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
Additional Articles about NWHHR:
- "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
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.
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.
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.
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.
- Legal Investigations: considerations meant to provide an overview of general procedural issues to be considered in legal investigations and evidence gathering.
- Medical Documentation: Considerations for health professionals who can provide critical documentation of torture and ill treatment in legal proceedings.
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.
A 40-minute video presentation by Drs. Adelaide Hearst and Alexandra Molnar (Harborview Medical Center/Univ of Washington) for providers about female circumcision and treatment considerations when working with patients with FGC
Evaluation and Treatment of Survivors of Torture
A PDF slideshow developed by Drs. J. Carey Jackson and Nicole Chow Ahrenholz 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 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.
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.
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 reprinted with permission from Western Journal of Medicine. By Barbara Chester, PhD and Neal Holton, MPH. West J Med, September 1992; 157:301-304.
Obtaining Survivor Histories- Video clips and Clinical Pearls
The following short video clips (less than a minute) are examples of issues to be aware of when obtaining a patient history. These clips are from an interview with a patient of Dr. Carey Jackson (used with permission) demonstrating aspects of torture histories commonly encountered among torture survivors.
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
Note: To view this clip, click on Memory Loss and the player will begin.
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 up 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.