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Torture

Module 6: Psychological Evidence of Torture and Ill-Treatment

Objectives

  • To appreciate the central role of psychological evaluation in medical evaluations of torture and ill-treatment
  • To understand how to conduct a psychological evaluation, document psychological findings, and formulate clinical impressions and conclusions regarding torture and ill-treatment
  • To review transference, counter-transference, re-traumatisation issues
  • Using the Psychological Evaluations # 1 and #2, students will be asked to develop interpretations of the psychological findings and conclusions and recommendations using Istanbul Protocol standards
  • To understand the value and limitations of diagnostic classifications (ICD-10 and DSM) in the evaluation of psychological evidence of torture and ill-treatment
  • To understand the value and limitations of psychometric instruments (questionnaires, scales, etc) during the psychological evaluation
  • To be familiar with psychological evaluations of torture and ill-treatment in children

Content

  • The central role of the psychological evaluation
  • Conducting the psychological evaluation
  • Psychological findings and diagnostic considerations
  • Components of the psychological/psychiatric evaluation
    • Identifying Data
    • History of Torture and Ill-treatment
    • Current Psychological Complaints
    • Post-torture History
    • Pre-torture History
    • Medical History
    • Past Psychiatric History
    • Neuro-psychological Assessment
    • Mental Status Examination
    • Assessment of Social Function
    • Psychological Testing and the Use of Checklists and Questionnaires
    • Clinical Impression
    • Recommendations
    • Treatment Considerations
  • Children and Torture
    • Developmental Considerations
    • Clinical Considerations
    • Role of the Family
  • International statistical classification of diseases and related health problems, Annex

Discussion Topics

  • Students should work in groups or individually on one or both of the Psychological Evaluations (#1 and #2, see Appendix I at the end of this Module). Each group should write up their interpretation of findings and conclusions and recommendations.
  • Additional Discussion Topics:
    • Discuss the reasons why some survivors of torture have difficulties recalling and recounting their experiences
    • Discuss possible reasons for inconsistencies in the evaluation and strategies to explain inconsistencies in medico-legal reports
    • Discuss how to assess the possibility of simulation of psychological symptoms
    • Discuss who can/should conduct the psychological evaluations in your country (consider: qualifications, authority, official vs. non-official, etc)
    • Discuss current, country-specific challenges in conducting psychological evaluations of torture and ill-treatment and their validity, or lack thereof, in medico-legal contexts

Teaching Formats

  • Group Activity:
    • Students should work in groups or individually on one or both of the Psychological Evaluations (#1 and #2, see Appendix I at the end of this Module). Each group should write up their interpretation of findings and conclusions and recommendations based on Istanbul Protocol standards.
    • A facilitator should be identified to moderate the discussion and rapporteur should be identified to record the group’s findings and report them when the class reconvenes.
    • After 20-30 minutes of group discussion, the entire class should reconvene
    • Rapporteurs should briefly report on their group’s findings
    • Open class discussion
  • Alternative Option:
    • Divide the class into several groups and assign each group with one or more (or all) of the Discussion Topics
    • Follow the usual sequence for conducting group activities as outlined above
  • Individual Research/Assignment:
    • Individual students should assigned to read one or both of the Psychological Evaluations and write up their interpretation of findings and conclusions and recommendations based on Istanbul Protocol
  • Journal Entry: (Instructor to assign; Write a few paragraphs — no more than a page)
    • Respond to one or more of the Discussion Topics
    • In your opinion, what are the most significant challenges in conducting a psychological evaluation of torture and ill treatment? Explain.

Primary Resources

  • The Istanbul Protocol, Chapter VI
  • Psychological Evaluation of Torture Allegations: An International Training Manual
  • The Medical Documentation of Torture
  • Medical Investigation and Documentation of Torture: A Handbook for Health Professionals
  • Trainers’ Guidelines for Health Professionals: Training of Users

Objectives To appreciate the central role of psychological evaluation in medical evaluations of torture and ill-treatment To understand how to conduct a psychological evaluation, document psychological findings, and formulate clinical impressions and conclusions regarding torture and ill-treatment To review transference, … Continue reading →

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Torture in the World Today

Amnesty International documented cases of torture and other cruel, inhuman or degrading treatment in 81 countries in 2007.[1] Some studies indicate that between 5 and 35% of the world’s refugees have been estimated to have experienced torture.[2] In 2007, there were 15.9 million refugees around the world and an estimated 26 million people displaced internally by conflict.[3] This suggests that the number of torture survivors in the world today may range from 2 to 15 million. These estimates do not include those affected by war or other human rights violations.

Among foreign-born patients presenting to an urban primary care center in the United States, approximately 1 in 9 met the definition established by the UN Convention Against Torture. As survivors of torture, these patients may have significant psychological and physical sequelae. This statistic underscores the necessity for primary care physicians to screen for a torture history among foreign-born patients and to effectively address their problems.[4]

[1] Amnesty International Annual Report 2008: The State of the World’s Human Rights. Available at: http://thereport.amnesty.org/eng/facts-and-figures [1]

[2] Baker R: Psychosocial consequences for tortured refugees seeking asylum and refugee status in Europe, chap 5, In Basoglu M (Ed): Torture and Its Consequences: Current Treatment Approaches. New York, NY, Cambridge University Press, 1992.

[3] Refugees International. Helpful Facts and Figures. Available at: http://www.refugeesinternational.org/get-involved/helpful-facts-%2526-figures [2]

[4] Crosby SS, Marie Norredam M, Paasche-Orlow MK, Piwowarczyk L, Heeren T, and Michael A Grodin MA. Prevalence of Torture Survivors Among Foreign-Born Patients Presenting to an Urban Ambulatory Care Practic. J Gen Intern Med. 2006 July; 21(7): 764–768.

Quelle

  • [1] http://thereport.amnesty.org/eng/facts-and-figures
  • [2] http://www.refugeesinternational.org/get-involved/helpful-facts-%2526-figures

Amnesty International documented cases of torture and other cruel, inhuman or degrading treatment in 81 countries in 2007.[1] Some studies indicate that between 5 and 35% of the world’s refugees have been estimated to have experienced torture.[2] In 2007, there … Continue reading →

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Issues surrounding examinations of individuals in the presence of security forces

Health professionals, whether working in places of detention, called to visit a police station or other place of detention, or working in national health services, may well be presented with detainees to examine in the presence of security forces. The reasons for such examination may include a statutory initial medical examination upon arrival in a place of detention, complaint of illness or ill-treatment by a detainee, or routine referral for medical treatment. When faced with a detainee, the health professional must apply their usual ethical principles in any assessment and treatment. The detainee must give informed consent to any examination, procedure or treatment, and this should include an explanation of who will have access to any findings, and how these findings may be used. Informed consent requires that the consenting individual:

  • Is mentally competent
  • Receives full disclosure of information, i.e. risks vs. benefits
  • Understands the information provided
  • Gives his/her consent voluntarily
  • Provides authorisation for his/her consent

Two further points of particular importance in the examination of detainees must be highlighted: the maintenance of medical confidentiality and the use of restraints (such as handcuffs) on detainees. Medical ethics dictates that consultations and the information gained therein should be confidential between the doctor and the patient. In the case of prisoners, the security forces (police, military or prison guards) will often maintain that they must remain present during any consultation, the most common reason being that it is for the protection of the health professionals. In some circumstances, the security personnel might insist that the detainee remain in restraints (handcuffs, ankle-cuffs) and even with a hood or blindfold during the consultation. Thus there is an immediate conflict between security and medical concerns.

As stated above, health professionals have a duty to observe their usual ethical practise in their treatment of detainees. In brief, there can be no blanket rule that dictates that all detainees are dangerous and merit, in all circumstances, the presence of security personnel and/or restraints. If escape is an issue, health professionals can conduct consultations with the security personnel outside the door, or as a less acceptable alternative, with the door open and the personnel out of range of hearing. Further, security concerns can be addressed by conducting the consultation in a room that has only one entrance, and either no windows or barred windows.

The routine use of restraints during medical consultation or treatment is also 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.

The use of hoods or blindfolds during any contact between a detainee and health professionals is absolutely unacceptable under any circumstances. The use of hoods or blindfolds has in itself been found to be a form of ill-treatment. In the health setting hoods or blindfolds not only impair any meaningful contact with the patient, they also prevent the identification of any health professionals and may thus add to a perception of impunity in any cases of ill-treatment.

Health professionals, whether working in places of detention, called to visit a police station or other place of detention, or working in national health services, may well be presented with detainees to examine in the presence of security forces. The … Continue reading →

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Objectivity

Conducting an objective and impartial evaluation should not preclude the evaluator from being empathic. It is essential for clinicians to maintain the professional boundaries and at the same time to acknowledge the pain and distress that they observe. The clinician should communicate their understanding of the individual’s pain and suffering and adopt a supportive, non-judgmental approach. Clinicians need to be sensitive and empathic in their questioning while remaining objective in their clinical assessment.

Conducting an objective and impartial evaluation should not preclude the evaluator from being empathic. It is essential for clinicians to maintain the professional boundaries and at the same time to acknowledge the pain and distress that they observe. The clinician … Continue reading →

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Psychosocial History (post-arrest)

It is also important to obtain information concerning the individual’s post-detention/torture psychosocial history, including any difficulties the individual may have experienced such as continued harassment/persecution by authorities, fear for his/her own safety as well as the safety of family/friends following release from detention, inability to return to work or school. Obtain summary information concerning the events of the individual fleeing his/her country of origin and arrival in subsequent locations.

It is also important to obtain information concerning the individual’s post-detention/torture psychosocial history, including any difficulties the individual may have experienced such as continued harassment/persecution by authorities, fear for his/her own safety as well as the safety of family/friends following … Continue reading →

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Asphyxiation

The most common way of inducing asphyxia to near-death is submarino as it is nicknamed in Latin American countries. The head is immersed in water for minutes at a time to the point of drowning, then brought out and immersed again. In some countries the victim is suspended by the ankles and lowered repeatedly into a tank. A variant of submarino is for a plastic bag or similar impervious material filled with liquid to be tied over the head. In all these techniques the water is often contaminated with sewage or chemicals, adding to the immediate distress and increasing the likelihood of permanent ill-effects.

“Waterboarding” is another form of asphyxiation torture that dates back to the Middle Ages and recently practised by the United States. Victims are strapped to a board or made to lie in a supine position with their heads lower than the rest of their bodies, their faces covered with cloth, and water is poured over their mouths to create the sensation of drowning.

Dry submarino is practised with a plastic bag or similar impervious material placed over the head and tied tightly around the neck. Again, there is often contaminated material or an irritant such as chilli powder inside the bag. In Sri Lanka a small amount of petrol is often put in the bag so that there is chemical poisoning as well as asphyxiation.

The immediate effects of these techniques vary according to whether there has been any contamination. If so, there is likely to be severe upper respiratory and perhaps broncho-pulmonary inflammation. Conjunctivitis or otitis media may follow, particularly after submarino. Irritants such as petrol or chilli may cause a dermatitis which is indistinguishable from acne. Any long-term effects of these techniques are not easy to assess but many victims attribute their asthma or bronchitis to having been asphyxiated many years previously. If there was no history of pre-existing disability, it may be reasonable to consider this as a possibility.

The most common way of inducing asphyxia to near-death is submarino as it is nicknamed in Latin American countries. The head is immersed in water for minutes at a time to the point of drowning, then brought out and immersed … Continue reading →

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Safeguards for special categories of detainees

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. Some groups may be targeted for discriminatory abuse by the staff of the institution where they are detained. They may also be vulnerable to abuse from other detainees.

Women in detention

The Human Rights Committee has expressed concern at the practise of allowing male prison officers access to women’s detention centres, which has led to serious allegations of sexual abuse of women and the invasion of their privacy.[1] It has also stated that female staff should be present during the interrogation of female detainees and prisoners and should be solely responsible for conducting body searches.[2]

The Standard Minimum Rules for the Treatment of Prisoners state that women in custody should be supervised by female members of staff.[3] They should also either be held in separate institutions, or segregated within an institution, under the authority of female staff. No male staff should enter the part of the institution set apart for women unaccompanied by a female member of staff.[4] In institutions where women are held in custody, facilities for pre-natal and post-natal care and treatment must be provided.[5] Whenever possible, arrangements should be made for children to be born in a hospital outside the institution.[6] The UN Special Rapporteur on Torture has recommended that states should provide gender-sensitive training for judicial and law enforcement officers and other public officials.[7]

Juvenile detainees

Some specific obligations with respect to the use of pre-trial detention in cases involving children are found in the Convention on the Rights of the Child. The Convention applies to children up to the age of 18, who would normally be regarded as juveniles within most criminal justice systems. Article 37 emphasises that the detention of children – pre-trial or any other form – should be a measure of last resort and used for the shortest appropriate period of time. It requires due account to be taken of the needs of children who are deprived of their liberty and that they should be kept separately from adults unless it is considered in their best interest not to do so. Article 39 obliges states, inter alia, to promote physical and psychological recovery and social reintegration of a child victim of torture or any other form of cruel, inhuman or degrading treatment or punishment as well as any form of neglect, exploitation, or abuse.

People with mental health problems

The Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care state that: ‘All persons with a mental illness, or who are being treated as such persons, shall be treated with humanity and respect for the inherent dignity of the human person.’[8] ‘All persons with a mental illness, or who are being treated as such persons, have the right to protection from economic, sexual and other forms of exploitation, physical or other abuse and degrading treatment.’[9]

The Standard Minimum Rules for the Treatment of Prisoners also state that people with mental health problems shall not be detained in prisons and ‘shall be observed and treated in specialized institutions under medical management.’[10]

[1] Observations of the Human Rights Committee: USA, UN Doc. CCPR/C/79/Add.50, 7 April 1995, para.20.

[2] Human Rights Committee, General Comment 16, (Twenty-third session, 1988), Compilation of General Comments and General Recommendations Adopted by Human Rights Treaty Bodies, U.N. Doc. HRI\GEN\1\Rev.1 at 21 (1994), para. 8.

[3] Standard Minimum Rules 8(a) and 53.

[4] Ibid.

[5] Rule 23.

[6] Ibid.

[7] Report of the UN Special Rapporteur on Torture, UN Doc. E/CN.4/1995/34, p. 8.

[8] Principle 2.

[9] Principle 3.

[10] Standard Minimum Rules para. 82.

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 … Continue reading →

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Module 7: Case Example #01

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 #01 by students
  • Interview of individual role-player (alleged torture victim) by students or instructors (NOTE: role-players use Case Narrative #01 to act their parts)
  • Instructor supervision/demonstration of interview(s) using Guidelines for Instructors
    Case #01 (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 Examples #01 (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 →

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Country-Specific Legal Standards and Torture Practices

Torture practises vary, to some extent, in different regions of the world, as do national legal standards, and the extent of human rights monitoring and documentation of such practises. A systematic, country-specific review of legal standards and torture practises is beyond the scope of this Curriculum. The editors of the Model Curriculum advise instructors and students to research and include relevant country-specific materials for effective national adaptation of the modules contained in this curriculum.

The Prevention through Documentation Project has included 10 target countries (Georgia, Mexico, Morocco, Sri Lanka Uganda, Ecuador, Egypt, Kenya, the Philippines, and Serbia). Country assessment reports by the IRCT are availabe (see: http://www.irct.org/Target-countries-2709.aspx [6]) and may serve as a model for national adaptation efforts. A series of national adaptation resources have been developed to relate generic, international materials to local settings (see: http://www.irct.org/Purpose—principles-2715.aspx [7] or contact the IRCT for additional information).

The following additional resources may be helpful in researching relevant country conditions:

Human Rights Reports

Treatment Centers for Survivors of Torture

Quelle

  • [1] http://cpt.coe.int/en
  • [2] http://www1.umn.edu/humanrts/research
  • [3] http://www.state.gov/g/drl/rls/hrrpt
  • [4] http://www2.ohchr.org/english/issues/torture/rapporteur
  • [5] http://www.ohchr.org/EN/Pages/WelcomePage.aspx
  • [6] http://www.irct.org/Target-countries-2709.aspx
  • [7] http://www.irct.org/Purpose---principles-2715.aspx
  • [8] http://www.amnesty.org
  • [9] http://www.hrw.org
  • [10] http://www.un.org
  • [11] http://www.irct.org/Find-IRCT-members-33.aspx
  • [12] http://www.medecinsdumonde.org
  • [13] http://physiciansforhumanrights.org
  • [14] http://www.ifrc.org
  • [15] http://www.irct.org
  • [16] http://www.amnesty.org/en/health-and-human-rights/research/links

Torture practises vary, to some extent, in different regions of the world, as do national legal standards, and the extent of human rights monitoring and documentation of such practises. A systematic, country-specific review of legal standards and torture practises is … Continue reading →

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Abusive medical treatment

Health professionals should also be wary of any attempts (from officials) to ask them to administer treatment or medication that are not aimed at benefiting the physical or mental health of the patient, but only at assisting an interrogation or the management of a patient or detainee.

The individual need not be in prison, or in detention at all, to be tortured. Health professionals must be aware that they might be considered responsible for ill-treatment in settings where patients do not have freedom of movement, for example, those detained under mental health legislation or in facilities for the elderly. Inappropriate use of medical treatment, such as overuse of sedatives, may also be ill-treatment.

For information on the role of medical personnel in torture by the United States in its “War on Terror,” see: http://www.uctv.tv/search-details.asp?showID=15575 [1], a presentation by: Vincent Iacopino MD, PhD, Physicians for Human Rights, in the Global Health and Human Rights series, offered by the UCSF Mini Medical School for the Public, October 23, 2008.

Quelle

  • [1] http://www.uctv.tv/search-details.asp?showID=15575

Health professionals should also be wary of any attempts (from officials) to ask them to administer treatment or medication that are not aimed at benefiting the physical or mental health of the patient, but only at assisting an interrogation or … Continue reading →

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