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You are here: Home Clinical Topics Torture 11 1 Obtaining Torture Survivor Histories- Video clips and Clinical Pearls

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.

Catastrophic Illness


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.

Starvation

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.

 

Confinement

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.

Spine Injury

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.