Module 8: Case Example #2

Introduction

Modules 7 and 8 each include a case example of alleged torture and ill-treatment. The Modules are designed for students to develop the clinical skills necessary for the effective documentation of medical evidence torture, including both physical and psychological evidence. These cases were used extensively in Istanbul Protocol trainings in Mexico and also, with some modifications, in Sudan. The content of each was specifically designed to represent common evaluation scenarios and to include a wide range of challenges related to the documentation of physical and psychological evidence of torture. The cases are complementary, i.e. one with “strong psychological and weak physical evidence” (Case #01) and the other with “strong physical and minimal psychological evidence” (Case #02) and reflect composite imformation of actual cases. Each case consists of 1) a brief Case Summary/Refferal that the students read before the evaluation, 2) a Case Narrative to guide role-players in acting their part as an alleged torture victim, and 3) a detailed set of Guidelines for Instructors (and/or individual student users if that is the case) which outline learning objectives, relevant case information, and points for discussion for each of the 8 primary components of medical evaluation:

  1. Introduction/Conditions of Interview & Identification Information
  2. Past Medical and Surgical History & Psychosocial History – Pre-Arrest
  3. Trauma History
  4. Review of Torture Methods
  5. Physical Symptoms (acute and chronic) and Disabilities
  6. Psychological Assessment and Mental Status Examination
  7. Physical Examination
  8. Interpretation of Findings & Conclusions

It is highly recommended for the instructors to contact local treatment centers for survivors of torture, and/or other experienced clincians or providers who may be available to participate in the case examples.

Modules 7 and 8 each include a case example of alleged torture and ill-treatment. The Modules are designed for students to develop the clinical skills necessary for the effective documentation of medical evidence torture, including both physical and psychological evidence. … Continue reading

Module 8 Answers

  1. Answer: B

    Police or other law enforcement officials should never be present in the examination room. This procedural safeguard may be precluded only when, in the opinion of the examining doctor, there is compelling evidence that the detainee poses a serious safety risk to health personnel. Under such circumstances, security personnel of the health facility, not the police or other law enforcement officials, should be available upon the medical examiner’s request. In such cases, security personnel should still remain out of earshot (i.e. be only within visual contact) of the patient. The presence of police officers, soldiers, prison officers or other law enforcement officials in the examination room, for whatever reason, should be noted in the physician’s official medical report. The presence of police officers, soldiers, prison officials or other law enforcement officials during the examination may be grounds for disregarding a negative medical report. The identity and titles of others who are present in the examination room during the medical evaluations should be indicated in the report.

  2. Answer: B

    Under no circumstances should a copy of the medical report be transferred to law enforcement officials or security personnel.

  3. Answer: B

    The routine use of restraints during medical consultation or treatment is contrary to medical ethics and international standards on treatment of prisoners. Health professionals must not accept such practises. Restraints not only interfere with the proper diagnosis, management and treatment of patients, but they also run contrary to the inherent dignity of all human beings. The only possible acceptable justification for use of restraints is as a last resort when there is substantiated reason to believe that this particular detainee presents an immediate and current violent threat to himself or others. Health professionals can and should question the use of restraints if they have reason to doubt such a risk exists. In the exceptional circumstances that restraints are used, they should be as minimal as possible.

  4. Answer: A

    It is important to obtain a complete medical history, including prior medical, surgical and/or psychiatric problems. Clinicians should document any history of injuries before the period of detention and any possible after-effects. Knowledge of prior injuries may help to differentiate physical findings related to torture from those that are not.

  5. Answer: B

    Mr. Adam’s psychosocial history contains information relevant to his psychological symptoms, or lack thereof, following the alleged torture and ill treatment. Mr. Adam’s political beliefs and activities have likely mitigated more severe psychological symptoms. His predominant reaction of anger is, in part, likely due to the killing of one of his brothers by security forces.

  6. Answer: C

    Mr. Adam’s history is significant for multiple lapses in consciousness. He was not blindfolded during the alleged torture, only during transport to the place where he was detained. Also, he does not demonstrate evidence of organic brain impairment or significant psychological sequelae.

  7. Answer: C

    Mr. Adam indicated that his multiple episodes of loss of consciousness were associated with asphyxia and electric shocks to his penis. Diagnostic imaging of the brain and EEG studies are not indicated in the absence of significant head trauma, seizure activity or a focal neurological deficit. Given minimal psychological symptoms and normal cognitive functioning, neuropsychological testing would not be indicated. A complete neurological examination would be adequate under the circumstances.

  8. Answer: B

    Sexual assault, including rape, is common among male detainees. Given the intense shame that is usually associated with sexual assault, additional information may not be spontaneously reported. It is important, therefore, to ask Mr. Adam something like: “Many men who are detained by police and security forces are assaulted sexually, including rape. Did anything like this happen to you?”

  9. Answer: A

    Mr. Adam’s difficulty having erections is most likely psychosomatic in origin since he indicated that he has noted normal erections upon waking from sleep.

  10. Answer: B

    Although Mr. Adam’s alleges being suspended from his hands tied behind his back, his acute symptoms of arm pain when lifting heavy objects and right arm numbness subsequently resolved. In the absence of any current complaint and/or numbness or weakness on physical examination, an EMG is not indicated.

  11. Answer: B

    Electric shock often does not result in acute lesions. When present, electric burns usually consist of a red brown circular lesion, 1 – 3 mm in diameter, usually without inflammation, and may result in a hyperpigmented scar. The absence of such changes should not be construed as an inconsistency.

  12. Answer: A, possibly C

    Survivors of torture who ascribe positive meaning to their suffering (e.g. World War II veterans and political activists) often have fewer and less severe psychological symptoms. Fear of police reprisals would likely increase Mr. Adam’s psychological symptoms. Although support from family member also may mitigate psychological symptoms, Mr. Adam’s parents expressed strong disapproval of his political activity and consider his action to be “foolish and dangerous.” This has resulted in considerable discord between them. He and his father have not spoken to one another in the past several weeks. Nonetheless, his parents’ concern may represent a longstanding source of support.

  13. Answer: C

    Cigarette burns typically result in 5 to 10 mm, circular, macular scars with a depigmented centre and a hyperpigmented, relatively indistinct periphery. The lack of a depigmented centre in Mr. Adam’s case may be related to the relative degree of heat applied. The characteristics of the lesions and location on one arm only, are highly consistent with his allegations of cigarette burns.

  14. Answer: B

    Mr. Adam was examined months after he was released from detention. The possibility of self-inflicted injuries cannot be fully excluded.

  15. Answer: C

    Mr. Adam’s physical examination findings of hyperpigmented, circumferential scars above both wrists are highly consistent with his allegations of “rope burns” from suspension torture.

  16. Answer: E

    All of the explanations listed indicate why these physical findings are not likely to be the result of self-inflicted injuries.

  17. Answer: D

    Striae distensae (stretch marks) are most common on the abdomen (especially after pregnancy), the lower back, the upper thighs, and around the axillae. They are hypopigmented lines in which the skin might be folded. They must not be confused with scars from whipping. In striae, the skin is intact. Axillary striae may not be noticed by individuals until after suspension torture.

  18. Answer: B

    Mr. Adam’s psychological findings may not be as extensive or severe as some might expect, but this can be adequately explained by symptom mitigation from his political beliefs and activities and possibly by support from family and friends. Effective coping mechanism also may help to explain his resilience, but this was not thoroughly assessed in Case Example #02. Mr. Adam’s allegations of abuse appear to be at least “consistent with” his psychological evaluation findings.

  19. Answer: B

    Psychological instruments may serve as a useful adjunct to the qualitative, psychological evaluation and may be particularly helpful if an individual has trouble expressing in words his or her experiences and symptoms. This is not the case for Mr. Adam, however. In addition, caution must be exercised in the interpretation of responses and scores of psychological instruments because established norms do not exist for many populations.

  20. Answer: E

    All of the considerations listed would support the credibility of Mr. Adam’s allegations of torture and ill treatment and, if relevant, may be included in the clinician’s written reports and oral testimony. Note that inconsistencies that are attributable to an individual’s torture experience may, in fact, support an individual’s allegations of abuse, rather than undermine it.

Answer: B Police or other law enforcement officials should never be present in the examination room. This procedural safeguard may be precluded only when, in the opinion of the examining doctor, there is compelling evidence that the detainee poses a … Continue reading

Preliminary Considerations

  1. There are a number of different formats to consider for the case examples contained in Module 7 and 8, depending on the time and resources available. Ideally, each student should have an opportunity to practice various components of the interview and engage in analysis of the information gathered. Options for teaching formats include but may not be limited to:
    • Student groups can be divided so that there are between 2 and 8 students per group. The instructor(s) should periodically check on each group to assess progress and address any questions or concerns that may arise. Student evaluation groups can work concurrently, with the 8 components of the interview divided up among the students. Each case example will require approximately 2 to 3 hours of time for the interview and feedback process.
    • If there is not adequate time in the course for the students to conduct Case #01 and #02 on separate days, it may be possible to have half of the students conduct Case 1 and the other half conduct Case #01 on the same day.
    • Alternatively, one demonstration evaluation may be conducted for the entire class and students asked to volunteer for various components of the interview. Several students may work together, or sequentially for each of the 8 primary components of medical evaluation so that each student has an opportunity to participate.
    • A single demonstration evaluation by one or more instructors may be another possibility, with student interaction at the end of each of the 8 components of the interviews.
    • Also, one or both Case Narratives may be assigned for students to read in advance (without role-play interviews) and followed by class discussion and/or a demonstration case.
    • Individual online users of the Model Curriculum may review all materials contained in Modules 7 and 8 and complete the related self-assessment quizzes.
  2. Regarding Role-players: If interviews are conducted in class, instructors will need to use their best judgment in selecting role-players. Role-players may be individuals outside the class or the students themselves. In either case, the instuctors should provide the role-players with adequate information to convey the information contained in Narratives for Case #01 and Case #02 and review a relevant process issues, for example:
    • Discuss the role-play for police coercion. Request permission to use paper handcuffs.
    • Provide role-players with Case Narratives
    • Instructor(s) and role-players will review the cases in detail and discuss content and process issues prior to class
    • Consider the following recommendations for role-players:
      • General affect or emotion conveyed in the interviews
      • Emotional responses to specific experiences related in the interviews
      • Importance of staying in the role of the detainee/alleged victim until the debriefing
      • Imagine having experienced what is alleged in the narratives or by a friend/spouse
      • Make effective use of silence or pauses when you respond to the interviewer
      • Make effective use of body language (eye contact, body position, tone and pattern of speech)
      • Discuss gender issues
      • Discuss how the detainee’s should appear and be dressed
    • Discuss the debriefing process
      • At the end of each case interview, role-players should provide feedback on trainee performances and process issues
      • Consider relevant transference and counter-transference issues (see Module 3): Clinicians who conduct medical evaluations of detainees should be familiar with common transference reactions (i.e., potential reactions of the survivors toward the physician) that survivors experience and the potential impact of such reactions on the evaluation process. Counter-transference (i.e. the interviewer’s emotional response to the torture survivor) reactions should also be discussed.
  3. Instructors should note:
    • Students may feel uncomfortable role-playing as it is likely to cause emotional stress which may or may not be associated with past experiences. Do not require or make students feel obligated to “volunteer” as role-players.
    • Remind the students of the objectives of this module before it starts and that the point of the exercise is to practice and learn rather than conduct a “perfect” interview.
    • Encourage participants to convey their emotions during their feedback.
    • During the feedback:
      • Ensure that the language is non-judgmental, but constructive and respectful.
      • Take the group dynamics into consideration.
      • Take care that the ones in the role of interviewers do not get frustrated and do not feel judged.
      • Underline positive aspects.
      • Remind the participants that the task of interviewing somebody can create tension, is difficult and doesn’t exactly reflect the real life interview experiences.
      • Show appreciation for the interviewee and interviewer.
  4. Case Summaries/Referrals: A brief Case Summarie/Referral will be distributed to the trainees before each of the training sessions (Modules 7 and 8). The format is intended to approximate the information that may be contained in an official request for a forensic medical evaluation.
  5. Case Narratives: The narratives provide considerable detail on the alleged trauma, subsequent symptoms and disabilities and physical and psychological assessments. The narratives will serve as background information and guidelines for the conduct of the interviews and will be used by the trainers and role-players in preparation for the training sessions. The students who conduct the interviews should not have prior access to the Case Narratives.
  6. Time-outs: A break in the interview action used to make teaching points. Note: The instructor should indicate whether time-outs can be initiated only by the instructor of by the students as well. To conserve time, it may be advisable for time-outs to be reserved for instructors only. There should be time for discussion at the end of each of the 8 interview components so that all participants can ask questions and engage in relevant discussion.
  7. Recommended Agenda: It is important to complete all components of the medical evaluation working sessions in the period allotted. This will help to ensure that each trainee has an opportunity to participate in the interview process and that the entire examination will be completed. The following recommended agenda is based on a 3 hour interview, but may be modified, proportionally, depending on the time available.
    • Identify sequence of participation among students (5 min)
    • Components:
      1. Introduction/Conditions of Interview & Identification Information
      2. Past Medical and Surgical History & Psychosocial History – Pre-Arrest
      3. Trauma History
      4. Review of Torture Methods
      5. Symptoms (acute and chronic) and Disabilities
      6. Psychological Assessment and Mental Status Examination
      7. Physical Examination
      8. Interpretation of Findings & Conclusions

      NOTE: For the above 8 components, a total of 120 minutes: 15 min for each component (student = 10 min + discussion = 5 min)

    • Debriefing with Role-Player (15 min)
    • Summary Discussion (40 min)
  8. Assessment of Student Performance: Instructors may assess each student’s performance for the two case interviews using periodic observation. It is recommended that students be required to take notes on all components of the case interviews in which they participate and to develop a written report that can be evaluated by the instructor. Any assignment for written reports should be due at the time of the final module, Module 9, which addresses Report Writing and Testifying in Court.
  9. Terminology: Please keep in mind that the subject being evaluated should not be referred to as a “victim” or “survivor.” Please use the individual’s name or “detainee,” “alleged victim,” “subject,” “individual,” or some other neutral term.
  10. Interview Setting: It is important that the students understand their role in providing a private and comfortable interview setting. Arrange the chairs so that the two interview chairs are next to one another and the other chairs in the room are some distance from those of the interviewer and the detainee.
  11. Optional Simulation of Police Coercion: The “alleged victim” or “detainee” (role-player) will be brought to the “examination” room (conference or class room) when the instructor indicates that he/she is ready. The instructor should consider arranging for the detainee to enter the room in paper handcuffs (assuming this is acceptable to the role-player) and in the custody of a “police officer.” The reason for this is to simulate conditions that examiners are likely to experience in evaluating alleged victims. The “police officer” should be present for the first five minutes of the examination unless asked to leave by the trainee. This activity will help each group to discuss how to handle the issue of police coercion.

There are a number of different formats to consider for the case examples contained in Module 7 and 8, depending on the time and resources available. Ideally, each student should have an opportunity to practice various components of the interview … Continue reading

Materials

Case Summary/Referral #02

(distribute to students who conduct the interviews)

(Strong physical, moderate psychological and strong historical evidence; medical evaluation 7 days after alleged torture)

Note: This case example #02 is written for male role-player. All names included in the narrative are fictitious.

  • Name: Mr. Hassan Bashir Adam
  • Date Reporting to the Center: dd/mm/yyyy (today’s date)
  • Date of Birth: dd/mm/yyyy (age 25)
  • Age: 25 yrs
  • Marital Status/Children: Single, no children
  • Religion: Muslim
  • Ethnic Group: Darfurian, Zagawa tribe
  • Profession: Student, Khartoum University
  • Political/Social Affiliation: Member of Student Democratic Front (SDF)
  • Date of Detention: dd/mm/yyyy (7 months prior to the exam date)
  • Place of Detention: XXX police station
  • Period of Detention: 3 days
  • Trauma History: On dd/mm/yyyy (7 months prior to the exam date), Mr. Adam as arrested by four officers from the NSA. He was placed in a truck with blackened windows, blindfolded and taken to a police station. His mobile phone and ID card were confiscated. His hands were restrained and he was punched, kicked and beaten with black water hoses and electric wires. They suspended him by his wrists and applied electric shocks to his genitals.
  • Alleged Perpetrators: Security personnel from the NSA, including Abdel Salih, and Kaleel Rahim, also 2 perpetrators referred to as Rasoul and Mujahid.
  • Reasons for Visit: Treatment for problems related to torture and to take legal action against the perpetrators. The client has already met with SOAT legal advisors, and they have requested a medical evaluation of the client’s allegations of torture.
  • Effects of Torture: Musculoskeletal pain, multiple bruises and burns.

Case Narrative #02

(distribute to role-players only)

Note: Case example #02 is written for male role-players. All names included in the narrative are fictitious.

Case Summary/Referral Information

  • Name: Mr. Hassan Bashir Adam
  • Date Reporting to the Center: dd/mm/yyyy (today’s date)
  • Date of Birth: dd/mm/yyyy (age 25)
  • Age: 25 yrs
  • Marital Status/Children: Single, no children
  • Religion: Muslim
  • Ethnic Group: Darfurian, Zagawa tribe
  • Profession: Student, Khartoum University
  • Political/Social Affiliation: Member of Student Democratic Front (SDF)
  • Date of Detention: dd/mm/yyyy (7 months prior to the exam date)
  • Place of Detention: XXX police station
  • Period of Detention: 3 days
  • Trauma History: On dd/mm/yyyy (7 months prior to the exam date), Mr. Adam as arrested by four officers from the NSA. He was placed in a truck with blackened windows, blindfolded and taken to a police station. His mobile phone and ID card were confiscated. His hands were restrained and he was punched, kicked and beaten with black water hoses and electric wires. They suspended him by his wrists and applied electric shocks to his genitals.
  • Alleged Perpetrators: Security personnel from the NSA, including Abdel Salih, and Kaleel Rahim, also 2 perpetrators referred to as Rasoul and Mujahid.
  • Reasons for Visit: Treatment for problems related to torture and to take legal action against the perpetrators. The client has already met with SOAT legal advisors, and they have requested a medical evaluation of the client’s allegations of torture.
  • Effects of Torture: Musculoskeletal pain, multiple bruises and burns.

Identification

My name is Hassan Bashir Adam. I live in Khartoum, and I am 25 years-old.

Additional Information:

  • Date of Birth: dd/mm/yyyy (age 25)
  • Citizenship: Sudanese
  • Marital Status/Children: I am single, and I do not have children.
  • Place of Birth: Nyala
  • Place of Residence: Khartoum
  • Highest Level of Education: Currently a student at Khartoum University.
  • Occupation: Student
  • Religion: Muslim
  • Identification: ID confiscated
  • Ethnic Group: Darfurian, Zagawa tribe
  • Physician Examiner Name and License #: Fill out
  • Individuals Present in the Examination Room and Reason for Presence: Fill out
  • Language Spoken: Zagawa
  • Name of Interpreter: None
  • Restrictions Noted: This depends on the response of the interviewer.
  • Detainee Status: Detained by police and released

Past Medical/Surgical History and Psychosocial History

Past Medical/Surgical History

Before I was arrested, I had no medical problems, no major illnesses or injury, no surgery, broken bones or head injury. I never had any mental problems, nor has anyone in my family. I am not on any medications. I do not use any illegal drugs or drink alcohol. I smoke about one pack of cigarettes per day.

NOTE: Provide information in parentheses only if specifically asked by the interviewer.

Psychosocial History Pre-Arrest

I was born in Nyala and have two younger brothers. My father owns a small grocery store in Nyala and my mother helps him out at the store. I was good in school and decided to go to Khartoum University for business studies. I have had various part-time jobs, but I have never worked for my parents. My plan was to have a good job with a large company in the future. I have been an active member of the SDA (Student Democratic Front) for the past two years. Many of my friends and I were detained after the student elections last year. I was beaten, but not as bad as the others. One of my brothers was killed by security forces in Darfur about 9 months ago. My parents worry about me, because they know I am an active member of the SDF and they do not approve.

Trauma History

NOTE: At the time of arrest, there was no arrest warrant or subpoena order, search warrant, or resistance by the accused.

On dd/mm/yyyy (7 months prior to the exam date), at about 10:00 pm, four officers from the NSA came to the flat that I share with two other students. They told me that they needed to ask me some questions. I asked them if I was being charged with a crime. One of them, Abdel Salih, told me “Keep your mouth shut if you know what’s good for you.” Another one of them was named Kaleel Rahim.

I was placed in a truck with blackened windows and taken to XXX police station.

They took my mobile phone and ID card. When we arrived, they locked me in a room, about one meter by one meter and a half in size. The room was filthy and smelled of urine. There were no light and the ventilation in the room was very poor. During the time that I was detained, I had difficulty sleeping and was given only a small amount of poor quality food.

Later that night, they took me to an interrogation room and started asking questions about members of the SDF, who I knew and worked with and the nature of our work. I had made a speech recently on the situation in Darfur and they told me, “You may think you are free to criticize us, but we are free to do anything we like. We could kill you tonight and no one would care.” They tied my hands with rope and started beating me with punches, kicks, black water hoses and electric wires. This went on for more than an hour. One of them, “Rasoul,” put a plastic bag over my head and I was gasping for air. He repeated this 3 or 4 more times and I passed out.

When I woke up, they started beating me again (punches, kicks, and hoses). They forced me to take off all of my clothes. My hands were tied behind my back with a rope that was hanging from the ceiling. They lifted me off the ground; the pain was unbearable. They continued beating me while I was suspended. Then they sprayed cold water over me with a hose and forced it in my mouth and nose so I had trouble breathing. One of the agents attached a clip with some wires to my penis and my right foot. He said insulting things (Like “you won’t be needing this anymore.”). My whole body cramped violently when they shocked me. I lost consciousness after they shocked me about five or six times. When I woke up, I was on the floor. I felt several burning sensations on my right forearm. One of them had a lit cigarette in his hand. He burned my arm again and again. One of them told me, “You better stop making speeches or you will end up like your brother.” I was locked in a cell for two days before I was released. I am not guilty of anything, and no one should be treated this way. That is why I had the courage to take legal action against the people who tortured me.

Review of Torture Methods

The following history should be revealed only on further questioning, unless asked in the context of the trauma history:

  • The review of torture methods is negative for the all other torture methods, physical and psychological.

Symptoms (Acute and Chronic) and Disabilities

Acute Symptoms
  • Multiple bruises over my arms, legs and back, no injuries to the head. The bruises are red and swollen and still visible on my body. (No cuts or bleeding)
  • Pain in the shoulders, arms and wrists.
  • A number of burn marks on my right forearm, which took about 2-3 weeks to heal.
  • I did not observe any lesion on the penis where they shocked me.
  • Difficulty lifting objects due to pain in my arms and numbness in my right arm for a few months, but this resolved.
Chronic Symptoms
  • Scars noted on right forearm from cigarette burns.
  • Difficulty having erections, i.e. not able to perform sexually but has noted erections upon waking for sleep.
Disabilities
  • None noted

Psychological Evaluation and Mental Status

Mental Status

Mr. Adam was appropriately dressed and groomed and looked 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 above average intellectual ability, with good insight and judgment. His speech was clear and fluent. There was no evidence of delusions, hallucinations or psychotic thought processes. Memory was intact. Attention and concentration appeared intact. His mood was apprehensive in the presence of the police officer who escorted him to my office, but then calm during the evaluation. There was no evidence of suicidal or homicidal ideation.

Psychological Findings

Mr. Adam did not admit to any symptoms of post-traumatic stress disorder or major depression. Though his affect was calm throughout most of the interview, he expressed considerable anger toward those who tortured him and the loss of his brother. Mr. Adam indicated that since being tortured, he is less sure of his future plans. He is now considering altering his career path to become more active politically. His parents have expressed strong disapproval, however; they consider his political activity to be “foolish and dangerous.” This has resulted in considerable discord between them. He and his father have not spoken to one another in the past several weeks.

Physical Examination

NOTE: Images of “virtual physical examination” findings will be presented in a separate room using PPT slides.

  • Slide #1 and #2 (day of exam): Hyperpigmented, circumferential scars above both wrists, highly consistent with wrist abrasions from alleged restraint with rope and suspension
  • Slide #3 and #4 (day of exam): Multiple hyperpigmented circular scars (about 1 cm in diameter) with indistinct margins and no central palor or atrophy. The characteristics of the lesions and location on one arm only are highly consistent with the alleged cigarette burns.
  • Slides #5 and #6 (6 days following alleged torture): Linear “tram-track” lesions with peripheral echymosis and central palor, consistent with acute signs of beating to the back with a water hose.

Interpretation and Conclusion

Per trainee’s assessment

Case Summary/Referral #02 (distribute to students who conduct the interviews) (Strong physical, moderate psychological and strong historical evidence; medical evaluation 7 days after alleged torture) Note: This case example #02 is written for male role-player. All names included in the … Continue reading

Module 8 Presentation: Case Example #02


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Download Module 8: Case Example #02 (PowerPoint Presentation) (ppt)

Self-Assessment and Quiz

  1. If you were called upon to evaluate Mr. Adam while in custody and one of the detaining police officers was present in the examination room, what should be your initial course of action?
    1. Allow the police officer to remain to ensure your safety
    2. Request the police officer to remain outside the examination room and/or out of earshot
    3. Document the presence and identity of the police office and continue your evaluation
    4. Refuse to conduct the examination
  2. After you complete your evaluation of Mr. Adam in custody, you must provide the attending police officer with a copy of your evaluation.
    1. True
    2. False
  3. It is acceptable for clinicians to examine detainees in hand and leg shackles as long as it is the policy of the detention facility.
    1. True
    2. False
  4. Obtaining information on Mr. Adam’s past medical/psychiatric history is necessary to distinguish pre-existing physical and mental conditions from possible torture-related sequelae.
    1. True
    2. False
  5. The information obtained for Mr. Adam’s psychosocial history is not particularly relevant to the assessment of medical evidence of torture and ill treatment?
    1. True
    2. False
  6. In Mr. Adam’s case, which one of the following factors is most likely to interfere with an accurate recounting of past events:
    1. Blindfolding
    2. Disorientation
    3. Lapses in consciousness
    4. Organic brain damage
    5. Psychological sequelae of abuse
  7. Mr. Adam’s lapses in consciousness warrant which of the following?
    1. Neuropsychological testing
    2. Diagnostic imaging of the brain (CT Scan or MRI)
    3. A complete neurological examination including a mental status examination, cranial nerves, CNS and PNS
    4. Electroencephalogram (EEG)
  8. Mr. Adam spontaneously alleged that he was stripped naked and given electric shocks to his penis while suspended. There is no need, therefore, to inquire about additional forms of sexual assault.
    1. True
    2. False
  9. What is the most likely cause of Mr. Adam’s difficulty having erections?
    1. Psychosomatic
    2. Neurologic damage due to electric shocks
    3. Peripheral vascular disease
    4. None of the above
  10. After you complete your medical evaluation of Mr. Adam, you should order an EMG (electromyogram) study to assess the possibility of a brachial plexus injury
    1. True
    2. False
  11. The absence of penile lesions on examination is inconsistent with Mr. Adam’s allegations electric shock torture.
    1. True
    2. False
  12. What factors may account for the relative paucity of Mr. Adam’s psychological symptoms?
    1. The meaning of his experience in relation to his political beliefs and activities
    2. Fear of reprisals from police
    3. Support from his family members
    4. Lack of exposure to psychological methods of torture
  13. How would you describe the level of consistency between, Mr. Adam’s allegations of cigarette burns and physical examination findings of multiple hyperpigmented circular scars (about 1 cm in diameter) with indistinct margins and no central palor or atrophy?
    1. Not consistent
    2. Consistent with
    3. Highly consistent with
    4. Virtually diagnostic of
  14. It is not possible that Mr. Adam’s cigarette burns were self-inflicted?
    1. True
    2. False
  15. How would you describe the level of consistency between, Mr. Adam’s allegations of “rope burns” from suspension torture and his physical examination findings of hyperpigmented, circumferential scars above both wrists?
    1. Not consistent
    2. Consistent with
    3. Highly consistent with
    4. Virtually diagnostic of
  16. In the course of presenting the following photographic evidence of Mr. Adam in court, the cross examining attorney states that the alleged injuries were, instead, self-inflicted.

    Which of the following may help to explain why the Mr. Adam’s findings are not likely to be the result of self-inflicted?

    1. The “tram-track” marks are characteristic of blunt trauma from significant blows with a rectangular or cylindrical object such as a police baton
    2. The location of the lesions are not consistent with self-inflicted injuries which require considerable force
    3. The repetitive nature of the injuries suggest a common defensive position during beatings and intentional rather than incidental use of force
    4. While it is possible that the injuries could have been inflicted by another person following detention, this is unlikely given all of the physical and psychological evidence in Mr. Adam’s case
    5. All of the above
  17. If you were to note the findings illustrated below on Mr. Adam’s physical examination, and Mr. Adam indicated that he hadn’t noticed the axillary marks until after he was tortured, what would you consider the most likely cause of the findings to be?
    1. Subucutaneous fibrosis resulting from alleged suspension torture
    2. Circumferential abrasions from ligatures
    3. Scars from lacerations
    4. Striae distensae
  18. How would you describe the level of consistency between, Mr. Adam’s allegations of abuse and his psychological evaluation findings?
    1. Not consistent
    2. Consistent with
    3. Highly consistent with
    4. Virtually diagnostic of
  19. Given Mr. Adam’s minimal endorsement of psychological symptoms, the examining clinician should administer psychological instruments for anxiety, Major Depressive Disorder and PTSD.
    1. True
    2. False
  20. Which of the following considerations would support the clinical assessments of Mr. Adam’s credibility and argue against the possibility of malingering or simulation?
    1. Lack of over-endorsement of physical and/or psychological symptoms
    2. Lack of a suspiciousness or defensiveness
    3. Consistency between Mr. Adam’s observed affect and the content of the evaluation
    4. Consistency between Mr. Adam’s pre-torture personality and the meaning he assigns to his torture/ill treatment experiences
    5. All of the above

If you were called upon to evaluate Mr. Adam while in custody and one of the detaining police officers was present in the examination room, what should be your initial course of action? Allow the police officer to remain to … Continue reading

Module 8: Case Example #02

Objectives:

  • To conduct a complete medical evaluation of an alleged torture victim using Istanbul Protocol standards, including assessments of physical and psychological evidence of torture
  • To develop essential interview skills including: effective communication, earning trust, balancing empathy and objectivity, applying appropriated questioning techniques, obtaining informed consent, ensuring procedural safeguards, providing an appropriate and comfortable setting, respecting gender considerations, taking steps to avoid re-traumatisation
  • To understand the relevant transference and counter-transference issues that may arise in the course of conducting medical evaluations of alleged torture victims
  • To identify possible reasons for difficulties recalling and recounting the story and/or inconsistencies in the story of the alleged victim
  • To provide a well-reasoned interpretation of findings and conclusions regarding torture and ill-treatment.
  • To appreciate the possible difficulties that may arise during an interview with an alleged torture victim
  • To identify and address individual interviewing strengths and weaknesses in conducting an interview

Content

  • See Introduction and Preliminary Considerations and Materials below
  • Review of Case Summary #02 by students
  • Interview of individual role-player (alleged torture victim) by students or instructors (NOTE: role-players use Case Narrative #02 to act their parts)
  • Instructor supervision/demonstration of interview(s) using Guidelines for Instructors Case #02 (see Guidelines for Instructors file)
  • Debriefing between interviewers and role-players
  • Class discussion
  • Assignment: Ask students (individuals or groups) to write up a medical report of evaluation findings to be used in Module #9

Discussion Topics

  • Interviewing skills: How did the interviewers feel they performed? What observations/comments can the instructor and/other students share?
  • Interview content: was the interview complete? Was there any relevant components left out?
  • Role-players should share their reactions to the interview, followed by the interviewers
  • Discuss strategies to effectively address transference and counter-transference issues that arise in the course of interviewing survivors of torture.
  • Discuss your most significant concerns in conducting a psychological evaluation. Discuss how you can address them.

Teaching Formats

  • Group Activity:
    • See Introduction and Preliminary Considerations and Materials below
    • See Discussion Topics above
  • Individual Research/Assignment:
    • Discuss your most significant concerns in conducting a psychological evaluation. Discuss how you can address them
  • Journal Entry: (Instructor to assign Write a few paragraphs — no more than a page)
    • Consider how transference and counter-transference reactions may affect routine medical encounters between patients and clinicians.
    • What are your most significant concerns in conducting a psychological evaluation? Discuss how you can address them.

Primary Resources

  • The Istanbul Protocol
  • Case Example #02 (Case Summary, Narrative and Guidelines for Instructors)

Objectives: To conduct a complete medical evaluation of an alleged torture victim using Istanbul Protocol standards, including assessments of physical and psychological evidence of torture To develop essential interview skills including: effective communication, earning trust, balancing empathy and objectivity, applying … Continue reading