When your patient is a survivor of torture

Kolbassia Haoussou writes of the hidden emotional turmoil that survivors of torture may endure for months or years after their experiences. Haoussou suggests that doctors should tread carefully when dealing with those who may be torture victims, especially as their demeanor is often cautious, shy, even reclusive.How fitting that his words were preceded in the previous issue of the BMJ, by Iona Heath’s essay on the need for compassion in medical practice, with less subservience to scientific protocols, and to the evidence of equivocal, pharma-funded RCTs.(1)

Heath wrote, “Clinicians must see and hear each patient in the fullness of his or her humanity in order to minimise fear, to locate hope (however limited), to explain symptoms and diagnoses in language that makes sense to the particular patient, to witness courage and endurance, and to accompany suffering.”

Colleagues in primary care, today, will recognise Heath’s words as a perfect, succinct, description of how one should approach consultations with asylum seekers and possible victims of torture, only to ask themselves how that approach can be assimilated into a ten minute appointment system. It cannot. Older readers may remember the advice of Michael and Enid Balint (2,3) on the necessity to set aside a longer consultation time for patients with complicated narratives. If we are to offer a meaningful service to people whose experiences may have scarred their bodies, and continue to torture their minds, we have to follow the Balints’ advice ourselves, or refer our patients to others who may help.

NICE guidelines advise trauma-focused psychological therapy as first line treatment for adults with Post-traumatic stress disorder, with SSRIs for those who do not wish to engage with it, or who fail to improve. (4)

Many asylum seekers with PTSD are provided with Home Office accommodation far removed from the few ‘Freedom from Torture’ clinics, but even they may be able to access free psychological help through the Cities of Sanctuary movement. (5)

Inevitably, given the paucity of psychological options in primary care, many asylum seekers and others damaged by torture, are prescribed SSRIs. Easily prescribed in hurried GP consultations,even in specialised units they give unremarkable results (6). They may cause side effects, especially in the doses and combinations sometimes resorted to, and are difficult to stop. (7)

The emotional results of torture encompass feelings of grief, remorse, humiliation, dread, fear, paranoia and shame, unrelentingly, as memories and flashbacks allow the victims no chance to concentrate by day or sleep by night. Little wonder that the unfocused and uncertain effects of SSRIs may leave a prescriber frustrated that he or she has no way to individualise their therapy, when victims present with disparate narratives and modes of distress.

We have seen about a hundred asylum seekers at a free homeopathic clinic in a Welsh City of Sanctuary in the past four years. Our anecdotal experience, and positive feed back, suggests that the individualised remedy choices we can make have an effect which is far in excess of what observers might dismiss as a placebo effect. These positive responses are seen in many victims who saw no such response to conventional options. (8)

There may well be a huge unmet need for help, out there. The NHS is often unable to provide time or opportunity for victims of torture to be assessed, far less able to offer effective treatment. May we suggest to colleagues in primary care who face this impasse, that they consider the possibility of a homeopathic referral.

1 http://www.bmj.com/content/355/bmj.i5705
2 Michael and Enid Balint, Psychotherapeutic techniques in medicine. Tavistock 1961.
3 Enid Balint and JS Norell, Six minutes for the patient. Tavistock 1973.
4 https://pathways.nice.org.uk/pathways/post-traumatic-stress-disorder
5 https://cityofsanctuary.org
6 http://www.bmj.com/content/351/bmj.h6161
7 Peter C Gotzsche, Deadly Psychiatry and Organised Denial. People’s Press 2015.
8 http://www.bmj.com/content/351/bmj.h6161/rr-0