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Training

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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Summary of Content

Module 1: International Legal Standards

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

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

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

Module 3: Interview Considerations

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

Module 4: Torture Methods and their Medical Consequences

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

Module 5: Physical Evidence of Torture and Ill Treatment

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

Module 6: Psychological Evidence of Torture and Ill Treatment

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

Module 7 & 8: Case Examples

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

Module 9: Writing Reports and Testifying in Court

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

Quelle

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

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

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Types of evidence

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

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

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

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Torture Methods

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General Considerations for Interviews

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

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

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

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

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Psychological Findings and Diagnostic Considerations

It is prudent for clinicians to become familiar with the most commonly diagnosed disorders among trauma and torture survivors and to understand that it is not uncommon for more than one mental disorder to be present as there is considerable co-morbidity among trauma-related mental disorders. The two most common classification systems are the International Statistical Classification of Diseases and Health Related Problems (ICD-10)[1] Classification of Mental and Behavioural Disorders and the Diagnostic and Statistical Manual of the American Psychiatric Association-Edition IV (DSM-IV).[2] Non-mental health clinicians such as internists and general practitioners who perform evaluations of torture survivors should be familiar with the common psychological responses to torture and be able to describe their clinical findings. They should be prepared to offer a psychiatric diagnosis if the case is not complicated. A psychiatrist or psychologist skilled in the differential diagnosis of mental disorders related to severe trauma will be needed for particularly emotional individuals, cases involving multiple symptoms or atypical symptom complexes, psychosis, or in cases presenting confusing clinical pictures.

It is important to note that the association between torture and both PTSD and depression has become very strong in the minds of health providers, immigration courts and the informed lay public. This has created the mistaken and simplistic impression that PTSD and depression are the main psychological consequences of torture. Torture-related mental disorders are not limited to depression and PTSD and evaluators must have comprehensive knowledge of the most frequent diagnostic classifications among trauma and torture survivors. In this sense, a detailed evaluation is always very important. Overemphasising PTSD and depression criteria might result in missing other possible diagnoses and reinforcing the simplistic notion that the psychological evidence of torture can be reduced to the presence or absence of PTSD and depression. A wide range of diagnostic considerations are provided below and ICD-10 diagnostic criteria are included in the Appendix II at the end of this Module.

The diagnosis most commonly associated with torture is Post-traumatic stress disorder (PTSD). Typical symptoms of PTSD include re-experiencing the trauma, avoidance and emotional numbing, and hyperarousal. Re-experiencing can take several forms: intrusive memories, flashbacks (the subjective sense that the traumatic event is happening all over again), recurrent nightmares, and distress at exposure to cues that symbolize or resemble the trauma. Avoidance and emotional numbing include avoidance of thoughts, conversations, activities, places or people that arouse recollection of the trauma, feelings of detachment and estrangement from others, inability to recall an important aspect of the trauma, and a foreshortened sense of the future. Symptoms of hyperarousal include difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, hypervigilance, and exaggerated startle response.

Depressive states are very common among survivors of torture. Depressive disorders may occur as a single episode or be recurrent. They can present with or without psychotic features. Symptoms of Major Depression include depressed mood, anhedonia (markedly diminished interest or pleasure in activities), appetite disturbance, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue and loss of energy, feelings of worthlessness and excessive guilt, difficulty concentrating, and thoughts of death, suicidal ideation, or suicide attempts.

A survivor of severe trauma such as torture may experience dissociation or depersonalisation. Dissociation is a disruption in the integration of consciousness, self-perception, memory and actions. A person may be cut off or unaware of certain actions or may feel split in two and feel as if observing him or herself from a distance. Depersonalisation is feeling detached from oneself or one’s body.

Somatic symptoms such as pain and headache and other physical complaints, with or without objective findings, are common problems among torture victims. Pain may shift in location and vary in intensity. Somatic symptoms can be directly due to physical consequences of torture, be of psychological origin, or both. Also, various types of sexual dysfunction are not uncommon among survivors of torture particularly, but not exclusively, among those who have suffered sexual torture or rape.

Psychotic symptoms may be present such as delusions, paranoia, hallucinations (auditory, visual, olfactory or tactile), bizarre ideation, illusions or perceptual distortions. Cultural and linguistic differences may be confused with psychotic symptoms. Before labelling someone as psychotic, one must evaluate the symptoms within the individual’s cultural context. Psychotic reactions may be brief or prolonged. It is not uncommon for torture victims to report occasionally hearing screams, his or her name being called, or seeing shadows, but not have florid signs or symptoms of psychosis. Individuals with a past history of mental illness such as bipolar disorder, recurrent major depression with psychotic features, schizophrenia and schizoaffective disorder may experience an episode of that disorder. .

The ICD-10 includes the diagnosis “Enduring Personality Change.” PTSD may precede this type of personality change. To make the ICD-10 diagnosis of enduring personality change, the following criteria must have been present for at least two years and must not have existed prior to the traumatic event or events. These criteria are: hostile or distrustful attitude towards the world, social withdrawal, feelings of emptiness or hopelessness, chronic feelings of “being on edge” as if constantly threatened, and estrangement.

Alcohol and drug abuse may develop secondarily in torture survivors as a way of blocking out traumatic memories, regulating affect and managing anxiety. Other possible diagnoses include: generalized anxiety disorder, panic disorder, acute stress disorder, somatoform disorders, bipolar disorder, delusional disorder, disorders due to a general medical condition, (possibly in the form of brain impairment with resultant fluctuations or deficits in level of consciousness, orientation, attention, concentration, memory and executive functioning), and phobias such as social phobia and agoraphobia.

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

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

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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Module 1: International Legal Standards (Overview)

Objectives

  • To understand basic definitions of torture and other forms of cruel, inhuman and degrading treatment or punishment.
  • To familiarize students with the international legal standards on the prohibition of torture and ill-treatment
  • To obtain a clear understanding of the torture practises in the world today and relevant country-specific practises.
  • To be familiar with international and regional monitoring mechanisms.
  • To understand basic torture prevention and accountability measures, including specific safeguards for those deprived of their liberty.
  • To identify international and country specific needs for prevention and accountability measures, including specific safeguards for those deprived of their liberty.
  • To identify country-specific challenges in preventing torture and holding perpetrators accountable including effective remedial measures in this regard.

Content

  • Definition of torture and ill-treatment
  • Brief review of the purpose of torture and its history
  • Review of relevant international standards for torture prevention
  • Torture in the world today, including practises, the role of state and non-state actors, common situations for allegations
  • Review of country-specific legal standards and torture practises [to be provided by Instructors]
  • Overview of prevention and accountability measures
  • International and regional monitoring mechanisms and formal inspections of detention facilities
    • Human Rights Committee
    • UN Committee against Torture
  • Regional monitoring mechanisms
  • Other monitoring mechanisms
    • The UN Special Rapporteur
    • International criminal courts and tribunal
    • The International Committee of the Red Cross (ICRC)
  • Safeguards against torture for those deprived of their liberty
    • Notifying people of their rights
    • Use of officially recognised places of detention
    • Humane conditions of detention
    • Limits on interrogation
    • Access to a doctor
    • The right to challenge the lawfulness of detention
  • Safeguards for special categories of detainees
    • Women in detention
    • Juvenile detainees
    • People with mental health problems

Discussion Topics

  • Compare and contrast similarities and differences between international standards and national legislation
  • Develop a 10-12 point country-specific plan for torture prevention and accountability
  • Discuss how international, regional and national organisations can work together for the effective investigation and prevention of torture.
  • Discuss the role of health professionals in torture prevention and accountability.
  • Discuss the relationship between human rights and human security in general, and specifically with regard to national anti-terror policies/practises and torture.

Teaching Formats

  • Group Activity:
    • Divide the class into several groups and assign each group with one or more (or all) of the Discussion Topics listed above.
    • 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
  • Individual Research/Assignment(s):
    • Conduct literature research on the psychology of abuse and write a two-page essay analyzing different theories. Provide your opinion with supporting information
    • Develop a 10-12 point, country-specific plan for torture prevention and accountability
    • Develop a country-specific list of organisations and bodies relevant to torture and ill-treatment
  • Journal Entry: (Instructor to assign students to write a few paragraphs — no more than a page on one or more of the following)
    • Respond to one or more of the Discussion Topics
    • Why do you think health professionals should or should not be concerned about torture and ill-treatment?

Primary Resources

  • The Istanbul Protocol, Chapters I and III, Annex I
  • The Torture Reporting Handbook
  • Action Against Torture: A Practical Guide to the Istanbul Protocol for Lawyers
  • Medical Investigation and Documentation of Torture: A Handbook for Health Professionals
  • Combating Torture: A Manual for Judges and Prosecutors
  • The Torture Reporting Handbook

Objectives To understand basic definitions of torture and other forms of cruel, inhuman and degrading treatment or punishment. To familiarize students with the international legal standards on the prohibition of torture and ill-treatment To obtain a clear understanding of the … Continue reading →

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Notifying people of their rights

Everyone deprived of liberty has the right to be given a reason for the arrest and detention. Article 9(1) of the ICCPR states that: ‘Everyone has the right to liberty and security of person. No one shall be subjected to arbitrary arrest or detention. No one shall be deprived of his liberty except on such grounds and in accordance with such procedures as are established by law.’

Everyone deprived of liberty has the right to be given a reason for the arrest and detention. Article 9(1) of the ICCPR states that: ‘Everyone has the right to liberty and security of person. No one shall be subjected to … Continue reading →

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