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Management of psychological effects of torture or other traumatic events

Overview

People from refugee backgrounds, including people seeking asylum, vary in their readiness to disclose previous trauma, and much depends on context, and the empathy, warmth and skill of the clinician. Talking about past experiences can may be psychologically beneficial in the right circumstances. However, the knowledge that the patient may have endured certain experiences due to their country of origin or transit is generally sufficient for you to orient your care.

Common psychological effects of torture or other traumatic events include a range of symptoms and behavioural effects. Some patients may suffer a mental health disorder, the most frequent being post-traumatic stress disorder, depressive disorder and anxiety disorders.1

Commonly occurring effects that may disrupt daily life include:

  • intrusive and recurrent memories of traumatic events, flashbacks, nightmares, avoidance of reminders of traumatic events, detachment from others, numbing, hypervigilance, exaggerated startle response
  • depression and grief
  • guilt and shame
  • distrust and anger, sensitivity to justice and injustice
  • difficulties with memory and concentration
  • interpersonal difficulties, including isolation
  • impact on physical health from factors such as poor appetite and sleep issues.

Children and adolescents experience similar psychological reactions to trauma as adults, however, the clinical presentation reflects their age and development. Presentations may include behavioural issues, sleep concerns, attention difficulties, low self-esteem, friendship difficulties, enuresis, and developmental/education concerns, as well as symptoms of anxiety, depression and post-traumatic stress disorder (PTSD). Parent mental illness affects child wellbeing, and addressing both parent and child mental health is important.

Approach to care

More detail of someone’s experiences is often required to understand and manage the causes of persistent psychological and psychosomatic symptoms. Details of past traumatic experiences are best elicited if:

  • a trusting relationship has developed
  • there is adequate time for the patient to respond
  • the patient feels comfortable with the professional interpreter, and their confidentiality has been assured.

Some useful questions include:

  • ‘Some people have had bad things happen to themselves and their families. Has anything happened to you or your family that could be affecting your health or the way you are feeling now?’
  • ‘When did the problem start? You do not need to tell me all the details, but can you tell me something of what was happening at the time?’
  • ‘Do you have any other problems that we have not talked about that I can help you with today?’

Responding to a disclosure of torture or trauma

  • Validate your patient’s reaction by acknowledging their experience (e.g. ‘That’s a terrible thing you have been through.’).
  • Remind your patient that their reaction is a normal response to their circumstances, as often survivors blame themselves and see their reactions as abnormal or weak.
  • Avoid false assurances. Nevertheless, indicate that with time and appropriate support, improvement can be achieved.
  • Expect that the patient who has disclosed a traumatic event may be unwilling to talk about it in subsequent consultations. Rather than pushing them to do so, talk about other things that may be currently troubling them.
  • Expect inconsistencies and/or fragmented accounts in the patient’s retelling of their trauma history.
  • Explain to the patient how you are able to assist them.

Management

There is a consensus among practitioners experienced in caring for people from refugee backgrounds that optimum treatment of psychological problems involves non-pharmacological approaches either in addition to medication or as the primary treatment modality.2

Medication may be required to manage symptoms that are sufficiently severe that they interfere with the patient’s functioning.

When a patient presents with persistent symptoms believed to be related to trauma, consider referral to a psychiatrist, psychologist or the specialist service for survivors of trauma and torture in your state or territory

Each state and territory has a specialised torture and trauma counselling service for people from refugee backgrounds. These free and confidential services are non-denominational, politically neutral and non-aligned. For more information regarding specialist services for survivors of torture and trauma see Forum of Australian Services for Survivors of Torture and Trauma (FASSTT).

In some areas, counselling services through community health centres or mental health nurses may be available to assist the client and facilitate other referrals. See State and territory referrals.

Practice tips

  • Explain to the patient your diagnosis or opinion of their condition, and the likely causes of the condition. The patient’s explanation for their problem is useful to enquire about.
  • Be aware of the stigma attached to psychological conditions.
  • Outline treatment options so that the patient is able to make a choice. Be specific about what the alternatives are.
  • Arrange emergency psychiatric management in the usual way for patients at risk of serious mental health deterioration, suicide, and violence to others or self-harm.
  • Ensure that professional interpreting services are available if required.

Considerations

Somatic complaints

It is not uncommon for patients from refugee backgrounds to somatise their psychological stress. Consider the following:

  • Take presenting concerns seriously, and conduct appropriate examinations and investigations as needed. People from refugee backgrounds may have received inadequate health care and usually need explanations of investigations. See Approach to consultation and management.
  • It may be helpful to discuss the relationship between the body and mind.
  • If somatic symptoms persist and a link between such symptoms and emotional distress is made, consider a referral for counselling and support.
  • Consider the trauma basis for symptoms and refer accordingly. Specialist services for survivors of trauma and torture are located in each state and territory. See State and territory referrals or FASSTT.

Mental health of people seeking asylum

The psychological implications of uncertain migration status

People seeking asylum face particular stresses owing to their uncertain migration status, limitations on their access to benefits and, in some cases, their experiences in immigration detention centres.3 Research indicates that people seeking asylum are vulnerable to being retraumatised and have particularly poor physical and mental health.4

Issues faced by people seeking asylum include:

  • a limited capacity to plan for their future and develop stable social connections
  • detention centre experiences that may compound a sense of injustice and loss of control, and serve as reminders of persecutory practices in countries of origin
  • perceptions that they are not being believed by the Australian Government, or that they are being treated in a discriminatory fashion
  • feelings of powerlessness resulting from the limited control over their lives
  • exposure to unsympathetic or hostile attitudes in the media and the wider community
  • no or uncertain access to family reunion provisions. See Asylum seekers.
  • anxiety about the safety of loved ones still in dangerous circumstances overseas
  • limitations on their access to the resources required for positive mental health (e.g. English language tuition, secure housing)
  • stressors on families, including concern for wellbeing of children
  • the need to overcome barriers to participation in the Protection Visa application process, such as poor mental health and effects of torture or other traumatic events.

See Asylum seekers,  State and territory referrals.

Other resources

References

  1. Turrini G, Purgato M, Ballette F, Nosè M, Ostuzzi G, Barbui C. Common mental disorders in asylum seekers and refugees: umbrella review of prevalence and intervention studies. International journal of mental health systems. 2017;11(1):51.

  2. TBC.

  3. Coffey GJ, Kaplan I, Sampson RC, Tucci MM. The meaning and mental health consequences of long-term immigration detention for people seeking asylum. Social science & medicine. 2010;70(12):2070-2079.

  4. Silove D, Steel Z, Mollica RF. Detention of asylum seekers: assault on health, human rights, and social development. The Lancet. 2001;357(9266):1436-1437.

Human Immunodeficiency Virus (HIV)

Chris Lemoh, Marion Bailes, David Isaacs

Recommendations

  • Offer HIV testing to all people aged ≥15 years, as prior negative tests do not exclude the
    possibility of subsequent acquisition of HIV.
  • Routine HIV screening of children <15 years is not warranted except in unaccompanied or
    separated minors. Screening should also be completed in children <15 years where risk factors or potentially associated conditions have been identified (see text).

Approach to consultation and management

 “The way the doctor treats you personally is half the medicine…” Community consultation participant, QLD

Key points

  • Person-centred care principles are useful to understand each individual’s background and current needs.
  • A universal precautions approach to pre-migration trauma is recommended when caring for people from refugee backgrounds, including people seeking asylum.
  • Consider health literacy and cultural factors in the delivery of health care.

Overview

Consider the impact of past trauma on the consultation when caring for people from refugee backgrounds.

Pre and post migration trauma may have an impact on people’s clinical presentations, their experience of the consultation and their ability to participate in management of their health concerns.

Communication difficulties may be further complicated by cultural and religious differences and a lack of familiarity with the Australian healthcare system.

Use person-centred care principles to build a relationship of trust and to understand each individual’s needs.

Trauma-informed approach to care

For some people from refugee backgrounds, particularly those experiencing psychological effects of torture or other traumatic events, the consultation may be a source of anxiety.

People from refugee backgrounds may have a distrust of authority figures, among them medical professionals.1,2 Humanitarian entrants, and people seeking asylum in particular, may mistakenly hold fears of deportation if they are found to have a serious health problem.

Symptoms such as memory loss, confusion, poor concentration and self-blame may affect the patient’s capacity to hear and understand instructions and to provide information to the doctor, nurse or other healthcare provider. Intrusive memories may be triggered in the course of the consultation.

Consultation

Conveying a sense of warmth and personal interest without rushing helps to build a therapeutic relationship.

Explain and emphasise patient confidentiality, patient consent, choice and control, and that this applies to all healthcare providers, settlement workers and professional interpreters.

  • Review previous records in detail where possible. For example there may be an existing refugee health nursing assessment that includes information about the person’s journey, including trauma experiences. This helps avoid asking repetitive questions and the need for the patient to repeatedly relay traumatic material.
  • Be aware that the clinical setting and aspects of the consultation may be reminders of past trauma (e.g. being made to wait, sudden movements, medical instruments).
  • Explain why certain questions are necessary.
  • Consider deferring sensitive questions and procedures such as mental health screening and sexual health until trust is established and there is sufficient time.
  • Understand that patient fear and hostility are responses to trauma and may have little to do with the consultation.
  • Defer invasive procedures until the process and reasons for undertaking them are fully understood.
  • Consider suspending and rescheduling procedures if the patient becomes overly anxious.

Taking a detailed history of torture or other traumatic events is not recommended; assume your patient has had traumatic experiences based on their country of origin and journey. However, psychological and psychosomatic symptoms may persist and acknowledgement of their causes may be required for ongoing management. Consider asking about past trauma only if appropriate and there is adequate time for response.

For more information to ask about, and respond to, a disclosure of torture or trauma see Management of psychological effects of torture or other traumatic events.

Investigations

  • Informed consent is essential for all investigations. However, it is not necessary to get a detailed history of past, possibly traumatic events before offering screening.
  • Give clear explanations for all investigations.
  • Respect client confidentiality, particularly for adolescents who should be seen without their parents or carers during at least part of the consultation.

Management

  • Assessment and management can take place over several sessions if a gradual approach is indicated.
  • Provide opportunities for the patient to ask questions or seek clarification about results. For example, ‘We have spoken about many things today, do you have any questions about anything we have talked about?’
  • Patients may need to be actively encouraged to ask questions or seek clarification. Some will have had experiences in their country of origin or other countries where this was not encouraged by health practitioners.
  • Consider gender issues. For example, male GPs may consider referring female patients to a female doctor; a male patient may prefer a male doctor.
  • Establish if there are any cultural or religious factors that need to be accommodated in your care.
  • Consider the diversity within cultural groups and across generations and avoid stereotyping.
  • Consider differences in health explanatory models between the client and health practitioner.
  • Use translated health information where available including internet video and audio resources and local peer health education if available.

Practice tip: Use the teach back technique to check understanding, especially when working with interpreters. Ask the patient, via interpreter if needed, to explain back to you what you have told them.

Referral

  • Consider seeking a specialist’s advice about whether a referral is appropriate prior to making the referral.
  • Travelling to a specialist or another health professional may require additional resources on behalf of the patient (e.g. cost of travel, arrangements for family or support person to travel with person).
  • Explain the culture and the structure of the healthcare system; the role of the GP and specialists; and the patient’s healthcare entitlements and rights, such as the right to ask for a female or male healthcare provider, right to a professional interpreter, right to a second opinion.

See Prescribing tips

See Tips for making referrals

References

  1. Moreno A, Piwowarczyk L, et al. Human rights violations and refugee health. JAMA 2001; 285(9): 1215 as cited in Finney Lamb C, Smith M. Problems refugees face when accessing heath services. NSW Public Health Bulletin 2002;13:161–3 
  2. Downs K, Bernstein J, et al. Providing culturally competent primary care for immigrant and refugee women: A Cambodian case study. J Nurse Midwifery 1997; 42(6): 499–508 as cited in Finney Lamb C, Smith M. Problems refugees face when accessing heath services. NSW Public Health Bulletin 2002;13:161–3

Malaria

Christine Phillips, Josh Francis

Recommendations

  • Investigations for malaria should be performed on anyone who has travelled from/through an endemic malaria area within 3 months of arrival if asymptomatic, or within 12 months if symptoms of fever (regardless of any pre-departure malaria testing or treatment).
  • Test with both thick and thin blood films AND an antigen-based rapid diagnostic test (RDT), as RDT alone is not significantly sensitive to detect all non P.falciparum infections.
  • All people with malaria should be treated by, or in consultation with, a specialist ID service. Discuss diagnoses urgently with an infectious disease service. Patients with malaria may deteriorate quickly, especially children, pregnant women and those with low immunity.
  • Admit all patients with falciparum malaria to hospital, at least for the initial part of their treatment. Experienced clinicians may treat individuals with non-falciparum or non-severe falciparum malaria infection as outpatients if they are in a non-malaria receptive area.

Sexually transmissible infections (STIs)

Aesen Thambiran, Mitchell Smith, Vanessa Clifford
(For other STIs – HIV, HBV, HCV).

Recommendations

  • A sexual health history should be completed sensitively, with awareness of gender issues, and with reassurance and careful explanations.
  • Offer an STI screen to people with a risk factor for acquiring an STI or on request (see text). Universal post-arrival screening for STIs for people from refugee-like backgrounds is not supported by current available evidence.
    • Syphilis serology should be offered to unaccompanied and separated children <15 years.
    • Children <15 years should be offered screening for other STIs including HIV and syphilis if there are clinical concerns (see text for details).
  • A complete STI screen includes a self-collected swab or first pass urine Nucleic Acid Amplification Test (NAAT) and consideration of throat and rectal swabs for chlamydia and gonorrhoea, and serology for syphilis, HIV and hepatitis B.
  • Asymptomatic patients with positive syphilis serology should be treated, unless there is documented prior treatment of treponemal infection. Treat syphilis with parenteral penicillin in consultation with a sexual health or ID unit.
  • Specimens for Neisseria gonorrhoea microscopy and culture should be taken before treatment is instituted. Treat gonorrhoea with ceftriaxone 500mg in 2mL of 1% lignocaine IMI, plus azithromycin 1g orally.76 Repeat NAAT and culture for test of cure of gonorrhoea two weeks after treatment.
  • Treat chlamydia with azithromycin 1g orally as a single dose, or, alternatively, doxycycline 100mg orally 12 hourly for 7 days.76
  • Treat anorectal chlamydia with doxycycline 100mg orally 12 hourly for 7 days or azithromycin 1g orally as a single dose with a repeat dose a week later.205
  • Offer women a pregnancy test and contraception, as appropriate (see Women’s Health).
  • An STI screen provides an opportunity for education about safer sex and condom use.

* Chlamydia testing is consistent with the current National STI Strategy206 and Australasian Sexual Health Alliance (ASHA) guidelines.205


Produced by

in consultation with

                  Refugee Health Network of Australia

Endorsed by

Funded by

The Australian Refugee Health Practice Guide was produced with funds from the Australian Government Department of Health.

Disclaimer

The information set out in the Australian Refugee Health Practice Guide (“the Guide”) is current at the date of first publication and is intended for use as a guide of a general nature only and may or may not be relevant to particular patients or circumstances. Nor is the Guide exhaustive of the subject matter. Persons implementing any recommendations contained in the Guide must exercise their own independent skill or judgement or seek appropriate professional advice relevant to their own particular circumstances when so doing. The statements or opinions that are expressed in the Guide reflect the views of the contributing authors and do not necessarily represent the views of the editors or Foundation House. Compliance with any recommendations cannot of itself guarantee discharge of the duty of care owed to patients and others coming into contact with the health professional and the premises from which the health professional operates.

Whilst the information is directed to health professionals possessing appropriate qualifications and skills in ascertaining and discharging their professional (including legal) duties, it is not to be regarded as clinical advice and, in particular, is no substitute for a full examination and consideration of medical history in reaching a diagnosis and treatment based on accepted clinical practices.

Accordingly, Foundation House and its employees and agents shall have no liability (including without limitation liability by reason of negligence) to any users of the information contained in the Guide for any loss or damage (consequential or otherwise), cost or expense incurred or arising by reason of any person using or relying on the information contained in the Guide and whether caused by reason of any error, negligent act, omission or misrepresentation in the information. Although every effort has been made to ensure that drug doses and other information are presented accurately in the Guide, the ultimate responsibility rests with the prescribing clinician. For detailed prescribing information or instructions on the use of any product described herein, please consult the prescribing information issued by the manufacturer.