The effects of a combined psychotherapy and physiotherapy group treatment program for survivors of torture incarcerated in an adult prison in Kurdistan, Iraq: A pilot study
Introduction: Survivors of torture have high rates of mental health problems and can experience a sequela of physical effects with the most common being persistent pain. Similar to survivors of torture, persons that are incarcerated have high rates of mental health problems, persistent pain and pain-related disability.The purpose of this study is to assess the effect of an interdisciplinary group treatment approach, involving psychotherapy and physiotherapy, with survivors of torture whom are incarcerated in a prison in Kurdistan, Iraq.
Methods: A parallel group study design was used to compare a treatment group (n=11) and a wait-list control group (n=16). The treatment group participated in an interdisciplinary treatment service for a total of 10 weekly group sessions for each discipline.The primary outcome measures were symptoms of nociplastic pain, anxiety, depression, and PTSD. Secondary outcome measures evaluated physical functioning, sleep quality, and general self-efficacy.
Results: A statistically significant reduction in outcome measure scores was seen in all symptoms measured immediately post-treatment.
Discussion and Conclusion: These findings suggest that a culturally and contextually appropriate interdisciplinary group treatment intervention for survivors of torture in a prison could be effective for short-term reductions in symptoms of anxiety, depression, PTSD, persistent pain, and function. The study has limitations including a small sample size, lack of long-term outcome measures, and an inability to isolate effect of each component of care. The study does demonstrate the feasibility of implementing research that follows international research standards and practices within under-researched settings and post-conflict areas.
Amnesty international ltd. (2014). Torture in 2014 - 30 Years of Broken Promises. Torture in 2014 - 30 Years of Broken Promises (pp. 1–50). London.
Amris, K., & Williams, A. C. D. C. (2015). Managing chronic pain in survivors of torture. Pain Management, 5(1), 5–12. doi: 10.2217/pmt.14.50
Asmundson, G. J., & Katz, J. (2009). Understanding the co‐occurrence of anxiety disorders and chronic pain: state‐of‐the‐art. Depression and Anxiety, 26(10), 888–901. doi: 10.1002/da.20600
Asmundson, G. J., Coons, M. J., Taylor, S., & Katz, J. (2002). PTSD and the Experience of Pain: Research and Clinical Implications of Shared Vulnerability and Mutual Maintenance Models. The Canadian Journal of Psychiatry, 47(10), 930–937. doi: 10.1177/070674370204701004
Bair, M. J., Robinson, R. L., Katon, W., & Kroenke, K. (2003). Depression and Pain Comorbidity. Archives of Internal Medicine, 163(20), 2433. doi: 10.1001/archinte.163.20.2433
Breivik, H., Eisenberg, E., & O’Brien, T. (2013). The individual and societal burden of chronic pain in Europe: the case for strategic prioritisation and action to improve knowledge and availability of appropriate care. BMC Public Health, 13(1). doi: 10.1186/1471-2458-13-1229
Bunn, M., Goesel, C., Kinet, M., & Ray, F. (2016). Group treatment for survivors of torture and severe violence: A literature review. Torture Journal, 26(1), 23. doi: 10.7146/torture.v26i1.108062
Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment - Addendum to Initial reports of States parties due in 1995 (PDF). U.S. Department of State. U.S. Department of State. 4 October 2020.
Darnall, B. D., & Sazie, E. (2012). Pain Characteristics and Pain Catastrophizing in Incarcerated Women with Chronic Pain. Journal of Health Care for the Poor and Underserved, 23(2), 543–556. doi: 10.1353/hpu.2012.0042
Dibaj, I., Halvorsen, J. Ø., Kennair, L. E. O., & Stenmark, H. I. (2017). An evaluation of combined narrative exposure therapy and physiotherapy for comorbid PTSD and chronic pain in torture survivors. Torture Journal, 27(1). doi: 10.7146/torture.v27i1.26534
Dirkzwager, A. J. E. (2019). The longitudinal course of prisoners’ mental health problems during and after imprisonment. European Journal of Public Health, 29(Supplement_4). doi: 10.1093/eurpub/ckz185.759
Fazel, S., & Danesh, J. (2002). Serious mental disorder in 23 000 prisoners: a systematic review of 62 surveys. The Lancet, 359(9306), 545–550. doi: 10.1016/s0140-6736(02)07740-1
Fazel, S., & Seewald, K. (2012). Severe mental illness in 33 588 prisoners worldwide: systematic review and meta-regression analysis. British Journal of Psychiatry, 200(5), 364–373. doi: 10.1192/bjp.bp.111.096370
Fazel, S., Hayes, A. J., Bartellas, K., Clerici, M., & Trestman, R. (2016). Mental health of prisoners: prevalence, adverse outcomes, and interventions. The Lancet Psychiatry, 3(9), 871–881. doi: 10.1016/s2215-0366(16)30142-0
Gifford, E. J. (2019). How Incarceration Affects the Health of Communities and Families. North Carolina Medical Journal, 80(6), 372–375. doi: 10.18043/ncm.80.6.372
Heartland Alliance International. (2015). Torture and ill-treatment in detainees in Iraq and the Iraqi Kurdistan Region - A Report on Prevalence and Practice. Torture and ill-treatment in detainees in Iraq and the Iraqi Kurdistan Region - A Report on Prevalence and Practice (pp. 1–80). Chicago, IL .
Heckman, C. J., Cropsey, K. L., & Olds-Davis, T. (2007). Posttraumatic stress disorder treatment in correctional settings: A brief review of the empirical literature and suggestions for future research. Psychotherapy: Theory, Research, Practice, Training, 44(1), 46–53. doi: 10.1037/0033-3126.96.36.199
Horn K.K., Jennings S, Richardson G, Vliet D. V., Hefford C, Abbott J. H. The patient-specific functional scale: psychometrics, clinimetrics, and application as a clinical outcome measure. J Orthop Sports Phys Ther. 2012 Jan;42(1):30-42. doi: 10.2519/jospt.2012.3727. Epub 2011 Oct 25. PMID: 22031594.
IASP Terminology. (2017, December 14). https://www.iasp-pain. org/Education/Content.aspx?ItemNumber=1698
Kabengele, E. M., Chastonay, P., & Frey, C. (2014). Economic burden of torture for a refugee host country: development of a model and presentation of a country case study. ClinicoEconomics and Outcomes Research, 165. doi: 10.2147/ceor.s56431
Kinner, S. A., & Young, J. T. (2018). Understanding and Improving the Health of People Who Experience Incarceration: An Overview and Synthesis. Epidemiologic Reviews, 40(1), 4–11. doi: 10.1093/epirev/mxx018
Kurklinsky, S., Perez, R. B., Lacayo, E. R., & Sletten, C. D. (2016). The Efficacy of Interdisciplinary Rehabilitation for Improving Function in People with Chronic Pain. Pain Research and Treatment, 2016, 1–6. doi: 10.1155/2016/7217684
Leder, D. (2018). Coping with chronic pain, illness and incarceration: what patients and prisoners have to teach each other (and all of us). Medical Humanities, 44(2), 113–119. doi: 10.1136/medhum-2017-011426
Loughran, M., & King, T. (2004). Developing Prison Inreach Services for Female Prisoners. Mental Health Review Journal, 9(2), 34–37. doi: 10.1108/13619322200400020
Louw, A., Zimney, K., Puentedura, E. J., & Diener, I. (2016). The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature. Physiotherapy Theory and Practice, 32(5), 332–355. doi: 10.1080/09593985.2016.1194646
Mayer, TG, Neblett, R, Cohen, H, Howard, KJ, Choi, YH, Williams, MJ, Perez, Y, Gatchel, RJ. The Development and Psychometric Validation of the Central Sensitization Inventory (CSI). Pain Pract 2012; 12(4): 276-85.
Massoglia, M. (2008). Incarceration as Exposure: The Prison, Infectious Disease, and Other Stress-Related Illnesses. Journal of Health and Social Behavior, 49(1), 56–71. doi: 10.1177/002214650804900105
Mcgeary, D., Moore, M., Vriend, C. A., Peterson, A. L., & Gatchel, R. J. (2011). The Evaluation and Treatment of Comorbid Pain and PTSD in a Military Setting: An Overview. Journal of Clinical Psychology in Medical Settings, 18(2), 155–163. doi: 10.1007/s10880-011-9236-5
McKernan, Lindsey C. PhD; Johnson, Benjamin N. MS; Crofford, Leslie J. MD; Lumley, Mark A. PhD; Bruehl, Stephen PhD; Cheavens, Jennifer S. PhD#Posttraumatic Stress Symptoms Mediate the Effects of Trauma Exposure on Clinical Indicators of Central Sensitization in Patients With Chronic Pain, The Clinical Journal of Pain: May 2019 - Volume 35 - Issue 5 - p 385-393 doi: 10.1097/AJP.0000000000000689
Mollayeva T, Thurairajah P, Burton K, Mollayeva S, Shapiro CM, Colantonio A. The Pittsburgh sleep quality index as a screening tool for sleep dysfunction in clinical and non-clinical samples: A systematic review and meta-analysis. Sleep Med Rev. 2016 Feb;25:52-73. doi: 10.1016/j.smrv.2015.01.009.Epub 2015 Feb 17. PMID: 26163057.
Olsen, D. R., Montgomery, E., Bøjholm, S., & Foldspang, A. (2007). Prevalence of pain in the head, back and feet in refugees previously exposed to torture: A ten-year follow-up study. Disability and Rehabilitation, 29(2), 163–171. doi: 10.1080/09638280600747645
Penal Reform International. (2015). Global Prison Trends 2015. Global Prison Trends 2015(pp. 1–44). London
Rasmussen A, Verkuilen J, Ho E, Fan Y. Posttraumatic stress disorder among refugees: Measurement invariance of Harvard Trauma Questionnaire scores across global regions and response patterns. Psychol Assess. 2015;27(4):1160-1170. doi:10.1037/pas0000115
Sareen, J. (2014). Posttraumatic Stress Disorder in Adults: Impact, Comorbidity, Risk Factors, and Treatment. The Canadian Journal of Psychiatry, 59(9), 460–467. doi: 10.1177/070674371405900902
Schwarzer, R., & Jerusalem, M. (1995). Generalized Self-Efficacy scale. In J. Weinman, S. Wright, & M. Johnston, Measures in health psychology: A user’s portfolio. Causal and control beliefs (pp. 35-37). Windsor, UK: NFER-NELSON.
Steel, Z., Chey, T., Silove, D., Marnane, C., Bryant, R. A., & Ommeren, M. V. (2009). Association of Torture and Other Potentially Traumatic Events With Mental Health Outcomes Among Populations Exposed to Mass Conflict and Displacement. Jama, 302(5), 537. doi: 10.1001/jama.2009.1132
Tay, A., Jayasuriya, R., Jayasuriya, D. et al. Measurement invariance of the Hopkins Symptoms Checklist: a novel multigroup alignment analytic approach to a large epidemiological sample across eight conflict- affected districts from a nation-wide survey in Sri Lanka. Confl Health 11, 8 (2017). https://doi.org/10.1186/s13031-017-0109-x
Tsang, A., Korff, M. V., Lee, S., Alonso, J., Karam, E., Angermeyer, M. C., … Watanabe, M. (2008). Common Chronic Pain Conditions in Developed and Developing Countries: Gender and Age Differences and Comorbidity With Depression-Anxiety Disorders. The Journal of Pain, 9(10), 883–891. doi: 10.1016/j.jpain.2008.05.005
Tsur, N., Defrin, R., & Ginzburg, K. (2017). Posttraumatic Stress Disorder, Orientation to Pain, and Pain Perception in Ex-Prisoners of War Who Underwent Torture. Psychosomatic Medicine, 79(6), 655–663. doi: 10.1097/psy.0000000000000461
Tsur, N., Shahar, G., Defrin, R., Lahav, Y., & Ginzburg, K. (2017). Torturing personification of chronic pain among torture survivors. Journal of Psychosomatic Research, 99, 155–161. doi: 10.1016/j.jpsychores.2017.06.016
United Nations: Draft Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. (1984). International Legal Materials, 23(5), 1027–1037. doi: 10.1017/s0020782900030990
Weiss, W. M., Uguento, A. M., Mahmooth, Z., Murray, L. K., Hall, B. J., Nadison, M., … Bolton, P. (2018). Mental health interventions and priorities for research for adult survivors of torture and systematic violence: a review of the literature. Torture Journal, 26(1), 27. doi: 10.7146/torture.v26i1.108061
Wildeman, C., Goldman, A. W., & Lee, H. (2019). Health Consequences of Family Member Incarceration for Adults in the Household. Public Health Reports, 134(1_suppl). doi: 10.1177/0033354918807974
Williams, A. C. D. C., Peña, C. R., & Rice, A. S. (2010). Persistent Pain in Survivors of Torture: A Cohort Study. Journal of Pain and Symptom Management, 40(5), 715–722. doi: 10.1016/j.jpainsymman.2010.02.018
Williams, B. A., Ahalt, C., Stijacic-Cenzer, I., Smith, A. K., Goldenson, J., & Ritchie, C. S. (2014). Pain Behind Bars: The Epidemiology of Pain in Older Jail Inmates in a County Jail. Journal of Palliative Medicine, 17(12), 1336–1343. doi: 10.1089/jpm.2014.0160
Yoon, I. A., Slade, K., & Fazel, S. (2017). Outcomes of psychological therapies for prisoners with mental health problems: A systematic review and meta-analysis. Journal of Consulting and Clinical Psychology, 85(8), 783–802. doi: 10.1037/ccp0000214
Zimney, K., Louw, A., & Puentedura, E. J. (2013). Use of Therapeutic Neuroscience Education to address psychosocial factors associated with acute low back pain: a case report. Physiotherapy Theory and Practice, 30(3), 202–209. doi: 10.3109/09593985.2013.856508
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