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Training

Curriculum Materials

Model Curriculum

Consisting of 9 Modules (see Summary of Content below). The Modules serve as the overall knowledge base for the Model Curriculum.

Istanbul Protocol

Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment

PowerPoint (PPT) Presentations

There is a PPT Presentation to accompany each of the 9 Modules. The Presentations were designed primarily for instructors who prefer to use a lecture format. The content of the PPT presentations closely parallels that of the Modules.

Case Examples #01 and #02

Two case examples have been incorporated into Modules 7 and 8. They are designed to give students practical experience interviewing alleged victims of torture and documenting physical and psychological evidence. The medical evaluations that students develop from these case examples should be applied to Mock Court Proceedings in Module 9.

Psychological Evaluations 1 and 2

Two Psychological Evaluations are included in Module 6 to provide students with an opportunity to develop clinical impression from information contained in actual asylum cases.

Self-Assessments (quizzes)

For each Module, there is a related Self-Assessment that is designed specifically for individual student users to assess their knowledge of curriculum content. The Self-Assessments may be applied to other teaching formats as well.

Audio File

In Module 3, students will listen to an audiotape of an interview with a torture survivor, Sr Diana Ortiz, to better understand the challenges of interviewing survivors, particularly the emotional reactions of survivors and clinicians.

Quelle

  • [1] https://phrtoolkits.org/toolkits/istanbul-protocol-model-medical-curriculum/module-7-case-example-01/materials/
  • [2] https://phrtoolkits.org/toolkits/istanbul-protocol-model-medical-curriculum/module-8-case-example-02/materials/
  • [3] https://phrtoolkits.org/toolkits/istanbul-protocol-model-medical-curriculum/module-6-psychological-evidence-of-torture-and-ill-treatment/apendix-i/psychological-evaluation-1/
  • [4] https://phrtoolkits.org/toolkits/istanbul-protocol-model-medical-curriculum/module-6-psychological-evidence-of-torture-and-ill-treatment/apendix-i/psychological-evaluation-2/

Model Curriculum Consisting of 9 Modules (see Summary of Content below). The Modules serve as the overall knowledge base for the Model Curriculum. Istanbul Protocol Model Medical Curriculum (pdf) Istanbul Protocol Manual on the Effective Investigation and Documentation of Torture … Continue reading →

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The aim of medical documentation

Medical documentation may be critical to legal investigations of torture through the following means:

  • Producing a contemporaneous record (a record as close in time as possible to the event) of signs and symptoms of ill-treatment when an individual presents to any health professional for treatment after the event – the examining health professional may not be called upon to produce a report, but in the future an expert may be asked to use this record to form an opinion of events at the time
  • Providing detailed understanding of the case so that the person can be referred for the appropriate treatment and rehabilitation in a specialised centre or by other specialists
  • The production of a medico-legal report for submission to a judicial or administrative body:
    • for judicial enquiries or court cases aimed at the prosecution of perpetrators
    • for a judicial process which decides on the responsibility of the state
    • for a judicial process which decides upon compensation/reparations for survivors
    • in individual cases where a medico-legal report may be used as part of a court application to end on-going abuse while the person is still in detention
    • for the case of asylum seekers when medical evidence may be used as part of the evidence (e.g. in hearings) to show a history of ill-treatment in another country and the physical and psychological consequences thereof.
  • The documentation of patterns of widespread abuse. Courts, NGOs, and inter-governmental mechanisms, can all have need for knowledge of the existence of widespread abuse. Assessment of the prevalence of torture and other ill-treatment, relies upon well-documented individual allegations
  • The production of supporting material during visits to places of detention. Medical documentation may not necessarily lead to the production of a medico-legal report on specific cases, but the medical findings can be used more generally to support allegations of conditions and treatment amounting to torture or other ill-treatment.

Medical documentation may be critical to legal investigations of torture through the following means: Producing a contemporaneous record (a record as close in time as possible to the event) of signs and symptoms of ill-treatment when an individual presents to … Continue reading →

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Introduction

Effective medical investigation and documentation of torture and ill-treatment require clinicians to have a detailed understanding of torture methods and their physical and psychological sequelae. This Module provides a review of common torture methods and their medical consequences. It is important to keep in mind that it is difficult to separate physical from psychological torture, as each has a component of the other; for example, hooding not only impedes normal breathing, but also produces disorientation and fear. In addition, physical forms of torture and ill treatment will generally produce both physical and psychological sequelae, and psychological forms of torture and ill-treatment often result in psychological sequelae, but may also produce physical sequelae as well.

The methods of torture and ill-treatment included in this module are not exhaustive. The actual methods that a survivor experiences are only limited by the imagination and cruelty of his or her torturers. As mentioned in Module 1, it is important to realize that, although there is much similarity of torture methods around the world, there can be regional and country-specific variations. Instructors and students who use this Model Curriculum should be aware of regional, country-specific, and local practises and adapt them to the Model Curriculum materials accordingly with relable and current human rights reports.

Although physical torture as practised around the world has many features in common, almost invariably including beating, slapping and kicking, more sophisticated techniques have been developed in many areas. In countries whose authorities wish to disguise the fact that torture takes place, methods are devised, sometimes with the help of doctors, that produce maximum pain with minimum external evidence. This must be recognised by the examiner if the after-effects of these techniques are not to be missed, especially after the passage of time. Documentation of special methods of torture alleged by an individual requires that the examiner has a detailed knowledge of torture techniques used in the country where the torture was alleged to have taken place. With this knowledge the interviewer can take an informed and detailed history (taking care to avoid using leading questions). This helps to give a precise picture of such details of torture as the victim’s posture, clothing, blindfolding or hooding, the implements used, duration of assault and his or her condition at the end of the session – whether he or she could walk or whether there were any bleeding wounds. It cannot be emphasised too strongly that such a detailed history is essential to ensure that, during the subsequent physical examination, signs in the relevant areas of the body are not missed and that a correct differentiation from accidental or self-inflicted injury is made. For this reason it is necessary to review, at length, some of the techniques employed in different countries before outlining the symptoms and signs to be expected during history-taking and physical examination. Of particular value in assessing the severity of the attack is a history of loss of consciousness, though this should be elaborated by questions aimed at finding out whether unconsciousness was caused by blows to the head, asphyxiation, unbearable pain or exhaustion.

As discussed in Module 3, survivors may be unable to describe exactly what happened to them because they may have been blindfolded, lost consciousness, sustained head injury, or have difficulty recalling or revealing the especially traumatic components of their experience. It is important to realize that torturers often attempt to conceal their deeds. For example, physical evidence of beating may be limited when a wide, blunt objects are used for beatings. Similarly, victims are sometimes covered by a rug, or shoes in the case of falaka, to distribute the force of individual blows. For the same reason, wet towels may be used with electric shocks. In other cases, torturers use methods with the intent of producing maximal pain and suffering with minimal evidence, for example, forced positioning, near asphyxiation, mock executions, temperature manipulation, sensory deprivation, prolonged isolation, threats of harm to the individual and his or her family, and sexual humiliations, among many others.

It is important to understand that some methods on their own may amount to torture; in other cases significance is attached to the use of a combination of methods, which may collectively amount to torture. Also, the length of time over which the individual is subjected to the methods may be decisive. Again, for this reason, it is important to document as accurately and completely as possible all the events to which an individual was exposed and their consequences.

The Subjective Element of Suffering

It is important to keep in mind that, when assessing the degree of suffering involved, one should take into account the identity and background of the alleged victim. For example, certain situations that might be relatively bearable for some people could be degrading and humiliating to those of a particular gender, culture or religious faith. Torture and other ill-treatment can also often go hand-in-hand with discrimination, based on race, religion, gender or other factors, which may exacerbate the distress. In addition, physical and mental suffering can differ amongst categories of victims, for example some tortures may exacerbate pre-existing health problems, and children may experience a higher degree of suffering than adults undergoing similar ill-treatment. All these factors should be taken into account in documenting the alleged victim’s experience.

Effective medical investigation and documentation of torture and ill-treatment require clinicians to have a detailed understanding of torture methods and their physical and psychological sequelae. This Module provides a review of common torture methods and their medical consequences. It is … Continue reading →

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The Central Role of the Psychological Evaluation

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 →

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Module 1 Answers

  1. Answer: A, B, D

    Torture as defined by CAT, involves the intentional infliction of severe mental or physical pain or suffering, by or with the consent or acquiescence of the state authorities, for a specific purpose, such as gaining information, punishment or intimidation or for any other reason. It does not include pain or suffering arising only from, inherent in or incidental to lawful sanctions.

  2. Answer: B, C, D

    Ill-treatment does not have to be inflicted for a specific purpose, but there does have to be an intent to expose individuals to the conditions which amount to or result in the ill-treatment. Like torture, ill-treatment is perpetrated by or with the consent or acquiescence of the state authorities.

  3. Answer: C

    Amnesty International documented cases of torture and other cruel, inhuman or degrading treatment in 81 countries in 2007.

  4. Answer: B

    Torture has been practiced throughout history, but universal prohibition against torture was codified in international law only in the aftermath of WWII in 1948. The UN Convention on Torture Against Torture was adopted by the UN General Assembly considerably later in 1984.

  5. Answer: E

    Torture commonly serves the purpose of suppressing and punishing political opponents and alleged criminals and to achieve social control by inducing a sense of terror in a population, but it is also frequently used in interrogations to force confessions. Moreover, torture can occur where there is no obvious purpose.

  6. Answer: D

    The prohibition of torture and ill-treatment is absolute; such acts cannot be justified under any circumstances including, national security, states of emergency, the need to counter terrorism, or following orders from one’s superiors.

  7. Answer: B

    Non-refoulment in the Convention against Torture refers to the forcible return or extradition of a person to another country where he or she is at risk of torture.

  8. Answer: True

    States are responsible for safeguarding the rights of everyone within their jurisdiction and may under some circumstances be held accountable for acts carried out by private individuals if it supports or tolerates them, or fails in other ways to provide effective protection in law and in practice against them.

  9. Answer: True

    Torture and ill treatment are often perpetrated in the process of criminal investigations in order to obtain false confessions to alleged crimes and in the context of claims of national security.

  10. Answer: False

    The prohibition of torture is not limited to a negative obligation to refrain from causing suffering, but also contains wider obligations: including the obligation to investigate allegations, even if there has not been a formal complaint about it, and to bring the perpetrators to justice. The UN Convention Against Torture states clearly in article 12: “Each State Party shall ensure that its competent authorities proceed to a prompt and impartial investigation, wherever there is reasonable ground to believe that an act of torture has been committed in any territory under its jurisdiction.”

  11. Answer: D

    The ICRC’s findings are communicated and discussed on a confidential basis with the concerned authorities and are not made available to the public. The ICRC undertakes visits under nonnegotiable modalities which include: access to all places of detention and all people detained and to make a register of all those who wish to have their details recorded; the possibility to select individual detainees to talk with in private, and the possibility to repeat the visits as often as is deemed necessary. During visits, the ICRC takes the humane treatment of detainees to encompass not only freedom from torture and other ill-treatment, but also general conditions of detention that maintain both the physical and mental integrity of the individuals.

  12. Answer: False

    The prohibition of torture is the concern not only of those countries which have ratified particular treaties, but is also a rule of general or customary international law, which binds all states even in the absence of treaty ratification. In fact, the prohibition of torture is generally regarded as having the special status of a ‘peremptory norm’ of international law, and states cannot choose to disregard or derogate from it.

  13. Answer: True

    The Convention Against Torture (Article 14) indicates that victims of torture have a right to redress and adequate compensation.

  14. Answer: E

    People are particularly at risk when they are deprived of their liberty, held in pre-trial detention or subject to interrogation. The greatest risk is in the first phase of arrest and detention, before the person has access to a lawyer or court. People being held in incommunicado detention – without access to anyone in the outside world – are particularly vulnerable.

  15. Answer: True

    Optional Protocol to the UN Convention Against Torture established a complementary dual system of regular visits by independent international and national bodies to places of detention in order to prevent torture and ill-treatment.

  16. Answer: E

    The Human Rights Committee has stated that the protection of detainees requires that each person detained be afforded prompt and regular access to doctors. The Body of Principles for the Protection of All Persons under Any Form of Detention or Imprisonment state that ‘a proper medical examination shall be offered to a detained or imprisoned person as promptly as possible after his admission to the place of detention or imprisonment, and thereafter medical care and treatment shall be provided whenever necessary. This care and treatment shall be provided free of charge. Detainees have the right to request a second medical opinion by a doctor of their choice, and to have access to their medical records.

  17. Answer: True

    Rule 22(2) of the UN Standard Minimum Rules for the Treatment of Prisoners states that detainees or prisoners needing special treatment must be transferred to specialised institutions or civil hospitals for that treatment.

  18. Answer: E

    All of the measures listed above are important in the prevention of torture and ill treatment. Additional prevention measures include non-refoulement or no transfer to a country where torture is likely, providing detainees access to family members and friends, and the training of state officials, including medical personnel, on torture prohibition.

  19. Answer: A, C, D

    Effective investigation of alleged torture and ill treatment and criminal prosecution of alleged perpetrators are essential for accountability. Adequate victim and witness protection is a critical component of such prosecutions. Allowing torture to be prosecuted as a lesser crime such as “abuse of police duty” would likely have a permissive effect on torture and ill treatment practices.

  20. Answer: False

    All detained people have the right to equal treatment without discrimination on the grounds of race, colour, sex, sexual orientation, language, religion, political or other opinion, national or social origin, property, birth or other status. Particular allowances should, however, be made for the rights and needs of special categories of detainees including women, juveniles, elderly people, foreigners, ethnic minorities, people with different sexual orientation, people who are sick, people with mental health problems or learning disabilities, and other groups or individuals who may be particularly vulnerable during detention.

Answer: A, B, D Torture as defined by CAT, involves the intentional infliction of severe mental or physical pain or suffering, by or with the consent or acquiescence of the state authorities, for a specific purpose, such as gaining information, … Continue reading →

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Summary of Content

Module 1: International Legal Standards

The first Module [3] provides students with a foundation for understanding how torture is defined in international law, and the duties of States to prohibit torture and ill-treatment. It reviews common torture practises in the world today. As mentioned above, instructors should add country-specific information such as national norms and regional practise. A number of resources are suggested for this purpose. Module 1 also discusses international and regional monitoring mechanisms that health professionals should be aware of and specific safeguards for individuals deprived of their liberty. Module 1 should provide students with a foundation for understanding country-specific challenges to torture prevention and accountability and help them identify effective remedial measures.

Module 2: Istanbul Protocol Standards for Medical Documentation of Torture and Medical Ethics

Module 2 [2] introduces students to the Istanbul Protocol, its purpose, history, content, applications and limitations. It reviews procedural safeguards relevant to medico-legal evaluations of torture and ill-treatment. Module 2 also provides a review of medical ethics relevant to torture documentation and outlines the duties of clinicians working with alleged torture victims and detainees in general. Instructors should include additional information on country-specific rules and regulations regarding medical documentation of torture and ill-treatment. This will aid students in addressing country-specific challenges. Module 2 also reviews general guidelines for gathering evidence.

Module 3: Interview Considerations

Module 3 [1] provides a detailed review of interviewing considerations that is relevant not only for clinicians, but lawyers, adjudicators and human rights investigators/monitors. The Module first reviews a wide range of preliminary considerations (interview settings, trust, informed consent, privacy, empathy, safety and security, re-traumatisation, gender considerations, cultural and religious awareness, working with interpreters, and transference and counter-transference reactions, among others) and then discusses how to conduct interivews and the content of the interviews. Students will be asked to listen to an audiotape of a radio interview with a torture survivor and apply what they have learned in Module 3 to their experience of listening to a survivor. This practical exercise will help students to understand the emotions reactions of survivors (transference) and common reactions of clinicians (counter-transference).

Module 4: Torture Methods and their Medical Consequences

Module 4 [4] provides students with a detailed review of the relationship between specific methods of torture and their physical and psychological health consequences. It reviews specific torture methods and ill-treatment, how they are applied, and the possible acute and chronic physical findings associated with them. This information will help students to correlate medical findings and specific allegations of torture and ill-treatment. The Module also provides a review of common psychosocial consequences of torture and ill-treatment and factors that may affect the variability of psychological evidence.

Module 5: Physical Evidence of Torture and Ill Treatment

Module 5 [5] provides a detailed review of physical examination methods used to evaluate physical evidence of torture and ill-treatment. It begins with a review relevant questions for the medical history, then provides a systematic organ system review of physical evidence, and concludes with information on medical photography and relevant diagnostic tests. Module 5 will help students assimilate the information needed to evaluate and effectively document physical evidence of torture and ill-treatment. The Self-Assessment quizzes for Modules 4 and 5 will also help students to recognise common physical evidence of torture, provide accurate interpretations of their findings, and understand indications for diagnostic test.

Module 6: Psychological Evidence of Torture and Ill Treatment

Module 6 [8] addresses psychological evidence of torture. It provide clinicians with understanding of the central role of the psychological evaluation, how to conduct and psychological evaluation and how to interpret relevant findings. It reviews the value and limitations of using diagnostic classifications and the use of psychometric instruments. It also includes information on evaluating children who have been directly or indirectly exposed to torture. Case information for two Psychological Evaluations are included at the end of Module 6 to provide students an opportunity to formulate their own clinical impressions and review them with other students and the instructor.

Module 7 & 8: Case Examples

Modules 7 [7] and 8 [6] are designed to help students develop interview and examination skills that are essential to the effective documentation of torture and ill-treatment. Modules 7 and 8 each consist of a Case Example for a role-play interview of an alleged torture victim. Each Module contains Case Summary/Referral infomation that the students review prior to conducting an interview. Role-players act the part of an alleged torture victim using a Case Narrative file, which the students do not have access to. The physical examination findings are limited to photographic images. Each Module contains suggestions for instructors on how to implement the Case Examples and detailed guidelines for instructors to assist with the analysis of the cases.

Module 9: Writing Reports and Testifying in Court

Module 9 [9] provides information on how to write a medical report and provide court testimony. The Module reviews a number of general considerations for report writing, the content of medical reports, how to formulate appropriate interpretations and conclusions, and how to convey them to adjudicators. The Module also discusses how to address the problem of inconsistencies in an individual’s case. Students may be asked to bring their written reports from the Case Examples in Modules 7 and 8 and participate in a Mock Judicial Proceeding, wherein they have an opportunity to present their evidence in “court” and play the role of a cross-examining lawyer. Instructors should consider adding course evaluation component to the end of Module 9.

Quelle

  • [1] https://phrtoolkits.org/toolkits/istanbul-protocol-model-medical-curriculum/module-3-interview-considerations/
  • [2] https://phrtoolkits.org/toolkits/istanbul-protocol-model-medical-curriculum/module-2-istanbul-protocol-standards-for-medical-documentation-of-torture-and-medical-ethics/
  • [3] https://phrtoolkits.org/toolkits/istanbul-protocol-model-medical-curriculum/module-1-international-legal-standards-overview/
  • [4] https://phrtoolkits.org/toolkits/istanbul-protocol-model-medical-curriculum/module-4-torture-methods-and-their-medical-consequences/
  • [5] https://phrtoolkits.org/toolkits/istanbul-protocol-model-medical-curriculum/module-5-physical-evidence-of-torture-and-ill-treatment/
  • [6] https://phrtoolkits.org/toolkits/istanbul-protocol-model-medical-curriculum/module-8-case-example-02/
  • [7] https://phrtoolkits.org/toolkits/istanbul-protocol-model-medical-curriculum/module-7-case-example-01/
  • [8] https://phrtoolkits.org/toolkits/istanbul-protocol-model-medical-curriculum/module-6-psychological-evidence-of-torture-and-ill-treatment/
  • [9] https://phrtoolkits.org/toolkits/istanbul-protocol-model-medical-curriculum/module-9-report-writing-and-testifying-in-court/

Module 1: International Legal Standards The first Module provides students with a foundation for understanding how torture is defined in international law, and the duties of States to prohibit torture and ill-treatment. It reviews common torture practises in the world … Continue reading →

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Types of evidence

Medical evidence is one of many types of substantiation given to allegations of torture and other ill-treatment, and will often be used in conjunction with other forms of evidence. These will commonly include:

  • The individual’s statement
  • Witness statements
  • Other forms of third party evidence, such as the testimony of a forensic scientist or other expert
  • Objective evidence of a widespread occurrence of torture in the circumstances referred to
  • Anything else which can help to support and prove an allegation.

Medical evidence is one of many types of substantiation given to allegations of torture and other ill-treatment, and will often be used in conjunction with other forms of evidence. These will commonly include: The individual’s statement Witness statements Other forms … Continue reading →

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Torture Methods

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General Considerations for Interviews

The Istanbul Protocol outlines some specific guidelines for forensic examiners to use when conducting evaluations. The purpose is to elicit information in a humane and effective manner. During the evaluation, examiners should pay attention to the psychosocial history of the alleged victim. Relevant psychosocial history may include inquiries into “…the person’s daily life, relations with friends and family, work or school, occupation, interests, future plans and use of alcohol and drugs.” Information about any prescription drugs is important, since the discontinuation of any medications during custody could affect the detainee’s health. Health professionals should be aware of the following considerations in the course of conducting their medical evaluations (see Module 3 for a detailed discussion):

  • Informed Consent: Health professionals must ensure that individuals understand the potential benefits and potential adverse consequences of an evaluation and that the individual has the right to refuse the evaluation.
  • Confidentiality: Health professionals and interpreters have a duty to maintain confidentiality of information and to disclose information only with the alleged victim’s consent.
  • Setting: The location of the interview and examination should be as safe and comfortable as possible, including access to toilet facilities. Sufficient time should be allotted to conduct a detailed interview and examination.
  • Control: The professional conducting the interview/examination should inform the alleged victim that he or she can take a break if needed or to choose not to respond to any question or to stop the process at any time.
  • Earning Trust: Trust is an essential component of eliciting an accurate account of abuse. Earning the trust of one who has experienced torture and other forms of abuse requires active listening, meticulous communication, courtesy, and genuine empathy and honesty.
  • Translators: Professional, bicultural interpreters are often preferred, but may not be available.
  • Preparation for the Interview: Health professionals should read relevant material in order to understand the context of the alleged abuse and to anticipate regional torture practises.
  • Interview Techniques: Initially, questions should be open-ended, allowing a narration of the trauma without many interruptions. Closed questions are often used to add clarity to a narrative account or to carefully redirect the interview if the individual wanders off the subject.
  • Past Medical History: The health professional should obtain a complete medical history, including prior medical, surgical or psychiatric problems. Be sure to document any history of injuries before the period of detention or abuse, and note any possible after-effects.
  • Trauma History: Leading questions should be avoided. Inquiries should be structured to elicit a chronological account of the events experienced during detention. Specific historical information may be useful in corroborating accounts of abuse. For example, a detailed account of the individual’s observations of acute lesions—and the subsequent healing process—often represents an important source of evidence in corroborating specific allegations of torture or ill-treatment. Also, historical information may help to correlate individual accounts of abuse with established regional practises. Useful information may include descriptions of torture devices, body positions, and methods of restraint; descriptions of acute and chronic wounds and disabilities; and information about perpetrators’ identities and place(s) of detention.
  • Review of Torture Methods: It complements the trauma history to explore abuses that could have been forgotten or avoided by the alleged victim due to their nature (e.g. rape). The review is not intended to be an exhaustive checklist; it should be individually tailored according to the trauma history or to the relevant regional or local practices.
  • Pursuit of Inconsistencies: An alleged victim’s testimony may, at first, appear inconsistent unless further information is gathered. Factors that may interfere with an accurate recounting of past events may include: blindfolding, disorientation, lapses in consciousness, organic brain damage, psychological sequelae of abuse, fear of personal risk or risk to others, and lack of trust in the examining clinician.
  • Nonverbal Information: Include observations of nonverbal information such as affect and emotional reactions in the course of the trauma history and note the significance of such information.
  • Transference and Counter-transference Reactions: Health professionals who conduct medical evaluations should be aware of the potential emotional reactions that evaluations of trauma may elicit in the interviewee and interviewer. These emotional reactions are known as transference and counter-transference. For example, mistrust, fear, shame, rage, and guilt are among the typical transference reactions that torture survivors experience, particularly when asked to recount details of their trauma. In addition, the clinician’s emotional responses to the torture survivor, known as counter-transference (eg, horror, disbelief, depression, anger, over-identification, nightmares, avoidance, emotional numbing, and feelings of helplessness and hopelessness), may affect the quality of the evaluation. Considering survivors’ extreme vulnerability and propensity to re-experience their trauma when it is either recognised or treated, it is critical that health professionals maintain a clear perspective in the course of their evaluations.

The Istanbul Protocol also provides a series of guidelines to ensure procedural safeguards for medical evaluations of detainees alledging torture and ill-treatment (see Procedural Safeguards for Detaines below).

The Istanbul Protocol outlines some specific guidelines for forensic examiners to use when conducting evaluations. The purpose is to elicit information in a humane and effective manner. During the evaluation, examiners should pay attention to the psychosocial history of the … Continue reading →

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Psychological Findings and Diagnostic Considerations

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)[1] Classification of Mental and Behavioural Disorders and the Diagnostic and Statistical Manual of the American Psychiatric Association-Edition IV (DSM-IV).[2] 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.

[1] American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th edition). Washington, DC:APA.

[2] World Health Organisation, (1994). The ICD-10 Classification of mental and behavioural disorders and diagnostic guidelines. Geneva.

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