Position Statement

Pain

Pain is a frequent problem of torture survivors and widespread in survivors of organized violence and war. However, it is not always recognised as a problem in its own right, particularly once it has become persistent. Care may focus on medical needs, disabilities, and on psychological and social effects. While all these are relevant needs, pain can be mistakenly assumed to be inevitable and to go untreated, or to be a symptom of psychological distress, and that distress is the target of treatment.

A few misconceptions in the field compromise pain assessment and treatment. One is the notion of a "torture syndrome", rarely defined but implying a specific constellation of post-traumatic symptoms. Another is that psychological problems resulting from torture or organized violence are best described as post traumatic stress disorder (PTSD). The effects of such experiences can be severe, diverse, pervasive, long lasting, and extend far beyond the individual him or herself, and do not easily fit descriptions of anxiety, depression, PTSD or other disorders developed in stable civilian populations.

While we know relatively little about the long term effects of torture, or about best treatment, continuing social circumstances seem to be important. Problems are worsened by being separated from family, friends, and community; by feeling that they or their families continue to be threatened; by struggles with everyday issues of food and shelter.

What this SIG aims to do

We are keen for pain expertise, across the disciplines involved in pain treatment and management, to become more available to these survivors, and to those providing health services for them. We also keen to make mainstream pain services as accessible and acceptable as possible to those who need them, but may need extra considerations because of their experiences and current social circumstances.

Inevitably, there is no way in such work of avoiding making statement which some people may take to be political. There are no easy distinctions: providing a service to survivors of torture, organized violence and war is inherently critical of those political or other systems involved. To uphold human rights is political, whether by treating a patient-survivor or by documenting pain and distress in survivor groups.

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What pain clinicians can do

Recognise signs of torture in patients in their practice: be aware of prevalence, likely signs, and conditions which enable torture survivors to disclose their experiences.

Assess and document torture injuries and lasting effects, such as pain. Assessment for clinical practice is rather different from assessment for documentation but does need special considerations. There are some internationally agreed guidelines for assessment: the Istanbul Protocol (Iacopino et al. 1999 & www.unchcr.org), to which health professionals made the major contribution, concerns effective investigation and documentation for torture and alleged torture and how to report it. Some projects have also produced useful guidelines.

Attempt to provide best possible evidence-based treatment for torture survivors, with attention to conditions which may be required to make this acceptable. IRCT is currently attempting to implement minimum standards in multidisciplinary rehabilitation of torture survivors provided at affiliated centres worldwide; input from pain specialists would be very welcome.

Offer clinical services, consultancy and/or training, paid or unpaid, to torture survivor organisations.

Be aware of the social and political context of torture in survivors' home countries, and the social and political system of the host country from the point of view of the refugee.

Raise awareness about the health effects of torture in professional bodies and promote lobbying of governments for humane treatment, particularly those which are signatories to the UN Convention Against Torture. There is an increasing tendency towards detention of refugees and asylum seekers in some countries while their status is resolved which can retraumatise refugees and often lacks adequate health care resources (see Nathanson 2001). Even in countries where torture is a routine act of an oppressive regime, international public awareness can have a surprisingly powerful influence (Basoglu 1993).

Be aware of the potential for the use of control methods in state custody, including the use of "nonlethal weapons", to meet the definition of torture (as did certain methods used in republican Irish prisoners by the British government in the 1980s).

Be alert to the involvement of doctors and other health professionals, wittingly or unwittingly, voluntarily or coerced, in torture procedures, as detailed in the Declaration of Tokyo adopted by the World Medical Association in 1975, and Physicians for Human Rights (see also Maio 2001).

Conduct and support local and international research and clinical case studies of the assessment and treatment of torture survivors, at the same time as being aware that there is a small risk that some research findings can be used to refine torture.

This page last modified 12 March, 2010 by Will Fitzmaurice