Components of the Psychological/Psychiatric Evaluation

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.)

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.

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.

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.

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.^[1]

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.

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.

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.

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.

1. Are the psychological findings consistent with the alleged report of torture?
2. Are the psychological findings expected or typical reactions to extreme stress within the cultural and social context of the individual?
3. 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?
4. 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?
5. What physical conditions contribute to the clinical picture? Pay special attention to head injury sustained during torture and/or detention.
6. 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

^[1] Jacobs U, Iacopino V. Torture and its consequences: a challenge to neuropsychology. Professional Psychology: Research and Practice. 2001;32(5): 458–464.