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Improving the assessment and treatment of pain in torture survivors

2020; Elsevier BV; Volume: 20; Issue: 4 Linguagem: Inglês

10.1016/j.bjae.2019.12.003

2058-5357

Amanda C de C Williams, John Hughes,

Health and Conflict Studies

Learning objectivesBy reading this article, you should be able to:•Discuss some of the wider problems facing the torture survivor with pain attempting to settle in the UK.•Address possible causes of under-recognition of torture survivors among your patients with pain.•Develop confidence in asking patients if they have been tortured.Torture occurs in many countries, including many that are signatories to the United Nations (UN) Convention against torture and other cruel, inhuman or degrading treatment or punishment.1Amnesty International https://www.amnesty.org/en/documents/pol10/6700/2018/en/Date accessed: September 23, 2019Google Scholar,2United Nations General AssemblyConvention against torture and other cruel, inhuman or degrading treatment or punishment. 5. 1984: 5https://www.unhcr.org/uk/protection/migration/49e479d10/convention-against-torture-other-cruel-inhuman-degrading-treatment-punishment.htmlGoogle Scholar Torture occurs both in stable states and in those with ongoing armed conflict. By the UN's definition, torture is 'any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purpose as obtaining from him or a third person information or a confession, punishing him for an act he or a third person has committed, or is suspected of having committed, or intimidating or coercing him or a third person, or for any reason based on discrimination of any type, when such pain or suffering is inflicted by, or at the instigation of, or with the consent or acquiescence of, a public official or other person acting in an official capacity. It does not include pain or suffering arising only from, inherent in, or incidental to lawful sanctions.'2United Nations General AssemblyConvention against torture and other cruel, inhuman or degrading treatment or punishment. 5. 1984: 5https://www.unhcr.org/uk/protection/migration/49e479d10/convention-against-torture-other-cruel-inhuman-degrading-treatment-punishment.htmlGoogle Scholar The number of victims and survivors is impossible to estimate but, among refugees and people seeking asylum in the UK and in other high income countries, it is likely that at least 30% and possibly more than 40% have experienced torture.3Amris K. Jones L.E. Williams ACdeC. Pain: Clinical Update. Pain from torture: assessment and management.Pain Rep. 2019; 4 (e794)PubMed Google Scholar,4Burnett A. Ndovi T. The health of forced migrants.BMJ. 2018; 363 (k4200)PubMed Google Scholar By reading this article, you should be able to:•Discuss some of the wider problems facing the torture survivor with pain attempting to settle in the UK.•Address possible causes of under-recognition of torture survivors among your patients with pain.•Develop confidence in asking patients if they have been tortured. The prevalence of post-traumatic stress symptoms, depression and other psychological disorders have been more thoroughly investigated than chronic pain, which is often dismissed as a non-specific aspect of a psychological disorder by mental health services.3Amris K. Jones L.E. Williams ACdeC. Pain: Clinical Update. Pain from torture: assessment and management.Pain Rep. 2019; 4 (e794)PubMed Google Scholar,5Jaranson J.M. Quiroga J. Evaluating the services of torture rehabilitation programmes.Torture. 2011; 21: 98-140PubMed Google Scholar Torture survivors (and refugees in general) also struggle with the effects of dislocation, loss of family, occupation, culture, language and financial resources.5Jaranson J.M. Quiroga J. Evaluating the services of torture rehabilitation programmes.Torture. 2011; 21: 98-140PubMed Google Scholar,6Porter M. Haslam N. Predisplacement and postdisplacement factors associated with mental health of refugees and internally displaced persons: a meta-analysis.JAMA. 2005; 294: 602-612Crossref PubMed Scopus (1092) Google Scholar Most refugees remain in their own or neighbouring countries; it takes substantial resources to reach host countries such as the UK.4Burnett A. Ndovi T. The health of forced migrants.BMJ. 2018; 363 (k4200)PubMed Google Scholar By this time many refugees are destitute and in poor health. The process of obtaining asylum and leave to remain is protracted and stressful. Further, poverty, discrimination, lack of safe accommodation or opportunity to work worsen refugees' mental health.6Porter M. Haslam N. Predisplacement and postdisplacement factors associated with mental health of refugees and internally displaced persons: a meta-analysis.JAMA. 2005; 294: 602-612Crossref PubMed Scopus (1092) Google Scholar Although torture survivors are unlikely to be referred to specialist pain services until years after arrival, their chronic pain cannot be adequately understood or treated without recognition of the wider context outlined above. Among torture survivors who present to clinicians, the prevalence of chronic pain appears to be very high.3Amris K. Jones L.E. Williams ACdeC. Pain: Clinical Update. Pain from torture: assessment and management.Pain Rep. 2019; 4 (e794)PubMed Google Scholar,7Williams A.C. Peña C.R. Rice A.S. Persistent pain in survivors of torture: a cohort study.J Pain Symptom Manage. 2010; 40: 715-722Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar,8Teodorescu D.S. Heir T. Siqveland J. Hauff E. Wentzel-Larsen T. Lien L. Chronic pain in multi-traumatized outpatients with a refugee background resettled in Norway: a cross-sectional study.BMC Psychol. 2015; 3: 7Crossref PubMed Google Scholar However, the prevalence has not been estimated with any reliability in unselected groups of non-clinical refugees. The most common reported sites of pain are the head, back, musculoskeletal system and limbs; pelvic and urogenital pain are very probably underreported.3Amris K. Jones L.E. Williams ACdeC. Pain: Clinical Update. Pain from torture: assessment and management.Pain Rep. 2019; 4 (e794)PubMed Google Scholar,7Williams A.C. Peña C.R. Rice A.S. Persistent pain in survivors of torture: a cohort study.J Pain Symptom Manage. 2010; 40: 715-722Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar,8Teodorescu D.S. Heir T. Siqveland J. Hauff E. Wentzel-Larsen T. Lien L. Chronic pain in multi-traumatized outpatients with a refugee background resettled in Norway: a cross-sectional study.BMC Psychol. 2015; 3: 7Crossref PubMed Google Scholar Although chronic pain can be severely limiting, the survivor's priorities may lie in addressing other social, family, housing or financial problems. He or she may also be uncertain about investing effort in settling, and have the active intention of returning home when conditions allow. Survivors of torture are seen as patients in primary care, emergency services and as inpatients, but specialist services such as pain management centres often present barriers to attendance (Fig. 1). These barriers may prevent referral, such as the assumption that trauma services are the only appropriate referral destination. Barriers are also created by systems of charging non-residents for certain health services that make survivors anxious about being required to pay for consultations; concerns that their information may be passed to the Home Office, a practice that began in 2010 and only stopped in 2019 (after facilitating many thousands of internments and deportations); or language barriers with appointment letters and phone calls in English to the patient who does not understand them.9Legido-Quigley H. Pocock N. Tan S.T. et al.Healthcare is not universal if undocumented migrants are excluded.BMJ. 2019; 366 (i4160)PubMed Google Scholar Such barriers can be largely mitigated where there is commitment to do so, by the education of staff and the provision of clear public information in multiple languages. Interpreting services should always be offered. Even when survivors appear fluent at the first meeting, they may only be competent in areas associated with education or work but not be fluent in describing emotions. Interpreters should be trained and, preferably, experienced in working with torture survivors. Interpreters should be briefed and debriefed at the first and, if possible, subsequent consultations. In some cases, phone interpreting may be preferred because it is anonymous, particularly where a face-to-face interpreter may come from the survivor's community. Phone interpretation is much less sensitive to non-verbal behaviour, and this can complicate conversation. The survivor may have particular needs for the gender and ethnicity, and preferred language, of interpreters and these should be respected. Untrained interpreters, such as family members or service staff in the hospital from the same language group as the patient, should not be used for reasons of confidentiality. Most torture survivors do not disclose their history of torture if not asked.10Crosby S.S. Primary care management of non-English-speaking refugees who have experienced trauma: a clinical review.JAMA. 2013; 310: 519-528Crossref PubMed Scopus (66) Google Scholar There are many reasons why clinicians do not ask, including concern at causing further distress, but asking is essential. Torture survivors do not conform to any stereotype; some will be destitute, while others will be well-established professionals, including doctors. There are many ways to ask (Box 1). The clinician can prepare by finding out the likelihood of torture in the patient's home country from websites such as Amnesty International or Human Rights Watch. The act of asking signals to the patient the clinician's concern, a wish to understand and readiness to listen. If patients have not been tortured, they are unlikely to be offended.Box 1Ways to ask about experience of torture.Can you tell me why you left your home/country? Was your life in danger?I have seen other patients from [patient's country of origin] who have experienced violence from others. Has that happened to you?Have you ever been arrested, put in prison or held captive? Has that happened to members of your family?When you were in prison, were you tortured? Knowing what was done will help me to understand your pain.Are you applying for asylum in the UK? If that is because of torture, can you tell me about it?Did your pain problem start after you were beaten or tortured?Key points•Ask patients about torture; do not expect spontaneous disclosure.•Explore the patient's understanding of pain, and correct any misunderstandings.•There is almost no research on pain from torture or its effective treatment.•Treat to the highest standards and monitor and share outcomes.•Recognise that the patient may lack social support or financial resources, and health may not be their highest priority. Can you tell me why you left your home/country? Was your life in danger? I have seen other patients from [patient's country of origin] who have experienced violence from others. Has that happened to you? Have you ever been arrested, put in prison or held captive? Has that happened to members of your family? When you were in prison, were you tortured? Knowing what was done will help me to understand your pain. Are you applying for asylum in the UK? If that is because of torture, can you tell me about it? Did your pain problem start after you were beaten or tortured? •Ask patients about torture; do not expect spontaneous disclosure.•Explore the patient's understanding of pain, and correct any misunderstandings.•There is almost no research on pain from torture or its effective treatment.•Treat to the highest standards and monitor and share outcomes.•Recognise that the patient may lack social support or financial resources, and health may not be their highest priority. This section concerns clinical assessment, not medicolegal assessment that requires training and supervision. Haoussou, writing both as a torture survivor and a doctor, advises clinicians to first establish trust and assure confidentiality, and then to aim for continuity of care and to avoid repeated questioning on torture by each member of the team or referral network.11Haoussou K. When your patient is a survivor of torture.BMJ. 2016; 355 (i5019)Google Scholar They should be sensitive to the shame of recounting torture, particularly, but not only, sexual torture, and should treat survivors with dignity and respect, both of which can be destroyed in the patient by torture. Establishing trust is particularly important, and can be disrupted by cultural differences in non-verbal behaviour such as a proscription of physical contact, even shaking hands, or lack of direct eye contact (for reasons ranging from embarrassment to cultural expressions of respect). Pain from torture can have profound and complex meanings for the survivor, from symbolising the loss of the old life and the dreadful experiences endured, to representing survival and a mission to right wrongs. The context of justice and reparation may be ingrained with concerns about pain and other sequelae of torture and with their treatment. This is often an unfamiliar dimension for the clinician, but awareness of these issues contributes to a better basis for treatment or onward referral. The clinician assessing a torture survivor for pain must take a very different frame of reference in addition to his or her usual understandings of possible cause. Torture is inflicted by a huge range of methods, some of which the survivor may find hard to describe for varied reasons, including loss of consciousness, lack of knowledge (of injected substances, for instance), memory losses from head injury, anxiety and post-traumatic symptoms induced by recall, shame, humiliation and others. Some methods leave clear marks that would be hard to account for other than by being inflicted deliberately, and there are a few high quality studies of characteristic pain syndromes after falanga (beating the soles of the feet) and suspension by the arms.12Amris K. Torp-Pedersen S. Rasmussen O.V. Long-term consequences of falanga torture-what do we know and what do we need to know?.Torture. 2009; 19: 33-40PubMed Google Scholar,13Rasmussen O.V. Amris S. Blaauw M. Danielsen L. Medical physical examination in connection with torture.Torture. 2006; 16: 48-55PubMed Google Scholar Many other torture methods (such as electric shock, sexual assault, severe strain to joints) do not leave marks, intentionally making it harder for the asylum seeker to substantiate his or her case. Multiple ways of inflicting pain and terror are used at the same time, in conditions of poor nutrition, hygiene, lack of healthcare and extreme and prolonged stress. There is, for obvious reasons, no literature from work in animals to help us understand what such practices do to the human body, in the short or long term. Nevertheless, intensity of acute pain and of concomitant distress is a consistent predictor of the persistence of pain in the longer term.14Rosenbloom B.N. Katz J. Chin K.Y.W. et al.Predicting pain outcomes after traumatic musculoskeletal injury.Pain. 2016; 157: 1733-1743Crossref PubMed Scopus (48) Google Scholar Hence a high prevalence is to be expected. Some familiarity with more common torture methods is helpful for the clinician, but a sufficiently detailed description should be obtained (within the limits of the patient's distress) for the clinician to have a reasonable understanding of what damage and pain the patient underwent, where on the body and over what time scales. The patient may struggle with the appropriate vocabulary for body parts, and with associated shame; drawings of the human body can be offered. Rape, of both sexes, is increasingly reported and may be particularly difficult to disclose; asking directly is helpful. It can be difficult to balance the ideal conditions of privacy, time and a well-prepared interpreter to explore the survivor's pain and its meanings with the reality of most clinics, or even of a recovery room where the survivor has woken from general anaesthesia with flashbacks and severe distress.10Crosby S.S. Primary care management of non-English-speaking refugees who have experienced trauma: a clinical review.JAMA. 2013; 310: 519-528Crossref PubMed Scopus (66) Google Scholar Nevertheless, because refugees often live difficult and unstable lives and may not attend further appointments, the opportunity to assess as fully as possible should be taken when it first arises, in the initial consultation. Although it is important to bear in mind the possibility that the cause of pain may warrant further investigation (there may be a malunited fracture, or foreign bodies such as shrapnel), torture would usually have occurred years before the patient presents with pain and central mechanisms are likely to be important in explanations of pain. There may be a substantial gap between the torture survivor's understanding of the cause of pain and its possible resolution, and a biopsychosocial model that does not expect to find unhealed damage or to treat by invasive methods. This gap is often exacerbated by cultural differences in expectations of medicine and respect for Western medicine and the resources it commands; by alienation of the survivor from his or her own body that may have roots in surviving trauma15Borsook D. Youssef A.M. Simons L. Elman I. Eccleston C. When pain gets stuck: the evolution of pain chronification and treatment resistance.Pain. 2018; 159: 2421-2436Crossref PubMed Scopus (91) Google Scholar; and by the stigma attached to suggestions of psychiatric or psychological symptoms in countries where psychiatry is reserved for the frankly psychotic members of the population, with less dramatic problems addressed within the family. Reframing persistent pain not as irreparable damage and deterioration but as plastic changes in the central and peripheral nervous systems provides a basis for more optimistic discussions of recovery of function and changes in ways of managing pain. Unfortunately, no good resources to bridge these gaps exist (to the authors' knowledge) in relevant languages, and the explanation of pain is best negotiated on a basis of trust and of drawing from examples of the torture survivor's own experience. It is unhelpful that many trauma services (to which survivors are more likely to be referred than to pain services) see all symptoms through the lens of psychological disorder, and either dismiss pain as 'psychosomatic' or assure the survivor that pain will resolve with trauma treatment, which is not the case.3Amris K. Jones L.E. Williams ACdeC. Pain: Clinical Update. Pain from torture: assessment and management.Pain Rep. 2019; 4 (e794)PubMed Google Scholar,16Kuehler B. Childs S. One-stop multidisciplinary pain clinic for survivors of torture.Pain Manage. 2016; 6: 415-419Crossref PubMed Scopus (3) Google Scholar Notwithstanding these comments, post-traumatic stress symptoms, depression and anxiety are common in torture survivors, with sleep disturbance and specific fears and triggers to flashbacks (such as of cell-like rooms, people in uniform and sounds of screaming, all of which can be encountered in hospitals), so psychological assessment is very helpful in identifying problems for which treatment should be offered. Where psychological assessment is unavailable, liaison with psychological or psychiatric colleagues and sensitive use of screening instruments can help to identify problems that need consideration in treating pain, because they may in their own right complicate treatment. Most pain clinicians have routine explanations of the pathophysiology of persistent pain, but it may be even more important than usual to acknowledge the reality of the original injuries, and to convey how common it is to feel distressed. Neuropathic pain may be induced by methods of suspension, constriction and traction and by sustained postures, such as in a small cage. It may be associated with sensory and motor symptoms; partial lesion of the brachial plexus or lumbar plexus can produce feelings of heaviness and unresponsiveness and apparent neglect and underuse of the affected limb(s); these phenomena need systematic investigation. Nociplastic mechanisms (with central descending amplification and reduced inhibition) may be suspected where there is peripheral hypersensitivity, widespread pain and fatigue.15Borsook D. Youssef A.M. Simons L. Elman I. Eccleston C. When pain gets stuck: the evolution of pain chronification and treatment resistance.Pain. 2018; 159: 2421-2436Crossref PubMed Scopus (91) Google Scholar A physiotherapist's assessment may identify idiosyncratic habits of tension, guarding, posture and gait that have developed as protective mechanisms, exacerbated by prolonged stress and not remitted despite contributing to disability.3Amris K. Jones L.E. Williams ACdeC. Pain: Clinical Update. Pain from torture: assessment and management.Pain Rep. 2019; 4 (e794)PubMed Google Scholar There are very few systematic studies of pain treatment in survivors of torture; a systematic review and meta-analysis found two RCTs of psychologically-based rehabilitative treatments and one of hands-on physiotherapy.17Baird E. Williams A.C.C. Hearn L. Amris K. Interventions for treating persistent pain in survivors of torture.Cochrane Database Syst Rev. 2017; 8: CD012051PubMed Google Scholar Such trials are hard to conduct and the population is unusually heterogeneous. Yet the complexity of their pain, the unfamiliarity of the biopsychosocial formulation of pain for many survivors and the complications of distress and difficult circumstances, mean that pain may not be as responsive to evidence-based treatments as it is in more familiar groups of patients. This should not deter plans to deliver the highest standard treatments, but is an argument for careful monitoring and comparison with best evidence. Although these patients present in many clinics, there is no clear pathway for management. Few clinics will see or recognise large enough numbers of survivors to develop a specific service for their needs. Language is a significant barrier at both the individual and group treatment level. Management follows the same principles as for any chronic pain condition: a multidisciplinary approach focused on aspects of pain and treatment methods agreed with the patient. Several interventions may be required to run concurrently across the biological, psychological and social domains. There is an opportunity for a more structured and integrated pathway to be developed for this complex patient population. Despite the concerns of healthcare staff about triggering flashbacks or exacerbating distress by use of particular equipment (e.g. electrical), investigations or procedures, with clear explanation (and illustration, often available on websites) of what is involved, and willingness to allow the patient control as far as possible, there is no reason to exclude any procedure. The possible adverse effects of drugs should be described, and understanding checked; for instance, tricyclic antidepressants could be helpful in restoring sleep and treating pain, but the sedating effects may also be unmanageable or intolerable for some survivors. Adherence to drug treatment is often low, for reasons such as inability to afford prescription charges, lack of understanding of what the drug is for, or experience of forcible medication during torture. Multidisciplinary rehabilitation may appear to offer a way to enable a torture survivor with chronic pain to develop more effective methods of self-management, to reduce distress and disability and to improve overall quality of life.5Jaranson J.M. Quiroga J. Evaluating the services of torture rehabilitation programmes.Torture. 2011; 21: 98-140PubMed Google Scholar It can be offered in groups, in individual sessions (more usual where interpreting is required) or mixed. However, treatment trials overall have been very disappointing.17Baird E. Williams A.C.C. Hearn L. Amris K. Interventions for treating persistent pain in survivors of torture.Cochrane Database Syst Rev. 2017; 8: CD012051PubMed Google Scholar,18Brodda Jansen G. Nordemar R. Larsson L. Blyhammar. Abstract: pain rehabilitation for torture survivors.Eur J Pain Suppl. 2011; 5 (S650): 284Crossref Google Scholar This is also the case when treatment methods effective elsewhere are used for survivors of torture with psychological problems, mainly post-traumatic stress symptoms.19Hamid A. Patel N. Williams ACdeC. Psychological, social and welfare interventions for torture survivors: a systematic review and meta-analysis of randomised controlled trials.PLoS Med. 2019; 16e1002919Crossref PubMed Scopus (11) Google Scholar Other systematic reviews are more optimistic.20Tribe R.H. Sendt K.-V. Tracy D.K. A systematic review of psychosocial interventions for adult refugees and asylum seekers.J Ment Health. 2019; 28: 662-676Crossref PubMed Scopus (41) Google Scholar It may be that in both cases, more naturalistic treatments with wider therapeutic aims may be promising.21Bunn M. Goesel C. Kinet M. Group treatment for survivors of torture and severe violence: a literature review.Torture. 2016; 26: 45-66Google Scholar There appear to be some common psychological processes in chronic pain and trauma symptoms, and both may improve with the same treatment, but integrated services designed for this population are very rare. 16Kuehler B. Childs S. One-stop multidisciplinary pain clinic for survivors of torture.Pain Manage. 2016; 6: 415-419Crossref PubMed Scopus (3) Google Scholar,22Rometsch-Ogioun El Sount C. Windthorst P. Denkinger J. et al.Chronic pain in refugees with post-traumatic stress disorder (PTSD): a systematic review on patients' characteristics and interventions.J Psychosom Res. 2019; 118: 83-97Crossref PubMed Scopus (49) Google Scholar As mentioned earlier, torture survivors often face prolonged struggles to obtain permission to stay, to establish a home and social network and to obtain meaningful work, education or training.23Kirmayer L.J. Ban L. Jaranson J. Cultural logics of emotion: implications for understanding torture and its sequelae.Torture. 2017; 27: 84-100PubMed Google Scholar Family and friends left in the country of origin may suffer persecution, and contact may not be possible; without a passport the survivor cannot travel, or travelling may be unsafe. Other survivors may be trying to find lost family members (often through the Red Cross). Life is fragmented, and the hostile environment policy in the UK has made settling even harder.9Legido-Quigley H. Pocock N. Tan S.T. et al.Healthcare is not universal if undocumented migrants are excluded.BMJ. 2019; 366 (i4160)PubMed Google Scholar Support in the form of a letter or phone call from a healthcare professional can help, and should be provided where possible. Torture is proscribed under human rights law and, just as they are obliged to provide asylum, countries are obliged to provide reparation and rehabilitation to torture survivors, but few countries have taken any initiatives towards these. The right to asylum is widely recognised, but in practice is restricted by the requirement to authenticate torture claims to sceptical staff. Healthcare staff has been drawn into this by requirements to check eligibility for treatment of those they believe may not be entitled, and to report those they believe to have suspect political views.9Legido-Quigley H. Pocock N. Tan S.T. et al.Healthcare is not universal if undocumented migrants are excluded.BMJ. 2019; 366 (i4160)PubMed Google Scholar International and national organisations for doctors, nurses and physiotherapists have issued statements concerning the obligation on member professionals to inform themselves on torture, its effects and rehabilitation, as a human rights issue. There are various ways in which this can be realised: engaging with torture survivor community groups (usually charitably funded) for mutual education and liaison; ensuring that there are no invisible barriers to access and that interpreting is available for consultations; discussing with all staff, including those in reception, how to make the pain service more accessible to refugees; and signposting local support services for these complex patients. Treatment should be evaluated, not only for pain relief but for aspects of quality of life, such as social support, community involvement, general health and, of course, distress. As there are so few data on pain treatment of torture survivors, sharing any data is valuable, whatever the outcome. Over time, accumulating data will enable us to ask questions about efficacy more systematically, and to develop our understanding of the effects of torture and interactions of those effects with psychological problems arising from it. Single case methods make data sharing easier.24Morley S.J. Single case methods in clinical psychology: a practical guide. Routledge, Abingdon2018Google Scholar Healthcare staff who are interested in developing their understanding and skills, or improving the situation for torture survivors, can find a range of medical and campaigning organisations online. The authors declare that they have no conflicts of interest.Clinical scenarioMs B is a 27-year-old female who has been referred to your chronic pain clinic by an orthopaedic surgeon because of widespread pain, particularly in her feet. The surgeon found nothing abnormal on assessment including a foot X-ray and bone scan. He offered injections, which she refused, and noting her difficulty sleeping, prescribed amitriptyline 25 mg daily. She arrived in the UK 4 years ago and speaks good English.She is thin, looks tired and walks slowly with an awkward gait. On taking her history you find that she has no family in the UK and is homeless, but is sleeping on the sofa at the flats or houses of people she met through English classes. She has a degree in engineering but is not employed. You ask why she came to the UK, and she replies 'They tried to kill me, and they will kill me if I am sent back.' On further questioning you find that she is appealing against the refusal of her asylum application and is considering suicide rather than being deported from the UK. You indicate your concern, offer her the contact details of a torture survivor organisation and encourage her to seek help and advice there on strengthening her case for asylum.She describes the pain as burning in the soles of her feet, with cramp-like pain in her calves, both worsening with weight-bearing; the burning pain also occurs at night. It started when she was beaten repeatedly on the soles of her feet with cables, then made to stand until she lost consciousness; this happened at least 12 times. When you ask if she was tortured by other methods, she denies it. You make clear that you are appalled: that torture is wrong and that you will try to help her pain. (You do not ask why she was tortured—this is often understood by survivors as asking whether they deserved it.)You explain neuropathic pain to her: although usually persistent it is worth trying to treat; you emphasise that walking does no harm. She seems relieved, and rather hesitantly asks 'so I am not mad?' As pain often triggers flashbacks, she had started to doubt the reality of all her senses.She admits she has not tried the amitriptyline, not understanding why she was prescribed an antidepressant. You explain its use in neuropathic pain, suggesting she starts on a low dose (10 mg), titrating the dose up depending on its effectiveness and adverse effects. You recommend taking the drug in the evening to promote sleep and minimise daytime drowsiness. You think it best to try this before gabapentinoids, because of once-daily dosing and being relatively well tolerated. On review, other neuromodulation medications would be considered as part of the broader biopsychosocial pain management plan. You also offer to refer her to physiotherapy, to see if desensitisation might help, and to psychology, to help with her pain and distress; she seems overwhelmed so you decide to wait and discuss again at the next appointment. Meanwhile, you advise her to try to weight-bear little and often rather than for prolonged periods.As she leaves, she says 'Thank you for believing me.' Ms B is a 27-year-old female who has been referred to your chronic pain clinic by an orthopaedic surgeon because of widespread pain, particularly in her feet. The surgeon found nothing abnormal on assessment including a foot X-ray and bone scan. He offered injections, which she refused, and noting her difficulty sleeping, prescribed amitriptyline 25 mg daily. She arrived in the UK 4 years ago and speaks good English. She is thin, looks tired and walks slowly with an awkward gait. On taking her history you find that she has no family in the UK and is homeless, but is sleeping on the sofa at the flats or houses of people she met through English classes. She has a degree in engineering but is not employed. You ask why she came to the UK, and she replies 'They tried to kill me, and they will kill me if I am sent back.' On further questioning you find that she is appealing against the refusal of her asylum application and is considering suicide rather than being deported from the UK. You indicate your concern, offer her the contact details of a torture survivor organisation and encourage her to seek help and advice there on strengthening her case for asylum. She describes the pain as burning in the soles of her feet, with cramp-like pain in her calves, both worsening with weight-bearing; the burning pain also occurs at night. It started when she was beaten repeatedly on the soles of her feet with cables, then made to stand until she lost consciousness; this happened at least 12 times. When you ask if she was tortured by other methods, she denies it. You make clear that you are appalled: that torture is wrong and that you will try to help her pain. (You do not ask why she was tortured—this is often understood by survivors as asking whether they deserved it.) You explain neuropathic pain to her: although usually persistent it is worth trying to treat; you emphasise that walking does no harm. She seems relieved, and rather hesitantly asks 'so I am not mad?' As pain often triggers flashbacks, she had started to doubt the reality of all her senses. She admits she has not tried the amitriptyline, not understanding why she was prescribed an antidepressant. You explain its use in neuropathic pain, suggesting she starts on a low dose (10 mg), titrating the dose up depending on its effectiveness and adverse effects. You recommend taking the drug in the evening to promote sleep and minimise daytime drowsiness. You think it best to try this before gabapentinoids, because of once-daily dosing and being relatively well tolerated. On review, other neuromodulation medications would be considered as part of the broader biopsychosocial pain management plan. You also offer to refer her to physiotherapy, to see if desensitisation might help, and to psychology, to help with her pain and distress; she seems overwhelmed so you decide to wait and discuss again at the next appointment. Meanwhile, you advise her to try to weight-bear little and often rather than for prolonged periods. As she leaves, she says 'Thank you for believing me.' The associated MCQs (to support CME/CPD activity) will be accessible at www.bjaed.org/cme/home by subscribers to BJA Education. Amanda C. de C Williams PhD CPsychol is a reader in clinical health psychology and consultant clinical psychologist at University College London (UCL), and the Pain Management Centre at UCL Hospitals. She has experience of working with torture survivors in the NHS and in the charitable sector. John Hughes is a consultant in pain medicine with an interest in abdominal and pelvic pain. He has seen a number of patients who are refugees and asylum seekers, some also torture survivors.