Empirically tested interventions for torture survivors: A systematic review through an ecological lens.

Abstract

Torture has been documented to occur in 81 countries (Amnesty International, 2008) resulting in 2–15 million torture survivors worldwide (Physicians for Human Rights, 2010). The problems torture survivors experience are best understood from an ecological perspective (i.e., understanding human behavior as contextual), but the solutions offered are rarely ecological in nature. Rather, most empirical literature on interventions for torture survivors discuss individually focused interventions only. This article is a critical review of the literature on interventions for immigrant survivors of politically sanctioned torture from an ecological perspective (Bronfenbrenner, 1977). A systematic literature review was conducted. The review included 22 articles, covering 13 interventions. Each article was coded to capture ecological intervention components. All interventions targeted individual-level change. Eleven interventions targeted additional ecological-levels surrounding survivors in the microsystem, macrosystem, and/or chronosystem levels of ecology. Interventions targeted several life domains, such as the legal, social, and occupational domains. Interventions included cultural adaptations such as using interpreters and designing interventions to be more congruent with the survivors’ cultures. The current body of literature on empirically tested interventions for torture survivors is limited, with few interventionists testing their work empirically and fewer sufficiently addressing the ecological needs of torture survivors. More intervention development is needed to address the ecological needs of survivors and make interventions that are multilevel, community-based, and culturally situated (Trickett, 2009). Future research should aim to involve torture survivors through community-based participatory research and seek suggestions for research from within the survivor community, so that interventions can be situated within their cultural context.

Psychological, social, and welfare interventions for torture survivors: A systematic review and meta-analysis of randomised controlled trials

“…Because refugees have a high rate of life events that can facilitate or undermine treatment gains, it would be helpful for studies to monitor these changes across the timescale of treatment and follow-up [35]. It was disappointing to find these shortcomings persisting despite comment in our previous review [12] and in others [36,37].…”

“…Other reviews of psychological treatments for torture survivors [36,38] or for traumatised refugees [39] have produced more optimistic accounts of benefits of therapy, although they raise similar concerns regarding methodology and cultural appropriateness of interventions. By contrast, Salo and Bray [37] reviewed interventions in relation to what they described (drawing on Bronfenbrenner [40]) as the ‘ecological’ needs of torture survivors: microsystem life domain, such as family, social, legal, and occupational domains; macrosystem domain, mainly consisting of cultural and language features of the trials; and the chronosystem domain, represented in time of follow-up assessments. They found relatively scant recognition of needs in any of these areas, either in assessment or intervention.…”

“…Furthermore, the development of interventions in terms of cultural and language appropriateness may require more fundamental exploration and questioning of Western models of psychological problems and treatment than was evident in these trials. Recent models of collaborative care [47] go some way towards this but still fall short of the ecological scope described by Salo and Bray [37]. Last, where resources are scarce and far outstripped by needs, as in many low- and middle-income countries, the model of training local volunteers or healthcare staff in Western methods of intervention delivered mostly as individual therapy may mean that interventions are more culturally embedded (depending on what the trainers or study researchers allow by way of adaptation).…”

Psychotherapy for torture survivors - Suggested pathways for research

“…It can be concluded that, overall, there are low to moderate outcome results for each model or technique and no clear conclusions when different models are compared. 21,24,33,36,37 This led some authors ten years ago to say that the whole rehabilitation sector was a waste of money until it reached a respectable scientific status through the adoption of "evidence-based" therapeutic models. 34 This in-turn generated a justifiable response of complaint from within the sector on rehabilitation of survivors of torture.…”

“…[20][21][22][23][24][25][26][27][28][29][30][31][32] On the whole, the evidence to support one model of intervention over another is usually poor. It can be concluded that, overall, there are low to moderate outcome results for each model or technique and no clear conclusions when different models are compared.…”