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Module 6: Psychological Evidence of Torture and Ill-Treatment
- Answer: E
Detailed psychological evaluations should be included in all medical evaluations for all of the reasons listed.
- Answer: E
All of the items listed are true about psychological sequelae of torture and ill treatment.
- Answer: B
Torture may not only have profound effects on individuals, but on families and society as well. It can terrorize entire populations and create an atmosphere of pervasive fear, terror, inhibition, and hopelessness. It can break or damage the will and coherence of entire communities. It often results in disruptions in family dynamics and may be associated with considerable family dysfunction.
- Answer: E
All of the items listed may explain why survivors of torture and ill treatment may not trust examining clinicians.
- Answer: H
When listening to individuals speak of their torture, clinicians should expect to have personal reactions and emotional responses themselves including avoidance and defensive indifference in reaction to being exposed to disturbing material, disillusionment, helplessness, hopelessness that may lead to symptoms of depression or “vicarious traumatisation,” grandiosity or feeling that one is the last hope for the survivor’s recovery and well-being, feelings of insecurity in one’s professional skills in the face of extreme suffering, guilt over not sharing the torture survivor’s experience, or even anger when the clinician experiences doubt about the truth of the alleged torture history and the individual stands to benefit from an evaluation.
- Answer: B, C, E
According to DSM IV criteria, the diagnosis of PTSD requires that:
A) A person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others; and the person’s response involved intense fear, helplessness, or horror.
B) One or more re-experiencing symptoms are present following the trauma.
C) Three or more avoidance symptoms are present following the trauma.
D) Two or more hyperarousal symptoms are present following the trauma.
E) The duration of symptoms in Criteria B, C, and D) is more than 1 month.
F) The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
- Answer: E
PTSD symptoms commonly occur under all of the circumstances listed above. Anniversary dates and interactions with police or security forces often serve as direct reminders of past traumatic experiences. Recalling traumatic experiences prior to, during, and following a medical evaluation often results in re-traumatisation. In gaining asylum, survivors of torture are often reminded of the loss of family, friends, job, language, etc. and/or may experience feelings of guilt in “abandoning” others who may still be detained.
- Answer: L
Symptoms of Major Depression include all of the symptoms listed above. Depressive states are very common among survivors of torture. Depressive disorders may occur as a single episode or be recurrent. They can be present with or without psychotic features.
- Answer: G
In addition to all of the items listed, other possible diagnoses include: generalized anxiety disorder, panic disorder, acute stress disorder, bipolar disorder, delusional disorder, disorders due to a general medical condition, (possibly in the form of brain impairment with resultant fluctuations or deficits in level of consciousness, orientation, attention, concentration, memory and executive functioning), and phobias such as social phobia and agoraphobia.
- Answer: B
Somatiform disorders manifest as repeated presentations of physical symptoms in the absence of physical findings. If any physical disorders are present, they do not explain the nature and extent of the symptoms or the distress and preoccupation of the patient.
- Answer: A
Neuropsychology has long been recognised as useful in discriminating between neurological and psychological conditions and in guiding treatment and rehabilitation of patients suffering from the consequences of various levels of brain damage. Neuropsychological evaluations of torture survivors are performed infrequently, but may be useful in evaluating individuals suspected of having brain injury and in distinguishing brain injury from PTSD. Neuropsychological assessment may also be used to evaluate specific symptoms, such as problems with memory that occur in PTSD and related disorders.
- Answer: G
All topics listed are components of the mental status examination with the exception of G, cranial nerve assessment.
- Answer: B
Significant psychological symptoms may not be present among survivors of torture for a number of reasons. Clinicians may fail to consider diagnostic possibilities especially if they simply focus on the most common psychological diagnoses. Survivors may not have significant psychological symptoms due to effective coping strategies, social supports and/or a positive meaning assigned to their experiences (i.e. suffering for an important cause). Under such circumstances the reasons for symptom mitigation can and should be explained in the clinician’s medical evaluation.
- Answer: A
The first step in addressing inconsistencies is to ask the individual for further clarification.
- Answer: B
Pre-torture psycho-social information is highly relevant to the interpretation of psychological evidence as it is provides a context for understanding individual behaviour and the meaning assigned to torture experiences.
- Answer: D
The administration of psychological instruments is up the discretion of the examining clinician. There are numerous questionnaires available. Though they may add complementary value to a clinical evaluation, routine use is not recommended. Caution must be exercised in the interpretation of responses and scores because established norms do not exist for many countries. The Istanbul Protocol makes clear that psychological instruments should not be given more weight than the clinical evaluation.
- Answer: A
The clinician should attempt to understand mental suffering in the context of the survivor’s circumstances, beliefs, and cultural norms rather than rush to diagnose and classify. Awareness of culture specific syndromes and native language-bound idioms of distress is of paramount importance for conducting the interview and formulating the clinical impression and conclusion. When the interviewer has little or no knowledge about the alleged victim’s language and culture, the assistance of an interpreter is essential.
- Answer: G
Interpretation of the clinical findings is a complex task. According to the Istanbul Protocol, all of the concerns listed should be included in clinical interpretations of psychological evidence of torture and ill treatment.
- Answer: A
In the course of documenting psychological evidence of torture clinicians are not absolved of their ethical obligations. Those who appear to be in need of further medical and/or psychological care should be referred to appropriate services. Clinicians should be aware of local rehabilitation and support services.
- Answer: F
All of the considerations listed are true about the effects of torture on children.
Answer: E Detailed psychological evaluations should be included in all medical evaluations for all of the reasons listed. Answer: E All of the items listed are true about psychological sequelae of torture and ill treatment. Answer: B Torture may not … Continue reading
Psychological evaluations can provide critical evidence of abuse among torture victims. It has a central role in the medical investigation and documentation of torture allegations. All medical investigations and documentation of torture should include a detailed psychological evaluation because:
- One of the main aims of torture is to destroy the psychological, social integrity and functioning of the victim.
Perpetrators often attempt to justify their acts of torture and ill-treatment by the need to gather information. Such conceptualisations obscure the purpose of torture and its intended consequences. One of the central aims of torture is to reduce an individual to a position of extreme helplessness and distress that can lead to a deterioration of cognitive, emotional and behavioural functions. Torture is a means of attacking the individual’s fundamental modes of psychological and social functioning. The torturer strives not only to incapacitate a victim physically, but also to disintegrate the individual’s personality: The torturer attempts to destroy a victim’s sense of being grounded in a family and society as a human being with dreams, hopes and aspirations for the future.— (IP, §235)
Internationally accepted definitions of torture acknowledge that provoking mental suffering is often the intention of the torturer.
- All kinds of torture inevitably comprise psychological processes.
- Torture often causes psychological/psychiatric symptoms at various levels.
- Torture methods are often designed not to leave physical lesions, and physical methods of torture may result in physical findings that either disappear quickly or lack specificity.
The improvement in the methods of detecting and providing evidence of physical torture has paradoxically led to more sophisticated methods of torture that do not to leave visible evidence on the victim’s body. Most physical symptoms and signs of torture, if there are any, rapidly disappear.
It is important to realise that torturers may attempt to conceal their acts. To avoid physical evidence of torture, precautions are taken with the intention of producing maximal pain and suffering with minimal evidence. Especially under conditions of raised awareness in society, torture applied with these precautions and sophisticated methods may leave almost no physical signs.
Torturers know that by not leaving permanent physical scars, they help their cause and make the work of their counterparts in the human rights arena more difficult. For this reason, in the Istanbul Protocol it is underscored that, “the absence of such physical evidence should not be construed to suggest that torture did not occur.”
- Psychological symptoms are often more prevalent and long-lasting than physical symptoms.
Contrary to the physical effects of torture, the psychological consequences of torture are often more persistent and troublesome than physical disability. Several aspects of psychological functioning may continue to be impaired long-term. If not treated, victims may still suffer from the psychological consequences of torture even months or years following the event, sometimes for life, with varying degrees of severity.
Psychological evaluations can provide critical evidence of abuse among torture victims. It has a central role in the medical investigation and documentation of torture allegations. All medical investigations and documentation of torture should include a detailed psychological evaluation because: One … Continue reading
Psychological evaluations may take place in a variety of settings and contexts; as a result, there are important differences in the manner in which evaluations should be conducted and how symptoms will be interpreted. For example, whether or not certain sensitive questions can be asked safely will depend on the degree to which confidentiality and security can be assured. An evaluation by a clinician visiting a prison or detention centre may be very brief and not allow for as detailed an evaluation as one performed in a clinic or private office that may take place over several sessions and last for several hours. At times some symptoms and behaviours typically viewed as pathological may be viewed as adaptive or predictable, depending on the context. For example, diminished interest in activities, feelings of detachment and estrangement would be understandable findings in a person in solitary confinement. Likewise, hypervigilance and avoidance behaviours may be necessary for those living under threat in repressive societies.
The clinician should attempt to understand mental suffering in the context of the survivor’s circumstances, beliefs, and cultural norms rather than rush to diagnose and classify. Awareness of culture specific syndromes and native language-bound idioms of distress is of paramount importance for conducting the interview and formulating the clinical impression and conclusion. When the interviewer has little or no knowledge about the alleged victim’s language and culture, the assistance of an interpreter is essential. An interpreter from the alleged victim’s country of origin will facilitate an understanding of the language, customs, religious traditions, and other beliefs that will need to be considered during the evaluation.
Clinicians should be aware of the potential emotional reactions that evaluations may elicit in survivors (see Transference and Counter-transference   in Module 3). Fear, shame, rage and guilt are typical reactions. A clinical interview may induce mistrust on the part of the torture survivor and possibly remind him or her of previous interrogations thereby “re-traumatizing” him or her. To reduce the effects of re-traumatisation, the clinician should communicate a sense of empathy and understanding. A torture survivor may suspect the clinician of having voyeuristic and sadistic motivations or may have prejudices towards the clinician because he/she hasn’t been tortured. The clinician is a person in a position of authority and, for that reason, may not be trusted with certain aspects of the trauma history. Alternatively, individuals still in custody may be too trusting in situations where the clinician cannot guarantee that there will be no reprisals for speaking about torture. Torture victims may fear that information that is revealed in the context of an evaluation cannot be safely kept from being accessed by persecuting governments. Fear and mistrust may be particularly strong in cases where physicians or other health workers were participants in the torture. In the context of evaluations conducted for legal purposes, the necessary attention to details and the precise questioning about history is easily perceived as a sign of doubt on the part of the examiner. Under these pressures, survivors may feel overwhelmed with memories and affect or mobilize strong defences such as withdrawal, affective flattening or numbing during evaluations.
As mentioned in Module 3 , if the gender of the clinician and the torturer is the same, the interview situation may be perceived as resembling the torture more than if the genders were different. For example, a woman who was raped and tortured in prison by a male guard is likely to experience more distress, mistrust, and fear when facing a male clinician than she might experience with a female. On the other hand, it may be much more important to the survivor that the interviewer is a physician regardless of gender so as to ask specific medical questions about possible pregnancy, ability to conceive later, and future of sexual relations between spouses.
When listening to individuals speak of their torture, clinicians should expect to have personal reactions and emotional responses themselves (see Transference and Counter-transference   in Module 3). Understanding these personal reactions is crucial because they can have an impact on one’s ability to evaluate and address the physical and psychological consequences of torture. Reactions may include avoidance and defensive indifference in reaction to being exposed to disturbing material, disillusionment, helplessness, hopelessness that may lead to symptoms of depression or “vicarious traumatisation,” grandiosity or feeling that one is the last hope for the survivor’s recovery and well-being, feelings of insecurity in one’s professional skills in the face of extreme suffering, guilt over not sharing the torture survivor’s experience, or even anger when the clinician experiences doubt about the truth of the alleged torture history and the individual stands to benefit from an evaluation.
Psychological evaluations may take place in a variety of settings and contexts; as a result, there are important differences in the manner in which evaluations should be conducted and how symptoms will be interpreted. For example, whether or not certain … Continue reading
Torture can affect a child directly or indirectly. The impact can be due to the child having been tortured or detained, the torture of his/her parents or close family member or the witnessing of torture and violence. When individuals in a child’s environment are tortured, the torture will inevitably have an impact on the child, albeit indirectly, because torture affects the entire family and community of torture victims. A thorough discussion of the psychological impact of torture on children and complete guidelines for conducting an evaluation of a child who has been tortured is beyond the scope of this Manual. Nevertheless, several important points can be summarised.
First, when evaluating a child who is suspected of having undergone or witnessed torture, the clinician must make sure that the child receives support from caring individuals and that he/she feels secure during the evaluation. This may require a parent or trusted care provider to be present during the evaluation. Second, the clinician must keep in mind that children often do not express their thoughts and emotions regarding trauma verbally, but rather behaviourally. The degree to which a child is able to verbalize thought and affect depends on his/her age and developmental level as well as on other factors, such as family dynamics, personality characteristics and cultural norms.
If a child has been physically or sexually assaulted, it is important, if at all possible, for the child to be seen by an expert in child abuse. Genital examination of children, likely to be experienced as traumatic, should be performed by clinicians experienced in interpreting the findings. Sometimes it is appropriate to videotape the examination so that other experts can give opinions on the physical findings without the child having to be examined again. It may not be appropriate to perform a full genital or anal examination without a general anaesthetic. Furthermore, the examiner should be aware that the examination itself may be reminiscent of the assault, and it is possible that the child may make a spontaneous outcry or psychologically decompensate during the examination.
Torture can affect a child directly or indirectly. The impact can be due to the child having been tortured or detained, the torture of his/her parents or close family member or the witnessing of torture and violence. When individuals in … Continue reading
(based on an asylum evaluation conducted by Dr. Kathleen Allden, M.D. in November 2000, Boston, MA, USA)
I. Case Information
Name: Mr. __
Birth Date: x/xx/68
Birth Place: __
Clinician’s Name: Kathleen Allden, MD
Dates of Evaluation: August 23, 2000 (2 hours), September 6, 2000 (1 hour), September 13, 2000 (2 hours)
Interpreter: Not needed as client speaks English
Exam Requested by: Attorney Jane Doe
Subject Accompanied by: Attorney Jane Doe (first appointment only)
II. Clinician’s Qualifications [deleted]
Attached is my curriculum vitae.
I have personally examined this individual and have examined the facts recited in this written report. I believe all statements to be true. I would be prepared to testify to these statements based on my personal knowledge and belief.
III. Psychological / Psychiatric Evaluation
Mr. __ is a 35 year old married man from [country A]. He came to the United States seeking asylum in February 2000. His wife and three children, ages 14, 10 and 5 years, are in a refugee camp in [country B], along with his mother and sister.
Summary of Collateral Sources
Draft Application for Asylum and Withholding of Removal supplied by his attorneys
Methods of Assessment Utilized
History of Torture and Ill-treatment
Mr. __ reports that he came to the United States in February 2000. He is seeking asylum because he feels it is not safe for him to return to [country A]. He says that in 1990 he was at his parents’ home when __ rebel forces attacked the house. He believes that his family was targeted because of his father’s job in the government, and because they are of the __ ethnic group. He was at home with his father, mother and sister when the house was attacked. Mr. __ and his family were taken to a rebel camp. He reports that the rebels forced him to hold his sister down while they gang raped her. Also, he was forced to watch as rebels tortured his father and cut off his limbs one at a time. He reports he was forced at gunpoint to hold his father down while they did this. He believes the rebels killed his father because at the time he was an officer in the government.
After a period of time, his mother and sister were able to leave the camp but Mr. __ says he was taken to another camp where he was burned and cut on the right arm and put in a pit. While in pit, the rebels urinated on him, threw dirty water on him and beat him. He remained in the pit for a long period of time. Conditions were filthy in the pit and his right arm became very infected. Mr. __ recalls becoming ill and coughing up brown sputum. While he was still in the pit, [country A] soldiers overtook the camp and freed him. He said that they could tell that he was not one of the __ rebel forces soldiers because it was obvious that he had been severely mistreated by them. For this reason, his life was spared at that time. He reports then being taken to the border where he escaped to [country B] and was able to reunite with his mother and sister.
During the years 1990-96, Mr. __ reports that there were many factions fighting in [country A]. He did not go back to [country A] until 1996 when there was a cease-fire. He went to check on the family’s property but found that the family’s house had been burned. He remained in [country A] where he participated in the presidential campaign of __, and was physically beaten by opposing political forces that were on the same side that had originally attacked his home and killed his father. The soldiers took him to a prison. Mr. __ and his family are members of the __ tribe. He reports that he and other __ tribe prisoners were taken away to the forest to be killed. The soldiers shot at the group of prisoners as the prisoners ran away. An unknown number were killed but Mr. __ escaped.
He went to live in barracks in an area where other __ tribe people were staying because they felt they might be safe there. In 1998, when __ rebel forces attacked this area, many people were killed. Soldiers attempted to arrest Mr. __. He believed they would take him away and kill him. He managed to escape and ran to __ peacekeeping base where other __ tribe people as well as other civilians had fled. __ peacekeeping base personnel helped Mr. __ and others flee the country by arranging for flights from an airbase. Mr. __ was flown to [country B] where he joined his mother and sister in a refugee camp.
In describing these events, Mr. __ reports that he witnessed many horrible atrocities. He said he saw soldiers ask people if they wanted a “long sleeve” or a “short sleeve” and then would chop off the arm accordingly. He also saw soldiers kill infants by bashing their heads until the brains came out. He reports seeing a group of children thrown in a well to die. While describing these experiences he said he felt ashamed to be telling me about these events. He said he felt ashamed of what had happened in his country and in other nearby countries such as [country C]. He said of the war and violence that he has experienced and witnessed, “It’s part of me now.” He describes feeling permanently changed, altered by these terrible things.
Current Psychological Complaints
Mr. __ reports that when he first arrived in the United States he was afraid to go out of the house. He lives with friends who reassured him that the United States is not like [country A] and that people are safe when they go out of their houses. He felt he might be attacked if he went out. With his friends’ encouragement, he gradually tried going out of the house and now is able to travel without significant difficulty. He has learned how to use public transportation and feels comfortable enough to use the bus.
He describes other symptoms and fears that were particularly bothersome when he first arrived in the United States but that have gradually diminished. For example, he would sleep in his clothes. He did this because in the past he felt he always had to be ready to run, ready to escape. When he came here he continued this habit until, gradually with friends’ encouragement, he was able to undress for sleep. He reports previously having difficulty falling asleep and staying asleep. He says that now he is able to sleep several hours per night but that he has nightmares of terrible past experiences during the war. His sleep disturbance and the frequency of his nightmares have improved slowly over the months since his arrival in the United States. He describes experiencing intrusive memories of the past and finds that he constantly worries about what would happen if he were sent back to [country A]. He describes being very sensitive to loud sounds and easily startled. During July 4 celebrations this summer, neighbor children were lighting firecrackers. This caused him to be very fearful and anxious as it reminded him of being in the war. His nightmares also worsened during that time period.
Mr. __ reports avoiding being reminded of the war and violence that he has experienced. For example, he avoids speaking about it. He also avoids television programmes that have violent scenes, or reports and news clips about war in [country C]. He says he avoids becoming angry or annoyed. He says he knows what people can do when they lose control and act on their anger. He says he tries to keep himself numb. He offers the example that if someone slapped him on the face, he would not feel it because he would be numb. He describes trying to push bad memories out of his mind and trying to distance himself from the past. He avoids going out on the street or in public and tries to stay indoors away from people he does not know. He says it is hard for him to see injustice or someone being mistreated. Because he becomes very angry when he witnesses injustices, he keeps himself isolated in order not to be exposed to situations that would anger him. He also feels that the cultural differences between the United States and his home are many and it is hard for him to cope with the differences. He says he only wants to be around people who encourage him and reassure him that things will turn out all right in the long run.
He worries about his family living as refugees in [country B]. His main goals are to bring his wife and children here and to work to send money to his mother and sister. (He has been told he will not be able to bring his mother and sister to the United States.) He says that having these goals helps him survive. He says that now that his father is dead it is his responsibility to look after the needs of his mother and the rest of the family. If it were not for these responsibilities, Mr. __ says he would prefer to be dead. He says he has seen too much suffering and cruelty. The past seems like a dream, the happy times in the past seem unreal. Although he contemplates suicide, he says all is not lost because if he is granted asylum, he may be able to bring his wife children to the United States so they can have a better future. He does not have confidence that there will be peace in his country for a long time.
Mr. __ says that his religious beliefs help him cope with his life. He reads the Bible every day. He speaks of his devotion to Jesus Christ and his faith in God.
Mr. __ was a refugee in [country B] before coming to the United States. He said that life in [country B] is very harsh. Food is scare, infectious diseases are common, and it is very hard to make a living. Also, people in the region do not trust people from [country A], according to Mr. __, fearing they are members of rebel groups. His family encouraged him to leave __ and go to the United States. He traveled to the United States via [country A] with the assistance of a close friend of the family. His mother, sister, wife and children are living in [country B] in a refugee camp. Currently, Mr. __ lives with friends in Massachusetts. He feels welcomed and supported by them. He has been staying with these friends since his arrival in the United States. His hosts are friends of his late father. Mr. __ does not work because he is not legally permitted to work. He feels he is able to work and he would like to work in order to earn money for his family.
Family history: Mr. __ is one of two siblings; he has one sister. He grew up in the home of his mother and father, who were Baptists. His father was a government official in the former government. According to Mr. __, his father was able to earn a good living and the family was well provided for. Mr. __ met his wife when they were both in school; they were married around 1985. After they were married they lived with Mr. __’s parents. They have three children ages 14, 10, and 5. He describes a happy childhood and family life until the time that war broke out in his country in 1990.
Educational history: Mr. __ reports he has a high school education and completed a junior college programme in computer science.
Occupational history: Mr. __ is trained in computer science. He has not practiced that profession. While a refugee in [country A], he supported his family as a vendor.
Cultural and religious background: Mr. __ was raised as a Baptist and continues to practice his religion in the United States. He is from the __ tribe.
Prior to the war, Mr. __’s had several episodes of malaria. Otherwise his health was good. During the time he was kept in the pit he developed a severe respiratory illness which he describes as bronchitis with a productive cough and vomiting that required long-term treatment with antibiotics after he was finally released. He says he still has right-sided chest pain and that when he takes a deep breath, he hears wheezes in his chest. He still coughs up phlegm. His chest pain is worse during rainy weather. Also, he complains of right arm pain where his arm was cut by his torturers. He has not had a physical exam since coming to the United States.
Past Psychiatric History
There is no past history of mental illness.
Substance Use and Abuse History
Prior to coming to the United States, Mr. __ reports that he had great difficulty falling asleep. He would drink alcohol to help fall asleep. He does not do this now. He denies using illicit drugs.
Mental Status Examination
- General appearance – Mr. __ is a neatly dressed man who was very polite and cooperative during the interviews. He was clearly distressed by having to retell his history of trauma. He was tearful and moderately agitated especially during our first meeting.
- Motor activity – No obvious psychomotor retardation. He was somewhat agitated and frustrated at times but able to tolerate the long interviews.
- Speech – His English is fluent but his accent is very heavy and I had difficulty understanding him at times. His speech was logical and goal directed. He was able to express his emotions and ideas very well.
- Mood and affect – Frequently during the interviews, he was clearly overwhelmed with feelings of loss and sadness. He also expressed horror at witnessing extreme cruelty and violence. He appeared frustrated at not being able to communicate to me how extremely awful the atrocities that he witnessed were. His affect was labile. He was often tearful. He was able to smile on occasion.
- Thought content – His thoughts centered on two main themes, his worries for his family and the horrors he has witnessed and experienced. These worries and memories seem to occupy his thought much of the time.
- Thought process – There is no evidence of paranoia, delusions, referential ideation or other disturbance of thought. There is no evidence of hallucinations.
- Suicidal and homicidal ideation – There is no evidence of homicidal ideation but he has thoughts of suicide. He says that he would prefer to be dead and that the only reason that he stays alive is that his family is his responsibility and he hopes to be able to help them have a better life.
- Cognitive exam – He is oriented and alert. He gives the proper date and place. He does not seem to have difficulty with long term recall but admits that giving precise dates of events is very hard for him. His immediate recall is impaired as evidenced by is ability to recall only 4 of 6 digits when asked to do so. His intermediate recall is similarly impaired as evidenced by his ability to recall only 2 of 3 objects that he is asked to recall after a 3-minute time lapse. His overall global cognitive function may also be impaired as evidenced by is inability to spell a five-letter word backwards.
Clinical Impression (Interpretation of Findings)
Conclusion and Recommendations
(based on an asylum evaluation conducted by Dr. Kathleen Allden, M.D. in November 2000, Boston, MA, USA) I. Case Information Name: Mr. __ Birth Date: x/xx/68 Birth Place: __ Gender: male Clinician’s Name: Kathleen Allden, MD Dates of Evaluation: August … Continue reading
It is prudent for clinicians to become familiar with the most commonly diagnosed disorders among trauma and torture survivors and to understand that it is not uncommon for more than one mental disorder to be present as there is considerable co-morbidity among trauma-related mental disorders. The two most common classification systems are the International Statistical Classification of Diseases and Health Related Problems (ICD-10) Classification of Mental and Behavioural Disorders and the Diagnostic and Statistical Manual of the American Psychiatric Association-Edition IV (DSM-IV). Non-mental health clinicians such as internists and general practitioners who perform evaluations of torture survivors should be familiar with the common psychological responses to torture and be able to describe their clinical findings. They should be prepared to offer a psychiatric diagnosis if the case is not complicated. A psychiatrist or psychologist skilled in the differential diagnosis of mental disorders related to severe trauma will be needed for particularly emotional individuals, cases involving multiple symptoms or atypical symptom complexes, psychosis, or in cases presenting confusing clinical pictures.
It is important to note that the association between torture and both PTSD and depression has become very strong in the minds of health providers, immigration courts and the informed lay public. This has created the mistaken and simplistic impression that PTSD and depression are the main psychological consequences of torture. Torture-related mental disorders are not limited to depression and PTSD and evaluators must have comprehensive knowledge of the most frequent diagnostic classifications among trauma and torture survivors. In this sense, a detailed evaluation is always very important. Overemphasising PTSD and depression criteria might result in missing other possible diagnoses and reinforcing the simplistic notion that the psychological evidence of torture can be reduced to the presence or absence of PTSD and depression. A wide range of diagnostic considerations are provided below and ICD-10 diagnostic criteria are included in the Appendix II at the end of this Module.
The diagnosis most commonly associated with torture is Post-traumatic stress disorder (PTSD). Typical symptoms of PTSD include re-experiencing the trauma, avoidance and emotional numbing, and hyperarousal. Re-experiencing can take several forms: intrusive memories, flashbacks (the subjective sense that the traumatic event is happening all over again), recurrent nightmares, and distress at exposure to cues that symbolize or resemble the trauma. Avoidance and emotional numbing include avoidance of thoughts, conversations, activities, places or people that arouse recollection of the trauma, feelings of detachment and estrangement from others, inability to recall an important aspect of the trauma, and a foreshortened sense of the future. Symptoms of hyperarousal include difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, hypervigilance, and exaggerated startle response.
Depressive states are very common among survivors of torture. Depressive disorders may occur as a single episode or be recurrent. They can present with or without psychotic features. Symptoms of Major Depression include depressed mood, anhedonia (markedly diminished interest or pleasure in activities), appetite disturbance, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue and loss of energy, feelings of worthlessness and excessive guilt, difficulty concentrating, and thoughts of death, suicidal ideation, or suicide attempts.
A survivor of severe trauma such as torture may experience dissociation or depersonalisation. Dissociation is a disruption in the integration of consciousness, self-perception, memory and actions. A person may be cut off or unaware of certain actions or may feel split in two and feel as if observing him or herself from a distance. Depersonalisation is feeling detached from oneself or one’s body.
Somatic symptoms such as pain and headache and other physical complaints, with or without objective findings, are common problems among torture victims. Pain may shift in location and vary in intensity. Somatic symptoms can be directly due to physical consequences of torture, be of psychological origin, or both. Also, various types of sexual dysfunction are not uncommon among survivors of torture particularly, but not exclusively, among those who have suffered sexual torture or rape.
Psychotic symptoms may be present such as delusions, paranoia, hallucinations (auditory, visual, olfactory or tactile), bizarre ideation, illusions or perceptual distortions. Cultural and linguistic differences may be confused with psychotic symptoms. Before labelling someone as psychotic, one must evaluate the symptoms within the individual’s cultural context. Psychotic reactions may be brief or prolonged. It is not uncommon for torture victims to report occasionally hearing screams, his or her name being called, or seeing shadows, but not have florid signs or symptoms of psychosis. Individuals with a past history of mental illness such as bipolar disorder, recurrent major depression with psychotic features, schizophrenia and schizoaffective disorder may experience an episode of that disorder. .
The ICD-10 includes the diagnosis “Enduring Personality Change.” PTSD may precede this type of personality change. To make the ICD-10 diagnosis of enduring personality change, the following criteria must have been present for at least two years and must not have existed prior to the traumatic event or events. These criteria are: hostile or distrustful attitude towards the world, social withdrawal, feelings of emptiness or hopelessness, chronic feelings of “being on edge” as if constantly threatened, and estrangement.
Alcohol and drug abuse may develop secondarily in torture survivors as a way of blocking out traumatic memories, regulating affect and managing anxiety. Other possible diagnoses include: generalized anxiety disorder, panic disorder, acute stress disorder, somatoform disorders, bipolar disorder, delusional disorder, disorders due to a general medical condition, (possibly in the form of brain impairment with resultant fluctuations or deficits in level of consciousness, orientation, attention, concentration, memory and executive functioning), and phobias such as social phobia and agoraphobia.
 American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th edition). Washington, DC:APA.
 World Health Organisation, (1994). The ICD-10 Classification of mental and behavioural disorders and diagnostic guidelines. Geneva.
It is prudent for clinicians to become familiar with the most commonly diagnosed disorders among trauma and torture survivors and to understand that it is not uncommon for more than one mental disorder to be present as there is considerable … Continue reading
A child’s reactions to torture depend on age, developmental stage and cognitive skills. The younger the child, the more his/her experience and understanding of the traumatic event is influenced by the immediate reactions and attitudes of caregivers following the event. For children under the age of three who have experienced or witnessed torture, the protective and reassuring role of their caregivers is crucial. Very young children’s reactions to traumatic experiences typically involve hyperarousal, such as restlessness, sleep disturbance, irritability, heightened startle reactions and avoidance. Children over three often tend to withdraw and refuse to speak directly about traumatic experiences. The ability for verbal expression increases during development. A marked increase occurs around the concrete operational stage (8-9 years old), when children develop the ability to provide a reliable chronology of events. During this stage, concrete operations and temporal and spatial capacities develop. These new skills are still fragile and it is usually not until the beginning of the formal operational stage (12 years old) that children are consistently able to construct a coherent narrative. Adolescence is a turbulent developmental period. The effects of torture can vary widely. Torture experiences may cause profound personality changes in adolescents, resulting in antisocial behaviour. Alternatively, the effects of torture on adolescents may be similar to those seen in younger children.
A child’s reactions to torture depend on age, developmental stage and cognitive skills. The younger the child, the more his/her experience and understanding of the traumatic event is influenced by the immediate reactions and attitudes of caregivers following the event. … Continue reading
(based on an asylum evaluation conducted by Dr. Uwe Jacobs, Ph.D. on May 8 2001, San Francisco, CA, USA)
Conditions of Interview
Prior to this psychological evaluation, Mr. Doe and his client agreed to the condition that I approach the assessment with no particular result in mind and that I would exercise independent professional judgment on all aspects of this evaluation. Further, the payment of fees would not be connected to the contents of any report or consultation or any particular finding or recommendation on the matter in question.
Prior to commencing the interview, I informed Mr. __ that confidentiality is limited in a forensic psychological examination. I further informed him that I would discuss my findings with his attorney and write a report that his attorney could submit as evidence to the court if deemed helpful. He indicated that he understood my role to be that of an objective evaluator and that a forensic evaluation was not psychological treatment. I further informed Mr. __ that I had reviewed the asylum declaration prepared by his attorney and that I would be reviewing the entire history with him once more.
I interviewed Mr. __ on 4/27/01 for a total of about 5 hours face-to-face at the offices of Survivors International, San Francisco. In addition, I administered the Hopkins Checklist-25 (HCL-25), the Trauma Symptom Inventory (TSI), and the Harvard Trauma Questionnaire (HTQ). Present for the evaluation were Mr. __, myself, Ms. Erika Falk (Survivors International Intake Coordinator and Psy.D. candidate), and Mr. __, who functioned as interpreter and provided limited collateral information where indicated. Prior to the interview, I reviewed the following history and background information which was provided by Mr. __ during the face-to-face interview.
Mr. __ was born and raised in __, a little village near __ in Region __ of __. His date of birth on all records has been 5/6/71. However, he states that this date of birth was registered falsely and that he is approximately three years younger. He cannot state his exact and true date of birth and has always used the one given to him. His father registered his sons as older so that they would be done with the compulsory military service sooner and “begin life earlier”. He adds that this was common practice in his geographical area. Mr. __ is the youngest of six children and spent the later part of his childhood alone with his parents after his siblings had all moved away to __. He completed five years of compulsory formal education and was working on his father’s farm from a young age. He briefly stayed with a relative to start a secondary education about 100 km away from his village, but soon returned home to work on the farm.
Mr. __ describes his early family life as harmonious and states that his father was generally more lenient and loving than most fathers. His mother was a homemaker and took care of the household and family. He states that he does not have a very clear memory of his childhood overall, except that he was always working and that his only pastime was riding horses. When he was about 15, the family moved to __, near __. His father had a job as a night watchman and he worked as an apprentice in welding. The interpreter adds here that child labor is illegal in __ but rather commonly practiced.
When asked about the reason for the family’s move, __ states that most of the other 300 families of the village had already left because of the increased clashes between the army and the guerilla army __. He also states that he does not remember seeing any of this activity himself, and that the older people in the village discussed it. Mr. __ does not describe a strong identification with his ethnic __ background and states that he gradually lost a lot of the __ language he spoke as a young child. In addition, he says that he did not grow up with a sense of tension between the ethnic __s and other groups in his village and that some families spoke __ language, others spoke the language of the majority, and yet others spoke dialects he could not understand.
Mr. __ was drafted into the army approximately three years following the family’s move to __. He was sent for basic training to __, which lasted 3 months. Subsequently, he was sent to become a member of a commando unit that fought the guerilla army __ in the __ region. He states that this was the worst experience he had ever had. He was involved in an estimated 10-15 battles, at times being forced to shoot at targets he could not even see. He had to spend long periods of time in the mountains, in both summer and winter, and suffered from constant sleep deprivation and poor nutrition. He saw comrades wounded and killed. One friend who was from a village near his own was mortally wounded in one of the clashes. He helped dispose of his body when the fighting had ceased. When asked about having suffered any differential treatment because of his ethnic __ identity, he states that he often heard rumors about ill-treatment but did not experience it directly, except for the constant derogatory remarks that were made about the “illiterate” ethnic __s. He says that he felt hurt inside by this, but that in the army one has to do what one is told. When asked about his feelings regarding fighting people of his own ethnic group, he became very gloomy and refused to discuss this further. When asked why, he simply stated that there are things in life that are better not discussed.
Due to his active combat duty, Mr. __ was released after 15 months of service instead of the usual 18 months. After returning to __, he stayed at home for the first two months and felt like he literally could not move. He had difficulty breathing, experienced chest pains, thought he was dying, and never went out for fear of falling down and passing out and being publicly embarrassed. He went to see a physician, who gave him a prescription and advised him to go out and try to do things he finds enjoyable. He states that the pills did not make him feel any better, but rather made him feel even emptier inside, so he discontinued taking them. However, he did follow the doctor’s advice, started going out, began to feel better, and eventually met the woman who later became his wife.
Mr. __ explained that he was discovered as a musical talent by his teacher in elementary school and has always been a singer. He met his wife while singing at a wedding in 1994-1995. He began his singing career mostly by singing at weddings but increasingly got more work, gave some concerts, and made a couple of recordings as well. He states that he was doing well financially because he kept his welding job and made as much money from singing as he made at welding. During this time, he increased his repertoire of ethnic __ folksongs, which he learned from colleagues who were more familiar with the language and culture than he was.
On May 21, 1995, Mr. __ had been invited by a production company to perform in a concert for the traditional ethnic __ coming of spring celebration. This was an important event for him, as he expected more and better work as a result of this appearance. He was performing together with a female ethnic __ musician by the name of Ms. __. While performing ethnic __ songs they were interrupted by two policemen who jumped onto the stage, separated them, and pushed them into the background, saying things like “Don’t you know you’re not supposed to sing in ethnic __ language?” and “Why are you provoking this audience?” The crowd booed the officers. Mr. __ and Ms. __ were arrested and taken to the police station separately and kept separated upon arrival at the police station. Mr. __ was detained for about 12 hours. His possessions were taken from him and returned upon release. During this explanation, Mr. __ looked around the interview room and stated that his holding cell had been similar in size but the windows were smaller, the walls were white, and there was no clock that he could see.
Mr. __ was forced to sit in the same chair for 12 hours and was not allowed to use the restroom when he requested to use it. The officer let him use the restroom about 1-2 hours after he had asked. Mr. __ asked to make a phone call and was denied. He was denied water and cigarettes. He was constantly talked at for the entire time he was there, being told over and over that he was not supposed to sing in ethnic __ language. He was interrogated about who had organized the event. When asked about his feelings, he stated that he was feeling very irritated in recounting this event, that his visual recollection was vague but felt very real at the same time. When asked, Mr. __ stated that he still has a newspaper clipping in his possession from this event, the headline of which reads something like “Local Artist Arrested”.
Regarding his later arrests, Mr. __ states that he does not remember precise dates but only the seasons and years. It was difficult to ascertain these dates during the rest of the interview, as Mr. __ was not telling the story chronologically as he described events and there were a few misunderstandings. There might therefore be some discrepancies between the dates identified in this report and those specified other documentation.
In 1996 there was at least one incident of police harassment in connection with Mr. __’s involvement with a musician’s association that helped artists get engagements and allowed them to learn from each other. The organisation’s founder is named __. Policemen visited Mr. __ at home on one occasion while he was playing with his child. The doorbell rang and he asked his wife to open the door. Two policemen charged in, insulted him in front of his wife, a fact about which he is particularly bitter, and threatened to beat him up. He was interrogated about the purpose of the musicians’ organisation and a large record collection and scores of regional folk music were confiscated.
Another incident occurred in 1997 while Mr. __ was singing for a group of striking workers at the factory where he had once worked. The strike and the performace had been organized by a labor union. He was accompanied by drums and reed instruments. When he and his friend Mr. __, with whom he had worked at the factory for some time, left the factory, the police stopped them within a block, checked their ID’s, and took them to the police station. They were separated from each other and Mr. __ was interrogated. The police accused them of being members of the __ party, which is an underground organisation and apparently stands for __ __ __, an organisation Mr. __ had never heard of. The police told him they knew who they were and threatened that if he did not tell them about his friend Mr. __, they would electrocute his genitals and he would be impotent for the rest of his life. They also threatened that he might not ever see his wife and children again.
At this point in the interview, the interpreter adds that Mr. __ had instructed him not to translate the part about the electrocution of his genitals. I asked him to inform Mr. __ that he had done so, which resulted in an angry face and disgusted gesture on Mr. __’s part. I then reminded him that this was also detailed in his declaration and the interpreter stated that when he had helped prepare the declaration Mr. __ had also requested that it not be translated. However, the interpreter was advised by the attorney that these details were important.
Mr. __ went on to say he was not, in fact, electrocuted but that the officer repeatedly twisted his arm and frequently hit him on his chin with the palm of his hand, which may not seem very bad now but was very uncomfortable at the time (he gestured to demonstrate the way he was hit). He was so uncomfortable that he considered making up a story about his friend Mr. __ in order to get away but did not. He was also pushed around and detained for close to 24 hours. After his release, he never saw his friend Mr. __ again. Mr. __ says that he feels ashamed of this now, but he never inquired about his friend because he was scared by the threat of electrocution and feared for the future of his child and his wife, who was pregnant with their second child at the time.
In 1998 a similar incident occurred in which two officers reportedly came to his apartment and took him to the police station. On this occasion, Mr. __ was interrogated about an artist named __ and other members of the musician’s association. The officers harassed him by saying things like, “Don’t you know that the __ flag is only __ and __ colors?” Officers twisted his arm, pushed him around and told him to shut up. Mr. __ describes this as “sort of harmless”, i.e., it did not result in injury, but says that he felt very afraid at the time. Mr. __’s colleagues later told him that they were detained and interrogated about him in similar fashion.
The latest event that prompted Mr. __’s decision to leave the country is one that was not listed in the declaration that was made available to me and seemed to arise almost by accident. Mr. __ did not seem to want to discuss this event, even though it is a crucial piece of his persecution history. He added that he still sees this event vividly and that he felt very uncomfortable discussing it. One night after walking home from one of his wedding engagements, he was suddenly attacked, had a sack put over his head and upper body, and was beaten up and repeatedly kicked. He was carrying money but nothing was stolen from him. After he was left in the street, he found that his nose was bleeding. He sustained no lasting injuries but had aches and pains that lasted for days. He did not want to face his wife in this condition so he went to a public restroom in a religious compound and cleaned himself. He decided to return home much later, around 3-4 a.m., and he did not tell his wife the details of this event. He did tell his brother-in-law, however, who advised him to “leave now”, and suggested fleeing to either Germany or the United States. Mr. __ added that even Romania seemed an alternative, but the brother-in-law opined that the United States was good and that the people there appreciated music. Earlier, Mr. __ had stated that he never wanted to come to the United States in the first place but that his brother (by whom he meant his brother-in-law) had made him come.
Mr. __ states that he had no idea what political asylum meant when he arrived and that he learned of this only through his conversations with his translator, a man whom he had met at a local restaurant and to whom he had opened up about his experiences over time.
Mr. __ denied any significant medical history apart from the psychiatric history following his combat experiences as described above and the presence of headaches in conjunction with his current psychological state. He uses over the counter medication for these headaches in low-moderate dosage and frequency. He described himself as generally healthy and denied any history of surgeries and accidents.
The following conclusions are drawn from the individual interview of Mr. __ and psychological testing (HCL-25, TSI, HTQ).
Behavioural Observations/Mental Status Exam:
Mr. __ appeared on time for the interview and was appropriately dressed and groomed, looking his stated age. He was alert, fully oriented, pleasant and cooperative throughout the evaluation. There were no gross abnormalities in movement or posture on observation. Sensory functions and motor functions appeared to be intact. He appeared to possess high average intellectual ability, with good insight and judgment, although he was not well educated by Western standards. He became distressed when discussing particular events and admitted to feeling irritable while discussing sensitive details. Speech appeared clear and fluent, and there was no evidence of delusions, hallucinations or psychotic thought processes. Remote memory was intact. Attention appeared intact. Concentration and working memory could not be formally assessed but Mr. __ reported that they were impaired. Mood was depressed and affect was constricted. There was no evidence of suicidal or homicidal ideation.
Mr. __ obtained a psychological profile on the TSI and HTQ that is highly suggestive of Posttraumatic Stress Disorder. Validity indicators suggest that he answered test items in a straightforward and internally consistent manner. There was no sign of dissimulation and results were valid for interpretation. Mr. __ reports the following psychiatric symptomatology:
- Persistent Reexperiencing of Traumatic Events and Avoidance Behaviour: Mr. __ evinced intermittent distress while recounting traumatic events as well as profound discomfort while discussing relevant details, particularly in relation to experiences he considered embarrassing according to his cultural norms. His discomfort was also a reaction to the fact that he was experiencing an active, intrusive recall of events, especially in relation to the last assault he suffered before leaving the country. He reported nightmares from which he awakens in a sweat. The content of his dreams includes trauma-related material to varying degrees, but usually not precise repetitions of actual events.
- Persistent Symptoms of Increased Arousal: Mr. __ suffers from poor sleep throughout the night and wakes up frequently. He states that this continues to be quite a problem, even though it has improved since he first arrived in the United States. He also startles easily, jumping in response to any kind of sudden noise. He feels that his concentration is impaired. He describes wandering through the city and not being able to find a major street, even though he has been there many times. He cannot concentrate on reading, even on familiar subjects in his national language. He has wanted to learn English but has had great trouble studying. Rather than studying from books, he has now begun to use tapes.
- Dissociative Symptoms: Mr. __’s most frequently cited complaint is that his mind “goes blank” for minutes at a time. He finds it rather distressing to have this symptom; he feels that at times his mind is so empty that he feels he is going crazy. He then also has faint auditory illusions, for example the repeated experience of hearing a whistle when no one is whistling. He states that he hates that experience.
- Somatic Complaints and Anxiety Symptoms: Mr. __ has a history of panic and anxiety symptoms dating back to his discharge from the military. The symptomatology described in terms of chest pains, shortness of breath, thoughts of death and dying and not leaving home for fear of fainting and embarrassing himself in public, constituted a diagnosis of Panic Disorder with Agoraphobia. This condition remitted without major treatment and on the advice of his physician to overcome his avoidance behaviour. Subsequent to the later events of persecution, these elements of panic disorder have reoccurred. Mr. __ frequently feels a lump in his throat, experiences shortness of breath and tingling and numbing sensations from his chest down through his extremities. He also suffers from frequent tension headaches that respond well to over-the-counter medicine.
Clinical Impression (Interpretation of Findings)
Conclusion and Recommendations
(based on an asylum evaluation conducted by Dr. Uwe Jacobs, Ph.D. on May 8 2001, San Francisco, CA, USA) Conditions of Interview Prior to this psychological evaluation, Mr. Doe and his client agreed to the condition that I approach the … Continue reading
The psychological evaluation starts at the beginning of the interview, with the very first contact. The individual’s overall appearance and manner of dress, posture, the manner of recalling and recounting the trauma, signs of anxiety or emotional distress, numbness or over-excitement, moments of emotional intensity, startled responses, posture and bodily expression while relating the events of torture, avoidance of eye contact, and emotional fluctuations in his/her voice can give important clues about the personal history and psychological functioning of an individual. Not only the verbal content of the examinee (what he/she says), but also his/her manner of speaking (how he/she says it) are important for the psychological evaluation. The individual may have difficulties in recollecting and recounting what s/he experienced or in talking about his/her complaints. Therefore, non-verbal communication may provide important information about his/her symptoms, as well as some clues for establishing and maintaining an effective relationship that allows the interviewer to elicit relevant information.
The psychological evaluation should provide a detailed description of the individual’s history, a mental status examination, an assessment of social functioning, and a formulation of clinical impressions/opinions. The impact of the symptoms on daily life can be highly relevant for forensic procedures or questions of compensation in torture cases. If appropriate, a psychiatric diagnosis should be given.
The components of psychological/psychiatric evaluation are as follows:
- Individual’s name, age, ethnicity, country of origin, marital status, number of children
- Referral source
- Summary of collateral sources (such as medical, legal, psychiatric records)
- Methods of assessment utilized (interviews, symptom inventories and checklists, neuropsychological testing, etc.)
History of Torture and Ill-treatment
Every effort should be made to document the full history of torture, persecution and other relevant traumatic experiences (see Module 3   ). This part of the evaluation is often exhausting for the person being evaluated. Therefore, it may be necessary to proceed in several sessions (if it is possible). The interview should start with a general summary of events before eliciting the details of the torture experiences and include:
- Summary of detention and abuse: Before obtaining a detailed account of events, elicit summary information, including dates, places, duration of detention, frequency and duration of torture sessions
- Circumstances of apprehension: What time, from where, by whom (with details, if possible); other persons around, witnesses/bystanders; interaction with family members; violence/threats used during the apprehension; use of restraints or blindfold
- Place and conditions of detention: What happened first, where, any identification process, transportation, distinctive features; other procedures; condition of the cell/room; size/dimensions, ventilation, lighting, temperature, toilet facilities, food; contact with third persons (family members, lawyer, health professionals); conditions of overcrowding or solitary confinement, etc.
- Methods of torture and ill-treatment:
- Assessment of background: Where, when, how long, by whom; special features of the environment, perpetrators, devices/instruments; usual “routine”, sequences and other information
- For each for of abuse: body position, restraint, nature of contact, duration, frequency, anatomical location, the area of the body affected and how and other information
- Sexual assaults
- Deprivations (sleep, food, toilet facilities, sensory stimulation, human contact, motor activities); threats, humiliations, violations of taboos, behavioural coercions and other methods
- Previous medico-legal reporting process (if any)
As mentioned in Module 3   , a method-listing approach may be counter-productive, as the entire clinical picture produced by torture is much more than the simple sum of lesions produced by methods on a list.
Current Psychological Complaints
Assessment of current psychological functioning constitutes the core of the evaluation:
- All affective, cognitive, and behavioural symptoms that appeared since the torture should be described. For each symptom: first emergence, duration, intensity, frequency, content, fluctuation of each symptom should be asked and recorded with examples and all details.
- Adaptative and maladaptive strategies and triggers such as anniversary reactions, specific stimuli or places, situations and topics causing avoidance should be noted.
- Specific questions about the most common symptoms and diagnostic criteria for most common diagnosis need to be asked.
The clinician should inquire about current life circumstances including:
- Sources of additional stress, traumas, losses, difficulties (i.e. other traumatic experiences or ongoing persecution to the individual or his/her family, refugee displacement, etc.)
- Formal and/or informal social support resources.
- Marital and family situation.
- Employment status, livelihood.
- Vocational, social status and conditions.
- Life conditions and quality of life of the interviewee and his/her family.
This component of the psychological evaluation obtains information about current life circumstances and stresses. The summary of pre-trauma history is important to assess mental health status and level of psychosocial functioning of the alleged torture victim prior to the traumatic events. In this way, the interviewer can compare the current mental health status with that of the individual before he or she was tortured. In evaluating background information the interviewer should keep in mind that the duration and severity of responses to trauma is affected by the severity and duration of the trauma events, the meaning assigned to the individual’s experiences, genetic and biological predisposition, developmental phase, age, prior trauma, pre-existing personality, and social support system. A Pre-torture History should include:
- Developmental history
- Family history: family background, family illnesses, family composition
- Educational history
- Occupational history
- Social history: activities, including political activities, interests, group interactions
- History of past trauma: childhood abuse, war trauma, domestic violence, etc
- Cultural and religious background
The medical history summarises pre-trauma and current health conditions and should include:
- Pre-trauma health conditions.
- Current health conditions.
- Body pain, somatic complaints.
- Physical injuries and findings: physical findings that might be related to trauma should be noted. It is important that the health professional that is making the psychological evaluation should also look for and document the physical findings of trauma. In some instances, the clinician who conducts the psychological evaluation may be the first or the only health professional with whom the alleged victim comes in contact with.
- Use of medications, including possible side effects and obstacles in using medications.
- Relevant sexual history.
- Past surgical procedures and other medical data.
Past Psychiatric History
One should inquire whether the individual has a past history of mental or psychological disturbances, the nature of the problems, and whether they received treatment or required psychiatric hospitalisation. Inquire which, if any, psychotropic medications were used in treatment.
Substance Use and Abuse History
The clinician should inquire about substance use before and after the torture, changes in the pattern of use and abuse, and whether substances are being used to cope with insomnia or psychological/psychiatric problems.
Torture can involve physical trauma that leads to various levels of brain impairment. Blows to the head, suffocation and prolonged malnutrition may have long-term neurological and neuro-psychological consequences that may not be readily assessed during the course of a medical examination. Frequently, the symptoms for such assessments have significant overlap with the symptomatology arising from PTSD and major depressive disorders. Fluctuations or deficits in level of consciousness, orientation, attention, concentration, memory and executive functioning may result from functional disturbances as well as organic causes.
Clinical neuropsychology is an applied science concerned with the behavioural expression of brain dysfunction. Neuropsychological assessment, in particular, is concerned with the measurement and classification of behavioural disturbances associated with organic brain impairment. The discipline has long been recognised as useful in discriminating between neurological and psychological conditions and in guiding treatment and rehabilitation of patients suffering from the consequences of various levels of brain damage. Neuropsychological evaluations of torture survivors are performed infrequently and to date neuropsychological studies of torture survivors is limited in the literature.
Despite significant limitations, neuropsychological assessment may be useful in evaluating individuals suspected of having brain injury and in distinguishing brain injury from PTSD. Neuropsychological assessment may also be used to evaluate specific symptoms, such as problems with memory that occur in PTSD and related disorders.
Mental Status Examination
The mental status exam begins the moment the clinician meets the subject. The interviewer should make note of the person’s appearance (such as signs of malnutrition, lack of cleanliness, etc.), changes in motor activity during the interview, use of language, presence of eye contact, and the ability to relate to the interviewer. The following list summarises the components of the exam: general appearance, motor activity, speech, mood and affect, thought content, thought process, suicidal and homicidal ideation, cognitive status (alertness, orientation, concentration and calculation, long term memory, intermediate recall, and immediate recall), and insight.
The individual’s responses to specific mental status items are affected by their culture of origin, educational level, literacy, language proficiency, and level of acculturation. The mental status examination of torture survivors requires flexibility on the part of the examiner, who must have a good understanding of the individual’s cultural, linguistic, and educational background before attempting any formal assessment. The level of education is an important factor in determining the appropriate questions and tasks.
Assessment of Social Function
Trauma and torture can affect a person’s ability to function. The psychological consequences of the experience may impair the individual’s ability to care for him/herself, earn a living, support a family, or pursue education. The clinician should assess the individual’s current level of functioning by inquiring about daily activities, social role function (as housewife, student, worker, etc), social and recreational activities, and perceptions of health status. For obvious reasons, one cannot accurately assess the social functioning of an individual held in detention.
Psychological Testing and the Use of Checklists and Questionnaires
If an individual has trouble expressing in words his or her experiences and symptoms, it may be useful to use a trauma event questionnaire or symptom checklist. These tools may facilitate disclosure of severely traumatic memories and reduce the anxiety often experienced in an unstructured interview. There are numerous questionnaires available; however, none is specific to torture victims. Caution must be exercised in the interpretation of responses and scores because established norms do not exist for most refugee populations. Similarly, there is little published information about the use of standard psychological and neuropsychological tests among torture survivors. Due to the fact that there is such wide cultural and linguistic diversity among survivors, one should exercise extreme caution when requesting or employing psychological and psychometric tests of any kind, most of which have not been cross-culturally validated.
In some countries and/or situations, courts and/or other authorities tend to give more weight to the results of psychometric tests and consider them more “objective” than the clinical impressions that clinicians obtain as a result of several interviews. However, for the psychological evaluation of trauma, the clinical interview, evaluation and the subsequent clinical formulation the clinician reaches are fundamental, whereas psychological tests have only complementary value. It is the clinician himself/herself who decides whether there is any need to use psychological testing in the evaluation process. Furthermore, the clinician must make his/her own decision without any interference in his/her clinical independence.
An essential aspect of the psychiatric evaluation is the formulation of a concise statement of the interviewer’s analysis of the case. Interpretation of the findings and formulation of a clinical impression are the last stages where the entire interview is discussed and evaluated; therefore care must be taken while formulating a clinical decision.
Interpretation of the clinical findings is a complex task. The following questions from the Istanbul Protocol will help guide the formulation of the clinical impression and diagnostic conclusions.
- Are the psychological findings consistent with the alleged report of torture?
- Are the psychological findings expected or typical reactions to extreme stress within the cultural and social context of the individual?
- Given the fluctuating course of trauma-related mental disorders over time, what is the timeframe in relation to the torture events? Where in the course of recovery is the individual?
- What are the coexisting stresses impinging on the individual (e.g. ongoing persecution, forced migration, exile, loss of family and social role, etc)? What impact do these issues have on the victim?
- What physical conditions contribute to the clinical picture? Pay special attention to head injury sustained during torture and/or detention.
- Does the clinical picture suggest a false allegation of torture?
When writing reports, clinicians should comment on the emotional state of the person during the interview, symptoms, history of detention and torture, and personal history prior to torture. Factors such as the onset of specific symptoms in relation to the trauma, the specificity of any particular psychological findings, as well as patterns of psychological functioning should be noted. If the survivor has symptom levels consistent with one or more DSM IV or ICD 10 psychiatric diagnosis, the diagnosis should be stated. If not, the consistency between the psychological findings and the history of the individual should be evaluated as a whole and stated in the report. Additional factors such as forced migration, resettlement, difficulties of acculturation, language problems, loss of home, family, social status, as well as unemployment should be discussed. The relationship and consistency between events and symptoms should be evaluated and described. Physical conditions such as head trauma or brain injury may require further evaluation. Behavioural, cognitive and emotional aspects of the individual observed during verbal and non-verbal communication should be noted as well.
It is common in medico-legal contexts for the clinician to be asked whether psychological symptoms were caused by that alleged torture and ill-treatment or other traumatic experiences that may have occurred before or after the alleged events. Clinician should note temporal relationships between the onset of symptoms and the alleged torture and ill-treatment. They should also consider content-specific symptoms that may relate to the alleged torture and ill-treatment such as: the content of nightmares, triggers for intrusive recollection, reliving experiences, avoidance reactions, etc.
It is important for clinicians to make clear to any court or judicial authority that not everyone who has been tortured develops a diagnosable mental illness. It must be stressed that even though a diagnosis of trauma-related mental disorder supports the claim of torture, not meeting criteria for a psychiatric diagnosis does not mean the person was not tortured. The absence of conclusive physical and/or psychological signs and symptoms does not invalidate an allegation of torture. The clinician should also take into consideration the possibility that an absence of psychological symptoms can be due to the episodic or often delayed nature of PTSD or to denial of symptoms because of shame or other difficulties.
It is possible that some people may falsely allege torture or exaggerate a relatively minor experience or symptoms for personal or political reasons. The clinician should keep in mind, however, that such fabrication requires a detailed knowledge about trauma related symptoms that individuals rarely possess. Also, inconsistencies can occur for a number of valid reasons such as memory impairment due to brain injury, confusion, dissociation, cultural differences in perception of time, or fragmentation and repression of traumatic memories (see Module 3   ). Additional sessions should be scheduled to help clarify inconsistencies and when possible, family or friends may be able to corroborate detail. Inconsistencies that are attributable to the psychological effects of an individual’s torture experiences may, in fact, support his or her allegations of abuse.
The recommendations following the psychological evaluation depend on the questions posed at the time the evaluation was requested. The issues under consideration may concern legal and judicial matters, asylum, resettlement, and a need for treatment. Recommendations can be for further assessments, such as neuro-psychological testing, medical or psychiatric treatment or a need for security or asylum. The clinician should not hesitate to insist on any consultation and examination that s/he considers necessary.
In the course of documenting psychological evaluation of torture allegations the clinicians are not absolved of their ethical obligations. Evaluation for documentation of torture for medico-legal reasons should be combined with an assessment for other needs of the individual. Those who appear to be in need of further medical or psychological care should be referred to the appropriate services. Clinicians should be aware of the local rehabilitation and support services.
A full discussion of treatment is beyond the scope of this Module. To briefly summarise, intervention necessarily begins with establishing safety, protection, and basic human necessities for survival (food, shelter, income, etc.). Without these basic elements, no meaningful “treatment” can be effective. Any meaningful clinical treatment and rehabilitation program should include social services and if possible, legal services. Treatment can begin once basic necessities are secured, or perhaps even while they are being secured. Because torture affects an individual on so many levels, an integrated, coordinated multidisciplinary approach to treatment is essential. Mental health treatment modalities include individual, group, and family psychotherapy, psychopharmacology, psychoeducation, and somatic therapies. Traditional medicine practices should be respected and included in the treatment if the individual wishes, provided they are safe and that one avoids deleterious interactions between medications and herbal preparations.
NOTE: An online course, “Caring for Torture Survivors ,” offered by the Boston Center for Refugee Health and Human Rights, is available at: http://www.bcrhhr.com/education/caring-for-survivors.html 
 Jacobs U, Iacopino V. Torture and its consequences: a challenge to neuropsychology. Professional Psychology: Research and Practice. 2001;32(5): 458–464.
The psychological evaluation starts at the beginning of the interview, with the very first contact. The individual’s overall appearance and manner of dress, posture, the manner of recalling and recounting the trauma, signs of anxiety or emotional distress, numbness or … Continue reading