Rehabilitation for Survivors of Torture: Understanding the Impact and Support Available

Working for in Greece Rachel Bingham

Before I went to Greece Medical school DMCC (2012) Medical Justice independent doctor GP ST1-2 in London OOPE in rural Kwazulu Natal, South Africa GP ST3 in Islington (2015) MSF Egypt (2016) Medical Activities Manager , project for refugees in Cairo Freedom from Torture Medical-legal reports doctor GP (fixed term salaried post, locum sessions)

Whats happening in Athens?

MSF projects in Greece

Rehabilitation for survivors of torture Person has experienced torture or ill-treatment (ICRC definition) Torture: severe pain or suffering, whether physical or mental, inflicted for such purposes as obtaining information or a confession, exerting pressure, intimidation or humiliation. Cruel or inhuman treatment: consists of acts which cause serious pain or suffering, whether physical or mental, or which constitute a serious outrage upon individual dignity. Person has a medical or mental health request related to the above

Common forms of torture Beatings, head injuries Sexual abuse, rape Burns with cigarettes or heated objects Threats, mock executions Crush injuries and removal of nails Forced confessions, forced to betray others Suspension Sensory deprivations Near drowning e.g. pushing head in bucket, waterboarding Other inhumane detention conditions

Abdul (not his real name) was a law student before the war in Syria. He was detained and tortured first by the regime, and later by ISIS. He lost his wife and two children in the conflict. (Image credit: Albert Masias)

Common consequences of torture Chronic pain Hypervigilance, anxiety, fear Injuries to joints and ligaments Insomnia Consequences of head injury including seizures, cognitive or memory problem Mood disturbance Flashbacks or intrusive memories, nightmares Consequences of sexual violence including physical injury, pregnancy, problems with relationships Problems with trust

Example patient Young man who was a student activist. He was detained in his country of origin after organising an illegal protest. In detention, he was repeatedly interrogated. The officials burnt him with cigarettes. They hung him suspended upside down until he lost consciousness. They were sexually violent to him before forcing him to sign a confession. By that point he would have signed anything. He was told to report back to the police station every week while waiting for his trial. His family helped him to flee using an agent/smuggler. He travelled overland; crossed the Mediterranean. In Lesvos he eventually presented to the MSF clinic who recognised him as a survivor of torture. Felt by Lesvos team to be at particularly high risk of re-traumatisation on the island, deteriorating mental health. After a prolonged legal intervention supported by MSF his geographical restriction was lifted and he was permitted to move to Athens where he could attend our clinic.

Example patient He still doesn t have asylum. What can MSF do for this person?

MSF clinic in Athens Develop trust, stabilise symptoms, support with medical and legal aspects, therapy when stable Multidisciplinary rehabilitation model Psychologist Medical doctor Social worker Physiotherapist Lawyer (partner NGO) Full medical assessment including STI screening, diagnosis and treatment of consequences of torture, medical evidence for asylum claim All teams: multidisciplinary plan for chronic pain Support with accessing services for accommodation, financial needs, national health service access Physiotherapy for and joint and ligament injuries and pain Manage asylum claim

Psychological therapies, such as this art group, have helped women who have been victims of torture or violence to express their feelings and manage the impact of their trauma. (Image credit: Albert Masias)

Medical evidence for asylum claim Could be included at any stage (initial decision, appeal, 2ndappeal ) Like in the UK, in Greece many asylum claims are rejected before medical evidence is considered Medical evidence often corroborative and could be diagnostic e.g. circumferential scars after binding of wrists and ankles, bilateral brachial plexus injury after suspension, characteristic burns on the back / back of the legs However, not all forms of torture leave physical scars Doctor may also address clinically relevant issues in asylum refusals missing or inconsistent detail in an account of trauma psychological reasons for delayed disclosure decision-maker s hypotheses about alternative causes of health conditions/scars

My job Technical support to the team Advise on medical management Training sessions for team on medical aspects e.g. chronic pain, headache, sexual violence Pull together guidelines and protocols relevant to topic of torture Recruitment and training of new doctors Advise team about reporting of medical evidence

Conclusion Perhaps not a traditional MSF mission but one of the new frontiers therefore typical of MSF to get involved As well as clinical experience, MSF will give you opportunities to be involved in management, project development, advocacy Lots of opportunities for relevant experience to be gained in the UK

Thank you rachelbingham@nhs.net twitter rachel_bingham_