Part of a Special Psycom Pro Series on Treating Trauma in the 21st Century

While virtually supervising a group of clinicians recently, the conversation turned to a discussion about evaluating victims of various forms of torture. Having worked on such cases extensively over the past 18 years, I would like to offer some thoughts based on my practice.

I have evaluated both child and adult victims of torture. Most have been adults who experienced detention due to their political and/or religious affiliations outside the United States. Many exhibited physical marks (eg, scars or deformities) and even permanent disability. Others have included victims of police brutality/abuse, chronic domestic violence, ritual child abuse, and additional forms of torture within the United States.

Defining Psychological Torture

McCoy referred to psychological torture as “no-touch torture.”1 Jacobs, in “Documenting the Neurobiology of Psychological Torture,” posited that psychological torture disrupts a person’s psyche through a powerful assault on the victim’s “basic conditions for mental survival.”2

The World Medication Association (WMA) defined “torture” in 1975 as the deliberate, systematic, or wanton infliction of physical or mental suffering by one or more persons acting alone or on the orders of any authority to force another person to yield information, to make a confession, or for any other reason.3 This includes any act that results in pain or suffering – whether physical or mental – that is meant to punish that individual for something the person has done, to coerce, to obtain a confession, or to discriminate against said individual. It should be noted that there are additional cases in which the aim of the perpetrator is to torture a third person by virtue of harming another. Former WMA President Mungherera dove deeper into “psychological torture,” noting that “Psychological effects of torture are probably the worst consequences of torture for survivors. This is because they tend to last longer, are more incapacitating and may be life long.”4

In Ojeda’s “What Is Psychological Torture,” he describes a variety of commonly used torture techniques designed to create conditions beyond those which are bearable for the subject, forcing the individual toward a psychological breaking point.5 These can include but are not limited to:

isolation, threats, spatial disorientation (through confinement in small places), sexual humiliation, desecration, temporal disorientation (generally through isolation), sensory disorientation, sensory deprivation, administration of neuroleptic medication to distress a person’s cognition, sensory overload (eg, bright lights and loud screams, or music), induced desperation (by proving to the victim that he or she is helpless), feral treatment (forcing the victim to act like an animal), and psychological debilitation (“breaking down the mind”) through stress positions, temperature manipulation, or deprivation of a basic need like food, water, clothing, or sleep.

A psychologist’s or mental health provider’s evaluation of torture is often utilized as a key component of various types of cases, including those dealing with asylum and human rights cases, war crime tribunals, and both civil and criminal cases. The questions addressed focus on the credibility of the client (ie, torture victim), both the immediate and long-term impact suffered, relevant diagnosis when available, a thorough explanation of the implications of this experience for the client, as well as available treatment recommendations.

A Psychologist’s Evaluation of the Torture Victim

The scope of the licensed psychologist or mental health provider has to be clear. The aim of the evaluation must never include issues of religious or political affiliation, justice, punishment for the guilty party, or due compensation to the client. Similarly, psychologists and providers of forensic evaluations are not to make inferences about the guilt or innocence of the perpetrator as it is beyond the scope of clinical practice. Instead, the client and his/her experience of torture is the focus of the assessment – its goal being to provide a psychological framework for understanding what occurred.

The Clinical Assessment

Of particular importance for the inexperienced evaluator is clarity concerning the difference between the role of a therapist/clinician and that of the forensic evaluator (described below) in conducting a legal/forensic assessment. When it comes to the clinical relationship, it is expected that the trauma/torture story will emerge over time. Rapport-building is key and must be established prior to addressing the core of the trauma. In a therapeutic relationship, feedback is provided, coping techniques are discussed, and testing is sometimes, though rarely, conducted. The client’s credibility is implicit and clinical notes are to be written but no report is expected in most cases.

The Forensic Assessment

The role of the forensic evaluator and the evaluation process can vary considerably, and the client must be made aware of this via written consent and be given an extensive opportunity to ask clarifying questions. Forensic evaluations can range from one to four sessions, during which the psychologist records information while the interview is being conducted. It is crucial to record both facts and observations (eg, whether or not the person’s statements match their affect; if they are dissociating, crying, tired, or have a particular reaction to a question; scars or visible deformities) simultaneously. Rapport is more challenging to establish due to the nature of this type of assessment and, similarly, the forensic evaluator must bear in mind that a goal of the evaluation is to establish credibility of the victim. There is to be no other type of relationship established with the client subsequent to the evaluation. If the client requires treatment, referrals must be made

A Quick Word About Forensic Training Requirements

Psychologists must undergo extensive education and supervised clinical practice prior to engaging in any sort of torture or trauma evaluation. There are many reasons for this, most notably the potential for psychologically harming/retraumatizing the client, making incorrect and invalid statements on reports or in expert testimony, and committing ethical violations. In addition, this type of work is considered to have a high likelihood for secondary trauma (on the part of the provider) – also known as vicarious traumatization.

Licensed psychologists, whether a Phd or PsyD, with backgrounds in trauma are well-equipped to evaluate survivors of psychological trauma based on our training, experience, and ability to test clients and integrate relevant cultural factors into our assessments. Writing about issues that arise during a torture evaluation can yield subject matter worthy of a book in its extensiveness. In an effort to simplify things, what follows are a few points to keep in mind based on nearly two decades of clinical experience with torture and abuse survivor cases.

The Clinical Evaluation Session: Expert Strategies

Control the Office Setting

A session with a torture victim may be severely triggering to the client as it may call up similarities to past torture. Attention to the therapeutic environment is therefore key to establishing rapport and making the client feel safe and comfortable. For example, an office displaying what might be considered graphic art could likely be triggering for the client. Similarly, uncomfortable furniture, sparse or striking décor, or temperatures that verge on extremes can all make the process more challenging. Clients also need to feel that they can escape – literally – the session and should thus be provided a clear path to the door. Traumatized clients will likely feel unsafe sitting with their backs to the exit.

Address Any Provider Bias

For the evaluator, biases in one’s knowledge base, preconceptions, or experiences may – unless recognized and addressed – lead to a flawed assessment. For example, consider a torture survivor who displays cognitive impairment and reports headaches. Most clinical providers would assume that these symptoms stem from the trauma, but they might also be the result of a head injury, an infection, or even a sinus headache. Therefore, it is always important to rule out the possibility that a particular medical condition is the root cause of physical, sometimes psychological, symptoms rather than make assumptions about psychosomatic presentation.

The accuracy of an evaluator’s assessment might also be obstructed by confirmation bias. It is normal to have preconceived notions of our clients’ experiences, but mental health professionals must be aware of these and manage them with great care. As persons and professionals, we tend to look for, recognize, and subscribe to statements and values that are consistent with our own beliefs and experiences. However, as evaluators, we need to be mindful not to discount information that does not conform to our experience or ideas.

There are many ways in which torture survivors express their experiences and the resulting impact. As an example, a patient with a fourth-grade education, who is practically illiterate, shared with me recently that upon release from prison due to political reasons, where she was raped and abused, she found her husband at home, “quite cold.” Upon further questioning, it became evident that she was referring to his being dead at the time of her arrival though I initially presumed she was referring to his being emotionally cold toward her. Therefore, guarding against confirmation bias requires keeping an open mind during the data-gathering process and, if we start forming theories early on, actively searching for disconfirming data and alternative explanations.

Use Appropriate Assessment Methods

Evaluators must select assessment methods that are appropriate for the case at hand.

Assessment tools must be well-tailored to the individual, the purpose, and the context.  It is often tempting to select tests based primarily on their reputation for demonstrating high validity and high reliability. But even for the most useful tests, there is no universal validity and reliability. Validity and reliability can only be demonstrated for specific purposes (eg, identifying cognitive deficits, revealing attempts to malinger, predicting response to group therapy), specific populations (eg, those proficient in Spanish, airline pilots, children aged 5 to11), and specific settings (eg, schools, medical inpatient facilities, prisons).

Psychological evaluations of victims of torture often involve standardized tests. Such tests derive their power from their standardization. Norms, validity, reliability, specificity, sensitivity, and similar measures emerge from an actuarial base: a well-selected sample of people providing data (through answering questions, performing tasks, etc.) in response to a uniform procedure in (reasonably) uniform conditions. However, many professionals adapt to the patient’s needs in order to administer the assessment. The changing, even slightly, of test instructions, items, or any aspect of the administration can result in losing the standardization and, therefore, rendering a test invalid.

Consider the Sensitivities Around Language and Culture

Language and cultural issues must be taken very seriously as they can heavily impact the findings of an evaluation. In fact, even in cases when both evaluator and client speak the same general language, issues of dialect, regional slang, and varied cultural semantics can interfere with clear communication and cause significant problems.

Cultural differences in meaning can be just as significant in a torture and abuse evaluation. For example, demeaning family members, ancestors, nudity and sexualized shame, embarrassment, or humiliation can play a role in extreme or enhanced interrogations or as a means of controlling people by usurping their pride. Such acts may have varied meanings from one group to the next (eg, men and women), so we must explicitly ask about their impact.

Clinical practice shows that many former detention victims either struggle or outright refuse to discuss their experiences due to shame, even years after being released. In some cultures, nudity and physical forms of coercion violate religious beliefs or cultural mandates. On the other hand, acknowledging certain forms of sexual victimization may result in ostracism or more extreme penalties including incarceration or death. It is possible that the survivor of unwanted sexual touching, abuse, or assault by opposite- or same-sex perpetrators may feel irrevocably bound by religious or cultural proscriptions against openly acknowledging such trauma, thus creating a bind that exposes that person to repeated trauma.

Finally, keep in mind that there are myriad potential barriers to a victim of torture first seeking and then actually utilizing mental health services. These include lack of information or knowledge, shame/stigma associated with seeking such aid, guilt, fear, ongoing isolation, racial/cultural factors, language barriers, and both legal and financial limitations. Thus, the importance of keeping an open mind in order to assess the full scope of a client’s situation or circumstances cannot be overstated.

 

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Last Updated: Feb 12, 2021