A significant proportion of the world’s 46.3 million displaced people (UNHCR, 2014), have been exposed to extreme human rights abuses like torture.
Torture can have profound long-lasting physical and psychological effects on the survivor, their families and communities (Quiroga & Jaranson, 2005). The extreme nature of the torture experience, which is human-instigated, prolonged and uncontrollable, can result in severe and complex posttraumatic psychopathology (McDonnell, Robjant, & Katona, 2013). The psychological sequalae of torture includes severe emotion dysregulation (Nickerson et al., 2015), learned helplessness (Nickerson, Bryant, Silove, & Steel, 2011), impaired interpersonal functioning and social withdrawal (Quiroga & Jaranson, 2005) and drastic changes to self and social identity.
While the application of neuroimaging tools – including functional Magnetic Resonance Imaging (fMRI) – has greatly advanced knowledge of the brain systems affected by trauma exposure and PTSD (Hughes & Shin, 2011; Pitman et al., 2012), the extension of these methods to understanding the neural effects of torture trauma is seriously lacking. At the Refugee Trauma and Recovery Program (RTRP) based at the University of New South Wales in Australia, we are conducting fMRI studies investigating the neural processes affected by refugee trauma, to better understand how torture impacts on the brain. This work aims to inform clinical interventions by gaining insights into the specific emotional and cognitive mechanisms that are disrupted by torture, more targeted and effective treatments can be developed.
Evidence concerning how the brain is affected by torture is also likely to have major human rights implications, yet the translational channels for linking neuroimaging research with human rights policy and programming are not well defined. I was recently awarded a Churchill Fellowship*, which supported an international research project investigating this issue. My inquiries led me to the United States, Denmark, Switzerland and Germany to speak with clinical neuroscientists and neuroimaging specialists, as well as clinicians, service providers, agencies and policy makers who specialize in the treatment and support of torture survivors and refugees.
Recent clarifications in international policy regarding the rights of torture survivors present a possible mechanism for aligning the disparate worlds of neuroimaging research and human rights. In November 2012, the UN Committee Against Torture released General Comment No. 3 in relation to clarifying the State’s responsibilities under Article 14 of the United Nations Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (U NCAT) (UN Committee Against Torture, 2012). Comment 3 specifically recognizes the physical and mental injury, and related emotional suffering, caused to the individual or group who is subject to acts that contravene the UNCAT.
The Comment states that torture victims should be afforded the right to a dignified recovery through access to rehabilitation services. If States are now accountable for the delivery of rehabilitation services to torture survivors, it is critical that there is an evidence-base that demonstrates that rehabilitation services are effective. Currently, there is a wide range of treatment and support approaches utilized globally to address the mental health needs of torture survivors. This support relies on a limited evidence-base (Silove, 2012), with implementation often proceeding on a trial-and-error basis (Carlsson, Sonne, & Silove, 2014).
Furthermore, mixed findings from clinical research suggests that current PTSD interventions may have limited efficacy in the treatment of torture survivors (Nickerson et al., 2011). It is critical therefore, that an evidence-base is formed to advance knowledge about the psychological, neurobiological, genetic and psychosocial mechanisms that underpin torture trauma, and to utilize this evidence to inform the development and validation of best-practice treatments. Brain imaging research that elucidates the neural mechanisms impacted by torture is essential as it will help focus rehabilitation efforts to core processes affected. Indeed, some research groups have already applied other neuroimaging tools (e.g. magnetoencephalography) to investigate the processes disrupted by war and torture exposure (Adenauer et al., 2010), and the mechanisms underlying Narrative Exposure Therapy (Adenauer et al., 2011), a treatment shown to be effective for war and torture survivors (Hensel-Dittmann et al., 2011; Neuner, Schauer, Klaschik, Karunakara, & Elbert, 2004; Schauer, Neuner, & Elbert, 2011).
When used to develop treatments and monitor clinical outcomes following treatment, neuroimaging could be utilized to provide objective evidence that treatments can effectively alleviate suffering and restore healthy functioning. Therefore, clinical neuroimaging research has an important role to play in the realization of the right to rehabilitation for torture survivors.
This global mechanism for bridging neuroimaging research and the human rights sector provides an opportunity for enacting multidisciplinary partnerships to facilitate the care of torture survivors. However, there are additional obstacles that are worth considering as these steps are taken.
Given that the social context is a crucial determinant of refugee mental health (Miller, Kulkarni, & Kushner, 2006), clinical neuroimaging research needs to develop empirical methods that account for how these factors impact on brain function (for an example, see (Kim et al., 2013)). Indeed, in the post-conflict literature there is evidence that daily stressors are powerful psychosocial elements that heavily influence posttraumatic mental health (Miller & Rasmussen, 2010).
However, the dominant framework for conducting clinical neuroscience research - the Research Domain Criteria (RDoC) implemented by the National Institutes of Mental Health (Insel, 2010) - separates mental health disruptions from their social determinants. By neglecting to consider the role of sociocontextual factors on mental health in refugees, neuroimaging and psychological research may risk losing face validity, limiting the relevance of research findings to the reality of the refugee and torture survivor experience.
On the other side, the human rights and refugee sectors could recognize the important contribution that quantitative empirical research may have to guide policy and program implementation, especially from a rehabilitation perspective. There may also be additional opportunities for neuroimaging research to have translational value in assisting survivors of torture in this space.
For instance, research findings may be utilized to contribute to the psychoeducation of decision-makers in the refugee determination process about the long-lasting effects of torture on emotional functioning, or assist in de-stigmatizing mental health symptoms amongst torture survivors. Such cross-sectoral conversations are essential to strengthening the support provided to survivors of torture and enhance pathways to recovery.
About the Author
Belinda Liddell, PhD, is a Research Fellow at the University of New South Wales (UNSW) Australia, and is Neuroimaging Director at the Refugee Trauma and Recovery Program (RTRP). Her current research investigates the neural mechanisms underlying refugee trauma including torture and other human rights violations (funded by the Australian Research Council), cultural differences in PTSD and the translation of research into policy and practice.
*The author was awarded a Churchill Fellowship by the Winston Churchill Memorial Trust of Australia to undertake this research (November-December 2014), and wishes to express her gratitude to the dedicated researchers, clinicians, lawyers and policy specialists she met during her fellowship. View the full report resulting from this research.
Adenauer, H., Catani, C., Gola, H., Keil, J., Ruf, M., Schauer, M., & Neuner, F. (2011). Narrative exposure therapy for PTSD increases top-down processing of aversive stimuli - evidence from a randomized controlled treatment trial. BMC Neuroscience, 12, 127.
Adenauer, H., Pinösch, S., Catani, C., Gola, H., Keil, J., Kißler, J., & Neuner, F. (2010). Early Processing of Threat Cues in Posttraumatic Stress Disorder—Evidence for a Cortical Vigilance-Avoidance Reaction. Biological Psychiary, 68, 451-458.
Carlsson, J. M., Sonne, C., & Silove, D. (2014). From Pioneers to Scientists: Challenges in Establishing Evidence-Gathering Models in Torture and Trauma Mental Health Services for Refugees. The Journal of Nervous and Mental Disease, 202(9), 630-637.
Hensel-Dittmann, D., Schauer, M., Ruf, M., Catani, C., Odenwald, M., Elbert, T., & Neuner, F. (2011). Treatment of traumatized victims of war and torture: a randomized controlled comparison of narrative exposure therapy and stress inoculation training. Psychotherapy & Psychosomatics, 80(6), 345-352.
Hughes, K. C., & Shin, L. M. (2011). Functional neuroimaging studies of post-traumatic stress disorder. Expert Reviews Neurotherapeutics, 11(2), 275-285.
Insel, T. R. (2010). Research Domain Criteria (RDoC): Toward a New Classification Framework for Research on Mental Disorders. American Journal of Psychiatry, 167(7), 748-750.
Kim, P., Evans, G. W., Angstadt, M., Ho, S. S., Sripada, C. S., Swain, J. E., . . . Phan, K. L. (2013). Effects of childhood poverty and chronic stress on emotion regulatory brain function in adulthood. Proc Natl Acad Sci U S A, 110(46), 18442-18447.
McDonnell, M., Robjant, K., & Katona, C. (2013). Complex posttraumatic stress disorder and survivors of human rights violations Current Opinion in Psychiatry, 26(1), 1-6. doi: 10.1097/YCO.0b013e32835aea9d
Miller, K. E., Kulkarni, M., & Kushner, H. (2006). Beyond Trauma-Focused Psychiatric Epidemiology: Bridging Research and Practice with War-Affected Populations. American Journal of Orthopsychiatry, 76(4), 409-422.
Miller, K. E., & Rasmussen, A. (2010). War exposure, daily stressors and mental health in conflict and post-conflict settings: Bridging the divide between trauma-focused and psychosocial frameworks Social Science & Medicine, 70, 7-16.
Nagan, W. P., & Atkins, L. (2001). The International Law of Torture: From Universal Proscription to Effective Application and Enforcement. Harvard Human Rights Journal, 14(87-121).
Neuner, F., Schauer, M., Klaschik, C., Karunakara, U., & Elbert, T. (2004). A comparison of narrative exposure therapy, supportive counseling, and psychoeducation for treating posttraumatic stress disorder in an african refugee settlement. J Consult Clin Psychol, 72(4), 579-587. doi: 10.1037/0022-006X.72.4.579
Nickerson, A., Bryant, R. A., Schnyder, U., Schick, M., Mueller, J., & Morina, N. (2015). Emotion dysregulation mediates the relationship between trauma exposure, post-migration living difficulties and psychological outcomes in traumatized refugees J Affect Disord, 173, 185-192.
Nickerson, A., Bryant, R. A., Silove, D., & Steel, Z. (2011). A critical review of psychological treatments of posttraumatic stress disorder in refugees. Clin Psychol Rev, 31(3), 399-417.
Pitman, R. K., Rasmussen, A., Koenen, K. C., Shin, L. M., Orr, S. P., Gilbertson, M. W., . . . Liberzon, I. (2012). Biological studies of post-traumatic stress disorder. Nature Reviews Neuroscience, 13, 769-787.
Quiroga, J., & Jaranson, J. M. (2005). Politically-motivated torture and its survivors: a desk study review of the literature. Torture, 16(203), 1-111.
Schauer, M., Neuner, F., & Elbert, T. (2011). Narrative Exposure Therapy: A Short-Term Treatment for Traumatic Stress Disorders, 2nd Edition. Gottingen, Germany: Hogrefe.
Silove, D. (2012). Treatment of refugees at the crossroads: The need for an evidence base. Australian and New Zealand Journal of Psychiatry, 46(10), 921-923.
United Nations Committee Against Torture (2012). United Nations Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment, General Comment No. 3 of the Committee against Torture relating to Implementation of article 14 by State Parties, 19 November 2012.
United Nations High Commission for Refugees (UNHCR). (2014). UNHCR Mid-Year Trends 2014.