR)between theages United Nations 2 1 http://www.fao.org/docrep/007/y5686e/y5686e00. households wherelivingconditions cannot Food Insecurity status cannotbeassessedis the nutritional = 0.013)(Ravaoarisoa etal., 2019). (p and lackoffinancialassistancefromfamily < 0.001), visits(p=0.013) absenceoffamily ceration duration ofmorethan10months(p insufficient energyintake(p<0.001), incar of two meals a day instead of three (p = 0.003), wasing. related totheintake Undernutrition including thosewhowere pregnantandlactat was 38.4%, femaleprisoners undernourished of (Madagascar) foundthat theproportion status inawomen’s in prison Anatinomora months. For instance, astudyofnutritional and, ideally, afollow upaftersome toperform dividuals with protein-energy malnutrition measure istoestimate thepercentage of in asawar weapon,starvation analternative or inthecontextofanalyzingusemass this is2100calories protein/kg/day. For anaverage 70Kgperson An alternative anduseful measure when visitstodetentioncenters In monitoring Based ontheMinnesotastudy(see for menandwomen. lacking specificdata, thevalue canbeassumed htm#Contents The Minnesotastudy onlyincludedmen, but

1 , foramoderately active 70 , usuallydefinedasthose 2 and36gr. ofproteins. - - - and strength, of wholesome quality ‘ Mandela Rule At anindividuallevel, Rule22of The Legal definitionandjurisprudence & Segall-Corrêa, 2008). al., 2013; Leroy etal., 2015; Pérez-Escamilla measures (Coates et al., 2003; A. D. Jones et scalestocomplexmultidimensional short measurements,posals offoodinsecurity from 2017). There areexcellentreviewsandpro or stealingfromotherinmates (Molokoetal., ful meansofobtainingfood, suchasbegging used,oners theythemselves believed, shame and nightwithouteating and62%ofthepris at night, staying awholeday 12%reported stated theyslepthungry 22% oftheprisoners anxiety over availability of food. Approximately feelings of day). reported 61%oftheprisoners that theycould getenoughfoodthe following ered themselves foodinsecure(i.e. uncertain in Malawian prisons, 95%ofinmates consid centers. For instance,study inacountry-wide detention also beenappliedtomonitoring members. has The idea of food insecurity ensure daily food provision for all family ficient nutrition”. what would beconsidered “adequate andsuf 2008). on Neitherdefinitioncontains clarity measure shallbeprohibitedby law as a disciplinary and itssuspensionorrestriction Such food shallbeprovided at regularintervals, bymedicalcriteria. needs ordietdetermined concerns,and religious as well as to any special nutrition, withdueconsideration totheircultural condition soastoensureadequate andsufficient to food insuchaquantity, quality, andhygienic “ XI)that:Human Rightsstates (Principle Commission on cas oftheInter-American inthe of Persons DeprivedofLiberty Ameri ciples andBestPracticesontheProtection food of nutritional value adequatefood for ofnutritional health Persons deprived of liberty shall have the right shallhavePersons ofliberty theright deprived s establishesthedutytoprovide EDITORIAL ’. The Prin ’. The ” (ICHR, Nelson ------5 TORTURE Volume 30, Number 3, 2020 - as ill-treatment or torture, especially especially or torture, as ill-treatment 4 According to the same review, providing food providing According to the same review, (Apr. 27, 2011) (eating blindfolded), Istratii Istratii blindfolded), 2011) (eating 27, (Apr. App. H.R., Ct. Eur. Moldova, and Others v. ¶ 62 (2007) 8742/05, 8705/05, 8721/05, No. standing “all detainees had to eat (noting that no chairs in their cells, because there were up” although the decisional body did not clarify whether this factored into their finding of torture Case Kvocka, Prosecutor v. and ill-treatment), ¶ 64 (Int’l Crim. Judgment, IT-98-30/1-T, No. 2001). 2, Nov. Yugoslavia for the Former Trib. and being beaten 3 minutes to eat (Only having afterwards). treatment); Abdulrahman Kabura v. Burundi, ¶ Burundi, v. Abdulrahman Kabura treatment); 11, (Nov. CAT/C/59/D/549/2013 Doc. U.N. 7.8, . “water denied the victim was 2016) (noting that which contributed of to a finding [and] food,” . . 2018) (IHRLC, ill-treatment). or contained in poor condition which was urine dead or like faeces, inedible elements, or torture, as amounting to ill-treatment animals, ¶ Uruguay, Cariboni v. cases: in the following CCPR/C/31/D/161/1983 (Oct. Doc. U.N. 4, Institute v. Reeducation Juvenile 1987), 27, Preliminary Merits, Objections, Paraguay, Inter-Am. Judgment, and Costs, Reparations 2004) 2, ¶ 16 (Sept. 112, C) No. (ser. H.R. Ct. Merits, Peru, Miguel Castro Castro Prison v. Inter-Am. Judgment, Costs, and Reparations, 2006), 25, ¶ 37 (Nov. 160, C) No. (ser. H.R. Ct. U.N. ¶ 2.7, Burundi, v. Déogratias Niyonzima 2014), 21, (Nov. CAT/C/53/D/514/2012 Doc. Doc. U.N. 10.2, 8.2, ¶¶ 2.1, Zaire, Muteba v. (noting 1984), CCPR/C/22/D/124/1982 (July 24, to be brought by outside food also needed that family in response to the provision the victim’s of “withholding” and the food, “insufficient” of which contributed to a food while in detention, finding of torture (IHRLC, and ill-treatment) the treatment Also in some instances, 2018). amounted to torture the food by the manner that U.N. ¶ 4, Uruguay, (Cariboni provided v. was 1987) 27, CCPR/C/31/D/161/1983 (Oct. Doc. Nepal, Giri v. with the fingers), to eat (having CCPR/C/101/D/1761/2008 Doc. U.N. ¶ 2.4, U.N. Doc CCPR/C/110/D/1890/2009 (Apr. 23, 23, (Apr. Doc CCPR/C/110/D/1890/2009 U.N. “food and of the deprivation 2014) (holding that contributed to a finding of torture and ill- water” note for details). 4 of food other methods (see foot when combined with - - , and manipulation and manipulation , 3 The review considers the following cases: The review considers cases: the following with no food” and that this contributedthat to a and with no food” Ali Radi & Abdel Hadi, finding of ill-treatment); Communication Republic of Sudan, Others v. 5, ¶ 74 (Nov. Comm’n H.P.R., Afr. 368/09, the general conditions of 2013) (holding that of the deprivation which included detention, Franck Kitenge treatment); constituted ill- food, ¶ 2.4, Republic of Congo, Democratic Baruani v. H.P.R., ¶¶ 51, 53 (May 22, 2008) (holding 22, 53 (May 51, ¶¶ H.P.R., to not regularly provided” “food was as that this “insufficient,” and was victims in detention, contributed Prosecutor v. of torture); to a finding ¶ 844 Judgment, IT-05-88-T, Case No. Popovic, June Yugoslavia for the Former Trib. (Int’l Crim. detained in “were victims that 2010) (finding 10, facilities intolerable conditions of overcrowded water” and that this omission was found, along found, this omission was and that water” Miguel with other factors, to constitute torture; 103 44, ¶¶ 37, 160, No. Castro Castro Prison, “did not inmates 2006) (finding that 25, (Nov. during on an attack water” . . [or] . food receive and that the prison detained, where they were this contributed Institute to a finding of torture); Africa v. in for Human Rights and Development Comm’n Afr. 292/04, Communication Angola, Polay Campos v. Peru, ¶¶ 2.1, 8.7, U.N. Doc. Doc. U.N. 8.7, ¶¶ 2.1, Peru, Campos v. Polay 1997) (noting 6, CCPR/C/61/D/577/1994 (Nov. “the food [was] detained, while the victim was this contributed a finding to and that deficient” Danilo Dimitrijevicof torture and ill-treatment); U.N. 7.1, 2.2, ¶¶ Montenegro, Serbia and v. 2005) 16, (Nov. CAT/C/35/D/172/2000 Doc. “denied food and the victim was (finding that Sendic v. Uruguay, ¶¶ 2.3, 2.4, 20, U.N. Doc. Doc. U.N. 20, 2.4, ¶¶ 2.3, Uruguay, Sendic v. 1981) (holding 20, CCPR/C/14/D/63/1979 (Oct. “lack of food” a subjecting the victim to that in addition to other while in detention was, factors, a form of torture and ill-treatment); It is beyond the scope of this medical review the scope It is beyond 3 that there is some, although limited legal pre there is some, that notably in the jurisprudencecedence, of the Inter-American for Court of Human Rights, considering deprivation reference a recent comprehensive preparatorya recent comprehensive reference Against Rapporteurdocument for the Special can be suggested 2018) it (IHRLC, Torture to analyze the legal precedents of food-deprito analyze the legal precedents a as Taking torture. to amounting as vation EDITORIAL 6 TORTURE Volume 30, Number 3, 2020 ing; and(ix)comprehensive societaltransfor (vii) extreme exploitation; (viii) war provision punishment; extractionortheft; (vi)material control;rial (iv)flushingoutapopulation; (v) weakening apopulation; (iii)gainingterrito or genocide;extermination (ii) control through to sustainlife. They suggestninepurposes: (i) nity toaccesstheminimumfoodrequirements orcommu the capacityofatargetedcountry tionally produced through actions that impede and (2019) advocate theterm inclusion inthe RomeStatute oftheInterna especially afterits of starvation of thecrime inthedefinition progress has beenenormous around theworld. andtribunals courts There missions, missions, andfact-finding inquiries in com that includes analysis of starvation ness. Especially useful is the 41-page annex to probeintentionality, andlawful purpose lective situation. They specificallyreviewhow asappliedtoacol of thedefinitiontorture Compliance, 2019)that follows theelements inaseminalpaper(GlobalRights starvation viewed accountabilityissuesregardingmass contexts.many othercontemporary Soviet republics(Sharipzhan, 2015)among sioner, 2018), Turkmenistan andother former 2019), Libya (United Nations High Commis (AmnestyInternational, 2016;Syria GRCI, and methodofwar in Yemen (Graham, 2020), atic as torture use of hunger and starvation Waal, 2005), aswell astheongoingsystem (Peterson,Armenia 2004) and Darfur (De Tyner & Rice, 2015), Ireland (Nally, 2006), Kampuchea /Cambodia(DeFalco, 2014; 2015) andpost-World War II(Autumn, 2009), in the useofstarvation World War -II(Gerhard, thought-provoking works arethehistorical on mation. De Waal andConleyhave extensively re For theinterested reader, especially At a collective level, Conley&de Waal starvation crimes starvation

when famine isinten whenfamine mass starvation mass starvation ------consequences areentirelydifferent. processesand the medicalandpsychological tions canultimately representadangertolife, Famine (seetable1). Although bothsitua and tion and Manipulation and Starvation ing two differentphenomena: Food Depriva reviewwillbedividedaccord and psychiatric Taking intoaccountalltheabove, thismedical Two separate analysis. situations that deserve Wayne Jordash etal., 2019). Marcus, 2003; Sheldon, 2012; Ventura, 2019; D’Alessandra & Gillett, 2019; Hutter, 2019; a complexissue(Akande&Gillard, 2019; remain ity andprosecutionsofperpetrators Court, although accountabil tional Criminal of these facts asamountingtotorture? of thesefacts to the legal world regarding the consideration that may berelevant criteria or psychological (c) andfamine? Starvation Are there medical of Food deprivation and manipulation and andthe sequels on theseverityofsuffering evidencethat exists medical andpsychological (b) of ill-treatment or torture? What is the deprivation within thestudyofmethods (a) Isitpossibletooperationally definefood Table 1 2. 1. We aimtoanswer thefollowing questions: and, ultimately, compromises life. to foodthat causesundernutrition inthe access and sustainedrestriction and famine. Starvation manner.in adenigrating food oflow qualityorwhichisprovided quantity, includingfoodinsecurity, or infood restrictions orpartial Short-term Food deprivation and manipulation. . Conceptualdomains EDITORIAL Prolonged - - - - 7 TORTURE Volume 30, Number 3, 2020

------ego-depletion ego depletion ego . There is an as . Hunger and emotions The idea behind this assumption is the crease impulsivity, aggression to un and leads crease impulsivity, Benton, 2016; stable mood (Anderberg et al., et al., DeWall 2014; Bushman et al., 2002; 2007). Hermanns et al., 2013; Gailliot, 2011; in folk culture - - even well-known accepts that 2007) Vohs, theory & (Baumeister amount of a limited a human being has that Self-regulation and mental energy. physical depend on having therefore, and self-control, Glucose deficit due to “ego energy”. sufficient provoke would food-deprivation occurs. The results must, therefore, be ana therefore, The results must, occurs. specifically will we Here, caution. with lysed on emo review the impact of food deprivation judgment moral functions, cognitive tions, and altruistic and prosocial behavior. emo negative evokes hunger that sumption sadness). irritability, anger, (rage, tions short-term Nevertheless, laboratory studies There is do not seem to confirm this idea. only indirect and inconsistent experimental in levels glucose low that suggesting evidence tions and drives. In this sense, the idea of “gut the idea of In this sense, tions and drives. more might have “gut feelings” or decisions” seem. meaning than it may of food: physical 2. Short-term deprivation and psychological effects research is based Almost all existing academic com on experimental studies with students, for academic credit or small pleted in reward where the motivational financial incentives elements are far is and attitudinal from what settings where tortureto be found in natural 2014). So, there are strong neural interconnec there are strong So, 2014). emo meanings, needs, physical tions between render the personemo to vulnerable more This has been linked to false con tional cues. interrogation the in fessions (Davis suspects of and allow negative emotions to appear and and emotions to appear negative and allow ------in regulating sensa in regulating , which signals energy , insulin ghrelin , which signals energy availability and availability energy signals which , How we become aware of and feel hunger become aware we How There is evidence of individual differ thirst) and to associated behaviours (Harshaw, thirst) behaviours (Harshaw, and to associated meaning (Quadt et al., 2018).These same cor same 2018).These et al., (Quadt meaning tical centres support the integration of all these hunger, sex, pain, (e.g., inputs into drive states grated (Stevenson et al., 2015). This process 2015). et al., grated (Stevenson and consciousness by awareness is mediated meaning to the afferent sensations, attach that including emotions and feelings linked to that ted via spinothalamic and vagal afferents to afferents to ted via spinothalamic and vagal somatosensorythe anterior orbi and insular, tofrontal cortices of the brain where it is inte ceptors (e.g. oxygen concentration, hunger hunger concentration, oxygen ceptors (e.g. and muscles and tendons (e.g., hormones), fatigue) is transmit feedback, proprioceptive formation from the bodily organs (e.g., bowel, bowel, formation (e.g., from the bodily organs the skin senses (e.g., heart), stomach, bladder, internal chemore itch), touch, warm, cool, (Chen & Knight, 2016). (Chen & Knight, Complex sensory in is still largely unknown. although there seems to be coincidence with although there seems to be coincidence human variability cardiac signals, in perceiving pointing to a general element of differences signals in the individual perception of vagal ences in the perception of gastricof perception ences in the of signals The reason is unknown, fullness or emptiness. stimulus. Furthermore, external be cues may stimulus. more important than internal signals in arous 2016). ing feelings of hunger (Chen & Knight, tions of hunger in humans. The level of these of level The tions of hunger in humans. substances depends on on internal chemore and environmental glucose level) ceptors (i.e. scarcity and drives towards food intake and towards scarcity and drives leptin add Both behaviour. inhibits food-seeking to the effects of feeding through sets of neurons in the hypo feeding through sets specific hunger segregate two thalamus that hormones: Setting the baseline: psychophysiology of hunger of hunger psychophysiology baseline: Setting the circuit emotions and the feeding controls that circuit There is a homeostatic EDITORIAL 8 TORTURE Volume 30, Number 3, 2020 neutral stimulusonlywhentheywere putin hunger reactedwithnegative emotions toa quist (2019)showed that subjectswhofelt ments withvolunteers, &Lind MacCormack text-dependent emotion. hunger should be better studied as acon ter & Vohs, 2007)suggestingthat short-term come the effect of glucose depletion (Baumeis and speciallythat highmotivation canover give sufficientconsideration tootherfactors, may betoo the theory “mechanical” andnot & Leo, 2012). Recentresearchsuggeststhat This effectseems toincreaseinobesesubjects (Gidlöf etal., 2020; Rummel&Nied, 2017). cognitive function withnormal interfering diate future related to food-relevant stimuli, haviour) andthinkinginactionstheimme be increases distraction(mind-wandering show significantly that offasting five hours ous reaction(Hoeflingetal., 2009). ing even iftheywere unaware oftheirprevi palatable that theypreviouslysaw asdisgust matically. Inotherwords, subjectsfoundfood and that auto thisattenuationhours occurred in subjectswhohadbeenfood-deprived for15 shown that disgustwas significantlyreduced food. researchwithvolunteershas Laboratory is disgusttowards inedibleorunpalatable the emotion. aware, hecaneasilyregain controlandmanage a resultofhunger. ismade When theperson as cating feelings of bad temper or irritability popularly-coined expression indi “hangry”, self-control. This iswhat probablyreflectsthe cluding hunger. Inmostsubjects, thisledto to expresstheemotionstheywere feeling, in disappeared whenthevolunteerswere asked oranger.ritability thiseffect Furthermore, able. Onlythen, reactedwithir theperson asunfavora contextthat theyinterpreted Cognitive functions relevant negativeA particularly emotion In asimilarvein, ofexperi inaseries

. studies Laboratory ------perhaps duetotheoverall feelingoftiredness tional andareguidedbyintuitive decisions, food-deprivation people tend to be less ra short-term tal data suggeststhat during overall elementoffatigue. This canpoten moral contexts, which mightbelinkedtoan injudging individuals seemtobelessstrict etal., 2019). (Kerry Hungry for transgressors al., 2018)andwithmorelenient punishments et tions indifferentethicaldilemmas (Vicario ated withamorelenientviewofmoralviola of amealtime, subjective hunger was associ studieswithstudentsdeprived two laboratory data onnaturalistic settingsisavailable. etal., properly(Vicario dangers 2019). No and do not assess risk als tend to take greater individu evidencesuggeststhat hungry inary (Brown etal., 2020). Also, prelim somevery or totheneedsave cognitive resources cognitive functionsperse. food-deprivation produces a declinein term the idea that short- and it does not support related tofood cues, but nottootherelements deprivation increasesattention andmemory with volunteers inlabconditions (Benau etal., 2014). Insummary, research seemedunaffectedinallexperiments memory and decision-making. and long-term Short- ecutive functionsincludingproblem-solving psychomotor speedandreactiontimesinex there was in alow tomoderate impairment cognitive task, whileintheremainingthree, inany didnotaffectperformance fasting term al., (2014)foundthat inseven ofthese, short- conclusive. Inareviewoftenstudies, Benauet tive functions, evidence isin theexperimental etal.,tagrin 2019). food itemsbut notfornon-fooditems(Mon for enhancesmemory offoodrestriction hours etal.,(Vicario 2019). Inasimilarvein, nine Moral judgmentandpunishment When turning tonon-food-related cogni When turning Taking decisions . Initialexperimen shows that food EDITORIAL . In . In ------9 TORTURE Volume 30, Number 3, 2020 ------All the the All Data provide strong support provide Data to Psychosocial background early and of food. value symbolic The of degradation, surreptitiously control showing of degradation, on all aspects of their life. way of example, in in-depth qualitative in qualitative in in-depth of example, way terviewscorrec a at inmates 30 female with found to food was tional facility in the US, be a significant determinant of the subjec impression of punishment carriedtive out by Al 2017). & Lopes, the institution (Smoyer the variety and though sufficient in quantity, cooked and food was the the way presentation, being rushed and while served, and watched seen as dehumanising experiences were eating deeply hu were of symbolic punishment that far was more than a means for Food miliating. survival seen as a mechanism and instead was associated with food-deprivation. In a series with food-deprivation. associated Allen & Nettle (2019) showed of experiments, with a personal adults that history of child reacted with hood socioeconomic deprivation situa a in emotionality and impulsivity more past ex tion of hunger probably as it evoked explanations periences negative and attached and meanings to it. in caloric intake, beyond that suggest above food has a symbolic value given context, any By to assess. is also extremely relevant that In the most comprehensive set of laboratory set In the most comprehensive acute in overall, game studies with volunteers, neither in pro-sociality, hunger did not affect games (Häusser nor competitive cooperative the these are lab studies: Again, 2019). et al., nor practi emotional any games did not have much less for the participant, cal implications survival competition for there was that or any risk to life. experiences. experiencesthe idea that and lack of of poverty resources frame the emotions and behaviours tions but, in fact, they are less prone to share they are in fact, tions but, 2013). (Aarøe & Petersen, they have what ------From the point of view of evo From the point of view In adults, there is a robust popular concep there is a robust In adults, Anthropological data suggests that in cul Anthropological suggests that data Social attitudes and short-term and attitudes Social food ian positions when these are theoretical ques only if it does not mean parting with their giving to a charity). money resources (i.e. Hungry individuals support more egalitar But the data shows conflicting results. Short- conflicting results. shows But the data term seems to increase pro food-deprivation hungry (for instance, social behaviour people but supportivemore are programs), welfare of tion, supported hunger that by various surveys, tion, undermines and human prosocial attitudes beings become selfish and survival-oriented. haviour in human adults and children and cul in human adults haviour elements are essential. tural and educational reinforced at school (Barragan et al., 2020). 2020). (Barraganschool at reinforced al., et hunger per The results strongly suggest that altruisticse cannot explain food-sharing be norm. In individualistic societies, food-shar In individualistic societies, norm. skills become less rele ing and cooperative in family patternsvant education and must be monious and empathic toward others, pay pay others, toward monious and empathic and childrear rules, reciprocity to attention supportpractices ing al of expression the food-sharing then the is truistic behaviour, shared their food (Huppert et al., 2020). 2020). shared their food (Huppert et al., tures where families on being har place value overall, but particularly but when sharing food-rel overall, ex children still Despite that, resources. evant to the contrary otherspected that behaved and action, even after a feeding delay (Barragan after a feeding delay et even action, Hungry But this changes with age. 2020). al., share less likely to children were 4-9-year-old beings seem prone to share food. 19-month 19-month share food. beings seem prone to old infants and spontaneously repeatedly nutritious food natural transferred high-value, of exchange and inter to a stranger as a way deprivation. in early infancy human lutionary psychology, tially have implications for explaining wrong for explaining implications tially have decisions in interrogations of in the context hunger. EDITORIAL 10 TORTURE Volume 30, Number 3, 2020 shows, forinstance, that (a)inanimalstudies, ent mechanismscan interact. However, data is notmuchresearchonhow thesediffer environments.the creation of torturing There elementsin tootherconcurrent interrelated mustbestudiedas the effectsofstarvation methods.tion with other torture ing ill-treatment andtorture. and as such, must be studied when document energy tothebody; itisanattack ontheself goes beyond simply cutting the supplies of ronments. envi and hunger in the creation of torturing fooddeprivation consequences ofshort-term data suggestingthecomplexinteractionsand food. inforce craving forsocialconnectednessand suggesting commonneuralpathways that re unclear, foundfMRIimages but theauthors tion in combination with total fasting of ponentially potentiating effectof10-hours and glucoselevels. (d) There isamutuallyex al., 2019). This seems to be linked to cortisol decreasesit(Gupta et foodrestriction partial creases ghrelin.acylated (c) Total in foodrestriction by decreasedcirculating concentrations of al., 2018). The effectseemstobemediated debilitating effect of both methods (Matu et and energyintake, potentiating ashort-term andwet asphyxia)ing ordry reduceshunger In humans, seded by Hungerwhen food is available. (b) both Fear andPain areinhibitedandsuper and food is not available.is hungry However, Both Fear andPain increasewhentheperson renk &Korotkova, 2018; Verma etal., 2016). pain hunger hascomplexinteractionswith (Tomova etal., 2020). The explanation is Combining short-term fooddepriva Combining short-term In overall, deprivation offood short-term All these elements are only preliminary All theseelementsareonly preliminary (Misanin & Campbell, 1969; Ponoma

sleepiness hypoxia innight shift-workers, while (linkedtoforcedexercis social isola fear Finally, and ------The MadnessofHunger down includingapathy andlossofhope. break cognitive topsychological deterioration ofsurvivors.haviours Helinksphysical and reason toexplaintheallegedlydefeating be oftheHolocaustsystemandmain nerstone was that thecor starvation (2014) considers ally labile, sad and depressed, without an ap victim shaky, dizzy and disoriented, emotion have even fewer food supplies. a Shedescribes “mad” when, cycles, they duetoagricultural weakened and debilitated state, that become ties chronicallymalnourished, inagenerally families, extensive shedescribes communi andtheir among Braziliansugarcanecutters andtheMiddleEast.terranean) Inherstudy South the Medi America, Europe (primarily and marginalised, inNorth ethnicminorities syndromes,ric that canbefoundamongpoor, the many folkdiagnoses, studied aspsychiat ness”). Sheconsiders er-Hughes (1988)studies Portuguese), Schep Nancy theanthropologist hunger andnothingelse (1966)summarises: Amery “ bread (Antelme, 1971; Wiesel, 1983). As Jean one’spoint ofrisking lifeforasmallpiece of Semprun, 1972)withadriveeven tothe anddreamoffood(Frankl,imagine 1964; (Levi, 1989; Nath, 1998), andpeopletalk, obsession withfooddominates allthoughts unbearable sourceofpain(Nath, 1998), the untilthepointofbecomingan be excruciating indetail.described can Prolongedstarvation are ofstarvation deprivation andexperiences able in the literature where prolonged food possible toreviewthemany testimonialsavail Testimonials of survivors. famine. 3. Prolonged deprivation:starvationand Anthropological studies.Anthropological In a mostly speculative paper, Young ". ". Nervos (“Delirio defome”(“Delirio in Nervos It would be im I was my bodyin anexampleof In heranalysis, EDITORIAL (“Nervous ------TORTURE Volume 30, Number 3, 2020 11 ------.” (Keys et al., 1950). (Keys et al., .” Duringinitial hours the The difference between us and the between The difference There was a plethora of animal There was Animal studies replicating Holocaust Animal studies replicating After that period, fat reserves period, After that are not Body adaptation and medical and and medical and adaptation Body sure, lower cardiac frequency, slower kidney slower frequency, cardiac lower sure, in progressive a is there and functioning) This crease in the consumption of proteins. is a down regulation to save resources and after to save regulation is a down brain glucose consumptions falls weeks to two variabilitysignificant is there Although 50%. among individuals and contexts (high versus this to hunger), of stress associated levels low compensatorysome for allows mechanism normal decreased but what during functioning this initial period of 10 to 15 days. normalkeep to enough the and functioning body resorts to further visceral and endocrine de to diminish calorieadaptations (i.e. needs blood pres lower crease in thermal regulation, of contemporary with animals. studies psychological of chronic consequences food-deprivation. there is a carbohydrate of acute starvation, affects muscle and brain func depletion that both highly dependent on tion in particular, producing fatigue and mild cogni glucose, After 24 hours the body begins effects. tive to resort to body proteins and fat to produce and glucose through glycogenesis procedures There the use of fat acids (ketosis metabolism). IQ of 130. Furthermore, as one of the particIQ of 130. ipants “ said: tryinghad they probably were people we to serve: starving were under the We did. than we less food knew the and we best possible medical conditions to end. our torture going on which was exact day the true was None of that of people in Belgium, or whatever Netherlands, conditions. decades (table 2). studies in the following be ethically unaccepta Most of them would a summary 2 also shows Table ble nowadays. highly motivated conscientious objectors. All objectors. conscientious highly motivated degreesof them had academic and an average , ------Food Food (Peru) Mancharisqa Africa).(Central or Nubila (Mexico), (Mexico), During the Holocaust, Jewish Jewish During Holocaust, the Minnesota Starvation Experiment, Minnesota Starvation Experiment, Susto Susto Pre-and post-starvation personality (Inuit) Important as it is, the study is, however, however, study is, the Important as it is, In the Ghetto studies and The Minnesota The Minnesota Ghetto studies and a torturing environment. The volunteers were The volunteers were a torturing environment. studies (Eckert et al., 2018). 2018). studies (Eckert et al., happen in would of what not representative ality Inventory (MMPI) scales of Depression, scales of Depression, ality Inventory (MMPI) The recovery Hypochondriasis and Hysteria. years period 8 months and two took between with no long-term consequences in follow-up one’s life”. life”. one’s a temporarytests showed and reversible in crease in the Minnesota Multiphasic Person in their ears (Keys et al., 1950). As one of As one of 1950). in their ears (Keys et al., “ years later: the participants explained, only thing really in and became the one central & Semba, 2005). The participants experienced 2005). & Semba, muscle soreness, extreme tiredness, dizziness, and ringing reduced coordination, hair loss, fatigue and apathy, extreme weakness, irritabil extreme weakness, fatigue apathy, and extremity and lower neurological deficits, ity, Kalm 2012; Bowman, & (Guetzkow oedema a regime of semi-starvation par in which most body ticipants lost in as much as a 30% of and psychologi medical with severe mass, chronic cal consequences including anaemia, conducted during World War II (Keys et al., II (Keys et al., War World conducted during thirty-six subjected to were volunteers 1950), and children. None of the authors survived. None of the authors survived. and children. published Their compelling observations were 2020). (Magowska, after the war doctorsmonitored and recorded the starva and the Warsaw tion process in the Ghetto of process of starving in Dachau in adult to death dromes as as dromes Wendigo Experiment. resents a psychiatrization of chronic cycleschronic of psychiatrization a resents Similar reasoning can likely be of starvation. syn “cultural-bound” applied to such diverse petite, and often alternating between periodsalternatingand often between petite, and unpredictable out withdrawal of passive she considersbursts what rep of rage in that EDITORIAL 12 TORTURE Volume 30, Number 3, 2020 tion willthen lead tolethargy, neurological (Wernicke'sment ofmemory encephalopathy). systems, impair withataxia andpermanent damage inthecardiovascular andneurological deprivation, producespotentially irreversible most dangerousconsequence of chronicfood after 12months. The deficitofthiamine, the D after4-5monthsand Vitamins A andB12 (Vitamin B1)aftertwo weeks, Vitamins Cand rhea. Vitamins decrease sequentially. Thiamine ing hypothyroidism symptomsandamenor functioning,decrease in endocrine includ pletion (seetable3). There isalsoan overall cells, de leadingtoanaemiaandlymphocyte the production of new cells, including blood inmusclemassand implies adeterioration • • • • • Table 2 • • • • • •

Selection of relevant contemporary studies Selection ofrelevant contemporary intents toscapeit(Misanin&Campbell, 1969). shocks and develop avoidance behaviours. did not diminish neither reactivity to pain nor Starvation shocks,When subjectedtoelectric hungerdidnotchangethecapabilitytodetectandrespond symptoms, eventually leadingtoapathy andlethargy. Hunger elicited an initial phase of feeding schemas(Ezinga&Becker,by irregular 1970). bybothbodilyweightHunger was lossandfeedingschedule, determined withmorehungerelicited towhat was expected(Cravenscontrary &Renner, 1969). Feelings ofhungerordriveforfoodwas difficulttocondition(forinstance, toalightorsound), 2017). towards food. At theendofexperiment, allrats hadasimilaramountoffood(Weiss etal., among them. There wasalways oneleadrat –notnecessarily thesameone-that guidedtheothers When albinorats werecollectively, starved hungerdidnotincreasehostileoraggressive attitudes die whatever actionswere takentohealit(Heron&Skinner, 1937) Once the 1937). from the4 when theirsearchactivitydecreasedabruptly. This When albinorats were starved, day untilapoint thedriveforfoodincreasedsteadilyfromfirst related behaviour, innate fear, etal. andsocialinteraction(Burnett 2016) a hierarchicalposition. Itisabletosuppresscompetingmotivational systems, suchasthirst, anxiety- drive at eachtimethat over allothers, supersedes whenfoodisavailable, drivein Hungeristhefirst Following that animalsshouldalways principle theethological have onesinglecentralmotivational hunger andviceversa(Ponomarenk &Korotkova, 2018). There isaninteractionbetween hungerandpain. When eitherissufficientlysevere, paininhibits other words, hungerseemstodecreasefeelingsoffear(Verma etal., 2016) the acquisitionoffear. Onceacquired, hungerincreasestherate at whichthat fearisextinguished. In In albinorats, hungerand fear interact. When exposedtoathreatening situation, hungerdiminishes If stillprolonged intime, extremestarva

. Selectionofanimalstudiesonstarvation breaking point th tothe15 th day withnoindication couldpredictit(Heron&Skinner, ofwhichvariables was reached, itwas almostimpossibletorecover theanimal. Itwould always anxiety symptoms - - - - - irritability, oedema and death fatal in an es suffer. Onehesitates tocallthemliving: onehesi dead withinthem, already too empty to really who marchandlabourinsilence, thedivinespark tinually renewed andalways identical, ofnon-men backbone ofthecamp, ananonymous mass, con they, theMuselmanner, the thedrowned form for death: waiting sideration for their actions – virtually who were apathetic and acting without con tivity had lost all identity and consciousness, vation andtheoppressive conditionsofcap beings that, through a combination of star locaust labelled as the “Muselmann”: human of the Ho to what survivors stage corresponds timated three to four months. This terminal in albino rats, that latterly evolved to depressive breaking point “ Their life isshort, but theirnumberisendless: was extremelyvariable, inarange . EDITORIAL ------TORTURE Volume 30, Number 3, 2020 13

1

Fragile hair and nails / Losing hair Dry can fissure and bleed skin that Pruritus. Chronic irritation of the cornea Memory and concentration fractures Pathological Weakness Cold intolerance Weakness Amenorrhea Loss of libido Irreversible memory and motor damage Weakness Susceptibility to infections Abnormal response fever Difficulties in healing wounds Bleeding Difficulties in swallowing Constipation Nausea after ingestion of food due to aspiration Death of confusion State Concentration Attention, Memory, Emotional instability In practice dizziness, palpitations, Fatigue, sudden death and weakness Fatigue Progressive oedema - - - - -

Slow movements Slow in dysfunction - Elevation Liver transaminases Brain atrophy neuropathies Peripheral Seizures due to glucose deficit Lanugo Alopecia Lagophthalmos Hypothyroidism gonadal hormonesLow High cortisol Hypercholesterolemia Wernicke-Korsa Thiamine deficit – koff syndrome Pancytopenia: Thrombocy Anemia / Leukopenia / topenia Dysphagia pneumonia Aspiration Impacts Short-term Hypo - Bradycardia, tension Arrhythmias Long -term - Mild pitting oedema Electrolyte abnormalities (Hy hypo-magnesae po-phosphataemia, hypo-calcaemia) mia, Renal calculi Renal failure Osteoporosis Myopathies - - . Physical consequences of chronic deprivation of food - starvation of chronic deprivation consequences Physical . Sources: Personal elaboration from Jones et al., (2012); Mehler & Brown, (2015); Phillips, (1994); (1994); Phillips, (2015); Mehler & Brown, (2012); et al., from Jones elaboration Personal Sources: (2016) et al., Westmoreland Sudden cardiac death is the main cause of death after suicide in chronic starvation after suicide is the main cause of death Sudden cardiac death

Eyes 1 Dermatological Neurological Gastrointes tinal Haematolog ical Endocrine Skeletal Renal Cardiovascular Table 3 Table EDITORIAL 14 TORTURE Volume 30, Number 3, 2020 4. Summary, conclusionsandproposals. stand…" they have nofear, astheyaretootiredtounder tates tocalltheirdeath death, intheface ofwhich 2. 1. a. method manipulation asatorture food-deprivation and Short-term erature. are differentmeasuresavailable inthelit is analyzingFood security, forwhichthere 2017). visits Al alternative formonitoring (Wischmeyer,be considered as starvation 2000 Kcal/day (30Kcal/Kg/day) should kg/day) forwomen. Any foodsupply under day) formenand2500kcal/day (36kcal/ mated around 3000 kcal/day (44kcal/kg/ adult withlow activitylevel canbeesti requirementsforahealthynutritional bodies recommendations, the detectable malnutrition. Based on UN tected whenthereisalreadysevere and as lackofenoughfoodwillonlybede nutrition. dition so asto ensure adequate and sufficient in suchaquantity, quality, con andhygienic receiving oftheperson to thecriteria population isbeing starved. They adhere fordecidingwhena tablishes criteria es ards forthetreatment ofprisoners stand None ofthedifferentinternational deprivation. hungerandfood Measuring

purpose, motivation andmeaningare wanting andneedingfood. Context, Hunger isasubjective sensation of humiliation ofthe anddenigration ofdehumanisation,used asaform terms, when deprivation incaloric manipulation andeven mildfood food-deprivation. Foodof short-term the impact essential for understanding (Primo Levi,(Primo If This IsaMan) canbeproblematic,This criteria

minimum food . ------5 3. b. tension andbreak theself. the detaineetocreate cognitive andemotional of of thecentralelements oftheexperience mental disconnect, thus makinghungerone from thepainofhunger; fromescapinginto absorption a. method. a torture as andfamine Prolonged starvation d. c. The Kubark Manual (CIA, 1963)defined environment, withpreliminary ofatorturing other methodsaspart and manipulation offoodwith deprivation combination of short-term It isespeciallyrelevant toassessthe identity. to producesevere andbreak suffering detainee may beapowerful method during the first two thefirst weeks.during After that to systemsofdownward regulation human bodymay adapt andresorts In chronicfood-deprivation, the physical status. state and psychological ofdeprivation ortrauma,experiences victim includingage, gender, past of each specific vulnerability criteria by casebasistakingintoaccount impacts mustbeassessedonacase Specific physical andpsychological techniques. cognitive andemotionalmanipulation implications in thesusceptibilityto cognitive functions. This haspotential neural connections, withaffective and as hunger–hasimplications, through A changeinaninteroceptive state –such inhungerfeelings absorption to exploreactionsthat fosterforced exhaustion exercises. Itisalsorelevant pain producingmethodsincluding fear, sleepdeprivation, hypoxia and evidences showing an interactionwith asthepracticeofpreventing distraction EDITORIAL 5 . forced TORTURE Volume 30, Number 3, 2020 15 ------Within the regular articles, MartaWithin the regular articles, Guarch 15 years to the work with torture15 years to the work survivors and who left a deep impression for his com mitment and humanity. Moa Nyamwathi Lonning et alt present a et alt present a Lonning Moa Nyamwathi study on public rehabilitation nation-wide The systems for torture victims in Norway. results suggest the absence of a common policyglobal shortcomings and plan the in urgent services require of ning would that Maria-Angeliki Psyrraki et alt Finally, action. of rehabilita present a study on the narratives tion and the importance of mutual support in Athens. in the Congolese refugee population is co-authored by Gianfranco di This work recently. who unfortunately passed away Maio, A person who has been linked for more than ahead. However, they also confirm the lack However, ahead. supportevidence-based of enough Physi for otherapy interventions the lack and especially to better profiling of proper research related and integrationother target populations with disciplines. presents worrying of on the prevalence data or torture of ill-treatment situations of asylum Their findings in seekers arriving to Serbia. suffered from most refugees have that dicate on European soil. of ill-treatment situations ability and feasibility of a School Pain Treat School Pain a and feasibility of ability ment programme affected by for populations its useful showing Arab countries, trauma in ness in changing traditional practices towards new contemporary models with an integra Finally Marie Nordheim perspective. tive Alme et alt describe the PREP programme, an international experience of consensus and for physi in training processes collaboration torturewith working otherapists victims. of the Special volumes the two Overall, how Section (issues 2020-2 and 2020-3) show and the challenges is evolving physiotherapy in recent years. Anne-Mette Karrer Anne-Mette alt et years. recent in of the cultural accept present an evaluation . - - in almost prolonged food food prolonged . There is a need . . The medical and The medical . . Physiotherapy for Torture Survivors Torture for Physiotherapy view, amount to torture view, for more interdisciplinary research medical and psychologicalbetween The experts and legal professionals. proposals aim to help in this seven direction. deprivation (established as less than 2000 is weeks) calories/day more than two for produces condition that threatening a life sufferingsevere almost all human in in most if not should, beings and that of point medical from a least at cases, all far, that the limit between short-term between the limit that far, is two and prolonged food deprivation short- while In other words, weeks. term two than (less deprivation food torture, to might amount weeks) especially when combined with other methods and conditions, changes leading to a break changes leading to all human beings psychological effects of chronic starvationcriticalare and produce sufferingsevere so suggests, The research reviewed period, severe consequences affecting consequences severe period, with thiamine deficit all organs occur, most dangerous as the earliest and with is associated This condition. emotional and personality cognitive, b. veloped by the Center for Victims of Torture Torture Victims of the Center for by veloped presents the development and gives initial presents the development of the Group physiotherapy assessment data with torturemodel survivorsbeen de has that present the results of a survey conducted regarding among professionals worldwide ser and use of physiotherapy the availability team same The torturewith vices survivors. We include the second part of the Special We Section on Laura Pizer Gueron and MaryAnn de Ruiter In this issue EDITORIAL 16 TORTURE Volume 30, Number 3, 2020 Akande, D., &Gillard, E. C. (2019). Conflict- Aarøe, L., &Petersen, M. B. (2013). HungerGames. References and readers, decideso. victims ifyou,bilitation oftorture ourauthors reference inthefieldofprevention andreha we of willstrivetokeeponbeingtheJournal that in2021therewillbenewchallengesand as anelementofdistortion. We areconfident close ayear markedbytheCOVID pandemic Baumeister, R. F., & Vohs, K. D. (2007). Self- Barragan, R. C., Brooks, R., &Meltzoff, A. N. Autumn, A. (2009). oftaste: Matters thepolitics Anderberg, R. H., Hansson, C., Fenander, M., Amnesty International. (2016). Amery, J. (1966). Allen, C., &Nettle, D. (2019). Hungerand Al-Shawaf, L. (2016). psychology The evolutionary 2, Issue5). ??? 1945-1971 of foodandhungerindividedgermany npp.2015.297 41 Impulsive Behavior. 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Stepien, M., Coro, M., Noakes, P., Catcheside, L., Heilbronn, of Starvation and Methods of Prosecution and Accountability War s Civil ’ Yemen SyriaStarvation Crimes: org/10.1177/0022146516675306 Publishers. our daily us today Give (2020). T. Otterbring, The effect of hunger on consumers’ bread: and the role of bread towards visual attention time orientation. 88 foodqual.2020.104079 166. self-control in the laboratory and across a self-control reducing hunger as the world: panacea. org/10.4236/psych.2013.41008 Third Reich in the of Food constant in the behavior experiment constant in the behavior employing schedule? food-deprivation a fixed Reports pr0.1970.27.3.735 WHO/UNU Expert report of a joint FAO/ Consultation. aggression. aggression. https://doi.org/10.1002/ab.20366 investigation follow-up A 57-year (2018). 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TORTURE Volume 30, Number 3, 2020 19 (Suppl 3). (Suppl 3). 21 , (3), 1–14. 1–14. (3), 12 , (5). https://idun. (5). 7 , Critical Care American Journal PLoS ONE (1), 30–37. https://doi. 30–37. (1), 129 Journal of International Criminal , (4), 849–879. https://doi.org/10.1093/ 849–879. (4), 17 , (2016). Medical Complications of Anorexia of Medical Complications (2016). Nervosa and Bulimia. of Medicine org/10.1016/j.amjmed.2015.06.031 to illness and recovery. https://doi.org/10.1186/s13054-017-1906-8 The of Starvation in the Holocaust: Victims. and Deterioration of its Dehumanization Honors Review Augsburg augsburg.edu/honors_review/vol7/iss1/5%0AThis doi.org/10.1007/s00426-017-0934-y Strategiesprosecuting mass for (2019). J. starvation. Justice jicj/mqz044 alone in do not eat Rats (2017). D. & Eilam, than rather socialize rats Food-deprived public: competing for baits. https://doi.org/10.1371/journal.pone.0173302 Young, K. (2014). The Psychological Effects (2014). K. Young, Weiss, O., Dorfman, A., Ram, T., Zadicario, P., P., Zadicario, T., Ram, A., Dorfman, O., Weiss, S. P. & Mehler, J., M. Krantz, P., Westmoreland, nutrition therapy Tailoring (2017). E. P. Wischmeyer, Wayne Jordash, Q. C., Murdoch, C., & Holmes, & Holmes, C., Murdoch, C., Q. Jordash, Wayne

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• Key pointsofinterest • mn.us to:Correspondence [email protected]. Physiotherapist withMinneapolisPublicSchools. Jordan Programs, Center for Victims of Torture. [email protected] to:Correspondence [email protected] Programs, Centerfor Victims of Torture. Clinical Advisor forPhysiotherapy, Kenya Former Clinical Advisor forPhysiotherapy, SPECIAL SECTION:PHYSIOTHERAPYFORTORTURE SURVIVORS (2) apy limiting accessbyclientstophysiother ceived asbeingthebiggestchallenges of physiotherapy were personnel per Lack offunds/resourcesandshortage or externally access tophysiotherapy, eitheron-site donothavesponding treatment centers at nearly1/3ofre oftorture Survivors : Literature abouttreatment of 10.7146/torture.v30i3.122775

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(33%) were PT, andofthese, 90%reported access toPS. Twenty-nine oftherespondents being the biggestchallenges limiting patients’ of physiotherapywere personnel perceived as PT. Lack of funds or resources and shortage treatment modalitiesprovided byreported ities andexercises were themostcommonly ercise, manualtherapy, massage, activ group (PT) outside of their centers. Therapeutic ex beingableto refertophysiotherapists reported treatment programs third ofrespondingtorture one thirdhaving physiotherapy onstaff. One that theirpatients havereport noaccesstoPS, some providing extensive interdisciplinary some providing extensive interdisciplinary atrange of care providers these centers, with of Torture (UNVF), 2020). There isawide United Nations Voluntary Fundfor Victims Capacity BuildingProject(NCB) (IRCT) Torture Victims Rehabilitation Councilfor (International (SoT)intheworld. oftorture for survivors There aremorethan200treatment centers Introduction modalities, collaboration. barriers, Keywords other PTworkingoftorture. withsurvivor being interestedincollaborative activitieswith at treatment centers for survivors (n=87).at forsurvivors treatment centers Results Methods : Physiotherapy, survey, international : Approximately 30%ofcenters : about utilisation of PS A survey ¹ , 2020; National ² , 2020; - - TORTURE Volume 30, Number 3, 2020 21 - . If an email was “automatically returned“automatically to If an email was English into Spanish and French. The cover The cover and French. English into Spanish the request to emailed made was letter that the survey forward to a staff PT if there was not there were If the center. at working any staff member any site, that at PT working questions targeted were There out. it fill could survey the end of the for PT only at surveya second ad to sent was sender,” the the same center ditional email addresses at A second survey also re-sent was if possible. where but where emails had not been rejected, the recipient had not responded. asked targeted questions of treatment center questions of treatment asked targeted staff members the survey and translated from - - n = 220 n = 200 n = 250 remaining members (n = 40) Total 359 Total members (n = 40) Obtained 87 completed surveys resent to email address without response to all centers with email address obtained Eliminated duplicate centers duplicate Eliminated by comparing the three lists List compiled of all recipients of funding from United Nations Voluntary Voluntary from United Nations List compiled of all recipients of funding . Sampling process for international survey. Emails sent to alternate email for rejected email address and organizational Fund (n = 169), IRCT members Capacity Building (n = 150) and National Fund (n = 169), Emailed Survey Monkey link and cover letter describingEmailed Survey the intent of survey cover Monkey link and Figure 1 the United States and UNVF. Six doctoral and UNVF. the United States PS students from the University of Minne surveyonline an create to helped sota which In 2014, a list of treatment centers a list of treatment around In 2014, compiled by combining lists of was the world NCB in centers for survivors from the IRCT, lacher et al., 2019; Nordbrandt et al., 2020; 2020; Nordbrandt et al., 2019; lacher et al., 2016). al., et Wang 2017; Stammel et al., Methods 2012) while some have an interdisciplinaryhave 2012) while some counseling and PS combines approach that Har 2017; Baird et al., 2019; (Amrisal., et services and some with a more limited focus. services limited focus. some with a more and a strong mental programs have for SoT Many Kira et al., 2016; et al., health focus (Bunn SPECIAL SECTION: PHYSIOTHERAPY FOR TORTURE SURVIVORS (2) SURVIVORS TORTURE FOR PHYSIOTHERAPY SECTION: SPECIAL 22 TORTURE Volume 30, Number 3, 2020 Global North and45fromtheGlobal South.Global North Of the 87 respondents, 42 were from the Results response rate was 43%outof200emailssent. fessionals working withSoT. and interestincollaborating withotherpro biggest perceived problemsinproviding PS is analyzedseparately forthequestionsabout educational level ofexperience. andyears Data non-PT, plusadditionalquestionsabouttheir Figure 2below. patients hadaccesstoPS, asindicated in inSouthand Central sponding centers Asia, referral, exceptthator byexternal inallre PSeitheronsite offering centages ofcenters andGlobalSouthintheper the GlobalNorth Serbia. Zealand, Nigeria, Norway, Romania, and Israel, Kyrgyzstan, Morocco, Nepal, New Ecuador, Egypt, France, Honduras, Ireland, Belgium, Bulgaria, Burundi, Chad, Chile, one respondenteachfrom Armenia, Austria, and theUnitedKingdom. Finally, therewas tine, Rwanda, Lanka, Sri Sweden, Turkey Indonesia, Jordan, Kenya, Liberia, Pales cratic Republic ofCongo, Finland, Germany, two respondents each from Australia, Demo Herzegovina, India, andLebanon. There were from Italy, andthreeeachfromBosnia six from Cambodia, five from Denmark, four wereFourteen working in the USA, at centers

There were nolargedifferencesbetween Eighty- seven were surveys completed. The PT were askedthesamequestions as SPECIAL SECTION:PHYSIOTHERAPYFORTORTURE SURVIVORS (2) - - - - - tional therapistsat 25%. therapists at 27%, andoccupa andnursing were onstaffat 33%ofthecenters, massage medicine(55%). (63%), PT atry and primary centers, followed bysocialwork (73%), psychi therapy/counseling was available at 85%ofthe highly educated and experienced with82% highly educated andexperienced who answered tendedtobeboth thesurvey The Americas (17) The Americas Primary medicine Primary Africa/Turkey (12) for SoT Figure 3. regions patients have noaccesstoPS, across Figure 2. South andcentral Massage therapy Psychotherapy / Middle East/N. Physiotherapy PT working atforSoT treatment centers forSoT,At thetreatment centers psycho Occupational Oceania (11) Sub-Saharan Social work Europe (29) SE Asia and SE Asia counseling Psychiatry Africa (11) Africa Nursing therapy Asia (7) Percentages where ofcenters Professionalsworking at centers

0% 10% 20% 30% 40% 50% 40% 30% 10%20% 0% 2 4 6 80100 60 40 20 0 - - - TORTURE Volume 30, Number 3, 2020 23 - - - - - 0% 40% 60% 70% 10% 20% 30% 50% 0% 10% 20% 30% 40% Percentage of patients receiving receiving of patients Percentage Percentage of patients receiving of patients Percentage PT were asked to check all modalities asked to check all modalities PT were physiotherapy physiotherapy physiotherapy physiotherapy physiotherapy 1-25% receive 1-25% receive physiotherapy physiotherapy physiotherapy physiotherapy 1-25% receive 1-25% receive 26-50% receive 26-50% receive 51-75% receive 26-50% receive 26-50% receive 51-75% receive 76-100% receive 76-100% receive Figure 7. PS when there is no PT onsite Figure 6. servicesPS when there are PS onsite 76-100% receive 76-100% receive No clients receive No clients receive tioned, including dry needing, body awareness dry including awareness body needing, tioned, graded method, the Feldenkrais training, which they used with patients. The most fre The most used with patients. which they individ for therapeutic exercise quently were massage manual therapy (75%), uals (85%), The groupor (70%) (65%). exercises/activities (15%), exercise aquatic least common were or taping (40%), (35%), home evaluations of durable medical equipment such provision Ul walkers (40%). crutches, as wheelchairs, trasound and electrical treatments stimulation used by 35 and 40% of PT respec also were men additional treatments There were tively. - - - - 0 5 10 15 20 25 30 35 0 10 20 30 40 50 Patient’s access to PS services access to PS Patient’s Educational level of PT at of PT at level Educational degree and offsite No access to physiotherapy Bachelaureate Bachelaureate In the one third of centersthird of the one In is there where While at 30% of the centers, the pa 30% of the centers, While at Master’s degree Master’s Doctorate of PhD Doctorate Figure 5. Figure 4. centers PT on staff with Access onsite only Access offsite only Combination of on Combination Diploma/certi cate mental material). mental material). a PT on staff, a higher percentage of patients a higher percentage of patients a PT on staff, than those where there is not a PS received (See full surveyPT staff. report in supple of patients receiving PS servicesof patients is increased. at their center for SoT or be referred their center at externally centersthe At is there where services. PS for the percentage unsurprisingly, staff, PT on a tients have no access to PS services, at 22% at no access to PS services, tients have PS offsite, of centers can receive the patients of 29% at and only center the onsite at 20% PS either can receive the patients the centers, habilitation. years of experience as a PT. Additionally, 55% Additionally, years of experience as a PT. least 6 years ex of at of PT respondents have perience in torture specialising and trauma re holding at least a baccalaureate bachelor bachelor baccalaureate least a at holding 5 years least of 86% percent with at degree, or more eleven having and 59% experience, SPECIAL SECTION: PHYSIOTHERAPY FOR TORTURE SURVIVORS (2) SURVIVORS TORTURE FOR PHYSIOTHERAPY SECTION: SPECIAL 24 TORTURE Volume 30, Number 3, 2020 therapy. motor imagery, heat therapyandlaser dry est challenges. were thegreat patients andsystemicbarriers limitation. PTindicated that lackoftimewith thelackoffundsasaperceived present decried respondents working withnoPT at centers to survivors.providing PS services Twenty-two among themainchallengesandlimitations to asbeing funds/resources andlackofpersonnel Supportive equipment Supportive Electrical stimulation Electrical Figure 8. Therapeutic exercise

Home evaluations Taping/bandaging Both PTandnon-PTindicated lackof SPECIAL SECTION:PHYSIOTHERAPYFORTORTURE SURVIVORS (2) Durable medical Group exercises/ Aquatic exercise Manual therapy Therapeutic Therapeutic Don’t know (individual) ultrasound ultrasound equipment activities Massage PSmodalitiesprovided 0 0 0 0 0 100 80 60 40 20 0 - Lack ofroomorspace Lack ofroomorspace Lack of interpretation Lack ofinterpretation Lack of interpretation Lack ofinterpretation ceptions ofthePTsthemselves wheretherearePTonsite—per centers at treatment viding adequate PSservices Figure 10. no PTonsite(answered bynon-PT) ing PSatwherethereis treatment centers Figure 9. or no program onsite or noprogram or no program onsite or noprogram No physion program No physion program Lack ofequipment/ Lack ofequipment/ Dif culty accessing Dif culty accessing Scheduling/Service Scheduling/Service Scheduling/Service Scheduling/Service research/education research/education Client motivation/ Client motivation/ Dif culty oftravel Dif culty oftravel Lack ofPersonnel Lack ofPersonnel client information client information Lack oftimewith Lack oftimewith systemic barriers systemic barriers Lack oftraining/ Lack oftraining/ Lack ofFunds/ Lack ofFunds/ coordination coordination Resources Resources medicine medicine services services Perceived limitations toprovid client client Perceived limitations topro 0 0 0 30 20 10 0 2 4 6 7 6 5 4 3 2 1 0 - - - TORTURE Volume 30, Number 3, 2020 25 , https:// Torture, Torture, (34). (34). Torture, Torture, https://doi.org 10 , European (2), 77-88. 77-88. (2), (2), (2), Psychotherapy, Psychotherapy, (2), 58-76. https:// 58-76. (2),

(3), e0230300. e0230300. (3), Torture, 30 Torture, Torture, 30 Torture, PLos One, 15 PLos One, Conflict and Health 10.1371/journal.pone.0230300 https://doi:10.4119/UNI9/ijcv.655 (2), this issue. (2), https://doi.org/10.1521/ijgp.2012.62.1.69 (1). (1), 45-67. https://doi.org/10.7146/torture. 45-67. (1), Montgomery, E., & Modvig, J. (2016). A novel A novel (2016). J. Modvig, & E., Montgomery, ofbio-psycho-social approach for rehabilitation victims of torturetraumatized in the post- and war A pilot randomized controlled conflict context: trial in Kosovo. doi.org/10.1186/s1303`-016-0100-y Therapy on balance and quality Awareness Body Wernicke of life in survivors of hunger strike with Korsakoff syndrome. https://doi.org/10.7146/torture.v30i2.120163 Iraq: A pilot study. A pilot study. Iraq: doi.org/10.7146/torture.v30i2.119199 (2020). J. Wesonga, & S., Nyambok, J., J. Kibet, with survivorsGroup physiotherapy in urban and Kenya. and camp settings in Jordan 30 for as a treatment Education (2019). C. & Sothera, chronic pain in survivors in Cambodia: of trauma Results of a randomized controlled outcome trial. 13 Violence, International Journal and of Conflict 1-26. Group therapy model for refugee and (2010). model innovations. Treatment torture survivors: International Journal of Group 62 refugees Trauma-affected (2020). J. Carlsson, therapy or with basic body awareness treated to activity as augmentation physical mixed randomized as usual—A pragmatic treatment controlled trial. https://doi.org/ & Bottche, P., M. Wenk-Ansohm, S., L.C. Multidisciplinary for (2017). treatment M. setting: refugees in a naturalistic traumatized symptom courses and predictors. 8 Journal of Psychotraumatology. /10.1080/20008198.2017.1377552 CD012051 for survivorsGroup treatment of torture and review. A literature violence: severe 26 v26i1.108062 The effects of combined (2020). J. Hartman, group psychotherapy and physiotherapy programtreatment for survivors of torture in an adult prisonincarcerated in Kurdistan, Kira, I.A., Ahmed, A., Mahmoud, V., & Wassim, E. E. Wassim, & V., Mahmoud, A., Ahmed, I.A., Kira, Stammel, S., Knaevelsud, C., Schock, K., Walther, Walther, K., Schock, C., Knaevelsud, S., Stammel, R., Rushti, M., Hallaba, S., Izeti, A., Bytyci, S., Wang, The impact of Basic (2020). T. & Bahrilli, H., Yuce, Nordbrandt, M. S., Sonne, C., Mortensen, E. L., & L., E. Mortensen, C., Sonne, S., M. Nordbrandt, Gamble, A, Ahmed, A. M. A., Rahim, S. H., & H., S. Rahim, A., M. A. Ahmed, A, Gamble, J., Chepngetcih, W., Chao, A., Amoyi, P., L. Gueron, P., Sok., P., Phana, S., Taing, P., Polatin, U., Harlacher, Bunn, M., Goesel, C., Kinet, M., & Ray, F. (2016). (2016). F. & Ray, M., Kinet, C., Goesel, M., Bunn, - - - - - Pain Pain 10.1097/ Cochrane Database Systems Database Cochrane 10.1002/14651858. 1 (6), e 794. https://doi.org/ e 794. (6), . https://doi.org/ . from torture: Assessment and management. Assessment and management. from torture: (2017) Interventions persistent for treating pain in survivors of torture. Review https://healtorture.org/content/physical- therapyphysiotherapy Reports, 4 Reports, PR9.0000000000000794 Once the survey results were analysed, all analysed, surveythe Once were results Ninety percent of the PT surveyedNinety percent expressed 1 Baird, E., de Williams, C., Hearn, A., & Amris, K. K. Amris, & A., Hearn, C., Williams, de E., Baird, References: Pain (2019). A. Williams, & L., Jones, K., Amris, PS article reviews and blogs about physiother apy for SoT. a PS section on the HealTorture.org website was website a PS section on the HealTorture.org in response to interests expressed on thecreated There are links to webinars, international survey. group SoT and other with for PTs working forms of trauma can correspond with either of the authors In addition, to get more information. resources for those working with refugees and resources for those working ap for those who are interested in mind-body in Anyone trauma. of healing the for proaches Facebook the join to vetted being in terested doctors who are members. There are also PS stu also are There doctorsmembers. who are countriesdents from several who participate in which has become a forum for sharingthe group, tries. While the group is mostly comprised of tries. therapists, occupational there are several PT, chiropractors and medical massage therapists, interest, in 2016, a Facebook group created was a Facebook in 2016, interest, with SoT. for PT who are interested in working The group has 224 members now from 36 coun and 21% in organizing on LinkedIn. and 21% in organizing participants sent a copy of the survey were on the PT expressed based In addition, report. were interested in participating were in a Facebook webinars about PS one third in attending group, part 19% in being of a listserv for SoT, treatment interest in participating in collaborative activitiesinterest in participating in collaborative One third SoT. with with other PT who work SPECIAL SECTION: PHYSIOTHERAPY FOR TORTURE SURVIVORS (2) SURVIVORS TORTURE FOR PHYSIOTHERAPY SECTION: SPECIAL 26 TORTURE Volume 30, Number 3, 2020 Craig Higson-Smith, forreviewing. andto in creating and analysingthesurvey Building Projectand Anna Zaros, forhelping to Ann LundbergfromtheNational Capacity special projectssuchasthissurvey. Thanks of Torture (CVT)physiotherapy teamwith who volunteer helpingtheCenter of Victims students at theUniversity ofMinnesota, Thanks tothemany doctoral physiotherapy Acknowledgements

SPECIAL SECTION:PHYSIOTHERAPYFORTORTURE SURVIVORS (2) TORTURE Volume 30, Number 3, 2020 27 ------, 5

7 : Provisional results are encour are results Provisional : On average, participants com who On average, : group PS, interdisciplinary care, interdisciplinary group care, PS, : Physiotherapist, CVT -Kakuma Physiotherapist, Trainer, CVT-Nairobi. Physiotherapy CVT-Nairobi Physiotherapist, Trainer, CVT-Kakuma. Physiotherapy Correspondence to: [email protected] Correspondence to: [email protected] Correspondence to: Results: Discussion 6) 6) Introduction survivors Many of torturea widefrom suffer and psychologicalrange of physical symptoms 2013) which may and conditions (Crosby, These include: benefit from PS intervention. nerve injury brain injuries, injuries, traumatic to various parts in of the body from beatings damage to burns; cluding those to the feet; fracturesthe pelvic floor from sexual torture; 4) 5) pleted 3-month follow-up assessments showed showed assessments pleted 3-month follow-up and clinically significant improve statistically ments. As nearly all participants both receive aging. it is diffi (PS), counseling and physiotherapy can be attributed which benefits cult to know to PS alone. Keywords pelvic floor. pain, refugee, program. Wherever possible, follow-up assess follow-up possible, Wherever program. after the ses ments are conducted 2 weeks and 9 months following 3, and at sions end, completion. - - - , Jepkemoi Joanne Kibet, PT, MS, doctoral candidate PT, Kibet, , Jepkemoi Joanne 4 and Joseph Wesonga, PT, MPH PT, Wesonga, and Joseph 6

Survivors through are identified 10.7146/torture.v30i3.121785 : The Center for Victims of Victims The Center for : Improvements noted were similar similar noted were Improvements survivorsbetween of torture (SOT) and non- SOT. Provisional results in a groupa in results Provisional physio and clinically suggest model therapy in improvement significant statistically mobility and sleep. pain, Physiotherapist, CVT- Nairobi CVT- Physiotherapist, CVT -Kakuma Physiotherapist, Clinical Advisor for Physiotherapy, Kenya Kenya Advisor for Physiotherapy, Clinical CVT. programs, [email protected] Correspondence to: Methods: • Key points of interest •

International Rehabilitation Council for Torture Victims. All rights reserved. Victims. Torture International Council for Rehabilitation 2) 3) https://doi.org/ 1) Following an informed consent process, sur an informed consent process, Following vivors participate individ in a comprehensive ual assessment and then progress to a 10-week referral systems, community education and and community education referral systems, contacts and trainings campaigns, sensitization with other NGOs and health care providers. set of indicators of participant experience and functioning. Torture has developed an interdisciplinary has developed Torture The program is supported group treatment. a broad records that assessment a clinical by Abstract Introduction Justine Chepngetich, PT Justine Nyambok, PT Stephen and Kenya Chao, PT³, Amoyi, PT², Winnie Arobogust DPT¹, MPH, PT, Gueron, Laura Pizer Group physiotherapy with survivors of survivors with physiotherapy Group Jordan camp settings in in urban and torture SPECIAL SECTION: PHYSIOTHERAPY FOR TORTURE SURVIVORS (2) SURVIVORS TORTURE FOR PHYSIOTHERAPY SECTION: SPECIAL 28 TORTURE Volume 30, Number 3, 2020 control bodilysymptomsofemotionaldis ment), self-regulation problems(unableto sations, decreasedflow andvitality ofmove of sensations anddifficultyidentifyingsen rience: decreasedbodyawareness (numbing oftraumaalsooftenexpe and otherforms Williams &Baird, 2016). al., 2019; Kauretal., 2020; Wang etal., 2016; (Harlacheret experiences lowing theirtorture have issueswithchronicpain, even fol years al., 2016). oftorture Further, many survivors etal.,and amputations (Amris 2019; et Prip progression ofexercises andfunctionalmobil progression improve sleep, insafe aswell asininstruction inwayspaired withgoalsetting, instruction to function. aretypically These interventions results indiminishmentofpain andimproved showing that painneuroscienceeducation & Baird, 2016). . Tsur etal., 2020; Wang etal., 2016; Williams Nordin &Perrin, 2019; Olsenetal., 2007; al., 2019; Bairdetal., 2017; Kauretal., 2020; et (Amris back painfollowing sexual torture der pain following suspension, and pelvic and head pain after traumatic brain injury, shoul etal., (Prip 2016), torture sustaining falanga tion oftorture, suchashaving footpainafter at withthetypeandloca timescorrelated etal.,(Amris 2019). The location ofpainis even after they have years torture experienced haveMany issueswithchronicpain, survivors Chronic paininsurvivorsoftorture Stammel etal., 2017). as well assleepissues(Sandahletal., 2017; of breath, chestheaviness, difficultybreathing, racing, shortness symptomssuchasheart tory turbances, chronicpain)and joint pain, headaches, gastrointestinaldis tension, headaches), depression( tress), ofbreath, anxiety(shortness muscle

There is an expanding body of evidence There isanexpandingbody of evidence who have torture Survivors experienced SPECIAL SECTION:PHYSIOTHERAPYFORTORTURE SURVIVORS (2)

cardiorespira fatigue, ------tions, sleeppositionsanduseofpropssuch relaxation techniques, mind-bodyconnec and quality. in The PTstypicallyinstruct improvements in patients’ sleep duration PS-led education oftenproducessubjective and energylevel (Andrewsetal., 2014). maintenance ofpain, anddecreasedmood resulting insufficientsleepoftenleadsto post-traumatic stress disorder(PTSD). The chronicpainand both thoseexperiencing Deficits ofsleeparecommonlyfoundamong Sleep deficits settini etal., 2020). effects andtominimizenocebo(Ros yet accurate ways, soastoenhanceplacebo aboutpaininreassuring present information It isalsoessentialthat physiotherapists (PTs) Wang etal., 2016; Wood &Hendrick, 2019). (Harlacher et al., 2019; Louw et al., 2016; clinically meaningfulimprovement inpain oftenyields somatic) skilledPSinstruction systemorpsycho nervous to somatosensory damage tobody, neuropathic—from damage pain (nocioceptive-from damageorpotential PS (Sallinen, 2018). Nomatter thetypeof ity, ofabiopsychosocialapproachto aspart improvements (Rosenberg, 2007). pelvic flooremphasis canleadtomeaningful orindividualPSwith pating ineithergroup topics. There is evidencetoshow that partici tion, painfulsexualactivity andotherrelated and fecal incontinence, constipa urinary such as:sessions inmatters ways toprevent andindividual inbothgroup programming patients in pelvic floor-related PTs instruct Pelvic floorconsiderations Siengsukon etal., 2017). sleep (Nielsen, 2014; Sandahletal., 2017; erages, inordertohelppatients toimprove timing of exercise and intake of food and bev as pillows to decrease pain, and even in ideal ------TORTURE Volume 30, Number 3, 2020 29 - - - - - study, where survivors randomly were study, groups showed similar improvement. As each similar improvement. groups showed in termsPS intervention of dura is different, and PS model, interdisciplinarytion, model, Rationale for group model development Rationale for group for as individual PS, Group PS is as effective both those with mental health (Skjaerven et health concerns 2018) and physical (An al., 2017). al., et O’Keeffe 2019; dersenal., et the demonstrate There are few studies that efficacy of group PS for survivors of torture Nordbrandt et al., 2019; (Harlacher et al., 2020). In a as usual (with assigned to either treatment Therapy Awareness Basic Body no PS), subjects in all activities, physical or mixed sible and to have knowledge about the role knowledge sible and to have body-mind management, pain exercise, of are connections and other concepts which 2014; presented during PS sessions (Nielsen, It is im 2019). Amris et al., 2015; O’Sullivan, portant also learn patients that about the role mood and on in improving of aerobic exercise symptoms as helping to decrease depressive an important PTs have role in helping well. to exercise ways to find enjoyable patients 2018). safely (Knapen et al., that when working with survivors of trauma, with survivors when working that of trauma, it chronic pain, who have and with patients fosteringagainst guard PTs that essential is It is crucial PT. dependence on the excessive survivors that learn utilize can they that skills they experience time that pain (Gard & cany PTs 2018). & Kulnik, Jones 2018; Gyllensten, learnto SoT empowering on focus to need im exercise, strategies reduction, of pain as well posture and body mechanics, proved control and to awareness as to restore body SoT should their most disturbing symptoms. as pos to be as independent be empowered Self-sufficiency in survivors of torture in Self-sufficiency emphasize and Stubbs (2018) Vancampfort ------Individuals with chronic pain from a a from pain chronic with Individuals Shepherd, 2001). 2001). Shepherd, be able to soften areas of muscular tension, tension, muscular of areas soften to able be survivors more control over can learn to have & Walker 2018; (Pricebodies their Hooven, & Care is taken to gradually progress the in to tolerance and to have tensity of exercises By learning to these activities be enjoyable. such as to inside of the body, focus attention faster breathing and heart rates, in a safe and faster and heart breathing rates, fears where their supportive environment, and concerns are normalized and addressed. ately (Buczynski et al., 2018; de Ruiter et al., de Ruiter et al., 2018; (Buczynski et al., ately The survivors 2018). Price & Hooven, 2017; such as exposure to sensations, should have vors to increase their interoceptive awareness, awareness, interoceptive their increase to vors understand, identify, the ability to is which and respond to signals of the body appropri Interoceptive awareness training awareness Interoceptive opportunities create should PTs survifor varietyoften benefit from a multi of causes disciplinary (Sara approach as well treatment 2016). giotto et al., terdisciplinary approach to treatment, includ terdisciplinary to treatment, approach (de Ruiter et is ideal ing PS and counseling, 2016). et al., Wang Stammel et al., 2018; al., Persson et al., 2008; Price & Hooven, 2018). 2018). Price & Hooven, 2008; et al., Persson Because of these complex needs and frequent in an that argued have many co-morbidities, opportunities these approaches to practice 2018; Buczynski et al., 2020; (Andersen et al., 2015; O’Sullivan, 2020; Nordbrandt et al., connections, including the role of breath, re including the role of breath, connections, mindfulness (Gard and practices of laxation It 2018). Damme, Van 2018; & Gyllensten, be allowed patients that has been proposed the need for PTs and other membersthe need for PTs and of the formsother and SoT with working team of trauma to teach survivors about mind-body Interdisciplinary needs Interdisciplinary Survivors of torture (SoT) typically have to supportThere is evidence complex needs. SPECIAL SECTION: PHYSIOTHERAPY FOR TORTURE SURVIVORS (2) SURVIVORS TORTURE FOR PHYSIOTHERAPY SECTION: SPECIAL 30 TORTURE Volume 30, Number 3, 2020 tients over have thelast3years beenfrom Amman. Inthisprogram, 74%ofthepa areprovided at theCVTofficein services by CVTPTsinJordan andKenya. InJordan, of trauma haveand otherforms beentreated In thelast10years, morethan7,000SoT group PSmodel ofTortureThe CenterforVictims (CVT) torture. ventions of aremosteffective forsurvivors ofPSinter to demonstrate whichportions and it isdifficulttocompareinterventions laborate and refer to social work services as laborate andrefertosocialwork services aswell.ing services col The teammembers PS, always eachparticipant receives counsel mechanics. that include InCVT programs range of movement, posture, gait and body sessments, strength, including measuring exercise bands. is simpleequipment, suchasyoga mats and participants. locations, Inallprogram there only andthedata sharedisregardingadult onlytheadultPSprogram describes article forchildren.specialized interventions This Burundi. IntheJordan program, thereare the Democratic RepublicoftheCongoand havebiggest population groups been from PS services. InbothKenya programs, the separate smallbuildings forcounselingand between Kenya andSouthSudan. There are refugee campandisclosetotheborder is located several from Kakuma kilometers Kalobeyei Settlement. Integrated Kalobeyei located in one of three “villages” (Village 1) in and Riruta). In Kakuma, is the program high refugeepopulations (Eastleigh, Kayole urban clinicslocated inneighborhoodswith attend sessions at oneofthree participants near the Kakuma refugee camp. In Nairobi, In Kenya, CVTprovides PSinNairobiand orIraq,either Syria with21%fromSudan.

PTs perform subjective andobjectivePTs perform as SPECIAL SECTION:PHYSIOTHERAPYFORTORTURE SURVIVORS (2) - - - - - the education. enhance their quality of sleep after they receive to bedandareablemakechangeswhich ages ortoexercise heavily soonbeforegoing caffeinated bever not to drink is important example, arenotaware many that survivors it painandwayspersistent toimprove sleep. For education about bodily symptoms of trauma, togoalachievement.ers eachotherinovercomingalso support barri topics. UnderthedirectionofPT, survivors of newactivitiesandeducation aboutrelevant ongoalattainment,support exercise, practice origin. Each session includes checkin and inNairobi, ofgroups aswell asbycountry with the exception of mixed gender LGBTI bygender, aretypicallygrouped participants ofbetweenseen ingroups eightand12. The ual PSsessions, ofCVTpatients are amajority (Probst& groups Van Damme, 2018). well as rehabilitation for both individuals and health promotion, preventive healthcare, as Health (IOPTMH). These includeproviding Organization ofPSinMental the International needed. CVT’s of PTs adhere to the principles ment modelson herwork. andPTsbase someaspectsofourtreat selors threestagesofrecovery.describes CVTcoun pioneer inthefieldofhealing fromtrauma, covery tion ofactivities. Inherbook, to avoidingas these often contribute resump be abletochallengetheirmaladaptive beliefs, of bodilysensations. to PTs guidesurvivors who have arehyperaware undergonetorture of survivors. Manycultural norms of those ticipants onlywithpermission, andrespect choices, useinvitational language, touchpar to maximize their improvements. PTs offer order to avoid and retraumatizing participants Although some survivors requireindivid Although somesurvivors PTs utilise a trauma-informed approach in approach in PTs utiliseatrauma-informed PTs leaddiscussionsandprovide psycho (1992), Judith Herman, arespected Trauma andRe ------TORTURE Volume 30, Number 3, 2020 31 ------Each participant a packet with is given pictures of their home exercise program, as as program, pictures of their home exercise mechanics body about posture, as tips well Participants are re and other key concepts. 3. Reconnection (Sessions 9 and 10) Reconnection 3. rebuilding The reconnection stage involves to able being By future. one’s and life one’s through the feelings of isolation overcome reconstruction of meaningful social connec who Many quality of life is enhanced. tions, are in the reconnection stage of recovery find such as playing they can resume activities, that children, their with running, playing football, taking care of their household needs and re activities. suming livelihood assured that despite negative messages which despite negative assured that by the torturers, been planted they have may can gradually and improve decrease their pain without functional mobility their overall reduce any To causing injury to themselves. stigma and to normalize the need for educa PTs instruct all grouption, members in tech and niques such as pelvic floor strengthening priorof The loss physi exercises. relaxation of as is the work cal abilities is acknowledged See for their loss. regaining or compensating for more detail. Figure 1 below decrease their pain. Discussions about pain about Discussions pain. their decrease by led are perspective neuroscience a from Survivors often express the PTs in groups. does not mean that chronic pain relief that pain worse that and injuryan not healed, has they In addition, injury. does not mean worse learnwhile acute pain has an important that chronic pain no longer function, protective Culturally appropriate meta has a function. 2019) such as; phors are used (Louw et al., chronic pain being like a lion in the room, an overly will not stop crowing, rooster which re often are They etc. alarm sensitive clock, education is provided for participants is provided education that localize and them to better identify, help may - - - - - (Sessions 4, 5, 5, (Sessions 4,

functioning. In all programs, therapeutic pain therapeutic In all programs, functioning. is an emphasis on pain education and reduc is an emphasis on pain education body balance, strengthening, stretching, tion, and pelvic floor aerobic exercise mechanics, trauma no longer overwhelm their capacity their overwhelm longer no trauma towards work to possible is it function, to integrationand trauma. the of assimilation there During sessions of this phase, the five Once the sense of safety is restored (to the Once the sense of safety is restored (to fullest extent possible) and the survivor is the effects of the stabilized to the extent that 2. Remembrance and Mourning. Remembrance 2. 8) 7 and 6, hygiene discussions and psychoeducation hygiene discussions and psychoeducation about symptoms of trauma are also typically duringprovided stage. this that follows. In PS group sessions, emphasis In PS group sessions, follows. that and posture breathing, and on relaxation is Sleep self-touch. gentle and mechanics body tiality and mutual support. In addition, PTs PTs In addition, support. mutual and tiality to principlesadhere carefully must of trauma- This stage is the starting point. informed care. It is necessary and engagement for all healing ing a sense of safety for those in PS sessions ing a sense of safety for those in PS sessions also refers to the importance par having of ticipants agree on principles such as confiden counselors and PTs refer survivors to other local or international and to CVT NGOs Provid issues. these address to workers social nomic status and security nomic status of their housing, various degrees of feeling safe in SoT have CVT As needed, environments. their overall on the safety measures in place in the countryon the safety measures such to which survivors of torture fled, have UN-protected they have as whether or not socioeco their to or aspects relating status to participants It is importantin this phase. is crucial and to stabilize their physiological Depending psychological reaction to trauma. 1. Safety and Stabilization. (Sessions 1, 2 and 3) (Sessions 1, and Stabilization. Safety 1. During introductory the survivor this phase, a safe space Providing often feels vulnerable. SPECIAL SECTION: PHYSIOTHERAPY FOR TORTURE SURVIVORS (2) SURVIVORS TORTURE FOR PHYSIOTHERAPY SECTION: SPECIAL 32 TORTURE Volume 30, Number 3, 2020 encouraged tocontacttheCVTPSteamas andare sessions withPTsat regularintervals minded that they will have follow up formal Figure 1.

SPECIAL SECTION:PHYSIOTHERAPYFORTORTURE SURVIVORS (2) Rememberence Safety and Reconnection and Mourning Stabalization Summary of Activities Carried Out During EachStage of of OutDuring Summary Activities Carried Trauma Recovery • • • • • • • • • • • • • • • • • tivities suchassports, livelihood programs, events, religious etc.) Empowering theindividualstoengagewiththeir communities(friends, family, inac and safephysical interactions withinsessions Rebuilding positive relationshipstopositivedynamics throughcontributing group ofsymptoms derstanding Ongoing self-managementofsymptoms usinggoalsetting, pacingandincreasedun sense ofconfidenceintheirbodies topracticesafemovements Providing opportunities that promotejoy andrenewa ercises ofawareness andself-regulation Reconnection withone'sbodythroughmastery ex ties) balance, coordination, sleep, continence, abilitytoperforrelevant functionalactivi Restoration ofwhat hasbeenlostwhereable(strength, range-of-motion, flexibility, and copingstrategies) maladaptive painbeliefsandbehaviors, pacing encouragement andunderstanding, programs, pain(graduated continuedreinforcementagainst Decreasing andmanaging reinforce relaxation andhomeexercise programs) thephysical Managing symptomsoftrauma(continuingtoidentifysomatic resources, approaches before using 'hands-on' granted of intervention,cultural appropriateness permission usingpracticesofinvitational Focus principles language, ontrauma-informed choice, how tosafeguardtheirphysical tounderstand health Empowering survivors feel moreincontroland"safe"theirbodies Teaching self-soothingtechniques and bodyawareness exercises toenableclients Teaching anxiety techniquesforrelaxation andmanaging torecognize theirfeelingsandassociated physical symptoms Helping survivorss Education abouttraumaanditseffects members cluding specificgoalsofgroup Explanations ofphysiotherapy, norms, expectations discussiongroup ofoutcomes in andphysiotherapist andbetween participants amongstparticipants Establishing trust considerations) (confidentiality, Safe spaceforsurvivors consent, informed privacy, environmental the activitiesinexactlysamemannerthat that whileSoTmay notbeabletoperform needed. There isoftenasenseofacceptance, - - - - - TORTURE Volume 30, Number 3, 2020 33 - - - - - Body outlines used to record The assessment is conducted in a private The assessment is conducted in a private The full PS assessment tool and follow up follow and tool assessment PS full The Figure 2. pain locations sions by PTs familiar with the cultural norms some and language needs of the participants; assessments are administered using trained measures are available from the authors on measures are available request. Further consent is sought verbal room by a PT. Assess and touch. examination for physical ses one or two ments are conducted over are asked to describe the parts of their body in Responses are which they struggle with pain. areas of body the relevant recorded by shading Part to social C relates outlines (Figure 2). part and participation, D includes items on mea of set entire The outlook. and coping to be feasible and ac sures has been found has been translated ceptable across cultures, strong inter and shows languages, into several A nal consistency within and across sites (Part 0.92; 0.86 to from range Alphas Cronbach’s 0.80 from range Alphas Part B Cronbach’s to 0.91). being the worst imaginable pain or functioning During this assessment participants problems. ------Part A Disability Rating Index (DRI). Index (DRI). A Disability Rating Part Participants are recruited into treatment This stage is focused upon looking to the This stage is focused 0 anchored to no pain or difficulties, and 10 0 anchored to no pain or difficulties, comprises questions on pain, sleep, bladder bladder sleep, comprises pain, on questions and body aware sexual functioning, control, ness and control using a ten-point scale with strong face (with more than 90% of validity questions correctly), able to answer patients reliability inter-rater and intra- strong and Part B 1984). (0.98 or higher) (Salen et al., Pain-related disability (Harlacher et al., 2016, 2016, disability (Harlacher et al., Pain-related excellent test-re 2011) has Prip et al., 2019; test reliability (ranging from 0.83 to 0.95), ferred for PS; in Jordan, all survivors are au in Jordan, ferred for PS; referredtomatically for PS. ticipants can opt-in to their de-identified data data ticipants can opt-in to their de-identified In Kenya, being used for research purposes. survivors needs in these areas are re who have from, and is interested in, CVT’s services. services. CVT’s and is interested in, from, counselorsDuring discuss in this process, par As part this process, of formed consent. following an initial mental health screening. mental health screening. an initial following This screening is conducted by psychosocial counselors to determine general problems and benefit symptoms and if an individual would working with survivors in Nairobi, Kakuma, Kakuma, with survivorsworking in Nairobi, and Jordan. Method This article presents a secondary analysis collected by CVT PTs of clinical datasets stand and control their symptoms and to use stand and control their resource. their bodies as a somatic the essence of this stage can be captured by the essence of this stage PS aims myself.” I have “I know the phrase, to facilitate reconnection with their survivors’ under better to them enabling bodies, own future and helping participants to utilize their Herman (1992) suggests that resources. own they could before their torturethey could experiences, and connect being active they can still enjoy ing with others. SPECIAL SECTION: PHYSIOTHERAPY FOR TORTURE SURVIVORS (2) SURVIVORS TORTURE FOR PHYSIOTHERAPY SECTION: SPECIAL 34 TORTURE Volume 30, Number 3, 2020 Kenya PSteamstoassessandbetteraddress was materials) created bythe supplementary formedicalcare. fractures arealsoreferred pre-eclampsia, breastcancer, anduntreated issues suchasgangrene, severe hypertension, organ prolapse, analfissuresorsevere or tears injuries, suchasmoderate tosevere pelvic attention, and balance. At this time, those with out ruling “red flag issues” in need of medical strength, involvement, nerve medicalhistory, tions of pain, posture, joint range of motion, interpreters. The assessmentmeasurespercep 1 follow-up. 3 onthenumberofareaspain at intakeand and concern scheme andareaofgreatest Table samples, Table 2 provides data on location number ofchildrenforeachthethree situation, oforigin, marital andcountry measures t-tests. d effect sizes, chi-square analyses and repeated tained throughouttheprocess. tion andconfidentialitystandardswere main and evaluation staff.Rigorousdata protec electronicdatabase bymonitoring encrypted and entered into an by clinical supervisors, Data was recordedonpaperforms, reviewed Data Management and Analysis are includedinthispaper. data fromthe intake and3-monthfollow up treatmentthe date session. ofthe first Only completed aswell asat 3-and9-monthsfrom hasbeen mediately after thePSintervention been usedonapilotbasiswith130survivors. issues withpelvicfloorfunction. This toolhas

Table 1 provides breakdowns bygender, ofdata is done using Cohen’sComparison Follow-up assessmentsareconductedim The “Pelvic Floor Distress Tool” dk/torture-journal/index See supplementary materials on materials See supplementary SPECIAL SECTION:PHYSIOTHERAPYFORTORTURE SURVIVORS (2) https://tidsskrift. 1 (see - - - - were sometroublingfindings. For example, control at least someofthetime. indicated having problemswithlossofbowel men and 12.7% of the women in the pilot at least “somewhat.” Inaddition, 20%ofthe constipation urgency at times, 29.2% urinary continence at least somewhat, 39.2%having in prolapse, having urinary 16.9%reported that they were having issues with pelvic organ indicated While only 12.3%of the participants Pelvic floortoolanddata BandD.only forParts improvement, anddifferenceswere seen, and However, only modest differences in rates of endured moretraumathannon-survivors. sessment tool, astheywould have typically provements inallfoursectionsofthePSas would showtorture significantly more im all theareasofPSassessmenttool. Table 5hasmoredetailedstatistical analysisof in at least one of the four areas of the measure. improvedcombined totalof1183participants Results pation orincontinence. foods andbeverages, whichcanmakeconsti psychoeducation abouttoiletingpostureand massage todecreaseconstipation andprovide For example, inself-abdominal PTs instruct the 10-week PScycle. longindividualorgroup teachingmodulesduring added specificbrief about bowel orbladderfunctioning, PTshave and thosewhodonot, having concerns report being gender-basedviolence(GBV)survivors many participants, boththosewhoreport for moreresultsofpelvicfloorpilot pain). ( sexualactivity (moderate tosevereduring that theyhadpainof4ormoreon1-10scale 27.9% ofmenand30.9%women indicated It was of hypothesized that survivors As noted in Table 4 below, 96% of the From thisinitialpelvicfloorpilot, there Please refer to supplemental materials Please refer to supplemental materials ). Because - - - - TORTURE Volume 30, Number 3, 2020 35 - The . 14% 12% 4% 16% 34% 50% 28% Kakuma (N=454) 44% 56% 31% 31% 0.4% 18% 16% 3% 1% 18-77 36 years 70% 19% 7% 5% 30% 38% 32% 60% Jordan (N=1632) 38% 62% 1% 43% 31% 21% 4% 14-82 39 years 69% 46% 9% 7% 41% 35% 24% 32% Nairobi (N=802) 40% 59% 1% 45% 20% 12% 0.2% 7% 13% 4% 13-74 32 years 39% why it is essential for PTs to address pelvic it is essential for PTs to why floor concerns. Discussion and Conclusions This report a description provides of the CVT groupsurvivorsfor model PS tortureof in contexts camp refugee and urban both bowel incontinence than the general popula than the incontinence bowel is another reason 2013) which tion (UNICEF, - - 4+ children medications Taking Iraq Sudan Other Age range Age mean Married/coupled Single Widowed Divorced/separated No children 1-3 children Men Women Non-binary DRC Burundi Somalia South Sudan Ethiopia Uganda Syria . Demographic factors. of participants in three program sites To reduce any stigma and to normalize any reduce To Rx Children Marital Situation Age Country of Origin Intake Demographics Gender Table 1 Table populations with which CVT works in Kenya in Kenya works with which CVT populations FGM 88%) Eritrea, estimates, (Somalia-98% andbladder both of survivorsrates higher have pelvic floor strengthening and relaxation ex and relaxation pelvic floor strengthening (FGM) mutilation genital Female ercises. is very among some of the patient common the need for education, PTs instruct all par the need for education, ticipants in the group in techniques such as SPECIAL SECTION: PHYSIOTHERAPY FOR TORTURE SURVIVORS (2) SURVIVORS TORTURE FOR PHYSIOTHERAPY SECTION: SPECIAL 36 TORTURE Volume 30, Number 3, 2020 tions andcombined Table 4 Table 3 Table 2 Area ofGreatest Concern Pelvis, hips Arm, wrist, hand Neck, spine Head, face Chest, abdomen, torso Leg, knee, ankle, foot Back, shoulders Areas ofPain at Intake Combined Jordan Kakuma Nairobi at sixmonths fewer areas Reporting 3+ areas 2 areas 1 area 0 areas areas Number of

Intake to 3-month SPECIAL SECTION:PHYSIOTHERAPYFORTORTURE SURVIVORS (2) . whoimproved Participants ineachsectionoftheassessmenttoolallthreeloca . Numberofareaspainat intakeandthree-monthfollow-up . Location ofPain and Area ofGreatest Concern 227 (64%) 202 (57%) 96 (27%) 53 (15%) 4 (1%) Intake 1183 634 194 355 participants participants Nairobi (N=355) assessed) N (total 99 (28%) 103 (29%) 121 (34%) 32 (9%) 3 Months

Head, (10%) face foot (14%) Leg, knee, ankle, (14%) torso Chest, abdomen, (47%) Back, shoulders Nairobi (N=782) 144 (18%) 201 (25%) 233 (29%) 329 (41%) 385 (48%) 457 (57%) 610 (76%) Nairobi (N=802) 838 424 168 246 N A 71 67 87 69 329 (53%) 174 (28%) 112 (18%) 6 (1%) Intake 329 (53%) % Jordan (N=621) 907 470 180 257 N Participants whoParticipants improved B 324 (20%) 583 (36%) 745 (46%) 599 (37%) 534 (33%) 988 (61%) 729 (45%) Jordan (N=1619) Head, (14%) face (17%) Back, shoulders foot (22%) Leg, knee, ankle, Neck, spine(23%) Jordan (N=1583) 77 74 93 72 % 193 (31%) 199 (32%) 217 (35%) 12 (2%) 3 Months 743 398 145 200 N C 63 63 75 56 % 889 441 172 276 156 (81%) (73%) 140 42 (22%) 10 (5%) 0 (0%) Intake N Kakuma (N=192) 59(13%) 132 (29%) 104 (23%) 313 (69%) 317 (70%) 268 (59%) 359 (79%) Kakuma (N=454) foot (14%) Leg, knee, ankle, Head, (17%) face (28%) Back, shoulders (31%) torso Chest, abdomen, Kakuma (N=443) D 75 70 89 78 % 1130 604 192 334 one area 52 (27%) 58 (30%) 58 (30%) 24 (13%) 3 Months At least N 96 95 99 94 % - TORTURE Volume 30, Number 3, 2020 37 *** *** *** *** *** *** *** *** *** p *** *** *** - 0.827 0.571 1.830 0.453 0.265 0.896 0.699 0.948 1.487 Cohen’s Cohen’s d 0.439 0.442 1.202 1.6 1.9 1.4 0.6 0.7 0.4 0.3 0.4 0.3 3- month SD 19.3 21.0 15.5 3.3 2.7 1.4 3.0 3.0 3.3 2.9 3.0 3.1 3- month mean 29.4 27.6 13.6 fetching water, or sweeping, and would rely and would or sweeping, water, fetching I am able to carry now but neighbors, on my attend Before a 10- liter container of water. I could not stand upright ing PS sessions, no I have now but pain, back because of my every exercises day. and I do my pain, back female survivor)(62-year-old I could not do most of my daily activities like I could not do most of my 0.6 0.6 0.5 0.3 0.4 0.4 Intake SD 21.1 19.5 21.0 1.6 1.7 1.7 - 2.8 2.8 2.9 2.7 2.6 2.6 Intake mean 38.3 36.5 35.8 4.6 3.7 4.2 638 355 194 638 355 194 N 634 356 194 638 355 194 Jordan Nairobi Kakuma Jordan Nairobi Kakuma Program Jordan Nairobi Kakuma Jordan Nairobi Kakuma - (40-year-old male survivor)(40-year-old Differences in mean scores at baseline and 3-month follow up and 3-month follow baseline in mean scores at Differences

to attend community meetings, but now I now but community meetings, to attend also joined a tailoring them and have attend much more hopeful about I feel Now, class. future and about the possibility of earningmy income! Before attending PS sessions, I was not able I was PS sessions, attending Before ** p≤0.01 *** p≤0.001 = best outcome measures t-tests from repeated (two-tailed) P-value * p≤0.05 Coping & outlook (11 items) outcome / 4 1=worst 1=worst outcome / 4 1=worst = best outcome Part D: Part C: Social participation & functioning (8 items) items) excellent / 0=no pain; poor pain; 10=worst Part B: Part B: Body functions (11 & physicality 0=without difficulty / 100=cannot do ac all tivity at Part A: Functional ability (12 items) Outcome area Table 5. Table quantitative results presented above are sup results presented above quantitative PTs. ported by anecdotal feedback to CVT’s SPECIAL SECTION: PHYSIOTHERAPY FOR TORTURE SURVIVORS (2) SURVIVORS TORTURE FOR PHYSIOTHERAPY SECTION: SPECIAL 38 TORTURE Volume 30, Number 3, 2020 strong therapeutic alliance, group support and and strong therapeutic alliance, support group suchasa of non-specific therapeuticfactors toacontrolgroup.parison The contribution results are presented without com preliminary when reviewingthesefindings. Firstly, these bladder accidentsontheway. bowel aboutembarrassing or without worrying able towalk longerdistancesinthecommunity bowels withresultant odor, andthat theyare will nolongerhave leakingoftheirbladderor munity events astheyareconfidentthat they activitiesandothercom tendance at religious pain. being able to resume at They also report as well asbeingabletorelaxandhaving less desire tobesexuallyactive withtheirpartners, a renewedin pelvicfloorfunctioningdescribe follow upinJordan, Nairobi, andKakuma Table 6. Part C: Part physicality Body functions& B:Part Functional ability A: Part *** p≤0.001 ** p≤0.01 * p≤0.05 P-value (two-tailed) fromchi-squaretestsofsignificance Coping &outlook D: Part & functioning Social participation

Similarly, notingimprovement survivors Several limitations mustbeconsidered SPECIAL SECTION:PHYSIOTHERAPYFORTORTURE SURVIVORS (2)

Number of participants showing improvement Numberofparticipants between baselineandthree-month 393 (80.4%) 309 (63.2%) 399 (81.6%) 361 (74.0%) torture of Survivors 495 (71.3%) 433 (62.4%) 506 (72.9%) 476 (68.8%) torture No reported - - - Secondly, sinceCVT’s approach includes both assessmentarewell documented.structured ment. Finally, we also lackdata onthose who we have lost contact following the end of treat no data onthefunctioningofthosewithwhom follow upischallenging. As aresult, we have areoftenmoving around, survivors long-term and limitedresources, andinplaces where the Jordan program. in of those receiving services and a majority who received treatment intheKenya program, ofthetotalsetsurvivors only asmallpart sizes presentedherearelarge, theyrepresent work.ciplinary Thirdly, although the sample resulting from different aspectsofour interdis in thisanalysistoseparate outthosebenefits counselling andPSintervention, we areunable In humanitarian settings with great need settingswithgreat In humanitarian 837 (70.9%) Total 888 (75.1%)*** 742 (62.7%) 905 (76.5%)*** 1180 assessed (N) participants number of Total 1183 1183 1183 - - TORTURE Volume 30, Number 3, 2020 39 Torture, Torture, Journal of (5), 519-528. (5), (1), 13-27. 13-27. (1), Torture Torture Abuse to Abuse

Torture, 27 Torture, Physiotherapy in Mental Physiotherapy Physiotherapy in Mental Physiotherapy Trauma and Recovery: The and Recovery: Trauma (pp. 206-225). Edinburgh: Edinburgh: 206-225). (pp. (pp. 134-140). Edinburgh: Edinburgh: 134-140). (pp. . New York, NY: Basic Books. NY: York, New . . International Journal of Conflict and . , 1-29. , , 1-26. doi: 10.4119/ijcv-3124 doi: 1-26. , , 3rd ed., (pp. 379–396). Edinburgh: Edinburgh: 379–396). (pp. 3rd ed., , (8), https://doi.org/10.1002/14651858. (8), 8 Physical Management for Neurological for Management Physical , (2), 74-84. (2), (1), 45-67. https://doi.org/10.7146/torture. https://doi.org/10.7146/torture. 45-67. (1), v27i1.108062 refugees who have of non-English speaking A clinical review. experienced trauma: the American310 Medical Association, with Physiotherapy (2018). C. & O’Reilly, J., Probst survivors In M. of torture and trauma. Skjaerven (Eds.) & L.H. 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Supplemental material (available at at Supplemental material (available tidsskrift.dk/torture-journa tries, and note the importancetries, of issues relat with survivorsing to the pelvic floor in working of torture. research into the efficacythe into research groupof inter PS with survivorsventions especially of torture, coun and middle-income those living in low cific therapeutic mechanism or comparative comparative or mechanism therapeutic cific to the important point We efficacy. treatment complimentary in inter PS can play role that call for more we In closing, disciplinary care. quality of life and functioning to those particthose to functioning and life of quality seen for follow are have ipants with whom we spe and make no claims to up assessments, dropped out of treatment before the end of the before of treatment dropped out these significant limitations, Given program. benefits in the authors merely note the overall SPECIAL SECTION: PHYSIOTHERAPY FOR TORTURE SURVIVORS (2) SURVIVORS TORTURE FOR PHYSIOTHERAPY SECTION: SPECIAL 40 TORTURE Volume 30, Number 3, 2020 Louw, A.,Puentedura Knapen, J., Morien, Y., &Marchal, Y. (2018). Kaur, G., Weinberg, R., Milewski, A. R., Huynh, S., Olsen, D., Montgomery, E., Carlsson, J., & O’Keeffe, M., Hayes, A., McCreesh, K., Purtill, H., Nordin, l., &Perrin, S. (2019). Pain and Nordbrandt, M. S., Sonne, C., Mortensen, E. L., & Nielsen, H. F. (2014). for Interventions Louw, A., Zimney, K., Puentedura, E. J., &Diener, I.

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- - (10), (10), pproach A Conflict (2), 234-249. https:// 234-249. (2), Physiotherapy, 87 Physiotherapy, 10.1016/S0031- https://doi.org/10.1186/ Current Anesthesiology Reports, https://doi.org/10.1007/s40140- (34). (34). 10 , 10.1002/ejp.1314 Physiotherapy in Mental Health and Physiotherapy (4). 319-326. 319-326. (4). R., Montgomery, E., & Modvig, J. (2016). (2016). J. & Modvig, E., Montgomery, R., bio-psycho-social approach for A novel of torture victims of traumatized rehabilitation A pilot in the post-conflict context: and war randomized controlled trial in Kosovo. and Health s13031-016-0100-y of pain from for the treatment considerations torture and war. 6 016-0187-0 review and meta-analysis of pain neuroscience Short- back pain: for chronic low education and long-term outcomes of pain and disability. 23 European Journal of Pain, doi.org/ settings: The need for autonomy, competence and competence for autonomy, The need settings: Skjaerven Probst & L.H. In M. social relatedness. (Eds.) Based A Scientific and Clinical Psyhiatry: Elsevier Edinburgh: 32-35). (pp. survey approaches A nation-wide of treatment used by physiotherapists. https://doi.org/ 536-548. 9406(05)65452-1 group physiotherapy model. group model. physiotherapy are not named in this article with who work Higson-Smith, Craig to survivorsevery day, from Shannon Golden and Raghda Elshafie helped who department, research CVT the greatly and especially to sur with this article, vivors of torture and other forms of trauma, Special thanks learnfrom whom we so much. to MaryAnn the first staff physi de Ruiter, who helped to create otherapist from CVT, assessment tool and to the physiotherapy for CVT pioneer integration of physiotherapy Fricker and to Ilona participants, and Claire the CVT ten -session who created O’Reilly, Wood, L., & Hendrick, P. A. (2019). A systematic A systematic (2019). A. 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Series, Treaty A statistical genital mutilation/Cutting: Female of the dynamics of overview and exploration doi.org/10.1080/20008198.2017.1377552 Dysfunctional pain perception and (2020). of The role among torturemodulation survivors: pain personification 15 jad.2020.01.031 Psyhiatry: A Scientific and Clinical Based Approach A Scientific and Clinical Based Psyhiatry: Elsevier. Edinburgh: 92-96). [pp. & Bottche, P., M. Wenk-Ansohm, S., L.C. Multidisciplinary for treatment (2017). M. setting: refugees in a naturalistic traumatized Symptom courses and predictors. 8 Journal of Psychotraumatology. information for physical therapists. information therapists. for physical 97 Therapy, ptj/pzx057 Group therapeutic factors(2018). for use in A core in group in mental health: physiotherapy Skjaerven Probst & L.H. In M. physiotherapy. (Eds): 2260-5 Multidisciplinary (2016). G. C. & Maher, P., for nonspecific biopsychosocial rehabilitation pain. back chronic low 759-763. Practical Sleep health promotion: (2017). 18 Vancampfort, D., & Stubbs, B. (2018). Improving Improving (2018). B. & Stubbs, D., Vancampfort, Van Damme, T. (2018). Relaxation therapy. In M. In M. therapy. Relaxation (2018). T. Damme, Van UNICEF, Statistics and Monitoring Section (2013). and Monitoring Statistics Section (2013). UNICEF, United Nations Convention Against Torture, article Torture, Against Convention United Nations UN General Assembly, Tsur, N., Defrin, R., Shahar, G., & Solomon, Z. Z. & Solomon, G., Shahar, R., Defrin, N., Tsur, Stammel, N., Knaevelsrud, C., Schock, K., Walther, Walther, K., Schock, C., Knaevelsrud, N., Stammel, Skjaerven, L.H., Parker, A.R., & Mattsson, M. M. & Mattsson, A.R., Parker, L.H., Skjaerven, Siengsukon, C. F., Al-dughmi, M., & Stevens, S. S. & Stevens, M., Al-dughmi, F., C. Siengsukon, Saragiotto, B. T., de Almeida, M. O., Yahato, T. T. Yahato, O., M. Almeida, de T., B. Saragiotto, Sandahl, H., Jennum, P., Baandrup., L., Poschmann, Poschmann, L., Baandrup., P., Jennum, H., Sandahl, SPECIAL SECTION: PHYSIOTHERAPY FOR TORTURE SURVIVORS (2) SURVIVORS TORTURE FOR PHYSIOTHERAPY SECTION: SPECIAL 42 TORTURE Volume 30, Number 3, 2020 Torture inKenya programs andJordan. is the largest funder of Center for Victims of Migration, ofState UnitedStates Department PRM (BureauofPopulation, Refugees, and ofthisarticle. funding forthewriting partial The Centerfor Victims of Torture provided Funding

SPECIAL SECTION:PHYSIOTHERAPYFORTORTURE SURVIVORS (2) TORTURE Volume 30, Number 3, 2020 43

- - - 3

- : Lack of mental health mea : Qualitative interviews Qualitative seven with : The aim of this study was to evalu The aim of this study was : persistent pain, traumatic stress, stress, traumatic persistent pain, : The qualitative analysis showed analysis showed The qualitative :

, Marie Louise D. Oestergaard , Marie Louise 2 Method: Results Limitations experiences and living under continuous loss of such as poverty, stressful conditions, and limited access to health services status, the participating physiotherapists. The pre- to the participating physiotherapists. also School, of Pain evaluation post-treatment effects. treatment positive of an indication gave author biases (authors carryingsures, out interviews training, and analyzing qualitative results) and no control group. Keywords: MENA. physiotherapy, feasibility study, Introduction survived having traumatic Being a refugee, education, physical exercises and self-reliance, self-reliance, and exercises physical education, program for and a capacity building developed with working MENA based physiotherapists pain and trauma-affected populations. participating physiotherapists Pain the in PreliminarySchool training program. results also ana were School treatment of the Pain sufferinglyzed in 38 patients from persistent stress. pain and trauma-related good feasibility and high acceptance among Abstract Introduction pain physiotherapeutic a of acceptability the ate patient focusing on School), (Pain treatment - - -

, Ane Kirstine Viller Hansen , Ane Kirstine 1 4 10.7146/torture.v30i3.122375 Limitations were found in possi were Limitations a ble author biases and in not having control group. iotherapists in the Middle Eastern and NorthernAfrican (MENA) region. outcome of this Initial quantitative also region, in the MENA treatment, results in traumatised positive indicated individuals. A mixed method study of a physiother A mixed for persistentapeutic pain treatment showed School), pain conditions (Pain acceptance and feasibility among phys MSc. DIGNITY: Danish Institute Against Danish Institute DIGNITY: MSc. Against Danish Institute DIGNITY: MSc. Against Danish Institute DIGNITY: PhD, MSc, DIGNITY: Danish Institute Against Against Danish Institute DIGNITY: MSc, Torture, Copenhagen, Denmark Copenhagen, Torture, Denmark Copenhagen, Torture, and Denmark; Copenhagen, Torture, Lund University, Department of Psychology, Sweden Lund, Torture, Copenhagen, Denmark. Copenhagen, Torture, [email protected] Correspondence to: • • Key points of interest • 3) 4) 2) 1) International Rehabilitation Council for Torture Victims. All rights reserved. Victims. Torture International Council for Rehabilitation https://doi.org/ Anne-Mette Karrer Anne-Mette and Linda Nordin lations in the Middle Easternlations in & Northern African region Acceptability of a physiotherapeutic pain a physiotherapeutic of Acceptability popu in trauma-affected school treatment SPECIAL SECTION: PHYSIOTHERAPY FOR TORTURE SURVIVORS (2) SURVIVORS TORTURE FOR PHYSIOTHERAPY SECTION: SPECIAL 44 TORTURE Volume 30, Number 3, 2020 need todevelop cost-effective, evidence-based (MENA),and North Africa indicate acrucial suchastheMiddleEast of refugeesinregions methods incombination withlargenumbers liams & Alayarian, 2019). (Husak &Bair, 2020; Nicoletal., 2016; Wil depression, pain poor sleep and persistent traumatic stress disorder (PTSD), anxiety, al., 2019), themostcommonbeingpost- et al., 2013; ElSountet Rometsch-Ogioun tive implications onaperson’s health(Pacella and education, canleadtolong-lastingnega time (Abbey, 2015; Moseley &Butler, 2015; tent paincan decrease and/orstabilizeover chronic.are indeednotnecessarily As persis painconditions by suggestingthat persistent pain minology fromchronicpainto persistent a change in ter plasticity research supports et.al., 2019). ofpainandneuro Recentyears by any otherspecificclassifieddisease(Perrot where thepainis, notbetteraccountedfor paincondition, painisapersistent primary pain. Chronic definition of chronic primary national Classification ofDiseases’ (ICD-11) Study of Pain (IASP) introduced The Inter In 2019, theInternational Association for the Study specifictheoreticalbackground pain andtrauma-related stress. treatment frompersistent inpatients suffering vestigate thepilotresultsofPain School treatment; fashion, in (3)Inapreliminary trainings of physiotherapists delivering the physiotherapists; (2)Evaluate theclinical forMENA-based capacity building program ment, developeda andcontextualizedduring of Pain School, aphysiotherapeutic paintreat (1) Evaluate theacceptability and feasibility these complexcases. as educating health professionalsinhandling pain,methods that address persistent aswell

The aimofthismixed methodstudyisto: The lack of pain specific treatment SPECIAL SECTION:PHYSIOTHERAPYFORTORTURE SURVIVORS (2) ------responses and pain conditions creates in system that ispresentinbothtrauma-related pain perception. inthenervous The alertness that affectstheresponsesystemandoverall sponse, leading to a modulation in the nervous or displacement, cancreate anemotionalre traumatic events, suchasviolence, torture ofpainandsuggeststhat the understanding ity model(Figure1). ity is Amundson &Katz´s sharedvulnerabil 2019). An attempt toillustrate thecomplex (Brennstuhl et al., 2014; McAndrew et al., pain throughacombination of mechanisms also depressionandanxietymay interactwith has beensuggestedthat notonlyPTSD, but Ruiz-Parraga &Lopez-Martinez, 2014). It tend toincrease(Harlacheretal., 2016; the severity, duration, andfunctionalimpact tential tissuedamage” (IASP, 2019). resembling that associated with, actual or po associated with,and emotionalexperience or definition ofpainas “An unpleasantsensory pain, inrecentyears, isclearlyseeninIASP´s of medical toabiopsychosocialunderstanding Moseley &Butler, 2017). A shiftfromabio et.al., 2017; Nordin&Perrin, 2019). as aresult(Asmundson&Katz, 2009; Defrin tion, with increased pain and stress reactions, and bodily sensa threshold for daily stressors hypersensitive systemleadingtoalow nervous an over-evaluation ofharm, creates ofrisk a tional neuroplasticchanges. What seemstobe creased sensitivityandcanproducedysfunc When bothPTSDandpainarepresent, The modelrepresentsabiopsychosocial ------TORTURE Volume 30, Number 3, 2020 45 - - - - - depression, depression, Chronic and disabling PTSD, disabling PTSD, anxietry and pain negative activities perceived as perceived of situations or of situations A Cochrane Review from 2017 (Baird et A Cochrane Review from 2017 (Baird by mental health professionals and therefore ef been made to explore have few attempts refu for the traumatized treatments fective survivors. The treatments that were evaluated evaluated were that The treatments survivors. therapy (CBT) with behavioral cognitive were with either phys in combination biofeedback, iotherapy group or physiotherapy treatment list (Liedl et waiting versus home exercises, and complex 2017) et al., Wang 2011; al., (Kim & manual therapy versus self-treatment demonstrated studies of the None 2015). Yu, and only the manual a reduction in pain, treatment, of end the at claimed, study therapy The reduced disability and distress. to have per the prevalent review also concluded that sistent pain condition tends to be overlooked similar across cultures and regions of the 2008). (Tsang et al., world only three documented at 2017) revealed al., address persistentto tempts torturein pain - - - worry, agitation worry, (e.g. fear, anxiety, anxiety, fear, (e.g. . Shared vulnerability model. model. vulnerability . Shared hyperalgesia dysregulation, dysregulation, sensitivity, high sensitivity, (e.g. high injury(e.g. (e.g. sympathetic sympathetic (e.g. anxiety sesitivity) Figure 1 Figure cluded that such co-occurrencecluded that to be seems A recent study, assessing Syrian assessing in refugees study, recent A the 2020) indicates et al., (McGrath Turkey, same symptomology and a 2008 study con pain and somatic distress, along the expected distress, pain and somatic co-occurrence with mental health conditions and malfunctioning among refugees in the or bordering is limited. countries, Middle East, negatively affects mental and physical health mental and physical affects negatively Martinez-Calderon et 2016); et al., (Boakye persistentof documentation The 2020). al., hances “fear-avoidance” behavior (Nordin behavior “fear-avoidance” hances 2000), & Linton, Vlaeyen 2019; & Perrin, which again leading to general inactivity, decreased quality of life, functioning and dis decreased quality of life, 2020). Nordin, 2014, ability (Buhman et al., stress en pain and trauma-related Persistent Persistent pain conditions among refugee Persistent in the western living in asylum populations, as a significant contributor to is known world, theory and research. Edited by Zvolensky MJ, Smits JAJ. New York: Springer, 2008, pp 207–235, p. 216. 216. p. pp 207–235, 2008, Springer, York: New Smits JAJ. MJ, Edited by Zvolensky theory and research. Copyright 2008. Symptomology and treatments Figure 1. Shared vulnerability model. From Asmundson GJG, Abrams MP, Collimore KC: Pain and Pain Collimore KC: Abrams MP, Asmundson GJG, From Shared vulnerability model. Figure 1. Contemporary illness in anxiety and its disorders: in Health behaviors and physical anxiety disorders, SPECIAL SECTION: PHYSIOTHERAPY FOR TORTURE SURVIVORS (2) SURVIVORS TORTURE FOR PHYSIOTHERAPY SECTION: SPECIAL 46 TORTURE Volume 30, Number 3, 2020 pain rehabilitation. the biopsy Understanding which equals IASP general guidelines for all &Jansen,adaptation topain(Amris 2019), self-management andbehavioral aspectsof nents of pain education, physical therapy, survivors, shouldcontaincompo in torture ment ofnon-malign, painconditions persistent habilitation. has changed theclinicalapproachesinpainre ofpain ing toabiopsychosocialunderstanding world. outsidethewestern in regions gees, oftorture, especially includingsurvivors with theaimto stabilizeandavoid pain, stress dailyactivities andphysical training,during durance byworking andrestingintermittently line onhow toeconomize strength anden Butler, 2013, p.118-125) provide aguide et al., 2015 draat et al., 2017; depression andphysical function( that BBAT hasapositive effectonpain, stress, method (Gyllensten navian developed body-mind physiotherapy and Pacing principles Commitment Therapy,ACT Acceptance, are: BasicBody Awareness Therapy (BBAT); within painandmentalhealthrehabilitation 2012; Malflietet al., 2018; Pardo etal., 2018). the studieshardtocompare(Chipchaseetal., in outcome measures makes and consistency others. However, lackofreplicableprotocols life quality and avoidance behavior amongst disability, painintensity, physical function, positive impactonself-perceived healthand painhave frompersistent atients suffering pain education andexercise therapyforpa world have shown that protocolscontaining al., 2016). Studiesconductedinthewestern to stabilizetheoverall conditions(Louwet that itissafetostay active,re-learning seem chosocial reasons for pain, as well as slowly

Three clinical approaches often used The shiftfromabiomedicalunderstand SPECIAL SECTION:PHYSIOTHERAPYFORTORTURE SURVIVORS (2)

). Pacing (Moseley & principles IASP recommendsthat thetreat Bravo et al., 2018.; etal., 2018). Studiesfind . BBAT is a Scandi Blaauwen Stade ------Research Involving HumanSubjects, includ EthicalGuidelinesfor Biomedical ternational 1964, asupdated mostrecentlyin2013: In Association The studyfollows the World Medical Ethical Considerations Method and self-reliance awareness tofacilitate, acceptance, resilience ACT, asBBAT, usesmindfulnessandbody activities despite their conditions. necessary individual toplan, forthem, meaningfuland pain, anxietyordepression and now” conditionandnotthecauseof et al., 2020). ACT focusesontheoverall “here and anxiety(A-Tjaketal., 2015; Zhenggang has proven tohave effectonpain, depression & Lundgren, 2006; Dahletal., 2004). ACT of cognitive behavioral therapies (CBT) (Dahl from the third waveapproach that originates ACT isanacceptance-based, action-oriented tostay activeenable aperson intheirdailylife. to useafear-avoidance strategy andthereby and BBAT exercises aimtodecreasetheneed outbursts.and fatigue BothPacing principles The study follows the new Medical Research Study Design training andpatients receivingtreatment. signed by bothphysiotherapists receiving tive outcomes.were consentforms Informed in Denmarkforyears, with noknown nega of clinical practices for the target group part since thecontentof the treatment hasbeen approval wasstudy nofurther appliedfor, tion (M&E)tool. At thisstageofthefeasibility and evalua ment manualandthemonitoring committee provided approval forthetreat Institute against Torture´s ethical internal and data (WMA, 2013). DIGNITY-Danish ing researchonidentifiablehumanmaterial ´s (WMA) Declaration ofHelsinki . . ACT

promotes the promotes the - - - - -

TORTURE Volume 30, Number 3, 2020 47 ------with with to de to Physiotherapeu The Pain School School Pain The Patient education Patient The firstThe group of trainees con to decrease fear-avoidance and in to decrease fear-avoidance The training program was designed to give program to training designed The was manual: of Configuration Population: crease fear-avoidance strategies and enhance crease fear-avoidance selfcare and self-reliance. daily functioning, of each groupThe duration is 2 x 45- session treatment manual aims to empower trauma trauma manual aims to empower treatment meaningful live to patients pain-affected and despite pain and trauma-re and engaged lives, consists The treatment stress conditions. lated three containing sessions, manualized 10 of 1) main components: general un the aim to increase the patient´s challenges mental and derstandingphysical of 2) and body-mind interaction, tic exercises 3) crease basic body function and awareness, changes behavioral for planning Active the physiotherapists clinical competences to to competences clinical physiotherapists the for groups School treatment apply the Pain The trainings consisted of lec and individuals. exercise physical roleplay, group work, tures, The program con training and supervision. tained one written evaluation and one practical and a required a number of case-presentations during online supervisions trainings. between rele ensure to used only were evaluations The supportvant individual physiotherapist for the motivate to and difficult found they areas in for self-study. sisted of 12 physiotherapists (seven females, females, (seven sisted of 12 physiotherapists com 10 physiotherapists which males) of five 4 x 5 days, The trainings, pleted the program. The training was Jordan. Amman, took place in with the supportcarried from out in English, The physiother Arab and French interpreters. and in refugee in health clinics apists worked Lebanon Morocco, Tunisia, based in camps, one and 30 They had between and Jordan. with the major years clinical experience, of 5-8 years of experience.ity having School treatment and to make the treatment treatment and to make the School treatment replicable. ------An already existing, not published, Danish published, not existing, already An In collaboration, DIGNITY and the NGOs DIGNITY and In collaboration, their clinical praxis when providing the Pain the Pain their clinical praxis when providing of a training program, using feedback from using feedback from of a training program, contextual to training in physiotherapists the ize and include enough materialssupport to liance as part of their treatment. liance as part of their treatment. manual guide was School treatment Pain ized and adapted throughout the first half ally, many also concentrated their treatment on their treatment also concentrated many ally, and did not include con relieving symptoms, or self-re prevention cepts of empowerment, manual and electrical techniques (i.e. TENS, TENS, manual and electrical (i.e. techniques pain while few used exer ultra-sound) to treat Addition education. cise therapy and patient It was observed physiothera the among was It that under biomedical an overall was there pists using were Many standing of pain conditions. identified areas in which the physiothera pists needed to increase their competencies. fective, and replicable ways to treat the large to treat and replicable ways fective, numbers of refugees and/or torture survivors, for severe who continued to seek treatment pain. who are treating trauma-affected patients that that trauma-affected patients who are treating The NGOs also suffer from persistent pain. cost-ef new, need for urgent an expressed governmental organizations (NGOs) in the organizations governmental The purpose of the program MENA region. training for physiotherapists to provide was pain school treatment building capacity a initiated DIGNITY in non- program working for physiotherapists of a complex intervention, applying a mixed a mixed applying of a complex intervention, method design. of the and configuration Development Phase I: phases; I: Development II: Piloting/Feasibil II: Development I: phases; and IV Implementation. Evaluation ity III: a phase I and II trialThis study represents Council´s (MIC) guidelines for developing for developing guidelines (MIC) Council´s interventionsand testing complex (Craig IV The guideline contains 2008). et al., SPECIAL SECTION: PHYSIOTHERAPY FOR TORTURE SURVIVORS (2) SURVIVORS TORTURE FOR PHYSIOTHERAPY SECTION: SPECIAL 48 TORTURE Volume 30, Number 3, 2020 2017). The as poorsleepandinactivity(Moseley&Butler, nisms, stressandco-related challenges such ofpain provide anunderstanding mannerwiththeaimto friendly lay-person ity anddailyliving(Table 1). and Stress, 3) Pain and Sleep, 4) Pain, activ the manual are 1) Pain Mechanisms, 2) Pain nents. The educational topicsaddressedin equal amountoftimeforallthreecompo sions. Eachsessionisplannedtocontain an minutes and60forindividualses by working and resting intermittently during during by working andrestingintermittently how toeconomizestrengthandendurance movements, theexercises provide practiceon 118-125). Pacing (Moseley&Butler2013, principles p. spired byBBAT Table 1 TION AND WAYFORWARDTION Session 10: REPETITION, EVALUA PAINLIVING AND Session 8and9: ACTIVITY, DAILY Session 6and7: SLEEP AND PAIN Session 4and5: PAIN AND STRESS Session 2and3: PAIN MECHANISMS Session 1: INTRODUCTION

The patient education ispresented, SPECIAL SECTION:PHYSIOTHERAPYFORTORTURE SURVIVORS (2) : SessioncontentPain Schooltreatment manual Through thecalmandrhythmical physiotherapeutic exercises arein (Gyllenstenet al., 2018)and mecha - ina - - - - - • • • • • • • • • • • • • • •

ized measuresofmentalandphysical health ment). complete standard All participants (receiving traininganddelivering thetreat withphysiotherapistsqualitative interviews tive analysisoftheinitialtreatment effectand with a mixed-method analysis using quantita The Pain Schooltreatment was evaluated Phase 2: Feasibility Pilot-Study addressed andself-reflection. of the topics used to promote understanding their dailylife. andanalogsare Metaphors in what theylearn the sessionstointegrate plans for home practice and exercises between changes. Ineachsession, the patients make used topromote outbursts.fatigue from Principles ACT are aim tostabilizeandavoid pain, stressand daily activitiesandphysical training, withthe What isacutepain? Tryout home-exercise the exercises and plan first sessions of the Introduction to the treatment and structure explore? Why arewe hereandwhat willwe learn treatment, accordingtotheneedofclients and encouragement toself-careafterfinished Repetition ofmodelsusedintheprevious sessions How doIbalancemy level ofactivity? How doIlive withpain? sleep? What can I do to reduce pain and stress during What canIdotoimprove my sleep? Why dowe needoursleep? What iscatastrophizing? we feelpain? How doesstressandanxietyaffecthow andwhen What istrauma-affectedstress? pain? and persistent How canIunderstand, andshouldIreacttoacute pain? What ispersistent active planningforbehavioral - - - TORTURE Volume 30, Number 3, 2020 49

- - - - α (Gyllensten, (Gyllensten,

= .91 and .93. α Body awareness was assessed using the assessed using the was Body awareness own views on how the body is functioning in views on how own Items focusing on 1) the expe their daily life. 3) pain 2) muscle tension, rience of the body, 4) ability to performand discomfort, ac daily to 6) relationship habits, 5) exercise tivities, as 8) as well and 7) breathing, appearance, conditions can belief in if the overall subjective and 9) coping strategies in daily life. improve where 0 equals The scale ranges from 0-3, no problems and 3 equals extreme problems. each on offers answers question Each narrative severity and pain interference (Cronbach interference pain and severity = .85 for use in and to be valid and .88), medical and psychiatric across populations et al., Tan 1994; Ryan, cultures (Cleeland & The internal reliabil 2003). et al., Turk 2004; pain severity and pain ity coefficients for the the currentinterference scales in sample were Cronbach Scale-Expe Awareness nine question Body (BAS-E) questionnaire rience, 2016). al., et Hedlund 2011; Mattsson, & BAS-E gives information the patient´s about tive items. The BPI has been found to possess possess to found been has BPI The items. tive of internalhigh levels consistency both pain for ------Pain severity and pain in and pain severity Pain : Session-outline for session 2-10 (60 minutes or 2 x 45 minutes) : Monitoring and evaluation tool for Pain Pain Monitoring tool for and evaluation If the session is carried where it seems most relevant. out in 2 x 45 minutes a break is placed Finishing the session (10/15 minutes) Short and pacing principles are used) plan for home practice (ACT Progressive muscle relaxation BBAT inspired exercises (minimum 20 minutes) inspired exercises BBAT topic (10-15 minutes) and sharingEducation on today’s Follow-up from last session (5-15 minutes) Follow-up Questions to be explored (See table 1) topic (10-15 minutes) and sharingEducation on today’s Starting the session (5-10 minutes) and groundingBreathing exercise Table 2 Table enjoyment of life). Pain severity (four items) Pain of life). enjoyment items) scores are and pain interference (seven for their respec the mean of the 0-10 ratings to rate interference from pain (0 = No inter to rate seven in interference) = Complete 10 ference, mood, different areas of life (general activity, and sleep, with others, relations work, mobility, use and the degree pain when of relief from = No relief, 100% (0% using the medication respondent the asks 9 Item relief). Complete = assess the worst, least, average, and current and average, least, the worst, assess Worst = 10 Pain, No = (0 interference pain items assess medication Two Imaginable). Pain and asked to shade in areas where they experiand asked to shade in assess the totalpossible to it making ence pain, The next four items number of shaded areas. asks whether the person has experienced any pre are then They week. past the over pain representation sented with a two-dimensional and rear projections)of the human body (front terference were assessed using the nine item, item, the nine using assessed were terference short-form Inven Brief the of version Pain 1 Item 1994). tory (BPI) (Cleeland & Ryan, (described below) pre- and post-treatment. (describedpost-treatment. pre- and below) School treatment: SPECIAL SECTION: PHYSIOTHERAPY FOR TORTURE SURVIVORS (2) SURVIVORS TORTURE FOR PHYSIOTHERAPY SECTION: SPECIAL 50 TORTURE Volume 30, Number 3, 2020 etal pain, schizophrenia, affective disorders, as been validated forpatients withmusculoskel questionnaire has, oftheBASMQ-E, aspart fore notincludedinthisstudy. The BAS-E of the Pain School assessment tool and there The movement qualityassessmentisnotpart movement. during about experience interview movement qualityassessmentandaqualitative (BASMQ-E),Experience that alsocontainsa Body Awareness Scale Movement Quality and the best. ofthe BAS-Ewas developed asapart answer that equalstheirsubjective experience level (0-3), ofwhichthepatient choosesthe medical journal and if this information was not andif thisinformation medical journal doctor, or tion fromthereferring psychologist toobtain thisinforma pists were instructed ever torture?”. experienced The physiothera traumatic war events?”rienced and “Have you ined withtwo questions; “Have you ever expe Benyamini, 1997; Schnittker&Bacak, 2014). andmorbidity(Idler& predictor ofmortality because ithas been establishedas a strong 5 equals poor. This question was included, five-point scalewhere1equalsexcellentand cellent, good, very good, fair, or poor ?”, ona general, would you say that your healthis: ex amined with the single-item question: “In turally validated yet. Self-rated health was ex patients inScandinavia but hasnotbeencul treating MiddleEastern habilitation centers author. The questionnaire is widely used in re cialists inDenmarkandSweden andthefirst inclosecollaborationlators withBBAT spe Translations weretrans made byexperienced the BAS-Equestionnairewere notvalidated. PTSD (Nyboeetal., 2016). a measureofbodilysymptomsinpatients with has also been found applicable and useful as ceptable (Sundén et al., 2016). BAS MQ-E validity wereability andconcurrent foundac well asforhealthy adults. reli The interrater

Exposure to trauma and torture was exam Exposure totraumaandtorture The Englishand Arabic translations of SPECIAL SECTION:PHYSIOTHERAPYFORTORTURE SURVIVORS (2) ------of 18 years, to physiotherapy and referral treat war trauma and/or torture, being above the age treatment and for thisstudywere; exposureto (Jordan,different countries Lebanon, Tunis). and malefemalerespondentsfromthe NGOs ofparticipating an equaldistribution 2020.and January It was attempted to achieve in thePain Schoolmanual, inDecember2019 with seven physiotherapists, receiving training came fromJordan andMorocco. inthisstudy.further The 38patients included treatment. These dropouts are not explored to and from lacking funds for transportation theprojectandpatients staff turnover during dropouts were analyzedandfoundtobedue also excludedinthisstudy. The reasonsfor ceiving less than six sessions of treatment were pre-assessed (data notavailable). Patients re for thisassessmentwas made, sincethiswas or mentalimpairment. Nospecificprotocol orongoingpsychosis)severeders cognitive disor (such as personality disorders chological 3 months. were severe Exclusioncriteria psy ment duetopaincomplaintslastingmorethan health beforeandaftertreatment. terference, andself-rated BAS-Eindicators andpainin used tocomparepainseverity of war andtorture. Paired-samples t-testswere der-based differencesinrelation toexperience ment. Pearsons chi health) was compared pre-andpost-treat bio-psychosocialinfluenceson derstanding status (pain, bodyawareness, copingandun (p<0.05) and calculated in SPSS 25.0. Health ducted with a two-sided level of significance could alsoaddressitdirectlywiththepatient. address thesekindsofsensitive questions, they If thephysiotherapists were alreadytrainedto available, toleave thequestionun-answered. Statistical analyses: Inclusion criteria forreceivingPain School Inclusion criteria wereQualitative conducted interviews 2 was used totestgen All analyseswere con ------TORTURE Volume 30, Number 3, 2020 51 ------: According to : However, one one However, It is difficult for It is difficult for Culturally, here in the Middle Culturally, Theme 2. Group versus individual treatment: individual treatment: Group versus Theme 2. and context Culture 3. Theme When I do Pain School in groups, I experience groups, School in When I do Pain I have learnedI have understand to better the language ditional methods. Encouraging behavioral Encouraging behavioral ditional methods. diffi was lifestyle, for a more active changes, who had been sedentarycult among patients sions. This would convince the few patients, patients, few the convince This would sions. the reluctant in the beginning, that who were the towards Reluctance could work. treatment cul as explained was treatment School Pain “ tural differences. from the physiother expect a massage you East, others liked “The majority liked the idea, apist.” ” more. regular physiotherapy torture explained that physiotherapist sur vivors did not like to be touched because of experiencesbad their authorities with touch Pain ing them violently and concluded that School could be an alternative to more tra the behavioral changes registeredthe behavioral by the phys Others patients the that explained iotherapists. shared thoughts and feelings and opened up, expressed relief in the meeting with others, who had the same symptoms and challenges. “ the pa a greater between on the interaction focus on the persistent pain the focus that tients and feel and stress condition are harder to sustain.” start patients noticing the physiotherapists, ses relief from their pain after three to four of the patient. Because the torture survivor does of the patient. to have you - so are, as they tell things, not always to better understand them.” look after other things, encompasses noticing the A holistic view also “ patient. body language of a everything to tell you the patients) di them (i.e. looking am I Now interpret. to have I so rectly, and breathing.” body language their behavior, at experiencedthe Most of the physiotherapists in when provided School most effective, Pain Breaking individual treatment. groups over engagingand isolation of some are socially when conducting the Pain School treatment. School treatment. the Pain when conducting “

------The Additionally, Additionally, A semi-struc “Usually, we just worked with just worked we “Usually, The physiotherapists expressed that expressed that The physiotherapists The new knowledge helped the physiother the helped knowledge new The The increased focus on psychologi Theme 1. The bio-psychosocial understandingThe bio-psychosocial Theme 1. All interviews recorded and tran were Interviews thematic analyses: Interviews analyses: thematic meeting between physiotherapist and patient and patient physiotherapist meeting between cal aspects means that verbal and non-ver and verbal that means aspects cal a greater role in the play bal communication The biopsychosocial approach to physiother approach to The biopsychosocial new to most of the was apy and rehabilitation physiotherapists as a body.” the patient apist to address the constant fear as a stressor, apist to address the constant fear as a stressor, of the pain. increases the severity that and how pain. For instance, one physiotherapist had a physiotherapist one instance, For pain. the pain constantly feared that who patient by a serious caused was condition. factors can influence pain intensity” factors they became increasingly they mentioned that stress and linkage between of the close aware how to conceptualize pain. One said: “ One said: to conceptualize pain. how to how has given me a new perspective training and psychosocial physical social, environmental, they learned to understand pain new ways expe type of pain any mechanisms and how It also produced by the brain. rience is always on perspective them with a broader provided given in the sections following below. below. given in the sections following of pain: school training program school training analysis from The themes of the qualitative the interviews are physiotherapists of the Results and pain of treatment evaluation Qualitative scribed. Data was analyzed using thematic analyzed using thematic was Data scribed. 2015). & Cornish, analysis (Skovdal and “evaluation of the training,” was used. The used. was training,” the of “evaluation and interviews carried with inter were out online, interviews. preters three of the seven at present tured interview to guide with 20 items related with a manual” “working “learning objectives,” SPECIAL SECTION: PHYSIOTHERAPY FOR TORTURE SURVIVORS (2) SURVIVORS TORTURE FOR PHYSIOTHERAPY SECTION: SPECIAL 52 TORTURE Volume 30, Number 3, 2020 the manual. “ the of withthefinalversion positive experience showedNevertheless, amutual theinterviews act orsay ofamanual. what fitstheformat withpatients thatlenging donotalways feel, cians that working manualizedcanbechal learning:driven tradictive tothePain Schoolapproach. people justtogohomeandrest, whichiscon in Jordanplained that medical doctors advised Jordan whereoneofthephysiotherapists ex for many years. This was especiallythecasein word itself, I understood, but it is not acceptable for had anissue with the PTSD inthemanual. The evolved as well. fromtheinterviews periences. process Challengesinthe learning to discuss, askquestionsand shareclinicalex was with theotherphysios (i.e. physiotherapists). ofpatientswith mybecauseIhaddoneit group priority... at theendIfelt relaxed andconfident process.ing “ activitiesfortheirlearn the mostsupporting ing thesessionsandphysical exercises, as iotherapists highlightedroleplay andpractic and sessionpractice, phys alltheinterviewed presentations,participants physical exercises combination oflectures, groupwork, roleplay, tectable. symptoms suddenlywas measurableandde vated by it, as the improvements in patients’ uation time-consuming, but mostwere moti of them. Few andeval found themonitoring andevaluationfor monitoring was newtomost standardizedtool working withastructured functional testsandquestionnaires. However, doing andwhen.” me,manual supports soIfeel Iknow what Iam do inthedifferent sessions, but now Ifindthat the felt confusedanditwas difficulttoknow what to

Theme 5. learning: Participatory Physiotherapists areusedtoworking with Theme 4. Working “manualized” and data

SPECIAL SECTION:PHYSIOTHERAPYFORTORTURE SURVIVORS (2) also expressedthat therewas enough time Practicing thesessionswere my top In the beginning ofthetraining I In thebeginning It iswell known amongclini

From the “At first I “At first ” It ------apists expressedthat thebodyawareness ex project responsibilities. sessions,for thesupervision becauseofother connectionandlimitedtime was poorinternet oretical test. A challengeexpressedbysome more confidentinthiscomparedtothe andfelt practical examwas moreimportant manual indepth. Someexpressedthat the ing, and that itforced them to study the ofthetrain that itunderlined theseriousness received bythephysiotherapists. Moststated The practicalandtheoreticaltestswere well self-assessment toexpressclinicalchallenges. was a big help and it gavepervision a sense of the trainingsessions. Itwas stated that thesu setupbetween about theonlinesupervision participants: andpasttraumatic experiences. stressors replace PTSDwith “stress” related topresent the Pain Schooltreatment, itwas decidedto therapists, of andbecausePTSDisnotpart among other physioon similar experiences the training andsowe changed thename.” back themoreIexplainedit. We talkedaboutitin these patients. that somegot flash Iexperienced was expressed by many as a result of the train to build newcompetenciesandself-confidence tive lifestyle andbadposture.” or good postureifImyself inac have asedentary believe ordoourselves… Icannottalkaboutbad tobelievevince others ordosomething, ifwe don´t growth tioned asapersonal “ a rolemodelwas alsosomethingthat was men self-awareness.” It changed my posture, my bodyawareness and level itchanged mebecauseIbecamemoreaware. on theirown stressreactions. and ability to detect and actof grounding and awareness oftheirown stability, sense ercise practicegave themtoolsforself-care Theme 7. Personal growth: Theme 6. andevaluation ofthe Supervision All physiotherapists were positive A conscious awareness of being The opportunity opportunity The W All physiother “On a personal “On apersonal e cannotcon Based ------TORTURE Volume 30, Number 3, 2020 53 - - - - - (2.6) (7.9) (7.9) (2.6) (73.7) (5.3) (10.5) % (26.3) (73.7) (2.6) (15.8) (36.8) (18.4) (7.9) (15.8) (2.6) (10.5) (42.1) (7.9) (28.9) I give them exer 1 3 3 1 28 2 4 (n= 38) 10 28 1 6 14 7 3 6 1 4 16 3 11

. Distributionof socio-demo . Patients that did not seem to benefit from did not seem that Patients Divorced Widow(er) Nationality Iraqi Syrian Sudanese Moroccan Other Missing Marital status Single Engaged Married Gender Male Female Age categories 16-25 26-35 36-45 46-55 56-65 66-75 Missing Table 3 Table graphic among patients. data terpretingthereby and the body from signals to care of themselves, being able to take better both de-conditioning and prevent active, be to “ stress. flareups of pain and pacing and gradedcises and tell them about ex is clear to them. the concept ercises to ensure that One phys also mentioned. were the treatment body awareness and using pacing principlesusing pacing and to body awareness supportsplan daily living, with in the patients - - - - - “They It was It was “Until

Practicing It is a more At the pre-assessment the At the pre-assessment the When the physiotherapists When the physiotherapists The body awareness exercises are are exercises The body awareness Through patient education, education, Through patient The physiotherapists stressed that the body stressed that The physiotherapists Compared to previous approaches to treat previous approaches to Compared Theme 8. Clinical experiences and perceived Theme 8. position, how they sit, how they walk.” how they sit, how position, to “ implement. more being up end patients the because favorite, my their of their bodies, conscious about their feelings, a level where everybody where could understanda level it to the cultural through metaphors developed The exercises lives. context of the patients’ and therefore easy effective, but simple, were awareness exercises, and the use of metaphorsof the use and exercises, awareness on impact biggest the had education pain in A complex pain theory taken to was patients. said that he not only tried to fix things, but he actu not only tried he said that to fix things, around the house.” ally succeeded in fixing things everyday activities. “ everyday activities. to fix things around initiate even wouldn’t patient patient the post-assessment the at but house, his cises and tools they can use at home. cises and tools they can use at tools improved the provided emphasized that sleep and helped them to manage the patients ing persistent pain conditions, the difference ing persistent pain conditions, knowl of achieved as a combination seen was stress and edge on the interaction between in particular exer caused by effective pain, is very good, because I have seen these patients for for these patients seen because I have is very good, more.” for coming back they kept where one year, affects the pain and they know how to deal with it.” it.” deal with to how know and they the pain affects expressed that, Another physiotherapist This after the last session. no one came back now, or three years, suddenly don’t need physiotherapy need physiotherapy don’t suddenly years, or three anymore.” stress how their pain comes from, where know treatment, a central theme arising was that the the arising theme central that a was treatment, indepen in resulted treatment School Pain “ dence from the physiotherapist. two for seen have I Patients strategy. long-lasting treatment effects: effects: treatment between differences the about asked were School and the Pain regular physiotherapy ing as well as feeling a sense of added value to a sense of added value as feeling ing as well their career paths. SPECIAL SECTION: PHYSIOTHERAPY FOR TORTURE SURVIVORS (2) SURVIVORS TORTURE FOR PHYSIOTHERAPY SECTION: SPECIAL 54 TORTURE Volume 30, Number 3, 2020 in Morocco(Table 3). Onaverage, patients 28.9% were localcitizensreceivingtreatment School treatment inJordan (71.1%), whereas refugees whoreceived physiotherapy Pain Most patients includedinthisstudywere Quantitative Evaluation like theothers.” money oraproperhome….Shegot better, but not but shehadotherproblems, shedoesnothave active inthetreatment sessionsandat home), “ iotherapist working inarefugee campshared, self-rated health. Many feltpain onnumerous for self-rated health was 3.95 indicating a poor enced torture. that theyhadexperi one missing, reported of thewomen (32.1%), whileallmen, except lation totorture, asapproximately one third difference (p=0.002)between inre genders sons had beendirectlyexposedtotorture. Pear not answer thequestion. Nearlyhalf(47.4%) enced traumatic war events. all” tothequestion answeredone person “no” and one “not at traumatic warexperienced events, asonly results fromtreatment were reported. not duetoaclinicalevaluation. Nonegative on what was possibleineachcontextandwas was solelypragmaticallyindividual orgroup individual, based. orgroup toeither Referral was notindicated whetherthetreatment was ceived treatment. group-based Inonecaseit individual treatment whiletheremainingre an out-patient clinic. 28(73.7.%)received while 23(60.5%)received Pain Schoolin tients (39.5%)were treated inrefugeecamps, of 7.97weeks (SD: 5.4range1-19). 15pa sions (SD: 1.7, range6-15)withaduration in this study received 9.92 treatment ses Not that she

Within this sample the vast majority had Within thissamplethevast majority A burdened target group: SPECIAL SECTION:PHYSIOTHERAPYFORTORTURE SURVIVORS (2) X 2 - test showed astatistically significant (patient) “Have you ever experi did notwant toact ” One patient did The meanscore (be ------to understand themainelements ofthetreat to understand able tobenefitfromPain School, itiscrucial with looks(d=.43). from d=1.1 to d=2.2, except for satisfaction ing, withlow tomoderate effectsizesranging on theBAS-E, ofbreath exceptexperience changes pre-topost-treatment forallscales to d=2.38. with higheffectsizes, fromd=1.04 ranging ate significant changesonallparameters, on thiswas available. toexplorethereasonorspecifics information ent typesofpainreliefmedications. Nofurther ment 47%. Othertreatment was mainlydiffer the pre-treatment assessment andpost-treat receivingothertypesoftreatment at reported pating inthePain Schooltreatment, 76.3% on a scale from 1-10. In addition to partici level was alsohighwithameanscoreat 7.02 verity ofpainwas 6.51. The paininterference can imagine, theaverage oftheperceived se from 1-10, where10equalstheworst painone felt pain in 11.95 areas on average. On a scale areas ofthebody. Outof45options, patients about the prospects of one’s pain condition before Pain School. replied at all”,“not true compared to18.4% oftreatment, thecourse ably during as84.2% method topainreliefhadchanged consider 13.2 %beforetreatment. by planningtheirdailyactivitiescomparedto ofstress they couldinfluencetheirexperience true”). Likewise, 55.3%fullybelieved that % before treatment (responses “completely the Pain Schooltreatment comparedto18.4 their pain byplanning their daily activities after believed theycouldinfluencetheintensityof ment approach. 65.8%ofthepatients fully Having resignedly negative thoughts Perceptions ofmedicineastheonly Patients’ andcoping outcomes learning Table 5alsoshows statistically significant Table 4 show statistical low to moder : Tobe ------TORTURE Volume 30, Number 3, 2020 55

- - - 2.22 1.56 1.32 1.12 0.43 - Cohen’s d Cohen’s Cohen’s d Cohen’s 2.38 2.12 1.26 1.04 1.31 The word [PTSD] itself, I un I itself, [PTSD] word The <0.001** <0.001** <0.001** <0.001** =0.003* =0.086 p-value p-value <0.001** <0.001** <0.001** <0.001** <0.001** assessment, due to lack of economic resources assessment, camps in Jordan was hard. Addressing mental Addressing hard. was camps in Jordan also new was such as PTSD, health challenges, and therefore the manual and overwhelming One physiotherapist adjusted accordingly. was mentioned “ that these patients.” it is not acceptable for but derstood, referringwas Whether the physiotherapist to or trauma reaction the a label for as PTSD but for riskingflashback reactions is not clear, neverthelessveryis it important in address to which The clinical reality in future trainings. treat School of the Pain the implementation for diagnostic ment took place did not allow for supervisionfor internet having and connec in the refugee especially when working tions, 0.45 (0.69) 0.89 (0.65) POST Mean (SD) 1.03 (0.59) 1.08 (0.67) 1.05 (0.66) 0.89 (0.77) - - - - POST Mean (SD) 2.41 (1.89) 2.64 (2.31) 0.89 (0.70) 2.87 (1.12) 4.76 (4.00) 0.79 (0.88) 1.18 (1.04) PRE Mean (SD) 2.32 (0.57) 2.05 (0.57) 1.95 (0.70) 1.78 (0.82) PRE Mean (SD) 6.51 (1.53) 7.02 (1.79) 1.78 (0.71) 3.95 (0.96) 11.95 (6.67) 81.6% replied “not true at all” to the “not true all” at 81.6% replied . Paired T-test comparing Pre- and Post-treatment on BAS-E comparing Pre- and Post-treatment T-test Paired . . Paired T-tests comparing Pre- and Post-treatment on BPI, Body Awareness and Awareness Body on BPI, comparing Pre- and Post-treatment T-tests Paired .

Exercise Satisfaction with looks Experience of breathing Pain or aching Pain limitations to day Day Muscle tension Self-rated health Self-rated Number of painful body areas Pain interference Pain Body awareness Pain severity Pain Table 5 Table Table 4 Table Health Self Rated seemed objectively confusing for most of the of for most confusing objectively seemed Some challenges can be con physiotherapists. the time Finding the interviews. from densed ment, as well as the training program. This This as the training program. as well ment, the experience even matches of the trainers, though the first period half of the training Discussion interviewsThe qualitative with the physi positive predominately otherapists showed as a treat School, both Pain towards attitudes it’s never going to get better,” post-treatment, post-treatment, to get better,” going never it’s pre-treatment compared to 21.1% improved markedly after Pain School treat School after Pain markedly improved as ment, “My pain is terrible and I think that statement SPECIAL SECTION: PHYSIOTHERAPY FOR TORTURE SURVIVORS (2) SURVIVORS TORTURE FOR PHYSIOTHERAPY SECTION: SPECIAL 56 TORTURE Volume 30, Number 3, 2020 pervisions supportive, whichalsogavepervisions the the contextingivenprogram. extentpossible,greatest reflectedtheneedsof toamanualthat, contributed period tothe ing. this The discussionsandfeedbackduring their treatments seemed, for many, overwhelm bothexercisegrate therapyandeducation into andinte andhaving tolearn the beginning added totheM&Etool. ofmentalhealthconditionsshouldbe tors and clinicalknow-how. Nevertheless, indica whether thePain School treatment provided Arabic andFrench, arerelevant contributions. survivors” with torture paper Arabic (Gamble, 2020), and a 2014praxis pain science and assessment in Kurdish and materials was described. Recently published teaching literature.French written A language barrier most cases, tomedicalorEnglishand referred as almost non-existant. The students are, in iotherapy literature in Arabic was described for physiotherapists inthisregion. Also, phys be addressedwhenproviding futuretrainings mental health conditions, shouldcontinuously This, andbasicknowledge ontrauma-related East that thephysiotherapists hadundertaken. cational physiotherapy intheMiddle programs ing ofpain, ofthestandardedu was notpart the trainingonabiopsychosocialunderstand the nextphase. not possible, but thisshouldbeconsideredin ment is. Pragmatically at thisphase, thiswas manual was usedandhow replicablethetreat given aclearerideaofhow thePain School would have supervision an offeronin-person ing andimplementation challenges. Even so, trainer achancetoevaluate theclinicalreason

The qualitative analysisalsoindicated that The physiotherapists foundtheonlinesu Not having afinalmanualtofollow from This studyshowed noclearindications on SPECIAL SECTION:PHYSIOTHERAPYFORTORTURE SURVIVORS (2) “Interventions for physiotherapist“Interventions working “Beyond Pain,” (Nielsen, 2014)in anevidence-based ------to recognize answers from each respondent. ability treatment andtrainingtheauthors pists towards a more positive attitude to both This couldhave influencedthephysiothera and a second having developed the M&E tool. and thedeveloper ofthePain Schoolmanual two oftheauthors. Onewas alsothetrainer were planned, outandanalyzedby carried A limitation inthisstudy isthat theinterviews Limitations this shouldbedoneinthefuture. was alsonotvalidated forthispopulation and be ACT-compatible. The BAS-Emeasurement or EMDR, would aslongsuchintervention longed exposure, narrative exposuretherapy, PTSD-focused intervention, suchaspro in combination with a psychotherapeutically the Pain School treatment were to be tested ment “as usual.” Itwould alsobebeneficialif given treat the futurewithacontrolgroup types of treatments. This couldbe solved in in thisstudy, toisolate the patients fromother phase oftheresearch. investigatedThis hastobefurther inthenext haddifferenteffects.for individualsorgroups their experience ofwar and-ortorture. their experience the patients were, infact, trauma-affectedfrom sured in this study, making it unclear whether depression, anxietyorPTSD were notmea out.similar studieshave been carried Also, few comes topreviousstudiessincevery sample, hard to compareout makesitvery theMENA evaluation-scales andparticularly was used. with cautionsincenocontrolgroup included inthenextphaseofstudy. strengthened thestudyoutcomesandmustbe withpatients would haveFurther, interviews It was neitherapriority, norapossibility The Pain School protocol, the selected The effectoftreatment shouldbereviewed - - - - - TORTURE Volume 30, Number 3, 2020 57 - - - - . , IASP (1), 30–6. 30–6. (1), 84 , . https://doi.org/10.1002/ . To all the participat To inc ,

Wiley-Liss

Chronic Pain: State-Of-The-Art - A Theoretical A State-Of-The-Art - Chronic Pain: Review. da.20600 (2015). M. P. & Emmelkamp, A., J. Smith, B., A metanalysis of the efficacy of acceptance and commitment therapy for clinically health problems. physical mental and relevant and Psychosomatics Psychotherapy https://doi.org/10.1159/000365764 Interventions persistent for treating (2017). K. rehabilitation for chronic low back pain: for chronic low rehabilitation International Journal Medicine of Osteopathic https://doi.org/10.1136/bmj. 239-240. 18(3), h444 management. consequence of torture: eu/wp-content/uploads/2019/02/13-Chronic- pain-as-consequence-of-torture-management- TEMPLATE.pdf Anxiety Disorders and the co-occurrence of Phase IV is planned to contain final evalua Phase IV is planned to Baird, E., Williams, A. C. D. C., Hearn, L., & Amris, Amris, & L., Hearn, C., D. C. A. Williams, E., Baird, Amris, K., & Jansen, G. B. (2019). Chronic pain as a Chronic (2019). B. G. & Jansen, K., Amris, https://europeanpainfederation. 13. no. Factsheet Understanding (2009). J. & Katz, G., Asmundson, M. Powers, N., Morina, L., M. Davis, G., J. A-Tjak, the patients that received an unknown type an unknown received that patients the Ibrahim Dr. to Director Finally, of treatment. Esam Arqel and Head of Field Operations, Albarahmeh of Noor al Hussein Foundation, for IFH Jordan, Health, Institute of Family their continuous support. References Multidisciplinary (2015). biopsychosocial H. Abbey, and meta-analysis. review Cochrane systematic tion and implementation in the MENA region. region. MENA the in implementation and tion in the implementation An additional ambition with collaborations phase is also to explore faculties region. MENA the in physiotherapy for future train This will secure sustainability ings in the region and further contextualiza tion. Acknowledgements: contributionfor their ing physiotherapists of the Pain throughout the development also to Acknowledgements manual. School ings will, expectedly, be conducted in Arabic in be conducted expectedly, ings will, by local physiotherapists. Sorani, and Kurdish ------Phase III should contain trainings of an ad an expected larger sample size. The 2021 train an expected larger sample size. region, with participants from Tunisia, Jordan, Jordan, Tunisia, with participantsregion, from collection on Data Iraq and Iraq. Kurdistan in 2021 with effects will be gathered treatment stress conditions in refugee populations in the stress conditions in refugee populations MENA region. the in groups of physiotherapists two ditional receiving treatment as usual. 6) Conduct a as usual. receiving treatment of baseline study assessing the prevalence coexisting persistent pain and post-traumatic through interviews. 4) Further4) interviews. through and review 5) Compare manual. enhance the treatment groupa control with treatment School Pain on trauma and persistent pain, such as PTSD, such as PTSD, on trauma and persistent pain, patients’ 3) Evaluate anxiety and depression. effects and tolerability treatment subjective the treatment response differsresponse the treatment when it is deliv Add mental ered individually or in a group 2) measures outcomes indicating health-related phase III is planned, in addition to collecting phase III is planned, 1) Iden to include: in a larger sample, data of socio-demographics might tification that predictors and if outcome show in treatment Phase III and IV: Evaluation and Evaluation Phase III and IV: Implementation a future Based on the results of this paper, ment for pain and trauma-affected popula ment for pain and trauma-affected tions in the MENAregion. sion on the training programsion on the training nor treatment study is a first this step Nevertheless, effects. treat to offer evidence-based standardized missing. The pre- to post- treatment evalua The pre- to post- treatment missing. of an indication School also gave tion of Pain Due to the limita effects. treatment positive a final conclu the results do not provide tions, otherapists. Monitoring and evaluation of Monitoring and evaluation otherapists. indications but found useful, was treatment to be evaluated were of mental health status Conclusion good feasibility and high This study showed the participatingacceptance among physi SPECIAL SECTION: PHYSIOTHERAPY FOR TORTURE SURVIVORS (2) SURVIVORS TORTURE FOR PHYSIOTHERAPY SECTION: SPECIAL 58 TORTURE Volume 30, Number 3, 2020 Boakye, P.A., Olechowski, C., Rashiq, S., Verrier, Blaauwendraat, C., Berg, A. L., &Gyllensten, A. Craig, P., Dieppe, P., Macintyre,S., Michie,S., Cleeland, C. S., &Ryan, K. M. (1994). Pain Cleeland, C. S. (1991). Pain Brief Inventory, BPI Chipchase, L., Sheffied, D., &Hill, P. (2012). The Buhman, C., Mortensen, E. L., Lundstrøm, S., Brennstuhl, M. J., Tarquinio, C., &Motel, S. (2014). Bravo, C., Skjaerven, L. H., Espart, A., Sein-

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recommandations. J Psychosom , Qualitative 85 The increasing (3), 317-332. J Pain, 5 PloS . E). https:// (2), 133- Zhenggang, B., Shiga, L., Luyao, Z., Sijie, W., & World Medical Association (WMA). (2013). Williams, A. C., & Alayarian, A. S. (2019) Declaration ofHelsinki: for EthicalPrinciples Assessment%20RUS.pdf a%20Consequence%20of%20Torture%20 Sheets/12%20Chronic%20Pain%20as%20 production/public/2019GlobalYear/Fact_ s3.amazonaws.com/rdcms-iasp/files/ pain inthemostvulnerable. Assessment. 2019. Globalyear against Chronic painasaconsequenceof Torture: org/10.1016/j.jad.2019.90.040 Affective Disorders systematic reviewandmeta-analysis. Therapy (ACT) toreducedepression: A Iris, C. (2020). Acceptance andCommitment involving-human-subjects/ helsinki-ethical-principles-for-medical-research- wma.net/policies-post/wma-declaration-of- Ferney-Voltaire, France. (2013). https://www. Medical ResearchInvolving HumanSubjects. , 260 (1), 728-737. https://doi. IASP . http:// Journal of Journal TORTURE Volume 30, Number 3, 2020 61 - - - - , Sarah , Aicha 3 7 and Joost 1 , Michel 2 , Ilona Fricker 1 , Nika Leskovsek 6 , Line M. Giusti 10 HAN University of Applied Sciences, Nijmegen, Nijmegen, Sciences, Applied of HAN University Alma Mater University, Maribor, Slovenia Maribor, University, Alma Mater Beirut, International Committee of Red Cross, Lebanon Ireland Dublin, College Dublin, Trinity Sweden Stockholm, Karolinska Institutet, USA Durham, Duke University, United Kingdom Physiopedia, The Netherlands , Kjersti Wilhelmsen , Kjersti ) ) ) 12 ) ) ) 11 12 13) refugees, we needed to gather and combine and needed to gather we refugees, experiences and expertisethe initial outside project group in consisting of educational care stitutions and the mainstream health and Equity in health is a challenge, system. groups that our society within are several there the health care servicedo not receive they that Refugees need and to which they are entitled. 7 8 9 10 and opinions on how such a collaboration a collaboration such and opinions on how will We competence. can be used for building are central for physiother discuss topics that and with victims of torture, apists working are the believe we will discuss what we finally, importantto within physiotherapy next steps be able to support this group. Collaboration for competence building 2018) started The PREP project (PREP, in order with an important acknowledgment; with to supportwho work physiotherapists interest to join us in this network. In this per interest to join us in this network. our thoughts to share want we paper, spective , Esra Alagöz ------5 , Djenana Jalovcic 2 , Anna Pettersson 9 , Rachael Lowe , Rachael 9 , Rolf Vårdal , William Hale 1 4 13 10.7146/torture.v30i3.121793 , Emer McGowan , Carina Boström 8 , Patricia Rocca , Patricia 1,11 3 Center for Victims of Torture, St Paul, St Paul, Torture, Victims of Center for Centre for Red Cross Rehabilitation Swedish Western Norway University of Applied Sciences, Applied Sciences, University of Norway Western Centre for migration health, Bergen municipality, Minnesota, USA Minnesota, Malmö, and torture, refugees affected by war Sweden United Birmingham, University of Birmingham, Kingdom Gaziantep, Association, Independent Doctors Turkey Bergen, Norway. Correspondence to: mana@hvl. Correspondence to: Norway. Bergen, no. Norway Bergen, ) ) 6 5 3) 4) 1) 2) van Wijchen Peters Benyaich Landry International Rehabilitation Council for Torture Victims. All rights reserved. Victims. Torture International Council for Rehabilitation https://doi.org/ nicians can meet, discuss, and learn from each discuss, nicians can meet, everyone who shares our welcome We other. physiotherapists worldwide. A central aim of worldwide. physiotherapists of a in PREP has been the creation the work students and cli in which educators, network to define competencies that physiotherapists physiotherapists to define competencies that Based on this, with refugees. need in working for made a course openly available have we searchers, educators, students, and clini students, educators, searchers, cians within institutions of higher education, health serviceshumanitarian and organisa together in this project worked have tions, otherapy and Refugees Education Project, Project, Education Refugees and otherapy project within funded an Erasmus+ PREP, KA2 strategicthe partnership Re program. Dear Editor for this opportunityThank you to share per within the Physi from our work spectives survivors of torture survivors Alme Maria Nordheim Collaborative effort to increase the physi increase to effort Collaborative of rehabilitation competence in otherapist’s PERSPECTIVES 62 TORTURE Volume 30, Number 3, 2020 sound knowledge frame concerning needed sound knowledge frame concerning of solving complex problems. In this way, a and worksations out effective can learn ways spaces wherehealthprofessionsandorgani tional institutionscanalsoprovide learning the competencetowork inclusively. Educa responsibility toeducate candidates whohave in healthcare, educational institutionshave a care system. To managetoreduceinequality cases shouldbetheroleofofficialhealth these populations,porting althoughitinmany rolesinsup ian organisations play important constitute oneofthesegroups. Humanitar meet thiscompetence need. to better within educational andhealthsectors topic andtocreate networks forcollaboration see theneedofraisingawareness aboutthis full, this topic has been left out. We therefore in an which educational is already program considered relevant forphysiotherapists, and many mightnothave countries, torture been is, oftorture sofar, missing.for survivors In ofphysiotherapeuticscription rehabilitation edge. Further, a well-defined and accepted de might nothave or relevant knowl experience awareness oftheproblemandacademicstaff erage ofthistopic. There mightbealackof ulate aboutthereasonsforlackofcov of torture” those withphysical effects andpsychological treatment ofvulnerablepopulations including forthe shouldincludeprinciples programmes level andcontinuingprofessionaldevelopment lum forprofessionalphysical therapistentry apy’s Torture Policy statement: The curricu 2020). This isdespitethe World Physiother (McGowanphysiotherapy et al., curricula topics that arenotsufficientlyaddressedin are oftorture itation forsurvivors strategies andrehabil health consequencesoftorture andimplemented. described competences forphysiotherapists couldbe During ourwork,During we have seenthat

(WP, 2011); Onecanonlyspec ------ics andneeds. tocreate aspace Italsoserves to beinclusive ofmany sectors, demograph This collaborative contentcreation hasproved on aneutralandopenlyaccessibleplatform. Content Development Projectishostedonline refugee health(Physiopedia, 2020). The knowledge inrelation tophysiotherapy and incommunicating needsandsharing holders stake tablished asaroutetoengagevarious PREP ContentDevelopment Projectwas es equity inhealthcare. just ofbenefit, but areessentialtoprovide 2019). like this are therefore not Partnerships habilitation, andphysiotherapy (Blessinger, health,future researchareasinmigration re education.this during Collaboration enables field, andtheyhave askedformorefocuson their healthprofessionalsspecificallyinthis organisations have identified the need to train competences that areneeded. Humanitarian onthe andup-to-date information rience educational institutionswithvaluable expe decision.gic Such collaborations can provide inaprojectlikePREPisstrate engaging ian organisations, andlocalpracticefields, important forphysiotherapists workingimportant with of physiotherapy practicethat we argueare raise awareness offive closelyrelated aspects in thiscontext. As aconsortium, we want to should,otherapy interventions orcouldbe, of perspectives and views on what physi and withinphysiotherapy thereisavariety oftorture, proaches forworking withsurvivors Physiotherapy isoneofseveral differentap torture Physiotherapy inrehabilitation ofvictims the course. worldwide have tocontentfor contributed knowledge. Inthisproject, physiotherapists toshare feelcomfortable where stakeholders For educational institutions, humanitar To accomplishaclosecollaboration, the PERSPECTIVES ------TORTURE Volume 30, Number 3, 2020 63 - - - - - An importantAn pain element of treating many cases, go unpunished. This adds to the go unpunished. cases, many appear to needs physiotherapist The burden. of a relationship human and build as a fellow require additional measures and use of a more require additional measures and use of a holistic approach. torture of of victims rehabilitation the in is the individual as to be able to acknowledge some suffered has that someone person; a is illegal under internationalthing that law in For of their human rights. and a violation it experiencewho dividuals violations, such work, impact on education, negative can have and activity of any relationships, family life, the person must suffer the In addition, kind. in while the perpetrators will, consequences, Physiotherapists are equipped with a toolbox toolbox a with equipped are Physiotherapists is a frequent result Pain with pain. for working tortureof psy to connected commonly is and chological 2000; discomfortal., (Thomsen et There is not one single 2010). Williams et al., can address the pain that method available and discomfort can be experienced that by A broad persons background. with a traumatic and contextual understanding of concepts of et al., pain are therefore paramount (Gamble opportuThe aim must be to create 2020). which might nities to change for the better, of the physiotherapist is to help their patients their patients is to help of the physiotherapist potential. their movement to use and develop to gain trust the patient they help In this way, varietya using done be can This body. the in methods adjusted of strategies treatment and to guideis point key The needs. individual to sensations, into how clients to gain insights experi from traumatic feelings and images ences are interrelated and affect the body. should be one of the main Empowerment goals of rehabilitation. management Pain al., 2019; Nyboe et al., 2017; Stade et al., Stade et al., 2017; Nyboe et al., 2019; al., The role 1991). Thornquist & Bunkan, 2015; ------advo ; body aware (Nilsson et ; pain management ; trauma-sensitive care trauma-sensitive These are: These are: ​ a conflicting inner state regulate, with the body and mistrust in activity perfor importantOne part mance. recoveryof to is or to deal with, learn to use movements how recognize physical experiences or sensations, experiences sensations, or physical recognize This can to understand needs and emotions. and to lead to an inability to trust the body, dissatisfaction body image, negative a develop trauma results in alterations of the body ego trauma results in alterations Loss of of an individual. or body awareness means loss of the ability to body awareness previous experiences, beliefs and thoughts experiences, previous cultural and envi within their unique social, and Torture 2011). (WP, context ronmental that physical and psychological dysfunc physical that tion is a response of the whole individual. This emotions, includes body structures, Physiotherapists work according to a view work Physiotherapists entity. indivisible an is being human the that recognizes “body and mind approach” The the quality of life of traumatised refugees the quality of life of traumatised 2015). Reeves, 2008; (Bath, and empowerment Body awareness health care strategies the psycho directed at as rigorous as well logical health, and physical control of risk to improve are likely factors, of what is at risk for the individual. As part of risk is at of what for the individual. trauma-focused thera care, trauma- sensitive Integrated an important pies can play role. care is not considered a method but a way of a way but a method not considered care is understanding and complex a health situation This includes an understanding health needs. Physiotherapists are trained to work with to work are trained Physiotherapists and trauma-sensitive various forms of trauma, care is an important part refu with of working Trauma-sensitive and torturegees survivors. cacy and self-care for the physiotherapist. the physiotherapist. cacy and self-care for care Trauma-sensitive survivors torture. of ness and empowerment PERSPECTIVES 64 TORTURE Volume 30, Number 3, 2020 been recognisedasakeycomponentofphysi ties, populations, andtheprofession.” Ithas well-being ofindividualpatients, communi topromotethehealthand and expertise “responsibly usingphysiotherapy knowledge Advocacy Advocacy session tothenext. improvements may notbevisiblefromone willingness tolisten, andmeansacceptingthat This requirespresence, time, andcapacity inwhichshameandguiltisnotapart. trust assist them to access the services theyneed.assist themto access theservices the physiotherapist as anidealadvocate to built throughthetherapeuticallianceplaces andprofessionals.range ofservices The trust 2012; Razavi etal., 2011). 2017; Khan& Amatya, 2017; Lindsay etal., how resourcesarefunded (Brzoska&Razum, system, thenature oftherapiesavailable and theorganisation ofthehealthcare derstand otherapists should betoassistrefugees to un rehabilitation). Therefore, akeyroleofphysi (e.g.able or how to access specific services tion, many avail are unaware of the services affect theaccessibilityofhealthcare. Inaddi gate foreignhealth systems, that areallfactors how tonaviand challengesinunderstanding communication, stereotyping, culturalissues, in their host countries.services Difficulties in manygees canface challengesaccessinghealth may impact their health and well-being. Refu inrelation toissuesthat support, particularly vocate forthemselves toobtainresourcesand of housing. They canalsohelprefugeestoad to health care, freedom to work or provision onissuessuchasaccess and asylumseekers apists canadvocate ofrefugees fortherights et al., 2020; Kellandetal., 2014). Physiother physiotherapy education orpractice(Bessette otherapy but isstillnot well into incorporated Survivors of torture may needtoaccessa oftorture Survivors

withinphysiotherapy isdefinedas, ------care professionalfeelingpowerless andunable ceived ashuman, anditcan leave thehealth foundation ofwhatcan rockthevery isper degrees.health care professional to various It Working affects the withtraumatised persons the burden of their clients’ testimoniesalone. for thephysiotherapist tonothave tocarry professional orpeercounsellingisimportant shouldbeconsidered.care providers Having Therefore, thehealthandwell-being ofhealth oftorture” canbeadifficultexperience.face us allindifferentways. Meetingthe “ugly affects Exposure to unknown experiences Self-care for thephysiotherapists these populations. specificto help addressthehealthconcerns health systemandnetwork ofconnectionsto their professionalexpertise, knowledge ofthe as advocates sothat theycaneffectively use should develop their competence of torture who are working with refugees and survivors & Amatya, 2017) . However, physiotherapists & Verma, 2008; Kellandetal., 2014; Khan lost among competingresponsibilities (Flynn fessionals, theroleofhealthadvocates canbe With theheavy demandsplacedonhealthpro periences. dealing withdifficultandcomplex humanex ness tothisdiscussioncanhelp thetherapists these topicstheattention theydeserve. Open of the health care giver,superiority would give “patient,” to manifest the as it can contribute the “receiver,” andeven challengetheterm and lookpastthesettingof “helper” and To discuss thenature ofthisrelationship ship where compassion can be a natural part. mightdevelop;trust aprofessionalrelation might takedifferentroads. A relationship of therapysessions pist andthepatient during to help. What happensbetween thethera PERSPECTIVES ------TORTURE Volume 30, Number 3, 2020 65 - - - -

Journal

(1), 74-80. 74-80. (1), (3), 17. 17. (3), (2), 58-76. 58-76. (2),

(5), 299. 299. (5),

Medical https://www. (5), 378-384. https:// 378-384. (5), . (3), 305-312. https://doi. 305-312. (3), Torture Journal, 30 Journal, Torture Die Rehabilitation, 56 Die Rehabilitation, 10.7146/torture.v30i2.119199 10.3138/ptc.2013-05 10.1055/s-0043-100014 Physiotherapy Canada, 66 Canada, Physiotherapy (7), e178-e183. https://doi. e178-e183. (7), Patrickblessinger.com 10.2340/16501977-2223 Reclaiming Children and Youth, 17 Youth, Reclaiming Children and 10.1080/01421590802139757 Iraq: A pilot study. A pilot study. Iraq: https://doi.org/ Excelling (2014). A. S. & Nixon, A., Andreoli, study a qualitative in the role of advocate: exploring as an essential physiotherapy advocacy competency. https://doi.org/ challenges and response. rehabilitation: 49 Medicine, of Rehabilitation doi.org/ care. care. advocacy and assessing Teaching (2020). C. programmes. in Canadian physiotherapy 72 Canada, Physiotherapy org/10.3138/ptc-2019-0013 for a better higher education Towards society. patrickblessinger.com/towards-higher-education- for-a-better-civil-society/ Care in Medical of Diversity-Sensitive Rehabilitation. https://doi.org/ components of a curriculum for residents in health advocacy. 30 Teacher, org/ a combined The effects of (2020). J. Hartman, group psychotherapy and physiotherapy programtreatment for survivors of torture in an adult prisonincarcerated in Kurdistan, Kelland, K., Hoe, E., McGuire, M. J., Yu, J., J., Yu, J., M. McGuire, E., Hoe, K., Kelland, Bessette, J., Généreux, M., Thomas, A., & Camden, & Camden, A., Thomas, M., Généreux, J., Bessette, Gamble, A., Ahmed, A. M. A., Rahim, S. H., & H., S. Rahim, A., M. A. Ahmed, A., Gamble, Refugee health and (2017). B. Amatya, & F., Khan, Blessinger, P., Sengupta, E., Mahoney, C. (2019). (2019). C. Mahoney, E., Sengupta, P., Blessinger, Challenges (2017). O. & Razum, P., Brzoska, Fundamental (2008). S. Verma, & L., Flynn, ously: 1) Further explore the experiences, ously: strat rehabilitation challenges and successful egies and survivors for refugees 2) torture. of into programsImplementation and curricula of 3) Continuation institutions. educational at multi between the dialogue and co-creation and most of all institutions, ple organisations, survivorsensure ongoing devel to of torture, opment. References pillars three The trauma-informedof (2008). H. Bath, suggest a future focus on three importantfuture focus on three suggest a simultane can be implemented steps that ------We strongly argue for an update of en strongly argue for an update We for physiotherapy for survivors of torture. We We for survivorsfor physiotherapy of torture. continuing along the pathway begun in PREP. begun in PREP. continuing along the pathway a more de Building upon the PREP work, be created may tailed competence framework health care professionals providing health health care professionals providing shared have We services for torture survivors. consider are key elements for physi we what suggest and we otherapists in this regard, a natural role. There is, however, a lack of an of lack a however, is, There role. natural a understanding concerningoverarching re and quired competencies for physiotherapists Conclusion of survivorsRehabilitation of torture is a have complex field in which physiotherapists broader perspective on health and health care on health and health care broader perspective services. raise awareness and support raise awareness physiotherapists the necessaryin building competences to a and to advocate further this field, develop topic could be included in master programs By connecting several or free-standing courses. sectors exists that and using the engagement can we hope that we in such student groups, least, it should be capable of building compe it should be capable of building least, tence in recognising the health consequences Deeper insight into this torture might have. try-level curricula physiotherapy to meet the with reha competency needed for working veryAt the torture. of of victims bilitation tegrate it in other programs they offer. The The tegrate programs it in other they offer. can advise on implementation. PREP network the five key points for physiotherapy rehabili key points for physiotherapy the five Participating presented here. have we tation stakehold and other interested organisations ers it as a stand-alone course can use in or course that is a resource for educational insti courseeducational for resource a is that and in humanitarian organisations, tutions, materialThe covers physiotherapists. dividual Next steps: towards better support of better support of towards Next steps: with physiotherapy survivors of torture digital openly available, PREP has made an PERSPECTIVES 66 TORTURE Volume 30, Number 3, 2020 Nilsson, H., Saboonchi, F., Gustavsson, C., Malm, McGowan, E., Beamish, N., Stokes, E., &Lowe, Lindsay, S., King, G., Klassen, A. F., Esses, V., & Williams, A. C. d. C., Peña, C. R., & Rice, A. S. Thornquist, E., &Bunkan, B. H. (1991). Thomsen, A. B., Eriksen, J., &Smidt-Nielsen, K. Stade, K., Skammeritz, S., Hjortkjær, C., & Reeves, E. (2015). A synthesisoftheliterature on Razavi, M. F., Falk, L., Björn, Å., & Wilhelmsson, S. PREP. (2018). Physiopedia. (2020). Nyboe, L., Bentholm, A., &Gyllensten, A. L. https://doi.org/10.7146/torture.v25i1.109507 https://doi.org/10.7146/torture.v25i1.109507 for traumatised refugees. still working.”–Basic Body Awareness Therapy body hasbeenthrough, Ifeelgoodthat itis Carlsson, J. (2015). “After allthetraumasmy 01612840.2015.1025319 Nursing, 36 care.trauma-informed org/ of PublicHealth, 39 healthcare.of long-term system: studywithrefugeesinneed aninterview (2011). oftheSwedish Experiences healthcare Project Development_Project https://www.physio-pedia.com/PREP_Content_ org/ Movement Therapies,21 and healthy controls. of traumatized refugees, Danishwar veterans, traumatic stressdisorder: A comparative study (2017). Bodilysymptomsinpatients withpost https://doi.org/ ofPsychotraumatology,Journal 10 discussions.study basedonfocusgroup activity andexercise treatment: aqualitative inphysicalrefugees’ ofparticipating experiences A., &Gottvall, M. (2019). Trauma-afflicted org/ review. physiotherapists working withrefugees: ascoping R. (2020, Sep). Corecompetencies for 10.3109/09638288.2012.667192 Rehabilitation, 34 providers.and communityservice challenges andrecommendations forhealthcare raisingachildwithdisability:families Stachel, M. (2012). Working withimmigrant (2010). oftorture: Persistent paininsurvivors psychomotor therapy? https://doi.org/ Forensic ScienceInternational, 108 (2000). survivors. Chronicpain intorture

10.1016/j.physio.2020.04.004 10.1177/1403494811399655 10.1080/08039480600790358 . HVL. Physiotherapy, 108 Physiotherapy andRefugees Education (9), 698-709. https://doi.org/ https://prosjekt.hvl.no/prep/ 10.1080/20008198.2019.1699327 10.1016/S0379-0738(99)00209-1 (23), 2007-2017. https://doi.org/ Content Development Project (3), 319-325. https://doi. NorwegianUniversityPress. Journal ofBodyworkJournal and (3), 523-527. https://doi. Issues inMentalHealth , 10-21. https://doi.

Torture, 25 Scandinavian Journal Scandinavian Journal (1), 1699327. (3), 155-163.

Disability and (1), 33-50. What is 10.3109/ European .

World Physiotherapy. (2011). physio/policy/ps-descriptionPT ofPhysical Description Therapy org/ Management, 40 study.a cohort 10.1016/j.jpainsymman.2010.02.018 Journal ofPainJournal andSymptom (5), 715-722. Policy Statement: PERSPECTIVES .

https://doi. https://world.

TORTURE Volume 30, Number 3, 2020 67 ------refoule (HTQ) Violence per 3 when attempting to cross when attempting Conclusions:

: 98.14% reported experienc: Results Harvard Trauma HarvardQuestionnaire Trauma (push-backs) post-traumatic stress disorder. Guaranteeing stress disorder. post-traumatic human rights for migrants/refugees through out their journey is needed. (PTSD) due to the cumulative effect of trau (PTSD) due to the cumulative found were Differences experiences. matic experiencesonly in the amount of traumatic economic migrants whobetween and refugees No differ fled for political or religious reasons. found in tortureences were experiences and PTSD diagnosis. by securitypetrated forces against migrants Migrants is crystallized the border-zones. at by amount would that held in conditions are experiences Traumatic to torture. themselves mental an effect on migrants/refugees’ have health and can trigger of the development was adapted to collect traumatic and torture to collect traumatic adapted was stressors experienced by the migrants/refugees and more Bosnia, Western during in their stay specifically during and their detention ment and Bosnia-Herzegovina the border between Croatia. ing multiple forms 81.5% reported of torture, stated 70.4% and propertytheir having looted, harmed had been physically they that during migratory 50% of participants fulfilled transit. the criteria stress disorder for post-traumatic 26 were self-declared economic migrants26 were they fled due to political that and 28 stated The Iraqi version or religious persecution. of the - - - - and Antonio L. Manzanero and Antonio 2 - : 54 partici :

Method , Steven Byrne

1 antonio.manzanero@psi.

10.7146/torture.v30i3.120232 : The number of people being : torture suffered in their country of origin. Migrantsduringrefugees and their transit through Europe are submit and of ill-treatment ted to situations torture of the add to the burden that Marta Guarch-Rubio (Lecturer Assistant, Assistant, Marta (Lecturer Guarch-Rubio of University ByrneSteven Researcher, (PhD Universidad (Professor, Manzanero Antonio L. Correspondence to: [email protected] to: Limerick (Ireland)). [email protected] Correspondence to: Compultense de Madrid Correspondence to: ucm.es University of Limerick (Ireland)). Key points of interest • 3) 1) 2) and at the gates of Europe. of Europe. the gates and at and 3 females, 51 males assessed, pants were migrants and refugees have not ceased arrivmigrants and refugees have societies despite facing violence Western ing in and torture both throughout their journey, rizedmade effortsenforcement border have The Euro migration a dangerous endeavour. pean Union is externalizing but its borders, Abstract Introduction forcefully displaced is increasing and milita International Rehabilitation Council for Torture Victims. All rights reserved. Victims. Torture International Council for Rehabilitation https://doi.org/ Union through the Western Balkans the Union through Guarch-Rubio Marta Violence and torture against migrants and migrants against and torture Violence the European to reach attempting refugees SCIENTIFIC ARTICLE SCIENTIFIC 68 TORTURE Volume 30, Number 3, 2020 Some have beatings, experienced sexualvio 2018; et al., Infante 2012; Koning, 2019). al., 2017; Crepetetal., 2017; Farhat etal., and at theborder crossing(Arsenijevi vulnerability theysufferbothalongthetrip hasbeguntoshinealightonthe countries tohost migrants’ during journeys rienced of displacementandrelated violenceexpe Increased coverage effects oftheharmful Introduction stress disorder, border, torture Keywords: criticized forattaching negativecriticized connotations age of the so-called crisis”“migrant has been threat to the nation state. Accordingly, cover inward migration, oftenpresenting itasa Pepe, & Vigliaroni, 2019). Reques etal., 2019)orinNiger (Veronese, al., 2012), inLibya (Be etthe UnitedStates andMexico(Infante world, forexampleat theborderbetween canbefoundaroundthe against migrants ity assessmentsofallegations. processesandcredibil interview appropriate system, detentions, delays in procedures, in lack ofaccess to thelegalandhealthcare may takeplace(Pérez-Sales, 2018), suchas process, manyviolations otherhuman rights agents andothermigrants. theasylum During areoftensmugglers,petrators police/border difficult todetect(Silva etal., 2018). The per quent. However, someoftheseincidencesare violations arefre and detentions at borders napping, extortion, trafficking, humanrights tection. process, themigration During kid pro the asylum process and in humanitarian country, process, the migration during during intheirhome evidence ofmigrants’ torture Sales (2018)pointsout, thereissignificant lence, and forced detention. torture As Pérez- Examples of human rights violationsExamples ofhumanrights In Europe, whooppose thereareactors migrant, trauma, post-traumatic ş er &Elfeitori, 2018; ć et ------EU’s external borders is a primary method EU’s isa primary borders external by state authorities. Systematic violence at the aviolent eventees experienced perpetrated through Serbia. Oneoutofthreeinterview crossing of protectionformigrants/refugees (11%).(24%) andkidnapping/torture ofdeathat (29%), risk detention/kidnapping finding themselves inasituation ofcombat or The most frequent events were experienced traumatic eventsrienced alongtheirjourney. (89%) expe migrants/refugees cently arrived al. (2017)foundthat alargepercentageofre oforigin.InItaly,ing thecountry Crepetet todepart prior experiences to alreadyharmful ence newpotentiallytraumatic events that add journey, experi migratory migrants/refugees 82.3%) and Turkey (7.8-59.3%). Along the bypoliceinbothGreece(33.3- perpetrated were subjectedtowas beatings, whichwere Greece, the main type of violence that refugees journey, finding that, whilst they were in theirugees’ ofviolenceduring experiences Farhat etal. ref (2018)examined728Syrian phenomena(Karamanidou, 2016).migratory focusing oncountries’ managementofthe to theterms dangers and risks formigrants. andrisks dangers but itremainsreplete with itsown initself, Sea lished alternative to the Mediterranean instance, isnow anestab theBalkancorridor transit. during experience Forlence migrants thetypology ofvio of theroutedetermine andthecharacteristics oforigin The country by motorvehicle (El-Shaarawi &Razsa, 2019). onfootor continuethe trip migrants/refugees Europe, therearealsolandroutesonwhich into remains thedominantpath formigrants route that theCentralMediterranean the fact Network,lence Monitoring 2020). Despite and aidingcollective expulsion(Border Vio of “gatekeeping” protection in international Arsenijevi migrant ć etal. (2017)denouncedalack SCIENTIFIC ARTICLE and refugee, rather than ------TORTURE Volume 30, Number 3, 2020 69 ------In the present project, the initial goals were the initial goals were In the present project, Bosnia-Herzegovina stands out as a transit Bosnia-Herzegovina suffered by the migrants/refugees, and con suffered by the migrants/refugees, However, sequently the presence of PTSD. a large observationthroughout field, in the govina represents an auspicious place for re represents an auspicious govina migrants search into how to are subjected violence or bodily trauma when attempting Violence Border the During 2019, EU. enter to recorded 3,251 (2020) MonitoringNetwork to Bosnia-Herzegov pushbacks from Croatia Moreover, Turkey. and from Greece to ina, of the documentation there is little quantitative of violence among these migrants, prevalence their period their experiences on the border, of transit or time spend in detention centres. and torture the traumatic to evaluate events provide neither adequate protection nor living neither adequate provide conditions for migrants Interna (Amnesty that locations the addition, In 2019). tional house migrants a concen frequently contain per of conditions on based violence of tration of which the quantification insecurity, vasive this, Given is almost impossible to manage. by virtue of of the complexity and volatility the patterns as the diver of mobility as well sity of experiences and itineraries of those who the at the situation arrived the border, at have and Bosnian-Herze Croatia border between 2200 per month. Most of them were located located Most of them were 2200 per month. Croatian Western and close to the in Sarajevo 2020). border (UNHCR, reported migrants/refugeescountry; have in other destination they intend to settle that (18%), France countries as Italy (27%), such Germanyothers (14%) and (41%) (IOM, along Limited capacity and resources, 2020). institutional and stalemate political the with has paralyzed the countrydysfunction that mean that in 1995, since the end of the war ill-prepared to has been Bosnia-Herzegovina 2018 to December 2019, 53263 refugees/mi 53263 2019, 2018 to December grants arrived - over in Bosnia-Herzegovina ------

Following the definition of torture definition the by the Following Violent deterrence is not exclusively per deterrenceViolent exclusively not is ternational, 2019; Meçe, 2018). From January 2018). Meçe, 2019; ternational, and Slovenia fortifying the so- and Slovenia its borders, emerged as one of the “Balkans route” called steps before arriving in the EU (Amnesty In Bosnia-Herzegovina and Croatia Bosnia-Herzegovina Bosnia-Herzegovina recently, Until relatively migrationestablished any of outside was Hungary with however, 2015, Since route. on mental health as PTSD. on mental health as PTSD. Current the border crossing between at situation govina. It also shows traumatic events as ex events traumatic It also shows govina. periencedmigrantsby during migratorythe in their home country and its impact journey, economic migrantseconomic duringrefugees and their period on the EU´s of transit and detention and Bosnia-Herze Croatia bordersbetween United Nations Convention against Torture Torture against Convention United Nations the present paper examines 1984), (UNCAT, violent and torture as experiencedby events to potentially traumatic events, time since events, to potentially traumatic of residency level and assessed status conflict, 2009). political terror (Steel et al., ability observed studies is across the different as due to a type of numerous factors, such exposure cumulative and of number torture, Steel et al.’s (2009) meta-analysis of 161 arti Steel et al.’s cles (181 surveys) reported of 30.6% for rates The vari PTSD and 30.8% for depression. Several studies have reportedthe effects of studies have Several and political violence on exposure to war in different countries. the civilian population (Holmes & Casteñada, 2016). 2016). (Holmes & Casteñada, of violence on migrantsPsychological effects and refugees migrants and refugees globally. In addition, In addition, migrantsrefugees globally. and second-countrybecoming less recep hosts are persons displaced toward hostile, or even tive, petrated throughout Europe; it also seems it also seems throughout Europe; petrated to discourage to be a wide buffering strategy SCIENTIFIC ARTICLE SCIENTIFIC 70 TORTURE Volume 30, Number 3, 2020 two pointsonthe Western Balkanroute. on thetowns ofBiha mentioned border. To achieve this, we focused alongtheafore treatment they experienced on theviolenceandinhumandegrading search goalswere thereforeadapted, focusing occurred, theyhad “lost thegame.” The re and clothes). Intheirown words, whenthis money andotheritemssuchasbags, glasses (mobile phones,and without their property Croatia. woundedThey usuallyreturned back illegallytoBosnia-Herzegovina from number ofpeoplewere detectedbeingpushed in Biha ered “on themove” astheywere intransit andwere migrants/refugees consid irregular sample.as anopportunistic All were deemed freelyintheresearch,if theywould takepart population ofthemigrant by askingmembers and Velika Kladuša. The samplewas obtained livinginBiha bymigrants as chainreferrals fromlocalNGOsand (2)snowball referrals 4.72). intwoThey were ways: recruited (1) between ( 17and41years males (94.4%)and3females, ofagesranging were assessed,Fifty-four participants 51 Participants Method services.to various tion duetoovercrowding access andrestricted couldaccesssuitableaccommoda migrants that hostmigrants.barracks However, notall both theselocations, therewere institutional (Amnesty poverty International, 2019). In fleeing conflict,migrants and persecution refugeforbetween 5000and5500 temporary nia-Herzegovina, both towns had become a ofBos border withCroatia inthenorthwest (Milan,and Hungary 2019). Located on the passing throughtheformer Yugoslav States This path extendsfrom Turkey toGreece, ć and Velika Kladuša (Bosnia-Her ć and Velika Kladuša, M =26.15; SD = ć ------

nostic andStatistical ManualofMental Disor measure PTSD symptomsaccordingtoDiag bit, 4=extremely). 16itemsaimto The first scale (1=notat all, 2=alittle, 3=quite a sity ofthesymptomsona4-point Likert-type 44 itemsthat evaluate the severityorinten the symptomsoftraumaand is composedof threatened?” to illhealth?” or “Were you humiliated and “Were conditionsleading you exposedtodirty sectionoftheHTQ;the torture forexample, binary “yes/no”the thirty-five questionsfrom Consequently, themainbodyofthisresearch orhumansmugglers.trated byothermigrants or perpe other stages of their journey during refugees sufferedintheirhomecountry, that migrants/ study includesthosestressors cally designed for this study were applied. The Mollica, 2007)andaquestionnairespecifi the Iraqipopulation (Shoeb, Weinstein, & Questionnaire The Arabic versionofthe andprocedure Instruments order toavoid Sea. crossingtheMediterranean of hadchosentheBalkanroutein North Africa from the mentioned that all migrants/refugees had “lost thegame their own words, thenumberoftimesthey number of attempts to cross the border; in to Bosnia-Herzegovina asthe was understood from Croatia considered as illegal deportations that takeplacethere.deportations) to thenumberofviolentpushbacks(unofficial “hot spots” inthe Western Balkanroute, due afforded tothem. These two towns aretwo EU, regardless oftheofficialpoliticalstatus zegovina) andwaiting totravelinto further perpetrated on the external EUborders. ontheexternal perpetrated focuses onthepresenceoftraumatic events In thisstudy, the number of pushbacks The fourth sectionoftheHTQmeasures The fourth For ofthisresearch, thepurposes we used (henceforth HTQ)adaptedfor (henceforth SCIENTIFIC ARTICLE .” Finally, tobe itdeserves Harvard TraumaHarvard - - - - - TORTURE Volume 30, Number 3, 2020 71 - - 87 9.3 3.7 11.1 88.9 48.1 51.9 % 38.9 18.5 14.8 14.8 3.7 3.7 1.9 1.9 1.9 94.4 5.6 53.7 40.7 5.5 = 54). N 47 5 2 6 48 26 28 N 21 10 8 8 2 2 1 1 1 51 3 29 22 3 Questionnaires were completed orally with completed orally Questionnaires were a trauma psychologist completing the ques answers. respondent’s the with line in tionnaire for the open questions interviewees However, of writingalso had the possibility the answer interviewsThe language. another or Arabic in individually. English and in conducted were written the questionnaires were In addition, so the particArabic, in both in English and both ipants could also read the questions in languages. status etc.); cause of the migration cause or length etc.); status of the migratory journey. - - - Better life persecution and Political/religious war Western Sahara Western Male Female 18-25 26-34 ≥ 35 Single Married Divorced Ye s No Algerian Moroccan Iraqi Syrian Palestinian Tunisian Lybian Pakistan

. Socio-demographic characteristics of migrants/refugees. to survey ( Also, an adapted clinical questionnaire was was questionnaire clinical adapted an Also, Reason of migration Progeny Marital Status Age Category (Years) Sex Origin Table 1 Table used as it permitted for the collection of so marital ciodemographic characteristics (age, their own daily life. The Cronbach’s alpha of The Cronbach’s daily life. their own .939 and inter was the section in this sample .253. item correlation was tify what the authors name “refugee specific,” specific,” “refugee the authorstify what name the traumatic the impact that which evaluates perception of had on their could have events ders (4th ed.; DSM-IV; American Psychiatric DSM-IV; ders (4th ed.; 1994) criteria, with a threshold Association, quan items 28 The other higher. or 2.5 of SCIENTIFIC ARTICLE SCIENTIFIC 72 TORTURE Volume 30, Number 3, 2020 which assesses the psychological needsofref which assessesthepsychological ofalargerresearchproject This studyispart Ethical aspects share information. orto gathered toregroup here wheremigrants campsandurbanparks.ganised migrant Itwas 2019. As such, we spenttimeat NGOs, self-or were conductedbetween Julyand August context in the region.ing migration Interviews that tookintoconsideration theever-chang recruitment dynamic approachtoparticipant and further into Europe.and further Nearly all the data to getintotheEUSchengenopenborderarea border from Bosnia-Herzegovina into Croatia tocrossthe were waiting fortheopportunity are shown in Table 1. All oftheinterviewees sourcesofthe54migrants/refugees referral and characteristics The socio-demographic Results exclusions basedongenderorethnicity. was obtainedverbally. As such, therewere no reasons, consent tural andsecurity informed tions (Ibrahim&Hassan, 2017)andforcul tine RefugeesintheNearEast(UNRWA). Nations Relief and Works forPalesAgency sioner forRefugee(UNHCR)andtheUnited interest totheUnitedNations HighCommis (Spain),versity ofMadrid anddeclaredof the EthicsCommitteeofComplutenseUni ugees andasylumseekers. Itwas approved by Table 2 Number of deportations fromCroatia toBosnia-HerzegovinaNumber ofdeportations Length stay inBosnia-Herzegovina (months) (months) journey Length migratory Like other studies with migrant popula Like otherstudieswithmigrant The strategy was to have a flexible and . process. ofthemigration Characteristics ------Middle East, and Sub-Saha North Africa with peopletravelling fromCentral Asia, the withotherroutes,that thisrouteintersects This isinlinewiththeliterature, whichshows to Europe tends to be continuously evolving. movements alongthisroute,tory asthispath representativeis not necessarily of all migra 2020; UNHCR, 2020). However, thispattern do sothroughthe Western Balkanroute(IOM, seekingtoenterEurope The mostmigrants (18.5%), (14.8%). Iraq (14.8%) and Syria was (38.9%),Algeria followed by Morocco (UNHCR, 2019). should have toapplyforasylum hadtheright law of refugees, regarding therights they country. As such, accordingtointernational whendecidingtoleave theirhome ing factors asthemotivat persecution cal andreligious over citedpoliti halfoftherefugees/migrants the MiddleEastandNorth Africa. Slightly in this researchcamemainlyfromcountries elled with dependent children. in Participants wereterviewees singleandnoneofthemtrav were old. menandunder35years Mostin of the migrants/refugees and the vast majority collection was conducted in Velika Kladuša of the to this (81%) who contributed Algerians through Italy andincreasearrivals Turkey. to the traditional routes from North Africa Europeanpoliciesdivert how newmigratory & Razsa, 2019). routeshows This emerging ran (Crepetetal.,Africa 2017; El-Shaarawi From anational perspective, themajority oforigin The largestdeclaredcountry SCIENTIFIC ARTICLE 5.87 5.84 20.50 M 5.50 5.03 17.66 SD ------TORTURE Volume 30, Number 3, 2020 73

- - - - = SD SD and Velika ć and Velika Kladuša, the Kladuša, Velika and ć research because participants they that stated had occurred throughout the whole migratory The expe journeycountry. or in their home had been physically tortured had been physically or perceived Table Despite as torturethemselves victims. research this for results, the of all showing 3 selected just the three mentioned have we experiencestraumatic (in bold in the table) tes because they took place according to their timonies during their detention on the Croa regarding the item Moreover, tian border. migrantsthe of 25 added harmed,” “physically Therefore, on the head. beaten they were that included as an extra item below this item was The rest of traumatic harmed.” “physically fully described are not in this however, events, to traumatic experiences their to traumatic to associated the vast migratory In addition, experience. majority (98.14%) reported experiencing multiple forms and psychological of physical trauma during or attempted their push-back to Bosnia-Herzegovina crossing from border from the first Data section of the Croatia. 81.5% reported that HTQ revealed having they that 70.4% stated their property looted, harmed been physically had 46.3% of which they had been subjected to maintained that they claimed that 40.7% to the head. beatings = 6.23) for economic reasons, and 4.82 ( reasons, = 6.23) for economic 4.60) for political/religious reasons. experiences Traumatic life in Biha that shows The data difficulties and fraught with Kladuša was a high prevalence and there was hardships, violence and tortureof instances of both re migrants/refugeesthe for addition, In ported. resident in Biha sense of insecurity push- and the frequent All the participants clearly issues. backs were they had been subjected that (100%) stated for refugees for political/religious reasons. The for political/religiousfor refugees reasons. deportations number of 7.00 ( was average

------= SD p (1,52) = 2.155, (1,52) = 2.155, = 160.86) days days 160.86) =

F SD (1,52) = 0.326, (1,52) = 0.326, F ten times or more. According to ten times or more.

= .040. Migrants for economic = .040. 2 η = .006; nor on the number of times = .006; 2 η When the motive for migration is consid When the motive Overall, departure from the country dates Overall, = .148, = .148, = 145.93), and 163.75 ( 163.75 and 145.93), = they had been deported, they had been deported, p ( of 187.69 days an average reasons stayed there were no effects on the length of time they no effects there were Bosnia-Her on the border between had stayed and Croatia, zegovina .570, ported to Bosnia-Herzegovina. found that we ered as an influencing factor, tried to cross had the opportunity nobody their statements, de unlawfully to apply for asylum and were process or access to asylum procedures. The process or access to asylum procedures. to cross the median number of attempts also close to six and 24.07% had border was the maximum was 2 years. Finally, 48 out of 48 out Finally, years. 2 was maximum the 54 participants to cross the border attempted deported were and once least at due without median length of time in Bosnia-Herzegovina Bosnia-Herzegovina in time of length median 22.2% of the inter with 6 months, barely was spending 12 months in the country. viewees and 10 days The minimum period was of stay Table 2 shows, the median length of their mi 2 shows, Table gratoryyears journey since two to close was the However, country. their home left they 2019. However, in this study, most of the most of the in this study, However, 2019. migrants/refugees their home countries left As December 2017 and June 2019. between refugees according to their migratory status. their migratoryrefugees according to status. to June 2012 August originof from ranged was the main motivational factor in their deci the main motivational was before, mentioned as Therefore, to leave. sion had the right to have half should slightly over been considered as have apply for asylum and said that they left because of political perse they left because said that is in comparisonThis the to 75% of cution. religious that Iraqis who stated persecution study cited “a better quality of life” as their life” “a better quality of study cited In con to Europe. for travelling motivation all Syrians (100%) trast and unsurprisingly, SCIENTIFIC ARTICLE SCIENTIFIC 74 TORTURE Volume 30, Number 3, 2020 Sorted from highesttolowestSorted frequency. specificevents inBiha letters occurred Table 3 Searched Lacked shelter Disappearance ofafriend Murder orviolentdeath offriend Confined tohomebecauseofchaosandviolenceoutside Suffered illhealthwithoutaccesstomedicalcareormedicine Physically harmed Forced tofleeyour country Suffered fromlackoffoodorcleanwater looted,Property confiscated, ordestroyed Witnessed someonebeingphysically harmed Trauma Events Sexually abused orraped(i.e., forced sexualactivity) Forced todestroy someone’s property Kidnapped ortaken asahostage Forced to pay member forbullet usedtokillfamily Forced someone to physically harm fromcombat situation physical orlandmine Serious injury Used asahumanshield Family memberkidnappedortakenasahostage ordeath ofinjury Forced onsomeoneplacingthemat risk toinform member Disappearance ofafamily Witnessed massexecution ofcivilians onyou placingyou ofinjury atSomeone informed andyour risk family Witnessed sexualabuse orrape Witnessed chemicalattacks onresidentialareasormarshlands kidnappedortakenasahostage Friend Received member thebodyofafamily member Murder orviolentdeath offamily shrines ofreligious Witnessed thedesecration ordestruction basedonancestralorigin,religion, orsect Expelled fromcountry Imprisoned Tortured fromcombat memberorfriend offamily physicalSerious injury Witnessed shelling, orrazingofresidentialareas burning, Witnessed thearrest, torture, leaders orexecution ofreligious Forced toleave ofthe your hometown andsettleinadifferentpart Oppressed becauseofethnicity, religion, orsect Witnessed murder Witnessed torture Witnessed rottingcorpses Present whilesomeonesearchedforpeopleorthingsinyour home. Beatings tothehead . Trauma events( amongmigrants ć and Velika July-August2019. Kladušaduring N =54) during their migration process. theirmigration =54) during Inbold SCIENTIFIC ARTICLE 35 25 38 40 43 44 45 N 2 5 6 6 8 9 10 11 13 14 15 16 16 16 17 17 17 20 20 21 22 25 25 25 26 27 28 28 28 30 31 32 33 34 35 64.8 46.3 70.4 74.1 79.6 81.5 83.3 % 3.7 9.3 11.1 11.1 14.8 16.7 18.5 20.4 24.1 25.9 27.8 29.6 29.6 29.6 31.5 31.5 31.5 37.0 37.0 38.9 40.7 46.3 46.3 46.3 48.1 50.0 51.9 51.9 51.9 55.6 57.4 59.3 61.1 63.0 64.8 TORTURE Volume 30, Number 3, 2020 75 5.6 5.6 3.7 3.7 3.7 1.9 1.9 55.6 53.7 51.9 46.3 38.9 38.9 29.6 29.6 27.8 25.9 25.9 20.4 14.8 14.8 13.0 13.0 13.0 5.6 7.4 % 92.6 66.7 66.7 64.8 59.3 3 3 2 2 2 1 1 30 29 28 25 21 21 16 16 15 14 14 11 8 8 7 7 7 3 4 N 50 36 36 35 32 =54) during N and Velika Kladuša ( Velika and ć

. Torture experiences migrants among in Biha Torture . Other experience of torture Suspended from a rod by hands and feet for longs period of time or raped Sexually abused Stretched on a rock for long periods or corrosive acid fire, hot oil, electricallyBurned rods, heated by cigarettes, with near-drowning Head submerged in water Subjected to mock executions Blindfolded Forced to write falseForced confessions arranged or sexually explicit positions in various humiliating Forcibly photographed where you ‘yes’, If Witnessed the sexual abuse, rape or torture of someone Witnessed the sexual abuse, Electrocuted Placed in an isolation cell with no clothes, toilet or ventilation cell with no clothes, Placed in an isolation Prohibited from ablution and prayer labor Forced Placed in a sack, box or very box small place Placed in a sack, on soles of feet with rods or whips Beaten Chained or tied in front of people to undress Forced Deprived of sleep Exposed to continuous/piercing noise from urinating or defecating Prevented Forced to stand for long periods of time Forced and threatened Humiliated Exposed to dirty leading to ill health conditions sun or light Exposed to strong heat, or stricken kicked with objects slapped, Punched, Deprived of food and water for long periods for water of time Deprived of food and care Deprived of medical Torture experiences Torture Exposed to rain or cold Table 4 Table frequency. Sorted to lowest from highest 2019. July-August SCIENTIFIC ARTICLE SCIENTIFIC 76 TORTURE Volume 30, Number 3, 2020 Trauma symptoms highest tolowest scores. Table 5 among migrants inBiha among migrants Feeling irritable orhaving of Feeling outbursts irritable Difficulty concentrating Feeling exhausted upon but god Feeling that you have noonetorely events orterrifying most hurtful ofthe thoughtsormemories Recurrent Trouble sleeping ing again Feeling asthoughtheevent ishappen people Feeling detached orwithdrawn from events with thehurtful Avoiding thoughtsorfeelingsassociated beingsqueezed Sensation oftheheart what happenedtoyou Feeling don’t that others understand Feeling humiliated byyour experience trayed you Feeling that be someoneyou trusted Feeling onguard Feeling asifyou don’t have afuture tiredness, andsomatic complaints of initiative, boredom, sleepproblems, Ruminations, poorconcentration, lack Less interestindailyactivities events when remindedofthemosthurtful Sudden emotionalorphysical reaction you didbefore. Feeling that you have lessskillsthan Feeling inothers notrust event the hurtful Avoiding activitiesthat remindyou of anger . Frequencies, meanscores(M)andstandarddeviations (SD)for ć and Velika July-August2019. from Kladuša(N=54)during Sorted - - at all Not 17 18 14 15 17 10 11 14 12 18 19 16 17 16 20 21 13 19 7 8 5 Little 19 10 14 14 13 12 13 17 13 19 15 13 18 A 5 8 5 7 9 6 9 7 Quite a bit 15 14 10 12 14 12 13 11 12 12 13 14 17 12 16 19 13 14 14 11 6 SCIENTIFIC ARTICLE Extremely 20 16 22 10 15 11 13 12 15 16 12 15 14 13 15 14 17 15 16 17 9 trauma symptoms 2.76 2.76 2.78 2.26 2.31 2.37 2.39 2.39 2.39 2.43 2.43 2.44 2.46 2.46 2.52 2.54 2.56 2.56 2.63 2.65 2.69 M 1.21 0.99 1.21 1.12 1.23 1.12 1.17 1.14 1.25 1.28 1.09 1.24 1.19 1.19 1.16 1.16 0.92 1.24 1.09 1.12 1.08 SD TORTURE Volume 30, Number 3, 2020 77 SD 1.03 1.14 0.94 1.07 1.07 1.20 1.16 1.09 1.10 1.20 1.05 1.10 1.24 1.16 1.06 1.09 1.13 0.91 1.05 1.12 1.16 1.19 1.14 M 1.74 1.72 1.72 1.65 1.63 2.07 2.04 2.02 1.96 1.96 1.94 1.93 1.93 1.89 1.83 1.78 1.78 1.76 1.74 2.26 2.24 2.22 2.09 7 8 4 7 6 8 7 5 8 9 7 7 7 4 6 11 10 10 11 12 12 12 10 Extremely 2 5 6 3 6 7 7 8 7 6 6 6 5 6 8 5 6 6 8 9 7 10 13 a bit Quite 5 8 4 8 5 9 9 5 A 15 15 11 12 15 11 10 14 14 19 10 20 15 12 15 Little 36 38 32 34 26 32 30 36 29 26 29 26 26 32 30 28 16 19 21 22 25 25 23 Not at all at - - -

Feeling that you are the only one who you that Feeling suffered these events people that you have done something done something have you people that can't remember you that Hopelessness Feeling a need for revenge Feeling Finding out or being told by other Poor memoryPoor ashamed of the hurtfulFeeling or trau happened to you have that events matic problems survivedfor having guilty Feeling others are hostile to you Feeling and your familyand your Unable to feel emotions by bodily pain or physical Troubled Blaming yourself for things that have have Blaming yourself things that for happened are a jinx to yourself you that Feeling Having difficulty dealing with new situ difficulty dealing with Having ations Spending time thinking why God is Spending time thinking why events go through such making you startled easily jumpy, Feeling Difficulty paying attention Difficulty paying Inability to remember parts of the most hurtful events the other is doing to help others powerless Feeling to make daily plans unable Feeling Recurrentnightmares are split into two as though you Feeling what is watching people and one of you tience, and anger outbursts tience, a of tightness in the chest and Feeling choking sensation) Irritability, nervousness, lack of pa nervousness, Irritability, Trauma symptoms Trauma SCIENTIFIC ARTICLE SCIENTIFIC 78 TORTURE Volume 30, Number 3, 2020 Torture experiences fered anaverage of22.93( reasons suf refugees for political or religious 12.15 ( for economicreasonssufferedanaverage of p the motives tomigrate, ( range [1-36]). Effectswere foundbasedon was 17.74( suffered bymigrants The average numberoftraumatic experiences effect on mental health (Steet et al., 2009). oftraumatic eventsrience hasacumulative and thepush-back. oftimebetween theperiod thearrest during others, tookplaceunderpolicecustodyor or “subjected tomockexecutions,” between time,” insexualpositions”“photographed such as of “forced tostandforlong periods actions that involved ordeprivations orders by cigarettes. Similarly, the maintenance of two peoplewhostated that theywere burned weaponselectrical suchastasers, exceptfor having been wounded(13%) described by rods, hotoil, fireorcorrosiveacid,” allofthem bycigarettes,“burned heated electrically when theysaidthat “were electrocuted” and was attributed toborderagents. For instance, monies, by others all the violence perpetrated ill health. According tothemigrants’ testi conditionsleadingto were exposedtodirty had been withheld when required and 64.8% of time, that medical care 66.7% reported deprived offoodandwater forlongperiods border, that theyhadbeen 66.7%reported ofdetention ofthe toperiods When referring objects intheirattempt tocrosstheborder. that theyhad been punchedorslappedwith to strongheat, sunorlightand55.6%stated (92.6%), beingexposed while59.3%reported was prolonged exposuretorainand/orcold (TableThe mostcommontypeoftorture 4) <.001, SD =6.67)traumatic experiences, and η 2 =.338). motivated Migrants F SD (1,52)=26.604, =8.49). SD =9.34, - - PTSD ( wereexperiences positively associated with agnosis. The cumulative effect of traumatic forPTSDdi refugees (50%)metthecriteria According totheHTQ, 27outof54migrants/ Psychological effects of 9.43( reasonssufferedanaveragelitical orreligious experiences, andrefugeesforpo 4.59) torture reasons suffered an average of 8.58 ( η nosis ( forthediag 5.22) whofulfilledthecriteria 8.56 ( events was from PTSDthenumberoftorture disorder. As such, for those who did not suffer topredicttheaforementioned not determinant innoPTSDcondition.experiences periences, for14.19( average of21.30( diagnosedwithPTSDsufferedan Migrants motives tomigrate, ( [0-27]). Noeffectswere foundbasedonthe ences sufferedwas 9.02( This studyexamines theprevalence oftrau Discussion each symptom. shows frequenciesandtheaverage scores for more presenceoftraumasymptoms. Table 5 tively). negativeThe greater experiences, the p trauma symptoms;chological ( were relatedriences tothepresenceofpsy cution reasonswere diagnosedPTSD. economic reasons and 17 (60.71%) for perse 2.670, p=.102). Ten (36.46%)for migrants to motivation for migrate, ( <.001, and 2 =.007). motivated Migrants foreconomic The average experi number of torture The amount of trauma and torture expe The amountoftraumaandtorture was experiences The numberoftorture No significant differences were found due SD F (1,52) =0.425, F SD (1,52) =9.006, = 5.20)comparedto9.48( =5.74). r (54) =.298, SCIENTIFIC ARTICLE SD F (1,52) =0.359, =9.59)traumatic ex SD p <.01, =7.73)traumatic p SD <.01, χ 2 p (1, N = 54) = =5.19, range <.05respec r (54) = .468, η 2 η =.148). 2 =.148). p =.552, SD SD = = ------TORTURE Volume 30, Number 3, 2020 79 ------et al. (2017), our data our data (2017), et al. ć Similar to Arsenijevi reach the European Union (Arsenijevic et al., reach the European Union (Arsenijevic et al., 2018; et al., Farhat 2017; Crepet et al., 2017; to exposure Psychologically, 2019). Koning, capacities are repressed or destroyed both at at both destroyed or repressed are capacities pro The territorial the beyond and border. within the cesses of border violence operate of of contemporary“geopolitics framework is char 2012) which (Hyndman, migration” acterizedthe a global process of worsening by restrictive, conditions for migration (selective, migration policies) and punitive repressive detention and render through surveillance, ing migrants legally and economically precar the frequent violence Research e reveals ious. and torture migrants/refugees that suffer by to agents in their attempt police and border site facility. site facility. while border closures in Balkan that indicates countries with a considerable are associated also be associated they may decline in arrivals, As with an increase in violence and torture. European policies are based on politi noted, agreementscal externalizathe promote that tion of borders condemning whilst not openly Border vio the use of violence as a deterrent. includes the entire set of pro therefore, lence, and mental somatic cesses whereby migrants’ (Steel et al., 2009). The migrant population 2009). (Steel et al., almost exclusively was in both of these towns is un This single males. made up of young, surprising, also gender differences given that vul example, For migratoryaffect processes. unac such as single women, nerable people, been companied minors or families have may migration orcentres reception directed toward Guarch-Ru 2017; et al., safer areas (Crepet Bouhe instance, For 2020). bio & Manzanero, in work in their that (2017) found nia et al. authorities local frequently (France), Calais off- to a separate and children women moved tentially explain the difference in prevalence in prevalence the difference tentially explain to other populations of PTSD as compared ------

To summarise, according to the data, data, the to according summarise, To ogy (Peace & Masliuk, 2011). This can po can This 2011). & Masliuk, (Peace ogy ous studies have pointed out, given the mo the given out, pointed have studies ous a be may there protection obtain to tivation tendency to overreport PTSD symptomatol their situation (Crepet et al., 2017). More 2017). al., et (Crepet situation their how into insight an provides data this over, politically supported is violence systematic as previ However, refugees. directed toward a multitude of human rights in violations cluding inhuman and degrading treatment. a better understanding provides of The data during the trip in the EU and their stay to subjected migrants/refugees were border, reports of experiences of torture then be can occurredassumed that mostly during the trip and during the border. pushbacks at experiences suffered because they add trauma in their origin during to those suffered the trip The to enter the EU. and in their attempts ably had no traumatic and torture and no traumatic had ably experiences could results These country. home their in refugees for political/religious that indicate reasons experienced more traumatic many have been in Bosnia for roughly the same been in Bosnia for roughly the have suffered similar numbers of they have time, migrants and economic deportations, prob no differences were found between refugees found between no differences were migrantseconomic and to tortureregard with Since both experiences and PTSD diagnosis. cal and religious reasons. The latter suffered The latter cal and religious reasons. experiences traumatic almost twice as many study present the in However, former. the as agents amongst the participantsagents amongst the during July- differences in showed data The August 2019. experienced events the number of traumatic by economic migrants and refugees for politi ences were associated with PTSD. Similarly, Similarly, with PTSD. associated ences were of other violent the study found the prevalence perpetratedpolice and border by events matic events experiencedmigrants/refu by events matic gees throughout migratoryand also transit these experi and how in their home country, SCIENTIFIC ARTICLE SCIENTIFIC 80 TORTURE Volume 30, Number 3, 2020 experiencing often-ignoredhighrates ofvi experiencing constitute a vulnerable populationmigrants theargumentthat studysupport the current threatened bytheir experiences. The resultsof felthumiliated and 51.9% oftheinterviewees themselves asvictimsoftorture, althoughthis mentioned,and torture just40.7%perceived al., 2017). and refugees(Dimitry, 2012; Manzaneroet ofmentalhealth issues formigrants the risk add toprevioustraumatic events andincreases to transitserves these violentepisodesduring can beexplained bytheconditionsendured fore, here described thetraumatic experiences beingexposedtorainorcold.reported There that ahighnumberoftheir respondents also refugees, Ibrahim and Hassan (2017) found Similarly, in their work with Syrian-Kurdish thebordercrossingor push-backs.during of food and water of time, for long periods deprivation and 66.7% reported the journey exposed tostrongheat, sunorlight through food orwater. Inaddition, 59.3%hadbeen tances on foot in extreme weather with little process.tory For example, travelling longdis nature ofthemigra bythe very understood exposuretorainandcoldcouldbe ported fortheirhealth.was arisk Secondly, there conditionswhich todirty exposed migrants lacked basicamenities. also This experience into improvised accommodation centresthat that hadbeenhastilyconverted empty factories dents, at thetimeofdata collection, occupied that manyplained bythefact oftherespon for two reasons. Firstly, beex itcanpartly posure torainorcold(92.6%). This couldbe public. aswellmedical authorities asthegeneral be broughttotheattention ofpoliticaland olence (Bouhenia et al., 2017). This should The most frequent form of torture was ex oftorture The mostfrequentform However, despite the institutional violence ------research islimitedinitsabilitytomakewider this studyisthesmallsamplesize. As such, this refuge inEurope. protection tothosefleeingconflictandseeking oftheEUtoofferreal is exposingthefailure migration that thecurrent “crisis” inEurope ings echoFreedman(2016), whomaintains and fearofracism. Adding tothis, ourfind issues detection, transport languagebarriers, care, oftenduetoobstaclessuchasfearof duetopooraccesshealth lems inmigrants (France) whofoundaggravated healthprob ducted byBouheniaet al. (2017)inCalais zegovina. This issimilartotheresearchcon of accesstomedicalhealthcareinBosnia-Her this, alack 66.7%oftherespondentsreported bymigrants.ination experienced Relating to tematic andorganised elementtothediscrim Data thereisasys suggeststhat inthisregion existed(UnitedNations,alternatives 2018). were closetocapacityandlimitedsustainable where centresat thetimeofdata collection isstrained, intheregion influx ofmigrants stitutional violence. processandalsoby in themigratory during of violence across settings, to identify potential as well aspotentialmechanisms andpredictors issues,Future researchshouldassess reporting was conductEDbeyond applying theHTQ. that examination nomedicalnorpsychiatric more vulnerated. Finally, the last obstacle is are andwhofeelthat theirrights experiences are morewillingtotalkabouttheirtraumatic samplelikelywithpeoplewho opportunistic an overestimation ofdata duetotheuseofan On theotherhand, anotherlimitation may be sensitive nature ofthetopic(Falb etal., 2013). for violence owing to the highly a key concern is participants. under-reporting Furthermore, the subjective to understand perspective of the inferences. Qualitative researchisalsoneeded In addition, thecapacitytorespond Limitations : Oneofthemajorlimitations of SCIENTIFIC ARTICLE ------TORTURE Volume 30, Number 3, 2020 81 , ć (4th ed.). (4th ed.). Diagnostic Conflict and , C., , D., & Vraneši & D., , ć Libya Detention Detention Libya ć , 1-11. https://doi. 1-11. , https://www. , 335-342. https:// 335-342. , 11 9

, , Đuri Pushed to the edge: Pushed to the edge: . Ankara: Migration Ankara: . https://www.amnesty.org/

, E., ć (5), 580-590. https://doi. 580-590. (5), 294 , https://aybu.edu.tr/gpm/contents/ , T., Sulji T., , ć Jama , 1-9. https://doi.org/10.1186/s13031- 1-9. , Conflict and Health International Health 11 , J., Schillberg, E., Ponthieu, A., Malvisi, Malvisi, A., Ponthieu, E., Schillberg, J., , , iškovi ć č lu, M., Livanou, M., Crnobari M., Livanou, M., lu, ğ doi.org/10.1093/inthealth/ihx040 A., Barbieri, G., Quaranta, P., Deiana, W., Mental health and (2017). S. & Di Carlo, trauma in asylum seekers landing in Sicily in study of neglected invisible a descriptive 2015: wounds. org/10.1186/s13031-017-0103-3 mental health of children and adolescents in areas of armed conflict in the Middle Violence and abuse against refugees and migrants refugees against Violence and abuse along the Balkans Route. en/documents/eur05/9964/2019/en/ Zamatto, S., Argenziano, E., A. W. Ahmed, L., A crisis of protection (2017). B. Vingne, … de F. violence experienced by and safe passage: Western along the migrants/refugees travelling Balkan corridor to Northern Europe. Health 017-0107-z reports. and border violence push-backs Illegal 2019. December Balkan Region. borderviolence.eu/wp-content/uploads/ December-Report-2019.pdf Fran effects of Psychiatric and cognitive (2005). M. of lack Association Yugoslavia: in formerwar stress of redress for trauma and posttraumatic reactions. org/10.1001/jama.294.5.580 of Impunity A State Centres: Center. Policy files/enesbeser.pdf M., Berthelot, M., Neuman, D., Visentin, S., Quantitative (2017). S. & Cohuet, K., Porten, survey on health and violence endured by refugees during their journey and in Calais, France. and statistical manual of mental disorders and statistical APA. DC: Washington, o er, M. E., & Elfeitori, F. (2018). (2018). F. & Elfeitori, E., M. er, ş ş Dimitry, L. (2012). A systematic review on the A systematic (2012). L. Dimitry, Bouhenia, M., Farhat, J.B., Coldiron, M.E., Abdallah, Abdallah, M.E., Coldiron, J.B., Farhat, M., Bouhenia, den Boogaard, Van A., Reid, F., Rita, A., Crepet, Border Violence Monitoring Network (2020). Violence Monitoring (2020). Network Border Ba Be Arsenijevi by the authors. References (1994). Association. American Psychiatric Amnesty International (2019). Conflict of interest interest Conflict of reported of interest was No potential conflict ------

This paper supports trau the claim that This research supports evidence previous PR75/18-21661). (ref. 971672), in the framework of the pro in the framework (ref. 971672), jects financed by Santander-Universidad Complutense de Madrid (PR26/16-20330, assessment of memories and psychological disorders refugees to trauma in associated by the UCM developed and victims of war, Testimony Eyewitness Group on Research Funding is partThis work of a research project on human rights of migrants are attempt who Balkan Western ing to enter Europe along the route. pean borders. Furthermore, this articlepean borders. lends support re to recent calls for an improved and sponse from the EU to ensure the safety as described in the previous sections, there is as described in the previous sections, examines a need for continued research that the conditions faced by migrants on the Euro shown how violence perpetrated security by violence how shown forces against migrantscrystallized is the at and notwith Considering this, border-zones. standing the dearth of research in the context matic experiences have an effect on migrants/on an effect experiences matic have mental health and can trigger the refugees’ also has study This PTSD. of development populations, as well as the violence and trauma as the violence and as well populations, they suffer is of central importance. Network, 2020). At a time that saw unprece saw that time a At 2020). Network, toward numbersdented move the on people of studying the vulnerability of mobile Europe, tations, with frequent use of violence against with frequent use of violence against tations, Bosnia-Her migrants border between the at (Amnesty Interna and Croatia zegovina Violence Monitoring Border 2019; tional, Conclusion depor unofficial deliberate and systemic of protective characteristics the use of to reduce protective violence during border crossings. attempted SCIENTIFIC ARTICLE SCIENTIFIC 82 TORTURE Volume 30, Number 3, 2020 Farhat, J. B., Blanchet, K., JuulBjertrup,P., Veizis, Falb, K. L., McCormick, M. C., Hemenway, D., El-Shaarawi, N., &Razsa, M. (2019). Movements International Organization(IOM). forMigration International Infante, C., Idrovo, A. J., Sánchez-Domínguez, Ibrahim, H., &Hassan, C. Q. (2017). Post- Hyndman, J. (2012). and The geopoliticsofmigration Holmes, S. M., &Castañeda, H. (2016). Guarch-Rubio, M. &Manzanero, A.L. (2020). Freedman, J. (2016). at the security Engendering M. S., Vinhas, S., &González-Vázquez, T. doi.org/10.3389/fpsyg.2017.00241 Iraq. Kurdish refugeesinKurdistanSyrian Region, andothertraumatic events among from torture traumatic stress disordersymptomsresulting 10.1080/14650045.2011.569321 mobility. amet.12259 Ethnologist and difference, lifeanddeath. andbeyond:in Germany Deservingness Representing the “European refugeecrisis” https://doi.org/10.1163/15718166-12340076 andLaw, ofMigration Journal 22 with unaccompaniedrefugeeminors. Credibility andtestimony in asylum procedures 29 ‘crisis’.Mediterranean ofEurope:borders women andthe migrants doi.org/10.1186/s12916-018-1028-4 while inGreece. and thejourney during and accesstoinformation withviolence,experience mental healthstatus, Cohuet, S. (2018). refugeesinGreece: Syrian A., Perrin, C., Coulborn, R. M., Mayaud P., & ijgo.2012.10.015 Obstetrics border. against refugeewomen along the Thai–Burma Anfinson, K., &Silverman, J. G. (2013). Violence 02757206.2018.1530668 Anthropology to opentheBalkanrouteEurope. upon movements: Refugeeandactiviststruggles 2214.2011.01246.x 38 East. Herzegovina 2019. (2020). s10903-011-9489-y Health border. Mexican transit: ontheNorthern experiences (2012). in Violence committedagainstmigrants , 153-161. https://doi.org/10.1111/j.1365- , 568-582. https://doi.org/10.1093/jrs/few019 Frontiers in Psychology Frontiers Child: Care, HealthandDevelopment, , International Journal of Gynecology & ofGynecology Journal International 14 Journal of Immigrant and Minority andMinority ofImmigrant Journal Flow monitoring surveys:Flow monitoring Bosniaand , Geopolitics , 449-459. https://doi.org/10.1007/ , 120 43 , 30 , 279-283. https://doi.org/10.1016/j. , 12-24. https://doi.org/10.1111/ , 91-112. https://doi.org/10.1080/ BMC Medicine https://bih.iom.int/sites/default/ , 17 Journal ofRefugee Studies Journal , 243-255. https://doi.org/ , 8 , 241-249. https:// American American , (2), 257-271. 16 , 1-12. https:// History and History European , Peace, K. A., &Masliuk, K. A. (2011). Do Milan, C. (2019). Refugeesat thegates oftheEU: Meçe, M. H. (2018). RiskFactors oftheIrregular Manzanero, A. L., Crespo, M., Barón, S., Scott, Koning, S. M. (2019). Displacementcontexts Karamanidou, L. (2016). Violence againstmigrants Organization(IOM) forMigration International Shoeb, M., Weinstein, H., &Mollica, R. (2007). Reques, L., Rolland, C., Aranda, E., Grippon, A., Pérez-Sales, P. (2018). andtorture: Migration displacement structure women’sdisplacement structure lives and and violentlandscapes: How conflictand 1080/01419870.2015.1124124 Racial Studies in Greece: beyond theGolden Dawn. key-migration-terms (2020). files/BiH2019report.pdf of SocialPsychiatry disorder inIraqirefugees. torture, traumaandposttraumatic stress formeasuring a cross-culturalinstrument trauma questionnaire:The Harvard adapting https://doi.org/10.1093/eurpub/ckz186.046 ofPublicHealth,Journal 29 transiting Libya, ItalyandFrance. (2019). Episodesofviolencesufferedbymigrants Fallet, N., Bensimon, C., ... &Luhmann, N. v28i2.106906 28 Building amapofknowledge. 9102-7 4 and traumatype. of malingeredPTSDasafunctionmotivation motivations matter? Symptoms formalingering 953.2018.1532686 Studies route. Balkans alongthewestern the refugeecrisis Civic initiatives responsesto andgrassroots 67). Cham,Switzerland:PalgraveMacmillan Crime. RealitiesandMediaRepresentations In E. Balica& V. (Eds), Marinescu Implications intheEuropeanUnionCountries. Migratory Waves onthe Western BalkanRoute: org/10.1177/0886260517742911 published November 23, 2017. https://doi. Strip. trauma inchildrenvictimsofwar intheGaza Traumatic events exposureandpsychological M. T., El-Astal, S., &Hemaid, F. (2017). org/10.1016/j.socscimed.2019.112557 Social Science&Medicine ongoing threats at the Thai-Myanmar border. (1), 44-55. https://doi.org/10.1007/s12207-011- (2), 1-14. https://doi.org/10.7146/torture. Journal of Interpersonal ofInterpersonal Journal Violence Journal of Balkan and Near Eastern ofBalkanandNearEastern Journal , 21 Key Migration TermsMigration Key , 43-60. https://doi.org/10.1080/19448 , 39 , 2002-2021. https://doi.org/10. SCIENTIFIC ARTICLE Psychological Injury andLaw,Psychological Injury , 53 , 447-463. https://doi. , International Journal Journal International 240 (Supplement 4). .

https://www.iom.int/ , 1-9. https://doi. Torture Journal, European Migration and Migration . First Ethnic and (pp. 45- (pp. TORTURE Volume 30, Number 3, 2020 83 Acción Jama, Jama, . https://doi. .

https://data2.unhcr. https://www.unhcr. https://www.unhcr.

. Refugee and MigrantRefugee Situation Forced Global Trends: Forced Global Trends: Bosnia and Herzegovina:

(1), 1-16. https://doi.org/10.5944/ 1-16. (1), International Social Work . https://data2.unhcr.org/en/documents/ . (5), 537-549. https://doi.org/10.1001/ 537-549. (5), push factors underpinning and return outward migration. org/10.1177/0020872818819736 (UNHCR) (2020). (UNHCR) (2020). Operational Team CountryUnited Nations and Migrant Refugee situation-December Update, 2019 download/74293 An exploratory study multi-site mixed-method The with migrants Niger transit centers: at (UNHCR) (2019). (UNHCR) (2019). Displacement in 2018 org/5d08d7ee7.pdf (UNHCR) (2020). Displacement in 2019. org/5ee200e37.pdf a systematic review and meta-analysis. review and meta-analysis. a systematic 302 jama.2009.1132 (UNHCR) (2018). in Bosnia and Herzegovina. org/es/documents/download/63869 in the Community of Madrid (Spain)]. in the Community of Madrid (Spain)]. 15 Psicológica, ap.15.1.19864. Association (2009). M. Ommeren, Van & A., R. of torture events and other potentially traumatic among populations with mental health outcomes and displacement: exposed to mass conflict org/10.1177/0020764007078362 de Indicadores de trata (2018). J. M. Contreras, personas que ejercen la prostitución en mujeres en locales de alterne de de la Comunidad Madrid [Indicators (España) of trafficking in Practicing Prostitution in strip clubs Women Veronese, G., Pepe, A., & Vigliaroni, M. (2019). (2019). M. Vigliaroni, & A., Pepe, G., Veronese, United Nations High Commissioner for Refugees High Commissioner United Nations United Nations High Commissioner for Refugees High Commissioner United Nations United Nations High Commissioner for Refugees High Commissioner United Nations United Nations High Commissioner for Refugees High Commissioner United Nations Steel, Z., Chey, T., Silove, D., Marnane, C., Bryant, Bryant, C., Marnane, D., Silove, T., Chey, Z., Steel, Silva, E. A., Manzanero, A. L., Bengoa, G., & & G., Bengoa, L., A. Manzanero, A., E. Silva, SCIENTIFIC ARTICLE SCIENTIFIC 84 TORTURE Volume 30, Number 3, 2020 ploring the challenges and opportunities pro thechallengesandopportunities ploring the Norwegianhealthcaresystem, andex within organisation ofrehabilitation services andduties,rehabilitation rights presentingthe It engagesthetopicfromoutsetofrelevant in Norway.victims with a refugee background fortorture vision ofrehabilitation services Introduction: Abstract Evy Aasnes Moa Nyamwathi Lønning Norway practice oftorture rehabilitation servicesin “A randomsystem”:Theorganisationand International Rehabilitation Council for International Torture Victims. reserved. All rights https://doi.org/10.7146/torture.v30i3.119875 Projectteammember at theNorwegian Seniorlegaladviser at theNorwegianRed 4) 3) , Postdoctoral researcherat theDepartment 2) 1) • Key pointsofinterest Cross. University ofOslo. of HealthandSociety, Faculty ofMedicine, redcross.no to Correspondence Correspondence [email protected] Correspondence Red Cross. to Correspondence Cross. [email protected] M.A., LL.M, PhD PhD, Senioranalystat theNorwegian Red ing practice is highly person dependent.ing practiceishighlyperson arefragmented,ground andtheresult- victimswitharefugeeback torture in Norway for Rehabilitation services This article addressesthepro- This article 4 . moa.nyamwathi.lonning@ [email protected] 1 , Anette Bringedal Houge - - - order dent. depen the resultingpracticeishighlyperson victimsinNorway arefragmented,torture and from the victimssuffer fortorture habilitation services for torture torture large chology, law, nursing, andpolicing, aretoa of prehensive rehabilitation processes. Students that tocom- cancontribute inclusion ofactors fromalackofcoordination and suffers services injuries. Moreover, thequalityofrehabilitation identification anddocumentation oftorture survey.programme educational email-based an and 2019 August in Norway, conducted between March and victims ment and rehabilitation for torture to or otherwise focus on treatcontribute programmes, capacity-building withinrelevant educational rehabilitation;on torture 2)knowledge and ing and implementing a national plan of action bilitation services victims views with46experts provide astheyseekto fessionals seeandexperience rele vant professions, suchasmedicine, psy torture torture Conclusion: Methods and material: Threerecommendations areproposedin extent to ensureminimumstandards in during their during injuries and injuries adequate absence of victims. not exposed 2 , IngaLaupstad the national health services and the national healthservices Rehabilitation services for Rehabilitation services treatment and rehabilitation SCIENTIFIC ARTICLE for Re- discussion: and Results professional studies. a rehabilitation for torture rehabilitation fortorture this group: 1)develop- systematic approach and to Qualitative inter practitioners that practitioners knowledge about 3 andAnn reha to - - - - - TORTURE Volume 30, Number 3, 2020 85

------what reha (OHCHR, (OHCHR, how much how Manual on Effective Investigation and Docu Investigation Manual on Effective The wording of UNCAT does not, does not, of UNCAT The wording Each State Party shall ensure in its legal ensure in its legal shall Party Each State Degrading Treatment or Punishment Treatment Degrading States Protocol. hereafter the Istanbul 2004), the rightmust enact legislation providing and help to acquire new needed functions, and and help to acquire new needed functions, as farbe rehabilitated as possible from their limited by 3) – not personal preconditions (p. Gaer resources (Sveaass, available the state’s Against The Committee 2018). & Grossman, further3) a for advocates p. (2012, Torture long-term and integrated ap rehabilitation takes account of the tortureproach that vic Specialised services individual situation. tim’s including a procedure must be made available, to according needs individual evaluating for the Inhuman or and Other Cruel, Torture of mentation however, provide many holding points to many provide however, or entails “full rehabilitation” nor does it clarify should be offered, bilitation holds the responsibility when the which state victim no longer resides in the country where The commentaries by the torture inflicted. was (2012) are there Torture Against Committee veryfore address to guidance their in useful The if non-binding. even such uncertainties, personsCommittee has made clear that sub jected to torture their shall be helped to regain receive or alternatively, previous functions, treaties are relevant. The UN Convention The UN Convention are relevant. treaties or Inhuman Other Cruel, and Torture Against or Punishment (1984), Treatment Degrading Article 14 makes it clear hereafter UNCAT, shall be ensured: rehabilitation that act of torture the victim of an system that obtains rightredress and has an enforceable and to fair as means for including the compensation, adequate of the In the event as possible. full rehabilitation torture, of act an of result a as victim the of death his dependants shall be entitled to compensation. tion following torture following tion legal a Norwegian in different international human rights context, ------

: Norway, professional practice, professional practice, Norway, : amining the rights and duties for rehabilita Health and Care Services, 2000). However, However, 2000). Health and Care Services, shall be in line Norwegian health regulations and when ex with international obligations, wegian legislation does not provide torturewegian legislation does not provide victims with explicit rights to rehabilitation. for individual as allow The health regulations (Ministry needs of sessment of each patient’s Halvorsen, 2012; Lie, Sveaass & Hauff, 2014; Hauff, 2014; & Sveaass Lie, 2012; Halvorsen, RVTS, 2014; PsychiatricNorwegian Society, Nor 2015). Varvin, 2013; Sveaass, 2014; Practitioners expressed and experts long have the quality and extent of rehabil concern over services itation 2017; groupfor this (Dyresen, been subjected to and survived torture before the reha arriving do not receive in Norway a right to. they need and have that bilitation as charities organisa and non-governmental This article starts a well- from tions (NGOs). founded concern who have individuals that health, care, social and other welfare services, social and other welfare care, health, immigrationthe as authorities well as the and encom as such, It may, reception system. as well institutions, pass public and private tion must be coordinated between different between coordinated be must tion service which for torture victims providers, with a refugee background include may (Patel, Kellenzi & Williams, 2014). The inju 2014). Williams, Kellenzi & (Patel, riespersonthe both affect tortureto subjected rehabilita that It follows and the next of kin. Torture leads to multifaceted rehabilitation Torture legal, social, mental, needs across physical, and spiritual aspects of life welfare-related, public health services, refugee background, refugee background, public health services, rehabilitation. Introduction ised expertise on the topic at all relevant levels. expertiseised levels. all relevant at topic on the Keywords other relevant public sector services; public and 3) other relevant interdisci strengthening and institutionalising plinary communities of practice with special SCIENTIFIC ARTICLE SCIENTIFIC 86 TORTURE Volume 30, Number 3, 2020 only applytoindividualswhohave beentor maintainthat rehabilitation doesnot further be trainedtousetheIstanbul Protocol. They professionals working with immigrants, must staff, healthpersonnel,and prison lawyers and Torture (2012, p. 8)also pointoutthat police and refugees(p. 3). The Committee Against accesstoasylumseekers placed onensuring be available (p. toeveryone 7). Emphasisis andrehabilitation must fied medicalpersonnel as soonpossibleafterassessmentbyquali Torture, 2012, p. 5). Access must be granted access torehabilitation (Committee Against trust, and thesuspicionandambivalence that Quiroga, 2011). Moreover, a climate of mis ception andwelfare provisions (Jaranson & destitution, intheabsenceofadequate re and canthereforeleadtopoverty, andeven tion, discrimination, andthelossofincome ofisola includeexperiences can furthermore works, andlifeprojects(Varvin, 2003). Exile ones, community, roles, self-worth, socialnet Exile ofteninvolves several lossessuchasloved difference between a senseofsafety–pointingtotheimportant secution, translate into itdoesnotnecessarily possibilities, andtheabsenceofwar andper & Williams, 2014). Even ifexileentailsnew elsewhere alsohave aneffect(Patel, Kellenzi forsignificant others andconcern of origin legalstatuses.porary Conditionsincountries that followrestrictions frominsecureandtem ranson, 2005), and inadditiontouncertainties that impacton wellbeing (Quiroga&Jafactors new societyandthetransnational space, are follow exile–suchasfindingone’s placeina can complicate thisprocess. Challengesthat Flight, exile, difficulties andpost-migration ground, rehabilitation entailshealinginexile. (p. 1). treatment subjected toinhumanordegrading tured, but alsotoindividualswhohave been For victims with a refugee back torture being safe and feeling safe. ------centres were established as a temporary solu centres were establishedasatemporary and Bergen(2013-). the Fromthebeginning, inOslo(2009-) for undocumentedmigrants health care centres and the Red Cross run health careservices, theChurchCityMission is limited. Inresponsetoalackofaccessible regular legalstatus, accesstopublicservices and displacement. For with an ir migrants inacontextofmigration injuries of torture future prospectsallow for, affecttheimpact treatment in the new country, and what exile, as well as integration, inclusion and (Varvin,and thetorture 2003, p. 25). Several have said that: itis worse than prison impacts trust, andthat canleadtobitterness. acquire anewtrauma, onethat fundamentally application for benefits, racism, xenophobia, can rejection oneconomicsupport, rejectionontheir plication, rejectionontheirhousingapplication, bureaucracy,friendly rejectionoftheirasylumap on. suspicion,A refugee who experiences anun bythosetheyhadcounted they were notsupported itation process: seek refuge, may heavily impacttheirrehabil in the societies where they refugees can face Cross, 2020). ofthisproject,As part thisarticle victims inNorway (see alsoNorwegianRed fortorture quality ofrehabilitation services Red Crossdecided to examinethestatus and Mission &OsloRedCross, 2020). comprehensive rehabilitation (ChurchCity andwho are inneedof have torture survived knowledge who at thesecentresmeetmigrants social workerswhovolunteer theirtimeand operation, andthehealthprofessionals legalstatus.irregular The centresarestillin withan forpersons able healthcareservices and predict secured necessary authorities ambition tobecomesuperfluousoncepublic needs,tion tohumanitarian withtheexplicit Many survivors relate that the worstMany was survivors that It isfromthisoutsetthat theNorwegian Accordingly, fromflightand experiences SCIENTIFIC ARTICLE ------TORTURE Volume 30, Number 3, 2020 87 ------We aimed for a We 1 te of Health hosts a professional The Directora We did not limit our interviews one any to We council for immigrant health, the National the National council for immigrant health, unit working Institute of Health has a dedicated and NKVTS and RVTS on migration health, refugee health and forced migration as have are, and the RVTSs part of their focus areas, furthermore, of by the Directorate mandated Health to include torture among their many specified topics.

strategic to include professionals with sample considerable experience with and knowledge including torture re “refugee health,” about fessional experience on refugee health focusing to more than spanned from around one year Half of the participants had worked 40 years. within this field for around 20 years or more. service or specific part provision profession, of sought have as we process, the rehabilitation 1 interviewed 46 of them. The strategic sam interviewed of them. 46 field the into insight given has approach pling of torture from across Nor rehabilitation West, four health regions (South-East, way’s number The lowest and North). Mid-Norway of participantsregion from one single 6 was that however, Note, 21. was and the highest the number of participants from each region size of the rel does not reflect the population practitionersof number or the region, evant interviewed we 28 In total, there. operate that and their individual pro and 18 men, women tion (RVTS), who also shared information who also shared tion (RVTS), professionals. about relevant startedAs we interviewing, we habilitation. and networks participants’ to introduced were colleagues – and benefitted greatly from this 57 invited we all, in All element. snowballing professionals to take part con – and as we had we August 2019, cluded the interviews in Health, the Norwegian Centre for Violence Violence for Centre the Norwegian Health, (NKVTS) and Stress Studies Traumatic and Vi Regional Centres about the five Resource and Suicide Preven Stress Traumatic olence, ------the topic is how

The primary contribution of this article rectorate of Health, the National Institute of the National of Health, rectorate professionals. We further Di the contacted We professionals. or in research, academia, care work, recep care work, academia, or in research, capac and and refugee integrationtion work, The recruitment process for these ity-building. interviews started with preliminary talks with expertspublicly known and scholars who in- troduced and shared an overview of relevant is, however, based on the qualitative inter based on the qualitative however, is, with professionals whose conducted views we concerns work torture clinically either victims This articleintakes from a litera combines a brief, email- ture and grey review; literature and programme educational based survey; interviewsqualitative with a diverse group of experts- and practitioners ad work whose contacted all We dresses torture injuries. offering institutions in Norway educational psychol- professional studies in medicine, and policing (see table 1 nursing, law, ogy, questions: with two for a complete overview), as a topic within the is covered ‘torture’ if programmesrelevant during the academic and if so, 2018/2019, year Methods and material integrated curriculumthe in teaching. and contacted the departmental administra- We tions of each given programme total of 25 (a which either programmes 16 institutions), at responded directly or referred us to relevant no response from received We staff members. incomplete an obtained and institutions three from one department. answer looks at the provision of rehabilitation services of rehabilitation the provision looks at health system national within the Norwegian – of services, addressing both the organisation and prac professions, in relevant knowledge titioners’ experiences of providing help, treat experiences help, of providing titioners’ according and what, ment and rehabilitation, rehabil is needed to secure adequate to them, servicesitation for torture victims. SCIENTIFIC ARTICLE SCIENTIFIC 88 TORTURE Volume 30, Number 3, 2020 and/or settlementphases(10outofthe46 While someexclusively focusonthearrival organisations. andhumanitarian structures affiliated withuniversities, refugeereception public sectors. are also Several participants vices, both within NGOs, and theprivate and healthcareser and seven work onprimary 35 work withinspecialisedhealthcareservices, havethe 46 participants a clinical background: arehealthcareproviders.interviewees 43of forthisstudy. injuries torture That said, most withtreatment andrehabilitationriences of to explorethebreadthofprofessionals’ expe also conducted three group interviews (two interviews also conducted threegroup ducted one-to-one, author. bythefirst She through referrals. victims for torture to rehabilitation services foraccess care system – andkey gatekeepers withinthenational health lineresponders first (GP) as such, tioners albeit they are important have generalpracti- thereforenotinterviewed onrefugee health.considerable experience We in that we professionals with have prioritised forthisstudyhasbeenstrategic of participants ant toemphasiseagainherethat theselection have completedspecialisations. Itis import a childwelfare worker, andalawyer. Many dentists (2), anoccupational therapynurse, (5), socialworkers (4), physiotherapists (3), (7),nurses (6), medicaldoctors psychiatrists (16outofthe46),are trainedpsychologists onthis.rience Byprofession, theparticipants topicsyeton various stillhave extensive expe health,migration whereastheotherhalfwork clusively withissuestodorefugeeand orex- work primarily Half oftheparticipants status to those who are Norwegian citizens. legal withanirregular statuses –from persons ingly, their patients/clients have different legal and subsequentstay inthecountry. Accord at allstages, spanningthearrival, settlement –mostwork withrefugeehealth participants) Most of the interviews (27)were con Most oftheinterviews ------constitutes comprehensive rehabilitation. of what specific ailments to understandings –fromhousingandhelpwith injuries torture asregards but spoketothe spectreofservices presented withadefinitionof “rehabilitation” victims.vices fortorture were Participants not ment ofthegeneralstate ofrehabilitation ser andtheirassess their professionalexperience to-depth. We toshareboth askedparticipants ofwhichtopicswere coveredterms mostin edge andrespective emphasis, in theyvaried themes, but dependingonparticipants’ knowl in thisfield. covered alleight Eachinterview also aspecificfocusonbeingpractitioner itation; and(8)qualityofservices, including socio-economic issues and social rehabil- (7) ability; (6)relevance ofexileandbackground; andperceived avail rehabilitation services (5) treatment andrehabilitation;terdisciplinary and competency; injuries (4) in of torture injuries; (3)documentationtion oftorture eight themes: (1)experience; (2)identifica guideasapointofdeparture, covering terview each. For allinterviews,we usedatopicalin withfourparticipants and threefocusgroups and onewiththree),with two participants “The so-called Norwegianmodel[isnot]a stated,subjected totorture, oneparticipant available forpeople theservices Describing Findings anddiscussion lated intoEnglish. between them). All quoteshave beentrans todifferentiate (and numberwherenecessary to byprofession quotes areusedreferred locations).geographic whose Participants (e.g.,variables participants’ professionsand that spanneddifferentbackground periences in perspectives,similarities positions, and ex- analysed inNVivo. We specificallylookedfor verbatimrecorded and later transcribed and were and17one-to-oneinterviews terview All focus group interviews, one group in interviews,one group All focusgroup SCIENTIFIC ARTICLE ------TORTURE Volume 30, Number 3, 2020 89 ------). Par ). § 11 e and a proper understanding of their impact 2017; (Alpers, lives in the patients’/clients’ 2005). Quiroga & Jaranson, 2004; OHCHR, ties (Directorate of Health, 2011), it is not 2011), of Health, ties (Directorate both adult and minor familyuncommon that Faryabi, e.g., (see, this function members have 2017). It on family an unduly burden places members can be com and can hinder what Furthermore,asusing children municated. interpreters (Ministry is prohibited by law of 2016, Justice and Public Security, ticipants also described general concern over system competency and cultural competency, are furtherwhich important in the aspects – and which may of rehabilitation provision of torturehinder both identification injuries always known. [Service providers] therefore known. always reservations about using interpretershave and experience unnecessary barriers. […] Many it[professionals] are poorly trained and find A survey among interpreters in the difficult.” interpreter national inter register that shows preters with formal used in were qualifications only four out of 10 interpretation assignments within the public sector in 2017 (Directorate Moreover, 2018). Integrationof Diversity, and familywhile members asused be not should interpretersservicespublic by authoriand (by video or telephone), how to facilitateto good how telephone), or video (by interpreters, themselves between collaboration of the implications and their patients/clients, (the mother tongue orwhich language is used and the importance of also another language), offering support peer to interpreters, many halting language servicesfocused in-depth on sometimes sector that and a hesitant public with interpret basic skills in working lacks even the within nurseone working instance, For ers. general health care services explained the situ as very I perceive basic “What as follows, ation interpreter about using an knowledge is not language, such as the benefits and drawbacks and drawbacks such as the benefits language, of face-to-face versus remote interpretation ------

ticipants discussed several issues pertainingticipants discussed several to lenges associated with language and interprelenges associated servicestation raised in 25 interviews, were While par including the three focus groups. Adequate translation and interpretationser translation Adequate vices for those who need it are preconditions servicesfor equal and adequate 2017; (Alpers, Issues and chal 2011). of Health, Directorate victims with a refugee background are affected immigrantsby general challenges that face in and welfare services. care, accessing health, provisions should be equally good and adapted should be equally provisions Yet, regardless of background. to each patient servicesthe rehabilitation torture to available of equal and adequate health and care servicesof equal and adequate (Ministryfor the whole population of Health implies that This and Care Services, 2013). Organisation of services of Organisation and inclusion in programmes educational a proclaimed goal Norwegian authorities have measures to ensure that Norwegian authorimeasures to ensure that from resulting needs rehabilitation meet ties torture injuries. components for adequate rehabilitation. Our rehabilitation. components for adequate to each findings are then discussed in relation also suggest where we other in the conclusion, injuries and the importance of interdiscipli proceed We nary practice. communities of by exploring the crucial their reflections on providing help, treatment and rehabilitation rehabilitation and treatment help, providing tortureto particulara with victims on focus of torture documentation and identification institutions of higher education providing providing education institutions of higher psychology, in medicine, studies professional the explore then We policing. and nursing,law experiencesparticipants’ on and reflections ing, we will present an overview will present of the or we ing, on The overview builds of services. ganisation greyinformationand from literature gathered model. The Norwegian system is a random Norwegian system The model. echoed in the This (Psychologist 1). system” In the follow participants. accounts of many SCIENTIFIC ARTICLE SCIENTIFIC 90 TORTURE Volume 30, Number 3, 2020 2 provider h Drcoae f elh (e-mail Health of Directorate two the patients; of share small to pe H resents rep- services access to order in transportation Several norm. for costs that out pointed also participants the represented than rather these exception However, charge. consultation where and referral, possi including professionals, (Norwegian RedCross, 2020). more broadly(e.g., theSwedish RedCross) witharefugeebackground and forpersons tised refugees(e.g., DIGNITYinDenmark Freedom from victims (e.g., free of charge for torture services at and pose pa tion cardforsuchexpenses. Several partici (NOK 2,460in2020) until theyhave paidthe annualmaximumfee It also means that theyareliable for fromthere.the specialisedhealthcareservices pa- 2019). a a persons for Norway, fa-c victims: in specialised exist rehabilitation G the than others by made be could referrals where Norway in places few toaG those witharight victims inNorwa w

crig o nomto w received we information to ccording i ea r hba TO (ietrt of (Directorate (TOO) odontophobia th rs nts notedthat treatment related expenses specialised centres ue nue patients injured ture The national health care service isthemain The national healthcareservice permission tostay inDenmark. permission torture for centres specialised no While With thelimitation that theyhave beengranted n wt a valid a with ons l income. h 2010). th, a barrier barrier an al, hs mutd o 18–22 to amounted this Yearly, of rehabilitation services for of rehabilitation services additional barrier. etl evc icue torture includes service dental This s ilitated dental health provision health dental ilitated u for patients with limitedfunds b T je y. Inpractice, thisimpliesthat orture in orture T ct contrasts withthe h ed to t to ed i s s elsewhere that r and receive anexemp P, to mustseekreferral eside rie s iie to limited is ervice orture, assault and assault orture, ersn a very a represent the n o ohr health other or P iiis o self- for bilities e permit ce

W UK), e identifieda a fe of free was a user fee August , situation trauma provide p torture torture erc and , from ent the 2 ), ), - - - t how t ci e ( to u an 2018/2019. number, a of tortured. This isfurthercomplicated byone and for treatmentandrehabilitation. tion oftortureinjuriesareimportant steps Identification, interdisciplinary communitiesof practice Identifying tortureinjuriesandtheimportanceof the 1990s. one only studies, their t r u p mandatory the of part institution granting psychology. Furthermore, in studies profes-sional the a an t ara atprofessional studiesinmedicinegiven f lenges w t M I i s professional ucational institutions offering n i i h h i i not is t eflected H tudies inmedicine, psychology, law, nursing, d n r n ca on on ents in2016to2018. Regardlessofthislow h p g rt seven e e of systematic approachto identification and et g other d d i this article’smain findings: the absenceof øyvik, Lie& te te topic the ether l te topic is part of the mandatory instruc ofthemandatory te topicispart

versities, asasep knowledge abouttorture in te ou i lmtd o establishing to limited is focus the tion, e about torture isensuredinrelevant dis e abouttorture i I u t policing. thetopicisincludedinselectededuca at one institution (University of Bergen) of (University institution one at a the to sinl tde i lw n plcn ed- policing and law in studies essional r n n p r pltn nvriy. Both University). opolitan l clinical practicehighlightmany chal- es

Arctic University of Norway). of University Arctic ordertogaininsightintohow knowl e totheface, themouth, andtheteeth r h p oh in identifyingpersons whohavebeen e andprofessions, we examined r researchshows that itiscommon with (The ogrammes during theacademicyear during ogrammes i i b pic a n no at f h criuu i ay of any in curriculum the of part i participants’ experiences. Among experiences. participants’

in f torture. of tion We contacted all Norwegian ed t W ntuto at instruction binding legally p r

examination, W e foundthat lectures address riiat wo discussed who articipants e overwhelmingly absent. For ny n nrig degree nursing one only i l SCIENTIFIC ARTICLE l u had m ha nlds h tpc as topic the includes s en, 2019). d en oee during covered been experienced this, in this, experienced and documenta- T t r a i wa his i n n (Oslo ing Research al s if and ou fo so r ------r TORTURE Volume 30, Number 3, 2020 91 - Other** Ye s No Incomplete Ye s No Ye s No reply Have you witnessed you Have No Ye s No Ye s Ye s Mandatory Incomplete Ye s Ye s No No No reply - - - - - refugees and family reunited persons reunited , IS-1022 and family refugees where both torture victims hereafter IS-1022, 2004) (OHCHR, Protocol and the Istanbul and which recom are referred to explicitly, mends offering a general health examination authority or by the local health (physician nurse)arrivalafter months three (Directorate a form the examination, For 2015). of Health, identifying questions about including two torture is recommended: to torture? been subjected you torture? (Di- Have participantsOur 2017). Health, of rectorate

University of Oslo (UiO), The Arctic The University of Oslo (UiO), (UiT) University of Norway Tech gian of Science and University nology (NTNU)* NTNU UiT, UiO, UiT UiO, University The Norwegian Police College University of Bergen (UiB), Norwe University of Bergen (UiB), UiB UiB Østfold University versity College, of South-Eastern University College, University of Norway Western Norway, Applied Sciences Applied University of Inland Norway Sciences Nord Uni VID Specialized University, Oslo Metropolitan University Agder, of University NTNU, UiT, Molde Uni University of Stavanger, Diaconal Univer Lovisenberg versity, sity College Educational institution Educational Guest lectures, part of non-mandatoryGuest lectures, lectures or similar. included in lectures about trauma and abuse. topic but Not as own

** * Medicine Psychology Law Policing Nursing . Overview of torture 1. programmes. as topic in selected educational Table Degree documentation, and an unclear division of re- and an unclear division documentation, during points There are several sponsibilities. where processes settlement and asylum the public service providers and asylum seekers both formally and in- and refugees interact, stake is therefore not The issue at formally. an absence of opportunities in which experi- ences of torture Sveaass can surface (Brekke, NOU, 2007; et al., Jakobsen 2010; Vevstad, & Health of the Directorate instance, For 2011). guidelines the National (2015) has developed servicesthe healthcare for asylum seekers, for SCIENTIFIC ARTICLE SCIENTIFIC 92 TORTURE Volume 30, Number 3, 2020 delayed andeven foryears decades. Some areidentifiedearly, injuries torture itcanbe spokeabouthow,of theseparticipants unless discussions.ing thethreefocusgroup Several usually identified was raised in nine, includ terviews, theissueof andNGOs.the asyluminterview) authorities immigration workers, teachers, receptioncentrestaff, the andsettlement:ing arrival healthandsocial follow injuries tant foridentifyingtorture impor asparticularly highlight someactors 3 with the needed health service. to They have tried Norway for 20 years and have never been in contact support, assuggested byanotherparticipant: or leaving peoplewithout adequate services can remain unidentified, injuries torture alised andfollowed inasystematic manner, accordingto thelaw torture know that what theyhadbeensubjectedtoiscalled was unabletocommunicate itorwhere theydidnot Where thepatient themselves, duetobrain damage, the questionof what caused it or why itis this way. disabled duetotorture, but where nooneever asked examples withpeoplewho have becomeextremely then we never askthequestion. There areextreme fied. Symptoms, you treat thesymptom[…]and identi injuries time without having their torture whether theyhadbeentortured: in Norway beforeanyone foryears hadasked victimswhohadbeen spoke abouttorture I sometimesget patients who have beenin areinstitution Unless identification efforts I have metpeoplewho have beenherealong While identification was discussedinall torturutsatte-i-asylprosedyren aktive-prosjekter/item/utredning-om- Norwegian): https://www.fafo.no/prosjekter/ asylum process. For more information, see(in victimsinthe ontorture of Immigration 2021)fortheNorwegianDirectorate February astudy (September2020– is undertaking Fafo InstituteforLabourandSocial Studies when 3 (especially during (especiallyduring (Psychologist 2). (Psychologist torture injuries are injuries torture ------dition andachallenge–itcantaketime habilitation. Trust isgenerallybothaprecon regardingaccesstotreatment andre concern dentiality, and thepresenceofinterpreters aboutissuesofconfi They may alsoworry & Woldstad, 2018; Quiroga&Jaranson, 2005). inflicted(Høyvikalienation duetothe injuries sciousness, dissociative amnesia, numbness, or have sufferedcognitive damage, lossofcon fessionals beingpresent. Torture victimsmay within institutions, and can include health pro professional representatives of public organs, providers, is often committed by as torture hesitant torevealservice theirexperiences victimscanbeafraid or torture Furthermore, (Høyvik & be challenging Woldstad, 2018). symptoms inrelation tooneanothercanitself identified asrelated to torture. Seeing different cal injuries, although the marks are not always marks aremoredifficulttoidentifythanphysi others. that donotleaveActs oftorture visible areeasiertoidentifythan forms of how certain spoke injuries, participants to identifytorture their mentalhealthneeds abled at somepointbut never for received support stay at home, toholddown ajob, tried becamedis of concern forothers’ wellbeing:of concern out theirexperiences also refrainfrom sharing have beensubjected to. Torture victims may hibit somefromever talkingaboutwhat they that pro and guiltwere alsoraisedasbarriers Intensefeelingsofstigma,behalf of. shame on that theycouldnotordaredintervene ofothers guilt whohadwitnessedthetorture they spokeofpatients/clients withsurvival difficult.phasised asparticularly Inaddition, em that the participants of torture a form isalso Having beenforcedto committorture to talkaboutregardlessofthevictim’s gender. difficult as particularly are described torture allows of for sharing.trust Sexualised forms to build asenseofsafety, asafespacewhere While acknowledging howWhile acknowledging difficult itcanbe SCIENTIFIC ARTICLE (Psychologist 3). (Psychologist ------TORTURE Volume 30, Number 3, 2020 93 f t - - - op life e o el v ctices, allow respond nd orks tha on where of torture a

hasis was on. As ex on. ti t ervice, they specialised -p e-w te pra ctitioners: on communities. itu . Full rehabili a tati s i s m r l we know the l ed, i a need for and p tati nt h d the important n a result of a b s a institutionalised r mapping of ser- i a treatment and l “Norway is not ful “Norway tice as to u edge about refugee h e, (Psychiatrist 1). l b l ac b w r tion and support, and ta l care service, and NGOs. u h reflect on practice, de e provision of adequate to th gist shared their experienc ealt ciplinary, communities of lies in common dedication and have been like this if I had just h . For all, the value of such We found several communities of to put all this into a clinical setting. k solutions initiated by dedicated what to and look I into; have also been r across the al systematic and equa interdis ul Protocol properly” wo often local, and in some instances, roups or teams at the inst offered guidance and was told what to had the opportunity and time, and have ed by one participant, ed by one participant, g on formulated in UN stateme tice and networks in o th. However, rather th i tment and reha-bilitation services. I know what to do, but that is because I Participants also describe n l red the value of esta e psychol-o ce of professional documen ce of professional i re o placed on institutional fra mmunities ac a n n ces with particular kno s ea a-t ebrief challenging r ea eing part of such a group of eer l co ehabilitation processes. An em stan-b ole played by accessi r a profession-als both within priva regional the national O have been It would not t p they skills, peer con-s r al for flexibility in their p b read and given time tumbled and practice for co value their expertise and assessmen to complex needs and situations. patients’/clients’ p vi h n we injuries subsequent re and p tation shall be offered. Nor do r Research participants shared the opportunity d filling its obligations to torture victims as I have seen torturetohaveIasvictimsobligationsitsfilling them I emphasised the meaning of such Some highlighted a reference need centre to for lean s a on; others na-tional under- t ------states it shouldit how how IS-1022 it should entail

what (Psychologist 4). (Psychologist 4). should do it, should do it, who The Istanbul Protocol represents the inter- The Istanbul Many of my patients were very were patients much in doubt of my Many At the system level, identification is chal identification At the system level, guard the rule of law, both when applying for guard the rule of law, in theprotection and for facilitation of the stay section 2015, Health, of (Directorate country” can add the impor we this, To 1). para. 3.2, resents a hampering factor. The resents a hampering factor. “Health certificates and [documentation that in immigration and preceding examination] asylum cases are necessary in order to safe for reimbursement also rep for documentation the Istanbul Protocol in the national health ser Protocol in the national the Istanbul canvices and an absence of professionals who undertakedocu- provide and examination an As noted by others according to it. mentation a lack of tariffs 2014), RVTS, 2015; (Lie et al., ment (OHCHR, 2004). There is no Norwegian no is There 2004). (OHCHR, ment edition nor summary Our study of the Protocol. of implementation points to a lack of systematic national minimum standards for examining and standards minimum national documenting torture- and other inhuman treat a concern that deliberate identification is uneth is concerna identification deliberate that end. other the offer at to one has nothing ical if participantsOur torture that emphasised a as causing topic can be experienced as difficult, A precondition some professionals to refrain. appears therefore identification for that to be service providers are confident about the topic pa they can offer or refer that moreover, and, and, furthermore, by whether there should be a and, 2020). & Lie, general screening or not (Sveaass about to insufficient knowledge It also relates health servicethe topic within the national and services. tients/clients to adequate whether I could bear to listen to what they had been I could bear to listen to what whether listen and to I be able to Would subjected to […] carry about it? If they told of knowing the burden They did not want I break into pieces? would me, they of listening to what to expose me to the strain had been subjected to SCIENTIFIC ARTICLE SCIENTIFIC lenged by a lack of guidelines for guidelines of lack a by lenged be done, be done, 94 TORTURE Volume 30, Number 3, 2020 presence of adequate support structures for structures presence ofadequate support injuries, accordingly,torture alsorelates tothe out get burned is mucheasiertofeel helpless, andthen you can If you donothave any methodsormeans, thenit situations.it ismucheasier to handlechallenging and implications offeeling competent: 2). (Psychologist competency sary toacquiretheneces theopportunity been given and rehabilitation]. injuries topic [torture I have 1. victims:rehabilitation processesfortorture that shouldbepresenttosecuresatisfactory factors speaktothreeinterrelated periences adequate rehabilitation. Combined, their ex componentsfor what theyseeasimportant our research, we alsoaskedthe participants and wheretheresponsibilitylies. of As part mends what such rehabilitation should entail Committee Against Torture (2012) recom “as full rehabilitation as possible” and that the victimsshallhave 14states that torture Article We have establishedthat UNCAT’s (1984) rehabilitation Practitioners’ reflections onadequate (Norwegian RedCross, 2020). key componentofthecentres’ infrastructure systemsiswell acknowledged,support anda for thisgroup, ofsuchpeer theimportance centres providing specialisedrehabilitation navian countries, wherethereareestablished ment, andrehabilitation. IntheotherScandi those whoprovide interpretation, help, treat - A satisfactory rehabilitation service for rehabilitation service A satisfactory involvement. capacity-building, etc.) that includes user perspective,vidual andfamily advocacy, tion, treatment andrehabilitation, indi approach (identification, documenta- andcomprehensive An interdisciplinary If you know that you candosomething, then alsoraisedtheimportance A psychiatrist (Psychiatrist 2). (Psychiatrist - - - - - dren of torture victims cope and manage in the victimscopeandmanageinthe dren oftorture tantly, therehasbeenlittlefocusonhow chil- andthelifecycle.services, Overall, andimpor ministrative authorities, social, care and health as afieldofpracticethat stretchesacrossad Quiroga, 2011). Torture rehabilitation emerges viding andthosereceivinghelp(Jaranson & quality oflifecandifferbetween thosepro ber that ideasabout illness, socialskillsand to remem provision it is of services, important a communityandsocietalperspective. Inthe life. Hence, rehabilitation shouldalsoinclude tive, livingconditionsandoverall qualityof an individualperspective, perspec afamily andconsiderboth between relevant services Rehabilitation should thereforebecoordinated victims’torture lives and for their next of kin. 3. 2. from torture withneedformental healthcare from torture how patients/clients with traumasoriginating out. pointed out Severalto carry participants or maketheneededresponsemore challenging victims quate responsestotheneeds oftorture frameworks that eitherdirectlyhinderade institutional inourstudydescribe participants witnesses totorture. that peopleofallagesaresubjectedtoand 2019). tokeepinmind Itisalsoimportant opment indiverseways (Johansen & Varvin, impacts onchildren’s dailylifeanddevel and trauma amongadultrefugees suffering emergent research highlights how parental Norwegian context(RVTS, 2014), although tends tohave cross-cuttingimplications in guage competency. systemic,Ensuring cultural, andlan public andNGOs). the roleofdifferentinstitutions(private, legal andsocial)consideration of (physical, providers across service mental, Coordinated andsystematic interventions According to the participants, torture According to the participants, torture It is a cause for great concern that several concern It isacauseforgreat SCIENTIFIC ARTICLE ------TORTURE Volume 30, Number 3, 2020 95

------Many torture victims I have met, have been have met, tortureMany I have victims entails rehabilitation Social rehabilitation trust the professional and an alliance between some ex At the same time, and the patient. it that their expertise, outside it was pressed that wegian can be impossible to comprehend forwegian can be impossible to comprehend including language skills and reasons, several partici Several digital or otherwise. illiteracy, pants within the specialised health care service and social worker had taken the coordination assisting This involves roles upon themselves. services available and in navigating patients broader circum acknowledging the patient’s helping pa clear that It was stances and needs. an importanttients with practical matters was and in establishing a component of treatment This is crucial as effective alliance. therapeutic in a therapeutic setting depends on treatment (Psychiatrist 1). (Psychiatrist 1). 2005). back into society (Quiroga & Jaranson, charge of social and broader someone in Having becomes particularly issues welfare-related im authoriportant administrative to in relation Welfare such as the Norwegian Labour and ties, par by highlighted As (NAV). Administration often asked for help with who were ticipants, interpretation during and translation therapy inter sessions and medical appointments, net-based services decision letters and in Nor of one another when several professionals are professionals several when one another of are and collaboration Coordination involved. Social importance. therefore of paramount competency the professional ca was worker in interviewspacity most asked for for this concerns rehabilitation Social living study. As de life conditions. conditions and general scribed one participant, by themselves placed and have given social benefits, and are sitting there in the dark in a small flat, There is quite a bit of social reha by themselves. life a dignified required in order to have bilitation are fragmented and emphasised the impor and emphasised are fragmented in silos independent tance of not operating

------(Psy

One of the first things you One of the first things Two functions were repeatedly described repeatedly functions were Two Participants spoke to the necessity of of necessity Participants the to spoke The rehabilitation situation for this group for situation The rehabilitation of pants pointed out how rehabilitation services rehabilitation pants pointed out how the various regulations and rightsthe various regulations in terms programmes of social welfare and work in partici Many line with social rehabilitation. as particularly or less more but important, a ded provisions: absent in the rehabilitation the process case manager to coordinate icated to facilitate and translate and a social worker feel an actual improvement of their situation situation their of improvement actual an feel chologist 1). out by one participant, out by one participant, ensure to is treatment, providing when do should they so that are helping people in a way you that and rehabilitation, ranging from food, housing, housing, ranging from food, and rehabilitation, of documents to surgeryand translation and As pointed different therapeutic interventions. participants described the importance of a understanding of rehabilitation comprehensive treatment, needs to include the spectre of help, emphasised the importance of responding offered examples They to basic needs first. of torture lacking the very victims who were These electricity. or food as such essentials, needs and allow for a holistic approach and for a holistic needs and allow minimises approach that an time; sufficient participants Several drop-out. patient/client (Psychiatrist 3). (Psychiatrist 3). service complex respond to that provisions tients to mental health services. Most of them must them of Most services. health mental to tients make do with the primary health care service. They take the great majority of these patients patients within the mental health serviceshealth mental the within patients un is do do the minimum effort if you You satisfactory. It is very these pa difficult to refer all. at anything creased production figures – into which com creased production programmes rehabilitation do not prehensive necessarily fit: in particular, experiencein particular, challenges in access increasingly, and that services, the needed ing these focus on short plans and in treatment SCIENTIFIC ARTICLE SCIENTIFIC 96 TORTURE Volume 30, Number 3, 2020 organisation ofrehabilitation services,rather where done despite of the that their efforts Importantly, pointed out several participants the result of institutional or national priorities. needs, than aremoreoftenperson-dependent what canbecomprehensive rehabilitation vulnerabilities,clients withparticular and ofpatients/ ofagroup work andprioritisation to respondcomplexneeds. However, their their dedication andallow timeand resources have employers whoacknowledge thevalue of themwiththeirexperiences.trusted Some profound dedication tohelpthosewhohave severance, initiatives, personal networks, and throughper they develop skillsandexpertise shying away fromatasktootalltohandle, fessionals likethemoutthere. Rather than fessional capacity. There are many other pro- victimswhotheymeetintheirpro of torture be expectedintheirjobs, toaddresstheneeds of whomhave beyond what stretchedfar can we methighlycompetentprofessionals, many rehabilitation service. Inourresearch, factory forasatis but areallcrucial and authorities differentsystemiclevels These issuesconcern violations.and othergrave humanrights relating tohaving beensubjectedtotorture background, but also more specific challenges for all regardlessof health andcareservices adequate and equalaccessto as ensuring issues. togeneralchallenges, Itpertains such Norway. This resultsfromseveral interrelated in access toadequate rehabilitation services fromsecured arefar a refugeebackground victimswith shows that torture This article Conclusion rehabilitation needs. sionals torespondadequately totheirpatients’ involvement alsoofotherprofes andsupport ofthe terventions; highlightingthe importance therapeuticin- ditional andequallyimportant was time-consumingandleftlittleroomfortra - - - - - than becauseofit. powerlessness withasys whenfaced ac t prehensive rehabilitation process, therehabilita nweg about knowledge further for need all. at place abo u law,nursing, andpolicing, aret ensure localrehabilitation serv that wouldof actors contri stitutional priorities, frameworks, and inclusion Ipraty with nec- is Importantly, approach systematic essary. a and torture feel-i authorities, s public of mistrust ap d ap practice quality i ( P Protocol (OHCHR, 2004). amination –asencapsulated intheIstanbul protocolsforidenti ternational ‘t byinsuffi characterised as ing, particularly n va edge aboutthetopicandthat studentsofrele may providers lack sufficient knowl service i rehabili full for precon-dition a – identification good undertake to challeng-ing often torture to subjected c W rehabilitation. satisfactory does not facilitate s d i ietrt o Hat, 2015), Health, of Directorate h ordingly, are services n ot exposed to the subj oc on orture’ asatopic r entification, refer -r e have alsofoundprelimin nt professions, suchasmedicin ross thecountr a otocol is importantly refe otocol isimportantly and p and binding legally not p p -f me and even denial, both knowle both denial, even and me u umentation Gvn t Given arbitrary. ears is roach Given thegenerallacko services for torture victim fortorture services am t otr ijre, t eoe extremely becomes it injuries, torture i l of services. As the organisation of organisation the As services. of a wt it. with iar s ta n ti ed tee s n urgent an is there end, this To mi d s to s of research that investigates GPs’ investigates that research s y. i otr ijre therefo injuries torture an n SCIENTIFIC ARTICLE co a, ntoa systemat national a day, P a g als, andrehabilitation. d n ad dniiain and identification and , ractitioners whostrive to ractitioners n T rcie etiig to pertaining practice d cerns rehabilitation.cerns Ac ect l cie i unfamiliarity within unfamiliarity h k i el as part of their as part s bu n r gi afcs the affects again y tocontinuebe W ofessionals may be may ofessionals t knowledge about rred toinIS-1022 rred f te towards acom- coordination, in ary evidencethat ary ou s h

fi a o i i th l k t ces d catio ain o take to tation r tuge with struggle e the a p hat e, psychology, a e fragmented

l g e ar dge n nowledge escribe a escribe g Ist tem t uide e extent and ex- g of ngs ersons train- anbul about l hat i ne r i e c ------TORTURE Volume 30, Number 3, 2020 97

e It v

- opic a ha etation, the resulting a systematic, among a wide ce science. In tudies and raised s

tion on torture reha- injuries may require c All participants high- physical, mental, across physical, Accessible and interdiscipli- law, and poli they emphasised the importance and administrative authorities. levels. Torture legal, social and spiritual aspects of social and legal, This necessarily includes different y person dependent practice. y person dependent l al, accessible and comprehensive h A national plan of action would tation. A national plan of action ysiotherapy, psychology, occup tional health services and other relevant u i ovide the framework for ovide the framework e importance of this topic within educa- g l trengthening and institutionalising inter- onal therapy, dentistry, interpr i h r national plan of a i q ehabilitation service to people who ehabilitation service h i life. lighted the importance of both general knowledge and expertise, services can be extremely challenging both for the person requiring different services and the professional trying to provide and coor- dinate these. nary communities of practice are therefore a as highlighted by of great importance, survived torture – rather than the current survived torture – rather and fragmented services h public sector services. group of professionals. Few participants had themselves been exposed to the t of torture as part of their t tional programmes in medicine, nursing, p t social work, addition, - of frameworks on identifying, document ing, treating and rehabilitating torture injuries and of strengthening competence within existent service provisions (as would be ensured by a national plan of action). S disciplinary communities of practice with specialised expertise on the topic at all rel- evant rehabilitation legal b p and capacity-building A focus on knowledge programmes, the within relevant educational e r na Norwegian authorities develop and implement authorities develop and Norwegian a . . 2 3. 1 - - - -

we presented these presented we First and foremost, we recommend that recommend we First foremost, and 4 Upon completing the study, recommendations in a series recommendations of consultations public, with about 30 individuals from relevant including and humanitarianprivate institutions, some whom had partaken in the study and the rest being first to comment on our invited In House Rules applied. Chatham findings. broad consensus there was these consultations, for the need to include the topic of torture in programmeseducational and capacity-building, The significance plan of action. and for a national also broadly of communities of practice was different weightings albeit with recognised, in terms these should or could be of how to relevant institutionalised and made available suggest this recommendation We stakeholders. in particular for further as a topic research and discussion. To secure rehabilitation for torture secure rehabilitation victims To Finally, our findings suggest that torture that suggest findings our Finally,

4 gaps. professionals we interviewed for this study, we interviewed for this study, we professionals we to ensure that make three recommendations the authorities meet the current rehabilitation in Norway, the shortcomings the current of re in Norway, to be addressed. needs “model” habilitation Based on the experiences for by the accounted of equal and adequate health and care servicesof equal and adequate (Ministryfor the whole population of Health 2013). and Care Services, qualifications, and different understandings qualifications, and health lit systemic knowledge of health, need urgent an also therefore is There eracy. identi address and to follow-up continue to 2018) of Health, fied challenges (Directorate goal the Norwegian authorities’ as to achieve in terms serving of diverse an increasingly for instance This is manifested population. includ- through issues arising from language, ing the usage of interpreters without formal ally share in accessing public health, care and care public health, ally share in accessing as issues pertainingwelfare services, such to a competence more needs still that sector public the same barriers same the immigrants that gener more SCIENTIFIC ARTICLE SCIENTIFIC victims with a refugee background refugee a with victims experience 98 TORTURE Volume 30, Number 3, 2020 References Directorate ofHealth(2015, lastupdated Directorate of Health (2011). Brekke, J.-P., Sveaass, N., & Vevstad, V. (2010). Alpers, L.-M. (2017). Directorate of Health (2010). Committee Against Torture (2012). General Church CityMission, &OsloRedCross(2020). existent anddecentralisedservices. communities ofpracticethat supports gathered in one or more institutionalised of service, should be strengthened and rehabilitation,torture asregardsalllevels about competency and interdisciplinary to this finding, we suggest that specialised ofourparticipants.majority Inresponse and family IS-1022 reunited persons for asylumseekers,the healthcareservices refugees, familiegjenforente IS-1022 helsetjenestetilbudet tilasylsøkere, flyktninger og 24.04.2020). IS-1924]. Directorate ofHealth. managers inhealthandcareservices andpersonnel for regarding communication throughinterpreters helse- og omsorgstjenesteneIS-1924 kommunikasjon viatolkfor ledereog i personell IS-1855]. subjected totorture, assaultsandwithodontophobia [Facilitated dentalhealthprovision for persons for tortur, ellerharodontofobi overgrep IS-1855 tannhelsetilbud for menneskersomerblittutsatt Rapport samfunnsforskning, organisation andmanagement inNorwayseekers andtheEU: Identification, ogorganisering håndtering Sårbare asylsøkereiNorge og EU: Identifisering, Høgskolen iOsloog Akershus. patients with ethnicminority personnel’s needsintheirencounters competency i møtemedetniskeminoritetspasienter aspx?Lang=en& TreatyID=1&DocTypeID=11 org/_layouts/15/treatybodyexternal/TBSearch. 14 byState parties. comment no. 3. Implementation of Article 31/A%CC%8Arsmelding-Helsesenteret-2019.pdf kirkensbymisjon/content/uploads/2020/06/051241 2019]. 2019: Healthcentre- The hiddenhealthneed skjulte helsebehovet 2019. [ Årsmelding 2019:Helsesenteret-Det https://fra1.digitaloceanspaces.com/ Directorate of Health. Nasjonal veileder for Helsepersonells kompetansebehovHelsepersonells https://tbinternet.ohchr. [National guidelinesfor [Vulnerable asylum Veileder om Tilrettelagte ]. Doctoralthesis. Annual report Annual report ]. Instituttfor 2010:14. [Guidelines ]. [Health Directorate

Faryabi, N. (2017). Dyresen, G. (2017). Pasienter blir utsatt fortortur Directorate andDiversity (2018). ofIntegration Hvor Directorate ofHealth(2018). Directorate ofHealth(2017). Skjemafor Høyvik, A. C., & Woldstad, M. I. (2018). Jakobsen, M., Sveaass, N., Johansen, L. E. E., Høyvik, A. C., Lie, B., & Willumsen, T. (2019). Halvorsen, J. Ø. (26June2012). Fraværende tilbud of Oslo. dental healthservices within services tannhelsetjenester [Useofinterpreting tidsskr.16.1029 7–8 (137), 511. https://doi.org/10.4045/ neglected]. [Patientsare neglisjert subjectedtotorture mye- ts/9471e477a7494d11826d63cf9af21ac1/hvor- 2018].register inthenational interpreter among interpreters work? much doqualifiedinterpreters A survey 2018[How blant tolkeriNasjonalttolkeregister mye tolker?Enundersøkelse jobberkvalifiserte health] (Unpublished). [Evaluation ofthenational onimmigrants’ strategy Nasjonal strategiominnvandreres helse2013–2017 helseundersokelse-flyktninger-asylsokere.pdf c6429c7 8496e47b185f9f7b45101e7b3/skjema- persons]. for asylumseekers, refugees, reunited andfamily [Formforhealthexaminations familiegjenforente forasylsøkere,helseundersøkelse flyktningerog of Health. Odontologisk psykologi(pp. 251–260). T. Willumsen, L. Myran subjectedtotorture], In treatment forpersons Tannbehandling [Dental av torturutsatt https://doi.org/10.1111/eos.12592 traumatisk stress. ]. seekers asylum mental healthamongrecentlyarrived reception centres: Trial for assessing ofinstruments helse hosnyankomne asylsøkere av psykisk for kartlegging Utprøving av instrumenter & Skogøy, E. (2007). Gyldendal Akademisk. of European Journal and symptomsofposttraumatic stressdisorder. experiences Dental anxietyinrelation totorture victims]. fortorture [Absentservices for torturofre jobber-kvalifiserte-tolker jobber-kvalifiserte-tolker Nasjonalt kunnskapssenteromvold og https://www.fhi.no/contentassets/ Klassekampen. Tidsskrift for legeforening Dennorske Tidsskrift https://www.imdi.no/contentasse Bruk av tolketjenesterinnenfor Bruk SCIENTIFIC ARTICLE ]. Masterthesis. University

Oral Sciences,127 65–71. Psykisk helseimottak: &J.P.Å. Evaluering av Evaluering [Mentalhealthin Lein (Eds.),

Oslo: ,

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The Status Status ]. Oslo: Oslo: ]. Årsmelding Status [Status (2–3), 1–111. 1–111. (2–3), https://www. 165 arbeid og forslag til forslag arbeid og

Torturert og glemt? og Torturert Istanbul Protocol: Manual Protocol: Istanbul https://www.ohchr.org/ , Torture Oxford textbook of migrantOxford (chapter 46). Oxford: Oxford Oxford: (chapter 46). . https://doi.org/10.1002/14651858. 11. https://www.regjeringen.no/contentassets/78c fs/ a1005cf834de8961f06357c91aa92/no/pd nou201120110010000dddpdfs.pdf norsk psykiatriskfor 1.1.2013–31.12.2013 forening [Annual report the Norwegian Psychiatric for 1.1.201331.12.2013].Association Identifiseringog rehabiliteringav torturutsatte i and Identification and forgotten? [Tortured Norge of persons torture subjected to rehabilitation Røde Kors. Human Rights) (2004). of and Documentation Investigation on the Effective Inhuman or Degrading Other Cruel, and Torture or Punishment. Treatment Documents/Publications/training8rev1en.pdf interventions social and welfare Psychological, for psychological of health and well-being of Systematic Database Cochrane torture survivors . Reviews, CD009317.pub2 A desk study torturemotivated and its survivors: review of the literature. stress og selvmordsforebygging) (2014). stress og selvmordsforebygging) (2014). for oppfølging av torturoverlevere i Norge i 2014. i 2014. i Norge torturoverlevere oppfølging av for tjenesteapparatets over Oversikt Torturkonvensjon tiltak i henhold til FNs of torture follow-up survivorsfor in in Norway and work Overview of the service2014. apparatus’ according to the UN’s provisions for suggestions (Unpublished). ]. Convention Torture Against plan]. a national have must plan [Norway Aftenposten. Article 14 of the Convention in Rehabilitation Inhuman, and Other Cruel, Torture Against or Punishment. Treatment or Degrading 1–25. International, 51 (1), Lawyer americanbar.org/groups/international_law/ publications/the_international_ lawyer/ of mental health and options for documentation of torture In arrived in newly asylum seekers. Bhugra (Eds.), D. psychiatry University Press. or Treatment Degrading Inhuman or Cruel, https://www.ohchr.org/en/ Punishment (1984). Norwegian Psychiatric Association (2014). (2014). Association Norwegian Psychiatric Norwegian Red Cross (2020). High Commissioner for OHCHR (Office of the (2014). C. D. C. A. Williams, & B., Kellezi, N., Patel, Politically- (2005). M. J. & Jaranson, J., Quiroga, RVTS (Regionalt ressurssenter om vold, traumatisk traumatisk (Regionalt ressurssenter om vold, RVTS Sveaass, N. (26 June 2013). Norge må ha en nasjonal (26 June 2013). N. Sveaass, (2018). M. C. & Grossman, F., Gaer, N., Sveaass, Early assessment (2020). J. N. B. & Lie, N., Sveaass, and Other Torture Against UN Convention 21, https://www. (2000, (2000, ].

— Young — Young adults’ I tell my mother mother I tell my , Torture Directorate of Directorate

In the welfare state’s state’s [In the welfare (pp. 30–39). Newcastle Newcastle 30–39). (pp. ]. Commissioned by the ]. (2), 221–235. 221–235. Childhood, 26 (2), I velferdsstatens venterom: venterom: I velferdsstatens Nordic work with traumatised with traumatised Nordic work https://lovdata.no/dokument/SF/ Identification and 2013–2014 [Identification approach. approach. Identifisering, tilrettelegging og oppfølging tilrettelegging Identifisering, last updated 01.02.2019). Forskrift om 01.02.2019). last updated prioritering rett til nødvendig helsetjenester, av rett helsehjelp fra spesialisthelsetjenesten, til behandling i utlandet og om klagenemnd (prioriteringsforskriften) about [Regulation prioritisation of health services, right to necessary specialised health care from the righthealth services, and abroad to treatment about appeals committee (the prioritisation regulation)]. forskrift/2000-12-01-1208 helse – god omsorgstjenester helse- og Likeverdige helse om innvandreres Nasjonal strategi alle. for care health and 2013–2017 [Equal and adequate strategy National services everyone. health for – good about immigrant 2013–2017 health regjeringen.no/contentassets/2de7e9efa8d341cfb8 rdige_tjenester.pdf 787a71eb15e2db/likeve om endringer mot (forbud i forvaltningsloven bruk barn av som tolk) [Act amending the Public Act (prohibition on the use of Administration children as interpreters)]. LOV-2016-06-10-23. https://lovdata.no/dokument/LTI/lov/2016-06- 10-23 services of torture programmes: rehabilitation history and recommendations. of Health and the Directorate (Unpublished). Immigration. asylsøkere for Mottakstilbudet https://doi.org/10.1177/0907568219828804 historical views and and healthcare in Norway: Guribye E. Overland, In G. critical perspectives. Lie (Eds.), & B. really care Do we refugees: Cambridge Scholars Publishing. Tyne: upon (2015). i sårbare asylsøkere med særskilte behov av fra anbefalinger Erfaringer og ankomsttransitt: pilotprosjekt asylum seekers with particular of vulnerable follow-up phase needs in the transit asylum for Reception provisions room: waiting Ministryseekers]. of Justice and Public Security. 98–140. 98–140. experiences of childhood in refugee families: A experienceschildhood in refugee families: of qualitative that … sometimes he didn’t love us love sometimes he didn’t … that Ministry Services of Health and Care (2013). Ministry Lov of Justice and Public Security (2016). NOU 2011:10 (2011). Jaranson, J. M., & Quiroga, J. (2011). Evaluating the Evaluating (2011). J. & Quiroga, M., J. Jaranson, Ministry Services of Health and Care SCIENTIFIC ARTICLE SCIENTIFIC Refugees (2014). E. & Hauff, N., Sveaass, B., Lie, M. & Bendixen, V., Vevstad, N., Sveaass, B., Lie, Johansen, J. D., & Varvin, S. (2019). (2019). S. Varvin, & D., J. Johansen, 100 TORTURE Volume 30, Number 3, 2020 this article. We also want to thank our col versionof commentstothefirst constructive four anonymous peerreviewers whoprovided their contributions. Thanks are also due to the for wishtothanktheparticipants The authors Acknowledgements Varvin, S. (27May 2015). Dårligbehandlingav Varvin, S. (2003). the project of thecourse vided valuable insightsduring leagues at the Norwegian Red Cross who pro victims]. [Insufficienttreatment oftorture torturofre coping mestring professionalinterest/pages/cat.aspx ] . [ Oslo: Universitetsforlaget. Dagsavisen. Nye Meninger. Tortured andforgotten? Flight andexile: Trauma, identityand Flukt og eksil: Traume, identitetog - - SCIENTIFIC ARTICLE TORTURE Volume 30, Number 3, 2020 101 ------

8

, Nathalie 3 Athens, Greece. Athens, Operational Centre Operational Operational Centre Operational

, Aikaterini Komita 7 Babel Day Centre for the Mental Health of Babel Day Médecins Sans Frontières, Greek Council for Refugees, Médecins Sans Frontières, Migrants and Refugees, Athens, Greece Athens, Migrants and Refugees, [email protected] to: Greece. Athens, Brussels, [email protected] to: Italy. Rome, Brussels, : In-depth interviews with surviMethods: 19 survivorsResults: and 10 key informants Correspondence to: [email protected] Correspondence to: Correspondence to: [email protected] Correspondence to: , Christos Eleftherakos , Christos 2 8) 9) was incomplete as it did not meet their accom their as it did not meet incomplete was through stability nor provide needs modation Survivors wary were granting refugee status. of trusting other Congolese people after expe 6) 7) vors of torture clinic a rehabilitation attending and key informant interviews with represen analysed to thematically was Data Athens. construct codes and themes. and develop reha survivors, many For interviewed. were Abstract This study explored the experi- Introduction: for male Congolese ences of rehabilitation as well survivorsAthens, of torture in living as the potential role of the wider Congolese in supportingAthens rehabili in community tation. Congolese community in of the wider tatives Despite the an unclear concept. was bilitation for services the clinic appreciation at received psycho- and physical of amelioration the and survivors logical rehabilitation felt symptoms, , Maria Episkopou 6

of Cape Centre Centre Centre Research Democratic 9 University , Emilie Venables Brussels, Belgium. 1

Centre Brussels, , Nikos Gionakis DRC) felt their Operational Operational Operational Operational 5 [email protected] [email protected] [email protected] [email protected] South Africa. Greece. Greece. Greece. Operational Luxembourg. Division of Social Sans Frontières, Sans Frontières, Sans Frontières, Sans Frontières, Athens, Athens, Athens, Department, Médecins Sans Frontières, Department, Cape Town, , Declan Barry 4 own, A synergic, participatoryA synergic, approach is between recommended in collaboration and policy-makersorganisations and the local Congolese community. Whilst many survivorsWhilst many did not trust local the people, Congolese other community could still support their by assisting with their rehabilitation integration in Athens. Survivors of torture from Republic of Congo ( without incomplete was rehabilitation refugee status stable accommodation, and employment. Médecins Médecins Médecins Medical Médecins Brussels, Operational Centre Brussels, Correspondence to: Brussels, T Correspondence to: Brussels, Correspondence to: Luxembourg, School of Public and Behavioural Sciences, Health and Family Medicine, Correspondence to: Unit (LuxOR), • • Key points of interest • 3) 5) 2) 4) 1) Severy and Gianfranco De Maio and Gianfranco De https://doi.org/10.7146/torture.v30i3.120895 All rights reserved. Victims. Torture International Council for Rehabilitation community in their support community in Athens and the role of the Congoleseand the role in Athens Psyrraki Maria-Angeliki litation for Congolese survivors of torture Congolese survivors litation for - of rehabi Experiences for stability: Looking SCIENTIFIC ARTICLE SCIENTIFIC 102 TORTURE Volume 30, Number 3, 2020 found themselves navigating anunstableand processes ofrehabilitation. Many participants dation and insecure asylum status, impeded Greece, including poor access to accommo other organisations. with and integration, especially in partnership sharing in practicalissuessuchasinformation clinical elementofrehabilitation but aiding organisations was notseenasreplacingthe nity. and The role of local Congolese leaders themselves withthelocalCongolese commu anddidnotalways torture associate riencing who have gonethrough borderprocedures tainment (Episkopou et al., 2019). Those of slow transit and con become acountry EU-Turkey statement in2016, Greecehas (Bourmpoulas, 2019; MSF, 2017) theydesperately need rehabilitation services often notrecognised, lackingaccesstothe andill-treatment are oftorture and survivors isincreasing(UNHCR,migration 2020a), Greekcontext,relevant inthecurrent where (SoT). of torture survivors This is especially rehabilitation responsetomeettheneedsof to Europehave highlightedtheneedfora (OHCHR, flows 2017). Increasedmigratory victims 35 percentofrefugeesaretorture UNHCR hasestimated that between 5and Introduction Greece, Congolese, asylumseekers, refugees. Keywords organisations and policy-makers. be moreproactive shouldnotbeignoredby theless, thewillingnessofcommunityto threatens socialcohesion.lack oftrust None rehabilitation remains complex and a porting wider Congolese community in Athens in sup towards “feeling wholeagain”. The role of the unpredictable landscape in theirjourney Discussion Following theimplementation ofthe : torture survivors,rehabilitation, torture : in Systemic shortcomings - - - - - law, identification and subsequent provision the list of vulnerabilities recognised by Greek are included in of torture While survivors according toUNHCR(OHCHR, 2017). in thegeneralrefugeepopulation of5percent even the lowest estimated prevalence oftorture plications in2019 (AsylumService,2020), or the77.285asylumap cantly low considering claim. This number, however, signifi appears cants identifiedat alater stageoftheirasylum registration; thereisnodata available onappli at history cants whodisclosedtheirtorture 2020). onlytheappli This numberconcerns ofviolenceorexploitation (AIDA,forms tered asvictimsoftorture, rapeorotherserious accommodation (UNHCR,ported 2020b). andrefugeesinUNHCR-sup asylum seekers and Athens hoststhehighestnumberof 2019 (Asylum Service, 2020),Greece during second highestnumberofapplications across units in the wider receivedAttica region the can takeyears. ofGreece,the borders but asylumprocedures to freedom of movementgain the right within lifted restrictions and hadtheirgeographical rights abuses, has rights sexualviolenceand torture fleeing thecountry. An increaseinhuman dependence, ledtopeople which has inturn byinstabilityandconflictsincein acterised The politicalsituation inDRChasbeenchar through Greece’s islands(UNHCR, 2020a). forpeople arriving oforigin common country within thenational healthsystem. As ofOctober2020, nosuchprovisions exist provider.a public-sectorhealthcareservice tal orbyanadequately trained doctorwithin shouldbedonebyapublichospi of torture law (L. 4636/2019), ofsurvivors certification 2020). Inaddition, accordingtoGreekasylum isnotalwaysof support guaranteed(AIDA, The regional asylumofficesand The regional In 2019, the DRC was the third most In 2019, were 233asylumseekers regis SCIENTIFIC ARTICLE ------TORTURE Volume 30, Number 3, 2020 103 ------Concerning the definition of SoT, MSF MSF Concerning the definition of SoT, 1030 individuals from 47 Approximately In October 2014, Médecins Sans Fron Médecins 2014, In October consideration the availability of potential par potential of availability the consideration recom and work seasonal had who ticipants from the MSF clinic therapeutic mendations Study Population The included in the study. groups were Two first consisted of key informants from the recruited Athens, Congolese community in who held formal sampling, using snowball or informal positions of leadership and/or with community involved influence and were The second consisted of male, organisations. the MSF enrolled at Congolese SoT actively including SoT also receiving servicesclinic, sampling Purposive GCR. and Babel from into Taking used to sample survivors. was follows the ICRC definition of torture of definition ICRC the follows and ill-treatment while GCR 2016), (ICRC, (UN UNCAT of definition the applies the ben As a result, 1984). Assembly, General eficiary cohort three services across the does the This study focuses on overlap. not always MSF clinic cohort. been seen in the have different nationalities with those MSF clinic since October 2014, from DRC comprising of the overall 26.2% beneficiaries. the rehabilitation: DIGNITY - Danish Insti the rehabilitation: Trauma, the Centre for Torture, tute against (University of Essex), Asylum and Refugees Human Rights Founda REDRESS and the tion Turkey. of with the collaborating tières (MSF) began health, mental medical, providing consortium, servicessocial and physiotherapy to SoT (the Interdisciplinary is collaboration MSF clinic). There is no public the core of this partnership. specialised support program for SoT. support. Babel and GCR have cooperated cooperated and GCR have Babel support. actorswith several experienced in the field of ------

, 2018; MSF, 2016, 2017). 2017). 2016, MSF, 2018; , ć In 2013, the Greek Council for Refu In 2013, The study aimed to understandThe study aimed more Men make up the majorityMen make up the of the adult ing legal, social, psychological medical and social, ing legal, psychologicalsupport and mi for refugees The in legal and social support. GCR grants; services holistic program provides includ the Mental Health of Migrants and Refugees Program the implementing began (Babel) Torture Survivorsof Rehabilitation the for of Babel specialises in Athens. in “Prometheus” Persson & Gard, 2013, ODIHR/CTI, 2018). ODIHR/CTI, 2013, & Gard, Persson Centre for gees (GCR) and the Babel Day Many rehabilitation programs rehabilitation multi a adopt Many disciplinary with sur working approach when 2011; vivors of torture & Quiroga, (Jaranson living in Athens. living in Athens. Study Setting study involved in-depth interviews (IDIs) study involved with selected survivors receiving rehabilita tion services key informants and Congolese Study Design exploratory used A qualitative approach was place taking collection data with study, this in This June and September 2019. between Methods Athens has a role to play in supportingin play to role a has Athens re their through informinghabilitation improving and services community links. and strengthening about the perceptions of the rehabilitation of of the rehabilitation about the perceptions male Congolese survivors of torture in Greece, in and whether the Congolese community culties in accessing supportculties in accessing particu services, to relating issues and health mental for larly torture (Arsenijevi migratory flows to Greece (UNHCR, 2020a). 2020a). migratory (UNHCR, to Greece flows “not as classified are frequently males Single leads to diffi which by default, vulnerable” been documented (Freedom from Torture, Torture, from (Freedom been documented 2018). UKFCO, 2018; SCIENTIFIC ARTICLE SCIENTIFIC 104 TORTURE Volume 30, Number 3, 2020 provided inFrench. were consentforms tion sheetsandinformed anonymity.tional steptopreserve Informa full nameontheconsentform, asanaddi consent but were their not required to write documents. gave Keyinformants written cautious ofsigningtheirnamesonofficial the processofapplyingforasylumareoften orwho arein who have torture experienced in this context as those deemed appropriate taken fromallsurvivors. Verbal consentwas Switzerland. Verbal consentwas informed Sans FrontièresEthicsReviewBoard, Geneva, This studywas approved bytheMédecins Ethical Considerations Braun andClarke(2006, p. 87). analysis followed thesixstepspresentedby containedwithin.information The processof the development ofmainthemesfromthe eration through examination, andinturn, was analysed inductively, withcodinggen- Thematic analysis was conducted, anddata Data Analysis view whichwas conductedover Skype. inter fromonekeyinformant in person, apart speak French. were conducted All interviews assistingtheinvestigatorstors whodidnot French, LingalaorGreekwiththreetransla pants. were conductedin In-depthinterviews investigator- to partici was providing services avoid therapeuticmisconception. Noother had directlyprovided socialwork services,to towhomshe survivors PI didnotinterview investigators conducted the interviews. The investigatorThe principal (PI)andtwo co- Data Collection were notin Athens. study. Sixrefusedtoparticipate, andeight aboutthe team, were informed 33survivors - - - - tion as the support theyreceived aftertheir tion asthesupport and 10keyinformants. were conductedwith19survivors Interviews Study Population Results iftheyrequested.psychosocial support were offeredand/orprovided withadditional to avoidtorture re-traumatisation. Participants of to talkabouttheirindividualexperiences werebeing identified. notasked Survivors have been omitted, to prevent individuals from person. ings andnotlinkedtotherehabilitation of a or build with therestoration offurniture word orconfused was oftenmisunderstood rently receivingrehabilitation services. The term “rehabilitation,” even iftheywere cur- pressed confusionwhenaskedtodiscussthe rehabilitation process: ex- Multipleparticipants “What isrehabilitation?” ofthe understandings ofRehabilitation Experiences citizens. orwere naturalisedresidence permits Greek rejected. had Sixoutoftenkeyinformants on theirasylumclaimorhadbeen 19 survivors, 13were waiting foradecision weretwo unemployed. keyinformants Ofthe cure accommodation. and Sixteensurvivors interviews, 10were stillhomelessorininse in they arrived Athens, andat thetimeof or residingininsecureaccommodation when tively. Ofthe19survivors,16were homeless was respec 36and35years ants andsurvivors key informant. The average ageofkeyinform Congolese, fromone andallwere maleapart Several survivors described rehabilita described Several survivors Official job profiles of the key informants Official jobprofilesofthekeyinformants SCIENTIFIC ARTICLE 1 wereAll interviewees - - - - - TORTURE Volume 30, Number 3, 2020 105 ------: An overarching : (Survivor 9). (Survivor 14). All survivors expressed fears around their Rehabilitation as stability Rehabilitation lems. I had problems; I had many problems I had many I had problems; lems. head… Everyin my time I had an interview I felt social worker, or a with a psychologist relieved” is to take someone rehabilitation “The biggest grant him international protection to safety, and I cannot ‘I am safe, he can say: so that for And after that, be deported country.’ to my to integrate someone in the society and it’s me, he can so that him as a human being, treat find a job” “Without the psychologists, the social workers; the social workers; “Without the psychologists, They […] already dead. be would I maybe give you they don’t money, give you can’t This helps. respect. you they show but food, prob expose all your you there, go When you itation process. process. itation living conditions, asylum papers, employment, employment, asylum papers, living conditions, They described feeling family or their health. insecure and being unable to make long-term These concerns the rehabil threatened plans. periences of rehabilitation was the need for periences the need for was of rehabilitation housing and inte to asylum, relating stability, Survivors dif at were gration in Greek society. whereas ferent stages in their asylum process, informantskey most for Greece in been had years and had residency citi many or Greek Survivors as es status their legal saw zenship. in life and believed forward sential for moving re being granted enhance their asylum would years for the waited had Many habilitation. outcome of their asylum interviews. theme of participants’ expectations and ex and expectations participants’ of theme health status, their ability to interact again with ability to interact their health status, support:others to receive and ------At - Survi Health is first ” (Survivor 9). ”

” (Key Informant 2). (Key Informant 2). ” I mostly see [rehabilita (Survivor 3). Ultimately, re Ultimately, (Survivor 3). (Survivor 13). (Survivor 13). Rehabilitation and improved health: health: and improved Rehabilitation A relationship based on trustA relationship with those it’s less than two. That’s what I call rehabilita what That’s less than two. it’s tion” stantly angry. But today there is no anger anger there is no But today stantly angry. I had a problem I can sleep. in me anymore. asked physiotherapist When my back. with my me a scale he gave the pain, me to evaluate When I came here, I think. to four, from zero today but three; above even was pain level my “Before I had difficulty sleeping, I was con I was I had difficulty sleeping, “Before a key part of seeing an improvement in their a key part of seeing an improvement providing care was described care was by survivorsproviding as one time I couldn’t be with other people, I was iso was I people, other with be couldn’t I time one crying was I my of thinking also I was and lated. has been reduced that but family… vors described how their physical and mental describedvors physical their how reha as a result of the health had improved “ Athens: servicesbilitation in they received habilitation for survivorshabilitation of torture about was whole and being able to func being healthy, tion again in their everyday life. part of it [rehabilitation]. Then the second part is part of it [rehabilitation]. Then the third part is being living conditions. good protected [legally]” ical symptoms, improved health and overall overall and health improved symptoms, ical One survivor rehabil saw life circumstances. “ three parts: as having itation pending on their condition survivorsMany described as the rehabilitation phys mental and in their change a for desire tation was mentioned: “ mentioned: was tation someone to talk to support, tion] as a psychological then graduallyabout their problems and someone de with medication, with advice, them, to follow workers, psychiatrists and lawyers. Key infor psychiatrists and lawyers. workers, on the need for mental mants focused more health support concept of rehabili when the experiences of torture and listed multi-dis ciplinarymembers team medical including social psychologists, physiotherapists, doctors, SCIENTIFIC ARTICLE SCIENTIFIC 106 TORTURE Volume 30, Number 3, 2020 also reflectedupon obstaclesrelating to the lenge forallthe survivors, andkeyinformants it pay for my rent?Eating? Don’t even talkabout looking for, how willithappenwhen Ican’t even homeless: “ poor-quality, sharedaccommodation orbeing was livingin the perspectiveofsurvivors bilitation went beyond papers: me alot the decisionIhave alotofthoughtsandthat hurts doing nothing…allthetimeIspendwaiting for secure andwell: “ vivors, preventing them from feeling stable, ” 4). (Survivor vivor 8). think ofwhat happenedinmy country” again. I’vehere, never beeninprison but I why I’mscared. I’mscaredofgoing toprison get rejectedandtheyputmeinprison? That’s know what willhappen, andthenwhat ifI where Idon’t have any papers? You don’t not OK. How canIbeOKinacountry “I was hopefulat thebeginning, but I’mstill rehabilitated 100percent” living you justcan’t say that we have been ill, mentallyandphysically. The way we are percent becausethelack ofjobsmakesusvery “We can’t say that we arerehabilitated 100 with my life’” strong,’very ‘I amstillalive’ and ‘I cango on mightsaysomething… theperson that ‘I am if [they]cannotovercome it, toat leastgain coming what happenedto[them]before, or papers. Rehabilitation hastodowithover “Rehabilitation doesn’t onlyhave todowith Another challengetorehabilitation from explainedhow reha This keyinformant The waiting processwas, formany sur Integration into Greek society wasIntegration a chal ” 17). (Survivor So, therehabilitation that we are (Key Informant 8). (Key Informant As longasIremainlikethis, (Survivor 5). (Survivor (Sur - - - - - not producing anything yet… What’s the point in point in staying alive? I am not productive; I am more. back inCongo, threatened that identityeven members family their basicneedsorsupport along withtheirpresentinabilitytocover even strong andself-reliant; experiences pasttorture I live? they’ve me, given erything withoutajob, how can a psychiatrist. Buttheproblemisthat despiteev worker, Ihave adoctor, Ihave apsychologistand as “breadwinners”: “ role their challenge for many who felt unable to fulfil I didn’t anything. understand Ileft Not inFrench. So, Istarted, day, first secondday: the lessons in English,they give Greek or Arabic. obstacle. “ classes that would helpthemovercome this suchaslanguage unable toaccessservices with thelanguage go becausethere isnotranslator, thereisaproblem vices. “ to beinvolved inactivitiesorbenefitfromser wereGreek meantthat many unable survivors language and culture. Not speaking English or for rehabilitation: asanessentialstep ognised bykeyinformants wassequent integration unanimously rec staying alive?’” we needtolook for ifwe want towork with feel betterinhisbody... These arethepractices morning, hewillhave anoccupation, hewill a rhythm. waking upinthe Hewillstart and hewillseeotherthings. Hewillget into GCR. Hewillgo towork, hewillsocialise, or tenpeopleheknows in Babel, MSF, or step away fromhiscommunity andthefive “[Employment] changes theperson. Hewill The importance ofemployment andsub The importance how menshouldbe described Participants Being unabletoaccesswork was alsoa ” 10) (Survivor “I was thinkingtomyself , ‘What’s the I can be referred toahospital,I canbereferred but Icannot I registered for [Greek]lessons.I registered But (Survivor 14) (Survivor ” 5). (Survivor were Others SCIENTIFIC ARTICLE ” 6). (Survivor I have a social - - - - TORTURE Volume 30, Number 3, 2020 107 ------amongst (Survivor no secrets” Word of mouth was of mouth was Word (Key Informant 3). Potential role of Congolese community members role of Congolese Potential Whilst there was some supportWhilst there was for the idea The formal de was community association Congolese interpreter and I said no. I refused. I refused. interpreterCongolese and I said no. someone having I prefer I spoke in French. not someone Congolese” Moroccan, 8). “I don’t want [another Congolese person] to [another Congolese want “I don’t is that My fear happened to me. what know some somebody else, he will tell somebody else, country my until maybe will be in body else, formed me” and look for bilitation services to spread. Many survivors Many servicesbilitation to spread. supportingto directed were services (includ by other Congolese people, ing rehabilitation) that the community could supportthat Congolese the issue of trustof talking and the fear SoT, partic tortureabout a challenge, remained ularly from the perspective of the survivors. in supporting rehabilitation: an important for information about reha way luctant to share and seek support from other A few survivors Athens. Congolese people in preferred with other French-speak associating Con other Africans purposely and avoided ing “ golese people as there are also concerned Participants were Congolese. tor about being identified and potentially and key informants and survitured again, vors shared anecdotes of information travelling back to Africa: scribed with ambivalence by survivors. It is It is scribed survivors. by with ambivalence although with paid registration, an association support to registered is offered freely members a was it some, For non-members and alike. others but described a di place of unification, Congolese migrants had vision between who years ago and those who had fled settled many andgossiping people of fear A asylum. seeking talking about them also led survivors to be re ------Par Being able Being (Key Informant

(Key Informant 9). Trusting other Congolese people: people: Congolese other Trusting Lack of participation in the formal com Key informantsKey reluc the stressed also Many key informants were unaware or re key informants unaware Many were reached the physical, bodily level then there bodily level reached the physical, the the other level, but might be a discussion, it is not discussed and is underesti psychology, mated” “No, we do not discuss [torture]. If it has do not discuss [torture]. we “No, this vulnerable population” population” this vulnerable 8). “Since I left my country…“Since I left my to trust someone? a asked me if I wanted [My social worker] golese people in Athens. golese people in to trust others a huge challenge for many was survivors seeking from them prevented and support from and interacting with other Con gain. Poor attendance also meant that there also meant that attendance Poor gain. to others. “reach out” occasions to few were munity association was attributed to lack of lack attributed to was association munity lack of interest or a lack of immediate time, tance to share psychological difficulties due to torture out of fear and embarrassment: grammes supporting SoT, although most were although most were grammes supporting SoT, services of individual aware such as language classes or mental health support. luctant to discuss issues surrounding torture. of pro also a limited knowledge There was the Congolese community could be involved could be involved the Congolese community this and how Athens, in supporting SoT in support could be given. association do for me?” do for association of rehabilitation: Community knowledge they thought asked whether ticipants were The Role of the Formal and InformalThe Role of the Formal Congolese can the “What Community in Rehabilitation: SCIENTIFIC ARTICLE SCIENTIFIC 108 TORTURE Volume 30, Number 3, 2020 Athens and inform themaboutavailableAthens andinform ser amongstCongolesepeoplelivingin torture of and churchestoraisetheissueofsurvivors munity organisations includingassociations andworking withothercom viding support mation aboutrehabilitation services the communitycouldaidspreadofinfor how theirinfluentialrolewithin ally described uals orthroughtheassociation. They addition information, and online, in person as individ already employing ofdisseminating strategies explainedhow theyare and keyinformants its entirety. in able tosubstitutearehabilitation program as specialistorganisations, thuswould notbe munity ingeneraldidnothave thesameskills others. their positive of rehabilitation experiences with expressedawillingnesstodiscuss survivors withCongolesepeople,their experiences some people who needed help.to successfully orient benefit fromtransferofknowledge andbeable up to the wider community, so that they could toopen rehabilitationsations services offering vices. theneedfor organi They described this role” haven’t studiedpsychology. They cannotplay psychologist orthepsychiatrist, becausethey don’t have thecapacitytoplay theroleof to play thisrole, do you understand? They “The communitydoesnothave thecapacity 8). (Key Informant been, quoteunquote, healed, andrehabilitated” have beenthroughthisprocessandtheyhave ofthoseprojects,have beenbeneficiaries who the churches, inviting seminars peoplewho “Meeting withthecommunity, meetingwith Key informants pointed outthat thecom Key informants Despite theoverall reluctancetoshare saw a potential role in pro Key informants (Key Informant 10). (KeyInformant ------literacy, inRiggsetal. asdescribed (2016), of services. This couldbeanissueofhealth many despitetheirdirectexperience survivors, habilitation ofSoT. there couldsupport community members if-andhow- localCongolese to understand mal Congolesecommunity. We alsowanted and infor of the formal and from members attending arehabilitation clinicin Athens, of torture tive of male Congolese survivors ofrehabilitation fromtheperspec periences This studyexploredtheperceptionsandex Discussion portance ofasecureand stablecontext–po portance However, highlightstheim thestudyfurther (Persson &Gard, 2013). This isnosurprise. tion were improved physical and mentalhealth etal.,provision (Bragin 2014). well-being future service that could inform definitionofrehabilitation and participatory It alsodemonstrates thepotentialforajoint, vices themselves andtheobjectives ofcare. theser understand ensure that beneficiaries suchastheonein thisstudy,tion programs to oftheintakeprocessinrehabilita portance unmet. highlights the im This lackof clarity tial toincludeexpectations that willremain as an unknown concept that has the poten lese in Athens was recognized. needsofCongo address thenewlyemerging what areyou going todowiththisinforma whoperson mightwant totellyou something, change ofmentality. Becauseit’s notonlythe “That’s what we want inthecommunity, a to confidein” regardless ofgender, peoplecouldfindsomeone tion? Ifthementalitychanges, thentomorrow, However, theneedforcommunityto Survivors’ mainexpectations of rehabilita Rehabilitation was anunclearconceptto (Key Informant 5). (Key Informant SCIENTIFIC ARTICLE ------TORTURE Volume 30, Number 3, 2020 109 ------” for ” a lack of ties with ethnic and host ethnic of ties with a lack Involving Congolese community organi Involving Destruction a direct aim of social links is service provision, enable more people to be be enable more people to service provision, the potential isolation reached and mitigate The potential for survivorsthat can face. of a “dominant” narrative, may fall into. We We fall may into. narrative, “dominant” of a do not intend to force the notion of a shared group upon beneficiariesclinic (Episko of the they disclose nor insist that 2018), pou et al., the horrific torture details of but with others, instead wish to reflect on ideas of belonging of finding sanctuaryand possible ways and stability in shared experience (Papadopoulos, 1999). in a country churches or associations sations, such as Greece where current services are could improve and overstretched limited have seen, originating from the same country seen, have com is not enough to constitute a functional tor been have who those for especially munity, belong to may Refugees tured by compatriots. not necessarily different communities, several with an restricted by language or nationality, importance placed on the definition coming Cor & (Mitchell itself community the from un (2019a) Papadopoulos 2009). rea-Velez, while talking about the derlines the same idea, assumptions and heterodetermination hu that representatives as manitarian organisations, and consequence of torture, and the restoration and the restoration and consequence of torture, of trust in othersis an integral part of the reha Most 2018). process (ODIHR/CTI, bilitation of the survivors described the care they how gradually received restored their capacity to Lack of trust also presented trust was others. as a deterrent to sharing their experiences with which brings to the issue us other Congolese; in Studies have of community involvement. dicated “ that communities can be a serious source of stress we as however, 181); p. 2011, migrants(Dow, ness on the perspectives of refugee men and of refugee perspectives ness on the especially in survivorsfathers, of torture. ------

, 2018, Neikirk, 2017) illustrates not so 2017) illustrates Neikirk, 2018, , Survivors also described torture how and Survivors the in this study clearly stated ć in-depth, but there is a definite need for aware but in-depth, services within the refugee context (Papado not did study This 2018). Gionakis, & poulos explore issues of masculinity and fatherhood jevi the systemic of gender but much a problematic of vulnera categorization and quantification supportingbility as a pre-requisite to receive not fulfilling their roles and obligations as as obligations and roles their fulfilling not Men being over sons and husbands. fathers, (Arseni population refugee the within looked then their subsequent living and employment then their subsequent living and employment their made them feel that Athens in situation challenged as they were identity as men was becomes a response to the uncertainty and un and asylum system. predictability of the state feelings of powerlessness and loss of personal and loss of feelings of powerlessness goes Rehabilitation 2001). agency (Merkord, focusing on the torturebeyond experience and 2020). This is especially poignant for SoT, as SoT, for poignant especially is This 2020). torture is characterised by a loss of control which is mirrored in 2001), and safety (Fabri, inciting the conditions of their everyday life, gration planning at a national level in Greece level gration a national planning at enormousare creating uncertainty and insta bility for asylum seekers (AIDA, and refugees ings support rehabilitation the conclusion that A lack of proper should include these factors. inte reception conditions and the absence of health of migrants and refugees in Greece have health of migrants and refugees in Greece have been previously documented (Bjertrup et al., find our and 2018) al., et Womersley 2018, need for a calm and stable environment. The stable environment. need for a calm and unpredictability of insecurity, consequences the mental for asylum on wait and the lengthy include aspects of the social and materialinclude aspects of the en indepen security, safety, vironment such as and social integration. refugee status dence, litically, legally, socially, economically– for economically– for socially, legally, litically, thus Rehabilitation process. the rehabilitation to health, mental and physical beyond extends SCIENTIFIC ARTICLE SCIENTIFIC 110 TORTURE Volume 30, Number 3, 2020 people to services or the support provided by orthesupport people toservices did notfeelabletoprovide this, beyond linking andthat they a needforspecialisedsupport acknowledged that therewasKey informants ence would makethisextremelychallenging. status, employment experi andmigration lese peoplelivingin ofsocial Athens interms between Congo divisions andlackoftrust et al., 2017). Ourresultsshow, however, that forSoT(Kotsze their roleinspecificservices studied (Williams& Thompson, 2010), ashas has been services of mental health support to aid in the provision community members covery” inapolarised “from-to” discourse, but as Athens. people inadisempowering environment such toempowerfrom arehabilitation program re-traumatising; theissueiswhat isrequired of this study are potentially by the participants whether thedestabilisingconditionspresented padopoulos, 2015). There isnoquestionof (Papadopoulos &Gionakis, 2018, p. 6; Pa plexity, uniquenessand totality 2012), takingintoconsideration the “ a holistic, approach(UNCAT, personalised bilitation isadynamicprocessthat requires assumed aboutSoT(Cullinan, 2001). Reha organisations’ part. without assumptionsofhomogeneityonthe allow communities the space to self-identify knowledge, andknow-how, experiences and ommendation that organizations should share sion in Athens. the rec Ourfindings support provi aboutservice and adviseitsmembers hubthat coulddirect tion asaninformation moreandmaintainitsfunc ciation tolearn Congoleseasso willingness fromtheformal reassuring. There was strongmotivation and at meetingswas alsocommunity members to tointroduceSoTservices key informants leaders.religious The suggestionfromseveral Likewise, homogeneity should not be Focus shouldnotbeon “trauma” and “re ” of theperson com ------Arsenijevi References itation process. oftheholisticrehabil equal memberaspart insocietyasan toparticipate opportunities creation of safespaces, collective activities and andencouragethe arefacing many survivors ofisolation thatshould alsoconsidertherisk needs. 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Torture to crush Republic of in the Democratic dissent Torture https://www.freedomfromtorture.org/sites/ . Congo default/files/2019-03/a_tool_to_silence_-_drc_ (5), 452-457. https://doi.org/10.1037/0735- 452-457. 32(5), 7028.32.5.452 reparation: Preliminary Survey reparation: redress.org/wp-content/uploads/2018/01/E.- June-2001-Torture-Survivors-Perceptions-of- Reparation.pdf perceptions and barriersmental to receiving Home Health Care Management health services. , & Practice Health, 018-0172-y De Bartolome Zamatto, F., Eleftherakos, C., den Van & Barry, D., Severy, N., Gisbert, F., A In island containment: (2019). Bergh, R. of social support exploration systems qualitative among asylum seekers in a mental health care Greece. programme island, on Lesvos and Health, s13031-019-0218-9 Adjustments to the therapeutic frame in the of survivorstreatment of political torture. Research and Practice Psychology: Professional org/10.1177/1084822310390876 & Roland-Gosselin, L. Kotsioni, I., Severy, N., “I prefer dying fast than dying slowly”, (2018). the mental worsens institutional abuse how Afghan and Congolese health of stranded Syrian, migrants the on Lesbos island following deal. of EU-Turkey implementation SCIENTIFIC ARTICLE SCIENTIFIC Braun, V., & Clarke, V. (2006). Using thematic Using thematic (2006). & Clarke, V. Braun, V., (2001). S. Cullinan, Bragin, M., Taaka, J., Adolphs, K., Gray, H., & Gray, H., Adolphs, K., Taaka, J., Bragin, M., Freedom From Torture. (2018). (2018). Torture. Freedom From Dow, H. D. (2011). Migrants’ mental health Migrants’ (2011). Dow, H. D. Whitehouse, K., Venables, E., Episkopou, M., Reconstructing safety: Fabri, M. R. (2001). Eleftherakos, C., Van den Boogaard, W., Barry, D., Barry, D., den Boogaard, W., Van Eleftherakos, C., 112 TORTURE Volume 30, Number 3, 2020 UN General Assembly. (1984). UN Committee Against Torture (CAT) (2010). Riggs, E., Yelland, J., Duell-Piening, P., & Persson, A., &Gard, G. (2013). Tortured refugees’ Papadopoulos, R.K. (2019b). Psychosocialsupport Papadopoulos, R.K. (2019a). Communityasa Papadopoulos, R. K., &Gionakis, N. (2018). Papadopoulos, R. K. (2015). Failure andsuccess Papadopoulos, R. K. (1999). community Storied Treatment or Punishment Torture and OtherCruel, InhumanorDegrading docid/5437cc274.html 14 bystates parties treatment orpunishment: implementation ofarticle andothercruel, torture inhumanordegrading General commentNo. 3, 2012: Convention against mja15.01112 Australia, in refugeepopulations. Brown, S. J. (2016). Improving healthliteracy org/10.2340/16501977-1101 Medicine, qualitative study. ofRehabilitation Journal rehabilitation programme: An explorative pain expectations of amultidisciplinary july_02_2019r2.pdf www.iom.int/sites/default/files/mhpss/manual_ Displacement. (pp.309-315). IOM. https:// inEmergencies and and PsychosocialSupport Manual onCommunity-BasedMentalHealth after adversity: A systemicapproach. InIOM, mhpss/manual_july_02_2019r2.pdf IOM. https://www.iom.int/sites/default/files/ Emergencies andDisplacement in Mental HealthandPsychosocialSupport system. InIOM, e1438. https://doi.org/10.1002/ppi.1438 Psychotherapy andPolitics International The neglectedcomplexitiesofrefugeefathers. Journal (VII)(pp.25–49).Series Louisiana, NO: Spring (Eds.), In U. Wirtz, S. Wirth, D. Egger, &K. Remark resilience, andadversity-activated development. dislocation: ofinvoluntary in forms Trauma, org/10.1111/j.1752-0118.1999.tb00456.x Psychotherapy, of lossandcreativity’. CaroHollander Nancy ‘Exile: Paradoxes as securebase: Responsetothepaperby final.pdf content/images/CTI-Rehabilitation_Tool5-ENG- andotherill-treatment torture Tool 5/18, Providing rehabilitation tovictimsof Initiative (CTI). (2018). The crucible offailure:The crucible Odyssey Jungian 45(3), 286-292. https://doi. 204(1), 9-10. https://doi.org/10.5694/ 15(3), 322-332. https://doi. Manual onCommunity-Based . https://www.refworld.org/ British Journal of Journal British Medical Journal of Medical Journal . United Nations, Treaty UNCAT Implementation Convention Against . https://cti2024.org/ . (pp.323-327). , 16(1), Womersley, G., Kloetzer, L., Van denBergh, R., & Williams, M. E., (2010).Thompson, S. C. United Kingdom, Foreign andCommonwealth United Nations HighCommissionerforRefugees. United Nations HighCommissionerforRefugees. abuse and insight will be will insight and solidarity. and dedication 2020, June in away passed routes. migration the along places and Rome City, Mexico Athens, in projects centre refer-ent technical as well torture for centre rehabilitation coordi-nator project was He 2001. since Dr. Gianfranco De Maio was a valued member passing author’s on Note IT). (SORT Initiative Training and Research Operational Structured the through conducted was research This Womersley. Gail and Provata Marina Rahimnejad, Minou as well as GCR and Babel clinic, SoT MSF the of support the acknowledge We stories. their with us trusting for participants all thank We Acknowledgments doi.org/10.7146/torture.v28i2.106825 in Athens. torture before”: Psychosocialrehabilitation ofvictims Zamatto, F. (2018). “My mindisnotlike Popontopoulou, C., Kokkiniotis, M., & Venables, E., Severy, N., Gkionakis, N., 9417-6 780-794. https://doi.org/10.1007/s10903-010- Health andMinority ofImmigrant Journal populations: A systematic reviewoftheliterature. impact ofconflict-related traumaamongrefugee in reducingmorbidityfromthepsychological The useofcommunity-basedinterventions docid/5b9109c4a.html Congo (DRC). https://www.refworld.org/ 2017-Democratic Republic ofthe Report Office. (2018). HumanRightsandDemocracy documents/download/75816 Accommodation scheme. https://data2.unhcr.org/en/ (2020b). download/73442 2019. https://data2.unhcr.org/en/documents/ (2020a). docid/3ae6b3a94.html Series, vol. 1465, p. 85. https://www.refworld.org/ n itninl violence intentional and for the Sea arrivals dashboardDecember Sea arrivals Population breakdown inESTIA eaiiain f uvvr o torture, of survivors of rehabilitation SCIENTIFIC ARTICLE Torture, missed by all. by missed His presence, His of 28(2), 72-84. https:// leaving the survivors in Rome, as Rome, in survivors Brussels operational Brussels n upr o the of support in He behind , untimely 13(4), knowledge for the for a f MSF of legacy of legacy other TORTURE Volume 30, Number 3, 2020 113 ------without a patient in front of his or her torturers in front a patient coercion and allowing without privacy, otherwise breaking privacy). Writing medical records or carrying out ignore or distort that examinations essen- informationtial of documentation the for the use of diagnoses instance, For torture. using of a person, justify isolation that injuries underestimate that euphemisms they are banal that or symptoms to show or examinations superficial or mild or carrying include that examinations out documen- Also, irrelevant information. of facts do not exist or have tation that destruction of relevant been manipulated; certifi signing death clinical information; psycho or human medical Conducting consent or without respecting the prin- ciples of research ethics. Each one of these practices has occurred, the place from where this review In Spain, Performance of pseudo-medical or of pseudo-medical Performance pseudo-psychological procedures consid forced anal examina ered as torture (e.g. tions to determinehomosexual alleged psychological tests to virginitytests, ity, use of victim, or discredit a humiliate medical or psychiatric facilities to conceal the torture or as a form of torture in itself). to causes other the death attributing cates destructionthan torture; in of evidence disclosure of information given autopsies; during medical acts among others. logical research with prisoners doctors in cover-ups. In 1981, by way of an of way by 1981, In doctorscover-ups. in MuruEsteban Dr many, among case example and of physical etagoiena died after nine days 4. (1987), Forest of Eva works the is written, who began collecting testimonies of torture in doc Country Basque the mid-1970s, the in umented the fundamental role of forensic 2. 3. and continues to occur, worldwide. worldwide. and continues to occur, - -

SiRa, Madrid. Madrid. SiRa, Correspondence to: [email protected] Correspondence to: Director, He develops a catalogue of the ways that a that of the ways a catalogue He develops Medical complicity has been an inherent Medical complicity has been an inherent dures on the detainee, denial of analgesia, dures on the detainee, or psychological designing of physical exploringtorture or treating methods, Using their medical or psychological inflict directly or indirectly, expertise to, or surgical medical torture proce (e.g. Professor Miles defines a torture a defines Miles Professor doctor a licensed physician who directly and indi who a licensed physician

DOI: 10.7146/torture.v30i3.123443 https://doi.org/DOI: All rights reserved. Victims. Torture International Council for Rehabilitation *) 1. health professional can be involved in torture health professional can be involved They can be summarised (chapters practices. 1 to 4 and annex) into four categories: medical license in the service of «torture» or «cruel, inhuman or degrading or punishment» treatment as such terms are understood in international law. as: as: or skills or (b) rectly puts (a) medical knowledge duties or privileges conferred by the the authorities, the 20th century with the beginning and of contemporary forms of torture under French Algeria. colonial rule in part of the history in particular of torture, in Professor Steven Miles, in his recently pub- Miles, Professor Steven the reviews book, long-awaited and lished be com- in which a doctor may ways many plicit with torture. justice. Press. 2020 Georgetown University By Pau Pérez-Sales* and the road to to and the road Steven. H. Miles. Human rights crimes Human rights The torture doctors. doctors. The torture BOOK REVIEW BOOK 114 TORTURE Volume 30, Number 3, 2020 rensic doctors supported thefamily’s thesis supported rensic doctors River. byDanishfo An independentinquiry tocrosstheBidasoa and drowned whiletrying tion, whilehandcuffed, toescape Zabalzatried Civil Guard’s transporta versionthat during «death byimmersion». Itgave credence tothe inNovemberrondo barracks 1985reported: of theCivilGuard, at theIntxaur tortured ing thedeath of MikelZabalzaat thehands attack. follow written The forensiccertificate anatural death byaheart cial autopsycertifies cilities inSanSebastianandMadrid. The offi at theGuardiaCivilfa torture psychological fascinating book,fascinating Rivas (1990) showed how that were bydoctors. falsified However, ina theissuingofforensicdocuments describes (CNVR,onciliation report 1991a, 1991b)also sitions ofservice. The Chilean Truth andRec from hospitalsandtotakeover andpo chairs their politicalposition to expel their colleagues ing mission showed. took advantage of Others as an (1983)fact-find Amnesty International nouncements orbydirectexecution oftorture, ornot,in uniform inraids, accusations, de Chile. were Doctors directlyinvolved, whether in thedictatorship during the roleofdoctors tion, example, byway ofanothercountry on 2017, 2019) . There is extensive documenta Petersen etal., 2002; Petersen &Morentin, Torture show Journal) (Morentinetal., 2008; (some of them published in academic reports inSpain,role ofofficialforensicdoctors as then, therehasbeenlittlechangeregardingthe finally dismissed and archived in 2009. Since democratic, Europeancountry. The casewas inany,required offorensicservices allegedly that theycomply withtheminimumstandards inSpainanddemanding of forensicdoctors abouttherole statement expressingitsconcern occasion, theEuropeanParliament issueda closetotheriver.quently transported Onthat iation («bathtub») andthat thebodywas subse bywet asphyxthat hehaddied duetotorture

------(Fiscalía General de la República), shows how bythe General’ssic experts Attorney Office foren by officialmedicalandpsychological out carried lyzing 54Istanbul Protocol reports and reports. A recently published study ana cases have beenthesubjectofacademicpapers the Istanbul Protocol (IP)tocover uptorture that denouncethe fraudulentuseof reports nant incovering uptheuseoftorture. The of forensic science has been most determi inLatin wheretherole the country America tersen, 1990), amongothers. 2006), Peru (HRW, 1997) or Venezuela (Pe de SaoPaulo, 1985), Paraguay (Bocciaetal., 1986; SERPAJ, 1989), Brazil(Arquidiocesis (Bloche,Similar casescanbefoundinUruguay without legalconsequencesforthoseinvolved. and detaineestheconcealmentoftorture inthecareofprisoners practice ofdoctors (CONADEP, theconniving 1984)describes Commission ontheDisappearanceofPersons fromtheNational tinian Never Morereport to look “the otherway.” Further, the Argen andinsteadpreferred stored democratic rule to prosecutethosedoctors, even underthere the ChileanMedical Association was not able 1 and criminality. This addsto coercionorfear a «lesserevil»toprotectsociety fromdanger as their values andaimsinregardingtorture cation withthecauseofinstitution, sharing rence was, in mostcases, thedoctors’ identifi foritsoccur factor shows that thedetermining dependent inMexicoaremade that forensicservices andlegalmeasures anddemand ontological 2020). insistontheneedfor de The authors Independientes, practices(Grupo up torture the IP has been used fraudulently to cover Unfortunately, inLatin America, thedata For several decadesnow, Mexicohasbeen http://www.psicosocial.net/ 1 . BOOK REVIEW ------TORTURE Volume 30, Number 3, 2020 115 - - -

. (10 .

(Doctors, (Doctors, Torture in Torture (20). (National Truth Truth (National and La tortura en Chile Encubriendo la tortura. Encubriendo la tortura. 255 , JAMA Nunca Más. Informe de la Nunca Más. 10 años de tortura y democracia Informe de la Comisión Nacional de Informe de la Comisión Nacional de . Vozes. vasive-use-of-torture-by- Vozes. . . EUDEBA. (Never More. Report More. (Never EUDEBA. . Comisión Nacional sobre la Desaparición de Personas Commission of the Forced of the National Dissappearance of Persons) years of torture and democracy) Gestoras Pro Amnistia - Euskadi. de la ProcuraduríaComplicidad de los forenses Análisis de 54 casos. de la República. General Complicity of forensic experts(Hidding torture. Analysis of 54 Attorney General Office. of the This book, a necessary read, confronts a necessary confronts read, This book, London. in Chile). (Torture Report Use a Shocking on the Pervasive Brazil: Military by Brazilian Governments, Torture of Archdiocese Secretly Prepared by the 1964-1979, of São Paulo brazilian-military-governments-1964-1979/ oclc/45727633&referer=brief_results Cogs. Physicians Paraguay en el Tortura Medicos Etica y Arandura in Paraguay). Torture Ethics and Asunción.. ediciones. 1. Vol y Reconciliación. Verdad Santiago de Chile. Commission.). Reconciliation 2. Vol y Reconciliación. Verdad CNVR. (1991a). (1991a). CNVR. (1991b). CNVR. (1984). CONADEP. (1987). E. Forest, (2020). Grupo Independientes. References (1983). Amnistia Internacional. (1985). Arquidiocesis de Sao Paulo. s Military Uruguay ’ (1986). G. M. Bloche, (2006). C. Arestivo, & C., Portillo, A., Boccia, als that make torture and impunity possible. make tortureals that possible. and impunity not be fair make them account to It would this is a that But professor Miles shows able. finally concludes The author viewpoint. naïve he something that is the rule, impunity that finds «profoundly disturbing». as medical boards and professional courts, practice to this end an for asks and sociations encourage the We of looking the other way. action. its pages and take readers to navigate When one doctor is part of a torturing system, all doctors are concerned. there is no other option and surely are the the are surely other option and there is no profession of the chain in element” “weakest ------

Professor Miles also reviews the fight for Professor Miles also reviews the fight for Those Latin American examples are Americanare examples Latin Those doctors would usually only be involved when doctors usually only be involved would almost exotic. It is certainly not, for them, for them, It is certainly not, almost exotic. something to worry about in a democratic Furthermore, in torture practices, country. medical complicity. For most doctorsmost who For complicity. medical with torturedo not work survivors, torture occursis probably a minor problem that in far and distant» countries «small, – something accountability with a particular focus on US policies and the ongoing efforts to combat ing in the interrogation of detainees took more interrogation took the in ing detainees of (Pérez- three yearsthan approval obtain to 2018). Sales et al., situation that has recently occurred at the has recently occurred the that at situation where a state Association, Psychiatric World psychiatristsforbid to ment participatfrom 2009). Chapter 10 brilliantly dis the uncovers 2009). Associ Medical World appointing role of the similar paralelling a cases in compelling ation with the American Psychiatric Association re Association American Psychiatric with the garding Guantanamo and the Israeli Medical concerningAssociation the torture of Pales minorsincluding (Yudkin, detainees, tinian British Medical Association in failingAssociation to take British Medical action when confronted with well-documented happened This chapter parallels what cases. ferent languages and from different contexts. ferent languages and from different contexts. He makes a particular case for the United the Kingdom (chapter 7) and the role of in at least one hundred countries, including in including least one hundred countries, in at He details in chapter 6 carefully democracies. dif documented examples using sources in similar to the many examples collected and de examples collected similar to the many an He draws Miles. tailed by Professor Steven of torture«atlas» physi that doctors shows that cians are a «necessary» part of modern torture ing to documentation and studies, empathy empathy and studies, ing to documentation with perpetrators is the rule. of negative evaluation by the institution, and, and, by the institution, evaluation of negative under an inadequate in a minority of cases, accord However, ethics. standing of medical BOOK REVIEW BOOK 116 TORTURE Volume 30, Number 3, 2020 Petersen, H., &Morentin, B. (2017). Detainees’ Pérez-Sales, P., Jan denOtter, J., Hardi, L., Wenzel, Morentin, B., Callado, L. F., &Idoyaga, M. I. (2008). Yudkin, J. S. (2009). The IsraeliMedical Association SERPAJ. (1989). Petersen, H., Morentin, B., &Callado, L. F. (2002). Petersen, H., &Morentin, B. (2019). Assessing org/10.1136/bmj.b4078 339 and doctors’ complicityintorture. ofForensicJournal Sciences Spain : The Doctor’ sRoleinthePrevention of. Issued inCentralPolice , Stations inMadrid Assessment oftheQualityMedicalDocuments forsciint.2019.05.043 301 physical torture. the level ofcredibilityallegations of org/10.7146/torture.v27i2.97217 ill-treatment. and impediment inthefightagainsttorture institution inSpanishpolicestations: An andthemedical perception ofthedoctors https://doi.org/10.1002/wps.20539 of Detainees. intheInterrogation Participation ofPsychiatrists (2018). WPA Position Statement onBanningthe T., Diaconu, G., Cors, G., &Kastrup, M. Methods inincommunicadodetaineesSpain./ torture A follow-up studyofallegations ofill-treatment Libros.cases) Irredentos

(oct07 1), b4078–b4078. https://doi. , 263–270. https://doi.org/10.1016/j. , February Uruguay. NuncaMas Torture Journal World Psychiatry Forensic ScienceInternational , 87–98. , 47 , 27 (4), 293–299. , 17 (2). https://doi. (2), 237–238. . Montevideo. BMJ , , BOOK REVIEW TORTURE Volume 30, Number 3, 2020 117

------3 non-heterosexual orientations as pa First of all, we would like to state strongly state like to would we First of all, By way of introduction, EMDR therapy therapy EMDR of introduction, By way and Carol Miles and Carol thology under any circumstances. The Code circumstances. thology under any major health authorities around the world, to major health authorities the world, around stress disorder (PTSD), post-traumatic treat including PTSD resulting from torture (APA, 2003; DNSCGMHC, 2017; VA/DoD, 2004; Health Organization World The 2018). ISTSS, recommends EMDR therapy for the treatment and adults adolescents, for children, PTSD of behavioral (beside trauma-focused cognitive 2013). therapy) (WHO, and EMDR Association EMDR Europe that (EMDRIA) do not Association International consider therapy. Nevertheless, we would like to draw like to draw would we Nevertheless, therapy. state to inaccuracies in several attention your and express our research ments in the Bothe’s therapy is men EMDR objection about how of the IFEG. tioned in the statement belongs to the wide range of psychothera pies which are categorized in the statement (IFEG, psychotherapy” or “talk therapy under cogni along psychodynamic, p.66) 2020a, and systemic psychotherapy, tive-behavioral, EMDR therapy is recommended by others. from physical torture physical from medication of to misuse This includes psychother or psychotherapy. excellent effects on ICD-10 have apies that such as EMDR recognized psychopathology, 2 - - - -

, Isabel Fernandez 1 10.7146/torture.v30i3.122782 EMDR Europe Association. EMDR Europe Association. EMDR Europe Association. EMDR International Association. Correspondence to: [email protected] Correspondence to: [email protected] Correspondence to: [email protected] Correspondence to: We are impressed by this important work We The Statement of the IFEG sheds light of the IFEG sheds light The Statement Oliver Piedfort Marin Forensic Expert Group’s statement on con statement on Expert Group’s Forensic version therapy. EMDR as an evidence-based therapy for therapy as an evidence-based EMDR to the Independent A reply trauma – 1) https://doi.org/ All rights reserved. Victims. Torture International Council for Rehabilitation 1) 1) which highlights that many methods are used many which highlights that to coerce people into becoming heterosexual, sion “therapy” (SOCE) that goes definitively goes definitively (SOCE) that “therapy” sion against human rights. tries where conversion “therapy” is legal. is legal. “therapy” tries where conversion strongly support the commitment of the We conver fighting in Bothe, Josina of and IFEG on a critical problem for many individuals, on a critical individuals, many problem for must have data Bothe’s adults and children. in coun even been very to obtain, difficult practices performed “to create change in an “to create practices performed sexual orientation.” individual’s not give the impression that it is a therapy. it is a therapy. not give the impression that included Eye The authors of this paper have and Reprocessing Desensitization Movement 2018) among the (EMDR) therapy (Shapiro, (Bothe, 2020). In the US the common ter common the US the In 2020). (Bothe, is Sexual Orientation Change minology now Efforts (SOCE) since the terminology should 2020a) made a “Statement on Conver “Statement 2020a) made a very Bothe’s based on Josina Therapy,” sion not therapy” torture, “It’s detailed report In the Volume 30 of the Torture Journal, the Journal, Torture 30 of the Volume In the ExpertIndependent Forensic Group (IFEG, LETTER TO THE EDITOR THE EDITOR TO LETTER 118 TORTURE Volume 30, Number 3, 2020 need of mental health treatment by virtue of their need of mental healthtreatment by virtue “does notbelieve LGBTQIAindividualsarein clearinstating that EMDRIAare alsovery who may beaffected.” human, ofclientsorothers legal andcivilrights avoid any actionthat willviolate ordiminishthe status and socio-economic status. They should religion, sexualorientation, orfamily marital ethnicity, gender, language, national origin, race, sively) thoseinvolving age, disability, education, tural and role differences, including (but not exclu that: of EthicsEMDREurope 2 https://www.emdria.org/about-emdria/emdr- 1 the clinicianswhouseitproperly standfor. that EMDRtherapyand posite ofeverything oftorture. be aform This is, infact, theop a conclusion that EMDR therapy could form that these twoalarmed cases are being used to Europe orEMDRIA’s CodeofEthics. We are Association anddonotabide by theEMDR two ofany cliniciansarenotmembers EMDR quality of the rest ofBothe’s report. These these sources are notscientificand lack the are for usa experiences (IFEG,newspapers 2020b). Although these tients’ testimoniesthat appeared in personal IFEG’s statement aboutEMDRaretwo pa proved TrainingProviders.” Approved Consultants, CreditProviders, and Ap by its Members,this purpose Certified Therapists, Association prohibitstheuseof EMDRtherapy for Association.ternational The EMDR International andvalues oftheEMDRIn outside thenorms and isinappropriate or othersimilarintervention the useofEMDRtherapy inany SOCEprogram andgender identity.sexual orientation Therefore, Furthermore, thesourceswhichledto Furthermore, November 18) international-association-policies/ and-values/ (2020, November 18) https://emdr-europe.org/about/mission-vision- “Therapists should respect individual, cul

The policiesofEMDRIA cause 1 of deepconcern, explicitlystates (2020, ------2

of thefewtherapieswheretherapist’s inter much a client-centered psychotherapy – is one statement. As amatter offact, EMDR–very this pointofattention mightbemissinginthe individuals misusing a method. We believe that but rather so-called psychotherapists or other some countries. The issueisnotthemethod professional organization or outside the law in working outsideoftheethicalcodetheir misused chotherapies (andmedications) areinfact lates humanrights. and unethicalbehavior “therapy”, whileitisthetherapists’ misuse precisely exposesitaspossibleconversion from Bothe’s data base. (Bauman, 2019). ismissing This information press that itwas amisuseofEMDRtherapy. EMDR Europemadeaclearstatement inthe of thetimeandactual Vice-President of this situation and oneofitsboardmembers The SwissEMDR Association was aware of apy” includingmisusingEMDRforSOCE. from Switzerlandproviding trist “psychother in themethod and intheclinicianisneeded duced by conversion processes. Confidence pro of torture, such as torture ing survivors oftrauma, includ with confidencetosurvivors EMDR therapywillcontinue tobeprovided EMDR therapy. We want tomakesure that therapy andtotheconfidence ofpatients for tothereputation ofEMDRdetrimental on onlytwo cases, couldactuallybe severely or SOCE. The statement oftheIFEG, based EMDR couldbeusedasconversion “therapy” EMDRIA stronglyfightagainsttheviewthat ledbythe patient.normally is the reprocessingoftraumatic experiences vention the sessions is minimal because during One ofthesetwo toapsychia casesrefers In conclusion, EMDR Europe and The statement highlightshow many psy Nonetheless, listingEMDR inthis context by specific groups orindividualsby specificgroups LETTER TOTHEEDITOR not EMDR, that vio ------TORTURE Volume 30, Number 3, 2020 119 ; Raw Raw Juli- , https://irct. Torture, 30, 1 30, Torture, Guidelines for Guidelines for Arlington. VA/DoD Clinical VA/DoD Clinical Gesundheitstipp . New York: Guilford. York: New . . Copenhagen: International Copenhagen: . Utrecht, Netherlands. Utrecht, PTSD Prevention and Treatment Treatment and PTSD Prevention Washington, DC. Washington, Eye Movement Desensitization Desensitization Movement Eye It’s torture not therapy. A global torture not therapy. It’s Chicago. Multidisciplinary Guideline Anxiety Practice Guideline for the Treatment Treatment the Guideline for Practice ; 22-23. ; Geneva. the management of conditions specifically related to specifically related of conditions the management stress. data of the study on conversion therapy. of the study on conversion data org/media-and-resources/latest-news/article/1027 (2018). ISTDD. Guidelines. and protocols, Basic principles, and Reprocessing: Third edition procedures. Mental Health Care – DNSCGMHC. Mental Health Care – DNSCGMHC. (2003). Care CBO/ Quality Institute Heath Disorders. Institute. Trimbos Therapy. on Conversion Statement 10.7146/torture.v30i1.119654 DOI: 66-67. Rehabilitation Council for Torture Victims. Victims. Torture Council for Rehabilitation https://irct.org/uploads/media/IRCT_research_ on_conversion_therapy.pdf (2017). VA/DoD Defense – of Post- the Management Guideline for Practice Stress. Traumatic of Patients with Acute Stress Disorder and with of Patients Stress Disorder. Posttraumatic healer]. [Visit to the Gay August perpetrators, practices, overview therapy: of conversion and the role of states (2004). We support efforts the against fight to We World Health Organization (2013). Health Organization World International Society for Traumatic Stress Studies – Traumatic International Society for (2018). F. Shapiro, Independent Forensic Expert Group (2020b). ExpertIndependent Forensic Group (2020b). Independent Forensic Expert Group (2020a). ExpertIndependent Forensic Group (2020a). Dutch National SteeringDutch National Guidelines Committee Department of Veterans Affairs & Department of Veterans Department of Bauman, K. (2019). Besuch beim Schwulen-Heiler (2019). K. Bauman, (2020). J. Bothe, American Psychiatric Association – APA overlooked by a focus on the psychotherapy by a overlooked they inappropriately use. method that References: any form misuse any and against any of coercion The focus on of recognized psychotherapies. the people performing torture should not be in order to overcome the sequala of traumatic of traumatic the sequala overcome in order to experiences. LETTER TO THE EDITOR THE EDITOR TO LETTER 120 TORTURE Volume 30, Number 3, 2020 Victims (IRCT) to the criticism expressedby Victims (IRCT)tothecriticism tional Rehabilitation Councilfor Torture The following isaresponsebytheInterna Asger Kjærum ons letter. national associati European andinter Response toEMDR International Rehabilitation Council for International Torture Victims. reserved. All rights https://doi.org/ 1) 3. 2. 1. following elements: Torture Journal. expressed in its letter to the points of criticism against conversion therapyandforthespecific position sociation forits strongandprincipled national Association andEMDREurope As treatment. andill- ited undertheglobalbanontorture the useofconversion therapycanbeprohib Forensic Group(IFEG), how whichdescribe and theStatement issuedbytheIndependent Europe Association inrelation toourreport EMDR International Association andEMDR our report. one ofthetwo caseswas notincludedin Swiss EMDR Association inrelation to That the strong condemnation from the oftorture. therapy couldbeaform are notsufficienttoconcludethat EMDR conversion therapyarenotscientificand The two instances of EMDR being used in We tocontainthe thecriticism understand We would liketothanktheEMDRInter for this. responsible therapy andthepractitioners than theirunethicalmisusein conversion focusesonmethodsrather That thereport Correspondence to:Correspondence [email protected] Director of Advocacy, IRCT

10.7146/torture.v30i3.122782 1

------the report. wouldcovered beincludedin bythereport or any inany otherauthority ofthecountries the responsebySwissEMDR Association sion therapy. We thereforeseenoreasonwhy to maptheirresponsesinstancesofconver nor orprofessionalgroups specific authorities place. isnotintendingtocriticise Ourreport take didinfact inourreport case described sociation, that the whichalso seemstoconfirm to notetheresponsebySwissEMDR As version therapy. has beenandthereforecouldbeusedincon challenged, areaclearindication that EMDR that thetwo cases, have whosefacts notbeen ual victims. In relation to EMDR, we believe aspresentbytheindivid relied onthestories ation oftheclaims madebyvictims, we have and thegeneralabsenceofjudicialconsider raise individualcases. thiscontext Considering to create oftheissuenotto aglobal overview is sion therapyandthat theaimofreport ogy appliedinidentifyingexamplesofconver themethodol clear andexplicitindescribing role oftheState. andthe cates several toperpetrators chapters pain orsuffering. Therefore, dedi the report lised forinflictingsevere physical or mental tools ofmethodsthat canpotentiallybeuti action andinaction, notthe mereexistenceof violations are caused by human Human rights andindividuals. targeting ofgroups inatory actsandthediscrim of otherwiselegitimate throughtheabusement isoftenperpetrated ment. shows, andill-treat As thereport torture andill-treat and theprohibitionoftorture law ofhuman rights mental misunderstanding andinadditionillustrates afunda the report inthecontentof hasnogrounding criticism In relation to point 1, our report is very In relation topoint1, isvery ourreport In relation topoint3, we believe that this In relation topoint 2, wepleased arevery LETTER TOTHEEDITOR ------TORTURE Volume 30, Number 3, 2020 121 - - - We therefore hope that this response will therefore hope that We Finally, we greatly appreciate that the the greatly that appreciate we Finally, focus back to the strong and principled advo therapy. cacy against conversion address any furtheraddress any concern the EMDR that EMDR Europe and Association International their shift can they so have may Association gally repurposed in a way that inflicts severe severe inflicts that repurposedgally way a in pain and sufferingexposed to it. on the people biggest focus of our work and the very and work reason biggest focus of our wrote the reportwe in question is to document ille being and methods and tools such how torture com is world takes place in this that use of otherwise mitted through the unethical electric wires – sticks, legal tools and methods the Therefore, etc. water music, and cables, their methodology featuring in a report about torture clients. by potential will be perceived the of much that is reality sad the However, EMDR International Association and EMDR Association EMDR International are concernedAssociation about how Europe LETTER TO THE EDITOR THE EDITOR TO LETTER 122 TORTURE Volume 30, Number 3, 2020 Bernard Duhaime(UniversitéduQuébecà Montréal, MemberoftheUnited Guest Editors:MarianaCastilla (Collective Against Torture andImpunity)& Pau Pérez-Sales -Editor-in-Chief, Torture Journal Enforced Disappearances Torture VictimsandPrevention ofTorture onRehabilitationof Journal Journal: Call forpapers.SpecialsectionofTorture or how investigative into account. methodology shouldtakethesefactors violations, how theStates actions oromissionscanre-victimize relatives ofdisappearedpersons, how impunityinthiscontextcangenerateare requiredforexampletobetter understand such perspective.these issuesfromaninterdisciplinary Indeed, additionalacademiccontributions pearance, thecomingspecialedition ofthe Torture some of seekstoexplorefurther Journal Conventionforce oftheInternational fortheProtectionof All Persons fromEnforcedDisap into oftheentry Group onEnforcedorInvoluntary Disappearancesandthe10th anniversary his orherrelative canalsobeavictimoftorture. inflicted upon the relatives” (A/HRC/16/48). Accordingly, in addition to the disappeared person, only adds to,abouts of the disappeared as such restriction and prolongs, the continuous torture ing confessionsfromthem. with the objective of punishing,are the object of specific acts of torture questioningor obtain Barbara Peasant CommunityvPeru). Inaddition, inmany instancesofdisappearances, victims (ej. Court, Santa oftorture Inter-American detention ofanindividualcanconstituteaform 1.2, UNGARes47/133). Indeed, tribunals, humanrights asreiterated thistypeof byregional treatment andothercruel, orpunishment” inhumanordegrading subjected totorture (art. law notto be ofinternational guaranteeing,constitutes aviolation(…)theright oftherules againsthumanity. ofcrime civilian population enforceddisappearancesalsoconstituteaform of anxiety, andfearinsociety. insecurity When committedasasystematic attack againstthe and tolegalpersonality. oftheworld, regions Invarious thispracticeseekstogenerate astate todueprocessandjudicialprotection, including theright tolife, theright integrity topersonal Enforced disappearances imply multipleandcontinuousviolations humanrights, ofvarious Background Nations Working Group onEnforced or Involuntary Disappearances) While this year marks the 40th anniversary ofthecreation oftheUnitedNations While thisyear marks the40th anniversary Working Moreover, andthewhere aState aboutthefate toknow thetruth theright “cannot restrict The UNGeneral Assembly hasindicated that “[a]ny actofenforceddisappearance(…)

CALL FORPAPERS - - - TORTURE Volume 30, Number 3, 2020 123 - - https://tidsskrift.dk/ - a site devoted to Torture Journal readers and Torture to devoted site a - https://irct.org/global-resources/torture-journal https://tidsskrift.dk/torture-journal/about/submissions https://irct.org/uploads/media/2eefc4b785f87c7c3028a1c ). Papers will be selected on their relevance to the field, appli to the field, will be selected on their relevance Papers ). rez-Sales, Editor in Chief ([email protected]) or Berta Soley, Editorial Editor in Chief ([email protected]) or Bertaerez-Sales, Soley, https://tidsskrift.dk/torture-journal act Pau P act Pau Rehabilitation programs for the damage generated by forced disappearance that develops develops programs by forced disappearance that Rehabilitation for the damage generated address the characteristicsspecific approaches that of this particular damage. Interdisciplinary of disappeared persons. on the harm documentation caused to relatives aimed at phenomenon and repeated disappearance as a systematic Analysis of cases of forced terror serious of generates producing a social state damage to communities and anguish that and social structures. disappeared persons cases in which the harm of Strategic of litigation has been to relatives of the rightdocumented as a violation to personal integrity Author guidelines can be found here: Author guidelines can be found here: 59ccd06ed.pdf Journal here: Torture Read more about the To make a submission, navigate here: here: navigate make a submission, To About the Torture Journal Torture About the to go Please issues. contributors and archived – to access the latest index.php/torture-journal/index of innovation. and level methodological rigor, cability, • ( Journal website Torture please see the guidelines, general submission For • • Cont please write general enquiries, to [email protected] more For Assistant ([email protected]). Submission guidelines and links 28th February 2021 information For more Deadline for submissions d. b. c. of knowledge. We welcome papers welcome following: on the We of knowledge. a. Call for papers Call for papers Journal authors encourages medical, papers present to psychological, a with topic this on Torture with interdisciplinary in particular, social or legal orientation other fields approaches with and, CALL FOR PAPERS CALL

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International survey of the utilization of “A random system”: The organisation and physiotherapy in treatment centers for survivors practice of torture rehabilitation services in of torture Norway

Group physiotherapy with survivors of torture Looking for stability: Experiences of in urban and camp settings in Jordan and Kenya rehabilitation for Congolese survivors of torture in Athens and the role of the Congolese Acceptability of a physiotherapeutic pain school community in their support treatment in trauma-affected populations in the Middle Eastern & Northern African region LETTER TO THE EDITOR: EMDR as an evidence- based therapy for trauma – A reply to the PERSPECTIVE: Collaborative effort to increase the Independent Forensic Expert Group’s statement physiotherapist’s competence in rehabilitation on conversion therapy. of survivors of torture CALL FOR PAPERS: Enforced disappearances.

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The Torture Journal is a scientific journal that Victims which is an independent, international provides an interdisciplinary forum for the organisation that promotes and supports exchange of original research and systematic the rehabilitation of torture victims and the reviews by professionals concerned with the prevention of torture through its over 150 biomedical, psychological and social interface member centres around the world. The objective of torture and the rehabilitation of its survivors. of the organisation is to support and promote It is fully Open Access online, but donations are the provision of specialised treatment and encouraged to ensure the journal can reach rehabilitation services for victims of torture. those who need it (www.irct.org). Expressions of interest in the submission of manuscripts or involvement as a peer reviewer are always welcome. The Torture Journal is published by the International Rehabilitation Council for Torture

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