Rehabilitating Torture Survivors - Dignity - Danish Institute Against ...

RehabilitatingTorture SurvivorsAn Evidence-BasedInternational ConferenceDecember 3-5, 2008Copenhagen, Denmarkorganized byRCT, the Rehabilitation and Research Centre for TortureVictims in collaboration with the Transcultural PsychiatryCentre, Psychiatric Centre, Copenhagen UniversityHospital/Rigshospitaletsupported byThe Danish Medical Research Council• Κey note lectures by outstanding internationalresearchers/clinicians in the field• Parallel workshops on rehabilitation issues in practice• Free communications on rehabilitation of traumasurvivors• Presentation of the new RCT Field Manual onRehabilitation• Joint sessions with the Danish National Network ofTrauma Treatment Centers (Danish program)RCT ● Rehabilitation and Research Centre for Torture VictimsBorgergade 13 ● DK-1300 Copenhagen K+45 3376 0600 ● www.rct.dk

PROGRAMWednesday Dec. 3, 2008Plenary SessionModerator: Marianne KastrupHourTheme: Assessment of Torture Survivors09.00 Presentation and Mental SymptomsAllen Keller, New York, USA10.00 Coffee/tea10.30 Chronic PainAndrew O Frank, London, UK11.30 An ICF ApproachBengt H Sjölund, Copenhagen12.30 Lunch14.00 Workshops1.Controversies inAssessmentModerator:Crt Marincek,LubljanaInvited:PTSDMarianne Kastrup,CopenhagenChronic PainUwe Harlacher,Copenhagen15.15 Coffee/tea15.45 Workshops, ctd’16.30 End2. Outcome Studiesin TOV SurvivorsModerator:Anders Foldspang,ÅrhusInvited:Mental Health Changesin Tortured RefugeesAdmitted toMultidisciplinaryTreatmentJessica Carlsson,CopenhagenThe Triple Burden ofTrauma Uprootingand SettlementBirgit Lie,Kristiansand, NorwayFree communication:Testimonial Therapy– a Brief InterventionInger Agger,Peter Polatin,Copenhagen3. The Context ofTortureModerator:Kamilla Portala,CopenhagenInvited:Mental Health inProtracted ConflictSituationsAbdel Hamid Afana,Quebec, CanadaEpidemiology – theExample of BangladeshShr-Jie Wang,Copenhagen

Thursday Dec. 4, 2008Plenary SessionModerator: Bengt H SjölundHourTheme: Rehabilitation of Torture Survivors09.00 Evidence for Psychotherapy in PTSDStuart Turner, London, UK10.00 Coffee/tea10.30 Evidence for Pharmacotherapy in PTSDSoraya Seedat, Stellenbosch, SA11.30 Pain Rehabilitation - What is the Current Evidence?Amanda C de C Williams, London, UK12.30 Lunch14.00 Workshops4. Team Work in TOVSurvivor Rehabilitation– the RCT ModelExampleModerator:Ann L Persson,CopenhagenTeam of clinicians:Uwe HarlacherBente MidtgaardLise WormAnnette Klahr15.15 Coffee/tea15.45 Workshops, ctd’16.30 End5. Internet-Based,Self-ManagementTreatment for PTSDModerator:Peter Polatin,CopenhagenInvited:Telehealth Methodsof Improving PTSDCareBrett T Litz,Boston, USAInternet-Based Cognitive-BehaviouralTreatment ApproachChristine Knaevelsrud,Berlin, GermanyFree communication:Towards a MoreComprehensive Modelof Care for Tortureand Ill TreatmentVictimsAbdelhak Elghezouant,Lausanne, Switzerland6. Children and theFamily of TortureSurvivorsModerator:Inger Agger,CopenhagenInvited:To Promote aMeaningful and MentalHealth PromotingContext for Childrenand the Family ofTorture SurvivorsSolvig Ekblad,Stockholm, SwedenTrauma and Resiliencein Young Refugees- the LongtermConsequencesof Exposure to Tortureand OrganizedViolenceEdith Montgomery,Copenhagen

Friday Dec. 5, 2008Plenary SessionModerator : Edith MontgomeryHourTheme: Critical Issues09.00 Imaging Studies in Torture SurvivorsJD Bremner, Atlanta, USA10.00 Coffee/tea10.30 Eye Movement Desensitization and Reprocessing (EMDR) – Mechanism,Procedure and EvidenceUdi Oren, Jerusalem, Israel11.30 Social Integration of Torture SurvivorsCécile Rousseau, Montreal, Canada12.30 Lunch14.00 Workshops7. The RCT Field Manualon Rehabilitation– an Update.Moderator:Jens Modvig,CopenhagenAuthor’s panel:Uwe HarlacherGunilla Brodda JansenMarianne KastrupAne-Grethe MadsenEdith MontgomeryKaren PripBengt H Sjölund8. The Danish NationalCenter NetworkAnnual Meeting(Effect studies; programin Danish)Moderator and introduction:Ulrik Jørgensen,CopenhagenInvited:On Controlled ClinicalTrials:Marianne Engberg,Århus15.15 Coffee/tea15.45 Workshops, ctd’16.30 End

PLENARY LECTURES: Assessment of Torture Survivors(Wednesday Dec 3 Morning)Presentation and Mental SymptomsInterrelated Symptoms and Integrated Care: Addressing the Physical,Mental and Social Dimensions of Health in Torture SurvivorsInvited lecturerAllen S. Keller, M.D.Associate Professor of Medicine, New York University School of MedicineDirector, Bellevue/NYU Program for Survivors of TortureNew York, New York, USAThe physical, mental and social dimensions of health are interrelated. In caringfor torture survivors, it is crucial that these 3 health arenas be evaluated andaddressed in a comprehensive, integrated fashion. When any one of these dimensionsof health is not evaluated and addressed, there is the potential for aprofoundly negative impact on the other two.In this presentation, I will discuss this interrelationship and present a multidisciplinarymodel for providing rehabilitative care for torture survivors. I will alsospeak to the crucial role of health professionals in promoting the health andwell-being of torture survivors through identification, treatment, documentationand advocacy.ReferencesKeller A, Lhewa, D, Rosenfeld B, Sachs E, Aladjem A, Cohen I, Smith H, PorterfieldK. Traumatic Experiences and Psychological Distress Among an UrbanRefugee Population. J Nervous and Mental Disease. 2006; 194 (3): 188-194.Keller A, Gold J. “Survivors of Torture.” In Comprehensive Textbook of Psychiatry.B Sadock, V Sadock, eds. New York: Lippincot Williams and Wilkins. 2005.Keller A. Caring and Advocating for Torture Victims. Lancet. 2002; 360, Supp1. pp. 55-56.7

PLENARY LECTURES: Assessment of Torture Survivors(Wednesday Dec 3 Morning)Chronic PainRefugees Presenting to a Rheumatological Servicewith Spinal Pain: Medical and Psychosocial ImplicationsInvited lecturerAndrew Frank, MBBS, FRCP, DSc (Hon); Arthritis Centre, Northwick ParkHospital and Institute of Medical Research, Harrow, UKAmanda C de C Williams, PhD, CPsychol, University College, London, UKAim of Investigation: To document the medical, physical and psychosocialproblems faced by refugees presenting to Northwick Park Hospital rheumatologicalneck and back pain clinics.Introduction: Audits from the rheumatology back and neck pain clinics fromNorthwick Park Hospital in the 1990s did not describe a single patient who hadbeen tortured 1;2 . We first reported patients who had been systematically torturedin 2002 3 , and since then increasing numbers have been seen in the spinalpain clinics.Many health care professionals still feel uncertain as to how to assess and treatrefugees who may have been tortured. Furthermore their rapid movement intoareas not previously exposed to their problems emphasises these difficulties.Methods: Patients likely to be recent refugees seen in the rheumatological lowback or neck pain clinics are normally asked their country of birth, duration ofstay in the UK and reasons for coming to the UK. A history of trauma or physicalabuse, where present, is documented during their NHS clinical consultation,sufficient to facilitate their medical management. A sleep history is taken. Patientsknown to the author will have their records reviewed retrospectively.Unique identification numbers were assigned and records entered (into an Exceldatabase) against them in accordance with the Data Protection Act. Descriptivestatistics were performed and data stored in password-protected hospital computers.Results: Sixty three refugees were seen in the rheumatology service with spinalpain between October 1993 and September 2006. Their country of birth wasIraq 24 (all Muslim apart from one Christian), Somalia 16, Afghanistan 8, Iran4, Lebanon 2 and one each from Libya, Sri Lanka, Algeria and Syria. Duration inthe UK had been a mean of 65 (range 5-228, SD 77) months.Discharge diagnoses: - mechanical low back pain 55 (87%), mechanical neckpain 28 (40%), anxiety/depression 48 (75%), post-traumatic stress symptoms41 (65%), torture/beating 30 (48%), knee pains 11 (17%), hiatushernia/reflux 11 (17%), abdominal pains ? cause 7 (11%) and metabolic bonedisease 7 (11%). Twenty six (41%) complained of some kind of gastrointestinaldisorder.8

Even when torture/abuse was denied, patients often admitted to repetitive horrificdreams consistent with post-traumatic psychological distress.Therapies tried included standard analgesia (using the analgesic ladder), tricyclicantidepressants and amelioration of social problems when possible. Standardphysiotherapy (aiming to improve self-management) usually appearedunhelpful whilst passive measures e.g. corsets seemed acceptable. Psychologicaltherapies were not usually available.CommentThe presentation will open up the hypotheses that, for many individuals, socialissues dominate psychological issues which dominate physical issues.ReferencesFrank AO, De Souza LH, Frank CA. Neck pain and disability: a cross-sectionalsurvey of the demographic and clinical characteristics of neck pain seen in arheumatology clinic. Int J Clin Pract 2005; 59: 173-182McCarthy J, Frank AO. Post-traumatic psychological distress may present inrheumatology clinics. BMJ 2002; 325: 221.Frank AO, De Souza LH, McAuley JH, Sharma V, Main CJ. A cross-sectional surveyof the clinical and psychological features of low back pain and consequentwork handicap: use of the Quebec Task Force Classification. Int J Clin Pract2000; 54: 639-44.9

PLENARY LECTURES: Assessment of Torture Survivors(Wednesday Dec 3 Morning)An ICF ApproachBengt H Sjölund, MD, DMScRehabilitation and Research Centre for Torture Victims, Copenhagen,Professor of Rehabilitation, University of Southern DenmarkWhat is the goal of management of torture survivors? Whom should we treat?Can we remove the cause of anxiety or of pain? Can we achieve permanentfreedom of symptoms or just temporary relief? Can we eliminate importantmaintaining factors for the presenting symptoms? Or should we rather aim atdiminishing the consequences of symptoms for an individual in a certain context,i e catastrophizing, fear avoidance, kinesiofobia, sleeplessness or aggressiveoutbursts? The diagnostic issues and labels are manifold. Consider e g thediscussion about the PTSD and DESNOS notions or the Idiopathic pain disorderwithout ‘organic’ pathology; the Somatoform pain disorder and the Pain disorder- psychological, organic or combination - see DSM-IV (APA 1994).In the International Classification of Functioning, Disability and Health (WHO2001), an impairment denotes a significant deviation or loss of function orstructure of any part of the body. Thus chronic pain and anxiety may both beconsidered as impairments, without necessitating a diagnostic label from theICD-10. Importantly, according to the ICF, impairments in relation to context,may give rise to activity limitations and participation restrictions for a person, ie various types of disability. When assessing a person to evaluate whether rehabilitationis necessary, it may be more meaningful and true to describe atraumatized person by the ICF categories rather than speculating if a particularorgan system is affected with an uncertain etiology and adding symptom diagnosesor an empirical psychological categorization (Sjölund, 2007).The first part of an interdisciplinary rehabilitation program is to make a functionalassessment by minimum a physician, a cognitively-behaviourally orientedpsychologist and a social worker, including interview of a significant other. Problemsin moving about often necessitate a physiotherapeutic assessment. Thereshould be a team conference with feedback to the patient.The goal setting in rehabilitation is facilitated by utilizing ICF notions:A) Can we reduce spedific impairments (remove the cause? achieve temporaryrelief?)B) How can the patient be empowered to overcome specific activity limitations(to support one self…)?C) Can the patient share life situations more effectively to reduce participationrestrictions (to share a family/community/vocational life…)?D) Can environmental & personal factors (e g attitudes; coping) be modified toimprove functioning?10

At present, the ICF taxonomy cannot be reliably used for outcome measurements(e.g. Grill et al 2007) but the biopsychosocial model and the ICF as aconcept is highly recommendable as a context-dependent model of humanhealth for all form of rehabilitation.ReferencesAPA. Diagnostic and Statistical Manual of Mental Disorders. WashingtonDC: American Psychiatric Association, 1994.Grill E, Mansmann U, Cieza A, Stucki G: Assessing observer agreement whendescribing and classifying functioning with the ICF. J Rehabil. Med 2007: 39:71-76.Sjölund BH: Dysfunctional pain and the ICF. In RF Schmidt & WD Willis (Eds)The Encyclopaedia of Pain. Berlin Heidelberg New York, Springer Verlag 2007,pp 670-672.WHO. International Classification of Functioning, Disability and Health. Geneva:World Health Organization, 2001.11

WORKSHOP 1: Controversies in Assessment(Wednesday Dec 3 Afternoon)Controversies in Assessment Regarding PTSDInvited lecturerMarianne Kastrup, MD PhD, PsychiatristCentre for Transcultural Psychiatry, Dept. Psychiatry, Rigshospitalet, Copenhagen,DenmarkIn the first half of the 20th century the prevailing thought was that traumaticlife events per se did not leave lasting consequences for mental health but aresult of a pre-morbid vulnerability. Following the Second World War studies ofe.g. concentration survivors and war sailors revealed that exposure to differentforms of extreme stress may induce fairly comparable mental problems amongpreviously well individuals.PTSD has been a nosological entity since DSM-III (1980) attempting to unitedifferent stress responses. Subsequently, revisions of DSM have modified diagnosticcriteria and ICD-10 has introduced two diagnostic categories (F 43.1 andF 62.0) covering consequences of traumatic stress.In recent years the diagnosis DESNOS has been suggested as covering betterthe condition.The tendency to inclusiveness of a biomedical paradigm has been criticized fromseveral sources claiming that this is a Western trend that does not sufficientlytake into consideration the socio-political context. The workshop will discuss theadvantages and shortcomings of current diagnostic categories vis-à-vis a reflectionof the universe of traumatized refugees and the need to develop methodsto assess the overall situation of this population.ReferencesRay S. Evolution of posttraumatic stress disorder and future directions.Arch Psychiatr Nurs 2008; 22: 217-25.Brunet A et al. Don’t throw out the baby with the bathwater (PTSD is not overdiagnosed)Can J Psychiatr 2007; 52: 501-2.McHugh P et al. PTSD A problematic diagnostic categoryJ Anxiety Dis 2007; 21: 211-22.12

WORKSHOP 1: Controversies in Assessment(Wednesday Dec 3 Afternoon)Controversies in Assessment – Chronic PainInvited lecturerUwe Harlacher, PhD, Chief PsychologistRehabilitation and Research Centre for Torture Survivors,Copenhagen, DenmarkThe assessment and measurement of pain implies manifold problems and controversies.Instead of focusing on technical aspects of pain-measurement suchas suitability of various measurement-instruments and scales, some more generaland principle controversies and problems will be discussed. These controversiesand problems arise because pain is a complex phenomenon, interactingwith other variables.The presented controversies and problems are:a) Pain might rather be secondary or subordinated to other problems than acentral problem per se. Examples of this will be presented and discussed.b) Unsuitable measurement of physical performance: the standardized measurementof physical performance, e.g. pre and post treatment might give misleadingresults if not embedded in a wider context of everyday activities.c) Too narrow focus on pain: a maximum reduction of pain is not a given centralgoal of treatment.d) Ignoring of long-term-perspective: short term strategies for coping with painmight not be suitable in the long run.e) Ignoring of subgroups: the population of pain-patients is not homogenouswith respect for e.g. general activity, some are (too) active, other (too) lowactivewith consequences on suitable treatment goals and interpretation oftreatment-results.f) Activity shift within individuals/pacing: This relatively complex phenomenonis described as important for some cases but at the same time as difficult toassess and measure.The treatment-philosophy of ”Acceptance and Commitment Therapy”(respectively a short and pronounced sharp formulation of that philosophy)is discussed in connection with points c), d) and f). It is argued that, dependingon subgroup and other variables that characterize the pain-problem,the utility of this philosophy can vary greatly from highly applicable (point c) tocounterproductive (points d) and f)).ReferencesTurck DC, WinterF. The pain survival guide, how to reclaim your life. WashingtonDC: American Psychological Association, 2006.Mc Cracken LM. Contextual cognitive-behavioral therapy for chronic pain. IASPpress, 2005.Butler D, Mosley L. Explain pain. Noigroup Publications, 2003.13

WORKSHOP 2: Outcome Studies in TOV Survivors(Wednesday Dec 3 Afternoon)Mental Health Changes in Tortured Refugees Admitted to MultidisciplinaryTreatmentInvited lecturerJessica Mariana Carlsson, MD, PhD 1 ; Marianne Kastrup, MD, LicMed 2 ; ErikLykke Mortensen, CandPsych 31Psychiatric Centre Amager, Research Department, RCT, Copenhagen, Denmark2Transcultural Psychiatry Centre, Psychiatric Centre, Copenhagen UniversityHospital/Rigshospitalet3Department of Health Psychology, Institute of Public health, University of Copenhagen,Copenhagen, DenmarkThe aim of this study is to examine changes in symptoms of PTSD, depression,anxiety, and in health-related quality of life in traumatised refugees admitted tomultidisciplinary treatment. The study group comprises 45 persons admitted tothe Rehabilitation and Research Centre for Torture Victims (RCT) in 2001-2002.Data on background, trauma, present social situation, mental symptoms(Hopkins Symptom Checklist-25, Hamilton Depression Scale, Harvard TraumaQuestionnaire), and on health-related quality of life (WHO Quality of life-Bref)were collected before treatment, after nine months, and 23 months. There wereno changes in mental symptoms from baseline to the nine months follow-up(1). A decrease in mental symptoms was observed in the period between thefirst and second follow-up, i.e. between the ninth and 23 rd month. Thesechanges and factors associated with these changes are currently being analysedand will be discussed during the presentation.ReferenceCarlsson JM, Mortensen EL, Kastrup M. A follow-up study of mental health andhealth-related quality of life in tortured refugees in multidisciplinary treatment.J Nerv Ment Dis 2005; 193(10):651-657.14

WORKSHOP 2: Outcome Studies in TOV Survivors(Wednesday Dec 3 Afternoon)The triple burden of trauma uprooting and settlement. A non-clinicallongitudinal study of health and psychosocial problems among refugeesin Norway. Implication of research for clinical work and health policy inthe treatment of traumatized refugees.Invited lecturerBirgit Lie, MD PhDSørlandet sykehus, Kristiansand, NorwayRefugees arriving in exile have different traumatic preflight experiences. Healthrelated consequences of trauma and migration and the need for targeted healthcare were focus of the study. To provide sufficient services represents moral,ethical and professional challenges for Norwegian healthcare. Increased forcedmigration has become part of daily life worldwide. Long term studies of effectsof trauma on mental health and more knowledge and clinical skills are neededin treatment of consequences of organized violence.The aim of the referred study was to investigate changes in psychologicalsymptoms and general health conditions over time. In addition the influence ofrisk factors (torture, pre- and post-flight traumatic events and demographicstatus) on psychological symptoms and to explore potential influence of psychosocialfactors on psychological healthThe project was a 3 year follow-up community study of non clinical group ofrefugees. Fully structured interviews performed by trained local health workerswith translators. The study was an action research with results used in localplanning and with an educational aspect using local health workers as interviewers.There was an epidemiological research aspect with the mapping ofsituation among refugees and a health policy aspect as part of the study methodswere implemented in healthservice guidelines.Implication of research on health policy guidelines and clinical work with refugeeswill be discussed in the presentation. New methods in trauma-treatmentwill be discussed where the starting point is TOV survivors but point towardsthe general clinical approach towards all traumatised patients in a psychiatricclinic.ReferencesLie B., The psychological and social situation of repatriated and exiled refugees:a longitudinal, comparative study. Scand J Public Health. 2004;32(3):179-87.Lie B., A 3-year follow-up study of psychosocial functioning and general symptomsin settled refugees. Acta Psychiatr Scand. 2002 Dec;106(6):415-25.15

WORKSHOP 2: Outcome Studies in TOV Survivors(Wednesday Dec 3 Afternoon)Free CommunicationTestimonial Therapy: a Brief Intervention to Improve Wellbeing in Victimsof TOVInger Agger, PhD; Peter Polatin, M.D., MPH;Lenin Raghuvanshi, B.A.M.S.Introduction:Testimonial therapy, provided through trained community workers and humanrights activists, helps victims of torture to tell their stories, and to receive psychotherapeuticand community support. Justice is the entry point in the testimonymethod, which originally was developed in Chile during the military dictatorshipin the 1970s 1 . It has been used successfully for the psychotherapeutictreatment of women refugees who are survivors of sexual torture 2 , and hasalso been a therapeutic tool employed within the social framework of an activehuman rights movement 3 . More recently, principles of cognitive behavioralexposure therapy and testimony therapy have been combined in Narrative ExposureTherapy for treatment of traumatized survivors of war and torture 4 .It is hypothesized that public testimony about human rights violations withinthe context of testimonial therapy serves as: 1.) a cathartic and positive reframingexperience for the survivors, 2.) desensitization and alternative learningfrom volitionally re-experiencing the trauma, and/or 3.) gratification andempowerment by active contribution to obtaining justice and preventing torturein the future.While some mental health workers believe the process of talking about traumaticexperiences alone can be helpful, the focus of testimonial therapy is oncollaboration and documentation, with the intention to use the testimonial toeducate an uninformed public and to advocate for justice. Human rights activistswho normally work with testimonies as legal documentation are trained toadd a “psychological” dimension to an activity with which they are already familiar.Therefore, testimonial therapy offers advantages when mental healthskills are in short supply and in communities suffering under extreme and frequenthuman rights violations.Method:A collaborative three month pilot training project was undertaken between RCTand the People’s Vigilance Committee on Human Rights (PVCHR) in Varanasi,India on ”Testimony as a Brief Therapy Intervention”. The project involved fourweeks of training of PVCHR staff by a consultant who is an expert in testimonialtherapy, the development of a context specific training manual, and the use ofa monitoring and evaluation system for the purpose of outcome evaluation,comparing results of measures before the intervention and 2-3 months thereafter.Twelve community workers were trained to work in pairs to utilize testimonialtherapy. Twenty three victims underwent treatment, under supervision.Most clients received 2 or 3 treatment sessions. Outcome measures used werethe WHO5, the Pain Analog, and a derived questionnaire utilizing ICF Activity16 and Participation categories.

The therapist allowed the survivor as much control over the story-telling aspossible, including the pace of the narrative and the amount of informationshared. A transcript was created, and the testifier had the final say in its exactwording and eventual distribution. The therapist utilized “mindfulness” and/orother culturally appropriate meditative relaxation methods to ensure that thetestimonial process was not overwhelmingly distressing. A public delivery sessionwas introduced, in which the survivor was honored after therapy (with consent),and the testimony read out and given to the survivor in a communityceremony.Findings:The individuals who participated in this pilot study were mostly primary victimsof torture. The perpetrators were almost always the police. Prior to participationin testimonial therapy, most of participants were having difficulties functioningunder stress. Many were able to work and support themselves with mild tomoderate difficulty, but all had been doing better before they were tortured,and had much more difficulty with income generating activities immediatelyafter being tortured. Quite a few had residual pain, and a low sense of wellbeing.Many of them had three or more residual psychological symptoms subsequentto the torture event. Many did not understand the issue of basic humanrights, or could not appropriately answer questions about issues related to politicsand human rights. Most of them had received very low levels of health careafter they had been tortured, although many of them had experienced fairlyextensive physical injuries. All had seen an attorney, reflective of the fact thatthey were involved with the PVCHR.After testimonial therapy, almost all subjects demonstrated significant improvementsin overall WHO 5 score. Four out of the five individual items improved byat least 40%. ICF items showed less significant change, possibly because thequestions had not been well understood, but did improve nevertheless.The community ceremony component which was introduced into this projectwas observed to be quite dramatic in promoting improved subject demeanor.This would suggest a fourth hypothesis to explain the benefit of testimonialtherapy: destigmatization and reintegration of the survivor into his family andcommunity.Interpretation:Testimonial therapy as it has been developed in this project is both an individualand community-based model, best adapted to a situation where work withthe trauma has been delayed. The usual format is brief (3-4 sessions). In thisvery small pilot study, brief testimonial therapy appears to improve the wellbeing of subjects who have completed treatment. However, a more extensivestudy is needed to verify these results, and better measures of ICF A&P functionsshould be used.17

References1 Cienfuegos, A.J. & Monelli, C. (1983). The Testimony of Political Repression asa Therapeutic Instrument. Amer. J. Orthopsychiat. 53 (1), 43-51.2 Agger, I. (1994). The Blue Room. Trauma and Testimony Among RefugeeWomen – a Psychosocial Exploration. London: Zed Books.3 Agger, I. & Jensen, S.B. (1996). Trauma and Healing Under State Terrorism.London: Zed Books.4 Neuner, F., Schauer, M., Klaschik, C., Karunakara, U. & Elbert, T. (2004). AComparison of Narrative Exposure Therapt, Supportive Counseling, andPsychoeducation for Treating Posttraumatic Stress Disorder in an AfricalRefugee Settlement. Journal of Consulting and Clinical Psychology, 71 (4), 579-587.18

WORKSHOP 3: The Context of Torture(Wednesday Dec 3 Afternoon)Mental Health in Protracted Conflict SituationsInvited lecturerAbdel Hamid Afana, PhDPresident, International Rehabilitation Council for Torture Victims (IRCT), DouglasHospital Research Institute, McGill University,Québec, CanadaThe implications of protracted conflict goes beyond the loss of individuals’ lifeand destruction of their infrastructure, its devastating consequences appear inthe social and cultural fabrics of people, their identity and their values system.They experienced oppression, multiple, repetitive and continuous traumaticexperiences. People are forced to leave their houses as internally displaced,where many others expelled from their villages and cities to find safe refuge inneighbouring countries, which represents not only the loss of live hood and politicalwell, it also represents the disintegration of society, the frustration ofnational aspiration and the beginning of rapid process of destruction of theirculture.The long period of victimization and traumatization aggravate the feelings offrustration and hopelessness which inevitably activate new waves of violenceand aggression aimed at restoring people’s dignity and self-esteem. Responsesto living in political conflict and to traumatic experiences are not universal innature and can be manifested in different social and psychological levels, butnot necessarily lead to psychopathology, but rather illustrate the aspects ofnormal cognitive functioning. These responses fall within the range of normalresponse to overwhelming events that may or may not lead medical or psychiatricinterventions.Unfortunately, the long term effects protracted conflicts have been reduced toindividual level, through establishing a direct linkage between the trauma andcertain symptoms in some individuals. Traumas must be examined not onlyfrom the trauma related disorders, but also on the individual and collective levels,where psychosocial and biological processes have to be linked to macrosocio-cultural and political determinants of trauma.In the Palestinian context, which is one of the main chronic protracted conflictsin the world, little is known about culturally specific expressions of distress thatmay be linked with exposure to political violence, torture and war. Examiningcultural variations in the understanding and expression of trauma-related distresshas implications for the definition of trauma in psychiatric nosology, aswell as for the design and delivery of clinical and community interventions. Thesocial representations of trauma and ways in which trauma is defined amongPalestinians living in protracted conflict situations in the Gaza Strip will be describedin this presentation.19

ReferencesPedersen, D.; Tremblay, J.; Errazuriz, C.; and Gamarra, J., (2008) The sequelaeof political violence: assessing trauma, suffering and dislocation in the Peruvianhighlands. Social Science & Medicine, 67 pp 205-217.Giacaman, R.; Matarieh, A.; Nguyen-Gillham, V.; and Safieh, R., (2007) Qualityof life in the Palestinian context: an inquiry in war like conditions. Health Policy,81 pp 68-84.Afana, A (2006) mental health situation for Palestinians, in Judy Kuriansky (etd)Terror in the Holy Land: inside the anguish of the Israeli-Palestinian conflictPraeger Publishers USA ISBN 0-275-99041-9.Summerfield, D., (1999) A critique of seven assumptions behind psychologicaltrauma programmes in war-affected areas. Social Science & Medicine, 48 pp1449-1462.20

WORKSHOP 3: The Context of Torture(Wednesday Dec 3 Afternoon)Collective Exposure to Organized and Political Violence (OPV) in theComplex Setting: Epidemiology in the Example of Bangladesh.Invited lecturerShr-Jie Wang, MPH, PhDRehabilitation and Research Centre for Torture Victims,Copenhagen, DenmarkBackground: Since 1972, ruling parties in Bangladesh have systematicallyused torture/inhuman treatment as a means of suppressing political opponentsor criminals. The vulnerable population is often hidden and lacks means to addresstheir victimization effectively. The aim was to compile a minimum dataseton OPV features in the Meherpur district.Methods: The population-based study consists of two parts: household surveyand OPV screening at a mobile clinic (not presented here). Multi-stage clustersampling method was used in the household survey: 22 clusters (sample size of1,101 households: population 4870).Results: In the household survey the annual injury rate was 36%, life experienceon violence-attributable injury was 50% and pain experience in the 2weeks preceding survey was 57%. 80% of population >35 years old complainedabout pain. Over 25% of households reported a house search or occupation bylaw enforcement agencies. 75% of families reported that family members hadwitnessed violent actions or degrading treatment against their friends orneighbours, and 29% reported that the family members had been arrested ordetained. 31% reported torture or other cruel, inhuman and degrading treatmentand punishment. It was more likely to report that a family member hasbeen arrested or detained and extra judicially executed if any in the samehousehold was involved in the party politics, had ever participated in a demonstration,union strike or human rights rally, or had personal or financial conflictwith neighbours. People from families with the highest income level had relativelyhigher risk of being arrested or detained. It was also likely reported torturefrom families with a member involved in politics.Discussion 1) Our study established a baseline on collective exposure to OPVamong the general population. We identified considerable amount of silent victimfamilies using a rapid assessment protocol. 2) The estimate of overall humanrights abuses (incl. torture) provided an insight on possible extent of OPVexposure. 3) It is the first epidemiological study to confirm the elevated prevalenceof annual injury, life experience on violence-attributable injury and paincomplaints in relation to the level of exposure to OPV. 4) High prevalence ofinjury, life experience on violence-attributable injury, pain complaints and mortalityhas become a financial burden for the families.21

5) It is also the first study to reveal the distinguished geographical variation inreporting inhuman and degrading treatment and punishment, suggesting theresponsibility of relevant police stations involved in torture and human rightsviolations.Conclusion:An immediate multilevel intervention with a rights-based approach in the rehabilitationand prevention is required at the western border of Bangladesh.22

PLENARY LECTURES: Rehabilitation of Torture Survivors(Thursday Dec 4 morning)Evidence for Psychotherapy in PTSDInvited lecturerStuart Turner, MDTrauma Clinic, London, UKPTSD is one of the psychiatric problems that may follow torture. Before embarkingon treatment, however, it is of course essential to undertake a full assessment.Any psychological intervention should be based on a psychologicalformulation. (Even where PTSD is present, it may not be the most importantproblem.)There is now considerable evidence for the efficacy of psychological therapies inPTSD. This derives from published trials, review papers, meta-analyses andclinical guidelines. In this paper, data prepared for the guideline published bythe UK National Institute for Health and Clinical Excellence(http://www.nice.org.uk/guidance/index.jsp?action=download&o=29770)will be presented. This guideline was largely based on a series of metaanalysesof randomised clinical trials of efficacy. There are limitations of thisapproach. Not all interventions have been subject to these trials. They arealmost all trials of efficacy (how well the intervention works in the researchunit) rather than effectiveness (how well the intervention works in the realworld). However, the strengths are obvious. It is possible to report that someinterventions have measurable effects and that these are unlikely to have occurredby chance. In this paper, the topic concerns the evidence base for treatmentand this will be the focus of the rest of the presentation.One feature of the NICE guideline was that it required more than a statisticallysignificant effect to be present before an intervention was recommended. Inthe guideline development group, pre-defined criteria for a clinically meaningfuleffect were agreed. In very large trials, statistically significant differences canoccur for effects that are so small as to be clinically meaningless. This issuewas confronted directly in the development of this guideline. What emergedwas that for PTSD, there is strong support for two structured treatments –trauma focused CBT and EMDR.However, none of the included trials were with refugees or torture survivors. Itis recognized that some people present with more complex groups of symptomsespecially after interpersonal trauma. In ICD-10, there is the diagnosis of EnduringPersonality Change after Catastrophic Experience, for example. In thefull guideline, although there was no trial evidence to support this, it was feltthat a phased intervention should be considered as with other forms of complexreaction to trauma.23

Since this guideline was produced there has been increasing interest in otherapproaches such as Narrative Exposure Therapy and this will be consideredhere. Also in the month before this meeting, the second edition of “EffectiveTreatments for PTSD; Practice Guidelines from the ISTSS” (Guilford) will havebeen published and this work will also be considered.The conclusion is that there are psychological treatments with a strong evidencebase. Not all interventions have been subject to randomized trial. Theapplicability of this evidence in settings where people present with more complexproblems (beyond PTSD) is less clear.24

PLENARY LECTURES: Rehabilitation of Torture Survivors(Thursday Dec 4 morning)Evidence for Pharmacotherapy in PTSDInvited lecturerSoraya Seedat, MD, PhDMRC Unit on Anxiety Disorders, Department of Psychiatry,University of Stellenbosch, Cape Town, South AfricaThis presentation will review the strength of the evidence for medicationswidely prescribed as first-line agents for PTSD (e.g. SSRIs, venlafaxine). Anumber of expert consensus guidelines have recommended SSRIs, or SSRIsand venlafaxine, as first line pharmacological agents in the treatment of PTSD.Other guidelines, for example, the NICE guidelines recommend that drug treatmentsshould not be routine first-line treatment for adults. Currently, two SSRIs(paroxetine and sertraline) are FDA-approved although effect sizes in shorttermPTSD trials have been modest. A Cochrane review which included 35short-term (14 weeks or less) RCTs (4 597 participants), found that symptomseverity in17 trials was significantly reduced in the medication groups, relativeto placebo (weighted mean difference (WMD) = -5.76, 95% confidence interval(CI)-8.16 - -3.36, N = 2 507). Similarly, summary statistics for responderstatus from 13 trials demonstrated overall superiority of a variety of medicationagents compared with placebo (relative risk (RR) = 1.49, 95% CI: 1.28, 1.73,number needed to treat (NNT) = 4.85, N = 1 272). Medication and placeboresponse occurred in 59.1% (N = 644) and 38.5% (N = 628) of patients, respectively.Of the medication classes, evidence of treatment efficacy was mostconvincing for the SSRIs. Medication was also effective in reducing the severityof the PTSD re-experiencing/intrusion, avoidance/numbing, and hyperarousalsymptom clusters in 9 trials (N = 1 304). In addition, medication was superiorto placebo in reducing comorbid depression and disability.Older antidepressant agents, such as the tricyclic antidepressants and themonoamine oxidase inhibitor, phenelzine, also have some proven efficacy inPTSD. However, concerns about poorer tolerability and risks of toxicity, in comparisonwith SSRIS and SNRIs, limit their frequent use. Beneficial effects ofother groups of medications, including anticonvulsants, atypical antipsychotics(e.g. olanzapine and risperidone), benzodiazepines, alpha-adrenergic blockers(e.g. prazosin), opiate antagonists (e.g. naltrexone) and novel drugs (e.g. cycloserine,inositol) will be reviewed. Other issues to be discussed include evidencefor (i) optimal dose and appropriate duration of pharmacotherapy, (ii)combined pharmacotherapeutic and psychotherapeutic approaches, (iii) predictorsof response to pharmacotherapy, (iv) pharmacotherapy of treatmentresistantPTSD and (v) early intervention. The few trials of early interventiondrug treatments (e.g. propranolol, hydrocortisone) are promising; howevergiven the small number and scale of early intervention drug studies, it is notyet possible to draw firm conclusions.25

In sum, while medication treatments can be effective in treating core symptomsof PTSD as well as the associated depression and disability, existing agents stillfall short of being ideal due to limited response and remission rates and tolerabilityissues. There are significant gaps in assessing the efficacy of pharmacotherapyin different trauma subpopulations (e.g. combat veterans, refugees)including ethnic and cultural minorities, women, and older individuals. Furthermore,adequately powered, appropriately designed trials to determine if pharmacologicaltreatments are superior in terms of efficacy and cost effectivenessto trauma-focused psychological treatments (such as CBT) in the treatment ofPTSD, and whether they are efficacious and cost-effective in combination aresorely needed. The need for improving the pharmacotherapy of PTSD remainscompelling.ReferencesBandelow B, Zohar J, Hollander E, Kasper S, Möller HJ on behalf of the WFSBPTask Force on Treatment Guidelines for Anxiety, Obsessive-Compulsive andPosttraumatic Stress Disorders. World Federation of Societies of Biological Psychiatry(WFSBP) Guidelines for the pharmacological treatment of anxiety, obsessive-compulsiveand posttraumatic stress disorders - first revision. World JBiol Psychiatry 9: 248-312, 2008.Institute of Medicine (IOM). Treatment of posttraumatic stress disorder: Anassessment of the evidence. Washington, DC: The National Academies Press,2008.Ipser JC, Carey P, Dhansay Y, Fakier N, Seedat S, Stein DJ: Pharmacotherapyaugmentation strategies in treatment-resistant anxiety disorders. CochraneDatabase Syst Rev 18;(4): CD005473, 2006.Stein DJ, Ipser JC, Seedat S: Pharmacotherapy for post traumatic stress disorder(PTSD). Cochrane Database of Systematic Reviews 25;(1):CD002795,2006.National Institute for Health and Clinical Excellence. The management of posttraumatic stress disorder in primary and secondary care. London, NICE, 2005.Stein DJ, Bandelow B, Hollander E, Nutt DJ, Okasha A, Pollack MH, Swinson RP,Zohar J: WCA recommendations for the long-term treatment of posttraumaticstress disorder. Cns Spectrums 8:31-39, 2003.Bandelow, B, Zohar, J, Hollander, E, Kasper, S, Moller, H-J, and WFSBP TaskForce on Treatment Guidelines for Anxiety, Obsessive-Compulsive and PosttraumaticStress Disorders. World Federation of Societies of Biological Psychiatry(WFSBP) guidelines for the pharmacological treatment of anxiety, obsessivecompulsiveand posttraumatic stress disorders. World J Biol Psychiatry 3: 171-199, 2002.26

Ballenger, J C, Davidson, J R, Lecrubier, Y, Nutt, D J, Foa, E B, Kessler, R C,McFarlane, A C, and Shalev, A Y. Consensus statement on posttraumatic stressdisorder from the International Consensus Group on Depression and Anxiety. JClin Psychiatry 61S5: 60-66. 2000.Foa, E B, Davidson, J R T, and Frances, A. Treatment of posttraumatic stressdisorder: The expert consensus guideline series. J Clin Psychiatry 60, 1-76.1999.27

PLENARY LECTURES: Rehabilitation of Torture Survivors(Thursday Dec 4 morning)Evidence for Pain RehabilitationInvited lecturerAmanda C de C Williams, PhD, CPsycholUniversity College,London, UKPersistent (noncancer) pain is commonly treated using psychologically-basedrehabilitation to improve quality of life. By definition, persistent pain has notresolved with physical and pharmacological treatments; or if partially improvedhas not led to the individual returning to his or her valued activities and roles inlife, or becoming self-managing. This is largely because the problems of persistentpain – loss of social and vocational activity, and pervasive distress, isolationand frustration – result not only from pain but from the fears and confusionsabout it, and from dealing with it in ways appropriate only to acute painproblems. These cognitive, emotional, and behavioural contributions to the persistentpain problem need to be addressed directly in treatment.Treatment using psychologically-based methods usually takes the form of apain management programme, with psychologists and physiotherapists in activetreatment roles, and doctors and others in important educational roles. 40years of such programmes has resulted in diverse methods and outcomes, onlypartly reflected in the randomised controlled trials incorporated in systematicreviews and meta-analyses 1-5 . These show consistently good outcomes: reduceddisability, reduced distress, and even reduced pain although this is not aprimary aim.None of the treatment elements alone is outstandingly effective, although allcontribute to better outcome. Treatment which uses predominantly physicalexercise and retraining has somewhat disappointing results 6 , and the model ofdeconditioning as a consequence of persistent pain is undergoing reevaluation 7 .Education is a weak way to change behaviour 3 ; cognitive therapy has evolvedfrom relaxation/stress management through changing catastrophic beliefs andthinking to problem solving and acceptance, and each shows benefits. The mosteffective alone is behavioural exposure 8 , but it can be hard to engage patientsor to apply across activities and social roles.Overall, the field needs a reassessment of implicit and explicit models, of outcomes(which may overlap little between patients and health care providers),and of process variables such as social context and group factors which maycontribute substantially to outcome. All of these issues will be considered in thelight of provision for torture survivors, amongst whom persistent pain is commonand disabling.28

ReferencesHoffman BM, Papas RK, Chatkoff DK, Kerns RD. Meta-analysis of psychologicalinterventions for chronic low back pain. Health Psychol 2007;26:1-9.Hayden JA, van Tulder MW, Malmivaara AV, Koes BW. Meta-analysis: exercisetherapy for nonspecific low back pain. Ann Intern Med 2005;142:765-775.Ostelo RWJG, van Tulder MW, Vlaeyen JWS, et al. Behavioural treatment forchronic low-back pain. Cochrane Database Systematic Reviews 2005:1-25.Verbunt JA, Sieben JM, Seelen HAM, et al. Decline in physical activity, disabilityand pain-related fear in sub-acute low back pain. Eur J Pain 2005;9:417-425.European Guidelines (2004) European Guidelines for the management of nonspecificlow back pain, www.backpaineurope.org/web/files/WC2_Guidelines.pdfVlaeyen JW, de Jong J, Geilen M, et al. Treatment of fear of movement/(re)injury in chronic low back pain: Further evidence on the effectiveness of exposurein vivo. Clin J Pain 2002;18:251-61.Guzmán J, Esmail R, Karjalainen K, et al. Multidisciplinary rehabilitation forchronic low back pain:systematic review. Brit Med J 2001;322:1511-6.Morley S, Eccleston C, Williams A. Systematic review and meta-analysis of randomizedcontrolled trials of cognitive behaviour therapy and behaviour therapyfor chronic pain in adults, excluding headache. Pain 1999;80:1-13.29

WORKSHOP 4: Team Work in TOV Survivor Rehabilitation- the RCT Model Example(Thursday Dec 4 morning)Invited lecturersTeam of Consulting CliniciansUwe Harlacher, PhD, Chief Psychologist; Bente Midtgaard, SocialWorker; Lise Worm, M.D. Specialist in General Medicine and AnetteKlahr, MSc, Physiotherapist,Rehabilitation and Research Centre for Torture Victims,Copenhagen, DenmarkRCT offers rehabilitation to people who have been exposed to torture, organizedviolence or other severely traumatizing events such as war, civil war and politicalpersecution. Further, RCT offers rehabilitation to family members of theprimarily traumatized person.People with present substance-abuse, psychotic disease, severe personalitydisorder and acute suicidal risk are excluded from treatment at RCT. Potentialclients have to have a residence permit in Denmark and a referral from a physician.The main characteristics of about 80 percent of the RCT-clients are that theyare males with heterogeneous educational and socio-economic backgrounds,currently having significant socio-economic problems, low skills in the Danishlanguage, which causes the necessity of using interpreters in the rehabilitationprocess, and that they are suffering from multiple symptoms. A further descriptionwill be given in the workshop.The clients suffer from multiple problems such as post-traumatic stress disorder,depression, anxiety, chronic pain, poverty, isolation and various other socialdistress factors. Typical problems and how these are dealt with will be presented.It is stated that the clients’ multiple problems highly interact with eachother; thus, they are not reducible to a single central diagnosis or domain ofsuffering, i.e. the psychiatric, somatic and socio-economic issues are equallyimportant. Accordingly, an interdisciplinary and bio-psycho-social rehabilitationapproach is adopted as a guiding principle at RCT.All patients on RCTs external waiting list, i.e. all patients on the waiting list whohave been referred correctly and belong to the target-group, undergo an interdisciplinary“assessment”, which includes a medical, a physiotherapeutic, a psychologicaland a social examination. After the assessment, the client is recommendedrehabilitation either at another treatment centre or at RCT within oneof the three rehabilitation programs that are offered. About 20% of the clientsare recommended rehabilitation at another treatment centre, typically (but notexclusively) clients who have a less pronounced need for an interdisciplinaryrehabilitation-approach, i.e. when a combination of improved psychiatric treatmentcombined with physiotherapy is judged to be sufficient. Clients with asignificant part of their problems being related to their intra- and/or extra familialsocial network are offered the family therapy-based rehabilitation program at30

RCT. Clients suitable to participate in groups are recommended RCTs groupbasedrehabilitation program, and clients best suited for individual rehabilitation(and those who may be suitable for group-based rehabilitation as well but donot fit in because of e.g. language or gender) are offered RCTs individual rehabilitationprogram.The three rehabilitation programs that are offered at RCT will be described inthe terms of how the rehabilitation teams are composed and organized as wellas how the guiding principle of interdisciplinary teamwork is implemented. Theorganizational aspects and the criteria for inclusion of clients into the three rehabilitationprograms, together with other formal aspects, will be outlined.The structure and content of the group-based rehabilitation program will bepresented in some detail, and the experiences since the implementation of theprogram nearly three years ago is communicated.Case examples will be used to illustrate the complexity of the target groups’health-related problems and the interdisciplinary approach to the rehabilitationprocess.On the basis of collected experiences, the possible future development of RCTsrehabilitation will be discussed as well as the possible necessity to transcendtraditional rehabilitation in a narrow sense by conducting advocacy at a political-societallevel. Further, it is an ambition to provide sufficient opportunity forthe audience to discuss issues based on their wishes.31

WORKSHOP 5: Internet-based Self Management Treatmentfor PTSD(Thursday Dec 4 Afternoon)Telehealth Methods of Improving PTSD CareInvited lecturerBrett T. Litz, PhDVA Boston Healthcare System,National Center for PTSD, Boston University School of Medicine,Boston, USAMost at-risk individuals and groups exposed to various forms of trauma andtraumatic losses do not get the care they need. Even when trauma survivorsbreak through various cultural, logistical, and psychological barriers to care,they typically do not get state-of-the-art, evidence-based treatments. Finally,expert specialty care for PTSD and other mental health problems implicated byexposure to trauma is very costly and typically inaccessible. As a result, it isimportant to pursue technologies that can get people the care they need in efficientand accessible ways. Dr. Litz will present ideas about using technologies,such as the Internet to help get quality care to individuals who would otherwisenot get care and improve the quality of professional care. He will also presentthe results of a randomized controlled trial of an Internet-based selfmanagementCBT (SM-CBT) versus Internet-based supportive counseling (SC)for PTSD. Service members with PTSD were randomly assigned to SM-CBT(N=24) versus SC (N=21). In the intent-to-treat (ITT) sample, SM-CBT led tosharper declines in daily logon ratings of PTSD symptoms and global depression.In the completer group, SM-CBT led to greater reductions in PTSD,(d=.95) scores at 6-months. SM-CBT may be a way of delivering effectivetreatment to large numbers with unmet needs and barriers to care.ReferencesLitz, B.T. & Bryant, R. (2008). Early Intervention for Trauma in Adults: Cognitive-BehavioralTherapy. In E. Foa, M. Friedman, T. Keane, J. Cohen (Eds) Effectivetreatments for PTSD: Practice guidelines from the International Society forTraumatic Stress Studies (Second Edition; pp. 117-135). New York: GuilfordPress.Litz, B.T., Engel, C.C., Bryant, R., & Papa, A. (2007) A Randomized ControlledProof of Concept Trial of an Internet-based Therapist-assisted Self-managementTreatment for Posttraumatic Stress Disorder. American Journal of Psychiatry,164, 1676-1683Litz, B.T., Williams, L., Wang, J., Bryant, R., & Engel, C.C. (2004). The developmentof an Internet-based program to deliver therapist-assisted self-help behavioraltreatment for traumatic stress. Professional Psychology: Science andPractice, 35, 628–634.32

WORKSHOP 5: Internet-based Self ManagementTreatment for PTSD(Thursday Dec 4 Afternoon)Internet-Based Cognitive-Behavioural Treatment ApproachInvited lecturerChristine Knaevelsrud, PhD, Research DirectorTreatment Center for Torture Victims, Berlin, Germany;Birgit Wagner, University of Zurich;Philipp Kuwert, University GreifswaldRecent developments in communication technology dramatically expand thetreatment possibilities in clinical psychology, and offer great potential to improvetreatment provision in the area of humanitarian aid (Knaevelsrud, Karl,Wagner & Müller, 2007). Previous research has shown that PTSD und relatedconditions such as complicated grief can be successfully treated through theInternet (Knaevelsrud & Maercker, 2006, Knaevelsrud & Maercker, 2007,Knaevelsrud & Maercker, in press; Lange et al, 2003; Wagner, Knaevelsrud &Maercker, 2006). Specifically, a highly effective Internet-based cognitivebehaviouraltreatment approach has recently been developed for posttraumaticstress disorder (Interapy). The treatment consists of structured writing assignmentsthat take place through a database implemented on the Internet. Communicationbetween therapist and patient is entirely text-based and asynchronous.The treatment manual is based on cognitive-behavioural therapy approachesthat have proved effective in regular face-to-face-settings. Results ofa randomized control trial of on Internet-based treatment for PTSD in a German-speakingsample with 96 participants will be presented. Significant andenduring improvements in posttraumatic stress symptoms, anxiety and depressedmood were found that sustained during an 18 months follow-up. Themain focus of the presentation will be two currently conducted studies exploringthe potential of Internet-based therapy in post-conflict countries and its applicabilityacross life-span. In cooperation with the University of Zürich the TreatmentCenter for Torture Victims, Berlin is providing an Arabic Internet-basedtherapy for survivors of war and torture residing in Iraq or neighbouring countries(www.ilajnafsy.org; www.virtual-traumacenter.org). In cooperation withthe University Greifswald an Internet-based biographical testimonial therapy fortraumatized child survivors and victims of war –related sexual violence of theWWII is provided. Current challenges of applying this approach in a postconflictsetting (Iraq) and across lifespan (patients who are older than 65 years)are discussed and preliminary data are presented.ReferencesKnaevelsrud, C. & Maercker, A. Long-term effects of an Internet-based treatmentfor posttraumatic stress disorder. Cognitive Behaviour Therapy (in press).33

Knaevelsrud, C., Karl, A., Wagner, B. & Müller, J. (2007). New treatment approaches:Integrating new media in the treatment of war and torture victims.Torture , 17, 67-78.Knaevelsrud, C. & Maercker, A. (2007). Internet-based treatment for PTSD reducesdistress and facilitates the development of a strong therapeutic alliance:a randomized controlled trial. BMC Psychiatry, 7:13.Knaevelsrud, C. & Maercker, A. (2006). Does the quality of the working alliancepredict treatment outcome in online therapy for trauma patients? Journal ofMedical Internet Research, Dec 19;8(4):e31.Wagner, B., Knaevelsrud, C. & Maercker, A. (2005). Wagner, B., Knaevelsrud,C., & Maercker, A. (2005). Internet-based Cognitive-Behavioural Therapy(INTERAPY) for Complicated Grief: A controlled Evaluation. Death Studies, 30,429-453.Lange, A., Rietdijk, D., Hudcovicova, M., Van de Ven, J-P., Schrieken, B. & Emmelkamp,P.M.G. (2003). INTERAPY. A controlled randomized trial of the standardizedtreatment of posttraumatic stress through the Internet. Journal ofConsulting and Clinical Psychology, 71(5), 901-909.34

WORKSHOP 5: Internet-based Self ManagementTreatment for PTSD(Thursday Dec 4 Afternoon)Free CommunicationTowards a More Comprehensive Model of Care for Torture and Ill TreatmentVictimsAbdelhak ElghezouaniAssociation Appartenances,Lausanne, SwitzerlandA deeper definition and/or approach of the sociopsychological impact of tortureand ill treatment on individuals and communities make it possible to improvetreatment programs towards a more comprehensive model of care.Drawing from a collective, political and sociocultural definition of the impact oftorture and ill treatment more than from a psychiatric or biomedical one, ourmodel of care is built on a group and community level as well as on a sociopoliticallevel.This model of care involves a clinical psychiatric (short-term designed) treatmentmainly based on education and emotion arousal management quickly followedby a group-based (medium-term designed) treatment which addressesand focuses on issues such as collective identity, existential coherence includingdistal and proximal variables, and needs-driven themes and concerns.The group-based program takes place in a site separated from the outpatientcenter. This site is devoted to sociotherapeutic activities designed on issues assecurity feeling, attachment to the place itself, to peers attending the place andto professionals caretakers and social workers, identity rebuilding, social skillsacquiring, and so on.This multidimensional “sociotherapeutic” (or “sociocentered group psychotherapy”)process is achieved by means of an interplay between individual psychologicallevel group and community, on one hand and on sociopolitical largercontext issues addressed within group discussion and group problem-solvingactivities on the other hand.Outcomes may be appreciated in terms of global mental health improvement aswitnessed by general practionners’ apraisals, social workers and employmentinstitutions.Refugees and asylum-seekers and victims of torture and ill treatment conceivetheir problems mainly as of political prime cause and as sociopololitical. Andwhen they refer to their present situation they tend to concieve and define itmore as a socialpolitocal problem than as a health problem. A global, comprehensivemodel of care should then encompass individuals, group, as well aspsychological, social, political and cultural healing resources.35

WORKSHOP 6: Children and the Family of TortureSurvivors(Thursday Dec 4 Afternoon)To promote a meaningful and mental health promoting context for childrenand the family of torture survivorsInvited lecturerSolvig Ekblad, PhD, Associate Professor,Stress Research Institute, Stockholm University and affiliated at Karolinska Institutet,Stockholm, SwedenAdverse pre-settlement trauma exposure and resettlement stress factorsamong newcomers are related to increased risks not only for morbidity andmortality but also of health risk life style behaviour, illness and functional impairment.Four dimensions of resettlement stress among adult refugees fromMiddle East have been found; social and economic strain, alienation, discriminationand status loss and violence and threats in Sweden (Lindencrona, Ekblad,Hauff, 2008). According to Harvard Program in Refugee Trauma, the best medication(anti-depressant) for people who have been exposed to violence is a job.Social and economic strain and alienation are important for explaining symptomsof common mental disorder. A person's capacity to handle stress playssignificant roles. Sweden like many countries, have implemented introductionrefugee programs, ie setting for health, with the aim at reducing inequality inimportant living conditions between the target group and the native Swedes.The literature shows the importance of limitation of stressors and treatmentwhen needed among refugees with traumatic experiences and posttraumaticstress, which otherwise increase the risk of failure in the reception program.PTSD is not the only outcome of importance. Anger maybe also a significantproblem in the resettlement context.The presentation will take up an ecological adaptive model with focus on fiveimportant health areas: attachment, security, identity/roles, justice/humanrights and existential/meaning (Silove, 1999). Psychological and social stabilityare mirror images (interconnected psychic and social pillars), safety and feltsecurity (PTSD), attachment and bounds, networks and communities (sense ofbelonging, grief), justice (treated fairly and with dignity, anger), identity andrules (being valued and useful, belonging, marginalisation), meaning and coherence(making sense social, political, cultural, religious, political, alienation).The significance of this model will be discussed in two studies; one focusing onpsycho-educative mental health promotion classes for new-coming refugees(Ekblad, 2008) and the second on how to approach vulnerable refugee childrenby using photographs to establish dialogue about everyday life (Svensson, Ekbladand Ascher, in press). Focusing on a holistic mental health promotion andpsycho-educative approach will empower the family of torture survivors andtheir children. In view of human right to health, such interventions need to beevaluated in further studies.36

ReferencesSvensson, M., Ekblad, S., Ascher, H. Making Meaningful Space for Oneself:Photo-based dialogue with Siblings of Refugee Children with Severe WithdrawalSymptoms. Children’s Geographies (accept 2008-10-03, in press).Ekblad, S. A health promotion course as a mental health promotion interventionamong new-coming refugees in the reception programme at a symposium“Follow-up studies of migrant and refugee populations”, chair: Edvard Hauff,Norway and co-chair: Marianne Kastrup, Denmark) for World Congress of Psychiatry;Prague; 19-25 Sep 2008Lindencrona, F., Ekblad, S., Hauff, E. Mental health of recently resettled refugeesfrom the Middle East in Sweden: the impact of pre-resettlement trauma,resettlement stress and capacity to handle stress. Social Psychiatry and PsychiatricEpidemiology 2008:43(2):121-131.Silove, D. The Psychosocial Effects of Torture, Mass Human Rights Violationsand Refugee Trauma – Toward an Integrated Conceptual Framework. Journal ofNervous and Mental Disease 1999:187(4):200-207.37

WORKSHOP 6: Children and the Family of TortureSurvivors(Thursday Dec 4 Afternoon)Trauma and Resilience in Young Refugees - the Long-term Consequencesof Exposure to Torture and Organized ViolenceInvited lecturerEdith Montgomery, PhD, Research DirectorRehabilitation and Research Centre for Torture Victims,Copenhagen, DenmarkThe trauma literature provides a sinister picture of the developmental perspectivesof children and adolescents who have been subjected to or have witnessedviolence and assaults, and many studies find a high level of psychologicalsymptoms among refugee children and adolescents. However, the symptomlevel is not always higher than in comparable groups of immigrant or nativechildren, and psychological symptoms do not necessarily imply poor social adjustmentin the country of asylum.There is little evidence of the longitudinal course of psychopathology in thesechildren. The follow-up studies on refugee children and adolescents that mightthrow some light on the long-term effects of traumatic experiences, related towar and other kinds of organised violence, are few but suggest that, as timegoes by, the secondary stress following traumatic events are more importantthan the traumatic experiences themselves. Factors such as close relationswith supportive adults, effective schools, good relationships with friends andsocioeconomic advantages are found to be essential for the mental functioningand social adaptation of young refugees following violent experiences.Drawing on the results on an 8-9 year follow-up study of refugee children inDenmark, the relative impact of early traumatic experiences and factors relatedto life in exile will be discussed.ReferencesMontgomery E. Long-term effects of organized violence on young Middle Easternrefugees’ mental health. Social Science & Medicine, 2008; 67:1596-1603.Montgomery E & Foldspang A. Discrimination, mental problems and social adaptationin young refugees. European Journal of Public Health, 2008; 18 (2): 156-61.Montgomery E. Self and parent assessment of mental health: Disagreement onexternalising and internalising behaviour in young refugees from the Middle East.Clinical Child Psychology and Psychiatry, 2008; 13: 49-63.38

PLENARY LECTURE: Critical Issues(Friday Dec 5 Morning)Imaging Studies in Torture SurvivorsNeurobiology and Neuroimaging of PTSDInvited lecturerJ. Douglas Bremner, MDEmory University and Atlanta VAMCAtlanta, USABrain imaging studies have implicated areas including the hippocampus, amygdalaand medial prefrontal cortex in PTSD. Alterations in hypothalamicpituitary-adrenal(HPA), noadrenergic, and benzodiazepine systems have alsobeen found in PTSDThese studies followed up preclinical studies showing thatstress is associated with changes in hippocampal morphology, inhibition of neurogenesis,and memory deficits. Studies in animals showed that both SSRIs andthe epilepsy medication phenytoin (Dilantin) block the effects of stress on thehippocampus. Imaging studies in PTSD have found smaller volume of the hippocampusas measured with magnetic resonance imaging (MRI) in patients withPTSD related to both combat and childhood abuse. These patients were alsofound to have deficits in memory on neuropsychological testing. Functional imagingstudies using positron emission tomography (PET) found deficits in functionin medial prefrontal cortex as well as hippocampus with provocation ofPTSD symptoms using traumatic reminders or emotionally valenced memorytasks. We have found increased hippocampal volume following treatment withparoxetine in PTSD and a 6% increase in both right hippocampal and rightwhole brain volume with phenytoin in PTSD. These studies show that PTSD isassociated with lasting changes in brain and neurobiology and suggest thatmedications may counteract the effects of stress on the brain in patients withPTSD.ReferencesBremner, J.D., Elzinga, B., Schmahl, C. and Vermetten, E. (2008) Structuraland functional plasticity of the human brain in posttraumatic stress disorder.Progress in Brain Research, Vol. 167: 171-186.Bremner, J.D (2007) Functional neuroimaging in post-traumatic stress disorder.Expert Rev Neurotherapeutics Vol 7(4) 393-405.Bremner, J.D (2006) Traumatic stress: effects on the brain. Dialogues in ClinicalNeuroscience - Vol 8 . No. 4 .: 335-355.39

PLENARY LECTURE: Critical Issues(Friday Dec 5 Morning)Eye movement desensitization and reprocessing (EMDR) –Mechanism, procedure and evidenceInvited lecturerUdi Oren, PhD, PresidentEMDR Europe Association,Tel Aviv, IsraelEye Movement Desensitization and Reprocessing (EMDR) was created by Dr.Francine Shapiro, a Psychologist and Senior Research Fellow at the Mental ResearchInstitute in Palo Alto, USA. It is an innovative clinical treatment, whichhas successfully helped over one million people who have experienced psychologicaldifficulties which originate from some kind of traumatic experience, suchas sexual abuse, childhood neglect, road traffic accidents and violence. EMDR isalso successful in treating other complaints such as performance anxiety, selfesteemissues, phobias, and other trauma related anxiety disorders.EMDR is a complex method of psychotherapy which integrates many of the successfulelements of a range of therapeutic approaches, and combines them witheye movements or other forms of bilateral stimulation in ways which stimulatethe brain's information processing system.Normally, the individual processes traumatic experiences naturally. However,when a person is severely traumatized, either by an overwhelming event or bybeing repeatedly subjected to distress, this healing process may become overloaded,leaving the original disturbing experiences unprocessed. These unprocessedmemories can be stored in the brain in a "raw" form where they can becontinually re-evoked when experiencing events that are similar to the originalexperience.EMDR utilizes the body's natural healing ability and allows the brain to healpsychological problems at the same rate as the rest of the body heals physicalailments. Because EMDR allows the mind and body to heal at the same rate,treatment can be rapid. The number of sessions required for EMDR treatment,however, will vary according to the complexity of the issues being dealt with. Ingeneral, the more isolated the traumatic memory being treated, the shorter thetreatment tends to be.There have been 14 controlled studies supporting the efficacy of EMDR, makingit the most thoroughly researched method in the treatment of trauma. Themost recent five studies with people suffering from a range of events such asrape, combat, bereavement, accidents, natural disasters etc. have found that84 - 90% of the participants no longer had Post-traumatic Stress Disorder followingEMDR treatment. Given its wide application, EMDR promises to be atherapy that will continue its development in to the future.The lecture will focus on EMDR's mechanism, procedure and evidence, and willlook in to the anecdotal evidence for the usefulness of EMDR treatment for thesurvivors of torture.40

ReferencesBisson, J., & Andrew, M. (2007). Psychological treatment of post-traumaticstress disorder (PTSD). Cochrane Database of Systematic Reviews 2007, Issue23. Art. No.: CD003388.pub3.Perkins, B.R. & Rouanzoin, C.C. (2002). A critical evaluation of current viewsregarding eye movement desensitization and reprocessing (EMDR): Clarifyingpoints of confusion. Journal of Clinical Psychology, 58, 77-97.Wilson, S., Becker, L.A., & Tinker, R.H. (1997). Fifteen-month follow-up of eyemovement desensitization and reprocessing (EMDR) treatment of posttraumaticstress disorder and psychological trauma. Journal of Consulting andClinical Psychology, 65, 1047-1056.41

PLENARY LECTURE: Critical Issues(Friday Dec 5 Morning)Social Integration of Torture SurvivorsInvited lecturerCécile Rousseau, MDDivision of Social and Transcultural PsychiatryMcGill University, Montreal, CanadaThe impact of the post migratory context and of the quality of social integrationon refugee mental health has been repeatedly demonstrated. Beyond the consensusemphasizing the importance of psychosocial interventions in rehabilitationof torture survivors there is a need to rethink those interventions at thecross road between therapeutic processes and social interactions.Organized violence severs the social bond, shattering both basic trust and alllevels of social networks. The progressive restoration of the social bond requiressimultaneously to overcome the relational paralysis linked to the traumatic experienceand to establish multilevel relations with the host society. This presentationwill first address the premises of social integration for torture survivors ina new society in terms of safety, status, rights and agency.Second, using Canada as an example, I will focus on the impact of the presentinternational context of war and terrorism on the shattering of the social linkwithin multiethnic societies. The sharp increase of discrimination in refugeereceiving societies is playing a complex role in retraumatization of torture survivors.Intersectorial intervention perspectives which emphasize equity and complexrepresentation of the “other” will be discussed, providing case illustrationsof work conducted in health and education institutions.ReferencesSilove, D. (2007). Adaptation, ecosocial safety signals, and the trajectory ofPTSD. In L. J. Kirmayer, R. Lemelson & M. Barad (Eds.), Understanding TraumaIntegration bilogical, clinical, and cultural perspectives. New York.Porter, M., & Haslam, N. (2005). Predisplacement and postdisplacement factorsassociated with mental health of refugees and internally displaced persons: Ameta-analysis. Journal of the American Medical Association, 294(5), 602-612.Rousseau, C., Rufagari, M., Bagilishya, D., & Measham, T. (2004). Remakingfamily life: Strategies for re-establishing continuity among Congolese refugeesduring the family reunification process. Social Science and Medicine, 59(5),1095-1108.42

WORKSHOP 7: The RCT Field Manual on Rehabilitation– an Update(Friday Dec 5 Afternoon)Authors’ PanelParticipants are kindly asked to consult their own copies of the manual. Thequestionnaire below has been mailed to more than 300 centers and replies willbe discussed.Questions regarding the TRC Field Manual on Rehabilitation, Version 1:1, 2007:1. What is your focus of activity (e g human rights activist/ communityhealth worker/ counselor/ registered nurse/ general practitioner MD/specialist MD)?2. How many torture survivors are treated per year by you/ your unit?3. What is your setting (local community/ rural town/ regional city/ largecity)?4. Which are the major obstacles hindering torture survivors from receivingtreatment in your area?5. In your view, what would be the best use of this manual?6. Which are the positive aspects of the manual?7. Which are the negative aspects of the manual?8. Specifically, is the organization of information according to ICF satisfactory?9. Which information in the present manual is not useful? Please specify:10. Do you miss important information in present manual? Please specify:Thank you for your time and contribution!43

WORKSHOP 8: The Danish National Network of Centers(Friday Dec 5 Afternoon)Evidensproblemer i forhold til behandling af traumatiserede flygtningeInvited lecturerDirector Ulrik JørgensenOASIS, Copenhagen, DenmarkI 2006 rejste Metin Basoglu fra Institute of Psychiatry, King’s College i Londonen debat i British Medical Journal om effektiviteten af den behandling, derforegår på rehabiliteringscentrene for traumatiserede flygtninge, herunder torturoverlevende.Han påpeger bl.a.:44”Most psychological treatments used in rehabilitation programmes stillappear to be a mixture of various psychotherapeutic elements, notbased on a consistent theory, and lack evidence on their effectiveness.”Der skal ikke herske nogen tvivl om, at det er et reelt problem, at der eftermere end 25 års erfaring med rehabilitering af traumatiserede flygtninge,endnu ikke findes undersøgelser, som tydeligt viser, hvilke metoder der er effektivei behandling og rehabilitering i forhold til traumatiserede flygtninge,ligesom der synes at mangle valide måleinstrumenter til at afgøre effekten afbehandling og rehabilitering for denne gruppe.I årevis har sygdomsbilledet for traumatiserede flygtninge været identificeretmed diagnosen Posttraumatisk Stressbelastning (PTSD), og den nærliggendeløsning har derfor været at måle behandlingseffekten på baggrund af symptombilledetfor PTSD.De få studier, der har været lavet vedr. ændringer i symptombilledet for PTSD,har ikke været særligt lovende, hvilket bl.a. har ført til en kritik af, at rehabiliteringscentreneikke anvender de såkaldte evidensbaserede psykoterapeutiskemetoder for PTSD, samt endvidere bruger ressourcer på social behandling,fysioterapi, afspændingsbehandling, og evt. andre ikke-medicinske og psykoterapeutiskeinterventionsformer, som der ifølge kritikerne ikke er evidens forvirker.I præsentationen vil der dels blive argumenteret for, at problematikken omkringtraumatiserede flygtninge er langt mere kompliceret, end at den kan rummesinden for en afgrænset diagnose som PTSD, hvilket også gør det yderst problematiskat basere outcome-studier alene på måleinstrumenter for symptombaseredediagnoser som f.eks. PTSD. Da vi erfaringsmæssigt har at gøre meden kronisk belastet gruppe, vil det formentlig i langt højere grad være relevantat fokusere på patienternes funktionsniveau.Der vil endvidere blive argumenteret for vigtigheden af, at der bliver sat indmed kvalificeret forskning omkring, hvilke interventionsformer der er nødvendigeog effektive overfor så komplicerede tilstande, som traumatiserede

flygtninge lider af. Hypotesen er, at der ikke findes én bestemt behandlingsmetode,som er effektiv, men at flere må bringes i spil på tværs af faggrænser og iforskellige faser af et rehabiliteringsforløb for at opnå et tilfredsstillende resultat.Men hvordan beviser vi det?ReferencesBaşoğlu M: Rehabilitation of traumatised refugees and survivors of torture. BMJ.2006; 333:1230-1231.45

WORKSHOP 8: The Danish National Network of Centers(Friday Dec 5 Afternoon)Undersøgelse af behandlingseffekt, det randomiserede kontrollerededesignInvited lecturerMarianne Engberg, MD, PHDUniversity of Aarhus, DenmarkDer mangler eksperimentelle undersøgelser af, hvilke behandlingsmetoder der”virker” i forhold til rehabilitering af traumatiserede flygtninge. Når man vilhave den bedst mulige viden om, hvordan en given behandling virker, ansesdet bedste bevis for at være et randomiseret kontrolleret forsøg (RandomisedControlled Trial).Et ”Randomised Controlled Trial” er baseret på, at man fra begyndelsen randomisererpatienterne til en eller flere grupper. Patienterne fordeles tilfældigt(engelsk: random) til enten at modtage den behandling, man vil undersøge(interventionsgruppen), eller en anden behandling som måske allerede er igang, eller ingen behandling (kontrolgruppen).Det man ønsker i et ”Randomised Controlled Trial” er, at behandlingsgruppenikke adskiller sig fra den ubehandlede eller konventionelt behandlede gruppe.Man får derfor et indtryk af, hvordan forløbet ville være været, hvis behandlingenikke var gennemført. At man ikke får det ved undersøgelser, som manigangsætter uden en tilfældigt valgt kontrolgruppe, af en given behandlingseffekt, er lige præcis den store akilleshæl ved disse undersøgelser. Andre faktorerend behandlingen kan påvirke resultatet, f.eks. det naturlige forløb ogsamfundet.Det lyder simpelt blot at lave en kontrolgruppe fra begyndelsen, hvis man vilundersøge en behandlingseffekt. Men dette er ikke tilfældet. Der er mange metodeproblemeri gennemførelse af et ”Randomised Controlled Trial”. Faktorersom afsmitning mellem interventionsgrupperne, randomiseringsteknikken, dimensioneringen,etikken, interventionens art, drop-out, effektmålets art, ogvarighed af undersøgelsen indtil måling af effektmål, er forhold, der skal tagesstilling til, beskrives og/ eller analyseres udover det egentlige effektmål.Et videnskabeligt undersøgelsesdesign afhænger af det spørgsmål, der stilles,samt rammerne for undersøgelsen. Et ”Randomised Controlled Trial” er ikkenødvendigvis det gyldne svar på det ”rigtige” design for undersøgelse af behandlingseffekt,men vil ofte være det. Hvis man vil evidensbasere en given behandlingseffekt,er det et ”Randomised Controlled Trial”, der skal gennemføres.46

This international conference addresses the rehabilitationof survivors of torture and organized violence in a multiprofessionalparadigm. The different workshops covera broad range of topics within the field of rehabilitationfrom assessment over rehabilitation programs to socialintegration and resilience.On the final day of the conference all participants areinvited to comment and suggest modifications to thefirst version of the RCT Field Manual on Rehabilitation,contributing to an improved multi-professional tool. Themanual represents more than two decades of the RCT’sprofessional experiences and joint interactive work withpartners in Latin America, Africa and Asia. Hopefully itwill be a valuable tool that can be employed globally inthe efforts to relieve the suffering caused by torture andorganized violence.Organizing committeeBengt H. Sjölund, MD, DMScMarianne Kastrup, MD, PhDAnn L. Persson, PT, PhDEdith Montgomery, Lic. Psychologist, PhDRCTRehabilitation and Research Centre for Torture VictimsBorgergade 13 ● DK-1300 Copenhagen K+45 3376 0600 ● www.rct.dk