A novel bio-psycho-social approach for rehabilitation of traumatized victims of torture and war in the post-conflict context: a pilot randomized controlled trial in Kosovo

BACKGROUND: Some evidence showed that multidisciplinary rehabilitation in Western countries is effective for treating war-related trauma, but it remains unclear whether this approach is applicable to civilians living in resource-poor countries affected by war. In 2012–14, Danish Institute against Torture (DIGNITY) conducted a randomized controlled trial (RCT), in partnership with Kosova Rehabilitation Centre for Torture Victims (KRCT), to examine the effects of multidisciplinary intervention among victims of torture and war in Kosovo. METHODS: A single-center, randomized, parallel-arm, single-masked, waiting-list controlled trial was implemented in northern Kosovo. Thirty-four participants meeting the recruiting criteria were randomized to either intervention group, which received integrated treatments plus a once-daily multivitamin, or the waiting list group, which received multivitamin alone. The integrated treatments consisted of 10 weekly individual 60-min sessions of cognitive behavioral therapy (CBT), based on an adapted prolonged exposure therapy manual, an individual 20-min breathing exercise with an emWave biofeedback device, and 90-min group physiotherapy. The waiting list group also received the same treatment after the intervention group had completed their sessions. Outcome assessments were conducted at 3, 6 and 9 months after baseline assessment. Outcomes measures consisted of 4 subtypes: mental, emotional, physical health, functioning and social outcomes, i.e. PTSD, depression, anxiety, chronic pain, anger and hatred expression, body mass index, handgrip strength, standing balance, income, employment rate and disability score. RESULTS: Over 1/3 of PTSD cases were successfully treated. Inconsistent patterns with mental health and chronic pain outcomes were observed while there was a definite impact of intervention on functioning and social outcomes, i.e. the employment rate, which increased nearly 15 %, and the monthly wage, which rose 45–137 %. There was also a noticeable improvement in handgrip strength and disability score; the feelings of anger and hatred diminished. However, most of these changes did not reach statistical significance. CONCLUSIONS: The impact of bio-psycho-social intervention is likely sensitive to the context of post-war economy in Kosovo and the treatment goals. The potential for improving the emotional well-being and employment outcome in victims was demonstrated. A larger scale RCT in a similar setting is needed, with close monitoring of treatment integrity and data reliability. TRIAL REGISTRATION: Clinicaltrials.gov (NCT01696578)

Screening asylum seekers in Denmark for torture using a structured questionnaire

The United Nations Committee against Torture recommends systematic torture screening throughout the asylum process.   The goal of this study is to evaluate the introduction of a structured questionnaire, coding for torture according to the definition from United Nations Convention Against Torture (UNCAT). This screening for torture is now an integrated part of the medical reception of newly arrived asylum seekers The screening was carried through during a 2 years period as a part of the routine health screening, and alleged torture victims were referred to further medical examination and offered assistance to carry information about the torture to the Immigration Service. The participation rate was 85.2%, and torture was reported among 27.8% of the males, with a mean of 21.2% among both sexes. Key words: Torture, screening, questionnaire, asylum seekers, UNCA

Health impact of electric discharge weapons: a review of case studies

Introduction Electrical discharge weapons (EDWs) are increasingly used by law enforcement around the globe as a less lethal option to firearms. Concerns have been raised about their use, inter alia from the UN Committee Against Torture (UNCAT). The purpose of this manuscript is to provide an overview of case studies to assess the health consequences of EDW exposure.  Methods Medline and Pubmed were searched for case studies on EDWs without restriction on language or date. Screening was first at abstract level and then at full article level. Articles were excluded if they were not case studies, concerned children under 15 years old or were off topic. A PRISMA flow diagram was created. Results A total of 71 studies were included, and they demonstrate a wide range of health consequences from minor injuries to lethal conditions. The injuries can be classified as direct and indirect, i.e., related to the use itself (e.g., penetration by darts) and related to falls and burns following neuromuscular incapacitation and ignition of flammable fluids. Cardiac incidents – some being fatal - were the health consequences found most reported, but the relation to the EDW is contested. In other cases, a very plausible association is established between EDW exposure and the health consequences. Description of pain and mental suffering related to EDW exposure was lacking in the reviewed case studies. Discussion EDWs may lead to physical and most likely mental suffering. When assessing patients and when documenting cases where persons may have been exposed to EDWs, including torture and ill-treatment cases, it is important to be aware of the different types of health consequences

The Istanbul Protocol: A global stakeholder survey on past experiences, current practices and additional norm setting

Introduction: The Istanbul Protocol (IP) principles and guidelines have served as international norms for the effective investigation and documentation of torture and ill-treatment since 1999. Given the widespread use of the IP and recent calls to update or enhance its norms, we conducted a large-scale study among stakeholders to understand current practices as well as opinions on additional IP norm setting. Methods: Between February 20, 2017 and April 7, 2017, we conducted an online survey of IP users using a combination of criterion and chain sampling. The survey instrument included the following domains of inquiry: 1) respondent characteristics (demographics, anti-torture work, country conditions, and IP training); 2) IP use, importance and practices, and; 3) opinions on additional IP norm setting. Results: The survey was distributed to 177 individuals and 250 organizational representatives with response rates of 78% and 47% respectively. The respondents came from a variety of clinical, legal, academic, and advocacy disciplines from around the world. The respondents indicated that they use the IP for a wide range of anti-torture activities: investigation and documentation, advocacy, training and capacity building, policy reform, prevention, and treatment and rehabilitation of torture survivors. The vast majority (94% of individual respondents and 84% of organizations) reported that the IP is important to their anti-torture work. A majority of individual (60%) and organizational (59%) respondents reported that updating or adding clarifications to the IP would help to address the challenges they face and provided specific suggestions. However, 41% of individuals and 21% of organizational respondents also reported concerns that additional IP norm setting could have negative consequences. Discussion: The IP provides critical guidance for a wide range of torture prevention, accountability, and redress activities and can be enhanced through the development of additional updates and clarifications to respond to the current needs of torture survivors and stakeholders

Voices of torture survivors in Tanzania: A qualitative study

Introduction: No published research has been found on torture in Tanzania, but individual cases were documented by human rights organisations. The aim of this study was to explore the salient physical, mental and social effects of torture in the country, and help-seeking behaviour by giving voice to a group of torture survivors in Dar-es-Salaam and Zanzibar City (Zanzibar). Methods: This explorative qualitative study consisted of 14 semi-structured in-depth interviews (12 males, 2 females) of which eight took place in Dar-es-Salaam and six in Zanzibar. Informants were selected purposefully through a mix of snowball and convenience sampling. Both the Standards for Reporting Qualitative Research (SRQR) and the Consolidated Criteria for Reporting Qualitative Research (COREQ) were followed. Results: Using the UNCAT definition of torture, all informants reported having been tortured within the past two years. The most common form of torture was beating with clubs to the joints. Other torture included, but was not limited to, gun shot, toenail removal and ‘poulet roti’. The most common physical consequence was persistent pain. Psychological consequences included suicidal ideation and sleep problems. Most interviewees lost their jobs as a result of the torture incident, instigating a cascade of financial and social problems. Conclusion: The findings present informants’ exposure to deliberate torture at the hands of public authorities. Informants confirmed their exposure to torture methods that had been previously reported by nongovernmental organisations. They also talked about exposure to more advanced, and previously undocumented, torture methods. Informants displayed a dire need for mental and physical health care, but had limited access to such care. Research is needed to better understand the magnitude, prevalence and context of torture in Tanzania

Voices of torture survivors in Tanzania: A qualitative study

Introduction: No published research has been found on torture in Tanzania, but individual cases were documented by human rights organisations. The aim of this study was to explore the salient physical, mental and social effects of torture in the country, and help-seeking behaviour by giving voice to a group of torture survivors in Dar-es-Salaam and Zanzibar City (Zanzibar). Methods: This explorative qualitative study consisted of 14 semi-structured in-depth interviews (12 males, 2 females) of which eight took place in Dar-es-Salaam and six in Zanzibar. Informants were selected purposefully through a mix of snowball and convenience sampling. Both the Standards for Reporting Qualitative Research (SRQR) and the Consolidated Criteria for Reporting Qualitative Research (COREQ) were followed. Results: Using the UNCAT definition of torture, all informants reported having been tortured within the past two years. The most common form of torture was beating with clubs to the joints. Other torture included, but was not limited to, gun shot, toenail removal and ‘poulet roti’. The most common physical consequence was persistent pain. Psychological consequences included suicidal ideation and sleep problems. Most interviewees lost their jobs as a result of the torture incident, instigating a cascade of financial and social problems. Conclusion: The findings present informants’ exposure to deliberate torture at the hands of public authorities. Informants confirmed their exposure to torture methods that had been previously reported by nongovernmental organisations. They also talked about exposure to more advanced, and previously undocumented, torture methods. Informants displayed a dire need for mental and physical health care, but had limited access to such care. Research is needed to better understand the magnitude, prevalence and context of torture in Tanzania