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Torture

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.

It is prudent for clinicians to become familiar with the most commonly diagnosed disorders among trauma and torture survivors and to understand that it is not uncommon for more than one mental disorder to be present as there is considerable … Continue reading →

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Psychosocial History (Pre-Arrest)

The examiner should inquire into the person’s daily life, relations with friends and family, work/school, occupation, interests, and use of alcohol and drugs, prior to the traumatic events. Inquiries into prior political activities and beliefs and opinions are relevant insofar as they help to explain why the person was detained and/or tortured, but such inquiries are best made indirectly by asking the person what accusations were made, or why they think they were detained and tortured. The psychosocial history is particularly important in understanding the meaning that individuals assign to traumatic experiences.

The occupation of the individual is sometimes relevant to the documentation of torture because it might affect the differential diagnosis of any lesions. Occupation can also be a marker of educational attainment, and so can be evidence of a change in cognitive and/or psychosocial functioning. Statements from former colleagues, or documentation of work appraisals, can act as corroboration of this point.

The social background can also be relevant. If the individual has some educational achievements documented, these can be used as indicators of the premorbid intellectual state (the psychological condition the individual was in prior to the trauma). They can then be compared with the evaluation of the individual’s present level of functioning, and judgements can be made about changes, and any possible causation.

The examiner should inquire into the person’s daily life, relations with friends and family, work/school, occupation, interests, and use of alcohol and drugs, prior to the traumatic events. Inquiries into prior political activities and beliefs and opinions are relevant insofar … Continue reading →

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Ear Trauma

Trauma to the ears, especially rupture of the tympanic membrane (eardrum), is a frequent consequence of harsh beatings. The ear canals and tympanic membranes should be examined with an otoscope and injuries described. A common form of torture, known in Latin America as telefono, is a hard slap of the palm to one or both ears, rapidly increasing pressure in the ear canal, thus rupturing the drum. There is often tinnitus for a while. Attacks of otitis media may supervene. Deafness usually gradually improves as the drum repairs itself. Very occasionally there is dislocation of the ossicles which will cause permanent loss of hearing. Even more rarely, a perilymph fistula may lead to vertigo. Few of the long-term signs are specific to torture, but a careful history may make the differentiation from disease possible and an expert may be able to differentiate a perforation resulting from trauma from one caused by infection.

Prompt examination is necessary to detect tympanic membrane ruptures less than 2 millimetres in diameter, which may heal within 10 days. Fluid may be observed in the middle or external ear. If otorrhea (leaking middle ear fluid) is confirmed by laboratory analysis, MRI or CT should be performed to determine the fracture site. The presence of hearing loss should be investigated, using simple screening methods. If necessary, audiometric tests should be conducted by a qualified audiometric technician. The radiographic examination of fractures of the temporal bone or disruption of the ossicular chain is best determined by CT, then hypocycloidal tomography and, lastly, linear tomography.

Trauma to the ears, especially rupture of the tympanic membrane (eardrum), is a frequent consequence of harsh beatings. The ear canals and tympanic membranes should be examined with an otoscope and injuries described. A common form of torture, known in … Continue reading →

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Preliminary Considerations

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

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

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

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

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Use of officially recognized places of detention and the maintenance of effective custody records

The Human Rights Committee has stated that ‘to guarantee the effective protection of detained persons, provisions should be made for detainees to be held in places officially recognised as places of detention and for their names and places of detention, as well as for the names of persons responsible for their detention, to be kept in registers readily available and accessible to those concerned, including relatives and friends.’[1] The European Court of Human Rights has stated that the unacknowledged detention of an individual is a ‘complete negation’ of the guarantees contained in the European Convention against arbitrary deprivations of the right to liberty and security of the person.[2]

The CPT recommends that there should be a complete custody record for each detainee which should record “all aspects of custody and action taken regarding them (when deprived of liberty and reasons for that measure; when told of rights; signs of injuries, mental illness, etc; when next of kin/consulate and lawyer contacted and when visited by them; when offered food; when interrogated; when transferred or released, etc). Further, the detainee’s lawyers should have access to such a custody record.”[3]

The UN Body of Principles for the Protection of All Persons under Any Form of Detention or Imprisonment state that the authorities must keep and maintain up-to-date official registers of all detainees, both at each place of detention and centrally.[4] The information in such registers must be made available to courts and other competent authorities, the detainee, or his or her family.[5] Further to this, these principles state that “in order to supervise the strict observance of relevant laws and regulations, places of detention shall be visited regularly by qualified and experienced persons appointed by, and responsible to, a competent authority distinct from the authority directly in charge of the administration of the place of detention or imprisonment. A detained or imprisoned person shall have the right to communicate freely and in full confidentiality with the persons who visit the places of detention or imprisonment . . . subject to reasonable conditions to ensure security and good order in such places.”[6]

[1] Human Rights Committee, General Comment 20, Article 7 (Forty-fourth session, 1992), Compilation of General Comments and General Recommendations Adopted by Human Rights Treaty Bodies, U.N. Doc. HRI/GEN/1/Rev.1. at 30 (1994), para. 11.

[2] Çakici v Turkey, ECtHR, Judgment 8 July 1999, para. 104.

[3] CPT/Inf/E (2002) 1, p.7, para. 40

[4] Principle 12.

[5] Ibid.

[6] Principle 29.

The Human Rights Committee has stated that ‘to guarantee the effective protection of detained persons, provisions should be made for detainees to be held in places officially recognised as places of detention and for their names and places of detention, … Continue reading →

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Nerve Damage

Many forms of torture can cause nerve damage, including stretching injuries associated with joint damage and physical damage from fractures and incisions. The speed of resolution of nerve damage is relatively predictable, so it may be possible for an expert to determine the approximate time of the original injury from a series of examinations over several months.

‘Palestinian suspension’ can lead to neuropathy of the brachial plexus, especially if it has been prolonged (see Module 4). Sometimes there will be residual signs of this, and if they are still present after two years, they will probably be permanent. ‘Winging’ of the scapula must be looked for (by asking the person to push against a wall and observing the shoulders from behind). Survivors will sometimes describe having suffered weakness of the muscles around the shoulder associated with the loss of certain movements which have recovered progressively over a period of months. If he or she did not have access to information about the clinical processes involved, this description can be very supportive of allegations of torture. Often there is residual pain around the chest and shoulder joint, which may be partially or completely physical or may be psychosomatic.

Peripheral nerve lesions of the hands and feet may also be detected following the prolonged application of restraints (wires, ropes, handcuffs, etc.) to the wrists or ankles. Motor and sensory changes may be transient or, in cases of excessive and prolonged tightening, may be permanent. These lesions are sometimes known as handcuff ‘neuropathies’.

Many forms of torture can cause nerve damage, including stretching injuries associated with joint damage and physical damage from fractures and incisions. The speed of resolution of nerve damage is relatively predictable, so it may be possible for an expert … Continue reading →

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Children and Torture

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Prevention and Accountability

Preventing torture and other forms of ill-treatment is primarily an act of political or professional will and the responsibility to combat it extends to all those in authority in society. Judges and prosecutors, given their role in upholding the rule of law, have a particular responsibility to help prevent acts of torture and ill-treatment by promptly and effectively investigating such acts, prosecuting and punishing those responsible and providing redress to the victims. Preventing and investigating alleged acts of torture poses particular problems for judges and prosecutors, and for the administration of justice, because the crime is usually committed by the same public officials who are generally responsible for upholding and enforcing the law. This makes it more difficult to deal with than other forms of criminality. Nevertheless, judges and prosecutors have a legal duty to ensure that the integrity of their profession and the justice they uphold are not compromised by the continued tolerance of torture, or other forms of ill-treatment.

Health professionals should understand that medical documentation of torture and ill-treatment is one of many critical prevention and accountability measures. The following obligations on governments to ensure protection against torture as recognised in international treaties and customary international law[1] illustrates the context within which medical documenation occurs. These prevention and accountability measures also demonstrate a range of advocacy activities in which health professionals can and should consider for the prevention of torture and ill-treatment.

[1] In particular the UN Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, Articles 7 and 10 of the International Covenant on Civil and Political Rights, Article 3 of the European Convention on Human Rights, Article 5 of the African Charter on Human and Peoples’ Rights, Article 5 Of the American Convention on Human Rights and the Inter-American Convention to Prevent and Punish Torture. Torture is also prohibited under international humanitarian law, in particular common Article 3 to the four Geneva Conventions of 1949, and constitutes an international crime, both in its own right and as an element of genocide, crimes against humanity and war crimes. See on the obligations of states parties under the Convention against Torture, REDRESS, Bringing the International Prohibition of Torture Home: National Implementation Guide for the UN Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, January 2006.

Preventing torture and other forms of ill-treatment is primarily an act of political or professional will and the responsibility to combat it extends to all those in authority in society. Judges and prosecutors, given their role in upholding the rule … Continue reading →

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The Paradox of Psychological Consequences of Torture

The psychological consequences of torture present two paradoxes. First, psychological wounds are the most personal, intimate, and enduring consequences of torture and can affect not only the victim but also his/her family and community. Yet these scars are invisible; there are no objective signs, measurable parameters, lab tests or x-rays that are able to document psychological wounds. The goal of torture is not to simply physically incapacitate the victim, but to reduce the individual to a position of extreme helplessness and distress and break his/her will. At the same time, torture sets horrific examples to those that come in contact with the victim and can profoundly damage intimate relationships between spouses, parents and children, and other family members, as well as relationships between the victims and their communities. In this way, torture can break or damage the will and coherence of entire communities.

The second paradox is that despite the fact that torture is an extraordinary life experience capable of causing a wide range of psychological suffering, extreme trauma such as torture does not always produce psychological problems. Therefore, if an individual does not have mental problems, it does not mean that he/she was not tortured. When there are no physical or psychological findings, this does not refute or support whether torture had actually occurred.

The psychological consequences of torture present two paradoxes. First, psychological wounds are the most personal, intimate, and enduring consequences of torture and can affect not only the victim but also his/her family and community. Yet these scars are invisible; there … Continue reading →

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Developmental Considerations

A child’s reactions to torture depend on age, developmental stage and cognitive skills. The younger the child, the more his/her experience and understanding of the traumatic event is influenced by the immediate reactions and attitudes of caregivers following the event. For children under the age of three who have experienced or witnessed torture, the protective and reassuring role of their caregivers is crucial. Very young children’s reactions to traumatic experiences typically involve hyperarousal, such as restlessness, sleep disturbance, irritability, heightened startle reactions and avoidance. Children over three often tend to withdraw and refuse to speak directly about traumatic experiences. The ability for verbal expression increases during development. A marked increase occurs around the concrete operational stage (8-9 years old), when children develop the ability to provide a reliable chronology of events. During this stage, concrete operations and temporal and spatial capacities develop. These new skills are still fragile and it is usually not until the beginning of the formal operational stage (12 years old) that children are consistently able to construct a coherent narrative. Adolescence is a turbulent developmental period. The effects of torture can vary widely. Torture experiences may cause profound personality changes in adolescents, resulting in antisocial behaviour. Alternatively, the effects of torture on adolescents may be similar to those seen in younger children.

A child’s reactions to torture depend on age, developmental stage and cognitive skills. The younger the child, the more his/her experience and understanding of the traumatic event is influenced by the immediate reactions and attitudes of caregivers following the event. … Continue reading →

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