title: Reviewing outcomes of psychological interventions with torture survivors: Conceptual, methodological and ethical Issues.
abstract: BACKGROUND
  Torture survivors face multiple problems, including psychological difficulties, whether they are refugees or remain in the country where they were tortured. Provision of rehabilitation varies not only with the needs of survivors and resources available, but also with service models, service provider preferences and the local and country context. Despite increasing efforts in research on effectiveness of psychological interventions with torture survivors, results are inconclusive.
  
  
  METHODS
  We undertook a Cochrane systematic review of psychological, social and welfare provision, with meta-analysis to best estimate efficacy. The process raised conceptual, methodological and ethical issues of relevance to the wider field.
  
  
  RESULTS
  We searched very widely, but rejected hundreds of papers which recommended treatment without providing evidence. We found nine randomised controlled trials, from developed and under-resourced settings. All conceptualised survivors' problems in psychiatric terms, using outcomes of post-traumatic stress symptoms, distress, and quality of life, by self-report, with or without translation or unstandardised interpretation, and with little mention of cultural or language issues. None used social or welfare interventions. Four related studies used narrative exposure therapy (NET) in a brief form, and without ensuring a safe setting as recommended. Five used mixed methods, including exposure, cognitive behavioural therapy, and eye movement desensitisation. Combined, the studies showed no immediate improvement in PTSD, distress, or quality of life; at six months follow-up, a minority showed some improvement in PTSD and distress, although participants remained severely affected.
  
  
  CONCLUSIONS
  While applauding researchers' commitment in running these trials, we raise ethical issues about exposure in particular, and about the effects of shortcomings in methodology, particularly around assessment using unfamiliar cultural frameworks and language, and the lack of concern about dropout which may indicate harm. The issues addressed aid interpretation of existing research, and guide clinical practice as well as future studies evaluating its effectiveness.
authors.affiliation: International Centre for Health and Human Rights and Professor of Clinical Psychology, Unviersity of East London, UK. Correspondence to amanda.williams@ucl.ac.uk.
authors.forename: Nimisha
authors.initials: N
authors.lastname: Patel
authors.forename: Amanda
authors.initials: A
authors.lastname: C de C Williams
authors.forename: Blerina
authors.initials: B
authors.lastname: Kellezi
mesh_terms: D001007:Anxiety / Q000523:psychology / Q000534:rehabilitation; D015928:Cognitive Behavioral Therapy / Q000941:ethics / Q000379:methods; D003863:Depression / Q000523:psychology / Q000534:rehabilitation; D057169:Eye Movement Desensitization Reprocessing / Q000941:ethics / Q000379:methods; D006801:Humans; D007171:Implosive Therapy / Q000941:ethics / Q000379:methods; D033262:Narration; D062525:Narrative Therapy / Q000941:ethics / Q000379:methods; D011613:Psychotherapy / Q000941:ethics / Q000379:methods*; D011788:Quality of Life; D013313:Stress Disorders, Post-Traumatic / Q000523:psychology / Q000534:rehabilitation*; D013315:Stress, Psychological / Q000523:psychology / Q000534:rehabilitation*; D017741:Survivors / Q000523:psychology*; D014104:Torture / Q000523:psychology*; D016896:Treatment Outcome