Caring for Survivors of Torture
Resources for clinicians and advocates around issues of torture. Highlights include information about Northwest Health and Human Rights (NWHHR) coalition, a partnership of three programs that currently serve refugees, asylum seekers, and immigrants in Washington State.
Northwest Health and Human Rights (NWHHR) Coalition
Information about a collaborative coalition that provides medical consultation, mental health and legal social services to survivors of torture in Washington State.
Northwest Health and Human Rights (NWHHR) coalition is a partnership of three programs that currently serve refugees, asylum seekers, and immigrants in Washington State, working together collaboratively to improve the health and well being of torture survivors. Lutheran Community Services Northwest has been funded through the Office of Refugee Resettlement to develop this coalition to identify and assist survivors of torture in the Puget Sound region.
The coalition will initially include entities that have been doing this work for decades. Mental Health services will be provided by International Counseling and Community Services, a program of Lutheran Community Services. Legal services will be provided by Northwest Immigrant Rights Project. Medical evaluations and services will be provided by the Northwest Health and Human Rights Clinic at Harborview Medical Center.
As the coalition evolves it will provide training and support throughout the region. Partnerships with and support from similar programs for torture survivors in other regions of the country undergird this coalition to provide depth and resources. Eventually relevant materials will be available on EthnoMed for those similarly providing varied services to survivors of torture.
Immigration Legal Services:
Northwest Immigrant Rights Project
Main number (206) 587-4009; toll-free: (800) 445-5771
Medical Evaluations and Services:
Contact (206) 744-4192
Mental Health Services:
Contact (206) 816-3252 (ICCS' Pathways to Wellness Program)
Brochure: Northwest Health & Human Rights, King County WA
- "Before Obtaining Asylum, Refugees Must Show The Scars Behind The Stories", NPR, 8/9/15.
- "Helping immigrant victims of torture heal in Puget Sound region", Seattle Times, published 11/30/13.
- "Universal Human Rights and the Northwest - Viewpoint", Carey Jackson, MD, Seattle/LocalHealthGuide, published 12/9/13.
- Local Coalition 'in the Business of Cleaning up after Warfare':
KPLU radio segment about the Northwest Health and Human Rights Project, 12/9/13.
The NCTTP is a U.S. based network of programs which exists to advance the knowledge, technical capacities and resources devoted to the care of torture survivors living in the United States and acts collectively to prevent torture worldwide. Contact information for members of the Consortium is included on the NCTTP website, including phone numbers, addresses and websites for programs and services in the following states: Arizona, California, Colorado, Connecticut, District of Columbia, Illinois, Maryland, Massachussetts, Michigan, Minnesota, Missouri, New Jersey, New York, Oregon, Pennsylvania, Texas, Utah, Virginia, Washington.
The following are links with brief descriptions of several programs that are part of the NCTTP:
Founded in 1994 by a small group of concerned professionals, Advocates for Survivors of Torture and Trauma (ASTT) provides comprehensive mental health care and social services to survivors of torture and war trauma.
The Center for Victims of Torture (CVT)
CVT conducts research, training, advocacy and healing services for survivors. In Minnesota, torture survivors receive out-patient care at a healing center that provides medical and nursing care, psychotherapy, social services and massage and physical therapy. CVT’s international healing initiatives train local community members and refugees to meet the mental health needs in refugee camps and post-conflict areas.
This organization in Florida develops and provides comprehensive care for refugees, asylees, asylum seekers and survivors of torture and genocide by partnering with numerous organizations including major refugee resettlement agencies.
The Harvard Program in Refugee Trauma cares for the health and mental needs of survivors of mass violence and torture through a combined practice of clinical experience and medical research. Their stated vison: To bring the advances of modern medical science to those members of our society who in spite of their great suffering have little access to care.
A global health and human rights organization working to build lasting access to health for excluded communities. Projects address health and social crises made worse by human rights violations, with a particular focus and expertise on: HIV/AIDS, TB, and malaria; women’s health; health and welfare of orphans and other at-risk children and youth; and care and support for survivors of human rights violations such as torture, trafficking, and domestic and gender-based violence.
Country Reports on Torture
The Gulf Coast Jewish Family and Community Services (GCJFCS) has published a number of reports which provide historical timelines, brief descriptions of common methods of torture, and synopses of current conditions and pertinent issues related to each country featured. Countries currently include Colombia, Haiti, Cuba, Iraq, Bhutan, Burma, Syria, Dem Rep of Congo.
Link to GCJFCS Country Condition Reports
Materials to help clinicians who treat victims of torture recognize the significance of this history, know how to record and document it, and how to integrate this history into medical decision making.
CVT’s has several publications about working with trauma victims.
Restoring Hope and Dignity: Describes CVT's group counseling model and contains detailed principles, instructions and exercises. The specialized therapeutic intervention outlined in this manual is a 10-session group counseling model that should be delivered by trained local counselors who are receiving ongoing clinical supervision and training.
Healing the Hurt: A Guide for Developing Services for Torture Survivors: Developed for practitioners who may or may not have worked previously with torture survivors this is a multidisciplinary guide that addresses some basic considerations when working with this population.
Treating Victims of Torture
This five part series at the Gulf Coast JFCS site includes leaders in the field discussing the lessons learned and the models of care at some of the leading torture rehabilitation centers in the country. There are many different ways in which programs deliver quality services to torture survivors. Watch members of the National Partnership for Community Training discuss their work with survivors of torture at the Harvard Program in Refugee Trauma, the NYU/Bellevue Program for Survivors of Torture and the Florida Center for Survivors of Torture.
|Impact of Torture on Medical Care - Video|
A 27 minute video presentation by Dr. Nicole Ahrenholz (Harborview Med Center/Univ of WA) about issues involved in the medical screening and treatment of victims of torture. Topics include who should be screened and how, how is it relevant to current issues, and how to use the information. Video includes clips with Dr. Carey Jackson and patient during a medical visit.
|Sequelae of Torture: Traumatic Brain Injury - Video|
A 40 minute video presentation by Dr. Carey Jackson (Harborview Med Center/Univ of WA) about working with torture survivors. Topics include mechanisms of traumatic brain injury, symptoms of TBI, and how to assess and treat.
Evaluation and Treatment of Survivors of Torture
A PDF slideshow developed by Drs. J. Carey Jackson and Nicole Chow Ahrenholz (Harborview Med Ctr/Univ of Washington) to help clinicians who treat victims of torture recognize the significance of this history, know how to record and document it, and how to integrate this history into medical decision making.
A PDF slideshow (28 slides) by Dr. Nicole Chow Ahrenholz (Harborview Med Ctr/Univ of Washington) which provides some background about electrical torture, prevalence in immigrant and refugees, signs and symptoms, and what long-term effects might be attributed to electrical torture.
Female Genital Cutting (FGC)
A 40-minute video presentation by Drs. Adelaide Hearst and Alexandra Molnar (Harborview Med Ctr/Univ of Washington) for providers about female circumcision and treatment considerations when working with patients with FGC
Female Genital Cutting: An Evidence-Based Approach to Clinical Management for the Primary Care Physician, Hearst and Molnar, Mayo Clinic Proceedings, June 2013:88(6):618-629.
Assessment and Documentation
Model Curriculum on the Effective Medical Documentation of Torture and Ill-treatment
A tool and resource of the Physicians for Human Rights, this Model Curriculum was developed to provide health professional students with essential knowledge and skills to prevent torture and ill-treatment through effective investigation and documentation of these practices using Istanbul Protocol standards. The following are modules in the curriculum: International Legal Standards, Istanbul Protocol Standards for Medical Documentation of Torture and Medical Ethics, Interview Considerations, Torture Methods and their Medical Consequences, Physical Evidence of Torture and Ill Treatment, Psychological Evidence of Torture and Ill Treatment, Case Examples, Writing Reports and Testifying in Court.
Credibility Assessment in Asylum Procedures - A Multidisciplinary Training Manual
This training manual (146 pages) provides a multidisciplinary learning method on credibility assessment, tailored to the needs of asylum decision-makers and other asylum professionals. It provides a framework for developing knowledge, skills and attitude through multidisciplinary learning to help asylum professionals reduce the possibility of errors, reach more objective and fair credibility findings, as well as to apply a more structured approach to credibility assessment. This publication was coordinated by the Hungarian Helsinki Committee.
General Physical Evaluation for Survivors / History Taking
A tool and resource of the Physicians for Human Rights, this Model Curriculum was developed to provide health professional students with essential knowledge and skills to prevent torture and ill-treatment through effective investigation and documentation of these practices using Istanbul Protocol standards.
Harvard Program in Refugee Trauma (HPRT):
- A 300-page manual entitled Measuring Trauma, Measuring Torture documents HPRT's scientific and field experience working for eighteen years with the Harvard Trauma Questionnaire (HTQ) and Hopkins Symptom Check List-25 (HSCL –25). The manual focuses on historical background to the instruments and their development and modification and provides guidance for their utilization and adaptation in three settings: clinical screening, research and treatment.
- Harvard Trauma Questionnaire
- Hopkins Symptom Checklist-25 (HSCL-25)
- Simple Depression Screen
Refugee Health Screener - 15 (RHS-15):
- RHS-15 is a tool for screening refugees for emotional distress and mental health. Packet includes the RHS-15 tool, background on the tool’s development, and guidelines on using the RHS-15 with recently resettled refugees. RHS-15 has also been translated into Somali, Russian, Arabic, Burmese, Karen, and Nepali.
Legal Issues and Resources
The Istanbul Protocol provides useful guidance for doctors and lawyers who want to investigate whether or not a person has been tortured and report the findings to the judiciary and any other investigative bodies.
The International Rehabilitation Council for Torture Victims provides many resources for those working in the field of torture rehabilitation and prevention. The IRCT is a health-based umbrella organisation that supports the rehabilitation of torture victims and the prevention of torture worldwide.
Quick links on the IRCT website include:
- Read/Download the Istanbul Protocol
- Legal and Medical and Psychological Documentation
These guides are available in English, French and Spanish and are aimed at professionals (legal, medical and psychological). They were developed for the health and legal professionals engaged in the investigation and documentation of cases of alleged torture.
Obtaining Torture Survivor Histories- Video clips and Clinical Pearls
Short video clips give examples of issues to be aware of when obtaining a patient history. These clips are from interviews with patients of Dr. Carey Jackson (used with permission) demonstrating aspects of torture histories commonly encountered among torture survivors.
The following short video clips are examples of issues to be aware of when obtaining a patient history. These clips are from interviews with patients of Dr. Carey Jackson (used with permission) demonstrating aspects of torture histories commonly encountered among torture survivors.
For many survivors of torture leaving the painful images and memories of what happened to them in past is a blessing that comes with time and only after years. We know that many are not able to do this, but many do move on with their lives and the nightmares and PTSD that burdened them early in resettlement, begins to dissipate after a decade or so. Unfortunately, major health events later in life like cancer, liver failure, heart disease, and chronic lung disease reactivate feelings of vulnerability and loss of control. This gentleman is identifying the end stage renal disease and his need for dialysis as a trigger that reactivated his PTSD and specifically his experiences of torture 40 years earlier under the Khmer Rouge.
Witnessing the Torture of Others: An Example of Mass Torture in Cambodia under Pol Pot
One thing you notice about this story is that it doesn’t sound like a classic story of torture. There is no incarceration, no beating, no interrogation and so the victim might not endorse the fact that they were tortured if asked “were you ever tortured?” But if you ask “Were you ever threatened with execution, did you ever witness the execution or mock execution of a friend or loved one, did you experience extended periods of intentional deprivation, were you forced to work against your will like a slave?” Then clearly this victim would say yes, even though he may feel his friend was tortured and not identify this own experience as torture. Specificity, and not a gloss using the word torture, can be central to getting the history. Another feature of torture survivors that I have been struck by after taking dozens of these histories is that often the trauma the victim experiences is not the haunting image that recurs routinely in their nightmares, and not the story that captures for them the horror and heartbreak of the events. It is what they witness of the suffering of others that grieves them the most and proves to be the lasting image hardest to shake. They often forget what they experienced themselves and can repress it and only the looks on the faces of others linger. For this reason, one should not minimize the impact of witnessing the torture of others. A woman held by the Ethiopian government for three months and beaten and bound tells mostly of watching someone have their face dipped in boiling water or another raped as the events most painful from her experience. The image, the screams, the inability to help these people forms the pains are harder to carry than receiving a blow directly, and it is exactly why including a history of the torture or execution of family and friends is important. The shared experience of suffering is exactly why this theatrical display is made by the Khmer Rouge in this case. They do not want information from this man or others, they do not want to clarify the rules, they want to display power and control over the population. The very public and outrageous dissection of this poor man was done to illustrate a point about rebellion and disobedience. The phrase “big liver” in Khmer connotes avarice, disregard for social conventions, and rebellion so the vivisection and removal of his liver in front of the group was intended to make the crowd carry this image in mind as a lesson. Finally, this happened many many years ago when he was a young man, but he has carried this his entire life, tucked away, and it comes back to injure him when he can afford it the least.
The Experience of Reactivation
How the patient feels this he says very clearly here “the memories started kicking in when the doctor told me that my kidney failed.” “That’s when it hit me really hard.” “I had a hard time sleeping….I had a lot of nightmares.….I felt hopeless…..I’m not going to go on living because there is no way that I have any hope I can survive.” For these reason he felt the dialysis and kidney failure and the Khmer Rouge were the same experience. “When these things come up, it’s very hard, the emotion, the tears, and the pain, it’s like stirring up.” The patient may not bring these experiences to the clinician’s attention, for many of my patients I have had to pry this out of them and only then can I medicate them or address it. This is their private hell and they do not want to burden their family or their physician with memories that are unrelated to the challenge and the work at hand. The focus of enormous effort is on the organ failure and it’s treatment, the details of the past can seem irrelevant. The parallels are obvious once identified. The clinician has to identify these because at times the hopelessness is unwarranted, as in this case. He is now doing well, and the physician can make it clear that the past is spilling into present events and carrying in a degree of pain and hopelessness that does not belong to the current issue, but nevertheless is active and must be addressed. The emotional weight and hopelessness borrowed form the past can at times immobilize patients, interfere with work-ups, result in missed appointments, and loss to follow-up as patients are sidelines by grief and PTSD.
Chronic Nightmares and Sleeplessness
This gentleman has been out of prison now for 30 or more years. He has never mentioned his sleep difficulties as an issue and has never mentioned the near nightly nightmares. Here he tosses them off as if it is a given that he lives with terror of “those people” (now a world away) coming to get him and that he revisits this nightly in his sleep which is often disturbed because of it. The manner in which he has learned to accept this and manage it, and consider it part of his life, can suggest to the clinician that it is not an issue. On the contrary it is a powerful source of distress. To not expect or look for and find relief from this suffering is a very sad reality. I am often struck by how many aging torture survivors never bother to mention their disturbed sleep and nightmares since they have accommodated this reality for so long.
This clip illustrates the significance of hunger on patients and their memories of torture. For the past 20 plus years I have heard survivors of warfare and imprisonment describe the horrific events of their lives. Hunger is always among the top items that people remember clearly as intense suffering. Bosnians, Somalis, survivors of the Khmer Rouge, lost boys from Sudan – all of those who recall being hungry never fail to mention it and they carry it with them. I suspect it is in part because we are better at suppressing external events than those that have survival value. For evolutionary reasons hunger is the neurologic phenomena at a hypothalamic level that spurs us to eat for survival. Since it is a survival mechanism at a limbic system level, like thirst, it is basic and difficult to suppress, especially once starvation sets in. As a consequence the feelings are constant. Look as he describes and remembers with detail what the meals were like. It is easy for the casual listener who has never really been hungry to underestimate the significance of this, but it is not lost on prison systems, and is one of the most common features of torture reported by survivors of warfare, camps, and imprisonment.
Distorted Timelines/Memory Loss
This clip illustrates how torture can impact a clear narrative of events and make it difficult for clinicians to reconstruct linear timelines. Clear sequential narratives are helpful in our work to establish causality and so the soliciting of timelines in history taking are habits that we find second nature. If someone cannot reproduce an easy to follow timeline we often describe them as a “poor historian.” In the case of torture, indeed the victim often is a poor historian for the reason that the traumatic events often cause memory loss, especially if head trauma is involved, but head trauma is not necessary. The extreme emotional and physical states that people find themselves in distort time and at times distort the sequences of events, leaving the historian confused and the clinician frustrated unless they understand what is going on. Documenting the confused narrative can become an important liability if the medical document is going to be cited in legal proceedings of any kind. The credibility of the witness and events often turn on a clear timeline. Any contradictions or lapses in time can make the narrative seem suspect and unreliable. The entire case may be dismissed or the witness found to be not credible if a timeline is submitted out of context and is found to be rambling, inconsistent, or contradictory.
This clip illustrates a common form of torture: confinement and isolation in restricted spaces. Torture survivors often describe being placed as this man was, in a space where he could neither lie down or stand and this affects them physically and mentally. Military Officers from Iraq describe being kept in 3 foot by 3 foot cells. Others buried in dirt up to their waste or chest for periods of time. This kind of postural confinement creates muscle spasms and resultant pain. Prisoners describe shifting constantly to try to stretch muscles that have gone into spasms. As this goes on for weeks and months tendons and ligaments contract or stretch, neuropathies can result from pressure injuries. The long term consequences vary by case, but they leave both a physical and psychological imprint and often a connection between the two. This man attributes many of his leg pains and his tendon contracture to the ways in which he was constrained and then repeatedly traumatized by the shackles used to confine him. (see clips). Of note, for him, anatomically unrelated symptoms can result from or associate with the leg pain the two phenomena having been linked in memory by the experience. When he is hungry or has nightmares the leg pains flare.
Arrest and Confinement
This vignette captures the details and brutality of the process of torture. Patients tend to focus on the “why” of the arrest, that is the political context or the historical details and gloss over the specifics of what happened to their bodies and to those around them in the process of arrest and detainment. They also often get the timelines and duration and order of events contracted or abbreviated in order not to dwell on it. To get a clear sense of the enormity of what the survivor had to endure the history taker often must back them up and shift focus from the political context to the physical context to get them to recall the details.
Did your parents witness your arrest? Did they see you beaten? The questions must be detailed and sequential. It is painful, the pain it causes this man is evident, but only this way will the full extent of what he suffered be known to us. If his parents witness his ordeal this is another layer of trauma to his family and to him that is endured and carried psychologically. He does not carry this if they did not witness it.
Did they cut you, burn you, rape you? These are relevant details for work-ups and future trauma work he may skip over. In his case it prompts him to recall the dental torture that was unknown to me. In this man’s case future dental work will always potentially trigger terror. It is key to know here it was not one horrific encounter but psychological and unbearable physical pain that was meted out slowly over many encounters.
“They took my parents’ home.” This is a detail of financial ruin that may not readily be registered, especially if this is an historical clan/family home of many generations.
Finally he describes years in a small 3 foot by 9 foot cell he lived in alone for 7.5 years getting out only once a week to clean it. His isolation in pain must be registered. You can see it on his face and he recalls the misery. He lived in this cell with a broken spine from torture for 7.5 years, every step and movement in teeth gritting pain. He would gloss over this if given the option because it is painful and describe instead the “why” of his arrest. The clinician must catalog the memories of what happened to him physically to address them and anticipate painful re-triggering in the future when he is referred for dental work, asked to stay in isolation for assessment of active TB, or immobilized by for a procedure.
Death of a Child
Here we are struck by the exquisite pain this man endured as he watched his infant son die from exposure, starvation, and eventual renal failure in a camp in Turkey. So many survivors of torture appear as traumatized by the suffering of others as they are by their own suffering, especially in cases where they feel they may have brought about the injury to family or friends, or where they feel they have failed to protect loved ones. For these reasons “witnessing the torture of others” is considered a form of secondary torture and should not be minimized, it is often the most enduring burden felt long after one’s own pain is healed or dissipates.
Warning about PTSD and Flashbacks
Here the patient describes the fact that he is resilient and strong and understands that the medical care is for his own good, and that he needs to survive for the good of his remaining children. Regardless of his resilience and understanding he will experience triggers and potential emotional deterioration when re-exposed to the settings that parallel the conditions and setting of his traumatic history. Warning him may give him some control, and at least gives him permission to report that it is difficult. Warning the techs and medical assistants performing procedures cues them to why this may be unusually emotional for this particular person.
In this vignette the patient describes in detail how he was tortured and begins to describe his symptoms and the related injuries he sustained. He confuses the symptoms likely sustained from gun blows to the head with those he sustained to his back. He again describes the agony of living in solitary confinement in a cell with chronic back pain and how it limited every movement. He is inclined to skip over details and has to be re-oriented to the chronology and the symptoms related to his back. He also makes the point that for torture survivors with traumatic brain injury memory losses are common, sometimes complete periods of time are gone. For this reason, the sequence of events can be jumbled, or key details left out. This can be very frustrating for the clinician.
Bibliographies, Journal Articles and Literature Reviews
The Physical and Psychological Sequelae in Adult Refugees or Asylum Seekers Who Have Survived Torture: Literature Review
Refugees and asylum seekers who have experienced trauma and torture present unique challenges to healthcare providers. This literature review examines findings from 23 research articles in peer-reviewed journals about the physical and psychological sequelae in adults who have survived torture.
Female Genital Cutting: An Evidence-Based Approach to Clinical Management for the Primary Care Physician
Female genital cutting (FGC) can be the basis of an asylum claim in the United States. This review article by Adelaide A. Hearst, MD and Alexandra M. Molnar, MD provides an introduction to the practice of FGC, reviews current laws on the issue, and some guidance on writing an affadavit. This article appears in the Mayo Clin Pro. 2013:88(6)618-629.
Refugee Mental Health Bibliography
Compiled by the Pathways to Wellness Project, in conjunction with The National Partnership for Community Training, this bibliography compiles prominent reseach and literature on refugee mental health, from general information to screening and assessment processes, effective interventions and best practices in therapy, clinical treatment and culturally specific modalities.
Working with Refugee Survivors of Torture
Article with practical considerations for health professionals who care for survivors of torture, reprinted on EthnoMed with permission from Western Journal of Medicine. By Barbara Chester, PhD and Neal Holton, MPH. West J Med, September 1992; 157:301-304.