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Torture

Psychological Evaluation #2

(based on an asylum evaluation conducted by Dr. Uwe Jacobs, Ph.D. on May 8 2001, San Francisco, CA, USA)

Conditions of Interview

Prior to this psychological evaluation, Mr. Doe and his client agreed to the condition that I approach the assessment with no particular result in mind and that I would exercise independent professional judgment on all aspects of this evaluation. Further, the payment of fees would not be connected to the contents of any report or consultation or any particular finding or recommendation on the matter in question.

Prior to commencing the interview, I informed Mr. __ that confidentiality is limited in a forensic psychological examination. I further informed him that I would discuss my findings with his attorney and write a report that his attorney could submit as evidence to the court if deemed helpful. He indicated that he understood my role to be that of an objective evaluator and that a forensic evaluation was not psychological treatment. I further informed Mr. __ that I had reviewed the asylum declaration prepared by his attorney and that I would be reviewing the entire history with him once more.

I interviewed Mr. __ on 4/27/01 for a total of about 5 hours face-to-face at the offices of Survivors International, San Francisco. In addition, I administered the Hopkins Checklist-25 (HCL-25), the Trauma Symptom Inventory (TSI), and the Harvard Trauma Questionnaire (HTQ). Present for the evaluation were Mr. __, myself, Ms. Erika Falk (Survivors International Intake Coordinator and Psy.D. candidate), and Mr. __, who functioned as interpreter and provided limited collateral information where indicated. Prior to the interview, I reviewed the following history and background information which was provided by Mr. __ during the face-to-face interview.

Relevant History

Mr. __ was born and raised in __, a little village near __ in Region ­__ of __. His date of birth on all records has been 5/6/71. However, he states that this date of birth was registered falsely and that he is approximately three years younger. He cannot state his exact and true date of birth and has always used the one given to him. His father registered his sons as older so that they would be done with the compulsory military service sooner and “begin life earlier”. He adds that this was common practice in his geographical area. Mr. __ is the youngest of six children and spent the later part of his childhood alone with his parents after his siblings had all moved away to __. He completed five years of compulsory formal education and was working on his father’s farm from a young age. He briefly stayed with a relative to start a secondary education about 100 km away from his village, but soon returned home to work on the farm.

Mr. __ describes his early family life as harmonious and states that his father was generally more lenient and loving than most fathers. His mother was a homemaker and took care of the household and family. He states that he does not have a very clear memory of his childhood overall, except that he was always working and that his only pastime was riding horses. When he was about 15, the family moved to __, near __. His father had a job as a night watchman and he worked as an apprentice in welding. The interpreter adds here that child labor is illegal in __ but rather commonly practiced.

When asked about the reason for the family’s move, __ states that most of the other 300 families of the village had already left because of the increased clashes between the army and the guerilla army __. He also states that he does not remember seeing any of this activity himself, and that the older people in the village discussed it. Mr. __ does not describe a strong identification with his ethnic __ background and states that he gradually lost a lot of the __ language he spoke as a young child. In addition, he says that he did not grow up with a sense of tension between the ethnic __s and other groups in his village and that some families spoke __ language, others spoke the language of the majority, and yet others spoke dialects he could not understand.

Mr. __ was drafted into the army approximately three years following the family’s move to __. He was sent for basic training to __, which lasted 3 months. Subsequently, he was sent to become a member of a commando unit that fought the guerilla army __ in the __ region. He states that this was the worst experience he had ever had. He was involved in an estimated 10-15 battles, at times being forced to shoot at targets he could not even see. He had to spend long periods of time in the mountains, in both summer and winter, and suffered from constant sleep deprivation and poor nutrition. He saw comrades wounded and killed. One friend who was from a village near his own was mortally wounded in one of the clashes. He helped dispose of his body when the fighting had ceased. When asked about having suffered any differential treatment because of his ethnic __ identity, he states that he often heard rumors about ill-treatment but did not experience it directly, except for the constant derogatory remarks that were made about the “illiterate” ethnic __s. He says that he felt hurt inside by this, but that in the army one has to do what one is told. When asked about his feelings regarding fighting people of his own ethnic group, he became very gloomy and refused to discuss this further. When asked why, he simply stated that there are things in life that are better not discussed.

Due to his active combat duty, Mr. __ was released after 15 months of service instead of the usual 18 months. After returning to __, he stayed at home for the first two months and felt like he literally could not move. He had difficulty breathing, experienced chest pains, thought he was dying, and never went out for fear of falling down and passing out and being publicly embarrassed. He went to see a physician, who gave him a prescription and advised him to go out and try to do things he finds enjoyable. He states that the pills did not make him feel any better, but rather made him feel even emptier inside, so he discontinued taking them. However, he did follow the doctor’s advice, started going out, began to feel better, and eventually met the woman who later became his wife.

Mr. __ explained that he was discovered as a musical talent by his teacher in elementary school and has always been a singer. He met his wife while singing at a wedding in 1994-1995. He began his singing career mostly by singing at weddings but increasingly got more work, gave some concerts, and made a couple of recordings as well. He states that he was doing well financially because he kept his welding job and made as much money from singing as he made at welding. During this time, he increased his repertoire of ethnic __ folksongs, which he learned from colleagues who were more familiar with the language and culture than he was.

On May 21, 1995, Mr. __ had been invited by a production company to perform in a concert for the traditional ethnic __ coming of spring celebration. This was an important event for him, as he expected more and better work as a result of this appearance. He was performing together with a female ethnic __ musician by the name of Ms. __. While performing ethnic __ songs they were interrupted by two policemen who jumped onto the stage, separated them, and pushed them into the background, saying things like “Don’t you know you’re not supposed to sing in ethnic __ language?” and “Why are you provoking this audience?” The crowd booed the officers. Mr. __ and Ms. __ were arrested and taken to the police station separately and kept separated upon arrival at the police station. Mr. __ was detained for about 12 hours. His possessions were taken from him and returned upon release. During this explanation, Mr. __ looked around the interview room and stated that his holding cell had been similar in size but the windows were smaller, the walls were white, and there was no clock that he could see.

Mr. __ was forced to sit in the same chair for 12 hours and was not allowed to use the restroom when he requested to use it. The officer let him use the restroom about 1-2 hours after he had asked. Mr. __ asked to make a phone call and was denied. He was denied water and cigarettes. He was constantly talked at for the entire time he was there, being told over and over that he was not supposed to sing in ethnic __ language. He was interrogated about who had organized the event. When asked about his feelings, he stated that he was feeling very irritated in recounting this event, that his visual recollection was vague but felt very real at the same time. When asked, Mr. __ stated that he still has a newspaper clipping in his possession from this event, the headline of which reads something like “Local Artist Arrested”.

Regarding his later arrests, Mr. __ states that he does not remember precise dates but only the seasons and years. It was difficult to ascertain these dates during the rest of the interview, as Mr. __ was not telling the story chronologically as he described events and there were a few misunderstandings. There might therefore be some discrepancies between the dates identified in this report and those specified other documentation.

In 1996 there was at least one incident of police harassment in connection with Mr. __’s involvement with a musician’s association that helped artists get engagements and allowed them to learn from each other. The organisation’s founder is named __. Policemen visited Mr. __ at home on one occasion while he was playing with his child. The doorbell rang and he asked his wife to open the door. Two policemen charged in, insulted him in front of his wife, a fact about which he is particularly bitter, and threatened to beat him up. He was interrogated about the purpose of the musicians’ organisation and a large record collection and scores of regional folk music were confiscated.

Another incident occurred in 1997 while Mr. __ was singing for a group of striking workers at the factory where he had once worked. The strike and the performace had been organized by a labor union. He was accompanied by drums and reed instruments. When he and his friend Mr. __, with whom he had worked at the factory for some time, left the factory, the police stopped them within a block, checked their ID’s, and took them to the police station. They were separated from each other and Mr. __ was interrogated. The police accused them of being members of the __ party, which is an underground organisation and apparently stands for __ __ __, an organisation Mr. __ had never heard of. The police told him they knew who they were and threatened that if he did not tell them about his friend Mr. __, they would electrocute his genitals and he would be impotent for the rest of his life. They also threatened that he might not ever see his wife and children again.

At this point in the interview, the interpreter adds that Mr. __ had instructed him not to translate the part about the electrocution of his genitals. I asked him to inform Mr. __ that he had done so, which resulted in an angry face and disgusted gesture on Mr. __’s part. I then reminded him that this was also detailed in his declaration and the interpreter stated that when he had helped prepare the declaration Mr. __ had also requested that it not be translated. However, the interpreter was advised by the attorney that these details were important.

Mr. __ went on to say he was not, in fact, electrocuted but that the officer repeatedly twisted his arm and frequently hit him on his chin with the palm of his hand, which may not seem very bad now but was very uncomfortable at the time (he gestured to demonstrate the way he was hit). He was so uncomfortable that he considered making up a story about his friend Mr. __ in order to get away but did not. He was also pushed around and detained for close to 24 hours. After his release, he never saw his friend Mr. __ again. Mr. __ says that he feels ashamed of this now, but he never inquired about his friend because he was scared by the threat of electrocution and feared for the future of his child and his wife, who was pregnant with their second child at the time.

In 1998 a similar incident occurred in which two officers reportedly came to his apartment and took him to the police station. On this occasion, Mr. __ was interrogated about an artist named __ and other members of the musician’s association. The officers harassed him by saying things like, “Don’t you know that the __ flag is only __ and __ colors?” Officers twisted his arm, pushed him around and told him to shut up. Mr. __ describes this as “sort of harmless”, i.e., it did not result in injury, but says that he felt very afraid at the time. Mr. __’s colleagues later told him that they were detained and interrogated about him in similar fashion.

The latest event that prompted Mr. __’s decision to leave the country is one that was not listed in the declaration that was made available to me and seemed to arise almost by accident. Mr. __ did not seem to want to discuss this event, even though it is a crucial piece of his persecution history. He added that he still sees this event vividly and that he felt very uncomfortable discussing it. One night after walking home from one of his wedding engagements, he was suddenly attacked, had a sack put over his head and upper body, and was beaten up and repeatedly kicked. He was carrying money but nothing was stolen from him. After he was left in the street, he found that his nose was bleeding. He sustained no lasting injuries but had aches and pains that lasted for days. He did not want to face his wife in this condition so he went to a public restroom in a religious compound and cleaned himself. He decided to return home much later, around 3-4 a.m., and he did not tell his wife the details of this event. He did tell his brother-in-law, however, who advised him to “leave now”, and suggested fleeing to either Germany or the United States. Mr. __ added that even Romania seemed an alternative, but the brother-in-law opined that the United States was good and that the people there appreciated music. Earlier, Mr. __ had stated that he never wanted to come to the United States in the first place but that his brother (by whom he meant his brother-in-law) had made him come.

Mr. __ states that he had no idea what political asylum meant when he arrived and that he learned of this only through his conversations with his translator, a man whom he had met at a local restaurant and to whom he had opened up about his experiences over time.

Medical History

Mr. __ denied any significant medical history apart from the psychiatric history following his combat experiences as described above and the presence of headaches in conjunction with his current psychological state. He uses over the counter medication for these headaches in low-moderate dosage and frequency. He described himself as generally healthy and denied any history of surgeries and accidents.

Psychological Assessment

The following conclusions are drawn from the individual interview of Mr. __ and psychological testing (HCL-25, TSI, HTQ).

Behavioural Observations/Mental Status Exam:

Mr. __ appeared on time for the interview and was appropriately dressed and groomed, looking his stated age. He was alert, fully oriented, pleasant and cooperative throughout the evaluation. There were no gross abnormalities in movement or posture on observation. Sensory functions and motor functions appeared to be intact. He appeared to possess high average intellectual ability, with good insight and judgment, although he was not well educated by Western standards. He became distressed when discussing particular events and admitted to feeling irritable while discussing sensitive details. Speech appeared clear and fluent, and there was no evidence of delusions, hallucinations or psychotic thought processes. Remote memory was intact. Attention appeared intact. Concentration and working memory could not be formally assessed but Mr. __ reported that they were impaired. Mood was depressed and affect was constricted. There was no evidence of suicidal or homicidal ideation.

Psychological Findings:

Mr. __ obtained a psychological profile on the TSI and HTQ that is highly suggestive of Posttraumatic Stress Disorder. Validity indicators suggest that he answered test items in a straightforward and internally consistent manner. There was no sign of dissimulation and results were valid for interpretation. Mr. __ reports the following psychiatric symptomatology:

  1. Persistent Reexperiencing of Traumatic Events and Avoidance Behaviour: Mr. __ evinced intermittent distress while recounting traumatic events as well as profound discomfort while discussing relevant details, particularly in relation to experiences he considered embarrassing according to his cultural norms. His discomfort was also a reaction to the fact that he was experiencing an active, intrusive recall of events, especially in relation to the last assault he suffered before leaving the country. He reported nightmares from which he awakens in a sweat. The content of his dreams includes trauma-related material to varying degrees, but usually not precise repetitions of actual events.
  2. Persistent Symptoms of Increased Arousal: Mr. __ suffers from poor sleep throughout the night and wakes up frequently. He states that this continues to be quite a problem, even though it has improved since he first arrived in the United States. He also startles easily, jumping in response to any kind of sudden noise. He feels that his concentration is impaired. He describes wandering through the city and not being able to find a major street, even though he has been there many times. He cannot concentrate on reading, even on familiar subjects in his national language. He has wanted to learn English but has had great trouble studying. Rather than studying from books, he has now begun to use tapes.
  3. Dissociative Symptoms: Mr. __’s most frequently cited complaint is that his mind “goes blank” for minutes at a time. He finds it rather distressing to have this symptom; he feels that at times his mind is so empty that he feels he is going crazy. He then also has faint auditory illusions, for example the repeated experience of hearing a whistle when no one is whistling. He states that he hates that experience.
  4. Somatic Complaints and Anxiety Symptoms: Mr. __ has a history of panic and anxiety symptoms dating back to his discharge from the military. The symptomatology described in terms of chest pains, shortness of breath, thoughts of death and dying and not leaving home for fear of fainting and embarrassing himself in public, constituted a diagnosis of Panic Disorder with Agoraphobia. This condition remitted without major treatment and on the advice of his physician to overcome his avoidance behaviour. Subsequent to the later events of persecution, these elements of panic disorder have reoccurred. Mr. __ frequently feels a lump in his throat, experiences shortness of breath and tingling and numbing sensations from his chest down through his extremities. He also suffers from frequent tension headaches that respond well to over-the-counter medicine.

Clinical Impression (Interpretation of Findings)

Conclusion and Recommendations

(based on an asylum evaluation conducted by Dr. Uwe Jacobs, Ph.D. on May 8 2001, San Francisco, CA, USA) Conditions of Interview Prior to this psychological evaluation, Mr. Doe and his client agreed to the condition that I approach the … Continue reading →

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Providing Testimony in Court

The main purpose of appearing in court is to present orally the material that has been submitted in the written report and to respond to questions from lawyers and adjucators. A judge may admit a written report into evidence without the health professional appearing in court personally. However, the judge may give the report limited weight or even refuse to accept the written document if the health professional does not appear in court because there is no opportunity for cross examination. For this reason, and because the oral testimony can more strongly substantiate the consistency with the clinician’s own testimony, it is preferable for the clinician to appear in court personally.

The tone and style of the hearing may vary considerably depending on the case, the judge, and the lawyers involved in the case. It is best for the health professional to be prepared for a challenging and even adversarial attitude, although this may not be the case. Prior to the court date, the individual’s attorney should arrange a meeting with the assessor to discuss the clinician’s testimony and to review the specific questions that the attorney might ask.

The clinician should bring to court all of the evidence that has been used in the affidavit, such as diagnostic imaging films, laboratory test reports, photographs and neuropsychological assessment reports.

Once in court, the first step is certifying the clinician as an expert witness. An expert witness is someone who, by virtue of knowledge, training, education, or experience, qualifies to offer expert testimony with regard to a particular subject area. Often, this certification will be a fairly simple process, with the clinician’s curriculum vitae serving as the basis for expertise. On other occasions, the judge or cross-examining attorney may challenge the clinician’s expertise. They may ask about the clinician’s specific area of expertise (e.g., torture, trauma, psychology, diagnosis). It is helpful to have considered this in advance with the attorney of the alleged victim and to arrive at a definition of expertise consistent with the clinician’s background and the needs of the case. Experience in assessing and working with trauma victims of any kind is, for example, relevant background.

The clinician’s testimony usually consists of a period of direct examination by the alleged victim’s attorney, during which time the clinician’s findings are presented, followed by cross-examination by the opposing attorney, and subsequent redirected questioning by the alleged victim’s attorney. Court proceedings may very considerably. In some cases, the judge will interject his/her own questions at any point in the proceeding. Sometimes there will be very little questioning from the judge and cross-examining attorney, and sometimes there will be very extensive questioning. Questions may take the form of information-seeking, and the attorney may present the clinician with the opportunity to educate the court about physical and/or psychological evidence of torture, as well as about this particular individual’s case.

Questions may also take the form of challenges to the clinician’s findings or the basis for those findings. One line of questioning commonly taken is: “How do you know what happened to the alleged victim? Do you have first hand knowledge? Aren’t you simply reporting what the alleged victim told you?” This question provides the clinician with an excellent opportunity to educate the court about the sources of his/her knowledge, including all of the components which go into the evaluation of physical and psychological evidence and the relevance of any additional historical information, including consistency of symptomatology with that seen in other traumatised patients and with commonly accepted professional standards such as the DSM-IV or ICD-10 and other diagnostic criteria. It may also be helpful to refer to the clinician’s application of Istanbul Protocol standards in his or her medical evaluation.

Another area of questioning may relate to cross-cultural factors: “What do you know about the respondent’s culture, about his/her country, or about how psychological response to trauma manifests in that culture?” Here, the clinician may refer to the analysis presented earlier concerning cross-cultural factors in assessment. The clinician can mention 1) expertise that he/she has with respect to the culture in question; 2) cross-cultural research on psychological trauma and symptomatology indicating the valid application of, for example, PTSD criteria across cultures; 3) skills in clinical listening and assessment which allow exploration of cross-cultural experience without being a specialist in that particular culture; and 4) common sense and face value components of the assessment process. This last factor should not be underestimated. When an alleged victim breaks into tears, explains how she was raped, nearly suffocated, threatened with death and says she is afraid that this may happen again, one need not be a cross-cultural expert to draw conclusions about her mental status.

In court, the finding of credibility is a legal matter that is the responsibility of the judge. The expert witness is one resource that the judge draws upon to make that determination. The clinician need not feel the compulsion to make that determination for the judge, and, indeed, judges may resent an expert who tries to do so. What the clinician can do is answer the questions of the attorneys and the judge as thoroughly and professionally as possible, along with his/her opinion about credibility, and let the judge arrive at his/her own conclusion. Indeed, there are many other factors in addition to expert testimony that go into the final decision.

Some general guidelines for oral testimony include the following:

  • Do not “react” to provocative statements.
  • Clarify questions that you do not understand before providing an answer.
  • Answer questions directly and succinctly. However, take the opportunity, when available, to editorialize and educate.
  • Do not offer opinions on subjects about which you are not qualified to comment.
  • Speak clearly, slowly, and make eye contact with whomever you are speaking.

Two excellent resources for any clinician preparing to testify in court are Stanley Brodsky’s Testifying in Court: Guidelines and Maxims for the Expert Witness and The Expert Expert Witness: More Maxims and Guidelines for Testifying in Court. Dr. Brodsky prepares the psychological expert for the most aggressive cross-examination of the expert’s credentials and conclusions. Perhaps the most helpful aspect of the books is the presentation of attitudes and appreciation of one’s own credentials as an expert, as well as exact phrasing to counter potential efforts to impeach one’s testimony. Though these guidelines and maxims were developed for psychological experts who testify in the United States, they may apply to other judicial proceedings. See Court Testimony Guidelines and Maxims [1], appended to this Module.

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  • [1] https://phrtoolkits.org/toolkits/istanbul-protocol-model-medical-curriculum/module-9-report-writing-and-testifying-in-court/appendix/

The main purpose of appearing in court is to present orally the material that has been submitted in the written report and to respond to questions from lawyers and adjucators. A judge may admit a written report into evidence without … Continue reading →

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Introduction

Purpose of the Model Medical Curriculum

The primary purpose of Model Curriculum is to provide health professional students with essential knowledge and skills to prevent torture and ill-treatment through effective investigation and documentation of these practises using Istanbul Protocol standards. The Curriculum was developed specifically for health professional students. Practicing clinicians interested in training other clinicians on the effective investigation and documentation of torture and ill-treatment should consider additional educational material developed through the PtD Project (see generic and country-specific Training of Trainers and Training of Users materials available at: http://www.irct.org/Purpose—principles-2715.aspx [2] [1]). Health professional students should seek to complement this curriculum with other educational materials that address the broader context of health and human rights, in an effort to promote health and human dignity through the protection and promotion of human rights.

Who Are These Educational Resources For?

Medical evaluations of physical and psychological evidence of torture and ill-treatment require students to have some basic scientific knowledge and clinical experience. The Model Curriculum is most appropriate for health professional students who have already learned anatomy, physiology, pathology, physical examination techniques, and have had some exposure to clinical medicine and psychiatry or clinical psychology.

The Model Curriculum was designed to be used by instructors who wish to teach a 10 to 20 hour course and by individual students or student groups. The Modules may be applied to a number of teaching formats including, seminars, lectures, and self-study. Instructors should contact the IRCT to access materials for instructor use only.

As mentioned above, clinicians and legal experts who are already in practise and have some familiarity with the investigation and documentation of torture and wish to implement Istanbul Protocol standards using a multiple-day symposium format should access PtD materials available at: http://www.irct.org/Purpose—principles-2715.aspx [2] [1].

The overall objective of the PtD Project is to make a substantial and tangible contribution to the prevention of torture and ill-treatment worldwide by conveying knowledge and skills to health and legal professionals about systematised and high quality investigation and documentation of these unlawful acts. The PtD training format includes national adaptation of generic, international material for the training of trainers and subsequent training of clinicians and legal experts. The PtD educational materials also may be helpful to train health professional instructors who intend to teach the Model Curriculum on the Effective Medical Documentation of Torture and Ill-treatment.

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  • [1] http://www.irct.org/Purpose---principles-2715.aspx
  • [2] http://www.irct.org/Purpose---principles-2715.aspx

Purpose of the Model Medical Curriculum The primary purpose of Model Curriculum is to provide health professional students with essential knowledge and skills to prevent torture and ill-treatment through effective investigation and documentation of these practises using Istanbul Protocol standards. … Continue reading →

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Brief History

The Istanbul Protocol was the result of three years of analysis, research, and drafting undertaken by more than 75 forensic doctors, physicians, psychologists, human rights monitors, and lawyers who represented 40 organisations and institutions from 15 countries, including the International Rehabilitation Council for Torture Victims (IRCT). The development of the Istanbul Protocol was initiated and coordinated by Physicians for Human Rights-USA (PHR), the Human Rights foundation of Turkey (HRFT), and Action for Torture Survivors (HRFT-Geneva). The project was conceived in March, 1996, after an international symposium on “Medicine and Human Rights” held at the Department of Forensic Medicine, Cukurova University Medical Faculty, in Adana, Turkey by the Turkish Medical Association. The drafting process culminated at a meeting in Istanbul in March, 1999, when the manual reached its final form and subsequently submitted to the United Nations High Comissioner for Human Rights (OHCHR) on the 9th of August 1999. In 2001, the Office of the OHCHR published the Istanbul Protocol in its Professional Training Series in the six official UN languages.

The Istanbul Protocol was the result of three years of analysis, research, and drafting undertaken by more than 75 forensic doctors, physicians, psychologists, human rights monitors, and lawyers who represented 40 organisations and institutions from 15 countries, including the International … Continue reading →

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Cognitive Techniques

Psychological research has shown that the ability to recall important incidents can be enhanced by using some basic cognitive techniques. Having established rapport with the individual, he or she should be allowed to give a free narrative about the events. The interviewer should allow the individual, as much as possible, the time to describe what happened in his or her own words. Clarification of points is permissible but not direct questioning which might break the individual’s recall. Only after the individual has finished his or her narrative should direct questions be asked to clarify points. The survivor of torture should know that it is acceptable to say: ‘I don’t understand the question,’ or ‘I don’t know the answer.’

The quality of the information gained can be improved by some specific techniques. Firstly, in a clinical setting in which time allows it, the individual should be told to describe everything surrounding the time of ill-treatment (for instance describing the events and process of being taken into detention), even if it does not appear directly relevant to him or her. This might relate to events that could be more important than the individual realises. Secondly, as he or she relates them, this can bring other events that are more relevant into his or her mind. It helps if he or she is encouraged to recall the context in which the events happened.

Having encouraged the interviewee to describe the events in a free narrative, in chronological order, the interviewer can seek more detail by asking questions in a different order. For example, by reversing the order: ‘You were telling me …, what happened just before that?’

Another tool is changing the perspective, which means trying to describe the events from another point of view, for example if the interviewee is sufficiently well-educated the interviewer could ask: ‘How would a tailor describe what the man was wearing?’ or ‘When you were arrested at the demonstration, what would a spectator have seen?’

It is important to remember that different cultures have different concepts of what is normal behaviour in an interview. In some societies it is considered polite not to look directly into the eyes of someone in a position of relative authority (such as an interviewer), whereas in other cultures such behaviour is considered to be a sign of dishonesty. People from some cultures find constant hand movements a normal part of communication, whereas those from others find them distracting. Personal space varies between and within cultures, and what might be normal between colleagues could feel too close in an interview setting. This could make the individual feel anxious, and behave in a way that the interviewer perceives as uncooperative.

Psychological research has shown that the ability to recall important incidents can be enhanced by using some basic cognitive techniques. Having established rapport with the individual, he or she should be allowed to give a free narrative about the events. … Continue reading →

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The Physical Examination

The physical examination is usually the last component of a medical evaluation of an alleged torture victim, after the acquisition of all background information, allegations of abuse, acute and chronic symptoms and disabilities, and after the psychological evaluation, if, in fact, the psychological evaluation is performed by the same clinician who is assessing physical evidence and conducting the physical examination.

As mentioned in Module 2 [1], it is essential to obtain the individual’s informed consent prior to the physical examination. The physical examination must be conducted by a qualified physician. Whenever possible, the patient should be able to choose the gender of the physician and, where used, interpreter. If the doctor is not the same gender as the patient, a chaperone who is of the same gender as the patient should be used unless the patient objects. The patient must understand that he or she is in control and has the right to limit the examination or to stop at any time (see Module 3 [2]). A complete physical examination is recommended unless the allegations of torture are limited and there is no history of loss of consciousness or neurological or psychological symptoms that may affect recall of torture allegations. Under such circumstances, a directed examination may be appropriate in which only pertinent positive and negative evidence are pursued on examination.

In this Module, there are many references to specialist referral and further investigations. Unless the patient is in detention, it is important that physicians have access to physical and psychological treatment facilities, so that any identified need can be followed up. In many situations, certain diagnostic test techniques will not be available, and their absence must not invalidate the report.

In cases of alleged recent torture and when the clothes worn during torture are still being worn by the torture survivor, they should be taken for examination without washing, and a fresh set of clothes should be provided. Wherever possible, the examination room should be equipped with sufficient illumination and medical equipment for the examination. Any deficiencies should be noted in the report. The examiner should note all pertinent positive and negative findings, using body diagrams to record the location and nature of all injuries (see anatomical drawings in Appendix 3 of the Istanbul Protocol [3] to record the location and nature of all injuries). Some forms of torture such as electrical shock or blunt trauma may be initially undetectable, but may be detected during a follow-up examination. Although it will rarely be possible to record photographically lesions of prisoners in custody of their torturers, photography should be a routine part of examinations. If a camera is available, it is always better to take poor quality photographs than to have none. They should be followed up with professional photographs as soon as possible.

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  • [1] https://phrtoolkits.org/toolkits/istanbul-protocol-model-medical-curriculum/module-2-istanbul-protocol-standards-for-medical-documentation-of-torture-and-medical-ethics/
  • [2] https://phrtoolkits.org/toolkits/istanbul-protocol-model-medical-curriculum/module-3-interview-considerations/
  • [3] https://phrtoolkits.org/downloads/?did=22

The physical examination is usually the last component of a medical evaluation of an alleged torture victim, after the acquisition of all background information, allegations of abuse, acute and chronic symptoms and disabilities, and after the psychological evaluation, if, in … Continue reading →

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Resources

As mentioned above, the content of the Model Curriculum is based on the Istanbul Protocol and a number of manuals and resources that were subsequently developed by Istanbul Protocol authors and editors, and their colleagues, to supplement the Istanbul Protocol, including extensive training materials developed by the IRCT and partner organisations, the Human Rights Foundation of Turkey (HRFT) and Physicians for Human Rights (PHR) for the Prevention through Documentation (PtD) Project. Selected materials were excerpted and adapted from these resources to develop a comprehensive curriculum for health professionals in the course of their training. The primary resources used for the development of the Model Curriculum include:

Each Module contains a list of the primary resources used for its development. It is important to note that clinicians who conduct forensic medical evaluations of alleged victims of torture and ill-treatment should be familiar with the entire content of the Istanbul Protocol, especially if they refer to the application of Istanbul Protocol standards in their medico-legal report(s).

Quelle

  • [1] https://phrtoolkits.org/downloads/?did=34
  • [2] https://phrtoolkits.org/toolkits/istanbul-protocol-model-medical-curriculum/module-7-case-example-01/materials/
  • [3] https://phrtoolkits.org/toolkits/istanbul-protocol-model-medical-curriculum/module-8-case-example-02/materials/
  • [4] http://www.essex.ac.uk/torturehandbook/
  • [5] http://www.essex.ac.uk/combatingtorturehandbook/
  • [6] https://phrtoolkits.org/downloads/?did=22
  • [7] http://physiciansforhumanrights.org/library/reports/examining-asylum-seekers-manual-2005-1.html
  • [8] http://www.preventingtorture.org
  • [9] http://www.preventingtorture.org
  • [10] http://www.irct.org/resources/irct-electronic-library/trainers-materials/presentations.aspx
  • [11] http://www.irct.org/Files/Filer/TortureJournal/16_2_2006/4_dermatological_findings.pdf
  • [12] http://www.irct.org/Admin/Public/DWSDownload.aspx?File=%2fFiles%2fFiler%2fIPIP%2ftraining2009%2fmedical+materials+for+practitioners%2fmedical_en_web_red.pdf
  • [13] http://www.irct.org/Files/Filer/publications/psychological_en_web_red.pdf
  • [14] http://www.redress.org/downloads/publications/PhilippinesManualNov07.pdf
  • [15] http://www.irct.org/Admin/Public/DWSDownload.aspx?File=%2fFiles%2fFiler%2fIPIP%2ftraining2009%2fmedical+materials+for+trainers%2fTrainers-Guidelines-Health-Professionals-ToU-final_password.pdfhttp://www.irct.org/Admin/Public/DWSDownload.aspx?File=%2fFiles%2fFiler%2fIPIP%2ftraining2009%2fmedical+materials+for+trainers%2fTrainers-Guidelines-Health-Professionals-ToU-final_password.pdf
  • [16] http://www.irct.org/resources/irct-electronic-library/trainers-materials/presentations.aspx

As mentioned above, the content of the Model Curriculum is based on the Istanbul Protocol and a number of manuals and resources that were subsequently developed by Istanbul Protocol authors and editors, and their colleagues, to supplement the Istanbul Protocol, … Continue reading →

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Head and Neck

Lesions on the face are particularly distressing for survivors of torture because they are a frequent reminder of the episode. Most traumatic scars on the face tend to be relatively small, and scars from acne and chickenpox, and tribal markings, must not be mistaken for them.

Lesions are common over bony points, especially the eyebrows and the cheekbones. These may be associated with a fracture of the malar bone (cheekbone). Bruises and scars in the scalp can be difficult to find, especially if the hair is thick. Bruises will normally be tender to touch. Broken or missing teeth are often shown by individuals as evidence of assault, but where the general oral hygiene is poor this usually makes this sign unhelpful. Petechiae of the palate may be evidence of forced oral intercourse. Slaps to the ear can sometimes damage the eardrum. However, the finding of scars of the tympanic membrane (eardrum) does not exclude childhood infections.

Eyes

Conjunctival hemorrhage, lens dislocation, subhyeloid hemorrhage, retrobulbar hemorrhage, retinal hemorrhage, and visual field loss may all be observed following torture. Referral to an ophthalmologist is recommended whenever there is a suspicion of ocular trauma or disease.

Ears

Blunt trauma to the external ear may result in haematoma. Cartilage necrosis and infection are likely sequelae if the ear is left untreated. Lacerations of the pinna vary from those of minor significance to complete amputation. Rupture of the tympanic membrane is a frequent consequence of harsh beatings. Prompt examination is necessary to detect tympanic membrane ruptures less than 2 mm in diameter, as they can heal within 10 days. About 80% of traumatic tympanic membrane perforations diagnosed within 14 days of injury will have healed spontaneously.

The short and long term sequelae of significant injury to the middle and inner ear are hearing loss, vertigo, tinnitus, unsteadiness and, less commonly, facial nerve paralysis. An audiogram should be performed to assess injury to the ossicles and inner ear. A conductive hearing loss is usually due to a tear in the tympanic membrane and blood in the middle ear. A hearing loss of less than 40 dB suggests an ossicular chain dislocation. Sensorineural loss indicates cochlear or retrocochlear damage.

Fluid may be observed in the middle and/or external ear. If otorrhea is confirmed by laboratory analysis to be CSF (cerebrospinal fluid), then MRI or CT should be performed, if possible, to determine the fracture site. 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.

Nose

The nose should be evaluated for alignment, crepitation, and deviation of the nasal septum. Initially soft tissue swelling may make interpretation difficult and it may be necessary to re-examine nose after 48 hours when this has subsided. Frequently there is an associated deviation of nasal septum which may result in nasal obstruction. For simple nasal fractures, standard nasal radiographs should be sufficient. Sometimes the fracture of the nasal bone includes the frontal process of the maxilla, and sometimes it extends to include ethmoid labyrinth. For complex nasal fractures and when the cartilaginous septum is displaced, and when rhinorrhea is present, CT and/or MRI are recommended.

Jaw, Oropharynx and Teeth

The oral cavity must be carefully examined. During the application of electric current to the mouth, the tongue, gingiva or lips may be bitten. Lesions might also be produced by forcing objects or materials into the mouth. Temporomandibular joint syndrome can be caused by electric current and blows to the face. It will produce pain in the temporomandibular joint, limitation of jaw movement, and in some cases subluxation of this joint.

A careful dental history should be taken and, if dental records exist, these should be requested. The patient should be referred to a dentist if there is any damage to the teeth. Mandibular fractures, avulsions or fractures of the teeth, broken prostheses, swelling of the gums, bleeding, pain, or loss of fillings from teeth can all result from direct trauma or electric shock torture. Dental caries and gingivitis should also be noted. Poor quality dentition may be due to conditions in detention, or may have preceded it. X-rays and MRI are suggested for determining the extent of soft tissue, mandibular and dental trauma.

Lesions on the face are particularly distressing for survivors of torture because they are a frequent reminder of the episode. Most traumatic scars on the face tend to be relatively small, and scars from acne and chickenpox, and tribal markings, … 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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An Overview of the Istanbul Protocol

The Istanbul Protocol is a set of guidelines for the effective investigation and documentation of torture and ill-treatment. These international standards help both legal and forensic experts to investigate and document torture and ill-treatment. The medical guidelines, in particular, help forensic experts to assess the degree to which medical findings correlate with individual allegations of abuse and to effectively communicate the findings and interpretations to the judiciary or other appropriate authorities.

Medical experts involved in the investigation of torture must conform to the highest ethical standards, including obtaining informed consent before any examination is undertaken. The examination must conform to established standards of medical practise. In particular, examinations shall be conducted in private under the control of the medical expert and outside the presence of security agents and other government officials. The medical expert should promptly prepare an accurate written report which includes at least the following: case-specific, identifying information; a detailed record of the subject’s allegations of torture and/or ill-treatment, including all complaints of physical and psychological symptoms; a record of all physical and psychological findings on clinical examination; an interpretation as to the probable relationship of the physical and psychological findings to possible torture and ill-treatment; recommendations for any necessary medical and psychological treatment and/or further examination; and the identify those carrying out the examination. The report should be confidential and communicated to the subject or his or her nominated representative.

According to the Istanbul Protocol, the following guidelines should be applied with due consideration to the purpose of an individual evaluation:

  1. Relevant Case Information
  2. Clinician’s Qualifications
  3. Statement Regarding Veracity of Testimony
  4. Background Information
  5. Allegations of Torture and Ill-treatment
  6. Physical Symptoms and Disabilities
  7. Physical Examination
  8. Psychological History/Examination:
  9. Photographs
  10. Diagnostic Test Results
  11. Consultations
  12. Interpretation of Physical and Psychological Findings
  13. Conclusions and Recommendations
  14. Statement of Truthfulness (for judicial testimonies)
  15. Statement of Restrictions on the Medical Evaluation/Investigation (for subjects in custody)
  16. Clinician’s Signature, Date, Place
  17. Relevant Appendices

As the Istanbul Protocol makes clear, the absence of physical and/or psychological evidence in a medical evaluation does not rule-out the possibility that torture or ill-treatment was inflicted.

The Istanbul Protocol is a set of guidelines for the effective investigation and documentation of torture and ill-treatment. These international standards help both legal and forensic experts to investigate and document torture and ill-treatment. The medical guidelines, in particular, help … Continue reading →

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