Taking a History of Torture

Author(s): J. Carey Jackson M.D. & Nicole Ahrenholz M.D.

Contributor(s): Videos edited by Matthew Jackson

Date Authored: June 20, 2020

This series of 7 videos were recorded in response to a survey of Internal Medicine residents at the University of Washington who worked in a clinic designated for refugee care and who even then reported feeling very uncomfortable taking histories of torture. We realized that while clinicians see routine history and physicals modeled often they are rarely present when a more seasoned clinician takes a history of torture. We thought together about the varied ways we find to segue into what is very emotionally laden and painful part of a survivor’s story and not always obviously relevant to their chief complaint.

In thinking about it we realized there is an anatomy of a torture experience that is fairly standard and each aspect of the ordeal provides a window of opportunity to retrieve important information. We describe the anatomy of the torture ordeal here, at times in vivid detail. To keep these from being overwhelming we have edited them to reasonable lengths and even then they are not intended to be watched sequentially or at one time.

In these vignettes we see how torture is difficult to discuss, how it informs care, and continues to be relevant to a patient’s health often decades later. We also see how witnessing the torture or killing of others can be as disturbing as being tortured yourself.

Each chapter contains supporting material related to the topic that may be of additional interest.

These patients have been courageous enough to share their stories for instructional purposes. These vignettes are to be respected and treated as sacrosanct and not reproduced from this didactic module.

Introduction

We begin with an overview of how the experience of torture shapes a person’s behavior as it shapes their narrative and potentially interacts with their other medical experiences ever after.

Chapter 1: Hearing the Political History

This is usually the “why and when” of the torture history. There is usually an affiliation to party, ethnic group, religious minority, gender preference that prompted an attack. The survivor often needs to start the story there, at times in details which seem extraneous, since for them that is the true beginning and the part of their life story that resulted in details they would rather forget , but that need to be known by their physician advocate.

Chapter 2: Arrest, Detention & Escape

In the “triple trauma” model, the escape is often as traumatic as the events of the imprisonment itself. Or, the details of the conditions of imprisonment (starvation, extreme heat) are omitted as survivors focus the telling on the beatings and interrogation. But for a full picture that may impact future fears and preferences those details of surveillance, arrest, and detention become critical. In the telling of that story is often the opportunity to solicit the details of torture that need clarifying.

Chapter 3: Torture

Too often the survivor slides past the details of beatings, threats, related events in the obvious attempt to minimize the horror for themselves and the hearer. They may omit their rape, or the rape of a spouse, the death of sibling or brother, the many details of their own abuse. This is the hardest part, to gently facilitate the clear detailed story to know what was done to the emotions, the mind, and the body for future reference as one moves forward with the person and helps to manage psychic wounds and interacting illnesses.

Chapter 4: Torture Symptoms

It is very easy for clinicians to explore symptoms and related “reviews of systems” and not link the symptoms to the detailed events that produced them. This is usually the most obvious point of entry into the trauma story. Although sometimes the torture seemed to leave no symptoms and yet subsequent illnesses will produce symptoms that become linked to historic traumatic events. These connections become important as the clinician attempts to understand the subterranean connections impacting a survivors health.

Chapter 5: Entry Points for Getting a Torture History

This is a summary of places that one can enter the torture history while interviewing and examining a patient. This might be a more effective overview to see before exploring the more detailed sections. It is intended to summarize and model the various points of entry into the survivor’s story.

Chapter 6: Secondary Torture

In this clip, while detention, confinement and beatings are mentioned, it is the constant threats and how these are used to create a climate of terror that is brought into focus. The disappearance of family members, murders, the disappearances in the night, threats of executions, and the witness of inhuman acts have a devastating life altering impact on the subject. Yet when given the opportunity to avoid the retelling she still wants to tell the story and have someone bear witness to her ordeal. It is very important to register the weight of secondary torture, especially if the object of the torture is a loved one or a child.