Introduction

Torture is a heinous crime that can severely impact survivors’ physical and mental health and quality of life. It also has an impact on the close ones, society, and community. Survivors of torture (SoT) often suffer from persistent pain in addition to post-traumatic stress disorder (PTSD), depression, and anxiety. The difficulties and insecurity usually continue after torture while the individual is trying to seek asylum. All the post- and pre-migration stressors have a negative synergy on the symptoms and often make the co-morbid pain worse. The assessment process of SoT typically focuses on symptom intensity and interference, as well as decreased physical functioning, while other aspects of victims’ lives are not thoroughly considered. (Lechner-Meichsner et al. 2024)

Adverse health outcomes due to torture

Widespread and persistent pain is one of the most defining features of torture victims. (Amris et al. 2019). It is a multidimensional and complex experience. As the pain is not only the nociception (Cohen et al. 2021), it is essential to understand that with SoTs, the experience is shaped by trauma-related factors such as the torture mechanism and the torture circumstances themselves. Additionally, in persistent pain, often together with PTSD or other mental health conditions, there is the probability of central sensitization or other dysregulated stress responses. (Negron 2016, Wang et al. 2016). Even if the individual survives the torture and can flee from the country of origin, the post-migration stressors, such as insecurity of refugee status, economic burden, isolation from society, language barriers, lack of medical, social, and legal services, and distance from loved ones are factors that can worsen the symptoms. (Kashyap et al. 2019). Often, physiological and psychological symptoms interfere with an individual’s full spectrum of life, decreasing their functioning, self-esteem, and hope. Studies have shown that SoTs experience a reduced quality of life (Dee et al. 2024).

Unfortunately, the pain is often dismissed, and professionals tend to focus on other physical health, mental health, or social and welfare issues as separate factors. The features and characteristics related to how a person experiences pain are not understood. This can lead to problems with assessment, treatment, or rehabilitation. Furthermore, the topic of torture-related pain is understudied. (Amris et al. 2019).

When a person’s entire life is negatively affected by post-torture-related symptoms, it is essential to consider the methods of assessment. Studies have shown the importance of cultural and language sensitivity in the process (Liedl et al. 2011); however, there is more to consider. The assessment of torture survivors requires a multidimensional approach that considers not only physical symptoms but also trauma history and psychosocial factors. Furthermore, beliefs and attitudes can color the experience of pain and mental health symptoms. The often-used structured tools, such as pain questionnaires or symptom interviews, may not be well understood by SoT for several reasons. Furthermore, the assessment methods and tools tend to evaluate the intensity, amount, or interference of specific individual symptoms, such as pain, or clusters of symptoms related to mental health.

Approach to the descriptive literature review

High symptom load, persistent pain, and co-morbidity cause multidimensional struggles in torture survivors’ lives and are frequently not widely studied, understood, or assessed (Amris. 2019). The master’s thesis was written to describe the assessment methods used with SoTs suffering from co-morbid pain and to determine the role of quality of life in the current literature. The purpose was to study assessment tools and methods and build themes to determine the approach intentions behind the chosen assessment. The background organization for the thesis process was the Helsinki Deaconess Foundation, Center for Psychotraumatology.

The thesis is a descriptive literature review, and thematic analysis has been used. The final analysis included 14 sources. In the thematization process, seven themes were constructed: Symptom Management and Coping Strategies, Symptom Interference and Daily Functioning, Understanding Individual’s Background and Trauma History, Social Participation and Integration, Diagnostic Properties and Symptom Characteristics, Physiological Measures and Functional Assessment, and The Role of Quality of Life.

Results and discussion

The results showed that the assessment processes of survivors of torture are mainly focused on the interference of the symptoms, diagnostic or characteristic features, and collecting personal information about the person. What was in the minority was the assessment focused on symptom management or quality of life. This means that the person’s coping and self-efficacy were not the focus point. Furthermore, the included literature showed that the quality of life for this patient group is low; however, none of the assessment tools or methods specifically focused on evaluating this factor.

It might be that our ideas of torture and torture victims are mainly focused on developing countries, and we think that we are not working with this patient group during our career. As we are aware, there are numerous global instabilities, and even Europe is currently at war. Unfortunately, we have seen the headlines about degrading acts happening closer to us than ever. At the same time, immigration increases for multiple reasons, and one of them is that survivors of torture are escaping to find better lives. The development of torture assessment and treatment has been on the shoulders of a relatively small group of professionals, and the topic has not been considered as interesting when thinking about the number of studies in this field compared to other patient groups.

In the included studies, the description of the complete medical or legal assessment is lacking, which raises questions about how persistent pain has been diagnosed and whether other possibilities have been ruled out, such as fractures and brain injury. It is known that as services of SoT and immigrants are shattered, it might be that the minimum standards of the assessment process are not fulfilled. It is becoming more evident that everyone working in Health Care should acknowledge the possibility of torture when working with immigrants and know what special features need to be noticed. In future studies, the assessment of SoT should include more patient-centered strategies and focus on individuals’ coping skills and quality of life.

Authors:

Pieta Myllykangas, Master’s Degree in Global Public Health student, Savonia University of Applied Sciences

Maria Luojus, Principal lecturer, Savonia University of Applied Sciences

References:

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