TORTURE 2 2018 Journal on Rehabilitation of Torture Victims and Prevention of Torture
Special section: Forced migration and torture: challenges and solutions in rehabilitation and prevention
VOLUME 28, NO 2, 2018, ISSN 1018-8185 TORTURE
Journal on Rehabilitation of Torture Victims and Prevention of Torture Contents
Published by the International Rehabilitation Council for Torture Victims (IRCT), Copenhagen, Denmark. Editorial: Migration and torture: Building a map of knowledge TORTURE is indexed and included in MEDLINE. Citations Pau Pérez-Sales, Editor in Chief 1 from the articles indexed, the indexing terms and the English abstracts printed in the journal will be included Review article: Debility, dependency and dread: On the in the databases conceptual and evidentiary dimensions of psychological torture
Volume 28, No 2, 2018 Ergun Cakal 15 ISBN 1018-8185 Scientific Articles The Journal has been published since 1991 as Torture Special section: Forced migration and torture: challenges – Quarterly Journal on Rehabilitation of Torture Victims and solutions in rehabilitation and prevention and Prevention of Torture, and was relaunched as Torture from 2004, as an international scientific core field journal Associated Guest Editor: Joost Jan den Otter, PhD, on torture MD, MSc “It never happened to me, so I don’t know if there are Editor in Chief Pau Pérez-Sales, MD, PhD procedures”: identification and case management of torture survivors in the reception and public health system of Assistant Editor Rome, Italy Nicola Witcombe, MA, LLM Caterina Spissu, Gianfranco De Maio, Rafael Van den Bergh, Editorial advisory board Engy Ali, Emilie Venables, Doris Burtscher, Aurelie Ponthieu, S. Megan Berthold, PhD, LCSW Mario Ronchetti, Narciso Mostarda, Federica Zamatto 38
Hans Draminsky Petersen, MD Validation of the Protect Questionnaire: A tool to detect mental health problems in asylum seekers by non-health professionals Jim Jaranson, MD, MA, MPH Ricarda Mewes, Boris Friele, Evert Bloemen 56 Marianne C. Kastrup, MD, PhD “My mind is not like before”: Psychosocial rehabilitation of victims of torture in Athens Jens Modvig, MD, PhD Gail Womersley, Laure Kloetzer, Rafael Van den Bergh, Emilie Duarte Nuno Vieira, PhD, MSc, MD Venables, Nathalie Severy, Nikos Gkionakis, Christina Popontopoulou, Manolis Kokkiniotis, Federica Zamatto 72 Önder Özkalipci, MD Non-professional interpreters in counselling for asylum seeking June C. Pagaduan-Lopez, MD and refugee women Filiz Celik, Tom Cheesman 85 José Quiroga, MD Acute short-term multimodal treatment for newly arrived Nora Sveaass, PhD traumatized refugees: Reflections on the practical experience and evaluation Morris V. Tidball-Binz, MD Mechthild Wenk-Ansohn, Carina Heeke, Maria Böttche, Nadine Language editing Stammel 99 Monica Lambton, MA, BA Satisfaction of trauma-affected refugees treated with antidepressants and Cognitive Behavioural Therapy Correspondence to IRCT Cæcilie Buhmann, Jessica Carlsson, Erik Lykke Mortensen 118 Vesterbrogade 149, building 4, 3rd floor, 1620 Copenhagen V, Denmark Case report: The impact of torture on mental health in the Telephone: +45 44 40 18 30 narratives of two torture survivors Email: [email protected] Simone M. de la Rie, Jannetta Bos, Jeroen Knipscheer, Paul A. Boelen 130 Subscription http://irct.org/media-and-resources/publications#torture-journal Perspectives: Building Survivor Activism: An organisational view
Price: EURO 100 per year. Shameem Sadiq-Tang 140 www.irct.org/Library/torture-journal.aspx. Book reviews The journal is free of charge for health professionals. Forensic Psychological Assessment in Immigration Court: The views expressed herein are those of the authors and A Guidebook for Evidence-Based and Ethical Practice by can therefore in no way be taken to reflect the official Barton F. Evans III, Giselle A. Hass opinion of the IRCT. Mari Amos 150 Front page: Mogens Andersen, Denmark After deportation: ethnographic perspectives by Shahram Khosravi Layout by Jordi Calvet Printed in Lithuania by KOPA. Louise Victorian Johansen 152 Tainted by Torture: Examining the use of torture evidence. A report by Fair Trials and REDRESS Sara Lopez 155 Letter to the Editor: Grotesque image can never be forgotten nor forgiven 158 1
EDITORIAL
Migration and torture: Building a map of knowledge
Pau Pérez-Sales, Editor in Chief
We already have more than twenty-five the “refugee crisis” in this period. These years of academic research on migration include, (a) Germany’s decision to both and torture; the field has developed into open its doors in 2015 and 2016 and an increasingly complex one since the first accept more than one million refugees, and descriptive and epidemiological studies. then subsequently restrict entry in 2017 after the political environment altered due The “refugee crisis” to various factors, including two Islamist The recent war in Syria, added to previous attacks attributed to newly arrived refugees; conflicts in Afghanistan, Iran, Iraq, has led (b)The EU decision in May 2017 to to mass displacement, especially since 2015, transfer 160,000 asylum seekers that were to neighbouring countries and Europe, in stuck in Greece and Italy to other European what has come to be known as the refugee member states was met with widespread crisis. The concept crisis as applied to resistance. The European Union was not Europe is a relative one. According to 2018 able to fully act on the decision and the UNCHR figures,1 while there are 22.5 transfer could only partially take place. As million refugees in the world, the top hosting a result, around 65,000 refugees remained countries are Turkey (2.9 M), Pakistan in both countries, and especially on the (1.4 M), Lebanon (1 M), Iran (979,000), Greek Islands in precarious conditions; (c) Uganda (940,000) and Ethiopia (791,000). In March 2016, in exchange for political While 30% of those living in Lebanon and financial benefits, the EU signed an (a country with a very unstable religious agreement with Turkey (recognised as a and political equilibrium) are refugees,2 safe country) to accept people being sent in Europe the proportion of refugees is back from Greece. In spite of that, only TORTURE Volume 28, Number 2, 2018 marginal in demographic terms, even around 2000 persons3 were sent back including the increase in the last two years. due to resistance of the Greek courts to Several episodes have marked the apply the agreement (Roman, Baird, & European political confrontation around Radcliffe, 2016). Those who were returned faced detention in overcrowded cells and deportation (Ulusoy & Battjes, 2017).
1 Resettlement data finder accesed in http://rsq. unhcr.org/en 2 https://ec.europa.eu/echo/files/aid/countries/ 3 http://www.dw.com/en/the-eu-turkey-refugee- factsheets/lebanon_syrian_crisis_en.pdf agreement-a-review/a-43028295 2
EDITORIAL
Europe is now trying similarly unacceptable As academic research has shown, if one arrangements with Libya, Egypt, Sudan, psychological element illustrates the migrant’s and Nigeria, among other countries, experience and provides a framework of countries which can never be considered as understanding of his or her inner experience, safe countries for refugees to be sent back to. it is that of trust. The decision to flee for torture survivors is part of a complex The true refugee crisis is of course that process. Voutira & Harrell-Bond (1995) around 4,600 persons are estimated to have showed, among others, how adaptive distrust died trying to cross the Mediterranean in shaped the experience of survivors of war 4 the 2015-2018 period, the sufferings of and torture. There is a mixture of individual, hundreds of migrants exploited, victims of community, institutional and social mistrust extortion, tortured and abused on their way shaped by the context of violence and north, pushed back at borders violating non- menace behind the decision to flee (Lyytinen, refoulement principles or abandoned to their 2017). Key decisions during the route that fate on the sea. could mean the difference between being dead or alive depended on trusting decisions. Research on migration and torture For years, mistrust is the norm (Daniel & Knudsen, 1995). particularly as refugees are It is worthwhile attempting a structural map often used as a bargaining chip in political of knowledge of where we are currently with disputes amongst countries, traders and local respect to research. Figure 1 is not meant to authorities, who often have their own hidden be exhaustive, but illustrative. agenda, and NGO’s and iNGOs can be unwilling to provide support for an extended Overarching issues period of time (Stedman & Tanner, 2003). The mental health impact of torture: Different Country of destination is rarely a reviews since the 1990s have provided decision of the asylum-seeker. Studies show strong evidence of the mental health impact that, at the beginning, the main concern of persecution and torture (Johnson & is to find a safe place. Final destination, Thompson, 2008; Momartin, Silove, however, depends on having funds and very Manicavasagar, & Steel, 2003; Steel et al., circumstantial decisions made in the heat 2009). Just to mention one, a meta-analysis of the moment, as well as being directed by of 161 articles reporting results from a smugglers, police, the military, governments, sample of 81,866 refugees from 40 countries and/or agencies to particular countries with showed that torture emerges as the strongest little choice (Robinson & Segrott, 2002). pre-migration factor associated with PTSD Dispersal within a country or between and depression, followed by cumulative countries can destabilise precarious social exposure to potentially traumatic events networks as well as disrupt the fragile bonds (Steel et al., 2009). of trust of early psychological care (Griffiths, 2012; Níraghallaigh, 2014) Distrust as a cross-cutting element: The impact of hardship and torture is not Crossing borders: when torture happens only measurable in clinical terms though. during flight Borders have become places of very serious human rights violations, as the Special Rapporteur against Torture (2018) 4 https://www.opensocietyfoundations.org/explain- has noted in his latest thematic report. ers/understanding-migration-and-asylum-euro- To give an example, just on the border
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Figure 1: Migration and torture - Psychosocial determinants of health and well-being and right to rehabilitation Negative factors:(0) No evidence, (*) Indicative evidence, (**) Strong evidence, (***) Conclusive evidence. Torture is according to UNCAT definition. Torture during migration progress includes where the State fails it's obligation to protect.
between Guatemala and Mexico, according seekers including extreme conditions in to official figures and reports of local cells, indefinite separation of minors from organizations,5 an estimated 20,000 people their parents, lack of information and were reported missing (“Desaparecidos”) access to legal counsel, victimisation and in the period 2015-2017 at the hands of other forms of coercion to accept returning organised crime and trafficking with the to Mexico, in what human rights groups necessary cooperation of the State and and the rapporteur himself have considered local police forces. This is to be added as amounting to systemic State torture to the general situation in the Mexican- (Hope Border Institute, 2018; Human TORTURE Volume 28, Number 2, 2018 United States border itself, where there has Rights First, 2017). Europe pursues similar been an estimated 800 cases of missing policies by funding detention centres and people in the last two years. According to coercive actions in North Africa where independent reports, the US is maintaining the systematic violations of human rights a policy of illegal detention of asylum- including torture and summary executions that take place have been denounced.6,7
5 Centro Fray Matias de Córdoba. http://cdhfray- matias.org/web/. Movimiento Migrante Mesoa- 6 See reports in http://ddhhfronterasur2017.org/es/ mericano https://movimientomigrantemesoameri- 7 See reports and maps by Migreurop. http://www. cano.org/inicio/ migreurop.org/ 4
EDITORIAL
There is a special need to address the per se produces learned helplessness and challenges of migrants who, along their powerlessness (Storm & Engberg, 2013). The migration route, have suffered violence transnational DEVAS study showed in 23 EU (including torture by non-state actors and countries that almost half of the detainees sexual violence). They should be offered in migration centres inside Europe did not similar protection against further abuses and understand the reason for their detention exploitation and to ensure access to basic and equate their detention centre with that human rights (to health, housing, education, rehabilitation etc). of a prison. Approximately one third referred to clear physical consequences and half Detention centres described a negative impact on mental health. The Global Detention Project (GDT) There was a general sense of indignity among monitors detention of immigrants in “host” detainees (Jesuit Refugee Service - Europe, countries,8 and has a global map and 2010). This is specially so in the subgroup detailed data of around 2,000 immigration- of torture survivors (Filges, Montgomery, & related detention sites across the globe. Kastrup, 2018) (Storm & Engberg, 2013). Within the United States, which is the According to recommendations from the most dramatic example, there has been a United Nations’ High Commissioner for sustained expansion with between 430,000- Refugees (UNHCR) (2012) and the Special 470,000 individuals being recently subject Rapporteur on Torture (2018), torture to some form of immigration detention survivors and other vulnerable groups annually compared to numbers as low as should generally not be detained. Health 6,000 in 1995 and 16,000 in 1998. Europe professionals should actively oppose this has also experienced a rapid expansion of measure based on ethical and deontological detention, including outsourcing detention principles (Brooker et al., 2016; Pearman, to border countries. Psych, Olinga-shannon, & Hons, 2017) There is a large body of literature that analyses the health impact of detention Accessing the system of protection for torture on victims fleeing torture and violence in survivors their countries and indicates that detention There is an important concern in the anti- substantially worsens the health of asylum- torture sector that torture survivors who seekers (Fazel & Silove, 2006; Keller et al., suffer trauma-related mental disorders 2003; Robjant, Hassan, & Katona, 2009; are being refused protection by countries Sobhanian, Boyle, & Bahr, 2006; Storm & in which they seek asylum. A pioneering Engberg, 2013). Data show symptoms of study (Loneragan et al., 2006) followed depression, anxiety, exacerbation of PTSD, a consecutive sample (n=73) of recently marked increase in reported negative arrived asylum seekers attending immigration mood states, suicidal ideation and self- agents in Sydney, Australia. Participants destructive thoughts. In all the studies the were followed up to assess the outcomes impacts are directly related to length of of their refugee applications. Although the detention. Prolonged or indefinite detention participants reported high rates of torture (51%), and this group is of course at the highest risk of suffering a combination of post-traumatic stress disorder (PTSD) and
8 TORTURE Volume 28, Number 2, 2018 Volume TORTURE https://www.globaldetentionproject.org/ major depression, neither past torture nor 5
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current psychiatric disorder predicted the that PTSD is neither the only nor the most outcomes of refugee applications. Although likely consequence of torture in the long the Asylum Procedures Directive (European term. Issues of transcultural validity of Council, 2013) establishes special measures screening tools are also relevant. A review to detect and properly document torture of validated measures and more theoretical survivors,9 there are serious concerns debate and consensus is needed (Gadeberg regarding its proper application (IRCT, 2016) & Norredam, 2016; McColl, McKenzie, & Faced with the increasing numbers Bhui, 2008). of asylum seekers, a number of initial screening tools—up to 20 documented in Post-migration without status academic journals and grey literature— Silove and colleagues have been providing have been proposed, the majority of large sustained evidence of the negative impact institutions having their own. There are on mental health of conditions of reception suggestions and formats from national and for asylum seekers in Australia, showing that international bodies including guidelines its impact was even greater than torture and from the European Union itself (PROTECT persecution in country of origin (Silove, Project, 2016)—see also Mewes, Friele, & 2000; Z Steel & Silove, 2001; Steel et al., Bloemen, (2018) in this issue. The scene 2009). A Norwegian case-control study in is variegated and requires revision as most an in-patient psychiatric ward found highly are non-validated instruments that can be significant differences in PTSD prevalence classified into two broad categories: (a) between asylum seekers, living in centres short clinical measures based on abbreviated (n=53, 43.3%), and refugees (n=45, 11%), diagnoses of post-traumatic stress or general associated to the stresses of life in reception psychological distress that can be applied centres and the risk of being expelled from by administrative staff (i.e. Hollifield et the country more than the experiences in al., 2013); and, (b) general indicators of countries of origin (Iversen & Morken, vulnerability (i.e. UNHCR-International 2004). Other studies have expanded these Detention Coalition - OAK, 2016). It results to medical conditions (Porter, 2007). should be remembered that there is a low to In a recent systematic review (Kalt, Hossain, moderate correlation between experiences Kiss, & Zimmerman, 2013), combining of torture and psychiatric disorders, and data from 23 peer-reviewed studies among asylum-seekers (30% torture survivors), it was concluded that highly stressful asylum-
seeking processes produced adverse mental TORTURE Volume 28, Number 2, 2018 9 The Asylum Procedures Directive (recast) was and somatic health effects, associated to adopted by the European Parliament and the Council in 2013 and was to be transposed specific forms of exclusion linked to social into Member States’ national legislations conditions and hostile policy environments. by July 2015. The Commission presented Whilst these conditions vary from country in July 2016 a Proposal for a new Asylum to country, there are some salient themes: Procedure Regulation. Point 31 states that, "National measures dealing with identification and documentation of symptoms and signs of torture or Poverty: Asylum seekers face economic other serious acts of physical or psychological violence, hardship through an increasingly short including acts of sexual violence, in procedures and limited system of state social support covered by this Directive may, inter alia, be based on the (...) Istanbul Protocol." and assistance even where there is one 6
EDITORIAL
(Allsopp, Sigona, & Phillimore, 2014). While mental health problems, especially in VoT waiting for a determination decision, they (Quinn, 2014). often receive basic temporary benefits, well below the minimum of the country, usually Cultural Barriers: Language and culture aggravated by the denial of permission to have been documented as central sources work. This situation can extend for a long of stress, particularly in the long term period of time. As an example, in a 2013 (Montgomery, 2011). The role of cultural study for Freedom for Torture, Pettitt reveals mediators is crucial, undoubtedly another that more than half of a sample of 84 torture insufficiently researched topic. survivors in the UK asylum system reported that they could never or not often afford to Access to justice and providing meaning to the buy enough food of sufficient quality and experience of torture: Arriving in a host country variety to meet their needs for a nutritionally is, for many survivors, part of a process balanced diet. 34 were never able to buy of social and political commitment which enough food of any quality to avoid hunger. cannot be easily continued. Giving testimony, 53 could not buy adequate winter clothing being part of an ideological or political (Pettitt, 2013). It is hard to imagine the movement, helping those who remain in situation of asylum seekers in countries with their country, and pursuing justice can be even lower levels of assistance. essential elements to providing meaning to the experience of torture and to have a sense Access to healthcare: According to the of continuity in life. The asylum system too HealthQUEST study (Tirado, 2008), often victimises survivors and keeps them in most European countries limit the access a vulnerable legal position that precludes any of migrants and asylum seekers to health possibility of activism or empowerment and care, usually reducing it to basic care the impacts of this are not well researched. and emergencies. The system of free (EATIP, GTNM/RJ, CINTRAS, & specialised healthcare is usually banned. SERSOC, 2002; Tay & Silove, 2017) The study shows that in Europe providing comprehensive adequate care (including Facing assessment mental health) would, paradoxically, save Abbreviated procedures: McColl (2008) has costs. In the United States where there is shown that processes that are too fast-track no national health system, the situation can preclude proper medical documentation is so precarious that Asgary, Charpentier, of allegations of torture or persecution. & Burnett (2012) showed in a sample of sub-Saharan asylum seekers (most of them Delay of decision: In a series of focus group torture survivors) that they had better access with survivors of torture in UK, , the to social and health services in their home three biggest problems described were African countries than in the US. uncertainty, lack of perspective and a shortened future associated with endless Stigma: There is growing evidence waiting for a decision (Haoussou, 2017). that perceived discrimination carries a Although the European Asylum Procedures psychological toll. A wide study following Directive (European Council, 2013) a participatory action research process in envisages a maximum of six months for
TORTURE Volume 28, Number 2, 2018 Volume TORTURE Scotland showed how this was linked to an asylum determination, the decision 7
EDITORIAL
normally takes much longer, sometimes 2016; Pérez-Sales, Witcombe, & Otero years. At the American border, asylum Oyague, 2017). claimants often spend many years waiting for the adjudication of their cases creating Credibility: It is probably the assessment a limbo situation (Haas, 2017). A cross- of the credibility of allegations of torture sectional survey with Iraqi refugees whose that is the one of the most complex issues determinations were pending showed that and on which, paradoxically, there is less survivors waiting for a decision generally academic research (Jubany, 2017). On the felt socially isolated and lacking in control one hand, there is a debate on whether over their life circumstances with a strong health professional should make judgments sense of injustice (Johnston, Allotey, of credibility (Good, 2004). The debate Mulholland, & Markovic, 2009). often mistakes the credibility of the victim with the credibility of the victim’s account. Stress of the interview and court hearings: There is arguably an ethical duty to have After initial acceptance, and after a long a forensic report provided, especially in waiting process, survivors of torture must contexts in which the victim of torture prepare and undergo an in-depth interview lacks any other evidentiary element, has (and sometimes a court hearing) where her fled without any documentation, and there fate will be decided. This is not a neutral are no physical injuries or witnesses that process. A recent study in Berlin suggested can support her allegations (Pérez-Sales, that the asylum interview might decrease 2017). This is particularly the case when posttraumatic avoidance but trigger considering the crude reality that torture posttraumatic intrusions (Schock, Rosner, survivors are being refused protection in all & Knaevelsrud, 2015). Due to this stress, likelihood due to the difficulties in giving a the interview might have a negative result. proper account of the facts (Loneragan et Similar studies in other countries have al., 2006; Masinda, 2004). found less conclusive results (Hocking, There are numerous guidelines for Kennedy, & Sundram, 2015) credibility assessment of the different institutions and bodies working within Medical reports: Some studies show the the framework of asylum (Gyulai, Kagan, importance of medical reports for proper Herlihy, Turner, & Lilli, 2013; Home Office, documentation of torture. In a sample of 2015; Kane, 2008; Mackey & Barnes, 2013; close to 2000 asylum-seekers in the US, Mind, 2010), with very different perspectives
89% of those with a medical report from and approaches and sometimes conflicting TORTURE Volume 28, Number 2, 2018 Physicians for Human Rights (PHR) were criteria. While in some cases the victim’s granted asylum, compared to the national account is said to be the weakest piece of average of 37.5% (Lustig, Kureshi, Delucchi, evidence, in others it is the opposite that Iacopino, & Morse, 2008). We need more is emphasised and guidelines are worked data on which aspects of forensic assessment out for the analysis of the narrative and its in general and the Istanbul Protocol in relationship with sources of corroboration or particular are relevant for an administrative triangulation. None of the available guides body or court to make a final decision on a to best practice have been validated and they protection claim, a much needed demand in are in any case only recommendations from the anti-torture sector (Freedom for Torture, experts. We also lack data for comparing 8
EDITORIAL
credibility in this area with credibility in studies on the hardships of reintegration other fields and the standards of proof after deportation for economic migrants required (Freedom for Torture, 2016). (e.g. Khosravi, 2018) but literature is scarce It unfortunately remains the case that the on rejected asylum claimants. asylum determination process relies heavily The organisation Justice First followed on remembering and narrating traumatising in 2011 a sample of Congolese people stories in a convincing way and without deported from France and found out that all contradictions, despite mental health issues. failed asylum seekers had been imprisoned, tortured, forced to pay a ransom, raped Deportation or subjected to sexual harassment upon In 2016 alone, the EU allocated a total their return (Ramos, 2011). Reports from of 806 million Euros to activities related Freedom for Torture (2012) and Human to the deportation of migrants, including Rights Watch (2012) have documented the expulsion of 113,835 people to the 15 the systematic detention and torture of countries with which Europe has signed a Tamils who were rejected asylum claimants repatriation partnership agreement and the and deported to Sri Lanka. Similar data financing of migrant centres in countries have been reported for deportees to such as Pakistan or Lybia. This figure would Eritrea, Malta, Libya including summary have increased noticeably if the agreement executions of deportees in Sudan (Alpes, with Turkey had not been a failure10 and if Blondel, Preiss, & Monras, 2017). There are transfer among EU members in application documented cases of detention and torture of the Dublin procedure were included.11 of Ugandan citizens that demanded asylum During President Obama’s administration, due to being a member of the LGTBQ a record 2.5–3 million immigrants were community (Onyoin, 2017), and already deported in his eight years in office. In mentioned is the fate of people deported 2016, immigrant detention and deportation to Turkey in application of the EU-Turkey machinery alone in the US cost 3.3 billion agreement. This data should not be a dollars (Baker, 2017). What happens with surprise. In many countries, the deported asylum-claimers who have been rejected person is handed to the national authorities and deported? Although some organizations on arrival. Having claimed asylum is viewed try to keep track of them (Amnesty as suspicious and the person is often International, 2017), there is scarce data immediately detained and interrogated. on their fate. There are some ethnographic All together, these studies suggest that there is a real danger for deported people and this must be the responsibility of 10 http://www.publico.es/internacional/union-euro- deporting authorities that do not have pea-agencia-deportacion-masiva-migrantes.html a post-deportation follow-up system 11 In January 2011, the European Court of Human (Stefanovska, 2016). Additionally, a Rights Rights (EchRT) declared that the transfer of one Disability International campaign claims person from Belgium to Greece in application of the Dublin rules violated Article 3 (torture that deporting people with severe mental and inhuman or degrading treatment or punish- disorders or disabilities to countries where ment) and Article 13 (effective remedy) of the they will have no access to proper care or European Chart of Human Rights. Following this treatment or be secluded in institutions decision, most of the member states of the Euro-
TORTURE Volume 28, Number 2, 2018 Volume TORTURE pean Union stopped Dublin transfers to Greece. with conditions that can amount to torture 9
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should be enough to stop deportation and ask for international protection obtaining humanitarian protection should always be it (Loneragan et al., 2006; Mueller et al., granted (Rosenthal, 2018).12 2011; UNHCR, 2017). The majority is, thus, undetected or rejected. There is a The top of the vulnerability pyramid: large body of literature showing that the undocumented migrants refugee population, even with protection The alternative for survivors whose status, has very high levels of psychological application has been rejected is to stay suffering resulting from their pre-migration undocumented in the host country in even experiences, but particularly from life in the worst conditions than before. If asylum new host country (Porter, 2007; Porter & seekers and refugees suffer poverty, stigma, Haslam, 2005). A decent standard of living lack of health services or a work permit, is not guaranteed. this is to be added to having to hide from police, being defenceless from crime and Right to rehabilitation violence and working in the underground Torture survivors have a right to economy. Overwhelming data show that this rehabilitation, as set out in the Convention is the group with the highest risk of severe against Torture and General Comment No. mental health disorders. One study, among 3. Programs for VoT who move about are many, in Zurich (Switzerland) showed that a challenge. There is a need for short-term more than 80% had at least one clinically interventions that follow the do-no-harm significant symptom, and more than 50% principles in contexts where it might not be fulfilled the criteria for PTSD. This should the time to talk. This creates a special set of come as no surprise as more than 60% had conditions for rehabilitation programs that suffered imprisonment and 30% torture. deserve special research, including long-term The prevalence of torture was slightly follow-up and non-clinical measures. lower than those of asylum seekers, but the prevalence of mental health problems Where next?: Concluding remarks was higher. The study showed, again, The over twenty-five years of research in the not only that refugee and humanitarian field appears to provide conclusive evidence decision-making procedures may be failing regarding the negative impact on torture but also that undocumented migrants are survivors of human right violations taking probably the most vulnerable and affected place throughout the migration continuum. of populations due to an aggravation of pre- This idea of a migration continuum migration symptoms and the impossibility of deserves special attention. Migrants who TORTURE Volume 28, Number 2, 2018 access to treatment according to their right along their migration route have been to rehabilitation (Mueller, Schmidt, Staeheli, suffering violence (including torture by & Maier, 2011). non-state actors, sexual violence, and being unable to access basic conditions Once status is granted: 'El Dorado' that respect human dignity) should be The long journey finally ends for an also offered protection and access to basic estimated 30-40% of torture survivors that human rights (to health, housing, education, rehabilitation etc). Figure 1 is intended to show a summary 12 https://www.driadvocacy.org/ of the relationship between mental health 10
EDITORIAL
and well-being and pre- and post-migration conference in Novisad (Serbia) on Mental factors and the amount and strength of health, mass people displacement and ethnic available evidence. Although we need minorities, and from a call from the Journal. more studies on psychosocial determinants It has been made possible thanks to the during the asylum claim process, there is financial support of the Danish Ministry of strong evidence on the impact of poverty Research. It starts with a paper by Caterina and limitations of access to health care. Spissu and colleagues from Médecins Sans Most of the research highlighted here is Frontières teams in Rome exploring the in relatively well-off host countries which difficulties in early identification of torture reflects the absence of literature in more victims by non-professionals working in complex situations (e.g. Lebanon and front-line resources. This is followed by a Greece, not to mention other neighbouring the study on the psychometric evaluation countries to refugee-producing countries of the Protect Questionnaire mentioned in the rest of the world). More research is above by Ricarda Mewes, Boris Friele, Evert especially needed regarding the migration Bloemen. Simone de la Rie, Jannetta Bos, process itself and the impact of massive Jeroen Knipscheer and Paul Boelen from human rights violations at borders, migrant Zentrum 45 in the Nertherlands present detention centres in third countries, and several case studies paradigmatic of the by State and Non-State actors on victims difficulties of the cases they attend, as do of persecution and torture fleeing from Gail Womersley and colleagues at Médecins their country. This also applies to research Sans Frontières, this time related to work on what happens to people being denied in Athens. Interpretation is then tackled protection and deported to their countries with Filiz Celik and Tom Cheesman from of origin. Although there are indicative Swansea University in Wales addressing data, more research is also needed on the whether non-professional translation by screening process and appropriateness volunteers from the same country can be of detention of torture survivors and a useful tool in counselling for refugees vulnerable populations, the impact of the and torture survivors in a context where asylum process and interviews, on the role professional interpretation is unaffordable. of translators and cultural mediators, and Mechthild Wenk-Ansohn, Carina Heeke, the effect of policies of dispersal and delays Maria Böttche and Nadine Stammel from in procedure decisions. With respect to Center ÜBERLEBEN in Berlin present proper identification procedures, the need results of a multimodal treatment for newly is poignant and urgent. Finally, we still lack arrived refugees that puts the focus on the more research and stronger evidence on initial six months’ work; they found mixed the efficacy of rehabilitation programs for results and reflect on them. Caecilie Böck migrant torture survivors. Buhmann, Jessica Carlsson and Erik Lykke Mortensen from the Competence Center for In this issue Transcultural Psychiatry in Denmark analyse Some of these topics are addressed in the the cultural acceptability of a western-style, Special Section of this issue, the papers trauma-focused programme combining CBT of which have been developed from and antidepressants showing that satisfaction presentations at the International Society for is linked to rapport with the survivor and
TORTURE Volume 28, Number 2, 2018 Volume TORTURE Health and Human Rights’ 2017 tri-annual not to clinical results. This collection of 11
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papers adds new data and knowledge and to information during the journey and while in shows some new avenues of work and Greece. BMC Medicine, 16(1), 1–12. https://doi. org/10.1186/s12916-018-1028-4 research especially regarding early detection, Brooker, S., Albert, S., Young, P., Steel, Z., Flynn, counselling in early stages of arrival and M., & Flynn, M. (2016). Challenges to Providing support in the long term. It could not have Mental Health Care in Immigration Detention About the Global Detention Project Challenges been possible without the invaluable help of to Providing Mental Health Care in Immigration Joost den Otter, past Editor-in-Chief of the Detention, (19). Journal and Associated Guest-Editor for this Crisp, J. (2009). Refugees, persons of concern, and people on the move: The broadening boundaries Special Section. Papers that are not directly of UNHCR. Refuge, 26(1), 73–76. related to the Special Section include a Daniel, E. V., & Knudsen, J. C. (1995). Mistrusting review entitled ‘Debility, dependency and refugees. Berkeley: University of California Press. dread: On the conceptual and evidentiary EATIP, GTNM/RJ, CINTRAS, & SERSOC. (2002). Paisajes del Dolor, Senderos de esperanza. Salud dimensions of psychological torture’ by mental y derechos humanos en el Cono Sur. Ergun Cakal and perspectives piece on European Council. (2013). L 180/60. Common the development and organisation behind procedures for granting and withdrawing survivor activism at Freedom from Torture international protection. Fazel, M., & Silove, D. (2006). Detention of refugees. in the UK by Shameem Sadiq-Tang which British Medical Journal, 332(7536), 251–252. offers a useful and practical guide. Whilst https://doi.org/10.1136/bmj.332.7536.251 this offers many positive stories, the rest of Filges, T., Montgomery, E., & Kastrup, M. (2018). the content in this issue suggests that, in The Impact of Detention on the Health of Asylum Seekers: A Systematic Review. Research the case of the migrant victims of torture, on Social Work Practice, 28(4), 399–414. https:// they are almost always deprived of any form doi.org/10.1177/1049731516630384 of control over their lives by an unjust and Freedom for Torture. (2012). Sri Lankan Tamils alienating system. tortured on return from the UK. Freedom for Torture. (2016). Proving Torture. Demanding the impossible. Home Office mistreatment References of expert medical evidence. London. Allsopp, J., Sigona, N., & Phillimore, J. (2014). Gadeberg, A. K., & Norredam, M. (2016). Urgent Poverty among refugees and asylum seekers in need for validated trauma and mental health the UK An evidence and policy review. IRiS screening tools for refugee children and youth. Working Paper Series, 1–46. European Child & Adolescent Psychiatry, 25(8), Alpes, J., Blondel, C., Preiss, N., & Monras, M. S. 929–931. https://doi.org/10.1007/s00787-016- (2017). Post-deportation risks for failed asylum 0837-2 seekers. Forced Migration Review, 54, 76-78. Good, A. (2004). Undoubtedly an expert? - Amnesty International. (2017). Human Rights in anthropologists in British asylum courts. the context of forced returns. (Vol. 1). https://doi. Journal of The Royal Anthropology Institute,
org/10.1007/978-3-319-39351-3_10 10, 113–133. https://doi.org/10.1111/j.1467- TORTURE Volume 28, Number 2, 2018 Asgary, R., Charpentier, B., & Burnett, D. C. (2012). 9655.2004.00182.x Socio-Medical Challenges of Asylum Seekers Griffiths, M. (2012). Vile liars and truth distorters. Prior and After Coming to the US. Journal Anthropology Today, 28(5). of Immigrant and Minority Health. https://doi. Gyulai, G., Kagan, M., Herlihy, J., Turner, S., & org/10.1007/s10903-012-9687-2 Lilli, H. (2013). Credibility assessment in asylum Baker, B. F. (2017). The Hidden Costs of Mass procedures. A Multidisciplinary Training Manual Deportation. Anthropology News, 58(5), e319– (Vol. 1). Hungarian Helsinki Committee. e323. https://doi.org/10.1111/AN.632 Haas, B. M. (2017). Citizens-in-Waiting, Deportees- Ben Farhat, J., Blanchet, K., Juul Bjertrup, P., Veizis, in-Waiting: Power, Temporality, and Suffering A., Perrin, C., Coulborn, R. M., … Cohuet, S. in the U.S. Asylum System. Ethos, 45(1), 75–97. (2018). Syrian refugees in Greece: Experience https://doi.org/10.1111/etho.12150 with violence, mental health status, and access Haoussou, K. (2017). Perspective—The long journey 12
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to rehabilitation for torture survivors i. Torture, Kalt, A., Hossain, M., Kiss, L., & Zimmerman, C. 27(1), 66–74. (2013). Asylum seekers, violence and health: Hocking, D. C., Kennedy, G. A., & Sundram, S. A systematic review of research in high- (2015). Mental disorders in asylum seekers: income host countries. American Journal of The role of the refugee determination process Public Health, 103(3). https://doi.org/10.2105/ and employment. Journal of Nervous and Mental AJPH.2012.301136 Disease, 203(1), 28–32. https://doi.org/10.1097/ Kane, J. (2008). Judging Credibility. New York: NMD.0000000000000230 American Bar Association. Hollifield, M., Verbillis-Kolp, S., Farmer, B., Keller, A. S., Rosenfeld, B., Trinh-Shevrin, C., Toolson, E. C., Woldehaimanot, T., Yamazaki, Meserve, C., Sachs, E., Leviss, J. A., … Ford, J., … SooHoo, J. (2013). The Refugee Health D. (2003). Mental health of detained asylum Screener-15 (RHS-15): development and seekers. Lancet, 362(9397), 1721–1723. https:// validation of an instrument for anxiety, doi.org/10.1016/S0140-6736(03)14846-5 depression, and PTSD in refugees. General Khosravi, S. (2018). After deportation. Ethographic Hospital Psychiatry, 35(2), 202–209. https://doi. perspectives. Palgrave McMillan. org/10.1016/j.genhosppsych.2012.12.002 Loneragan, C., Steel, Z., Touze, D. le, Harris, E., Home Office. (2015). Asylum Policy Instruction: Ceollo, M., Susljik, I., … Brooks, R. (2006). Assessing Credibility and Refugee Status. Torture, Mental Health Status and the Outcomes Hope Border Institute. (2018). Sealing the border. The of Refugee Applications among Recently Arrived criminalization of asylum seekers in the Trump era. Asylum Seekers in Australia. International Journal El Paso. of Migration, Health and Social Care. https://doi. HRW. (2012). UK: Halt Deportations of Tamils to org/10.1108/17479894200600002 Sri Lanka. Lustig, S. L., Kureshi, S., Delucchi, K. L., Iacopino, Human Rights First. (2017). Violations at the V., & Morse, S. C. (2008). Asylum grant rates Border, (February). Retrieved from http:// following medical evaluations of maltreatment www.humanrightsfirst.org/sites/default/files/hrf- among political asylum applicants in the United violations-at-el-paso-border-rep.pdf States. Journal of Immigrant and Minority Health IRCT. (2016). Falling Through the Cracks: Asylum / Center for Minority Public Health, 10, 7–15. procedures and reception conditions for torture victims https://doi.org/10.1007/s10903-007-9056-8 in the European Union. Copenhahue: IRCT. Lyytinen, E. (2017). Refugees’ ‘Journeys of Trust’: Iversen, V. C., & Morken, G. (2004). Differences Creating an Analytical Framework to Examine in acute psychiatric admissions between Refugees’ Exilic Journeys with a Focus on Trust. asylum seekers and refugees. Nordic Journal Journal of Refugee Studies, few035. https://doi. of Psychiatry, 58(6), 465–470. https://doi. org/10.1093/jrs/few035 org/10.1080/08039480410011696 Mackey, A., & Barnes, J. (2013). Assessment of Jesuit Refugee Service - Europe. (2010). Becoming Credibility in Refugee and Subsidiary Protection vulnerable in detention - Civil Society Report on the claims under the EU Qualification Directive Detention of Vulnerable Asylum Seekers and Irregular Judicial criteria and standards Prepared by Allan Migrants in the European Union (DEVAS). Mackey and John Barnes for the International Johnson, H., & Thompson, A. (2008). The Association of Refugee. development and maintenance of post-traumatic Masinda, M. T. (2004). Quality of Memory: Impact stress disorder (PTSD) in civilian adult survivors on Refugee Hearing Decisions. Traumatology. of war trauma and torture: a review. Clinical https://doi.org/10.1177/153476560401000205 Psychology Review, 28, 36–47. https://doi. McColl, H., McKenzie, K., & Bhui, K. (2008). org/10.1016/j.cpr.2007.01.017 Mental healthcare of asylum-seekers and Johnston, V., Allotey, P., Mulholland, K., & Markovic, refugees. Advances in Psychiatric Treatment, M. (2009). Measuring the health impact of human 14, 452–459. https://doi.org/10.1192/apt. rights violations related to Australian asylum bp.107.005041 policies and practices: A mixed methods study. Mewes, R., Friele, B., & Bloemen, E. (2018). BMC International Health and Human Rights, 9 (1). Validation of the Protect Questionnaire: A Tool Jubany, O. (2017). Screening asylum in a culture to Detect Mental Health Problems in Asylum of disbelief: Truths, denials and skeptical borders. Seekers by Non-Health Professionals. Torture, Screening Asylum in a Culture of Disbelief: Truths, This issue. Denials and Skeptical Borders. https://doi. Mind. (2010). Achieving justice for victims and witnesses org/10.1007/978-3-319-40748-7 with mental distress. A mental health toolkit for TORTURE Volume 28, Number 2, 2018 Volume TORTURE 13
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prosecutors and advocates. London: Mind-For PROTECT Project. (2016). PROTECT. Process of better health. Recognition and Orientation of Torture Victims Momartin, S., Silove, D., Manicavasagar, V., & Steel, in European Countries to Facilitate Care and Z. (2003). Dimensions of trauma associated with Treatment. Brussels. posttraumatic stress disorder (PTSD) caseness, Quinn, N. (2014). Participatory action research severity and functional impairment: a study of with asylum seekers and refugees experiencing Bosnian refugees resettled in Australia. Social stigma and discrimination: the experience from Science & Medicine, 57(5), 775–781. https://doi. Scotland. Disability and Society, 29(1), 58–70. org/10.1016/S0277-9536(02)00452-5 https://doi.org/10.1080/09687599.2013.769863 Montgomery, E. (2011). Trauma, Exile and Mental Ramos, C. (2011). Unsafe Return: Refoulement of Health in Young Refugees. Acta Psychiatrica Congolese Asylum Seekers. Scandinavica, 124(September). Robinson, V., & Segrott, J. (2002). Understanding the Mueller, J., Schmidt, M., Staeheli, A., & Maier, T. decision-making of asylum seekers. Home Office (2011). Mental health of failed asylum seekers Research Study, (243), 84. as compared with pending and temporarily Robjant, K., Hassan, R., & Katona, C. (2009). accepted asylum seekers. European Journal Mental health implications of detaining asylum of Public Health, 21(2), 184–189. https://doi. seekers: systematic review. British Journal org/10.1093/eurpub/ckq016 of Psychiatry, 194(4), 306–312. https://doi. Níraghallaigh, M. (2014). The causes of mistrust org/10.1192/bjp.bp.108.053223 amongst asylum seekers and refugees: Insights Roman, E., Baird, T., & Radcliffe, T. (2016). Why from research with unaccompanied asylum- Turkey is Not a “Safe Country.” Statewatch seeking minors living in the republic of Ireland. Analysis, 2013(February), 1–26. Journal of Refugee Studies, 27(1), 82–100. https:// Rosenthal, E. (2018). The right of people with doi.org/10.1093/jrs/fet006 disabilities to asylum and protection from Onyoin, C. A. (2017). A grim return : post- deportation on the grounds of Persecution or Torture deportation risks in Uganda. Forced Migration Related to their disability. Review, (February), 81–83. Schock, K., Rosner, R., & Knaevelsrud, C. (2015). Pearman, A., Psych, B., Olinga-shannon, S., & Hons, Impact of asylum interviews on the mental health B. B. A. (2017). Australian immigration detention of traumatized asylum seekers. European Journal and the silencing of practitioners, 90–93. of Psychotraumatology, 6(March). https://doi. Pérez-Sales, P. (2017a). Psychological Torture: org/10.3402/ejpt.v6.26286 definition, evaluation and measurement. London- Silove, D. (2000). Policies of Deterrence and the New York: Routledge. Mental Health of Asylum Seekers. Jama, 284(5), Pérez-Sales, P. (2017b). Psychotherapy for torture 604. https://doi.org/10.1001/jama.284.5.604 survivors—Suggested pathways for research. Silove, D. (2013). The ADAPT model: a conceptual Torture : Quarterly Journal on Rehabilitation of Torture framework for mental health and psychosocial Victims and Prevention of Torture, 27(1), 1–12. programming in post conflict settings. Pérez-sales, P., Witcombe, N., & Otero Oyague, D. Intervention, 11(3), 237–248. (2017). Rehabilitation of torture survivors and Sobhanian, F., Boyle, G. J., & Bahr, M. (2006). prevention of torture: Priorities for research Living in the Australian Community through a modified Delphi Study. Torture, Psychological Status of Former Refugee 27(3), 3–48. Detainees From the Woomera Detention Centre Pettitt, J. (2013). The Poverty Barrier: The Right to Now Living in the Australian Community. TORTURE Volume 28, Number 2, 2018 Rehabilitation for Survivors of Torture in the Psychiatry, Psychology and Law, 13(2), 37–41. UK, (July). Special Rapporteur Against Torture. (2018). Porter, M. (2007). Global Evidence for a Migration-related torture and ill-treatment (A/ Biopsychosocial Understanding of Refugee HRC/37/50). United Nations. https://doi.org/ Adaptation. Transcultural Psychiatry, 44, 418. CAT/C/MAR/CO/4 https://doi.org/10.1177/1363461507081642 Stedman, S. J., & Tanner, F. (2003). Refugee Porter, M., & Haslam, N. (2005). Predisplacement manipulation. War, politics and the abuse of human and postdisplacement factors associated with suffering. Washington: Brookings Institution Press. mental health of refugees and internally displaced Steel, Z., Chey, T., Silove, D., Marnane, C., persons: A meta-analysis. Journal of the American Bryant, R. A., van Ommeren, M., & Steel Z, Medical Association, 294(5), 602–612. https://doi. Chey T, Silove D, Marnane C, Bryant RA, van org/10.1001/jama.294.5.602 O. M. (2009). Association of torture and other 14
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potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysis. JAMA : The Journal of the American Medical Association, 302(5), 537–549. https://doi.org/10.1001/jama.2009.1132 Steel, Z., & Silove, D. M. (2001). The mental health implications of detaining asylum seekers. Medical Journal of Australia, 175, 596–599. Stefanovska, V. (2016). Diplomatic Assurances and the State ’ s Responsibility When Considering Extraditing a Person Whose Human Rights May Be Violated. VARSTVOSLOVJE, Journal of Criminal Justice and Security, (2), 167–182. Storm, T., & Engberg, M. (2013). The impact of immigration detention on the mental health of torture survivors is poorly documented - A systematic review. Danish Medical Journal, 60(11), 1–7. Tay, A. K., & Silove, D. (2017). The ADAPT model: bridging the gap between psychosocial and individual responses to mass violence and refugee trauma. Epidemiology and Psychiatric Sciences, 26(02), 142–145. https://doi.org/10.1017/ S2045796016000925 Tirado, M. C. and I. G.-S. (2008). Quality in and Equality of Access to Healthcare Services. Country Report for Romania. Brussells. Ulusoy, O., & Battjes, H. (2017). Situation of Readmitted Migrants and Refugees from Greece to Turkey under the EU-Turkey Statement, (15), 1–42. UNHCR-International Detention Coalition - OAK. (2016). Vulnerability Screening Tool. Identifying and addressing vulnerability: a tool for asylum and migration systems. UNHCR. (2017). UNHCR- Global Trends. Forced displacement in 2016. Geneva. Switzerland. United Nations High Commisioner for Refugees. (2012). Detention guidelines. UNHCR. Viñar, M. (2007). Civilization and torture : beyond the medical and psychiatric approach. International Review of the Red Cross, 89(867), 619–633. Voutira, E., & Harrell-Bond, B. (1995). In search of the locus of trust: the social world of the refugee camp. In E. V. Daniel & J. C. Knudsen (Eds.), Mistrusting refugees (pp. 207–225). University of California Press. TORTURE Volume 28, Number 2, 2018 Volume TORTURE 15
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Debility, dependency and dread: On the conceptual and evidentiary dimensions of psychological torture1
Ergun Cakal, LLM*
its perpetrators. A review of the current Key points of interest: literature to map conceptual and evidentiary •• Psychological torture is prohibited shortcomings from an inter-disciplinary by international law, but is ill- perspective is therefore warranted. Method: defined and regularly interpreted as The relevant texts were identified through not amounting to torture. Mental a systematic full-text search of databases, suffering needs to be clarified namely HeinOnline, HUDOC, UNODS and and expanded upon as part of the DIGNITY´s Documentation Centre, with definition of torture. the keywords `psychological torture´, `mental •• Psychological torture is complex and pain and suffering´, `severity´, `humiliation´, lacks appropriate acknowledgement `interrogation techniques´, and `torture in evidence-based fora. methods´. The identified texts, limited to English-language journal articles, NGO Abstract: reports, court-cases and UN documents Background: Psychological torture is from 1950 to date, were then selected deployed to break and obliterate human for relevance pertaining to conceptual, resistance, spirit and personality, but it evidentiary, technological and ethical critique is rarely afforded sufficient attention. provided therein. Results/Discussion: Deficiencies in conceptualising, documenting Evidential invisibility, subjectivity of the and adjudicating non-physical torture suffering, and perceived technological mean that it is frequently left undetected control are the primary ways in which and uncontested by the public, media psychological torture methods are designed, and the courts, bolstering impunity for and how they manage to evade prosecution TORTURE Volume 28, Number 2, 2018 and consequently be perpetuated. Cognisant of the need for further research, pertinent questions highlighting the need *) Legal Advisor, DIGNITY - Danish Institute to develop approaches, sharpen standards Against Torture. 1 This review has significantly benefited from an and use a medical/psychological/legal ongoing REDRESS-DIGNITY collaboration on interdisciplinary approach are suggested. the topic. Whilst particular appreciation is owed to REDRESS, any errors and views remain the author’s own. The title is a reference to Farber, Definitions and Concepts Harlow & West (1957). Whilst it is important to view torture in its Correspondence to: [email protected] totality and to not disproportionately focus 16
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on certain methods to the exclusion of others threats), with the latter being the focus of (see Ginbar, 2017, p. 305), there exists this review. clear definitional and conceptual challenges Terminology used to describe, with respect to otherwise headline-grabbing dismissively or otherwise, the mental examples of psychological torture, e.g. suffering as produced by such methods ‘enhanced interrogation techniques’. reflect these intersections. Some notions, This section will broadly outline the main such as ‘evidence-free torture’, emphasise the conceptual approaches that have been or invisibility of the torture whether inflicted may be used to define and conceptualise through physical means or not. Terms used psychological torture. in the literature include but are not limited to: ‘non-physical torture’; ‘white torture’; Methods of torture and the mind and body ‘invisible torture’; ‘no-touch torture’; ‘clean dichotomy torture’; ‘evidence-free torture’; ‘hands-off Difficulties in adequately defining torture’; ‘mental torture’; ‘torture-lite’, and torture are magnified when it comes to ‘psychological torture’. psychological torture. As the physical and Sveaass points out that ‘it may be psychological may be viewed as two sides possible to describe extremely painful of the same coin, conceptually delineating situations where no direct or obvious between the two poses a difficulty in itself, physical pain is inflicted’ (2008, p. 315). For as we straddle the mind/body dichotomy. these situations, the label of ‘psychological According to Sveaass, the psychological torture’ remains apt given that ‘the impact of powerlessness, fear and brutality of psychological torture is very uncertainty for any victim of torture means much based on what we know of human that ‘there is no such thing as physical psychological function [‘personal agency, torture “by itself”’ (2008, pp. 313-314). In values, emotions, hope, relationships, and other words, physical methods of torture trust’], on information and knowledge also have strong psychological effects on a developed within the realm of psychology’ victim, and vice-versa. Rape is an oft-cited (Sveaass, 2008, p. 316). As the methods with example here as, although often involving a which this review concerns itself target an physical act, its objective is a psychological individual’s psychological integrity based one to ‘punish, intimidate and humiliate’ on psychological or pseudo-psychological (see Raquel Martí de Mejía v. Perú, 1996). concepts, the term ‘psychological torture’ Providing an additional distinction, Pérez- will be used throughout this review. Sales differentiates between two categories Notwithstanding this, the pedagogical nature within psychological torture, namely of this choice must be borne in mind. between pure psychological techniques (e.g. humiliation, threats) and attacks on the Definitional elements self through attacks on bodily functions (e.g. While international and regional human exhaustion, sleep deprivation) (Pérez- rights frameworks recognise that the use of Sales, 2017, p. 9). For present purposes, psychological methods in and of themselves psychological effects of torture (e.g. anxiety, can constitute torture (as one need only depression, PTSD) will be distinguished refer to the inclusion of ‘mental pain or from psychological methods (both targeted suffering’ under Article 1 of the Convention
TORTURE Volume 28, Number 2, 2018 Volume TORTURE at the body, e.g. exhaustion, and ‘pure,’ e.g. against Torture (UNCAT)), there is a need 17
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to produce more workable understandings. to methods of psychological torture. It It is notable to find that its drafters did is beyond the scope of this review to not discuss at any length the meaning of further outline the definitional dynamics ‘mental pain or suffering’ but some agreed (interpretative variations, gaps, and on the difficulties therein (Nowak & limitations) with respect to psychological McArthur, 2008, p. 38). Nowak points to methods of torture in international law. the travaux preparatoires in arguing against What is clear is that, with the exception any notion that the ‘drafters intended a of the UN Special Rapporteur on Torture narrow interpretation that would exclude (UNSRT), there is a tendency, where conduct as intentional deprivation of food, specific conclusions have been reached by water, and medical treatment from the certain bodies, to fix a high threshold for definition of torture’ (2006, p. 819). While psychological torture violations. It suffices strict categorisations of forms of torture to say, however, that it remains unclear are avoided, it is clear in most jurisdictions why some factual matrices are found to that some psychological forms have been attract stronger criticism than others, and accepted as constituting torture or inhuman the inconsistency which reigns with respect and degrading treatment or punishment. to when exactly these bodies specifically Beyond a handful of cases, there condemn a psychological method as torture remains a superficiality to judicial reasoning appears to thwart any meaningful analysis. which warrants further dialogue with non-legal understandings here. Surveying Categorisation and typology relevant jurisprudence, Crampton proposes Another approach in striving for conceptual the following criteria as being useful, but clarity, amidst such ambiguities, has been not definitive, indicators of psychological through categorisation (or an extensional torture: i. actions that prevent the detainee definition), which involves providing a from maintaining stable mental health detailed list of techniques known to not (i.e. forced absorption); ii. significance of leave physical marks. Rejali provides four the psychological maltreatment; iii. design categories with which to conceptualise such and planning of the torture; and, iv. the techniques including: i. positional torture, perpetrator’s focus on affective bonds ii. exercising to exhaustion, iii. restraint to pressure the victim (2013). Similarly, torture, and iv. beatings (2007). Admittedly, another set of criteria entails: ‘i. the these are also known to leave physical relationship pattern between torture and marks such as bruises and nerve damage.
tortured; ii. circumstances of the torturing Ojeda, defining the phenomenon as ‘the TORTURE Volume 28, Number 2, 2018 system (political persecution, ethnic intentional infliction of suffering without cleansing, law enforcement procedure); resorting to direct physical violence’, iii. Whether techniques target identity; iv. provides a relatively detailed starting point the severity of each experience from both here in his 13 categories: an objective and subjective point of view’ isolation (including complete or semi- (Pérez-Sales, 2017, p. 4). solitary confinement); psychological Notwithstanding its breadth, a debilitation (deprivation of basic preliminary review of international needs, forced physical exertion); spatial jurisprudence reveals that international disorientation (small, dark cells); law does not provide a uniform approach temporal disorientation (denial 18
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of natural light, erratic scheduling of and/or family members of death, non- activities); sensory disorientation repatriation, endless isolation and (inducing perceptions of sensory interrogation, vague threats); lies failure, narcosis or hypnosis); sensory and deception (re evidence against deprivation (hooding, blindfolding, detainee, use of falsified documents darkness, sound proofing etc.); sensory or reports); occasional indulgences; assault (overstimulation) (bright demonstrating omnipotence lights, loud noise/music); induced and omniscience; degradation desperation (arbitrary arrest, indefinite (use of foul language, preliminary detention, random punishment, humiliation, confinement, denial of forced feeding, implanting sense personal hygiene, filthy environment, of guilt or abandonment); threats denial of privacy, stripping, removal of (to self or others, mock executions, clothing); enforcing trivial demands forced witnessing of torture); feral (forced writing, enforcement of treatment (forced nakedness, denial extremely detailed rules); heightened of personal hygiene, overcrowding, suggestibility, hypnosis and forced interaction, bestialism, incest); narcosis; self-induced physical sexual humiliation (forcing victim to pain (forced sitting on edge of chair witness or partake in sexual behaviour); of stool, forced upright kneeling and desecration (forcing victims to standing, stress positions); physical witness or partake in violating religious abuse (waterboarding, manhandling, practices (irreverances, blasphemy, mild physical contact such as grabbing, profanity, defilement, sacrilege); poking, pushing); exploitation of pharmacological manipulation (non- phobias (individual or religious phobias, therapeutic use of drugs or placebos). such as dogs); sexual humiliation (Ojeda, 2008, pp. 2-3) (forced stripping etc.) (Behan as quoted A similar categorisation is found in in Ojeda, 2008, p. 120) Behan’s work: Unless explicitly emphasised that they are disruption of daily rhythms and non-exhaustive, the patent danger with routines (night interrogation, disruption such categorisation, inter alia, is it becoming of sleep and biorhythms, early morning restrictive. As Pictet observed in his arrest, manipulating diet, sleep patterns, commentary to the Geneva Conventions as removal of all comfort items); isolation early as 1958: and sensory deprivation (solitary However great the care taken in confinement, eliminating lights, sounds, drawing up a list of all the various odors, hooding); monopolisation forms of infliction, it would never of perception (constant bright cell, be possible to catch up with the physical isolation, barren environment, imagination of future torturers who restricted movement, monotonous wished to satisfy their bestial instincts; food, sensory overload, interrogation and the more specific and complete a in non-standard locations); induced list tries to be, the more restrictive it debilitation; exhaustion (starvation, becomes. (Pictet, 1958, p. 204) sleep deprivation, prolonged constraint, The Human Rights Committee (‘HRC’)
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not ‘necessary to draw up a list of prohibited prolonged mental harm, a requirement not acts or to establish sharp distinctions found in the UNCAT. The latter point was between the different kinds of punishment explicitly made by the Committee against or treatment; the distinctions depend on the Torture (Conclusions and Recommendations: nature, purpose and severity of the treatment USA, 2006; hereinafter ‘CAT’). applied’ (Human Rights Committee, 1992, §4). This rings especially true if we are to Conceptions and their contestations: The legal accept the assertion, by one account, that versus the non-legal military technology is a decade or two more The ruling of whether a particular act or advanced than that of clinical or academic omission constitutes torture is ultimately research (Pérez-Sales, 2017, p. 331). a judicial one. It is, however, inevitably A narrow definition embracing informed by medical understandings categorisation, or enumeration, of due to the anatomical and psychological prohibited acts of psychological torture conceptualisations of pain. The dominance has been adopted by the United States of of blindly legal conceptualisations of torture America. In domestically implementing has been contested for being devoid of the UNCAT, the definition adopted by the this necessary non-legal perspective, for United States’ federal government presents its opaque focus on severity, bias towards an interesting case study. It refers to the physical, and its Euro-centrism. A psychological torture as the: number of experts, namely Pérez-Sales, ...mental pain or suffering refers to Sveaass and Başoğlu, have argued for a prolonged mental harm caused by better-informed definition which can help or resulting from: (1) the intentional instigate a more scientific understanding of infliction or threatened infliction of particularly psychological torture. Başoğlu, severe physical pain or suffering; (2) to reproduce one argument, explains that the administration or application, ‘a legal understanding of torture provides or threatened administration or protection from torture to the extent application, of mind altering substances that it comes closer to its psychological or other procedures calculated to formulation’ (2017, p. 492) and that disrupt profoundly the senses or the what is needed is a ‘broader definition of personality; (3) the threat of imminent torture based on scientific formulations death; or (4) the threat that another of traumatic stress and empirical evidence person will imminently be subject to rather than on vague distinctions … that
death, severe physical pain or suffering, are open to endless and inconclusive debate TORTURE Volume 28, Number 2, 2018 or the administration or application and, most important, potential abuse’ of mind altering substances or other (2017, p. 397). procedures calculated to disrupt Sveaass understands psychological profoundly the senses or personality. torture to be ‘the process by which (18 U.S.C. §2340(2)(B)) psychological pain is transformed into There have been two main criticisms made humiliation and dehumanisation, where the against this definition: that enumerating the essence of being human—namely personal actions unduly (to threats of imminent death agency, values, emotions, hope, relationships, for instance) narrows the understanding of and trust—is under attack’ (2008, p. 304; psychological torture, and that it requires see also Sveaass, 1994, p. 43). Pérez-Sales 20
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also attempts to posit a workable definition to act as an illusion of control purportedly as being ‘the use of techniques of cognitive, safeguarding the process from breaching the emotional or sensory attacks that target the pain threshold. conscious mind and cause psychological This was recognised as early as 1978 suffering, damage and/or identity breakdown in the case of Ireland v. the United Kingdom, in most subjects subjected to them; such where in his dissenting opinion, Judge techniques may be used alone or together Evrigenis, calling the majority out on their with other techniques to produce a reasoning, found that torture in the case was: cumulative effect’ (2017, p. 8). ... based on methods of inflicting The disconnect between the legal suffering which have already been and non-legal conceptualisations coupled overtaken by the ingenuity of modern with the dominance of the former clearly techniques of oppression. Torture no presents a problem for the advancement longer presupposes violence, a notion to of our understanding of torture generally, which the judgment refers expressly and and perhaps an even greater hindrance generically. Torture can be practised— with respect to psychological torture. and indeed is practised—developed in The minor role given to dignity and multidisciplinary laboratories which humiliation (linked to self and identity) claim to be scientific. (ECHR, 1978) which feature more prominently in non- Rejali points out that at best this is also legal understandings is problematic when sourced from the perceived humanism compared to ‘pain-producing techniques’ in and polyvalent use of technology. Pointing legal understandings (Pérez-Sales, 2017, p. to the general public value in electricity- 262). As shall be discussed later, severity has based technologies as an example, Rejali also proven a challenge for legal minds. argues that any ill-conceived use, say as constituting a torture method, is faced Practices and perpetuation of with a ‘civic doubt’ as to whether such psychological methods a technology can be as harmful given its This section will explore how psychological benefits to humanity (2003). methods are designed, enabled and Relatedly, revelations on the use of perpetuated under the guise of science music as torture (its coerced listening and lawfulness. The conceptual argument (loud or otherwise), playing, singing or persists as we draw on ‘lawful sanctions’, dancing) by the United States in places ‘intentionality’ and the difficulties with such as Guantánamo Bay promptly respect to distinguishing between torture spawned a debate amongst academics and and cruel, inhuman and degrading musicians alike. Music’s use as therapy treatment (CIDT). renders it difficult to think of its use as torture. Spielmann, a past president of Scientific complicity: The ‘benevolence’ of the European Court of Human Rights, technology has observed that certain uses of music The scientific milieu out of which these ‘can amount to torture, and lyrics can methods have sprung is also of import to be the vehicle of human rights abuses’ understanding the phenomenon. Technology, (2012, p. 371). Such statements have be it in the use of techniques, knowledge been seen to herald a change in perceiving
TORTURE Volume 28, Number 2, 2018 Volume TORTURE or personnel, has been used by state actors non-physical methods (Papaeti, 2013). 21
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Grant’s assessment is that there is nothing contained to a level below that of torture intrinsically harmful about music so (American Psychological Association, context is paramount. She prescribes: 2005, p. 2). Trust in science was co-opted Preventing the worst abuses of physical in order to appease public and institutional and mental integrity that can be inflicted consciences. The wheeling out of the through music begins with the much phrase ‘safe, effective, legal, and ethical’ by more simple act of removing the sheen the Bush Administration was symbolic in from musical activities as in some way manipulating the perception of torture: intrinsically beneficial and morally good. … into an expert activity with “scientific We need to face up to both the possible techniques” and other accoutrements of negative health effects of different professionalism provided advantages to musical practices and the long-standing the torturers, conscious and unconscious. conjunction between music and processes The pseudo-scientific façade Jessen of humiliation and shaming (Grant, and Mitchell developed for the military 2013, p. 11). created a fig-leaf of cover that the torture was not the primitive and sadistic Perceived control: The perversion of ‘trust’ behaviour it really was. It also gave senior and ‘regulation’ military personnel a chance to escape The complicity of psychology and, perhaps accountability by turning torture over to a lesser extent, psychiatry, intentionally to “the docs”.” The Justice Department or not, in lending their expertise to state in effect created a “safe harbour” for intelligence apparatuses, from the beginnings interrogators. If a psychologist was of the Cold War to the ‘War on Terror’, is involved in the interrogation, by the mere widely accepted in the literature (Physicians fact of the psychologist’s involvement, for Human Rights, 2005; Pope & Gutheil, the “enhanced interrogation” was per se 2009; Soldz, 2011). It is important to “safe, effective, legal, and ethical”. There recognise the psychology underpinning the was no requirement that the psychologist psychological techniques of torture and even do anything of a protective nature. warfare, which has been well-documented His or her very presence, by executive elsewhere (Lavik, 1994; McCoy, 2012; definition, meant that the enhanced Suedfeld, 1990). interrogation was “safe, effective, legal, Soldz has, for instance, illustrated and ethical”. (Welch, 2010, p. 6) in some detail the role of psychologists For Kalbeitzer, the coerciveness of at Guantánamo Bay, in designing the interrogations, as designed by psychologists, TORTURE Volume 28, Number 2, 2018 environment to disrupt cohesion and was as simple as ‘designing the room in communication among detainees and such a way as to create an intimidating to foster dependence and compliance atmosphere’ (Kalbeitzer, 2009). Such instead, and also controlling the tailoring took into account the individual minutiae of interrogations to the point vulnerabilities of the subject. Başoğlu of prescribing the limited provision of also provides a comprehensive account of toilet paper to one detainee (2010). Yet, the centrality of ‘learned helplessness’ in to the American public, the role of mental CIA’s design of its torture regime (Reyes & health professionals were represented here Başoğlu, 2017). as ensuring that the pain threshold was For what it is worth, the US Senate 22
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confirmed that the CIA conducted no efforts at prosecution and prevention. ‘significant research to identify effective As a belated point of qualification, one interrogation practices, such as conferring must bear in mind that as much as Rejali with experienced US military or law alludes to the unacknowledged malleability enforcement interrogators, or with the of technology towards different ends, one intelligence, military, or law enforcements must also refrain from holding science services of other countries with experience to be ‘purely truth-seeking’ and devoid in counterterrorism and the interrogation of values. Moreover, Evans and Morgan of terrorist suspects’ (US Senate Select militate against torture as conventionally Committee on Intelligence, 2014, p. 20).. ‘unrestrainedly savage’, instead depicting it Observing this, O’Mara has deployed as having long been cruel yet controlled, a the term ‘cargo cult science’ to refer to such ‘carefully-regulated practice’ (1998, p. 58). ‘use of the language and even behaviours that bear some resemblance to science but Humiliation: Torture or inhuman and critically without the scientific method and degrading treatment? the intellectual commitments that follow Back-tracking to powerlessness, fear and from the adoption of the scientific method’ uncertainty, the relational dynamics, or the (2015, p. 30). Similarly, McCoy has also power imbalance, between the perpetrator explored the nexus between science and and the victim, particularly with the use impunity, and the means by which science of psychological methods must also be sanitises and assists in emboldening and considered. Whilst it is not exclusive to legitimating psychological methods of psychological torture, it may be argued torture, where he states: that its significance is distinct when The language of science can make compared to the use of physical methods. psychological torture seem like a series For Pérez-Sales, torture arises where, upon of carefully controlled procedures, this background of ‘powerlessness and sanctioned by rational experts who have suppression’, there occurs a violation of the aura of authority that comes with dignity and autonomy (2017, pp. 84-85, knowledge and credentials (McCoy, 261). When the phenomenology of torture 2012, p. 24). is surveyed further, we can see that the As a side note, McCoy’s work on the torturer demonstrates his power to exhaust, CIA’s development and propagation of disorient, create dependency, create fear psychological methods of torture extensively and humiliate his victim (Hauff, 1994, explores the relationship between impunity, p. 21). Such a violation may also involve history and public forgetting. The fragility self-betrayal, where a victim for instance is of collective memory means that publicised forced in the circumstances to do something cases of psychological torture are also to acknowledge their absolute helplessness susceptible to contestation and manipulation and submission. Doerr-Zegers, speaking by media and the state, which, according from experience on treating Chilean torture to McCoy, ‘tear at the threads of collective victims, states that the ‘psychological memory, making each exposé seem isolated, component of torture becomes a kind anecdotal, and ultimately insignificant’ of total theatre, a constructed unreality (McCoy, 2012a, p. 38). He goes on to of lies and inversion, in a plot that ends
TORTURE Volume 28, Number 2, 2018 Volume TORTURE underscore the power of history in diffusing inexorably with the victim’s self-betrayal and 23
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destruction’ (McCoy, 2006, p. 10). Guantánamo Bay, it was pointed out that: The notion of humiliation readily Treatment aimed at humiliating victims springs to mind here, which is may amount to degrading treatment conventionally associated with cruel, or punishment, even without intensive inhuman and degrading treatment, and pain or suffering. It is difficult to assess more specifically with degrading treatment in abstracto whether this is the case (Ireland v. United Kingdom, §167). Yet, as with regard to acts such as the removal shall be discussed below, psychologically- of clothes. However, stripping detainees informed systems of torture, such as those naked, particularly in the presence operated by the CIA, feature humiliation of women and taking into account as a part of an overall method as a cultural sensitivities, can in individual means of breaking the will and extracting cases cause extreme psychological information. It is upon this background pressure and can amount to degrading that Nowak as UNSRT unearthed the treatment, or even torture. The same centrality of ‘powerlessness’ to torture: holds true for the use of dogs, especially as the most serious violation of the if it is clear that an individual phobia human right to personal integrity and exists. (UN Commission on Human dignity, presupposes a situation of Rights, 2006, §51). powerlessness of the victim which usually Başoğlu, Livanou & Crnobaric, in their oft- means deprivation of personal liberty or cited study, conclude that stress indicators of a similar situation of direct factual power psychological methods including humiliation and control by one person over another. are similarly severe when compared to … A thorough analysis of the travaux physical methods. They posit this as follows: préparatoires of Art 1 and 16 CAT as well Ill treatment during captivity, such as as a systematic interpretation of both psychological manipulations, humiliating provisions in light of the practice of the treatment, and forced stress positions, Committee against Torture has led me to does not seem to be substantially the conclusion that the decisive criteria different from physical torture in terms for distinguishing torture from CIDT is of the severity of mental suffering they not, as argued by the European Court of cause, the underlying mechanism of Human Rights and many scholars, the traumatic stress, and their long-term intensity of the pain or suffering inflicted, psychological outcome. Thus, these but the purpose of the conduct and the procedures do amount to torture, thereby
powerlessness of the victim. (Nowak & lending support to their prohibition by TORTURE Volume 28, Number 2, 2018 McArthur, 2006, p. 150; 2008, p. 76; see international law. (Başoğlu, Livanou & also Nowak 2006, p. 832; Sifris, 2013) Crnobaric, 2007) This is also central for Manderson who sees This brings into question the feasibility the ‘experience of absolute powerlessness of equating humiliation with the lesser that reduces the victim, in their own eyes as category of inhuman and degrading well as their torturer’s, to an animal, a body treatment as most adjudicatory bodies without will or dignity of any kind … the continue to do. It must be said that, destruction of identity’ (Manderson, 2005, whether assumed or dismissed, explicit p. 640). Applying this conceptualisation mention of ‘powerlessness’ in the work in his assessment of the detainees at of relevant human rights bodies and 24
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international law is negligible. Given its analysis here when compared to the depth centrality, techniques of humiliation that of discussion on other constitutive elements seek to achieve a sense of powerlessness in also found therein such as severity of pain the victim and the victim’s family, and are and suffering and official capacity. During the all too often found to amount to be less drafting process, it seems that the United severe than torture, need to be seriously Kingdom’s proposal to include ‘gratuitous reconsidered, given the material differences torture’, conceivably meaning torture between the consequences that flow from without purpose or for self-gratification, was it, and any underestimation of pain and not adopted (Nowak & McArthur, 2008, p. suffering addressed. 75). As pointed out by Burgers and Danelius, Whilst it is accepted that the particular purposes explicitly stated in the definition stigma attached to torture must remain are based on state interest (1988, pp. 118- reserved for the most atrocious instances 119). This may mean that acts intended to of ill-treatment, the use of powerlessness humiliate or debase, those arguably closer to firms up an opening for ill-treatment to gratuitous, do not fall within the category of be treatment that is not simply physically state interest, and therefore do not amount brutal. Yet, the resort to severity in to torture. That said, even where private differentiating between torture and CIDT sadism predominates, there is ‘usually an has also been increasingly critiqued and element of punishment or intimidation’ abandoned. In Keenan v United Kingdom sufficient to satisfy the purposive element (2001), the European Court stated that under Article 1 (Burgers & Danelius, 1988, while ‘it is true that the severity of suffering, p. 119). Conversely, Article 2 of the Inter- physical or mental, attributable to a American Convention against Torture, particular measure has been a significant whilst listing similar purposes, includes ‘for consideration in many of the cases decided any other purpose’, hence not proscribing by the Court under Article 3 of the ECHR, purposes to ones based on state interest. there are circumstances where proof of the actual effect on the person may not be a ‘Enhanced Interrogation Techniques’ (EITs) and major factor’ (§113). Coupling this with the the ‘Five Methods’ Selmouni ruling, for the European Court, Despite experience disproving the efficacy ‘the level of pain inflicted is increasingly of coercive tools in eliciting reliable a less determinate factor, as acts it once information, the context of interrogation considered only “inhuman” could now rise poses a fertile ground for the infliction of to the level of torture, depending on the torture (Costanzo & Gerrity, 2009). This context and purpose for which physical force is front and centre of UNCAT Article 1’s is employed’ (Evans, 2002, p. 373; Selmouni purposive element. Yet, much in the vein of v. France, 1999). psychological methods of torture, abusive A brief note on purpose under the interrogations have not been adequately and UNCAT definition is warranted. It is widely explicitly proscribed by international law. interpreted to be inclusive of ‘such purposes In remedying this, by calling for a protocol as’ obtaining information or a confession, for non-coercive interviewing, the UNSRT punishment, intimidation and coercion or (Mendez) recently stated that: discrimination and that it is, therefore, not Torture and ill-treatment harm those
TORTURE Volume 28, Number 2, 2018 Volume TORTURE exhaustive. Yet, there remains a dearth of areas of the brain associated with 25
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memory, mood and general cognitive deprivation, isolation, sleep deprivation, function. Depending on their severity, forced nudity, the use of military working chronicity and type, associated stressors dogs to instil fear, cultural and sexual typically impair encoding, consolidation humiliation, mock executions, and the threat and retrieval of memories, especially of violence or death toward detainees or where practices such as repeated their loved ones’ (PHR, 2006, p. 1). suffocation, extended sleep deprivation Herman underscores that such and caloric restriction are used in ‘techniques of establishing control over combination. Such practices weaken, another person are based upon systematic, disorient and confuse subjects, distort repetitive infliction of psychological trauma’ their sense of time and render them prone (Herman, 2015, p. 69). Moreover, it is in the to fabricate memories, even if they are context of ‘highly controlled detention and otherwise willing to answer questions. interrogation environment used to exploit They are also detrimental to the helplessness and vulnerability’ engendering establishment of trust and rapport, and the ‘denial of autonomy and dependency compromise the interviewer’s ability to on interrogators’ that such techniques understand a person’s values, motivations must be viewed (Physicians for Human and knowledge — elements required for a Rights & Human Rights First, 2007, p. 6). successful interview. (UNSRT, 2016, §18) Similarly, this system has been described Accusatorial, protracted or suggestive as ‘ambiguous almost by design’ and the interviews overlayed with threats, ‘product of deliberate attempts to engineer manipulation and coercion are underscored tactics that provoke subtle forms of pain, as unethical, and depending on their relying on technological, psychological, and ‘degree, severity, chronicity and type, undue pharmacological innovations that maximize psychological pressure and manipulative the pain or discomfort of the detainee’s practices’ may be ill-treatment (UNSRT, experience while leaving minimal perceptible 2016, §44). At the very least, one must evidence of brutality’ (McDonnell, Nordgren accept the view of the CAT that ‘moderate & Loewenstein, 2011). physical pressure’, even when viewed as a Further on the point of ‘design’, it ‘lawful’ mode of interrogation by a state is axiomatic to say that trauma can be (i.e. Israel), is ‘completely unacceptable’ as ‘culture-bound’ and can differentiate it creates conditions leading to the risk of across individuals as the ‘meaning of torture or CIDT (CAT, 1994, p. 10). torture and trauma is shaped by social
Undoubtedly, the gravest contemporary support and religious, cultural and political TORTURE Volume 28, Number 2, 2018 regime of psychological torture, to be beliefs’ (Physicians for Human Rights & publicised at least, has been the United Human Rights First, 2007, p. 7). Another States’ abuses of prisoners, by the later primary point of discussion has been the disavowed use of ‘enhanced interrogation exploitation of cultural sensitivities of Arab techniques’, in various ‘black-sites’ around men regarding sexual taboos (e.g. forced the world and notoriously in Abu Ghraib nakedness, contact with a woman) and and Guantánamo Bay. In their seminal other phobias (e.g. relating to dogs), based report ‘Break Them Down’, Physicians on a text called The Arab Mind by Patai for Human Rights (PHR) lists the from 2002. employed techniques as including: ‘sensory Surveying the mentioned regimes of 26
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psychological torture, Reyes concludes that interrogation techniques’ as UNSRT, ‘accumulation of methods’ together with Rodley pointed out that ‘[e]ach of these ‘unpredictability and uncontrollability’ measures on its own may not provoke (an aggravating feature similar to severe pain or suffering’ but may do so in ‘powerlessness’) are distinct features here combination ‘applied on a protracted basis (Reyes, 2007, p. 591). In the same vein, of, say, several hours’ (UNSRT, 1997, §121). Başoğlu posits that the ‘most deleterious Therefore, he considered a certain degree of consequences stem from uncontrollable combining methods or their accumulation aversive events that are also unpredictable’ and duration as requisite before the severity (Başoğlu & Mineka, 1992, p. 199). threshold became relevant. Sleep deprivation The cumulative or combined nature of may also prove an apt case to illustrate these techniques warrants some expansion. the cumulative, as opposed to inherent, Contextually, some legitimate interrogatory dynamics here. In its criticism of Israel, the methods which may seem ‘minor’ or CAT did not categorically state that sleep ‘innocuous’ at first glance ‘become coercive deprivation, in all cases, amounted to torture if used over prolonged lengths of time’ but detailed certain durations over specific (Reyes, 2007, p. 599). That is not to say periods that did (CAT, 1998, §24). that this is exclusive to or necessary for Two European Court of Human Rights psychological torture. Also, isolated instances cases of Al Nashiri v. Poland (2014) and of methods such as mock executions, death Husayn (Zubaydah) v. Poland (2014) where threats or forcefully witnessing torture ‘EITs’ were found as having been used have been found to amount to torture. The in CIA black-sites in Poland make for thesis here rather is that such seemingly enlightening reading here. In Al Nashiri, the legitimate or innocuous means ‘form a victim was subjected to two mock executions system deliberately designed to wear and (one with a power drill), stress positions break down, and ultimately also to disrupt and ‘EITs’. The Court characterised these the senses and personality’ (Reyes, 2007, techniques as ‘deliberate inhuman treatment p. 599). In its latest report to the United causing very serious and cruel suffering’ States, the CAT explicitly recommended amounting to torture under Article 3. In that uses of sensory deprivation and sleep its assessment, the Court stated all the deprivation at Guantánamo Bay were measures were applied in a: violations of the UNCAT and should be premeditated and organised manner, abolished (CAT, 2014, §17). The UNSRT on the basis of a formalised, clinical has similarly assessed that ‘jurisprudence of procedure, setting out a “wide range both international and regional human rights of legally sanctioned techniques” mechanisms is unanimous in stating that such and specifically designed to elicit methods violate the prohibition of torture and information or confessions or to ill-treatment’ (UNSRT, 2004, §17). obtain intelligence from captured Furthermore, the UNSRT has also terrorist suspects. Those—explicitly seen it necessary to explicitly point out that declared—aims were, most notably, “to ‘the simultaneous use of these techniques psychologically ‘dislocate’ the detainee, is even more likely to amount to torture’ maximize his feeling of vulnerability and (UN Commission on Human Rights, 2006, helplessness, and reduce or eliminate his
TORTURE Volume 28, Number 2, 2018 Volume TORTURE §52). During his examination of ‘enhanced will to resist ... efforts to obtain critical 27
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intelligence”; “to persuade High-Value stand on their toes with the weight Detainees to provide threat information of the body mainly on the fingers”; and terrorist intelligence in a timely (b) hooding: putting a black or navy manner”; “to create a state of learned coloured bag over the detainees’ heads helplessness and dependence”; and their and, at least initially, keeping it there all underlying concept was “using both the time except during interrogation; physical and psychological pressures (c) subjection to noise: pending their in a comprehensive, systematic and interrogations, holding the detainees in cumulative manner to influence [a a room where there was a continuous High-Value Detainee’s] behaviour, loud and hissing noise; (d) deprivation to overcome a detainee’s resistance of sleep: pending their interrogations, posture”. (§§ 515-516) depriving the detainees of sleep; (e) Husayn (Zubaydah) v. Poland involved deprivation of food and drink: another CIA detainee who had been subjecting the detainees to a reduced subjected to the ‘EITs’, and at ‘least 83 diet during their stay at the centre and waterboard sessions in a single month’, pending interrogations. (§96) before being implicitly threatened with such When considering these methods, the a method again if he failed to comply. In its (now defunct) European Commission of assessment, the Court observed: Human Rights, focusing on the combined that this permanent state of anxiety psychological impacts, found that the five caused by a complete uncertainty about techniques constituted torture on the grounds his fate in the hands of the CIA and of the intensity directly affects the personality: a total dependence of his survival on physically and mentally [and that] the provision of information during the systematic application of the the “debriefing” interviews must have techniques for the purpose of inducing significantly exacerbated his already a person to give information shows a very intense suffering arising from the clear resemblance to those methods application of the “standard” methods of systematic torture which have been of treatment and detention in the known over the ages... a modern exceptionally harsh conditions. (§ 509) system of torture falling into the same A clear antecedent to this system was the category as those systems... applied ‘five techniques’ as used by the British in previous times as a means of Military firstly in Northern Ireland, during obtaining information and confessions. the Troubles, on individuals suspected to (ECommHR, 1976: Ireland v. United TORTURE Volume 28, Number 2, 2018 be involved with the Irish Republican Army Kingdom, § 512) (IRA). It consisted of: When it progressed to the European Court (a) wall-standing: forcing the of Human Rights however, it disagreed detainees to remain for periods of some and held that the ill-treatment only hours in a “stress position”, described amounted to cruel inhuman and degrading by those who underwent it as being treatment but not to torture because the “spreadeagled against the wall, with necessary severity and intensity of harm their fingers put high above the head that a finding of torture required was not against the wall, the legs spread apart established (according to the de minimis and the feet back, causing them to rule). In his dissenting opinion, holding that 28
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the treatment constituted torture, Judge It assessed this regime as amounting Matscher stated that: to violations of Articles 1 and 16 of the the more sophisticated and refined the UNCAT (CAT, 1997, § 257). Similarly, the method, the less acute will be the pain HRC assessed the Israeli use of ‘the methods (in the first place physical pain) which it of handcuffing, hooding, shaking and sleep has to cause to achieve its purpose. The deprivation to have been and continuing as modern methods of torture which in their being used as interrogation techniques, either outward aspects differ markedly from alone or in combination’ and that it violated the primitive, brutal methods employed Article 7 of the International Covenant on in former times are well known. In this Civil and Political Rights (HRC, 1998, §19). sense torture is in no way a higher degree of inhuman treatment. On the contrary, Assessment and documentation of one can envisage forms of brutality which psychological methods cause much more acute bodily suffering The preceding discussion has attempted to but are not necessarily on that account sketch out a number of inter-related elements comprised within the notion of torture. which obscure a thorough consideration By some accounts, this was a lost of psychological torture. Compounding opportunity to stamp out the contemporary these, perhaps more intentional, biases are uses of such techniques, and has been shortcomings in assessing and documenting linked to the reluctance of the Court to find allegations of psychological ill-treatment. a violation of torture from 1978 to 1996 When compared with the visibility of physical (Rouillard, 2005, p. 30). Recently reviewing signs of ill-treatment, the relative invisibility the case upon disclosure of new evidence, of psychological impact can frustrate the the Court decided not to change its original processes of evidence-seeking fora. conclusion (Ireland v. the United Kingdom, The ‘Break Them Down’ report observes 5310/71, 20 March 2018) primarily upon the health consequences of psychological the principle of legal certainty. Despite this, methods to be ‘extremely destructive’ in the in view of its subsequent statements as noted short and long term, including: above and in Selmouni v. France (1999, see … memory impairment, reduced §101), the Court would now clearly find capacity to concentrate, somatic a regime similar to the five techniques as complaints such as headache and amounting to torture. back pain, hyperarousal, avoidance, Two decades later, a combination of irritability, severe depression with interrogation methods comparable to the vegetative symptoms, nightmares, five techniques, for instance, as has been feelings of shame and humiliation, used by Israel on Palestinian prisoners, were and posttraumatic stress disorder … documented by the CAT in 1997 to include: incoherent speech, disorientation, (1) restraining in very painful conditions, hallucination, irritability, anger, (2) hooding under special conditions, (3) delusions, and sometimes paranoia … sounding of loud music for prolonged depression, thoughts of suicide and periods, (4) sleep deprivation for nightmares, memory loss, emotional prolonged periods, (5) threats, including problems, and are quick to anger death threats, (6) violent shaking, and (7) and have difficulties maintaining
TORTURE Volume 28, Number 2, 2018 Volume TORTURE using cold air to chill … relationships and employment. Based 29
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on past experience, post traumatic stress bias (that is, a preference for the physical) disorder is likely to be common. (PHR, of decision-makers render this declaration, 2005, p. 9) despite increasing awareness, less than fully The main issue with respect to the realised in practice. evidentiary dimension is formulating Ultimately, however, the Istanbul Protocol approaches to best understand and conflates the physical and psychological document such effects. Most conventional methods and rejects a clear dichotomy understandings of torture involve the as ‘artificial’ (OHCHR, 2004, §145). For application of physical force; documentation Reyes, this is understood by the fact that, has, therefore, entailed primarily analysing from a holistic, evidence-based perspective, the ensuing physical marks and indicators. both physical and psychological torture and Thus, it is imperative to find processes, effects need to be anticipated. Yet, for him, legal and medical, on which evidentiary this somewhat undercuts the stand-alone corroboration can be formed, specifically importance of psychological torture and sensitive to psychological torture. obfuscates the understanding of the stand- Admittedly, specific means of alone impact of psychological methods (2007, documenting psychological torture remain pp. 600-603). Also, for Pérez-Sales, the limited. Psychiatric and psychological Istanbul Protocol needs to refine its conception sequelae are strong indicators of here, and that just because ‘the distinction psychological torture as it is of physical is artificial (i.e. made for epistemological torture. Yet, it is notable that psychological purposes), it does not mean that we shouldn’t methods are used in combination, either keep in mind that the ultimate target of simultaneously or sequentially, to reach torture is the conscious self, and that we a desired effect, as illustrated in the ‘five should reflect on contemporary torture and techniques’ and ‘EITs’ (see ICRC, 2007, the complex ways in which this conscious self p. 9). It has been argued that this makes it is attacked and controlled’ (2017, p. 308). ‘nearly impossible to determine the specific The logic between the act and the cause of psychopathology shown’ (PHR, effect (without overemphasising the effect) 2005, p. 70). is problematic. It is difficult to frame the question with sufficient specificity; concepts Psychological methods of torture and the like ‘causality’, ‘link’, and ‘relation’ though Istanbul Protocol useful can prove to be problematic as direct Importantly, the Istanbul Protocol accepts causality rarely exists in medicine. Medical that, since torturers increasingly seek to professionals work with percentages and TORTURE Volume 28, Number 2, 2018 conceal their crimes, ‘the absence of such likelihoods in merely identifying where physical evidence should not be construed there is corroboration and working with a to suggest that torture did not occur, patient’s statement. It is important to refrain since such acts of violence against persons from overemphasising the role of individual frequently leave no marks or permanent resilience. Therefore, requiring effect will scars.’ (OHCHR, §161; see also §§ 159, disadvantage resilient victims. While existence 259, 260). Yet, the unrealistic expectations of psychiatric sequelae remains a ‘powerful placed on medical experts who treat and indicator’ of psychological torture insofar document torture (Freedom from Torture, as ‘depression, anxiety and posttraumatic 2015) coupled with the persisting materialist symptoms’ can corroborate the treatment 30
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alleged (Pérez-Sales, 2017, p. 144), such the authors underscore that this methodology sequelae, however, can never be said to be builds on conventional descriptive and diagnostic of ‘any particular source in the testimonial documentation to encompass a way that a particular scar is diagnostic of a broader epidemiological approach: burn or electrical shock’ (Jacobs, 2008, p. The creation of a Torturing Environment 169). Moreover, in rejecting legal notions of requires the interaction of several causality in favour of relativity, Pérez-Sales elements: (a) sensorial and temporal points out that it is a fallacy to expect science disorientation and confusion of the to establish ‘an unequivocal causal relationship self- reflecting mind; (b) fear and terror between certain practices and their that starts from the outset of detention consequences in order to determine the limits and remains present throughout; (c) of torture’ (Pérez-Sales, 2017, pp. 274-275). humiliations and attacks on identity Difficulties arising out of the invisibility that contribute to eroding any sense of of impact lead the discussion to exploring control; and, (d) tension and beatings the purposive alternatives as well as that produce physical and emotional environmental assessments. For Pérez- exhaustion. The capacity of the victim Sales, evaluating torture environments for proper understanding, retrieval of can be a significant means to document memories, judgement and reasoning psychological torture. He defines the is progressively undermined. The torture environment as: techniques of emotional manipulation … a milieu that creates the conditions and cognitive distortion used during the for torture … made up of a group of interrogation complete the process. contextual elements, conditions and Soon strengthened by validation (see Pérez- practices that obliterate the will and Sales, Martínez-Alés, Gonzalez Rubio, control of the victim, compromising p. 2018), the Scale represents a leading the self. … In epidemiological terms, tool of documentation with respect to any element can be considered part of psychological methods. a torturing environment if it has been This is identified by its author as identified as likely to increase the relative complementing and compatible with the risk of severe physical or psychological Istanbul Protocol, primarily to bring to the suffering, if it is used within the context fore, and hence better appreciate, methods of torture or if it is employed with the of psychological torture. Whilst this is purpose of inflicting torture. … Given a promising and innovative proposal, it that methods aren’t used alone but as remains to be tested and used more widely. part of a system, the environment they Similarly, explorative studies into the operate in also needs to be holistically neurobiology of psychological torture also assessed. (2017, pp. 285, 330) promise to provide corroborative evidence In a study conducted by Pérez-Sales et al, through identifying biological markers Basque prisoners held in incommunicado (Ojeda, 2008). detention were interviewed at length in order to ‘elaborate a prototypical process of Subjectivity and severity: Obfuscation of pain, detention and ill-treatment which helped to bias, resilience understand the dynamics of an interrogation Whilst also tied to physical instances of ill-
TORTURE Volume 28, Number 2, 2018 Volume TORTURE procedure’ (Pérez-Sales, 2016, p. 21). There, treatment, the elements of subjectivity and 31
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severity feature distinctively with respect understandings of severity also reveal a to psychological torture. Subjectivity is materialist or physical bias, ‘that the physical used here to refer to both specific factors is more real than the mental’ (Luban & Shue, pertaining to individuals claiming to have 2011, p. 823). Reyes compares the relative been subjected to torture as well as the ease of documenting the physical with the unfounded bias of decision-makers assessing psychological in the following passage: ‘severe pain’ to require the physical and Physical forms of pain and suffering downplaying the psychological. are more readily understood than In her seminal work, Scarry explains psychological forms, although physical that the ‘unshareability’ of pain underscores suffering may also be hard to quantify and the significance of considering subjectivity measure objectively—defining severe pain in assessing torture claims (Scarry, 1986). and suffering involves an assessment of Some commentators have argued that this gravity that is difficult to make, as these ‘unshareability’ is constant, for it is seen notions are highly subjective and may to be based on human impulses to be depend on a variety of factors, such as the self-serving in our assessments (in using age, gender, health, education, cultural ends-based reasoning) and having a hot- background or religious conviction of the cold empathy (not being able to register victim. (Reyes, 2007, p. 593) pain through witnessing or hearing about Attempts, by notorious figures in the it) (Nordgren, McDonnell & Loewenstein, Bush Administration, to obscure the 2011). Tied to this, the concept of conceptualisation of torture have entailed severity has been critiqued by prominent the unfounded claims such as ‘mental commentators as being ‘vague and open to suffering is often transitory, causing no interpretation’, ‘not susceptible to precise lasting harm,’ (US Senate Committee on gradation’ and ‘virtually impossible’ based on Foreign Relations, 1990, p. 17) or that these reasons. torture is ‘broken bones, electric shocks to Conversely, it must be pointed out genitalia … pulling your teeth out with pliers that medical professionals diagnose and … cutting off a limb … Is waterboarding administer relief when treating varying at the same level? I’d say probably not.’ levels of pain, physical and psychological, Similarly, it has been suggested that on a daily basis. It is instructive to note psychological methods such as solitary that the difficulties present with respect to confinement or sleep deprivation are more subjectivity have also been used as an excuse readily dismissed as we all experience to conclude ‘pain is a subjective experience and tolerate small doses of solitude and TORTURE Volume 28, Number 2, 2018 and there is no way to objectively quantify it’ sleeplessness in our daily lives, without ever (Stover, Koenig & Fletcher, 2017, p. 392). understanding the impact of the extremities Accordingly, theoretical problematising, as (McDonnell, Nordgren & Loewenstein, outlined below, must be approached with 2011). Commenting on this mentality, some degree of caution. O’Mara assesses this as being: The methods at hand challenge ‘reliance the all-too-common mistake of consulting on a solely objective analysis of suffering, due the contents of his consciousness to define to the difficulties in measuring intangible torture—not statute law, not international psychological injuries’ (Yarwood, 2008, p. treaties, not medical authorities, not the 336). Partially arising out of this, conventional scholarly literature. This leaves us with a 32
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problem: when we think of torture, our Biased preconceptions against defining thinking is deeply colored by images of psychological methods as torture are medieval cruelty: the rending of flesh, infamously illustrated by the European the breaking of bones, and pain made Court of Human Rights’ decision in Ireland visible through scar and scream. We do v United Kingdom as the five techniques not think of techniques that leave no were found not to ‘occasion suffering visible record of their presence, techniques of the particular intensity and cruelty that manipulate the metabolic and implied by the word torture’. This equated psychopathological extremes of body, torture with ‘acts of extreme barbarity’ brain, and behaviour, and which are, and not the ‘systematically researched and by any reasonable standard, torture. applied subtle techniques of psychological (O’Mara, 2015, p. 11; see also Posner, manipulation which nullify the human will’ 2004, pp. 291-292) (Spjut, 1979, p. 271). This brings into focus the discomfort This has been remedied, fully cognisant versus ill-treatment debate. Pérez-Sales of subtle mechanisms of torture, in the admits that it is ‘difficult to know why some definition of the Inter-American Convention to techniques [such as the use of music] and Prevent and Punish Torture which reads: not others would qualify as “uncomfortable”; Torture shall also be understood to the distinction between “torture” and be the use of methods upon a person “discomfort” seems to be merely semantic’ intended to obliterate the personality of (2017, p. 328). Interrogations, after all, the victim or to diminish his physical or regularly exploit specific vulnerabilities of an mental capacities, even if they do not individual in making them uncomfortable. cause physical pain or mental anguish. What is more, recognising that a vast (OAS, 1985, Article 2) proportion of torture victims prove resilient Here: i. pain is not required; ii. severity of (as high as 60% by one measure (Pérez- suffering is not required as the emphasis is Sales, 2017, p. 144), distinguishing the on methods not consequences; iii. purpose impact of psychological torture as opposed is to ‘obliterate the personality of the to discomfort is made additionally difficult victim’ or to ‘diminish his mental capacities’ (Başoğlu, 2009, p. 142). (Pérez-Sales, 2017, p. 3). As the measure Compounding this, psychological torture of severity is side-stepped, a purposive is defined as anything but torture by those measure of psychological torture, one more partaking in its infliction or legitimisation: conducive to capture the phenomenon, the torturer defines it as a technologically- can be applied. This also brings into play a controlled method designed to fall short number of elements Pérez-Sales deems to of severe harm (Sveaass, 2008, p. 304); be especially significant to the psychological politicians have narrowly defined it in times torture context, including: i. the relationship of national security issues as ‘enhanced pattern between torturer and tortured; interrogation’ (McDonnell, Nordgren & ii. circumstances of the torturing system Loewenstein, 2011, p. 94; see also Luban (political persecution, law enforcement & Shue, 2011, pp. 826-827); and, some procedure, etc.); iii. whether techniques domestic courts have avoided attributing target identity; and, iv. the severity of each torture to state authorities, if possible (see experience from both an objective and
TORTURE Volume 28, Number 2, 2018 Volume TORTURE PCATI v. Israel, 1999). subjective point of view. 33
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Taking into account the conceivably Conclusions: Room for reflection infinite iterations of psychological methods and research as designed to target an individual’s In light of the difficulties outlined in this particular values, it can be argued that the paper, international and national bodies complexity of subjectivity surpasses that need to better incorporate a medical of physical pain. Interpersonal elements, understanding, particularly a psychological such as the increased susceptibility to one, that is workable within the severity psychological harm for those with a paradigm. Questions arising from some of supportive familial environment (‘securely the key literature in this review include: How attached’) on the background of their trust can the law better reflect the phenomenon in humanity and benevolent worldview of psychological torture through the prism (Kanninen, Punamäki, Qouta, 2003), and of psychology, in terms of quantifying the use of an individual’s severe phobia of severity, duration and effects? How do we the dark during coercive interrogations have then achieve a confluence between the two been but two aspects documented in the fields with respect to this issue? To quantify literature (Lewis, 2005). level of pain, medical professionals resort A comparable complexity is confirmed to notions of ‘duration’, ‘frequency’, and in medical literature on trauma, as ‘intensity’. Other notions such as ‘dignity’, there ‘are infinite ways of reacting and ‘agency’, and ‘fear’ perhaps need to be psychologically processing the same event’ factored in more strongly. (Pérez-Sales, 2017, pp. 129-133). Pérez- At the very least, these must be Sales points out that DSM’s definition understood and engaged with by the law. of trauma has been refined from ‘an Related understandings also need to be extensional definition (“extraordinary accepted. The three decades of research, events”), to a subjective consequentialist some of which is outlined here, does not definition (“overwhelming emotions”), support the equation that the magnitude of and now to an objective consequentialist applied stress will result in a corresponding definition (“threat”)’ (2017, pp. 133-134). magnitude of impact. That is, little stress To mirror this development, torture would could lead to a significant impact, and exclude the objective severity test, avoid great stress to little impact. There are many an extensional definition, and consider variables (e.g. age, culture, health) to render ‘exposure to threat as the core feature’. general rules unsuitable such as a minimum How does, for instance, a male six hours of sleep for every 24, or that decision-maker fully appreciate the impact certain symptoms are exclusively linked to TORTURE Volume 28, Number 2, 2018 of sexual humiliation of a woman? (Arcel, certain acts. 2003) How does one articulate witnessing Given the shortcomings in the law, there the regular desecration of the Koran or exists enough space to develop and sharpen being prevented from praying? (Khan, standards, both regionally and internationally. 2010; McCoy, 2012) How can a decision- Identifying institutional, cultural and practical maker gauge the anguish of a third party shortcomings of professionals, namely police, such as a relative or witness who vicariously lawyers, judges, psychologists and doctors experiences the impact of torture? The etc., and their related institutions in this area questions abound but not for a lack of will be important in developing the necessary interest in the answers. tools of training and documentation. 34
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Relatedly, it has been pointed out psychological torture? What is the level of that what is required is to fix a common awareness that psychologically coercive understanding of psychological torture acts can amount to torture? How many which is defined based on strong research, domestic criminal codes fail to recognise which international and national bodies, the mental element? What training recognising its value, would adopt and tools can be developed to complement operationalise in their work. Specifically, or re-work the existing deficiencies in they need to clarify and expand on the knowledge and process? notion of ‘mental suffering’ as part of the Outstanding questions necessitating further definition of torture. To that end, two broad reflection and research, arising out of sets of issues can be identified as those that this review, point to improved dialogue impede this understanding, as follows: between of psychology and law, developing i. How do victims’ prior psychological and sharpening standards with respect to states (broader than the notion documentation and, in turn, prevention, of ‘condition’ to include personal prosecution and adjudication. values and other subjective qualities) influence assessments of psychological References torture’s impact? Can we, and if so American Psychological Association. (2005). Re- port of the American Psychological Association how do we, differentiate the trauma an Presidential Task Force on Psychological Ethics and individual is subjected to, due to their National Security. http://dx.doi.org/10.1037/ mere interaction with criminal justice e419822005-001 apparatus and processes, from anything Arcel, L. T. (2003). Inhuman and degrading treat- ment of women: psychological consequences. that amounts to ill-treatment of any In: Kjærum, M., Thelle, H., Xia Yong & Bi Xiao severity (torture or not)? Taking victims Quing (eds.). (2003). How to eradicate torture (pp. as one finds them is a basic principle of 951-984). Beijing: Social Sciences Documenta- civil and criminal law. At the very least, it tion Publishing House. Başoğlu, M. (ed). (2017). Torture and Its Definition in is not a mitigatory factor in international International Law: An Interdisciplinary Approach. law. Accordingly, factoring in a victim’s New York: Oxford University Press. https://doi. ‘predisposition to suffer’, or conversely org/10.1093/med/9780199374625.001.0001 ‘resilience’, raises complicated issues. Başoğlu, M. (2009). A multivariate contextual analy- sis of torture and cruel, inhuman, and degrad- ii. How do we overcome the existing ing treatments: implications for an evidence- hierarchies (where some physical torture based definition of torture. American Journal methods enjoy quicker recognition than, of Orthopsychiatry, 79(2), 135–45. https://doi. for example, humiliation)? Is a western org/10.1037/a0015681 Başoğlu, M., Livanou, M., & Crnobaric, C. (2007). psychological understanding of trauma, Torture vs other cruel, inhuman, and degrading particularly with respect to psychological treatment. Archives of General Psychiatry, 64, 277– torture, applicable and transferrable 85. https://doi.org/10.1001/archpsyc.64.3.277 Ba o lu, M., & Mineka, S. (1992). The role of uncon- to non-western jurisdictions? If not, ş ğ trollable and impredictable stress in postraumatic what are the issues arising for the stress responses in torture survivors. In: Başoğlu recognition of psychological torture in M. (Ed.). (1992). Torture and its consequences: those jurisdictions? What are the factors, Current treatment approaches (pp. 182-225).New York: Cambridge University Press. such as common misconceptions, Burgers, J.H, & Danelius, H. (1988). The United Na- professionals demonstrate in contributing tions Convention against Torture: A Handbook on the Convention Against Torture and Other Cruel, Inhu-
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man or Degrading Treatment or Punishment. Violations in Mental Health. (pp.19-28). Oslo: Dordrecht-Boston-London: Martinus Nijhoff. Scandinavian University Press. Costanzo, M.A. & Gerrity, E. (2009). The effects Herman, J. (2015). Trauma and Recovery: The After- and effectiveness of using torture as an inter- math of Violence - from Domestic Abuse to Political rogation device: using research to inform the Terror. New York: Basic Books. policy debate. Social Issues and Policy Review, High Court of Israel. (1999). Public Committee Against 3(1), 179-210. https://doi.org/10.1111/j.1751- Torture in Israel v. Israel H.C. 5100/94. 2409.2009.01014.x Inter-Am.C.H.R, Raquel Martí de Mejía v. Perú, Case Crampton, D. (2013). What indicators exist, or may 10.970, Report No. 5/96, OEA/Ser.L/V/II.91 exist, to determine whether a violation of the prohibi- Doc. 7 at 157 (1996) tion of torture, inhuman or degrading treatment or International Committee of the Red Cross. (2007). punishment has occurred on the basis of psychological Report on the Treatment of Fourteen “High Value De- maltreatment, and whether it amounts to psychologi- tainees” in CIA Custody. cal torture. LLM Dissertation. School of Law. Jacobs, U. (2008). Documenting the neurobiology of University of Essex (on file with author). psychological torture: conceptual and neuropsy- ECHR. (1978). Ireland v. United Kingdom, 5310/71, chological observations. In: Ojeda, A. E. (Ed.). 19 January 1978. (2008) The trauma of psychological torture (pp. ECHR. (2018). Ireland v. United Kingdom, 5310/71, 163-172). Connecticut and London: Praeger. 20 March 2018. Kalbeitzer, R. (2009). Psychologists and Interroga- ECHR. (2001). Keenan v. United Kingdom, 27229/95, tions: Ethical Dilemmas in Times of War. Eth- 3 April 2001. ics and Behaviour, 19(2), 156-168. https://doi. ECHR. (2014). Al Nashiri v. Poland, 28761/11, 24 org/10.1080/10508420902772793 July 2014. Kanninen, K., Punamaki, R-L. & Qouta, S. (2003). ECHR. (2014). Husayn (Zubaydah) v. Poland, Personality and Trauma: Adult Attachment and 7511/13, 24 July 2014. Posttraumatic Distress Among Former Politi- ECHR. (1999). Selmouni v. France, 25803/94, 29 July cal Prisoners. Peace and Conflict: Journal of Peace 1999. Psychology, 9(2), 97–126. https://doi.org/10.1207/ ECommHR. (1976). Ireland v. United Kingdom, Euro- s15327949pac0902_01 pean, Yearbook of the European Convention on Khan, A. (2010). Faith-Based Torture. Global Human Rights, 19. Dialogue, 12(1-2). https://doi.org/10.2139/ Evans, M.D. (2002). ‘Getting to Grips with Tor- ssrn.1504754 ture’. International and Comparative Law Quar- Lewis, N. A. (2005). Interrogators cite doctors’ aid at terly 51(2), 365-383.. https://doi.org/10.1093/ Guantánamo. New York Times, 24 June 2005. iclq/51.2.365 Luban, D., & Shue, H. (2012). Mental torture: A cri- Evans, M.D. & Morgan, R. (1998). Preventing Torture: tique of erasures in U.S. law. The Georgetown Law A Study of the European Convention for the Preven- Journal, 100, 823–63. https://doi.org/10.1017/ tion of Torture and Inhuman or Degrading Treatment cbo9781107279698.011 or Punishment. New York : Oxford University Press. Manderson, D. (2005) Another Modest Proposal. Farber, I.E., Harlow, H.F. & West, L.J. (1957). Deakin Law Review, 10(2), 640-653. https://doi. Brainwashing, conditioning, and DDD (debility, org/10.21153/dlr2005vol10no2art297 dependency, and dread). Sociometry, 20, 271-285. McCoy, A. (2006). A Question of Torture: CIA Interro- https://doi.org/10.2307/2785980 gation, from the Cold War to the War on Terror. New Freedom from Torture. (2015). “Proving” Torture: An York: Metropolitan Books. TORTURE Volume 28, Number 2, 2018 ever-rising bar for medical evidence? Conference McCoy, A. (2012). Torture and Impunity: the US Doc- October 2015. trine of Coercive Interrogation. Madison: University Ginbar, Y. (2017). Making Rights Sense of the Tor- of Wisconsin Press. ture Definition. In: Başoğlu, M. (ed.). (2017). McCoy, A. (2012a). In the Minotaur’s Labyrinth: Torture and Its Definition in International Law: An Psychological Torture, Public Forgetting, and Interdisciplinary Approach (pp. 273-314). New Contested History. In: Carlson, J. & Weber, E. York: Oxford University Press. (eds.). (2012). Speaking about Torture (pp. 37-58). Grant, M. J. (2013). The illogical logic of music tor- New York: Fordham University Press. https://doi. ture. Torture, 23(2), 4–13. org/10.5422/fordham/9780823242245.003.0003 Hauff, E. (1994). The Phenomenology of Torture. In McDonnell, M., Nordgren, L. F., & Loewenstein, Lavik, N.J., Nygaard, N., Sveaass & E. Fannemel G. (2011). Torture in the eyes of the beholder: (eds.). (1994). Pain and Survival: Human Rights the psychological difficulty of defining torture in 36
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“It never happened to me, so I don’t know if there are procedures”: identification and case management of torture survivors in the reception and public health system of Rome, Italy
Caterina Spissu,*, Gianfranco De Maio,*, Rafael Van den Bergh,*, Engy Ali,*, Emilie Venables,*,**, Doris Burtscher,***, Aurelie Ponthieu,*, Mario Ronchetti,****, Narciso Mostarda,****, Federica Zamatto*
this task. This study explores practices in Key point of interest: the identification and case management of •• Staff who come into contact torture survivors in the reception structures with refugees should be trained and in the public health sector in Rome, in how to sensitively identify Italy. Method: Data were analysed manually torture survivors and to refer and codes and themes generated. Results: them to appropriate services for A non-homogeneous level of awareness rehabilitation. and experience with torture survivors was observed, together with a general lack Abstract of knowledge on national and internal Background: Access and linkage to care for procedures for correct identification of migrant torture survivors is contingent on torture survivors. Identification and case their identification and appropriate referral. management of torture survivors was However, appropriate tools for identification mainly carried out by non-trained staff. of survivors are not readily available, and Participants expressed the need for training the (staff of) reception systems of host to gain experience in the identification and countries may not always be equipped for management of torture survivors’ cases, as well support and increased resources at both the reception and public health system levels. Conclusions: The crucial *) Médecins Sans Frontières - Operational Centre Brussels process of identification and prise en charge **) University of Cape Town, School of Public of survivors of torture among migrant and Health and Family Medicine, Division of refugee populations is relegated to non- Social and Behavioural Sciences, Cape Town, South Africa trained and inexperienced professionals ***) Médecins Sans Frontières, Vienna Evaluation at different levels of the reception system Unit, Vienna, Austria and public health care sector, which may ****) Azienda Sanitaria Locale Rome 6, Rome, Italy carry a risk of non-identification and TORTURE Volume 28, Number 2, 2018 Volume TORTURE Correspondence to: [email protected] 39
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possible harm to survivors. Additional resources and structured interventions are Acronyms urgently needed, in the form of developing ASL: Azienda Sanitaria Locale [Local Health Authority] procedures, training, and adapted multidisciplinary services. CARA: Centri Accoglienza Richiedenti Asilo [Reception Centres for Keywords: Torture; asylum seeker; refugee; Asylum Seekers] identification; case management CAS: Centri Accoglienza Straordinaria [Emergency Reception Centres]
Introduction CDA: Centri di Accoglienza Torture survivors constitute a sizeable [Reception centres] proportion of mixed-migration flows CIR: Consiglio Italiano Rifugiati (OHCHR, 2017), with an estimated [Italian Council for Refugees] 5 to 35% among refugee populations (Baker, 1992). In addition to the torture, CPSA: Centri di Primo Soccorso e Assistenza [Centres for First Aid persecution and abuse faced in their country and Assistance] of origin, refugees and migrants are exposed to violence and ill-treatment during the long CSM: Centro di Salute Mentale [Public and perilous journey to reach safety, and Mental Health Department] they also face a variety of post-migration INMP: Istituto Nazionale per la difficulties (Carswell, Blackburn, & Barker, promozione della salute delle 2011). This can constitute a challenge popolazioni Migranti e per il for countries faced with mixed flows, as contrasto delle malattie della Povertà [National Institute for detection and care for survivors of torture Health, Migration and Poverty] may be complex and can require a high level of specialisation (Wenzel, 2007). While McT: Medici contro la Tortura [Doctors against torture] State signatories of the United Nations Convention Against Torture (UNCAT) are MeDU: Medici per i Diritti Umani obliged to offer rehabilitation services for [Doctors for Human Rights] survivors of torture, this is not systematically MoH: Ministero della Salute provided. Even in countries where [Ministry of Health] rehabilitative services—such as medical MoI: Ministero dell’Interno TORTURE Volume 28, Number 2, 2018 and psychological care, along with legal [Ministry of the Interior] and social support—are provided, access is MSF: Médecins Sans Frontières challenging for survivors of torture in transit [Doctors without Borders] or in a post-migratory condition, due to cultural and language barriers, the sense of NHS: National Health System confusion and disorientation upon arrival in SPRAR: Sistema di Protezione per a new context (Kirmayer, Narasiah, Munoz, Richiedenti Asilo e Rifugiati
Rashid, Ryder, Guzder, et al., 2011), and [Protection System for Asylum the sense of isolation and distrust which Seekers and Refugees] is a common feature of individuals who 40
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have experienced torture (Sousa, 2013). however, contain provisions for the redress These challenges are compounded by a and the overall rehabilitation of survivors general lack of appropriate tools for the of torture. Italy is one of the few European identification of torture survivors, and can states which does not legislatively foresee an prevent or delay identification and referral identification procedure of torture survivors of torture survivors to specialised care. during the asylum interview process Identification and referral are essential to (Towers, Reventlow, de Rengervé, de Witte, prevent physical and mental conditions from 2016). Nevertheless, the Italian Ministry of deteriorating and becoming chronic (OSCE, Health (MoH) has newly issued guidelines 2016), or from impacting the accuracy of on the psychological treatment of refugees the incident account (Yawar, 2004) to the who have faced torture or other forms of determining/adjudicating authorities; in violence (Ministry of Health, 2017), though Italy the Territorial Commissions in first it is unclear whether any form of training or instance, and the Civil Courts in case of sensitisation on their use will be provided. appeal (OSCE, 2016; Towers, Reventlow, de Refugees who are survivors of torture Rengervé, de Witte, 2016). are also included among the vulnerable In recent years, Italy has experienced categories listed by the Law Decree a fluctuating and growing influx of mixed- 142/2015, which recognises their specific migration flows, mainly arriving through reception needs in compliance with the the Central Mediterranean Route (Frontex, European Reception Directives (European 2017). In 2016, it became the first entry Union, 2013). point in Europe for migrants and refugees, Such developments in legislation seem with 181,436 migrants disembarking to collide with the reality of the response in the country after being rescued at that survivors of torture receive in the sea. According to official data, the main country. A number of specialised services for nationalities declared at arrival are Nigerian, survivors of torture exist in Italy, including Guinean, and Ivorian (UNHCR, 2017). a Médecins Sans Frontières (MSF) clinic Prior to arrival in Italy, many transited for opened in Rome in 2015. In this clinic, most weeks or months in Libya, where they were cases come from reception structures in the confronted with violence, torture, arbitrary Rome province. However, anecdotal figures detention, ill-treatment and forced labour show that many referred individuals are not (UNSMIL, 2016). The reception system survivors of torture, with approximately in Italy is overstretched in its attempts 33.5% being considered out of scope to respond to the needs of the migrant following in-depth assessment at the MSF population hosted in both ordinary and clinic which took place during the period emergency reception facilities across the October 2015-December 2017. Additionally, country. With regards to the obligation numbers of self-referred cases are increasing to provide access to redress—including (from 4,3% in 2015 to 37% at the end of rehabilitation—to survivors of torture, Italy 2017), suggesting that there is a gap in the has been a signatory to the UNCAT from identification and referral processes. 1989 but has only recently introduced a Understanding the challenges in bill criminalising torture. This bill does not, identification and referral is essential for TORTURE Volume 28, Number 2, 2018 Volume TORTURE 41
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improving referrals and for enhancing the control) at the sub-district levels of the possibility of survivors of torture accessing (Azienda Sanitaria Locale)-District 6 (ASL) rehabilitation services. However, there is in Rome, covering the southern metropolitan limited published evidence on this topic. territory. Practitioners from the MSF While a 2016 review assessed the challenges rehabilitation of victims of torture clinic in of identifying victims of torture in various Rome were involved in the study design, national asylum systems in Europe, North and facilitated its implementation. As the America and the Pacific, it focused mainly research did not directly involve survivors of on organisational and procedural issues, torture, they were not involved in the design and did not fully address the challenges or implementation of the study. and needs at the level of the frontline workers in the reception systems (Towers, Study setting - the reception system in Italy Reventlow, de Rengervé, de Witte, 2016). Migrants and refugees making their way to We therefore conducted a qualitative study Italy typically arrive by sea in the southern investigating practices in the identification regions of the country (UNHCR, 2017; and management of torture survivors’ cases Ministry of the Interior, 2017. Cruscotto in the Italian reception and health contexts, Statistico), most commonly after being and specifically in the reception centres and rescued at sea. Once registration and MoH sub-districts in the metropolitan area finger-printing procedures are finalised, of Rome. migrants and refugees are transferred to the reception structures throughout the Method1 country. In Italy, the reception of those Study design seeking protection is managed by the This is a qualitative study, based on in- Ministry of the Interior (MoI) through depth interviews with care providers at the Department of Civil Liberties and reception centres, general practitioners, and Immigration. The reception system consists the syndromic teams (tasked with disease of different types of reception facilities for the lodging of international protection seekers across all regions in Italy (Decree Law, no. 142, 2015): 1 This research was conducted through the •• first aid and assistance structures (CPSA), Structured Operational Research and Training
Initiative (SORT IT), a global partnership led mainly located at disembarkation points TORTURE Volume 28, Number 2, 2018 by the Special Programme for Research and (first phase). Training in Tropical Diseases at the World •• collective/governmental centres (CDA Health Organization (WHO/TDR). The model is based on a course developed jointly by the and CARA (second phase). International Union Against Tuberculosis and •• reception by the SPRAR (Protection Lung Disease (The Union) and Medécins Sans System for Asylum Seekers and Refugees) Frontières (MSF/Doctors Without Borders). The specific SORT IT programme which resulted (third phase). in this publication was jointly developed and •• reception in extraordinary/temporary implemented by the Centre for Operational structures (CAS) is foreseen where there Research, The Union, Paris, France and the is no space in the governmental centres Operational Research Unit (LuxOR), MSF Brussels Operational Centre, Luxembourg. or in SPRAR. In fact, the majority of 42
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protection seekers are hosted in CAS social worker, a medical doctor and a number (78%) and in governmental centres of technical referents. (8.5%) (Ministry of the Interior, 2017. According to the administrative status of Cruscotto Statistico). the migrant/refugee hosted in the reception In governmental and CAS centres, a number centre a general practitioner should be of services such as provision of food and assigned. However, due to administrative non-food items, health care assistance, legal delays or obstacles in the registration, often information, administrative assistance, and entitled migrants/refugees do not have a social and psychological support should general practitioner assigned. be ensured (Ministry of the Interior, Workers in the SPRAR and CAS are 2017. Schema di Capitolato). In SPRAR, assisted by cultural mediators, a cadre of in addition to the services provided in workers whose responsibilities and tasks are governmental centres and CAS, services aimed at improving mutual understanding, aiming at promoting socio-economic and facilitating access to public services and inclusion (SPRAR, 2017) are provided: the process of integration for immigrants these include orientation to employment (Ministry of Interior, 2009). and enrolment in training courses. The Guidelines on the identification and composition of reception centre staff includes referral of possible cases of torture or both general workers and specialised staff ill-treatment were issued in 2017 by the such as social and legal workers, cultural Ministry of Health, to health staff and mediators, psychologists and in some cases reception staff alike. The guidelines stipulate nurses and/or doctors. Although the SPRAR a short training for reception centre staff system is dedicated to the reception and on the issue of identification of cases of integration of protection seekers and refugees, torture, as also specified in Decree 142, its capacity is limited and it currently art. 17, clause 8. The implementation hosts only 13.5% of those applying for of these guidelines is however a regional international protection. responsibility, and is therefore highly In 2015, syndromic teams were created dependent on the regional resources and at a sub-district level within Rome ASL-6: the presence of actors at local/regional/ the task of these teams is the prevention of national level. In Rome province, there are outbreaks such as tuberculosis and scabies seven service providers to which cases of among the migrant population. Each sub- torture and ill-treatment can be refferred: district team consists of one medical doctor, the Istituto Nazionale per la promozione one nurse and one social worker. Socio- della salute delle popolazioni Migranti e per il medical activities include the provision of contrasto delle malattie della Povertà (INMP), medical services to migrants/refugees, physical the SaMiFo clinic, a joint public and private and psycho-social support for conditions initiative (ASL 1 and Centro Astalli), the related to torture and ill-treatment, and Consiglio Italiano per Rifugiati (CIR), Medici the monitoring of health conditions in the contro la Tortura (McT), CARITAS, MSF reception structures. All sub-district teams and Medici per i Diritti Umani (MeDU) (De work under the coordination of the ASL-6 Maio, Pettinicchio, 2018). The range of district team consisting of a psychologist, a services provided differs from one service TORTURE Volume 28, Number 2, 2018 Volume TORTURE 43
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provider to another, however, it might the ASL-6 district were purposively selected include medical care, psychological and based on discussions with the social worker psychiatric support, physiotherapy, legal and of the district team of ASL-6 and the project social services, and provision of medical, coordinator of the MSF rehabilitation legal and psychological certification. clinic. The selection of reception structures was based on the location of the reception centres, the characteristics of the hosted Study population migrant and refugee population (mixed Professionals were purposively selected gender and age, adult males, families, in order to gain a range of the different women and accompanied minors), and the professions for the interviews. A total of 28 capacity and status of centres (SPRAR and in-depth interviews were conducted with the CAS structures). To ensure that a variety following categories of professionals: of reception centres were considered in the •• Reception officers in six reception study, we included two centres designated centres: 15 interviews were conducted for adult males, one centre for women, with nurses, psychologists, social and accompanied minors and families, one legal workers and cultural mediators. centre for women and accompanied minors, •• Syndromic teams in charge of and one centre for men and families. reception centres in three sub-districts Governmental centres such as CARA of ASL-6: 11 in-depth interviews were excluded, as these structures have a were conducted with medical doctors, larger capacity and are usually intended to nurses, and social workers. host the migrant and refugee population •• General practitioners assigned by for short periods of time. Likewise, the local health system: two in-depth structures dedicated to unaccompanied interviews were conducted with minors were disregarded, as the MSF medical doctors. clinic for rehabilitation of survivors of All participants were frontline workers torture mainly sees adult survivors. Sub- interacting at reception and health system district teams with an incomplete working level with the migrant/refugee population. team were also excluded. Only one person refused to participate General practitioners were selected when asked. through the reception structures: over the course of the interviews with the reception Exclusion criteria: Reception officers in centre staff, contact information of general TORTURE Volume 28, Number 2, 2018 reception centres and health practitioners in practitioners assigned by the National the ASL-6 district who had received training Health System was obtained. sessions by MSF on the identification and Once the selection was completed, the management of survivors of torture were ASL-6 district sent an informative note to excluded from the study before the initiation centres and sub-district teams to introduce of the interviews. the study and its content, and facilitated contact between the principal investigator Selection and recruitment of study population: (first author) and the staff of the reception Reception centres and sub-district teams in centres and sub-district teams. The 44
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first author then contacted and visited reading the transcripts. The transcripts were the staff of the sub-district teams, the then re-read several times by the first author selected reception centres and the general and one of the co-investigators, and were practitioners to present the study and subsequently manually coded and analysed request their participation. The interviews line by line. No data analysis software was were conducted in the ASL-District of used during the analysis process. A thematic Rome by the first author. content analysis was used, following an approach in which the researcher becomes familiar with the data, generates codes, Data collection searches for and names themes, whilst The study took place between July and continuously reviewing and refining the September 2017. Data was collected by the themes that arise (Creswell, 2007; Braun, first author, who is a member of the MSF Clarke, 2006.). The coding framework was coordination team in Italy, working in the developed based on pre-identified themes advocacy department. Interview questions as well as themes that emerged during data were initially elaborated by the first author collection and discussions with the study and validated by two experienced co- team who were familiar with the data and authors; questions were also shared and the context. Neutrality was ensured by discussed with some of the MSF clinic having the second investigator, who was not staff. Interviews were audio-recorded upon present during the interviews, review and agreement of participants and in-depth code the transcripts in parallel. Differences interview guides with open-ended questions in interpretation were resolved through were used. On a few occasions, manual discussion between the investigators. notes were also taken during the interview. The length of the interviews varied from 40 minutes to approximately two hours. The Informed consent and confidentiality language used in the interview was Italian, Written informed consent was obtained from which is the native language of the first all interviewees before starting the interviews. author and most of the participants. One All participants read and understood the interview was conducted in both Italian and informed consent in Italian, and translation English, as the interviewee whose native was thus not necessary. A non-disclosure language was English found it easier to use agreement was signed by the translator- the native language. transcriber to ensure that confidentiality of data would be maintained. All identifying information, including names of participants, Data analysis reception centres, indication of sub-districts, An external transcriber-translator was hired and references to names or locations, was for the translation and transcription of the removed from transcripts before analysis. audio files, which were transcribed and translated verbatim from Italian to English. The first author verified the accuracy of both Ethical approval the translation to English and its transcription The study was approved by the Ethics by listening to the audio-recordings and Review Board of MSF (Geneva, TORTURE Volume 28, Number 2, 2018 Volume TORTURE 45
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Switzerland) and by the Lazio 2 Ethics refugees, and it does mention torture victims, Committee (Rome, Italy). but I can’t say exactly which law this is. They were issued by the Ministry (...) for Results Social Policies.” Social worker—T10 The main themes identified in this study “I must confirm there is no dedicated included participants’ knowledge of the [internal] procedure. It would be beneficial, definition of torture and (identification) very beneficial…” Psychologist—T13 procedures, practices and challenges in identification/detection, and case Participants showed different degrees of management. knowledge and understanding when asked to define torture and degrading treatment. Identifying survivors of torture— A lack of prior experience with torture practices and gaps survivors was also observed. The type and When questioned on the process of level of violence reported by migrants identification, many professionals reported in relation to their journey in Libya, as a lack of awareness or an absence of well as trafficking episodes, were often standardised procedures at national and identified as torture. internal levels to correctly identify torture survivors. They also expressed limited “I can intuit something because I’ve heard knowledge and doubts on the effectiveness someone talk, I’ve seen reports on TV. I’ve of the guidelines recently issued by the read books, articles… I’ve read magazines Ministry of Health. and so on. But first-hand experience, I’ve never had.” Health practitioner—T16 “I miraculously stumbled upon these “How would I define torture? An guidelines on torture. That was recently!” inhumane act.” Legal advisor—T2 Social worker - T1 “Previously my idea of torture was, say, “I have them [MoH guidelines] on my I am a military, an official in a dictatorship, tablet. I read those and I read the Istanbul I torture someone to get information, because Protocol but I think that for a reception there is political opposition. But here I officer or an ASL professional they don’t discovered there is another kind of torture, have much practical value in managing which is gratuitous... with no real reasons.” daily tasks and meeting guests, it is for a Health practitioner—T7 TORTURE Volume 28, Number 2, 2018 higher level. In any case the sub-district “[T]hen there is Libya. And here we can team in ASL does not have the skills for avert our gaze, because what is happening in that. The information has no practical Libya is unspeakable, whether you are there relevance for the ASL sub-district team for one day, two days or six months. (...). or for a reception officer, so we rely on The women who went through Libya and instinct and our own common sense.” Social suffered rape, gang rape, imprisonment, what worker—T3 is that? (…) Well I don’t think they are held “There are guidelines to be followed. by the military, or by officials, but that’s still The latest is from May 2017, for political torture.” Psychologist—T5 46
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“We saw cases of traditional or ritual quotations show the differing ways that conditioning when they leave for Italy. To professionals suspected or identified torture ensure they will compensate for this travel, in the migrant and refugee populations they which is paid by third parties, they undergo worked with. a sort of voodoo ritual which (…), keeps them in a condition of constant stress, ... if “With a visit we can see if they have the person does not pay the debt, damage physical damage, so to speak. But we would be done through this ritual to this don’t know if these are signs of torture. person or to their loved ones. This is a Psychologically you can look at them, type of psychological torture (…) Almost observe them a moment (…) but I everyone travelled through Libya, ..., some really don’t know how to start.” Health were openly sold in these sex houses, and practitioner—T15 they were tortured in sexual terms, because “If they stay all day in the room they were forced to agree to these actions, and don’t eat, something isn’t right. If for various reasons, because they were he argues and discusses with everyone, imprisoned, threatened, or had to pay a that is another symptom. If when seeing ransom.” Cultural mediator –T6 a reception officer he starts asking a “Torture is a situation in which a person thousand things, there is a state of anxiety is nullified as an individual. Practices are (…) For sure physically you can tell, you put in place to collect information from see wounds, scars. On the psychological the person tortured, who for this reason is level, it’s harder. It depends on the subject to repeated mistreatment (…) The reception officer’s sensitivity to understand.” essential difference is maybe that in torture there is an objective to gather information, Legal advisor –T2 the others are conditions of general violence.” “You can recognise victims of torture Psychologist - T8 from how they are in the centre. It’s not that you automatically recognise them but you notice who is doing worse than Overall, the identification of torture the others. They are isolated, may have survivors can occur in all of the stages aggressive reactions. Sleeping problems of the reception process by reception are very common, sleeping pattern officers or health practitioners in the public changes, nightmares, recurring flashbacks. health sector. It can happen during the (…) It is evident, some cases are more preparation for a Commission hearing, when evident, and some are more hidden.” physical scars are noticed during a medical Psychologist—T8 consultation, in counselling sessions, during the observation of the refugees and migrants by reception officers, or at any other point Other obstacles in the identification in the reception process. However, signs of torture survivors indicated by the and symptoms were seen as arduous to interviewees included language barriers and “read” and often certain behavioural traits refusal to talk. Others mentioned survivors such as isolation and/or aggressive conduct having a lack of trust towards the reception officers. The tension between the need TORTURE Volume 28, Number 2, 2018 Volume TORTURE were perceived as “difficult”. The below 47
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for “identification”—instrumental for the Management of torture survivor provision of protection—and the reticence of cases within the reception and public the migrants to open up; and the presence of health systems staff with no prior experience in the context Prise en charge in the reception centres was of migration within the reception system. reported to be challenging at different levels. While basic needs are met, the provision of The ability to provide adapted services within specialised care is left to improvisation. the reception structures was seen as being restricted due to the limited availability of human resources, while the public health “The topic of cultural mediators becomes system was seen as unprepared to respond essential, it’s the first thing, language. I to the specific needs of this population. One must be able to ask everything, get answers participant indicated that power dynamics on everything.” Health practitioner—T 27 embedded in the reception system, where “When he was asked ‘were you a reception officers exert control on the hosted victim of violence?’ He was troubled. But migrants, could lead to the perception of more (…) a refusal to remember, like ‘talk officers as perpetrators, a situation that to me about something else, please ask me requires trained professionals to manage. This something else’.” Health practitioner—T16 combination of factors tended to trigger the “Because we work in the legal aspect decision to rely on specialised actors with an we are seen as policemen, and they put up expertise in the field. defences.” Legal advisor—T2 “When I meet people for the first time I always ask. Usually with the intention of “There is no enough time for all the work letting them know that if they have physical here, I bring work home with me. This is signs, obviously it’s important for the very frustrating and leads all us reception Commission that these are documented. I say officers to burnout.” Psychologist –T8 this and it’s a little soft, like blackmailing: “[It’s necessary] to have a different behaviour towards these people than with the ‘if you tell me this, it can help with the other beneficiaries, a special care that is not Commission’, and at the same time it will always possible to provide or guarantee in help me get the information about the the SPRAR. These people for example need, problem.” Psychologist—T5 if they don’t want to be in contact with the “I think the challenge is that there is other beneficiaries, to have a room of their no clarity in the procedure. With staff there TORTURE Volume 28, Number 2, 2018 own. The team needs to work with everyone is too much of a difference among reception and cannot always dedicate attention to officers: those who are trained and those who a single beneficiary and give them the are not. So it’s left to improvisation. [they attention they need.” Legal advisor—T25 are] not specialists in the field. So since “The possibility for all of us to access staff are not homogeneous (…) if roles are [cultural] mediators at any time (…) If I confused, it’s a problem. And it’s a problem want to speak with someone, for example in if you have to control it: it’s a problem for an emergency situation, I cannot. I have to people to trust you and share things that book an appointment, postpone, sometimes it might inform you.” Legal advisor—T26 takes time, and sometimes this brings us far 48
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from the problem (...). The CSM don’t have the need to promptly submit medico-legal a specialist’s knowledge in this field: while certification to the authorities adjudicating [specialist external actors] have a lot, a lot protection claims. of cases, they are specialised in this kind of case.” Psychologist—T5 “She might tell me ‘this person has a “These people are specific cases. psychological vulnerability so maybe he We cannot treat them in the same way should be referred for psychological support as someone going to physiotherapy with [specialist external actors]. They also for arthrosis. These people might do work with the forensic doctor, who checks physiotherapy after a very strong the scars and can say if they are derived trauma and must be followed in overall from torture, which I don’t know how to do.” psychosomatic terms. Once more, this Health practitioner—T7 is a very delicate sector, I cannot say “All the problems are around timing. there is a service which can perform Say maybe the appointment in Court this function in terms of rehabilitation is in 10 days and a report is not ready, and psycho-dynamics. Certainly the so you don’t know whether to delay rehabilitation services we have today work, the appointment. And it’s important to but are not really dedicated to this aspect.” understand at what point the person is of the Psychologist—T 13 medical process.” Legal advisor—T12 “I had the feeling of being put in the “What i have seen is that [specialist role of oppressor. (…) It’s difficult unless a external actors] are overcrowded…but they reception officer is well trained to distinguish still give appointments. (...) There are too that this is symbolic and not related to him/ many, too many cases in need.” Health her personally. There are complicated (…) practitioner—T7 power dynamics, someone who has suffered “One day I was with a colleague who torture, in the relation with a reception accompanied a young man to [their clinic], officer can relive it. The reception officer is and the reception officer, my colleague… the one who has to tell an adult that ‘you they sent her outside and said “we need to cannot do this or that, you cannot cook in talk to this person on his own and you must your room (...).” Legal advisor—T26 wait outside.” So in that case we don’t know anything about the person, we don’t know Referral of torture survivors to what they talked about, what the doctor specialised actors said, what he lived through or didn’t live Reception officers acknowledged their through, and so on. If you are not there, with reliance on specialised actors for the the doctor, specifically, you cannot follow or provision of specialised services and care. organise.” Cultural mediator—T23 However, they also highlighted the limits “Sometimes we are lacking reference of this reliance, due to the overstretched contacts, people who have the role of capacity and the length of time necessary taking care of referrals (...) often we for the prise en charge by these specialised don’t know who we should talk to (...) actors. The waiting times were not seen as Knowing how sensitive these cases are.”
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Self-identified recommendations so it’s necessary to distribute skills on these within the reception system matters.” Psychologist—T13 First and foremost, interviewees called for training on the identification and Other recommendations included the management of torture survivor cases. importance of guaranteeing reception in The lack of training was seen as both a smaller-sized structures, supported by handicap to the reception officers and health specialised and multidisciplinary services. practitioners and as a possible danger to the Services should be structured to develop beneficiaries. An interest was expressed in social inclusion, relying on synergy between having experts from the different external the different stakeholders. The responses also actors in the field share their experiences. highlighted the importance of a guaranteed response that takes into consideration the “We lack training. We have never had individual and the specific needs of torture courses on this topic. We have always been survivors. Public services stressed the need considered a centre for suspected victims of to have additional internal resources that can trafficking. Torture, we’ve never even talked serve the response. about it.” Cultural mediator—T6 “Some have never worked in this sector, “A smaller context, in distributed some do but may not be having the same reception would be ideal (…) Also with sensitiveness. It would be useful to the team the internal presence of a team for support, to have guidelines, because I might notice because (…) if he wakes up at night he some things, but someone else might not. needs someone, a reception officer who And I may be bound by confidentiality. knows.” Psychologist—T8 My colleague who does not know anything “In order for torture to emerge, what might not understand the instructions given is required is a dedicated space and skills by the coordination team, and would then of the person managing the conversation. behave differently. Maybe we are not dealing Much more than we can do today.” with situations in the correct way. After this, Psychologist—T13 after doing this internally in the centres, at “Multi-professional, for sure: a the level of ASL there is really a need for a psychiatric consultation or assistance on serious dedicated training, really serious.” its own could not solve the issue (…)
Legal advisor—T2 TORTURE Volume 28, Number 2, 2018 Social services because he must be slowly “A training to enable us to face such re-acquainted with a context which is delicate topics (…) If one doesn’t know even harder for him, because he is also how to manage them, one can create further foreign. [He] would find it difficult to problems for the person who suffered. So integrate again in his natural environment, it’s a very, very, very delicate terrain.” imagine in a foreign environment.” Health Psychologist—T13 practitioner—T22 “If we are not given the opportunity “We come twice a week, so identification of training specifically, they [survivors of is already difficult. To offer continuous torture] can escape us. Some people are not support with such a large number of guests is skilled, it’s not their fault, but they aren’t, 50
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even harder. We can support, we can identify, existence and implementation of procedures, but we need external assistance for sure, both at national level and internally in the so more adequate situation would perhaps reception and health structures where they be a centre where people can be followed are to be implemented. The knowledge and individually.” Social worker—T10 understanding of the phenomenon of torture “Someone vulnerable who is a victim was mainly related to the personal exposure of torture [will] find it more difficult to and/or prior experience of the individual, access jobs, trainings and so on, but I think and was commonly associated and/or there should be extra funds for this, because confused with episodes of trafficking or a vulnerable case should be supported.” extreme violence faced by migrants/refugees Psychologist—T8 in Libya. “In terms of improvements, mediators Our results indicate how the detection are essential, possibly ours, and not and linkage to care of torture survivors from the [reception] centre.” Health among the migrant and refugee population practitioner—T16 principally occurs at the hands of non- “Since the Municipality is involved in trained health practitioners and reception managing the SPRAR… the idea of creating officers, with no prior experience in the a project, combining the various actors, areas of torture and migration in general. the Prefecture the Municipality, us for the This observation is consistent with similar healthcare aspects and place them in a civic studies (Asgary, Metalios, Smith, Paccione, context to give a sense to their stay here, for 2006), and a recent review that identified months and months.” Social worker—T21 that Germany and Croatia are the only European states with legislation on who is Discussion responsible for the identification of torture This study represents an in-depth qualitative survivors (Towers, Reventlow, de Rengervé, exploration of the challenges in identification de Witte, 2016). In addition to the lack and linkage to care of torture survivors of training, reception officers and health among the migrant and refugee population practitioners are confronted with a number in the reception and public health systems in of difficulties ranging from linguistic and Italy. The study comes at a historic moment cultural barriers—due to a lack or insufficient when the country is called to manage an presence of cultural mediators—and mistrust influx of migrants and refugees—who are at and reticence of torture survivors. high risk of having been exposed to torture This set of conditions may carry adverse and ill-treatment (Baker, 1992; Carsell consequences for the rehabilitation of et al., 2011; OHCHR, 2017)—while just survivors of torture among the migrant having introduced torture as a crime in population. The lack of trust of survivors national legislation. Against this background, and their refusal to talk as a consequence of guidelines on the rehabilitation response their experiences, also described elsewhere and psychological treatment of victims of (Yawar, 2004), is further exacerbated by the torture and violence were also recently dynamics in the reception system, where published. Considerable confusion and the role of reception officers appears to be linked to a degree of power and control over
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the refugees/migrants, evoking memories of formulated by the participants tended and generating associations with perpetrators towards requests for additional resources in of torture and potentially impacting the order to address the self-identified gaps in development of a trusting relationship—a the area of training—considered essential fundamental aspect in rehabilitation for accurate identification and to avoid (Larson-Stoa, Jacobs, Jonathan, Poudyal, possible harm—and to strengthen the 2015). In light of this complex interaction, capacity of reception officers and health the lack of expertise and skills related to practitioners to appropriately handle cases the identification of torture survivors, in and refer survivors. combination with the lack of appropriate The study faced a number of limitations, tools for identification, carries the risk of including being conducted in one specific non-identification, and may conceivably geographical region of Italy, the small cause harm when survivors are solicited for sample size and the focus on SPRAR and catharsis or ventilation (Jaranson, Kinzie, CAS centres, while CARA and centres for Friedman, Ortiz, Friedman, Southwick, unaccompanied minors were excluded. et al., 2001), or when exposed to direct Additionally, the study focused on care questioning. Our study also highlights the providers only, and thus no triangulation with difficulty and possible risk of subjecting experiences of the migrant/refugee population torture disclosure to time constraints in the was done. A particular strength of the study frame of a legal procedure, rather than being was that it was conducted with frontline considered an instrumental aspect of the staff, capturing the situation “on the ground” rehabilitation process. while benefiting from the expertise of the The available resources, including staff, practitioners from the MSF rehabilitation of were considered dramatically insufficient victims of torture clinic in Rome. to respond to the needs of the migrant and A number of conclusions and refugee population and of torture survivors recommendations can be drawn from this in particular. The presence of a small study. In light of the multiple gaps in the number of external actors specialised in correct identification and case management torture represented a solution for the prise of survivors of torture and ill-treatment, en charge of survivors in the region, but and the general difficulties in identifying seemed insufficient in the face of the large such conditions, partly due to the lack number of referrals. Additionally, in several of appropriate screening tools (Towers, instances, referral was perceived as a means Reventlow, de Rengervé, de Witte, 2016; TORTURE Volume 28, Number 2, 2018 to comply with the timeframe of legal Asgary, Metalios, Smith, Paccione, 2006; procedures, rather than as a step toward Visentin, Pelletti, Bajanowski , Ferrara, 2017), rehabilitation. The collaboration with a considerable number of unidentified cases services offered by specialised actors was likely exist within the migrant and refugee characterised by a general lack of structured population in Italy: the prevalence of torture communication and referral systems, is an overlooked issue by both the MoH conceivably hampering the referral process and MoI. The lack of knowledge of the legal and possibly impacting the effectiveness definition of torture has an impact not only of the intervention. The recommendations on the correct identification of victims of 52
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torture but also on victims of other forms emergence or identification of the torture of violence, equally entitled to a range of condition. Trainings should be designed services and specialised care. It is paramount and tailored to fit the specificities of each that cases who face similar violence or profession involved. criminal acts, without falling under the Professional cultural mediation should be UNCAT definition, are correctly identified systematically provided in reception centres and referred to specialised services. This and public health structures to overcome would prevent delay in the necessary delivery language and cultural barriers, to establish of care and avoid excessive workload for the and facilitate relationships between reception clinics specialised in the rehabilitation of officers and beneficiaries, and to enhance torture survivors. the chances of detection or self-reporting of While the legislative tools exist, defining physical or psychological symptoms (Flores, the crime of torture to ensure the right of 2005). It is essential that public health torture survivors to access rehabilitative structures and general practitioners work care (OHCHR, 2012), proper assessment with the systematic support of dedicated and of reception needs (European Union, trained cultural mediators without having 2013), and provision of specific measures of to rely on cultural mediators employed by assistance including adequate psychological reception centres, in order to guarantee support (Decree Law, no. 142, 2015) and strict respect of confidentiality and avoid any while guidelines to orient the rehabilitative possible conflict of interest. intervention were issued (Ministry of Furthermore, we recommend that Health, 2017), they urgently need to be the Italian government allocates funds reinforced through dissemination, coupled to support the existing expertise in the with training and implementation. This mixed private-public sector and for the should be combined with clear instructions development of specialised structures on how identification should be conducted within the public health services, employing and, in the long run, development of tools to dedicated multidisciplinary teams of allow/help identification. Such reinforcement experienced medical and non-medical should at the very least consist of relevant personnel and including cultural mediators training—as foreseen by relevant legislation as part of the interdisciplinary model. (European Union, 2013)—for all reception This would offer a conducive environment officers employed in the reception structures (far from the possible forms of control and health and social practitioners at the present in the reception structures) for public level. torture survivors to develop a sense of trust Other trainings for health practitioners and rapport with those involved in their and social workers in public health services, rehabilitation. Additionally, considering and for reception officers employed in that housing constitutes a major social reception structures, should focus on determinant in health outcomes, alternative migration-related topics to strengthen their solutions to the current reception measures sensitivity and the adoption a culturally should be explored to meet the subjective adapted approaches with the migrant needs of torture survivors and to strengthen population, which would facilitate the rather than inhibit the rehabilitative process TORTURE Volume 28, Number 2, 2018 Volume TORTURE 53
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( Ziersch, Walsh, Due, Duivesteyn, 2017). Funding In conclusion, our study identified The training programme and open access a lack of awareness and a vacuum of publications costs were funded by the (the implementation of) procedures for Department for International Development identification and referral of torture (DFID), UK and La Fondation Veuve Emile survivors among the migrant population Metz-Tesch (Luxembourg). The funders had arriving in Italy. These essential no role in study design, data collection and processes are relegated to non-trained analysis, decision to publish, or preparation and often inexperienced professionals of the manuscript. at the different levels of the reception system and public health care sector. References Additional resources and structured Asgary, RG., Metalios, EE. , Smith, CL., Paccione, interventions are urgently needed, in the GA. (2006). Evaluating asylum seekers/torture form of developing and implementing survivors in urban primary care: a collaborative approach at the Bronx Human Rights Clinic. procedures, training and dedicated Health and human rights, 9(2):164-79. interdisciplinary services. Baker, R. (1992). Psychological consequences for tor- tured refugees seeking asylum and refugee status in Europe. In: Basoglu M. editor (Ed), Torture Acknowledgements and Its Consequences: Current Treatment Approaches We acknowledge with gratitude the general (pp. 83-101). Cambridge, England: Cambridge practitioners and the personnel of the University Press. Braun, V., Clarke, V. (2006). Using thematic analysis selected reception centres and the sub- in psychology. Qualitative Research in Psychology, districts in the Rome ASL 6 for their 3(2):77-101. enthusiastic participation in this study. Carswell, K., Blackburn, P., & Barker, C. (2011). Without their contribution this article could The relationship between trauma, post-migration problems and the psychological well-being of never have been written. We would also refugees and asylum seekers. Int J Soc Psychiatry, like to show our gratitude to the Direction 57(2):107-19. of the ASL Rome 6 for the collaboration Creswell, J. (2007). Qualitative Inquiry & Research De- and for allowing Médecins Sans Frontières, sign: Choosing Among Five Approaches. Thousand Oaks, CA, USA: Sage Publications, Inc. Italy Mission, to conduct this study in Decree Law, no.142. (2015). Attuazione della di- its territory. Additional thanks to MSF rettiva 2013/33/UE recante norme relative colleagues from the clinic for Victims of all’accoglienza dei richiedenti protezione inter- nazionale, nonche’ della direttiva 2013/32/UE,
Torture in Rome for providing their inputs, TORTURE Volume 28, Number 2, 2018 recante procedure comuni ai fini del riconosci- suggestions and reflections on the topic. mento e della revoca dello status di protezione A special posthumous acknowledgment internazionale, Decreto Legislativo 18 agosto goes to Mrs. Maria Grazia Germani, who 2015, no. 142. [Implementation of the directive worked as Responsible for the Social 2013/33/UE on current norms regulating the re- ception of asylum seekers]. Services Department ASL 6, Rome Italy. De Maio, G., Pettinicchio, V. (2018). Accoglienza e Mrs. Germani’s contribution has been cura delle vittime di tortura a Roma, 30 anni di instrumental for the identification of esperienze. Osservatorio Romano, Tredicesimo reception centers and the sub-district teams Rapporto Report on the reception conditions and rehabilitation for victims of torture in Rome, of ASL Rome 6 and for facilitating the 30 years of experience. [Report on the recep- contact with the principal investigator. 54
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tion conditions and rehabilitation for victims of interno.gov.it/sites/default/files/allegati/schema_ torture in Rome, 30 years of experience.]. Centro di_capitolato_di_appalto_p.pdf. Studi e Ricerche Idos. Ministero della Salute. [Ministry of Health.] (2017). European Union., (2013). Directive 2013/33/EU of Linee guida per la programmazione degli inter- the European Parliament and of the Council of 26 venti di assistenza e riabilitazione nonché per il June 2013 laying down standards for the reception trattamento dei disturbi psichici dei titolari dello of applicants for international protection. status di rifugiato e dello status di protezione sus- Flores, G. (2005). The impact of medical interpreter sidiaria che hanno subito torture, stupri o altre services on the quality of health care: a system- forme gravi di violenza psicologica, fisica o ses- atic review. Medical care research and review : suale. [Guidelines for the programming of inter- MCRR,62(3):255-99. vention of support and rehabiliatation programs, Frontex., (2017). Central Mediterranean Route. including for the treatment of mental health dis- Frontex. http://frontex.europa.eu/trends-and- orders affecting refugees and asylum seekers en- routes/central-mediterranean-route/. titled to subsidiary protection, victims of torture Jaranson, JM., Kinzie, JD., Friedman, M., Ortiz, SD., and of cruel or other forms of inhumane degrad- Friedman, MJ., Southwick, S., et al. (2001). As- ing treatment, psychological, physical violence or sessment, Diagnosis, and Intervention. In: Ger- sexual violence.] Rome, Italy. rity, E., Tuma, F., Keane, T.M., (eds). The Mental OHCHR, UN Committee Against Torture (2012). Health Consequences of Torture The Plenum Series on Convention against Torture and other Cruel, Inhu- Stress and Coping. Boston, MA, USA: Springer, man or Degrading Treatment or Punishment. pp. 249-275. OHCHR, UN Committee Against Torture (2012). Kirmayer, LJ., Narasiah, L., Munoz, M., Rashid, M., General Comment no. 3: Implementation of Article Ryder, AG., Guzder, J., et al.(2011). Common 14 by State Parties. mental health problems in immigrants and refu- OHCHR, & United Nations Human Rights - Office gees: general approach in primary care. in CMAJ of the High Commissioner( 2017). Two-thirds Canadian Medical Association journal = journal de of torture victims supported by UN Fund are mi- l’Association medicale canadienne, 183(12), E959-67. grants and refugees. New York, USA. http://www. Larson-Stoa, D., Jacobs, GA., Jonathan, A., Poudyal, ohchr.org/EN/NewsEvents/Pages/DisplayNews. B. (2015). Effect of counseling by paraprofes- aspx?NewsID=21533&LangID=E. sionals on depression, anxiety, somatization, and OSCE, Regional meeting on Rehabilitation for functioning in Indonesian torture survivors. Torture, Victims of Torture for countries in the OSCE 25(2):1-11. region (2016). Good Practices and Current Ministero dell’Interno. [Ministry of the Interior.] Challenges in the Rehabilitation of Torture (2009). Ministero dell’Interno, European Un- Survivors - discussion paper, June 23rd 2016. ion. Linee di Indirizzo per il Riconoscimento Copenhagen, Denmark. della Figura Professionale del Mediatore In- Sousa, CA. (2013). Political violence, collective func- terculturale, del Gruppo di Lavoro Istituzion- tioning and health: A review of the literature. ale per la promozione della Mediazione Inter- Medicine, Conflict and Survival, 29(3): 169-97. culturale. Rome, Italy: Centro Informazione e SPRAR., (2017). System of Protection for refugees Educazione allo Sviluppo. [Guidelines on the rec- and asylum seekers [Sistema de Protezione per ognition of intercultural mediators.] Rome, Italy. Richiedenti Asilo e Rifugiati. SPRAR - English.] Ministero dell’Interno. [Ministry of the Interior.] Rome, Italy] (2017). Cruscotto Statistico Giornaliero 12 Towers, R., Reventlow, M., de Rengervé, H. , de Aprile 2017. Rome, Italy: Ministero dell’Interno. Witte, M. (2016). Recognising victims of torture in [Daily statistics on 12th April 2017.] Rome, Italy. national asylum procedures - A comparative overview http://www.libertaciviliimmigrazione.dlci.interno. of early identification of victims and their access to gov.it/sites/default/files/allegati/cruscotto_statis- medico-legal reports in asylum-receiving countries. tico_giornaliero_12_aprile_2017.pdf. Copenhagen, Denmark: IRCT. Ministero dell’Interno. [Ministry of the Interior.] UNHCR (2017). Operational portal - refugee (2017). Ministero dell’Interno. Schema di Capi- situations. Mediterranean situation. https:// tolato di Appalto. [Contract documents.] Rome, data2.unhcr.org/en/situations/mediterranean/ Italy. http://www.libertaciviliimmigrazione.dlci. location/5205#category-1. TORTURE Volume 28, Number 2, 2018 Volume TORTURE 55
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UNSMIL, United Nations Support Mission in Libya, United Nations Human Rights - Office of the High Commissioner (2016). “Detained and de- humanised”: Report on human rights abuses against migrants in Libya. Libya. Visentin, S., Pelletti, G., Bajanowski, T., Ferrara, SD. (2017). Methodology for the identification of vulnerable asylum seekers. International journal of legal medicine. Wenzel, T. (2007) Torture. Current opinion in psychia- try, 20 (5):491-6. Yawar, A. (2004). Healing in survivors of torture. Journal of the Royal Society of Medicine, 97(8): 366-70. Ziersch, A., Walsh, M., Due, C., Duivesteyn, E.(2017). Exploring the Relationship between Housing and Health for Refugees and Asylum Seekers in South Australia: A Qualitative Study. International journal of environmental research and public health, 14(9), 1036. TORTURE Volume 28, Number 2, 2018 56
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Validation of the Protect Questionnaire: A tool to detect mental health problems in asylum seekers by non-health professionals
Ricarda Mewes, PhD*, Boris Friele, Prof. Dr.**, Evert Bloemen, MD***
Abstract Key points of interest: Introduction: Prevalence rates of •• Early recognition of mental trauma-related mental disorders such as health sequelae of torture or posttraumatic stress disorder (PTSD) or serious violence is of utmost major depression (MD) are high in asylum importance for asylum seekers seekers. The PROTECT Questionnaire who enter the EU since such (PQ) was designed to detect indications sequelae are likely to have a of those disorders in asylum seekers. significant impact on the asylum Empirical data are needed to evaluate the procedure itself as well as PQ psychometrically. The objective of rehabilitation and integration. this study is to investigate the reliability, •• It is important that non-health validity, sensitivity, and specificity of the professionals are able to detect PQ. Method: The PQ and validated mental health issues using effective questionnaires for PTSD (Posttraumatic screening tools. Diagnostic Scale, PDS) and depression •• Data presented here supports (Patient Health Questionnaire-9, PHQ- the hypothesis that the 9) were filled in by a sample of recently PROTECT Questionnaire is arrived asylum seekers in Germany (n=141). a valid and reliable tool for A sub-sample of 91 asylum seekers took non-health professionals in part in a structured clinical interview to deciding whether to offer an diagnose PTSD or MD (SCID-I). Results: asylum seeker special legal The PQ showed a one-factor structure procedures and whether or and good reliability (Cronbach’s ⍺ = .82). not to refer an asylum seeker It correlated highly with the PDS and the for a clinical examination. PHQ-9 (rs=.53-.77; ps≤.001). Diagnostic accuracy with regard to PTSD (AUC=.74; SE=.06; p<.001; 95%-CI=.63-.84) and MD * ) Outpatient Unit for Research, Teaching and (AUC=.72; SE=.06; p<.001; 95%-CI=.61- Practice, Faculty of Psychology, University of Vienna .83) was adequate, suggesting an optimal **) Faculty of Social Work, IUBH International Uni- cut-off of 8 or 9. By categorizing participants versity, Campus Berlin into a low- and high-risk category, the PQ *** ) Pharos, Dutch Centre of Expertise on Health differentiated well between asylum seekers Disparities, Utrecht, The Netherlands who fulfilled a PTSD or MD diagnosis and TORTURE Volume 28, Number 2, 2018 Volume TORTURE Correspondence to: [email protected] 57
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those who did not. Discussion: The results Office (EASO) considers these mental support the use of the PQ as a reliable and health problems as one of the indicators valid instrument for the purpose of detecting for special procedural needs in asylum signs and symptoms of the two most procedures. For this reason a practical guide common mental disorders in asylum seekers. on evidence assessment and a digital tool Persons found to be at risk of mental were developed (EASO, 2015 & 2016). disorders should be referred to a clinical Evidence shows that mental health diagnostic procedure. problems are associated with impairments in concentration and memory, which hinder Keywords: asylum seekers, major depression, asylum seekers from properly recounting posttraumatic stress disorder, screening tool, the often traumatic background of their validation asylum request, resulting in wrongful asylum decisions (Cameron, 2010; Herlihy, Jobson, Introduction & Turner, 2012; Memon, 2012; Rogers, Fox, The recent large influx of asylum seekers & Herlihy, 2014). These impairments also in the European Union (EU) represents hinder learning capacities and can influence a major public health challenge. Many the person’s ability to take part in social and of the asylum seekers as well as other working life in the host country. On the other migrants have been confronted with hand, secure life circumstances and adequate adverse conditions, e.g. war, violence, care and treatment have considerable positive torture, loss of beloved persons, jobs, and health impacts for asylum seekers (Heeren property. This makes them vulnerable to et al., 2014; Laban, Gernaat, Komproe, negative mental health consequences. In Schreuders, & De Jong, 2004; Silove, the EU, the Asylum Procedures Directive Sinnerbrink, Field, Manicavasagar, & Steel, and the Receptions Conditions Directive 1997; Steel et al., 2006). give guidance to member states on how to Considering the high number of steadily deal with the special needs of vulnerable arriving asylum seekers, a procedure which asylum seekers (European Union, 2013). allows for an efficient identification of According to these directives, the needs vulnerable persons needing special mental have to be identified and taken into health care and special procedural attention account with respect to reception facilities, is imperative. There is a need for a tool to health care provisions, and the need for easily detect symptoms of mental disorders special legal procedural guarantees. These as an expression of vulnerability and special requirements are based on the knowledge of needs. Non-health professionals especially TORTURE Volume 28, Number 2, 2018 high prevalence rates of mental disorders in are in need of such a tool, as they are asylum seekers and refugees. Posttraumatic most often in contact with asylum seekers Stress Disorder (PTSD) and Major without having the clinical knowledge and Depression (MD) are among the most experience to detect mental health problems. frequent mental disorders in asylum seekers The PROTECT Questionnaire (PQ), and refugees who have experienced war, investigated here, can be used by non-health torture, or other forms of serious violence staff even in less favorable situations such (Gäbel, Ruf, Schauer, Odenwald, & Neuner, as asylum hotspots or detention centers. 2006; Ikram & Stronks, 2016; Steel et al., In these places, mental health is a major 2009). The European Asylum Support issue and the identification of vulnerable 58
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individuals is a challenge due to lack of only four which consisted of fewer than 15 capacity to respond and an absence of items. However, the BPTSD (Fullerton et standardized tools (European Union Agency al., 2000) and the SPAN scale (Meltzer- for Fundamental Rights, 2016; MSF, 2017). Brody, Churchill, & Davidson, 1999) require Against this background, a group of a severity scoring from 0 to 4 for each item specialized treatment centers for torture instead of the recommended simple rating victims in several European countries scales. The Disaster-Related Psychological started the PROTECT project that focused Screening Test DRPST (Chou et al., 2003) on early identification of vulnerable was specifically designed for survivors asylum seekers as a result of posttraumatic of disasters and might not be applicable problems. The PROTECT project1 suggests to other populations. The Primary Care a three-step procedure: PTSD Screen PC-PTSD (Prins et al., (1) detecting signs and symptoms of typical 2003) claims good predictive validity by mental health-related sequelae of using a very low cut-off of three or even adverse experiences through a simple two positive answers. Another frequently and short questionnaire and categorizing used screening instrument for PTSD in into risk categories; refugees (published after Brewin’s review) (2) referring medium-risk and high- is the Trauma Screening Questionnaire risk cases to an in-depth medico- (TSQ) (e.g.(McDonald & Sand, 2010)). psychological examination, including However, the PC-PTSD and TSQ were the diagnosis of disorders and the developed for specific contexts. They identification of related special needs; presuppose the experience of a potentially (3) making known these needs in order traumatic event and were validated under to provide adaptations in the asylum this premise. A rather new questionnaire, procedure and adapted reception currently attracting attention, is the conditions, care, and treatment for the Refugee Health Screener-15 (Hollifield, respective asylum seekers. With regard 2013; 2016) . The RHS-15 was designed to step one, an easy to use screening specifically as a screening instrument for tool is needed. refugee populations, and good psychometric As Brewin (2005) summarizes, screening validity was found in two evaluation tools should be short, with items that are studies. However, despite this broad range easy to understand, and avoid extended of instruments, none of them meet the rating scales (e.g. use yes/no answers). They requirements for screening asylum seekers should have a clear purpose, be acceptable as outlined by Brewin (2005). Moreover, to respondents, and provide a simple scoring they do not cover signs of depression as a method to yield results. Focusing on short frequent disorder among asylum seekers screening instruments for PTSD as one (Steel et al., 2009). typical mental health-related sequelae in asylum seekers and refugees, Brewin PROTECT Questionnaire (Brewin, 2005) found 14 instruments that The PROTECT Questionnaire (PQ) had been subject to evaluation studies, but (PROTECT, 2012) was developed for adult asylum seekers to meet the demands described above. The PQ is designed to be
1 TORTURE Volume 28, Number 2, 2018 Volume TORTURE http://protect-able.eu used by non-health professionals as they 59
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lack the repertoire of questions to identify The present study aimed at investigating symptoms of mental disorders. Health the reliability, validity, sensitivity, and professionals do not need a tool like the specificity of the PQ in a sample of recently PQ as they have their diagnostic skills and arrived asylum seekers in Germany. clinical experience. In terms of its general structure, the Materials and methods PQ is similar to the TSQ. Ten questions Local ethics committee approval for the addressing specific symptoms are answered study (Institutional Review Board of the with yes or no. The questions are related Department of Psychology, University of to symptoms of PTSD (nightmares, anger, Marburg, Germany) was obtained and thinking about painful past events, being all subjects provided written informed scared or frightened) and to symptoms of consent before participating in the study. both MD and PTSD (sleeping problems, The study was conducted in accordance forgetting, losing interest, troubles with the Declaration of Helsinki. The concentrating). In order to account for study design was cross-sectional in nature. possible cultural differences without being Data assessment took place in the German too specific to any particular culture, Federal state of Hesse between February the questions of the PQ also place some 2014 and March 2015. emphasis on pain symptoms (headaches and non-specified pain), as it is well known Procedure and participants that persons from non-Western cultures, Asylum seekers were recruited for a study as well as refugees, are more likely to investigating the psychological health of experience, or at least report, somatic adult asylum seekers who had been living in rather than psychological symptoms Germany for a maximum of one year. The (Rohlof, Knipscheer, & Kleber, 2014). By study was funded by the European Refugee counting the “yes” answers a sum score is Fund (EFF-12-775). Asylum seekers living produced. The result is then assigned to in Hesse, a Federal state of Germany, were one of three categories of risk for suffering approached in their accommodation or at from posttraumatic symptoms suggested by meeting points for asylum seekers (e.g., the PROTECT project based on clinical cafés) and provided with information about experience and preliminary data. A score of the study. Asylum seekers who were willing three or less is considered as low risk, a score to take part in the study were asked about of four to seven reflects a medium risk, and several risk factors and protective factors for a score of eight or above suggests a high risk. mental health using questionnaires and a TORTURE Volume 28, Number 2, 2018 For the medium- and high-risk categories, structured clinical interview (see below). referral to a more in-depth examination by a Eligibility criteria were an age above psychologist or psychiatrist is recommended. 18 years, had been living in Germany Contrary to other screening instruments for a maximum of 12 months, and had for PTSD, the PQ does not ask about the applied for asylum but not yet being existence of potentially traumatic event(s). recognized as having a right of asylum. Such questions would presuppose a Moreover, the participants had to be fluent specific context in terms of time, trust, and in understanding and speaking (but not expertise that is not compatible with a fast reading or writing) Farsi, Arabic, Kurdish, screening setting. or English, or had to bring a translator of 60
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their language of choice. The choice of the 0). The second part of the PDS comprises available languages was based on data about questions concerning the time and impact the most frequent countries of origin and of the most severe traumatic event. The mother tongues of asylum seekers in 2014 third part consists of 17 items assessing re- and the years before 2014 (Bundesamt für experiencing, avoidance, and arousal. The Migration und Flüchtlinge, 2014). total score of the third part can range from 0 to 51, with higher scores indicating more Assessment instruments severe posttraumatic symptomatology. The All questions were provided in Farsi, validity of the PDS has been supported Arabic, Kurdish, or English according to in several studies. Among others, good the participant’s choice, and translators reliability and validity for the Arabic version for these languages were present in case of were found (Norris & Aroian, 2008). further questions. Moreover, the software Cronbach’s alpha for the PDS (third part) in ‘MultiCasi’ (Knaevelsrud & Müller, 2008) the present study was .96. was used to present the questions and Depressive symptoms were assessed using possible answer categories in a language- the Patient Health Questionnaire-9 (PHQ- based manner via a laptop with touch- 9) (Kroenke, Spitzer, & Williams, 2001). screen. Questionnaires that were not The PHQ-9 is a nine-item self-rating available in the languages of interest were instrument, with each item representing translated in a forward-backward translation one of the DSM-IV criteria for a depressive process in accordance with the guidelines of episode. Each item can be scored as 0 (not Van de Vijver and Hambleton (1996). at all), 1 (several days), 2 (more than half Sociodemographic data were assessed the days), or 3 (nearly every day), according through questions about sex, age, country of to the frequency of experiencing difficulties birth, mother tongue, religion, highest level in the respective area in the previous two of education, and the amount of time living weeks. Sum scores range from 0 to 27, with in Germany. higher scores indicating a higher intensity Traumatic events and posttraumatic of depressive symptoms (Kroenke, Spitzer, symptoms were assessed via self-report using Williams, & Lowe, 2010). The PHQ-9 is an extended version of the Posttraumatic one of the most frequently used and best Diagnostic Scale (PDS) (Foa, 1995). The validated questionnaires for the assessment first part of the PDS, the trauma scale, of depression worldwide (Löwe et al., 2004; was extended by adding items from the Lowe et al., 2004). It is recommended as Harvard Trauma Questionnaire (Mollica a general measure of depression severity et al., 1992) asking about traumatic events by the DSM-5 (American Psychiatric often experienced by asylum seekers. At the Association, 2013) and has been translated same time, the answer format was extended into over 70 languages and dialects (Pfizer in accordance with the suggestions for Inc., 2013). Cronbach’s alpha for the traumatic events in the DSM-5 (American PHQ-9 in the present study was .92. Psychiatric Association, 2013). Thus, it In a subsample of the participants, ranged from ‘experienced the event myself’ the diagnoses Posttraumatic Stress Disorder (highest score, 3), via ‘experienced it as a (PTSD) and Major Depression (MD) witness’ (2), and ‘heard of it’ (1), to ‘none (episode) were assessed by thoroughly trained
TORTURE Volume 28, Number 2, 2018 Volume TORTURE of the named possibilities’ (lowest score, psychologists with the help of translators. 61
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To this end, the respective sections of the (PHQ-9), the sum score of the extended Structured Clinical Interview for DSM-IV trauma list of the PDS, and posttraumatic (SCID-I) (Wittchen, Schramm, Zaudig, & symptoms (PDS total symptom score) Unland, 1997) were used. Moreover, the were calculated. Moreover, two t-tests for section for PTSD was complemented by independent samples were conducted, with questions assessing the newly introduced (a) PTSD (SCID-I criteria fulfilled vs. not) criteria for PTSD in the DSM-5 (i.e., and (b) MD (SCID-I criteria fulfilled vs. negative cognitions and mood (American not) as group variables and the sum score of Psychiatric Association, 2013)). the PQ as dependent variable. The variables were tested for inequality of variances using Statistical analyses the Levene test and statistics were adapted SPSS 22.0 was used for all statistical in accordance with the results. To determine analyses and only persons with full data on the ability of the PQ to detect persons the respective questionnaire were included with a PTSD or MD, the percentages of in the corresponding analyses regarding that participants with or without the respective questionnaire, i.e. persons with missing data disorder in each of the three risk categories were excluded from the relevant analyses but of the PQ were determined. not from other analyses. Fourth, to assess diagnostic accuracy, First, the factor structure of the PQ a receiver operating characteristic (ROC) was analyzed using exploratory factor curve was calculated with the PQ as analysis to determine the underlying factor predictor variable and the SCID-I diagnosis structure of the PQ and to have a basis for of PTSD and MD, respectively, as the following analyses. To test the adequacy dependent variable. of the items for factor analysis, the Kaiser- Meyer-Olkin test of sampling adequacy Results and Bartlett’s test of sphericity were Description of the investigated sample applied. A principal axis factor analysis 141 asylum seekers participated in the with promax rotation was conducted that study. They had an average age of 32 years, allows for intercorrelations between factors, and two thirds were men (see Table 1). as intercorrelations are typical for scales The percentage of men precisely mirrors assessing symptoms of mental disorders. the percentage of all new asylum seekers in The scree plot was used to determine the Germany in 2014 and the relatively young number of factors to be extracted. As a age is typical for asylum seekers in Germany measure for the reliability of the PQ total (Bundesamt für Migration und Flüchtlinge, TORTURE Volume 28, Number 2, 2018 score, Cronbach’s ⍺ was determined. 2014). Most participants came from Iran, Second, descriptive analyses of the Afghanistan, Syria, or African countries PQ and calculations of percentages of and had been living in Germany for eight participants in each of the three risk to nine months at the time of the study. To categories of the PQ (low risk for a PTSD, achieve a meaningful sample size, 16 asylum MD, or other trauma-associated mental seekers who had been living in Germany disorder: sum score of 0-3; medium risk: for more than 12 months at the date of the 4-7; high risk: 8-10) were carried out. assessment (up to a maximum of 42 months; Third, Pearson correlations between the their asylum cases were still ongoing) were PQ score and the measure for depression included in the study sample. 62
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128 asylum seekers provided full data (χ²(45) = 335.2; p ≤ .001), showing that the in the PQ (the remainder had missing data) variables were appropriate for factor analysis. and 91 of them took part in the structured The scree plot favored a single-factor solution, clinical interview (SCID-I). The most precluding the need for a rotation strategy. frequent reasons for not taking part in The factor accounted for 39% of the variance the SCID were the person was no longer in the items. Internal consistency can be reachable (n=10), illness (n=8), no time considered as good (Cronbach’s ⍺ = .82). (n=7), no longer interested in the study (n=4), deportation (n=2), or no translator Descriptive data on the PQ available (n=1). The group that did not take The factor analysis showed that the PQ was part in the SCID-I did not differ from the a one-dimensional measure. Therefore, the group that did take part in the SCID-I with use of a sum score as the core descriptive regard to age and symptoms scores in the value seems to be appropriate. The PQ, PDS, or PHQ-9 (all p>.16), but there investigated sample had a sum score of 7.9 were more women in the group that did not (SD = 2.5) on average. Twelve participants take part in the SCID-I than in the group (9.4%) were categorized into the lowest that did take part (64% vs. 31%). category of vulnerability for PTSD, MD, or other trauma-associated disorders, 28 Factor structure and reliability of the PQ (21.9%) were in the medium category, and The items in the present data set yielded a 88 (68.8%) were in the highest category. good Kaiser-Meyer-Olkin value of .85. The Bartlett test for sphericity was significant Relationships with other questionnaires and with diagnoses The PQ showed high correlations with Table 1: Sociodemographic characteristics the PHQ-9 (r(119)=.73; p≤.001), with (n=141) the extended trauma scale of the PDS (r(89)=.53; p ≤ .001), and with the PDS Age (years); mean ± SD 31.9 ±7.8 Min-max (19 - 55) total symptom score (r(106)=.77; p≤.001). Percentage men 67% Participants who fulfilled the SCID-I Highest education criteria for a PTSD had significantly higher No graduation from formal 12.5% sum scores on the PQ (8.9, SD = 1.5) schooling than participants who did not fulfill the Primary school 8.3% criteria (6.9, SD=2.7; t(51.6)=-4.1; p≤.001). Secondary school 14.6% Likewise, participants with MD (according School leaving examination or higher 51.4% Missing information 13.2% to the SCID-I) had higher scores (8.9, SD Born in = 1.4) than participants without MD (6.8, Iran 47.9% SD=2.9; t(42.1)=-3.99; p ≤.001). Afghanistan 16.0% Table 2 shows the descriptive results of Syria 12.5% the percentages of participants who fulfilled Somalia 6.9% the criteria for PTSD (SCID-I) versus Eritrea 5.6% Algeria 2.1% those who did not and their respective risk Other countries/ missing information 9.1% categorization according to the PQ. The PQ Living in Germany for (months) 8.5 ± 7.5 differentiated well between participants with mean ± SD
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high-risk categories, but was only at chance Table 3: Number and percentage with/without level in the medium-risk category major depression according to SCID-1 The results for the differentiation with regard to MD were similar, with good No Major Major differentiation in the low- and high-risk Depression Depression categories but at chance level in the medium Low risk (0-3), 8 0 category (shown in Table 3). n (% of category) (87.5%) (0%)
Diagnostic accuracy Medium risk (4-7), 8 10 n (%) (44.4%) (55.6%) The PQ showed adequate diagnostic accuracy with regard to PTSD (AUC=.74; High risk (8-10), 18 47 SE=.06; p<.001; 95%-CI=.63-.84) and MD n (%) (27.7%) (72.3%)
Table 2: Number and percentage with/without the provision of appropriate care and for PTSD according to SCID-1 adaptations in the asylum-seeking procedure. To this end, a screening instrument, the No Post- Post- PROTECT Questionnaire (PQ), has been traumatic traumatic developed. The current study investigated Stress Stress the reliability, validity, and diagnostic Disorder Disorder accuracy of the PQ. Low risk (0-3), 7 1 The PQ showed a one-factor structure n (% of category) (87.5%) (12.5%) together with a good internal consistency. It correlated strongly with validated (but longer) Medium risk (4-7), 11 7 n (%) (61.1%) (38.9%) questionnaires assessing symptoms of PTSD and MD. Moreover, persons with a diagnosed High risk (8-10), 19 46 PTSD or MD, respectively, had significantly n (%) (29.2%) (70.8%) higher scores on the PQ than persons without the respective disorder, and the PQ showed adequate diagnostic accuracy for a short (AUC=.72; SE=.06; p<.001; 95%-CI=.61- screening instrument. Using the three risk .83) in the present sample. Considering categories, the PQ differentiated well between the higher importance of sensitivity than asylum seekers who fulfilled the respective specificity for a screening instrument for the diagnosis and those who did not in the low- early detection of posttraumatic symptoms, and high-risk categories. Additionally, the cut- TORTURE Volume 28, Number 2, 2018 cut-off scores of 8 (sensitivity was .85 for off criterion for the high-risk category of a sum PTSD and .83 for MD; specificity was .49 score of eight was confirmed by the presented for PTSD and .47 for MD) or 9 (sensitivity analyses. However, the PQ was at chance level was .74 for PTSD and .68 for MD; in the medium-risk category. Those findings specificity was .68 for PTSD and .62 for are in line with the recommendation of the MD) might be regarded as optimal. suggested PROTECT procedure, which is to refer all persons in the medium- and high- Discussion risk categories for a follow up and a more The early detection of signs of mental in-depth examination. That said, even persons disorders in asylum seekers is essential for in the low-risk category might have a mental 64
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disorder, although the probability is lower that is easy to handle and distribute can be than for persons in the other categories. Those administered broadly, leading to a fairly good persons might benefit from re-testing. cost-benefit ratio. Even more importantly, it Whereas pragmatic requirements such as starts addressing mental problems at an early ‘short and simple’ are crucial for screening stage after arrival in the host country, thus tools, psychometric criteria cannot be contributing to the prevention of silencing ignored. In this regard, our findings are in these problems, as happens often in many of accordance with Brewin (2005, p.59), who the cultures where asylum seekers come from. states that “measures with fewer items, As long as there is a lack of available simpler response scales, and simpler methods health professionals to conduct screenings of scoring perform as well if not better than and further evaluations early in the asylum longer measures requiring more complex procedure, investing in mental health rating.” Nevertheless, in order to consider screening of asylum seekers by non-health specific requirements for a screening tool to professionals seems to be the best solution to be administered in the asylum procedure, it improve awareness about the special needs is fruitful to take into account the concerns of asylum seekers. This should eventually regarding cultural sensitivity expressed by result in appropriate consideration of Jakobsen, Thoresen, & Johansen (2011). those needs in the asylum procedure and They investigated the validity of the Harvard care provided. In addition, awareness and Trauma questionnaire (HTQ) and the knowledge about special needs revealed by Hopkins Symptom Checklist-25 (HSCL-25) mental health screenings underlines the need among asylum seekers in Norway and did to foster and support treatment facilities not find acceptable sensitivity and specificity for asylum seekers with mental health care for detecting PTSD. In accounting for needs. These two challenges, i.e., a mental these shortcomings, they emphasized the health screening with potential further influence of differing cultural backgrounds evaluation and appropriate treatment, are on the performance of screening tools. This closely linked to each other. However, the factor was also highlighted by McDonald early documentation of symptoms of mental and Sand (2010), who are in favor of an disorders itself, even independent of an 8-step methodology for developing culturally appropriate treatment, might be of high sensitive assessment tools as suggested by importance for the course of the asylum Miller and colleagues (2006), and exemplified application and procedure, particularly when this by creating the Afghan Symptom claiming mental health concerns at any point Checklist (ASCL). However, it may not be of the administrative or judicial procedure. practicable to conduct such a large scale cross-country study. At the same time, Limitations pragmatic considerations and the available Beside the strengths of the presented study evidence might complement rather than (e.g., the investigation of recently fled contradict each other. The PQ is a shorter asylum seekers from different countries and hence less demanding instrument than and the comparison with validated the HTQ and the HSCL-25 and might questionnaires and diagnoses), there are possibly be less influenced by cultural factors also some shortcomings. The current study and could be much easier to translate and was restricted to persons who spoke Farsi,
TORTURE Volume 28, Number 2, 2018 Volume TORTURE administer to different cultural groups. A tool Arabic, Kurdish, or English. Although these 65
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are the main languages among the current risk doesn’t exclude the possibility of the asylum seekers in Germany, generalizability asylum seeker having suffered traumatic to other languages and other ethnic groups experiences”. Even persons whose sum is nevertheless limited. Similarly, although scores in the PQ are in the low risk category the lower percentage of women in the may benefit from a retest after a month investigated sample is in line with the and a short psychoeducation about possible available data on sex percentages in asylum counseling services and contact addresses. seekers in Germany, this may reduce the Future studies should further investigate the ability to transfer the findings to women. diagnostic accuracy of the PQ as well as its validity in other ethnic and language groups. Conclusion The presented results support the use of References the PQ as a reliable and valid instrument American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, Fifth for the early identification of posttraumatic Edition (DSM-5®). symptoms in asylum seekers from the Brewin, C. R. (2005). Systematic review of screening main countries of origin at the time of the instruments for adults at risk of PTSD. Journal study. They underline the use of the PQ in of Traumatic Stress, 18(1), 53-62. https://doi. org/10.1002/jts.20007 the first step of the three-step procedure Bundesamt für Migration und Flüchtlinge (2014). suggested by the PROTECT project, i.e. Migrationsbericht des Bundesamtes für for the detection of signs and symptoms of Migration und Flüchtlinge im Auftrag der typical mental health-related sequelae of Bundesregierung [Migration Report of the Federal Office for Migration and Refugees severe violence and the categorization into on behalf of the Federal Government] risk categories. However, persons working (Migrationsbericht 2014). with the PQ should be aware that it, like Cameron, H. E. (2010). Refugee Status every screening instrument, only gives a Determinations and the Limits of Memory. International Journal of Refugee Law, 22, 469-511. first impression of symptoms and a first https://doi.org/10.1093/ijrl/eeq041 evaluation of the risk of suffering from Chou, F. H., Su, T. T., Ou-Yang, W. C., Chien, I. C., depression and/or PTSD. The PQ does Lu, M. K., & Chou, P. (2003). Establishment of not replace normal diagnostic work, but a disaster-related psychological screening test. Aust N Z J Psychiatry, 37(1), 97-103. contributes to finding those asylum seekers European Asylum Support Office (EASO) (2015). who have psychological symptoms and who EASO Practical Guide: Evidence Assessment. do not mention their symptoms without European Asylum Support Office (EASO) (2016). EASO tool for identification of persons with prompting. In case of a high or medium special needs. score, those persons need to be examined European Union (2013). Directive 2013/32/ TORTURE Volume 28, Number 2, 2018 more thoroughly. This clarification is even EU and Directive 2013/33/EU of the more important with regard to the legal European Parliament and the Council of 26 June 2013. Official Journal of the European context in which screening results could Union, 29.6.2013 (L 180/60). https://doi. be communicated. Although the PQ seems org/10.3000/19770677.L_2013.180.eng to be successful in identifying affected European Union Agency for Fundamental Rights persons, false-negative cases are possible. (FRA) (2016). FRA Opinion on fundamental rights in the ‘hotspots’ set up in Greece and Misunderstanding the result of the PQ as Italy, 2016, 5. a diagnosis could particularly cause harm Foa, E. (1995). Posttraumatic Stress Diagnostic Scale for those individuals. Thus, the front page Manual. United States of America: National of the PQ contains the comment “A low Computer Systems Inc. 66
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Fullerton, C. S., Ursano, R. J., Epstein, R. S., Knaevelsrud, C., & Müller, J. (2008). MultiCASI Crowley, B., Vance, K. L., Craig, K. J., & Baum, (Multilingual Computer Assisted Self Interview). A. (2000). Measurement of posttraumatic Berlin: Springer. stress disorder in community samples. Nordic Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). Journal of Psychiatry, 54(1), 5-12. https://doi. The PHQ-9: validity of a brief depression org/10.1080/080394800427519 severity measure. J Gen Intern Med, 16(9), Gäbel, U., Ruf, M., Schauer, M., Odenwald, 606-613. https://doi.org/10.1046/j.1525- M., & Neuner, F. (2006). Prävalenz der 1497.2001.016009606.x Posttraumatischen Belastungsstörung Kroenke, K., Spitzer, R. L., Williams, J. B., & Lowe, (PTSD) und Möglichkeiten der Ermittlung B. (2010). The Patient Health Questionnaire in der Asylverfahrenspraxis. [Prevalence of Somatic, Anxiety, and Depressive Symptom posttraumatic stress disorder among asylum Scales: a systematic review. Gen Hosp Psychiatry, seekers in Germany and its detection in the 32(4), 345-359. https://doi.org/10.1016/j. application process for asylum] Zeitschrift für genhosppsych.2010.03.006 Klinische Psychologie und Psychotherapie, 35(1), 12- Laban, C. J., Gernaat, H. B., Komproe, I. H., 20. https://doi.org/10.1026/1616-3443.35.1.12 Schreuders, B. A., & De Jong, J. T. (2004). Heeren, M., Wittmann, L., Ehlert, U., Schnyder, U., Impact of a long asylum procedure on the Maier, T., & Muller, J. (2014). Psychopathology prevalence of psychiatric disorders in Iraqi and resident status - comparing asylum seekers, asylum seekers in The Netherlands. J Nerv refugees, illegal migrants, labor migrants, Ment Dis, 192(12), 843-851. https://doi. and residents. Comprehensive Psychiatry, org/10.1097/01.nmd.0000146739.26187.15 55(4), 818-825. https://doi.org/10.1016/j. Löwe, B., Grafe, K., Zipfel, S., Witte, S., Loerch, comppsych.2014.02.003 B., & Herzog, W. (2004). Diagnosing ICD- Herlihy, J., Jobson, L., & Turner, S. (2012). Just tell 10 depressive episodes: superior criterion us what happened to you: Autobiographical validity of the Patient Health Questionnaire. memory and seeking asylum. Applied Cognitive Psychother Psychosom, 73(6), 386-390. https://doi. Psychology, 26(5), 661-676. https://doi. org/10.1159/000080384 org/10.1002/acp.2852 Lowe, B., Spitzer, R. L., Grafe, K., Kroenke, K., Hollifield, M., Toolson, E. C., Verbillis-Kolp, S., Quenter, A., Zipfel, S., Buchholz, C., Witte, S., Farmer, B., Yamazaki, J., Woldehaimanot, T., Herzog, W. (2004). Comparative validity of three & Holland, A. (2016). Effective Screening screening questionnaires for DSM-IV depressive for Emotional Distress in Refugees: The disorders and physicians’ diagnoses. J Affect Refugee Health Screener. J Nerv Ment Dis, Disord, 78(2), 131-140. https://doi.org/10.1016/ 204(4), 247-253. https://doi.org/10.1097/ S0165-0327(02)00237-9 NMD.0000000000000469 McDonald, T. W., & Sand, J. N. (2010). Post- Hollifield, M., Verbillis-Kolp, S., Farmer, B., Toolson, Traumatic Stress Disorder in Refugee Communities: E. C., Woldehaimanot, T., Yamazaki, J., SooHoo, The Importance of Culturally Sensitive Screening, J. (2013). The Refugee Health Screener-15 Diagnosis, and Treatment. New York: Nova Science (RHS-15): development and validation of Publishers. an instrument for anxiety, depression, and MSF (Medecins sans Frontieres( (2017). A Dramatic PTSD in refugees. Gen Hosp Psychiatry, Detoriation for Asylum Seekers on Lesbos. 35(2), 202-209. https://doi.org/10.1016/j. Meltzer-Brody, S., Churchill, E., & Davidson, J. genhosppsych.2012.12.002 R. (1999). Derivation of the SPAN, a brief Ikram, U., & Stronks, K. (2016). Preserving and diagnostic screening test for post-traumatic stress Improving the Mental Health of Refugees and disorder. Psychiatry Res, 88(1), 63-70. https://doi. Asylum Seekers. Den Haag: bijlage bij Briefadvies org/10.1016/S0165-1781(99)00070-0 Geestelijke gezondheid van vluchtelingen [The Memon, A. (2012). Credibility of Asylum Claims: Hague, attachment with Advisory letter mental Consistency and Accuracy of Autobiographical health of refugees]. Memory Reports Following Trauma. Applied Jakobsen, M., Thoresen, S., & Johansen, L. (2011). Cognitive Psychology, 26, 677-679. https://doi. The Validity of Screening for Post-traumatic org/10.1002/acp.2868 Stress Disorder an Other Mental Health Problems Miller, K. E., Omidian, P., Quraishy, A. S., Quraishy, among Asylum Seekers from Different Countries. N., Nasiry, M. N., Nasiry, S., Yaqubi, A. Journal of Refugee Studies, 24(1), 171-186. https:// A. (2006). The Afghan symptom checklist: doi.org/10.1093/jrs/feq053 a culturally grounded approach to mental TORTURE Volume 28, Number 2, 2018 Volume TORTURE 67
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health assessment in a conflict zone. Am J 188, 58-64. https://doi.org/10.1192/bjp. Orthopsychiatry, 76(4), 423-433. https://doi. bp.104.007864 org/10.1037/0002-9432.76.4.423 Van de Vijver, F.J.R., & Hambleton, R. K. (1996). Mollica, R. F., Caspi-Yavin, Y., Bollini, P., Truong, Translating Tests - Some Practical Guidelines. T., Tor, S., & Lavelle, J. (1992). The Harvard European Psychologist, 1(2), 89-99. https://doi. Trauma Questionnaire. Validating a cross- org/10.1027/1016-9040.1.2.89 cultural instrument for measuring torture, Wittchen, H. U., Schramm, E., Zaudig, M., & trauma, and posttraumatic stress disorder Unland, H. (1997). SKID. Stukturiertes klinisches in Indochinese refugees. J Nerv Ment Dis, Interview für DSM-IV, Achse I, deutsche Version. 180(2), 111-116. [Structured clinical interview for DSM-IV, German Norris, A. E., & Aroian, K. J. (2008). Assessing Version]. Göttingen: Hogrefe. reliability and validity of the Arabic language version of the Post-traumatic Diagnostic Scale (PDS) symptom items. Psychiatry Res, 160(3), 327-334. https://doi.org/10.1016/j. psychres.2007.09.005 Prins, A., Ouimette, P., Kimerling, R., Cameron, R. P., Hugelshofer, D., S., Shaw-Hegwer, J., Thrailkill, A., Gusman, F.D., Sheikh, J. I. (2003). The Primary Care PTSD Screen (PC-PTSD): Development and operating characteristics. Primary Care Psychiatry, 9, 9-14. https://doi. org/10.1185/135525703125002360 PROTECT. (2012). Project Report. Process of Recognition and Orientation of Torture Victims in European Countries to Facilitate Care and Treatment. Rogers, H., Fox, S., & Herlihy, J. (2014). The importance of looking credible: the impact of the behaviourial sequelea of post-traumatic stress disorder on the credibility of asylum seekers. Psychology, Crime & Law, (21(2), 139-155. doi.or g/10.1080/1068316X.2014.951643 Rohlof, H. G., Knipscheer, J. W., & Kleber, R. J. (2014). Somatization in refugees: a review. Soc Psychiatry Psychiatr Epidemiol, 49(11), 1793-1804. DOI 10.1007/s00127-014-0877-1 Silove, D., Sinnerbrink, I., Field, A., Manicavasagar, V., & Steel, Z. (1997). Anxiety, depression and PTSD in asylum-seekers: assocations with pre- migration trauma and post-migration stressors. Br J Psychiatry, 170, 351-357. https://doi. org/10.1192/bjp.170.4.351 TORTURE Volume 28, Number 2, 2018 Steel, Z., Chey, T., Silove, D., Marnane, C., Bryant, R. A., & van Ommeren, M. (2009). Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysis. JAMA, 302(5), 537-549. https://doi.org/10.1001/ jama.2009.1132 Steel, Z., Silove, D., Brooks, R., Momartin, S., Alzuhairi, B., & Susljik, I. (2006). Impact of immigration detention and temporary protection on the mental health of refugees. Br J Psychiatry, 68
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“My mind is not like before”: Psychosocial rehabilitation of victims of torture in Athens
Gail Womersley,*, Laure Kloetzer,*, Rafael Van den Bergh,**, Emilie Venables,**, ***, Nathalie Severy,**, Nikos Gkionakis,****, Christina Popontopoulou,*****, Manolis Kokkiniotis,*****, Federica Zamatto,**
experienced during and after migration. Key points of interest: Method: To present three case studies to •• Torture and forced migration explore culturally-informed perspectives on represent two significant trauma among victims of torture and track interrelated sources of trauma. trajectories of psychosocial rehabilitation •• This study highlights the in relation to environmental factors. The significant impact of the case studies are part of a larger qualitative political, legal, and sociocultural study of asylum seekers and refugees in environment on processes of a center for victims of torture in Athens, psychosocial rehabilitation. managed by Médecins Sans Frontières and Babel in collaboration with Greek Council Abstract for Refugees, which follows beneficiaries, Introduction: The dual trauma of being their care providers and community a victim of torture as well as a refugee is representatives and leaders. Results: Key related to a myriad of losses, human rights themes emerging include the substantial violations and other dimensions of suffering psychological impact of current material linked to torture experienced pre-migration, realities of migrant victims of torture as well as different forms of violence as they adapt to their new environment and engage in rehabilitation. Delayed asylum trials, poor living conditions and * Institute of Psychology and Education, University unemployment have a substantial impact of Neuchatel, Switzerland on posttraumatic symptoms that in turn ** Médecins Sans Frontières - Operational Centre influence psychosocial rehabilitation. Brussels *** Division of Social and Behavioural Sciences, Personal, social, and cultural resources School of Public Health and Family Medicine, emerged as having a mediating effect. University of Cape Town, South Africa Discussion: The results highlight **** Babel Mental Health Day Care Centre, the significant impact of the political, Athens, Greece ***** Médecins Sans Frontières - Operational legal, and sociocultural environment on Centre Brussels, Centre for Victims of Torture psychosocial rehabilitation. Practical and ill-treatment, Athens, Greece implications for interventions are to ensure
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holistic, interdisciplinary, and culturally political one. These far-reaching effects may sensitive care which includes a focus on interact and manifest in complex and diverse environmental factors affecting resilience; ways, mediated by culture, gender and other and with a dynamic focus on the totality of aspects of the context of the torture survivor, the individual over isolated pathologies. the context of torture and the context of the recovery environment (Patel, Kellezi, & Keywords: Torture, rehabilitation, Williams, 2014). Furthermore, environmental environmental impact, trauma, post- stressors associated with exile, resettlement, traumatic stress disorder and acculturation continue to further threaten individual health and well-being Introduction among refugee VoTs. Post-migration factors The mental health impact of atrocities are a fundamental consideration in light endured by refugees1 is clear, with a of the additional critical life events which high prevalence of post-traumatic stress refugees face, and which have clearly emerged disorder (PTSD) reported among this in the literature as exacerbating post- population. Torture has emerged as a traumatic reactions (Hollander et al., 2016; particular triggering factor (Haenel, 2015; Schock, Böttche, Rosner, Wenk-Ansohn, Hodges-Wu & Zajicek-Farber, 2017; Silove, & Knaevelsrud, 2016; Song, Kaplan, Tol, Ventevogel, & Rees, 2017; Song, Subica, Subica, & de Jong, 2015; ter Heide, Mooren, Kaplan, Tol, & de Jong, 2017). This is no & Kleber, 2016). Yet, despite this growing surprise, given the multiplicity of challenges body of critical literature, there has been to which refugee Victims of Torture (VoTs) relatively little research regarding how current are exposed. The dual trauma inherent in environmental factors and resettlement being both a VoT as well as a refugee is variables affect the psychosocial rehabilitation related to a myriad of losses, human rights of VoTs (Hodges-Wu & Zajicek-Farber, 2017; violations and other dimensions of suffering Whitsett & Sherman, 2017). linked not only to torture experienced pre- It must be noted that criticism has migration, but trauma experienced during been levelled against the use of PTSD as and post-migration as well (Hodges-Wu & a diagnosis within this context. Navarro- Zajicek-Farber, 2017). Trauma does not Lashayas and colleagues (2016) highlight stop at the border. the risk of medicalising a socio-political Torture itself represents an extraordinary problem and individualising social suffering. exception in the psychopathology field. The This oversimplification of the complexity act itself is taught, organised, elaborated, and of human suffering serves to depersonalise TORTURE Volume 28, Number 2, 2018 perpetrated by humans against other humans, and victimise the individual (Kotsioni, disrupting our connections to all that make 2016). Torture is not a disease. In terms of us human (Sironi, 1999; Viñar, 2005). It clinical approaches, Papadopoulos (2007) is not an individual act, but a social and underlines that psychological reactions to adversity vary enormously from individual to individual. His framework suggests that even psychological phenomena such as a post- 1 Here, we use the term “refugee” as defined by traumatic response do not occur in social the Geneva Convention of 1951 to include both isolation; the wider community and cultural refugees legally recognised in a host country as well as asylum-seekers. contexts matter a great deal as they are 74
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active in forming at least part of the meaning sanctuary. While the country is still gripped systems, and consequently the rehabilitation, by one of the worst financial and societal of each individual. crises of the past 40 years, little attention These theoretical frameworks take or funding is available to provide mental into account the fact that humans are health and psychosocial support to refugees essentially social beings, and that, equally, (Gkionakis, 2016). According to recent symptom severity is not static but fluid and statistics provided for March 2018 by the changing due to a wide range of interacting UNHCR,2 over 50,000 asylum seekers intrapsychic and external factors. There is and refugees currently remain in Greece, thus a need to explore trauma ‘in context’— following the 2015-2016 mass flow. This notably through exploring processes of population is legally entitled to free access psychosocial rehabilitation of victims of to medical care, yet the ability of the torture within the specific historical, cultural, Greek health system to provide adequate social, and political context of the “reception health care to refugees upon entry is crisis” in Europe. This is important not only severely stretched as a result of the ongoing in order to challenge the concept of PTSD, economic crisis, resulting in numerous but also to provide more appropriate mental barriers to access (MDM, 2016). These health care to VoTs with a consideration challenges are even more pronounced for for both cultural factors as well as the migrants faced with a lack of information impact of current environmental stressors and linguistic and cultural barriers to on the process of rehabilitation. Therefore, accessing an unfamiliar system. Often living in order to i) explore culturally-informed in harsh and isolating conditions, a 2017 perspectives on trauma among VoTs from an report by UNHCR3 estimates that many individual, qualitative perspective and ii) track migrants will wait for over two years to find trajectories of psychosocial rehabilitation in out about their asylum status. relation to environmental factors, we present There are few reliable statistics concerning a case series from the results of 12 months of the number of VoTs currently in Greece research among asylum seekers and refugees (European Union Agency for Fundamental in a center for victims of torture in Athens, Rights, 2017; MSF, 2016; UNHCR, 2017). managed by Médecins Sans Frontières The UNHCR has estimated that among (MSF) and Babel (a mental health unit for refugee populations, between 5 and 35 migrants and refugees operating in Athens percent are torture survivors, yet highlights since 2007) in collaboration with the Greek that the actions that are needed to identify Council for Refugees (GCR). and support and enable them to claim their rights are too often ignored or purposely Methodology excluded (UNHCR, 2017). In Greece, few The study design involved in-depth rehabilitation or identification services are interviews with three VoTs and their care providers over the course of a year.
Study setting 2 https://reliefweb.int/sites/reliefweb.int/files/re- Victims of torture in Athens, Greece: As the sources/62950.pdf 3 “reception crisis” continues unabated, http://www.unhcr.org/publications/ operations/58d8e8e64/unhcr-recommendations-
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provided to survivors of torture by a state inflicted for such purposes as obtaining structure or sustainably by NGOs apart from information or a confession, exerting one organisation, Metadrasi, who certified pressure, intimidation or humiliation) and 650 VoTs from 2017-2018.4 Most efforts operates as an interdisciplinary team of identification appear to be ad-hoc or applying a holistic approach to the dependent on some form of self-identification. rehabilitation of torture survivors. This complex asylum system, the poor identification of VoTs and the many barriers Study population in accessing basic services in Athens and This case series is a part of a larger qualitative across the country have had a substantial, study conducted by the first author over adverse impact on mental health (Kotsioni, the period of a year in the MSF clinic in 2016). It has also lead to health professionals collaboration with Babel, with supervision under pressure “medicalising” the and assistance by the other authors. Ten psychological suffering (for example, through individual VoTs, collectively identified by the use of a certified PTSD diagnosis) as the health professional team were followed part of the identification process (FRA, over this period, with an average of five in- 2017), as has been noted elsewhere in Europe depth interviews being conducted with each (d’Halluin, 2016; Fassin & d’Halluin, 2005). participant. All ten had been beneficiaries of the clinic for over six months and had MSF and Babel clinic for rehabilitation of victims found accommodation in Athens, not in the of torture and other forms of ill-treatment: In refugee camps. For this case series, three VoT April 2013, the GCR jointly with Babel Day participants out of the ten were selected as Centre and Dignity (the Danish Institute representative cases to explore the impact of Against Torture) started the implementation the environmental, legal, and cultural context of the Prometheus project, funded by the EU. on psychosocial rehabilitation of torture. Prometheus project’s main goal was to deliver identification and rehabilitation to VoTs Ethics through health and mental health service All study participants were informed of provision, as well as legal and social support. the purpose of the research, and provided In September 2014, MSF joined this written consent for the interviews to be partnership. Since 2014, MSF, Babel and taken and their information to be used. GCR have established a unit delivering Consent was given for care providers to be medical care, legal support, mental health interviewed by the individual beneficiaries care and social support to VoTs, training and of the project. The study was approved by TORTURE Volume 28, Number 2, 2018 supervision to the staff of this unit and the ethics committee of the University of training and consultation to other actors who Neuchatel, the Ethics Review Board of MSF work with VoTs. The unit adopts the IFRC and the scientific review committee of Babel. definition of torture and ill-treatment (where torture is defined as consisting of severe pain Results or suffering, whether physical or mental, Key themes emerging across interviews with the three selected participants included the substantial psychological impact of current material realities of migrant VoTs 4 http://metadrasi.org/en/campaigns/certification- of-torture-victims/ as they adapt to their new environment 76
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and engage in a process of psychosocial origin, often for months at a time, due to rehabilitation. The periods before and after his involvement as a political activist. He being granted asylum were identified as managed to escape from prison with the two distinct phases in the psychological help of an uncle, and arrived, alone, in lives of these individuals, each with specific Athens to seek asylum where he was referred stressors. Delayed asylum trials, poor living to the MSF/Babel centre. conditions and unemployment emerged Over the course of the four interviews, as having a substantial impact on post- he described the various methods of torture traumatic symptoms that in turn influenced to which he was subjected, in minute detail, psychosocial rehabilitation. Personal, social, including sexual abuse, his legs being and cultural resources similarly emerged as “ripped apart”, the meta-tarsals in his feet having a mediating effect on the stressors being broken, as well as electrification: identified above. "They give me the scars on my soul…lots of The first case presented, that of D, things from my mind has been wasted." focuses on the influence of environmental For the first four months after his arrival, context (including, for example, current he was living alone in a 30 meter-squared political, material and economic conditions). hotel room in an old building recently The second case, that of J, focuses on the remodelled to house asylum seekers. During legal context and the third case, that of B, this time, he explained: focuses on the cultural context. "I don’t have any friends here, I don’t have any relatives, I don’t have any family The case of D members, I don’t even know any [religion D is a 30-year-old asylum seeker and VoT. removed] community here. I know that there In 2007, he was arrested and tortured are a lot of [religion removed] people living on numerous occasions in his country of here, my new community is here, not ‘my’
Figure 1: Timeline of the key elements in the pre-migration and post-migration life of D, emphasising the influence of environmental context. TORTURE Volume 28, Number 2, 2018 Volume TORTURE 77
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community… when I am staying at a hotel, to be homeless. The voices also told him whenever somebody is knocking at the door, that “they” would not believe him, that I feel scared… I never go out" “they” would send him back to his home The physical, social, and cultural country. Given his current living conditions isolation served merely to exacerbate his in Athens, these fears were not without post-traumatic symptoms: a vicious cycle reasonable grounds. of feeling scared and alone, alone and He was hospitalised as a result of these scared. Furthermore, the disconnection hallucinations in a psychiatric ward of a cannot be considered as a “one-off” general hospital. He perceived this repeated event, which occurred at a particular institutionalisation as a further enforced moment: disruptions continued with each period of detention where he was subjected phone call bringing news from his home to bodily treatments against his will. It country and every day spent alone in a appeared to have triggered memories of the hotel room. D was given an appointment past torture he endured. He described the for his asylum interview. However, hospital as having a prison-like atmosphere. the administrator responsible was not The hospital staff promised that they present on the day and the procedure would not give him injections, which they was delayed. This contributed to further subsequently did. This deepened his sense disconnections in visibility, representation of mistrust, paranoia and isolation—further and the acknowledgement of the torture exacerbating symptoms. Furthermore, which he had endured. The uncertainty, during this period he received news that his and sense of being “stuck” also mother was in prison, and suffering from appeared to have impeded his process of severe medical complications. There was no psychosocial rehabilitation: clear news about his father. With each phone "I know only one thing, that my world is call from his country of origin, psychotic just only this room… I’m just killing my symptoms worsened. time here until I’m not getting my papers or One caregiver noted the impact of his they are not going to take my interview" current reality on the process of diagnosis: Due to financial reasons, he was forced "I could see the face of the psychiatrist who to move out of his small hotel room into at first said, ‘You think the secret services of shared accommodation. He accused his [country removed] are after you?’ I could see roommate of spying on him, a roommate the paranoia. Then he said his story. There who incidentally came from a neighbouring he goes, “Oh, oh, oh, oh.” [laughter] This is country that D suspected of having political not paranoia. This is real life." TORTURE Volume 28, Number 2, 2018 ties with his own. Psychotic symptoms The phrase “this is real life” is indeed started to emerge, including auditory telling: D’s “real life”—characterised by hallucinations and symptoms of paranoia. poor living conditions, social isolation, and Many of the voices were those of authority delayed asylum trials, played a key role figures, including the torturers in his in his mental health. His case highlights country of origin and, tellingly, police the role of “feedback loops" (Kirmayer & officers, bureaucrats and judges in the Ramstead, 2017)—vicious cycles wherein asylum procedure in Greece. He reported symptoms were exacerbated by “real life” experiencing auditory hallucinations, events and which played a key role in his with voices claiming that he was going psychosocial rehabilitation. 78
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The case of J His mental health, did, however start J is a 45-year-old African man, unmarried to improve with a multi-disciplinary and the father of one nine-year-old son. He intervention. A few weeks later, he was arrested and tortured after engaging confirmed that: in anti-government protests. After arriving "I was traumatised before, I had too much in Athens in December 2015, he was fear, but the social worker did everything referred to MSF/Babel for serious medical to calm me […] the psychologist is also a complications as a result of the torture person that you can tell everything to: social, he suffered, and was seen by a doctor, emotional, everything…" physiotherapist, lawyer, social worker and During his first asylum interview, he had psychologist. to speak about the torture he endured, When first interviewed, J described his an event that he described as having situation as the following: “retraumatised” him: "We are human beings, but I am an adult "It’s a story that hurts you and causes a without a wife, without a child. My life lot of emotions […] the pain that I felt that is bloody ruined, everyone is in the same day, that could be at 10%, if the pain has hole, who can change it? Nobody. Nobody passed, but if you have to repeat the story, cares about us… [these problems] devour you feel it at 100% […] it hurts you to have us. If I was well, you could see that I was to tell your story, yes it hurts. Even during well, but I’m sick, I’m not in good health. the interview, it hurts you." I’m physically fine, but in my interior— Despite his testimony, and having medical I’m not at all okay […] I’m with the certification attesting to the physical injuries others but not in spirit"5 resulting from the torture, his request for asylum was denied. J, however, refused to accept this: "I refused. I said “no, this can’t be 5 Loose translation from the original interview happening, I have all the proof to show…I conducted in French.
Figure 2: Timeline of the key elements in the pre-migration and post-migration life of J, emphasising the influence of the legal context. TORTURE Volume 28, Number 2, 2018 Volume TORTURE 79
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can talk, I can lie, but the proof doesn’t psychosocial rehabilitation and, simply, lie, the echocardiogram proves everything.” time. His case exemplifies the impact of the I was really affected. I had a fever […] legal context on mental health. It highlights yes I was emotional, I was alone with the the necessity of a multi-disciplinary interpreter and the three judges and the approach to psychosocial rehabilitation, lawyer. It’s tough. Man, man has no pity for including a team of social workers, lawyers, man, no pity. Oh it’s tough! To be a migrant psychologists, doctors, cultural mediators, is tough, to re-enter into a normal life is and psychiatrists. If one element of these tough […] during the asylum interview, my is lacking, it may slow down or inhibit the head heated up. All of the calculations that activities of the others. I’d had, none of them worked out. I thought that, with this news, they won’t give me The case of B a house, it’s difficult to eat, in these really B is a 35-year-old African woman, mother bizarre conditions." of four children and a victim of torture As was the case for D, the fact that his story and of forced circumcision. Upon arriving was not believed appeared to have the most in Greece, she presented frequently to the significant impact on him. Furthermore, emergency services with multiple physical he equated being an asylum seeker as complaints, which were diagnosed as living in “bizarre conditions” of permanent psychosomatic. She was similarly diagnosed temporariness. He described feeling mocked, with PTSD and referred to MSF/Babel for teased, humiliated and ill-treated by mental health care. bureaucrats throughout the asylum process. When asked about her experience Despite his request for asylum being denied, of trauma during our first interview, B Mr J requested an appeal and continued his explained that: process of psychosocial rehabilitation. When "I have a fear of everything, a fear of life, interviewed after submitting the appeal, he in fact, because me, I always say, “if you stated that: don’t take decisions, I wouldn’t have left "There have been some big changes because my country” and that fear of ‘that practice’ when you cry a lot, there’s a moment where [of torture] also evoked fear in me. I left you stop crying. You see the reality in front my children behind me—what will happen of you. I have already suffered a lot from to them? How are they over there? How thinking, thinking. I must think until where do they live? How are they eating? How and until when? Must I spend my whole life are they sleeping? This fear has developed
crying? […] Since being here, the pain has in me and it’s tiring. I even told my TORTURE Volume 28, Number 2, 2018 changed […] The essential is that I’m in psychologist that I have this fear that I good health. I’m alive. It’s not the end of the don’t know how to explain, this fear that I world. Life continues." want to leave me…" He suggested that his improvement in She related her experience of fear to both mental health was related to a variety of the isolated incident of torture she endured, factors: the resilient spirit that his father as well as to multiple other factors, including had instilled in him as a young boy, the having been forced to leave her children, as assistance of a community in Athens well as her uncertain future. She felt unable from his country of origin, the holistic to return to her country, but also unable and multidisciplinary approach of his to engage in a process of rehabilitation for 80
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Figure 3: Timeline of the key elements in the pre-migration and post-migration life of B, emphasising the influence of the cultural context.
the future. No one single incident could B was confronted with two varying, and account for this unexplainable fear. Thus culturally informed, ways of understanding paralyzed, she remained isolated from her post-traumatic symptomatology. For others, barely leaving her apartment except her, the nightmares she experienced may for the occasional visit to the clinic to see be explained “spiritually”—in other words, her psychologist. based on the spiritual and cultural belief A few months later, she explained: systems of her home community. Within "The psychologist told me that the this belief system, the nightmares are not nightmares are linked to the past, because I perceived to be directly linked to the torture told him that I’m being chased. He told me she experienced, but to witchcraft: the family that it’s linked to the past, that’s it." has cursed her for leaving. She appeared to I told him that it’s spiritual, but afterwards, examine these two possible explanations. when he spoke, I told myself that “I don’t Her words, “I don’t know but it’s also know” but it’s also possible that it’s linked possible” reflected her ambivalence towards to what I’m thinking in my head. It’s also the meaning behind the nightmares: that. Because I leave what’s in my head. "Because maybe, in my head, I am If I remove what’s in my head, it can sort guilty, it’s true….but Christ has already itself out. Apparently, when you have forgiven me. That’s also the problem […] dreams where people are chasing you, spiritually, it’s complex. What I see, I explain we, we say that it’s witchcraft. Among the spiritually with the hand of witchcraft. Africans, we say that it’s witchcraft. But It means that the family isn’t leaving me he, he explained to me that … for example, in peace. Spiritually, they are following I had a dream the night before last. I me, they followed me two nights ago until remember two dreams. Where they chained I was scared. I don’t know, there are me up, he said that it’s linked to my past two explanations. Apparently there is an and that it’s me myself who is chaining explanation that’s different to what I think
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take. I don’t know…but I told myself that connections possibly reflect both the cause maybe that one’s right as well." and consequence of the improvement in The spiritual resources she drew on to her mental health; a positive feedback loop understand the meaning of the nightmares wherein connection to others decreases the are linked not only to African traditional post-traumatic symptoms and this decrease spirituality involved in witchcraft, but to in symptoms allows for an increase in ability Christian beliefs. She herself highlighted the to connect socially. complexity of this. On a symbolic level, the fact that she believed Christ to have forgiven Discussion her appears to have had a significant impact The cases above attest to the significant on her levels of guilt and other associated impact of the environmental, legal, and forms of emotional distress. She further sociocultural context on processes of explained that apart from going to see her psychosocial rehabilitation among refugee psychologist, the other person to whom she VoTs. This includes the broader socio- was able to share her experiences of trauma economic framework in host countries and was her priest. the ways in which these frameworks may A few months later, she described a hinder or facilitate rehabilitation. Daily dramatic decrease in her symptoms— stressors represent proximal, ongoing and both physical and psychological. There often chronic threats to psychological was similarly an increase in her social wellbeing. Due to this chronicity, these connections to others: daily stressors may gradually erode coping "I was speaking with the psychologist. resources and tax mental health—creating Speaking really helped me a lot. I don’t conditions for feelings of powerless and have nightmares any more. Because of helplessness linked to a real or perceived speaking with him, because of his advice, loss of control over the environment (Miller I would say that things are going all right. & Rasmussen, 2017). This echoes the And there are many changes, because of plethora of research already conducted on speaking with him, I smile, I’m not too mental health of refugees indicating the stressed like before. There are many changes adverse effects of post-migration stressors that I see in myself." (Chen, Hall, Ling, & Renzaho, 2017). As What’s interesting to note is the key for many other VoTs across the world, involvement of social relations in her the process of seeking asylum itself was a rehabilitation process. The decrease in seemingly retraumatising experience for symptoms was attributed to “speaking” the participants on many levels. Firstly, it TORTURE Volume 28, Number 2, 2018 which “really helped me a lot.” Another could be argued that the perception of ill- integral part of her rehabilitation has been treatment at the hands of an indifferent yet the connection to others. Being able to powerful state apparatus may be reminiscent speak not only to the psychologist, but to of the torture conditions to which they her roommates, was part of the process were subjected in their country of origin. of rehabilitation as well as a potential Secondly, the very experience itself of having indicator of its success—she framed the to recount the horror of the experience social connection as both something which of torture in an asylum tribunal may be helped her to forget, as well as an indicator equally traumatising (Schock, Rosner, & of change in herself. As such, the social Knaevelsrud, 2015). 82
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All three people in the cases highlighted migration environment, interdisciplinary above were diagnosed with PTSD, yet the approaches to care and quality cultural diagnosis did not appear to be particularly mediation. Interventions should become the relevant to their lives, or the way in which mirror in which the individual will be able they made sense of their psychological to relink the shattered pieces of him/herself suffering. None referred to the diagnosis into a totality. This requires a strong team spontaneously during the multiple interviews of experienced professionals, teamwork of conducted over a 12 month period. Their an inter-disciplinary nature, and stability at main concerns appeared to be focused on an organisational level (Kotsioni, 2016) for the present conditions in which they found an integrated system of care for VoTs which themselves, characterised by numerous provides a coordinated, compassionate, environmental stressors and an uncertain and comprehensive support (Kira, 2010). future. There did not seem to be anything For the above aim to be achieved, it is “post” about the “P” of PTSD. This echoes important that the interventions planned the conclusions of Patel and colleagues and implemented take into consideration (2014) that “problems of torture survivors the environmental factors and the broader need to be defined far more broadly than by socio-economic and political system of PTSD symptoms, and recognition given to the reception countries. The needs of the contextual influences of being a torture this population are varied and complex, survivor, including as an asylum seeker or necessarily demanding a multidisciplinary refugee, on psychological and social health” approach to intervention which may be (p. 2). In contrast to the seeming irrelevance beyond the current capacity of the national of the formal diagnosis of PTSD, the health service at present. relationship with the multidisciplinary team VoTs may experience a disconnection was noted by all of the participants as being from their body, their emotions and their an integral part of their rehabilitation. What identity and need to regain trust in other appears to have had the most impact was human beings, society and themselves. This being seen as an individual human being, is a complex process in which professionals and being treated with dignity. need to be able to acknowledge the individual not as a patient, but a totality. It is vital that Conclusion the professionals do not limit themselves The research findings highlight the need for to a diagnosis and treatment of symptoms psychosocial interventions to incorporate but rather focus on how to empower the a more contextualised understanding of individual to regain control. Conceptualising trauma as being largely determined by the mental health of refugees requires the larger cultural systems and socio-political recognition of the role of both pre-migration contexts. It also highlights the importance of trauma and post-migration stressors and seeing the strengths and resilience of most that psychological distress can manifest in refugees and their potential contributions various ways. As stated by Viñar (2005), to host societies (Bäärnhielm, 2016). we cannot listen to a tortured man and see Psychosocial rehabilitation of torture an understanding of his person unless we survivors, particularly refugees, needs to dare to take a little interest in the oppressive reflect this complex reality. Focus should be order that destroyed him; not only to seal his
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References cultures. Traumatology, 16(4), 128. https://doi. Bäärnhielm, S. (2016). Refugees’ mental health-a org/10.1177/1534765610365914 call for a public health approach with focus Kirmayer, L., & Ramstead, M. J. (2017). Embodi- on resilience and cultural sensitivity. European ment and Enactment in Cultural Psychiatry. In Journal of Public Health, 26(3), 375-376. https:// Durt, C., Fuchs, T. & Tewes, C. (Eds.) Embodi- doi.org/10.1093/eurpub/ckw055 ment, enaction, and culture: Investigating the consti- Chen, W., Hall, B. J., Ling, L., & Renzaho, A. M. tution of the shared world. Cambridge, MA: MIT (2017). Pre-migration and post-migration Press. 2017, p. 397-422. factors associated with mental health in hu- Kotsioni, I. (2016). Rehabilitation for survivors of manitarian migrants in Australia and the torture and other forms of ill-treatment in Athens, moderation effect of post-migration stress- Greece - Responding to a protracted refugee crisis. ors: findings from the first wave data of Paper presented at the 4th MSF Workshop on the BNLA cohort study. The Lancet Psychiatry, the thematic of torture: caring for the human be- 4(3), 218-229. http://dx.doi.org/10.1016/ S2215- yond the torture, Rome, Italy. 0366(17)30032-9 MDM [Medecins Du Monde/Doctors of the World]. d’Halluin, E. (2016). Le nouveau paradigme des (2016). Legal report on access to healthcare in 17 «populations vulnérables» dans les politiques countries. European Network to Reduce Vulner- européennes d’asile [The new paradigm of «vul- abilities in Health. nerable populations» in the European politics of Miller, K., & Rasmussen, A. (2017). The mental asylum.] Savoir/Agir, 36(2), 21-26. https://doi. health of civilians displaced by armed conflict: org/10.3917/sava.036.0021 an ecological model of refugee distress. Epidemi- Fassin, D., & d’Halluin, E. (2005). The truth from ology and psychiatric sciences, 26(2), 129-138. the body: medical certificates as ultimate evi- https://doi.org/10.1017/S2045796016000172 dence for asylum seekers. American Anthropolo- MSF, [Medecins Sans Frontieres/Doctors Without gist, 107(4), 597-608. https://doi.org/10.1525/ Borders] (2016). Obstacle Course to Europe: A pol- aa.2005.107.4.597 icy-made humanitarian crisis at EU borders. https:// FRA [European Union Agency for Fundamental www.doctorswithoutborders.org/article/obstacle- Rights]. (2017). Current migration situation in the course-europe-policy-made-humanitarian-crisis- EU: Torture, trauma and its possible impact on drug eu-borders on 30/05/2018. use. Luxembourg: Publications Office. http:// Navarro-Lashayas, M. A., Pérez-Sales, P., Lopes- dx.doi:10.2811/82527 Neyra, G., Martínez, M. A., & Morentin, B. Gkionakis, N. (2016). The refugee crisis in Greece: (2016). Incommunicado detention and torture in training border security, police, volunteers and Spain, Part IV: Psychological and psychiatric con- aid workers in psychological first aid. Intervention, sequences of ill-treatment and torture: trauma and 14(1), 73-79. human worldviews. Torture, 26(3), 34-45. Haenel F. (2015) Special Problems in the Assess- Papadopoulos, R. (2007). Refugees, trauma and ad- ment of Psychological Sequelae of Torture versity-activated development. European Journal and Incarceration. In: Schouler-Ocak M. (eds) of Psychotherapy and Counselling, 9(3), 301-312. Trauma and Migration (pp. 95-107). Springer, https://doi.org/10.1080/13642530701496930 Cham. https://doi.org/10.1007/978-3-319- Patel, N., Kellezi, B., & Williams, A. C. d. C. (2014). 17335-1_8 Psychological, social and welfare interventions Hodges-Wu, J., & Zajicek-Farber, M. (2017). Ad- for psychological health and well‐being of tor- dressing the Needs of Survivors of Torture: A ture survivors. The Cochrane Library. https://doi. TORTURE Volume 28, Number 2, 2018 Pilot Test of the Psychosocial Well-Being Index. org/10.1002/14651858.CD009317.pub2 Journal of Immigrant & Refugee Studies, 15(1), Schock, K., Böttche, M., Rosner, R., Wenk-Ansohn, 71-89. https://doi.org/10.1080/15562948.2016. M., & Knaevelsrud, C. (2016). Impact of new 1171941 traumatic or stressful life events on pre-existing Hollander, A.-C., Dal, H., Lewis, G., Magnusson, PTSD in traumatized refugees: results of a lon- C., Kirkbride, J. B., & Dalman, C. (2016). gitudinal study. Eur J Psychotraumatol., 2016, 7 Refugee migration and risk of schizophrenia and (32106). https://doi: 10.3402/ejpt.v7.32106 other non-affective psychoses: cohort study of 1.3 Schock, K., Rosner, R., & Knaevelsrud, C. (2015). million people in Sweden. BMJ, 352, i1030. Impact of asylum interviews on the mental health https://doi.org/10.1136/bmj of traumatized asylum seekers. Eur J Psychotrau- Kira, I. A. (2010). Etiology and treatment of post-cu- matol., 6. https://doi.org/10.3402/ejpt.v6.26286 mulative traumatic stress disorders in different Silove, D., Ventevogel, P., & Rees, S. (2017). The con- 84
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temporary refugee crisis: an overview of mental health challenges. World Psychiatry, 16(2), 130-139. https://doi.org/10.1002/wps.20438 Sironi, F. (1999). Bourreaux et victimes: psychologie de la torture. [Executioners and victims: psychology of torture]. Odile Jacob. Song, S. J., Kaplan, C., Tol, W. A., Subica, A., & de Jong, J. (2015). Psychological distress in torture survivors: pre-and post-migration risk factors in a US sample. Social Psychiatry and Psychiatric Epidemiology, 50(4), 549-560. https://doi.org/10.1007/s00127-014-0982-1 Song, S. J., Subica, A., Kaplan, C., Tol, W., & de Jong, J. (2017). Predicting the Mental Health and Functioning of Torture Survivors. The Journal of nervous and mental disease. 206 (1), 33-39. https://doi.org/10.1097/ NMD.0000000000000678 ter Heide, F. J. J., Mooren, T. M., & Kleber, R. J. (2016). Complex PTSD and phased treatment in refugees: a debate piece. Eur J Psychotraumatol., 7. UNHCR. (2017). Torture victims in the context of mi- gration: identification, redress and rehabilitation. Viñar, M. N. (2005). La spécificité de la torture comme source de trauma [The specificity of torture as a source of trauma]. Revue française de psychanalyse, 69(4), 1205-1224. Whitsett, D., & Sherman, M. F. (2017). Do reset- tlement variables predict psychiatric treat- ment outcomes in a sample of asylum-seeking survivors of torture? International Journal of Social Psychiatry, 63(8), 674-685. https://doi. org/10.1177/0020764017727022 TORTURE Volume 28, Number 2, 2018 Volume TORTURE 85
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Non-professional interpreters in counselling for asylum seeking and refugee women
Filiz Celik,* PhD, Tom Cheesman,* MA, DPhil
Abstract Key points of interest: Introduction: Non-professional interpreting •• Given appropriate training and warrants further study, particularly in supervision, non-professional environments where professional interpreters interpreters can bridge the are scarce. Method: The lead researcher language gap, act as cultural (a qualified interpreter and counsellor) mediators, and improve joined 32 group sessions as a participant the quality of multilingual observer, and 12 individual sessions as an counselling provision. observer. Additional data sources were 30 •• Possible disadvantages (quality, semi-structured interviews with counsellors, confidentiality, safeguarding clients and interpreters, and two half- and ethics) are outweighed by day forums organised for community the benefits. interpreters to discuss their concerns. •• When they share similar Results: The positive value of engaging backgrounds to those of asylum non-professional interpreters is highlighted seekers and refugees, non- within the specific context of non-medical, professional interpreters may community-based, holistic counselling. In be invaluable to the therapeutic this context, formal accuracy of translation process by joining in the is less important than empathy and trust. conversation and contributing Non-professional interpreters may be more to a culturally sensitive, user- likely than professionals to share clients’ led and holistic counselling life experiences, and working with them
approach, and this approach in counselling has positive psychosocial TORTURE Volume 28, Number 2, 2018 has a particular value to women value for all participants. This is because it who come from cultures that entails inclusive, non-hierarchical practices place greater stigma on mental in the client-counsellor-interpreter triad: health issues. mutual sharing of linguistic resources and translingual communication, and a more relaxing dynamic with fluid roles. In group sessions, a strong sense of a cross- *) Department of Modern Languages, Translation linguistic community is created as women and Interpreting, Swansea University, Wales, UK interpret for one another, an expression Correspondence to: [email protected]; [email protected] of mutual support. In the context of this 86
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study, counsellors, clients and interpreters she wanted to and could afford the course alike all regard non-professionals as being fees. However, Z. could be a good candidate more appropriate than professionals in most for work as an interpreter at the ACC in counselling situations. future (if she is granted refugee status and gets a work permit). If the counsellors deem Keywords: Asylum seekers; refugees; her to have appropriate personal qualities, counselling; torture; translating; interpreting; and if she responds well to training and multilingualism; mental health services supervision, then they may employ her, in preference to a professional. Introduction This paper argues that, in the field of "A lot of things happened to me, I don’t like refugee counselling at least, non-professional talking about them because no one believes interpreters are not just a necessary evil, me… and sometime, I think may be if I plugging gaps due to local lack of suitable speak good English they understand me, I professionals, and/or lack of means to pay don’t know… I have counselling here, I had professional rates. Non-professionals can interpreter, she was nice, you know, from my bring skills and experience to counselling country, she was not like the interpreters on the settings that may enhance the quality of the phone. I now go to women’s group, it is good, mental health services significantly. Engaging at least I am not sitting at home and crying, non-professionals in counselling must be other people are like me, there other asylum done carefully, but it can bring therapeutic seekers, some of them have worse English than and psychosocial benefits to the client and me, we wait for each other to speak, sometimes additional benefits to her environment. I interpret if they are from my country. We do It is important to understand that other things as well, not just counselling, it is ‘counsellor’ and ‘counselling’ have specific like you are not alone here…" (An asylum- meanings here. This kind of counsellor seeking woman receiving counselling; we will is someone trained to ‘help people talk refer to her as Z.) about their feelings’ such as relationship These are the words of a client of the difficulties, grief, mild to moderate mental counselling services at the African health problems, substance abuse issues, etc. Community Centre (ACC) in Swansea, A counsellor ‘holds sessions with individuals Wales, where the first author conducted and groups in a safe and confidential research in February to August 2017. environment’ in order to ‘encourage them to ‘Z.’ does interpret: informally, in group look at their choices and find their own way counselling sessions and other meetings to make a positive change in their life’ (NHS of local asylum-seeking women. She has Health Career Service, 2018). Counsellors experience of being ‘formally’ interpreted— may have various kinds of training and work both by professionals over the telephone in various contexts with various approaches. (widely used in UK health services), and by a At the ACC, the counsellors are part of a ‘nice’ woman ‘from my country’, in individual large team of paid workers and volunteers counselling at the ACC—a woman who in who collectively aim to make life better fact has no interpreting qualifications. Z.’s for asylum seekers and refugees, displaced English is much better than many asylum people who face many problems. The seekers, but still, she would struggle to gain emphasis is placed on building community
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together. The ACC’s counselling approach professional interpreters’ poorer language is non-medical (concepts of diagnosis, skills directly correlated with their potential treatment, or cure are not used), holistic to make errors. At the same time, it is well (deals with the person as a whole: mind, known that in many times and places, there body, emotions, spirit, and their entire life- is inadequate interpreting provision for a context), culturally sensitive (acknowledges variety of pragmatic reasons (Bauer and and works with cultural differences) and Alegria, 2010; Raval and Smith, 2003; Sen, community-based. Community-based 2016). However, the positive value of non- counselling is an ‘approach linked to a professional interpreters, in certain contexts critical perspective, [which] highlights the and appropriately managed, has not been importance of going beyond individualist explored enough in the literature. assessments and interventions towards Asylum-seekers and refugees have been comprehensive approaches that locate the socialised in widely different cultural value person in context, and that listen carefully systems, and are initially unfamiliar with the to and engage openly with all voices in a systems of law, care, education and so on way that highlights dynamics that oppress in the host country. These factors, as well ourselves and others, for the purposes of as lack of host-country language skills, have building a supportive and health promoting been cited as factors jeopardising migrants’ environment for all.’ (Lazarus et al., 2009) access to mental health services (Raval and In the particular kind of counselling context Smith, 2003). Asylum seekers and refugees at the ACC, non-professional interpreters in Wales come from all parts of Africa, Asia are valued as active promoters of the and eastern Europe, and speak a great variety mutually supportive environment which of languages. Languages encountered at the creates a context in which people can ACC during this study, beginning with A, flourish through supporting one another. As included: Afrikaans, Albanian, Arabic, Aruba, part of a culturally informed approach to and Azerbaijani. In total we observed about mental-health service delivery (Harris and 40 languages spoken during our research. In Maxwell, 2000), interpreters drawn from the 2000, the local education authority reported same cultural field as the clients are valued 50 languages spoken in schools in the area, because their formal linguistic skills are less in addition to English and Welsh.1 By 2017 essential than their capacity for empathy and this had risen to 145.2 Speakers of languages ability to inspire trust. other than English, who are new to the UK, Use of professional interpreters is may have fluent English. Some were educated generally recommended in mental health up to postgraduate level in English. Most TORTURE Volume 28, Number 2, 2018 provision, as in other contexts when clients have little English and are learning it at and service providers do not share the beginner to intermediate level. same language. The use of non-professional interpreters such as family members, children, friends, acquaintances, or random people recruited ad hoc, is generally said to 1 Personal communication (September 2017) from lead to communication failures and to less the local authority’s Migration, Asylum Seeker and Refugee Officer. full disclosure of information by the client 2 Pupil census (January 2017), reported in a local (Bauer and Alegria, 2010; Miller et al., authority consultation document (http://www1. 2005). Bauer and Alegria argue that non- swansea.gov.uk/snap/snapforms/2018/03_18/ EMAU/emau_t.htm) and in Youle (2018). 88
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Some professional interpreters are professional interpreters in counselling available in Wales, especially for some locally deserves much more detailed investigation. ‘large’ languages such as Arabic, Bengali, It is not that it is ‘hidden’; these interpreters or Mandarin and other Chinese languages. are formally recruited, trained, supervised, Communities speaking these languages and paid for their time. But the value of in Wales are rooted in the 20th century. this kind of work is still hidden to those However, even in these cases, an Arabic who are strictly committed to the ideal of a interpreter with, for example, Egyptian monopoly of professional interpreting. heritage, and fluent in formal Arabic, will It is well known that interpreters in most struggle to communicate with someone settings, certainly healthcare settings, are from a village in northern Iraq. A Mandarin not expected (or even able) to be simple interpreter is little use to a Hakka speaker. ‘conduits’, ‘transmitters’ of information Linguistically appropriate professional across language gaps. Instead, their role is interpreters are rarely available to the ACC defined variously in the literature as ‘cultural But even if they were, they would not brokers’, ‘clarifiers’, ‘managers’ of the medic- necessarily be employed. patient relationship, and sometimes (though An increasing volume of research this strictly requires additional qualifications) addresses the work of professional ‘advocates’ or ‘mediators’ (Sleptsova et interpreters in various counselling settings al. 2014). In mental health, cross-cultural (Bauer and Alegria, 2010; Guruge et al., misunderstanding of how psychological 2009; Paone and Malott, 2008; Raval and distress is communicated in a different Smith, 2003; Tribe and Morrisey, 2003). culture can result in incorrect psychiatric Non-professional interpreting (which is diagnoses, as a human response to trauma of course universally far more common and extreme distress is construed as mental than professional interpreting) is also disorder (Di Tomaso, 2010; Guruge et al., gaining increasing academic attention 2009; Silove et al., 1998). Interpreters must (Pérez-González and Susam-Saraeva, 2012; then do much more than ‘transmit’ the Smith et al., 2013). But non-professional meanings of words, and ‘broker’ or ‘advocate’ interpreting in counselling has yet to be are preferred terms. In the particular context adequately studied. Ours is only a small case we studied, one of community-based, non- study in a very specific context. However, medical counselling sessions at a small non- it adds weight to findings such as that profit organisation which serves an extremely reported by Smith et al. (2013: 493), who diverse migrant population, none of these describe ‘informal interpreters’ (in their descriptions fits the requirements, because case, cleaners in a psychiatric hospital in they all posit a role hierarchy which the South Africa) as ‘fulfilling an additional counselling practice aims to avoid. beneficial role in terms of the overall care of patients which goes beyond the ambit of the Background interpreting session’. Smith et al. also argue The African Community Centre is located that ‘it is clear that informal interpreting in Swansea, a city of under a quarter of a may usefully be viewed as a form of hidden million people, in Wales (a semi-independent care work. A detailed ethnographic study UK nation), about three hours by rail or aimed at exploring this further is therefore road from London. Despite its name, the
TORTURE Volume 28, Number 2, 2018 Volume TORTURE recommended.’ Similarly, the work of non- African Community Centre provides a 89
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range of services for people of all continents: such as the few hundred Syrians who have primarily Black and Minority Ethnic so far been resettled in Wales under the UK (BAME) people, but also members of Government’s Syrian Resettlement Program. majority British white populations. The ACC Refugees can (and do) become UK citizens. runs two counselling projects specifically Asylum seekers and refugees are very for the growing local population of ‘asylum often suffering traumas, due to events in seekers and refugees’. the countries they have fled, and often also These two terms ‘asylum seeker’ events during the journey to safety, in other and ‘refugee’ refer to distinct migration countries, at sea, in lorries etc. (Sen, 2016). statuses. Asylum seekers are people who Many also have traumatic experiences in have registered an asylum claim with the the UK. Many endure a long, anxious Home Office (ministry of the interior), wait for a decision on their asylum case: citing the UNHCR Refugee Convention. commonly two to four years and some up Most do so when they enter the UK to 10 years or more, with no right to work, (legally or illegally); some do so after a no autonomy, very limited opportunities for visa has lapsed. If they cannot support meaningful use of their time. Asylum seekers themselves, they are ‘dispersed’ somewhere are highly vulnerable to psychological in the UK, accommodated, given a small distress and many suffer mental illness such weekly allowance, and wait for their case as PTSD, clinical depression and anxiety to be adjudicated. Eventually they will (Cowen, 2003; Fazel, Wheeler and Danesh, usually either be deported, or given ‘leave 2005) due to the ongoing uncertainty of to remain’ (permission to settle) at least for their migration status, their experiences some years, or else just evicted and left to of the threat of detention, their long-term fend for themselves. forced inactivity as well as loss and lack Asylum seekers have come to Wales of family support (Robjant, Hassan and in significant numbers only since 2000: Katona, 2009). They are liable to unlimited they have been ‘dispersed’ from London ‘immigration detention’ at any time. If following implementation of the 1999 an asylum claim is refused, many are not Immigration and Asylum Act. In Wales in detained or deported, instead just evicted 2017 there were 2,872 occupied asylum- and left destitute: homeless, unable to access seeker accommodation places (National any kind of state support, totally dependent Assembly for Wales, 2017). About one third on the charity of friends or others. Decision- of these places are in the city of Swansea. making by the Home Office is inconsistent.
Asylum seeker accommodation is in If refusals are appealed, the appeal is very TORTURE Volume 28, Number 2, 2018 ordinary rented private dwellings, scattered often successful, but accessing the necessary all over the urban area. Public transport is legal advice and support is difficult. Also, very expensive, and many asylum seekers casual racism is widespread in some parts of become very isolated. the local ‘white’ populations. For ‘refugees’ there is no general Many asylum seekers and refugees have statistical data, but the National Assembly previously suffered severe trauma, including for Wales (2017) estimated 10,000 in Wales. rape and torture. Pre-‘dispersal’ screening Refugees are people who have been granted in London should keep people in the capital leave to remain. A few refugees enter the city, if they need specialist services, such as UK with refugee status already granted, torture and rape survivors (Gorst-Unsworth 90
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and Goldenberg, 1998). However, the affiliated local organisations where they screening is rudimentary, and traumatised are welcomed and supported. Counselling asylum seekers often do not disclose clients are often self-referred, having heard pertinent issues. The ACC refers people with of the services through others; they may severe mental health problems to statutory also be referred from other non-statutory (state-run) services. However, no specialist organisations, or the local team of the services for the ‘new’ population, such as National Health Service which serves the cross-cultural services specialising in severe asylum-seeker population. issues faced by asylum seekers and refugees, have yet been established in Wales. Method The ACC is a non-profit charity, funded The first author is a qualified interpreter by grants from charitable foundations. It and counsellor, so was permitted to provides counselling services tailored to join 32 group sessions as a participant the needs of asylum seekers and refugees observer, and 12 individual sessions as with moderate mental health problems. an observer. Additional data sources A group of qualified counsellors, who were 30 audio-recorded, semi-structured have been specifically recruited for their interviews with counsellors, clients and relevant expertise and outlook, provide interpreters (average length 25 minutes, counselling through two interlinked range 4-180 minutes), and two half-day projects: AMANI (individual counselling)3 forums organised for ‘interpreters in the and PAMOJA (group counselling and art community’ to discuss their concerns. therapy).4 The ACC’s overall mission is to Invitations to these interpreter forums were create a positive impact on the lives of the circulated through local NGO networks. beneficiaries across cultures, faith groups, Participants included 20 non-professionals gender, sexual orientation, disabilities, age (of whom three were affiliated to the ACC) groups and migration statuses. Inclusivity and five professional interpreters (the latter and community are key watchwords. The also work in a voluntary capacity in various ACC delivers a range of services, such as community settings). Further details of data advice, arts and cultural projects, for the collection can be found in the Appendix. local Black, Asian and Minority Ethnic The research was conducted over nine (BAME) communities, ‘in partnership months in 2017. The main focus was on with indigenous Welsh people’.5 The staff asylum seeking and refugee women receiving and volunteers work to ‘integrate’ new counselling at the ACC, and interpreters asylum seekers and refugees by helping working with them. The women ranged them participate in the full range of in age from 19 to 58. Their experiences activities open to them at the ACC or with included torture, rape, female genital mutilation (FGM), loss of members of the close family and other loved ones, loss of livelihood and identity through traumatic 3 AMANI means ‘what you wish’ for in Swahili. The AMANi Project provides individual counsel- displacement, among others. ling services. Recorded data were anonymised during 4 PAMOJA means ‘together’ in Swahili. The transcription, triangulated with data noted PAMOJA Project provides group therapy and during session observations and participant other art-based therapeutic activities. 5 TORTURE Volume 28, Number 2, 2018 Volume TORTURE See africancommunitycentre.org.uk. observation, and coded using Thematic 91
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Analysis (TA), which enables flexible coding determine their needs and offered individual of emerging themes, independent of prior or group counselling as appropriate. In theory and epistemology (Roulston, 2001). individual counselling, interpreters were TA is based in a constructionist paradigm needed for the majority of women clients. (Braun and Clarke, 2006) where ‘meaning’ Women from countries such as Nigeria and is understood as constructed rather than India may have English as their mother ‘expressed’ in language (Barrett, 1992, tongue or have been educated in English, p.203). Critical self-reflection is essential to but still most experienced challenges due to minimise the researchers’ own assumptions their accents and unfamiliarity with British and worldviews skewing the analysis (Elliot, English and the local spoken English usage. Fischer and Rennie, 1999). The first author Most women clients encountered during this kept a reflexive journal and had frequent research had only very basic English. discussions with the other researcher (who is The ACC does not have a policy against very different in terms of gender, ethnicity, recruiting professional interpreters, but migration history, disciplinary training, etc.). during our research we only observed them Ethics approval for our research project engaging non-professional interpreters, was obtained both from our university that is, people who have no accredited through the Human Ethics Committee training but have acquired enough bilingual and from the ACC, in accordance with resources to translate spoken messages their ethical procedures. Verbal consent between English and a language used in was obtained from all clients, interpreters the asylum and refugee population. Most and counsellors involved, if necessary are refugees. Non-professional interpreters using one of the ACC’s non-professional are very carefully assessed for their roles, interpreters. Ethics were revisited as rigorously trained by the ACC, and their required, e.g., when a new member joined work is subject to ongoing supervision. a counselling group, or a client requested Training includes, first, an initial that information be excluded from the generic session for potential interpreters, research process. Our ethical guidelines were introducing the ACC, its ethos, the aims examined and developed in collaboration of counselling, and fundamental issues of with participants as Tagg, Lyons, Hu and ethics, confidentiality and safeguarding. Rock (2016) recommend: ethical issues Next, the potential interpreter meets the should be approached as a decision-making counsellor for an information session process, rather than a fixed set of guidelines about a potential match with a client. This to follow. This gives participants autonomy session involves assessing whether the social, TORTURE Volume 28, Number 2, 2018 to align themselves with the research as the political and cultural backgrounds of client circumstance and perceptions shift. and interpreter may create conflict for either party (e.g. affiliations with different Findings sides of a political conflict). All being well, The value of non-professional interpreters the interpreter and client are introduced at The ACC provides help and support to all a counselling session. The first statement members of the Black, Asian and Minority which the interpreter is asked to convey Ethnic communities, but the counselling from the counsellor explains that the client services are offered to asylum seekers can refuse to work with them, and that and refugees only. Clients are assessed to this would not be construed as a personal 92
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affront; a different interpreter would be at the requisite level. They relied on others to identified. If there is no objection, the interpret for them, usually informally, in most interpreter then begins the interpreting cases outside the home. process by translating messages from From observations, interviews and counsellor to the client about the ground- forums, three themes emerged, all embedded rules of confidentiality between client, in the cross-cultural, community-based counsellor, and interpreter. ethos: translanguaging; migration status; and After each counselling session, the vicarious traumatisation. interpreter is de-briefed about any linguistic difficulties they experienced (understanding Interpreting and translanguaging in group the client, their speech style, accent, counselling: When group counselling vocabulary) as well as difficulties arising from members acted as interpreters for each the nature and content of the conversation. If other, they drew on resources including needed, a session is arranged to work on the digital tools and aids (translation apps, possible vicarious effects on the interpreter bilingual dictionaries, images and maps), (see below). If possible, the ACC ‘pairs’ body language, mimicking and role playing, clients and interpreters throughout the singing and dancing, in order to facilitate counselling process, which lasts at least eight communication. They presented speech weeks and sometimes much longer. to the group in their own languages, In group sessions there are no assigned inviting efforts to interpret by others who interpreters, but members of the group are at least knew related languages. They self- encouraged to interpret for one another interpreted into the common language, as needed. Issues of ethics, confidentiality English, as best they could, with help from and safeguarding are addressed via an others. Understanding one woman became explicit ‘group contract’, which is developed a group effort of all. This can be understood between the members of the group and the in terms of ‘translanguaging’, a concept that counsellor at a first session. The contract is originally referred to interactions among both written and oral: many of the women non-native English speakers in educational are only partially literate. The contract is settings, where various cognitive, linguistic presented to new group members orally and material tools and skills are used and in writing, via informal interpreting to enable small-group communication as needed. It is revisited at least every (Garcia, 2014). The term translanguaging eight weeks, and occasionally amended in challenges ‘monolingual’ normative views response to changed circumstances. of language behaviour and strengthens Women clients who took part in this the understanding that flexibility in using study were native speakers of 15 different diverse language resources, at diverse languages. Many were bilingual or multilingual levels of familiarity and fluency, is not only (e.g. women from Pakistan or Afghanistan functionally effective but helps build cross- speaking combinations of Punjabi, Urdu, lingual communities (Creese and Blackledge, Dari). All women were keen to learn English, 2011). In group counselling at the ACC, the but their English language acquisition was diversity of languages in the room became being hindered by inability to attend English a common resource for facilitation of the language classes in local colleges due to travel group’s conversations, engaging women of
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Multi-lingualism as translingualism brought self-sufficiency (Simich, Beiser, Stewart and much more of the ‘unsaid’ into the sessions Mwakarimba, 2005). for each woman, and strengthened their sense of common identity and solidarity. Migration status—common experience of Across all our observations and clients and non-professional interpreters: The interviews, there was no perception that model of interpreting in group counselling linguistic diversity or the wide variance in sessions, with informal translanguaging ability to communicate in English was in building mutual social support, is similar any way negative. On the contrary, this is a to that used in individual counselling, in typical statement from a participant (first terms of the underlying ethos. The essential language Nigerian English): elements are trust and wellbeing through "We need to stand together, as women we common identity. The benefits of non- need to try to understand each other... I professional interpreting were articulated think it is good that some women cannot by both clients and counsellors. They stated speak good English, we learn how difficult that non-professional interpreters have it is to not speak English, we wait for each specific skills and understanding to aid the other, we learn… We support each other, process of communication, partly because our English are different level but our pain they are not bound by fixed professional is similar…" codes and norms. They are freer to act as In the group counselling sessions, women cultural brokers and better at understanding were respectful of each other, appreciated implications or making educated predictions linguistic challenges, and came together to about the intersubjective meanings specific give space to those whose level of English to micro-cultures. Whilst this may also apply did not match others’. Linguistic barriers in to professional interpreters, above all, it was fact brought women together through the clear that the interpreters in this study had effort and process of trying to understand clients’ trust because they have empathy each other, creating a sense of solidarity in with them and more often than not share the the group. clients’ experiences of being asylum seekers. The ACC’s counsellors encourage They have experienced the same problems this translingual dynamic. They avoid in the country of origin, the same flight to presenting English speech which is likely safety, the same process of arriving in the to be hard to translate (e.g. professional UK, claiming asylum, being ‘dispersed’ to a terminology), they strive to be cross- random town, waiting for the Home Office culturally sensitive and inclusive, they decision, enduring the precarious status of TORTURE Volume 28, Number 2, 2018 support mutual translanguaging. Their ‘asylum seeker’, as well as all the other issues non-medical, community-based approach related to adapting to the new country. to mental wellbeing promotes integration We observed that the interpreters often and community building among a very asked counsellors to expand on the issues vulnerable and underprivileged population. relating to the migration status of the It promotes clients’ self-empowerment as clients, such as psychological stress relating a group because mutual social support is to their current migration status and the an important protective factor in emotional indefinite period of waiting during which wellbeing, critically important to reducing they are unable to function in society. stress, maintaining health, and achieving The interpreters, in sessions, prompted 94
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counsellors to give clients more space to them, but when they know you are from the articulate their experiences and feelings community they trust you more and they tell about their current status. Among women you more, which helps the English speaker to receiving counselling, migration status better understand their issues…" emerged as a major factor affecting their This could be seen as self-serving psychological wellbeing, and it was often rationalisation. But the point was generally interpreters who brought this out. agreed by all research participants. Asylum Migration status also had a strong seekers and refugees who need interpreters negative impact on English language in counselling have also had experience of acquisition in many cases, hence on the interpreters in other settings: immigration need for interpreters. One asylum seeker interviews, legal proceedings, and in the client reflected: state healthcare system. As Z. said (quoted "As an asylum seeker, you don’t know at the start of this paper), the interpreter at what is going to happen tomorrow… I am the ACC is ‘not like’ others; she is ‘nice’ and thinking about the past, I don’t want to she is ‘from my country’. This was a typical but I think about it... I feel afraid when statement. Professional interpreters are someone is walking behind me, I feel perceived as acting for the organisation which afraid that something is happening to my pays them, i.e. serving the interests of the mother… I want to learn more English but Home Office (which is looking for reasons my mind is not accepting new learning, to refuse an asylum claim) or the National because I don’t know if Home Office will Health Service (which is seeking to save accept my case. If they send me back, what money and trouble). It can therefore be very good is to speak English…" challenging for professional interpreters to English language acquisition is motivated by win the trust of asylum seekers. In the ACC, confidence that the learner has a future in professionally qualified interpreters could in the English-speaking world. Uncertain status principle do the work, though for lower rates undermines that confidence. Professional of pay than they would normally charge. We interpreters, who have invested heavily in did not observe any. Professionals who work acquiring advanced, formal English skills, in legal and medical interpreting may also may be less likely to empathise with this avoid working in counselling because of a state of mind than non-professionals. potential conflict of interest, e.g. if they deal Participants in the interpreters’ forums with the same client in different settings. we organised all agreed that acting in a non- professional capacity helped to establish Effects on interpreters: vicarious trauma and better relationships with the clients. This personal growth: Interpreting is taxing work. view was shared by the professionally Interpreters not only witness others’ intense qualified interpreters who participated, all of emotions and narratives, but are obliged to whom also worked in a voluntary capacity voice them. Vicarious traumatisation is a major in their communities. The interpreters risk in interpreting with survivors of torture agreed that clients trusted non-professional and other trauma (Paone and Malott, 2008). interpreters more, so they disclosed more. Vicarious detrimental effects were reported by One non-professional explained: interpreters we interviewed, and participants "When an interpreter comes from an agency, in the interpreters’ forums. The issues reported
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in clients’ experiences of torture and other to attach two kinds of meaning to their extreme violence and suffering; feeling shock experiences during the counselling sessions, and disbelief towards clients’ narratives; feeling which correlated with the way they reported clients’ pain and suffering themselves; having the impact on them. All interpreters flashbacks about the content of sessions; and expressed a desire to help the clients. being unable to forget what they interpreted. However, some concluded that they could The efforts of the ACC to deal with these not make any difference. Then they referred effects were viewed as exemplary, compared to their experiences as making them feel with other organisations interpreters had sad, upset and powerless, and they reported worked with (non-professionals are widely disturbances such as compulsively thinking employed in a range of medical, advisory, legal about their client after the session. However, and other settings). if the interpreter felt they were successfully However, the interpreters also talked supporting their clients, enabling them to about experiences of personal growth and get through a difficult ordeal, then they enhanced appreciation of their experiences reported feeling useful and empowered. One as a result of their work with asylum interpreter explained: seekers and refugees in the counselling "It’s often difficult not to be affected by their setting. Little research addresses the stories. I find some comfort in knowing that balance or imbalance of negative and at least I can assist them. I try to separate positive effects experienced by interpreters. my work from my personal life. And I keep Splevins et al. (2010) introduced the idea in mind that I’m not there to feel upset for of ‘vicarious post-traumatic growth’ (see them, sorry for them, but to be resourceful, to also Manning-Jones et al., 2015). Many help them…" non-professional interpreters in our study We observed that in most cases the training, indicated that they have emerged from briefing and supervision provided by the challenging and upsetting experiences with ACC helped interpreters working there to a sense of personal fulfilment through appraise their roles in a more favourable light helping others, and a sense that they for the clients, community and themselves. have greater resilience in facing their own difficulties. They described developing new Concluding Remarks life skills during their work as interpreters, The ACC’s practice is still developing. and transferring them into other parts of Managing the counselling projects for the their life, in ways which correspond closely full benefit of participants and the wider to the features of vicarious post-traumatic community is often challenging. The lead TORTURE Volume 28, Number 2, 2018 growth, i.e. enhanced interpersonal counsellor was asked in an interview: ‘How relationships, self-perception and life do you manage when members of the philosophy (Tedesschi & Calhoun 1995, group have really differing levels of English 2004, cited in Splevins et al., 2010). language competency?’ She replied at It is worth asking whether non- length, beginning: professional and professional interpreters "I hope that there will be someone in the would experience this differently, as well as group who may be able to translate or which other factors (interpreting settings, interpret for them. But I would probably modes, work-patterns) would be influential. be watching that person who is not able to We observed that interpreters tended understand and I might perhaps get from 96
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their body language what is, if they are her son blown up in front of her in [X]. That feeling comfortable or uncomfortable… It was so shocking, shocking for the three of us is a rather difficult one but I think I would really. […] Everything started to come out, rather have them in the group, experiencing when she realised what counselling was. The being together, rather than being isolated and interpreter then came back to us [the team of being on their own." counsellors] saying that she recognised that Community, participation, escape from isola- she [the interpreter] had trauma, she was tion are essential. The counsellor immediately carrying trauma as well. So I worked a little turned to non-linguistic challenges: bit with her as well, to keep her safe, it is "When I started group [counselling] six years really really important to keep people safe." ago we had two [X] ladies in the group, it The counsellor returns finally to her was a very small group […] and we had a initial point: [professional] interpreter and it just didn’t "I think from that point on, I was much work, because the two [X] ladies knew each more careful, it taught me something: other and the [X] community is very close, people don’t always understand what and they were not able to disclose their stuff counselling is, [or] what group therapy because they didn’t want each other to hear is, but even so to be in the group is better about what their life experiences was or didn’t than being isolated at home." want to tell their personal stuff. So we decided From our observations at the ACC, we to abandon that…" believe that with appropriate training, The small scale and closeness of migrant supervision and support, non-professional communities in this location presents interpreters can bring skills to counselling many such problems. With these specific that enhance the quality of mental health clients in mind, the counsellor goes services significantly. Indeed, they enable on to discuss problems in individual mental health services to be offered which counselling which couple the linguistic would otherwise certainly not exist. What with the cultural. Noticeably, in this they bring into the sessions goes beyond narrative, the pronoun ‘we’ or ‘us’ is used cultural brokerage. What we observed in twice for the team of counsellors, at one community-based counselling sessions point for counsellor and interpreter, and was that counselling became a triadic at one point, at the emotional heart of the relationship, in which the interpreter’s story, for the triad of client, counsellor ability to comprehend and convey the and interpreter: difficulties of the clients, their empathy "The older lady, we decided it was better and ability to inspire trust, were more if she started one-to-one counselling, […] important than their English language we had a very good [non-professional] proficiency. At the ACC, interpreters interpreter for her and it was about session often ‘negotiated’ meanings with the client five that I realised this women didn’t know and the counsellor, and provided context what counselling was, she thought she was for both to better understand intended coming for chatting. So I had to challenge her meanings, helping the culturally distant about what the counselling meant, through parties to come closer in understanding. the interpreter, and we realised that she But beyond this, the non-professional doesn’t understand. And […] later she [the interpreters, sharing similar migration
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interpreting process with their inputs. They References did not just bridge the communication Bauer, A. M., & Alegria, M. (2010). Impact of patient language proficiency and interpreter service use gap, they joined with counsellor and client on the quality of psychiatric care: A systemic in seeking wellbeing. review. Psychiatric Services, 61(8), 765-73. https:// Involving non-professional interpreters doi.org/ 10.1176/ps.2010.61.8.765-773. in a counselling or other therapy process Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research does raise concerns about confidentiality in Psychology, 3(2), 77-101. https://doi. and safeguarding of the clients, and about org/10.1191/1478088706qp063oa. impacts on interpreters. In the case we Cowen, T. (2003). Suffering alone: an examination of observed, these concerns were addressed in the mental health needs of asylum seekers and refu- gees in Barnet. London: Refugee Health Project, a professional way. The African Community Barnet Voluntary Service Council, Barnet Pri- Centre in Swansea has developed excellent mary Care Trust. skills in providing counselling services Creese, A., Blackledge, A., et al. (2011). Separate and to asylum seekers and refugees. Staff are flexible bilingualism in complementary schools: Multiple language practices in interrelationship. highly experienced in understanding the Journal of Pragmatics, 43(5), 1196-1208. https:// difficulties associated with the forced doi.org/ 10.1016/j.pragma.2010.10.006. migration process, from pre-migratory Di Tomasso, L. (2010). Approaches to counsel- traumatic experiences of torture, loss and ling resettled refugee and asylum seeker survivors of organised violence. International trauma to post-migratory experiences, Journal of Child, Youth and Family Studies, the uncertainty of the asylum process, 1(3/4), 244-264. http://dx.doi.org/10.18357/ resettlement and adaptation in the UK. ijcyfs13/420102086 Falzon, M.-A. (2016). Introduction: Multi-sited They choose to use non-professional ethnography: Theory, Paraxis and Locality in interpreters for the benefit of their clients Contemporary Research. In M.-A. Falzon (Ed.), and for the wider benefit of the newly Multi-sited Ethnography: Theory, Praxis and Local- developing local community of asylum ity in Contemporary Research (pp. 1-24). London: Routledge. seekers and refugees. Fazel, M., Wheeler, J., & Danesh, J. (2005). Prevalance of serious mental disorders in 7000 Acknowledgements refugees resettled in Western countries: a system- For their generous collaboration and support atic review. The Lancet, 365(9467), 1309-1314. https://doi.org/10.1016/S0140-6736(05)61027-6. in this research, we thank all staff and Garcia, O. (2014). Translanguaging and Education. In volunteers, clients and interpreters at the O. Garcia & L. Wei, Translanguaging: Language, Bi- African Community Centre, in particular Jill lingualism and Education (pp. 63-77). Hampshire, Duarte, the lead counsellor and director of UK: Palgrave Language and Lingusitic Collection. Gorst-Unsworth, C., & Goldenberg, E. (1998). the organisation. Psychological sequelae of torture and organised TORTURE Volume 28, Number 2, 2018 violence suffered by refugees from Iraq. The Brit- Funding ish Journal of Psychiatry, 172, 90-94. https://doi. This research was funded during 2017 by org/10.1192/bjp.172.1.90 Guruge, S., Berman, R., Tyyska, R., Kilbride, K. M., the Arts and Humanities Research Council Woungang, I., Edwards, S., & Clune, L. (2009). (AHRC) through the Open World Research Implications of English proficiency on immigrant Initiative (OWRI) ‘satellite’ project (part women’s access to and utilization of health ser- vices. Women’s Health and Urban Life, 8(2), 21-41. of the OWRI Cross-Language Dynamics Harris, K., & Maxwell, C. (2000). A needs assess- programme) at Swansea University’s ment in a refugee mental health project in Department of Modern Languages, North‐East London: Extending the counselling Translation and Interpreting. model to community support. Medicine, Con- 98
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flict and Survival, 16(2), 201-215. https://doi. British Journal of Psychiatry, 13(2), 30-32. doi: org/10.1080/13623690008409514. 10.1192/S2056474000001069. Lazarus, S., Baptiste, D. & Seedat, M. (2009) Com- Silove, D., Steel, Z., McGorry, P., & Mohan, P. munity counselling: values and practices, Journal (1998). Trauma exposure, postmigration stress- of Psychology in Africa, 19(3):449-454. https://doi. ors, and symptoms of anxiety, depression and org/10.1080/14330237.2009.10820314. post-traumatic stress in Tamil asylum-seekers: National Assembly for Wales (2017). “I used to be some- comparison with refugees and immigrants. Acta one”: Refugees and asylum seekers in Wales. Cardiff: Psychiatrica Scandinavica, 97(3), 175-181. https:// Equality, Local Government and Communities doi.org/10.1111/j.1600-0447.1998.tb09984.x. Committee, National Assembly for Wales. Simich, L., Beiser, M., Stewart, M., & Mwaka- Manning-Jones, S., de Terte, I., & Stephens, C. rimba, E. (2005). Providing social support for (2015). Vicarious posttraumatic growth: A sys- immigrants and refugees in Canada: challenges tematic literature review. International Journal of and directions. Journal of Immigrant Health, Wellbeing, 5(2), 125-139. 7(4), 259-268. https://doi.org/10.1007/s10903- Marcus, G. E. (2015). Multi-sited Ethnography: 005-5123-1. Five or Six Things I Know about It Now. In: S. Simon, S. (1996). Gender in Translation: Cultural Identity Coleman & P. Von Hellerman (eds.), Multi-Sited and the Politics of Translation. London: Routledge. Ethnography: Problems and Possibilities in Transloca- Sleptsova M., Hofer G., Morina N., Langewitz W. tion of Research Methods (pp. 16-34). New York: (2014). Role of the health care interpreter in a Routledge. clinical setting–a narrative review. Journal of Com- Miller, K. E., Martell, Z. L., Pazdirek, L., Caruth, munity Health Nursing, 31(3), 167-84. https://doi. M., & Lopez , D. (2005). The role of interpret- org/10.1080/07370016.2014.926682. ers in psychotherapy with refugees: an explora- Smith, J., Swartz, L., Kilian,S. and Chiliza, B. (2013). tory study. American Journal of Orthopsychiatry, Mediating words, mediating worlds: Interpreting as 75(1), 27-39. https://doi.org/10.1037/0002- hidden care work in a South African psychiatric in- 9432.75.1.27. stitution. Transcultural Psychiatry, 50(4), 493–514. NHS [National Health Service] Health Career Ser- Splevins, K. A., Cohen, K., Joseph, S., Murray, C., vice (2018). Counsellor. Retrieved May 1, 2018: & Bowley, J. (2010). Vicarious posttraumatic www.healthcareers.nhs.uk/explore-roles/psycho- growth among interpreters. Qualitative Health logical-therapies/roles/counsellor. Research, 20(12), 1705–16. https://doi.org/ Paone, T. R., & Malott, K. M. (2008). Using inter- 10.1177/1049732310377457. preters in mental health counselling: A literature Tagg, C., Lyons, A., Hu, R., & Rock, F. (2017). The review and recommendations. Journal of Mul- ethics of digital ethnography in a team project. ticultural Counselling and Development, 36:130- Applied Linguistics Review, 8(2-3), 271–292. doi: 142. https://doi.org/10.1002/j.2161-1912.2008. 10.1515/applirev-2016-1040. tb00077.x. Tribe, R. (1999). Bridging the gap or damming Pérez-González, L., & Susam-Saraeva, Ş. (2012). the flow? Some observations on using inter- Non-professionals translating and interpret- preters/bicultural workers when working with ing: Participatory and engaged perspec- refugee clients, many of whom have been tor- tives. The Translator, 18(2), 149-165. DOI: tured. Psychology and Psychotherapy: Theory, 10.1080/13556509.2012.10799506. Research and Practice, 7(4), 567-576. https://doi. Raval, H., & Smith, J. A. (2003). Therapists’ experi- org/10.1348/000711299160130. ences of working with language interpreters. Inter- Tribe, R., & Morrisey, J. (2004). Good practice is- national Journal of Mental Health, 32, 6-31. https:// sues in working with interpreters in mental doi.org/10.1080/00207411.2003.11449582. health. Intervention, 2(2), 129-142. https://doi. Robjant, K., Hassan, R., & Katona, C. (2009). org/10.1080/17542860903115976. Mental health implications of detaining asy- Tribe, R., & Morrissey, J. (2003). The refugee context lum seekers: sytematic review. British Journal of and the role of interpreters. In R. Tribe, & H. Raval Psychiatry, 194(4), 306-312. doi: 10.1192/bjp. (Eds.), Working with Interpreters in Mental Health bp.108.053223. (pp. 198-218). London and New York: Routledge. Roulston, K. (2001). Data analysis and ‘theorising as Youle, R. (2018). These are the top 10 languages ideology’ . Qualitative Research, 1(3), 279-302. spoken in Swansea schools after English and https://doi.org/10.1177/146879410100100302. Welsh. Walesonline. https://www.walesonline. Sen, P. (2016). The mental health needs of asylum co.uk/news/wales-news/top-10-languages-spoken- seekers and refugees - challenges and solutions. swansea-14427381. TORTURE Volume 28, Number 2, 2018 Volume TORTURE 99
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Acute short-term multimodal treatment for newly arrived traumatized refugees: Reflections on the practical experience and evaluation
Mechthild Wenk-Ansohn,*1, Carina Heeke,*, **1, Maria Böttche,*,**, Nadine Stammel*,**
Abstract Key points of interest: Background: A short-term multimodal •• A multimodal short-term acute treatment program of approximately treatment program of six months' duration for newly arrived approximately six months refugees at Center ÜBERLEBEN (Berlin was developed including Center for Torture Victims) was developed. psychotherapy, social work, The purpose of this study was to evaluate group therapy and psychiatric treatment modules for newly this program by examining changes in arrived refugees who experienced PTSD, anxiety and depression symptom trauma-related symptoms after severity after treatment, and to reflect on recent traumatization in their practical experiences in carrying out the home country and/or during program. Methods: At the beginning (T1) their flight. and following completion of the short- •• Improvements in symptom term treatment program (T2) patients in a severity could be achieved despite single-group design were assessed with the the extremely high symptom load Posttraumatic Stress Disorder Checklist at the beginning of treatment, for PTSD and the Hopkins-Symptom uncertainties regarding residence Checklist for depression and anxiety (per- status, and the often unstable protocol analysis). Results: Of the 92 living conditions. patients who completed T1, 44 completed • In addition to psychotherapy, • T2 assessments. Medium to large effect sizes newly arrived refugees need were found for reductions in overall PTSD comprehensive social work and (d = 0.88), depression (d = 0.83), and TORTURE Volume 28, Number 2, 2018 counselling for legal aspects in anxiety symptoms (d = 0.67). While at the order to deal with difficulties regarding their asylum beginning of treatment (T1) 97.7% (n = 43) applications. fulfilled diagnostic criteria for both PTSD and depression, and 95.5% (n=42) for anxiety, at T2, 70.5% (n = 31) fulfilled the criteria for clinically relevant PTSD, 79.5% *) Center ÜBERLEBEN, Berlin, Germany (n = 35) for depression and 70.5% (n = 31) **) Freie University Berlin, Department of Clinical- for anxiety. Discussion: Despite the high Psychological Intervention, Germany symptom load at the beginning of treatment, 1 Shared first authorship. Correspondence to: [email protected] uncertainties regarding residence status, and 100
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the unstable living conditions, patients seem Younan, Uribe Guajardo, Heriseanu, & to benefit from the multidisciplinary short- Hasan, 2015; Steel et al., 2009; Tinghög term treatment. This study adds preliminary et al., 2017). For refugees in Germany, evidence to the efficacy of multimodal PTSD rates between 18% and 40% and treatment and suggests that improvements in for depression between 22% and 55% have symptom severity can be achieved within the been reported (Butollo & Maragkos, 2012; often extremely stressful period after arrival. Führer, Eichner, & Stang, 2016; Gäbel, Keywords: Refugees, asylum seekers, trauma, Ruf, Schauer, Odenwald, & Neuner, 2006; multidisciplinary, short-term treatment, Richter, Lehfeld, & Niklewski, 2015). stepped care, early interventions, PTSD Due to a lack of representative studies in Germany, the findings in these studies were Introduction only preliminary. Global forced displacement has increased A number of factors can affect the and many people flee their homes due complexity and severity of a mental to war, armed conflict, torture and other disorder after trauma, such as the gravity systematic human right violations. Current and duration of the trauma, the number of estimates project that there are 65 million cumulative traumatic events, experiences refugees, most of which are internally associated with feelings of shame and displaced persons (UNHCR, 2016). In 2015 guilt, few personal resources to deal with and 2016, altogether 1,164,269 asylum and compensate the trauma, as well as the requests were submitted to the German situational context after the traumatic event Federal Agency of Migration and Refugees (Brewin et al., 2017; Herman, 1992; Wenk- with 36.5% of asylum applicants coming Ansohn, 2017). from Syria, 13.6% from Afghanistan, and Post-migration stressors such as 10.8% from Iraq (Bundesamt für Migration problems with the asylum process or difficult und Flüchtlinge [German Federal Agency of living conditions may hinder refugees to Migration and Refugees], 2017). In addition feel safe in their host country and therefore to the potentially traumatic experiences in aggravate psychological disorders. Several their home countries, refugees are often studies demonstrated that the extent of confronted with further potentially traumatic post-migration stressors was associated experiences during their flight and ongoing with psychological distress (Nickerson, stressors in their host country (Lambert & Schick, Schnyder, Bryant, & Morina, 2017; Alhassoon, 2015). The traumatization is Schweitzer, Melville, Steel, & Lacherez, often experienced sequentially (i.e. before, 2006). These studies also suggested that during and after the flight), increasing the refugees who have been traumatized in the risk for the development of severe mental past may have a greater vulnerability to health problems, such as posttraumatic develop adverse mental health outcomes stress disorder (PTSD) or depression such as PTSD when confronted with post- (Bogic, Njoku, & Priebe, 2015; Fazel, migration stressors. Wheeler, & Danesh, 2005). Average rates Depending on their experiences prior, of 25-30% for PTSD and 30-43% for during and after their flight, refugees may depression have been reported among suffer not only from PTSD or depression, populations exposed to mass conflict and but also from adjustment disorders,
TORTURE Volume 28, Number 2, 2018 Volume TORTURE displacement (Chung et al., 2018; Slewa- suicidal tendencies, somatic symptom 101
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disorders, anxiety, impulse control disorders, care approaches seem generally useful to severe dissociative disorders, substance adequately meet the demand and to ensure abuse, prolonged grief, or even enduring an overall better health care provision personality change after catastrophic for this patient group and to offer care experiences (Priebe, Giacco, & El-Nagib, as soon as possible. Figure 1 displays the 2016). Additionally, pre-existing or newly various levels of an intervention pyramid developed physical illnesses due to stress for traumatized refugees adapted from the might develop or become more aggravated intervention pyramid for humanitarian (Gurris & Wenk-Ansohn, 2013). catastrophes (IASC Guidelines, Inter- Although refugees are at high risk of Agency Standing Committee, 2007) and psychological impairment, their access to adjusted to the conditions of a developed the German health-care system is initially health care system in Western host countries restricted (Bozorgmehr & Razum, 2015). (see Wenk-Ansohn, 2017). A transfer from Even when after 15 months this structural one level to the next is possible, depending restriction to the welfare system is lifted, on the needs of the survivors over time the lack of interpreters and resulting similar to a “stepped care-model” (see communication difficulties often impede NICE-Guidelines for PTSD, National access to adequate care. Specialized Institute for Health and Care Excellence psychosocial centers offer comprehensive (NICE), 2005). care and treatment, taking into account Adequate material and social reception the diverse problems faced by refugees. conditions for refugees form a basic requisite However, these centers usually have limited in order for medical and psychotherapeutic capacities and are not available in every part measures to be effective. In the European of Germany. As a result, the mental health Reception Directive (Art. 19 Par. 2 RL care provision in Germany, as well as in 2013/33/EU, European Union, 2013), other European countries, is insufficient, consideration and care for the special leaving a great number of refugees without needs of vulnerable groups is demanded— necessary treatment (Bozorgmehr & Razum, but many European countries are yet to 2015). Figures for 2015 show that an implement this guideline (CIR Rifugiati, estimated 379,848 refugees were in need of 2017; Leisering, 2018). mental health treatment in Germany, but only about 5% actually received treatment Specialized care (Bundesweite Arbeitsgemeinschaft der Specialized centers for the medical and psychosozialen Zentren für Flüchtlinge und psychosocial rehabilitation for victims of TORTURE Volume 28, Number 2, 2018 Folteropfer (BAfF) [German Network of war and torture (in Germany organized Rehabilitation Centres for Refugees and under the umbrella organization BAfF) Survivors of Torture], 2016). Thus, many offer comprehensive care and treatment traumatized refugees did not find access to for refugees who are victims of war- the regular mental healthcare system during related violence, torture or other human the vulnerable period after arrival in the rights violations. This is mostly realized host country. with a multidisciplinary and multimodal Depending on the needs of the approach, which differs to a large extent patients as well as on the locally existing from out-patient primary care provided mental health care structures, stepped by hospitals and resident psychiatrists or 102
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Figure 1: Elements of adequate health care
Source: Adapted from Inter-Agency Standing Committee (2007).
psychotherapists. Nonetheless, where no The multimodal approach addresses specialized center is accessible, establishing the broad spectrum of problems refugees networks of different professions can provide present following exposure to torture or war- similar levels of care. related traumatic events, subsequent post-- Usually, multimodal treatment refers migration stressors, as well as resettlement to the application of different interventions and acculturation challenges by providing and multidisciplinary approaches refer to medical, psychotherapeutic and psychosocial the collaboration of persons with different assistance, as well as legal support during professional backgrounds. Multimodal the asylum procedures. This approach and multidisciplinary approaches requires knowledge of psycho-traumatology, often go hand in hand, meaning that a at various levels (body, mind, social multimodal treatment is carried out by a field), cultural awareness, and specialized multidisciplinary team and the terms are interpreters (Maier & Schnyder, 2007; often used interchangeably. For reasons of Pabst, Gerigk, Erdag, & Paulsen, 2013; brevity, in the following we only use the Sjölund, Kastrup, Montgomery, & Persson, term “multimodal” when referring to both 2009). The aim of a multimodal approach is multimodal and multidisciplinary treatment. to offer the patients an individually tailored TORTURE Volume 28, Number 2, 2018 Volume TORTURE 103
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psychotherapeutic concept by taking into receive regular supervision with regard to account the individual’s syndrome, their complex and problematic cases, potential limitations in day to day life, their current secondary traumatization as well as setting, situational context, their cultural heritage methods and cultural issues. Depending as well as their level of education (Silove, on the indication presented by the patient, Ventevogel, & Rees, 2017). Thereby, a treatment in the center is offered in various close cooperation between the attending settings, such as the outpatient clinic for physicians, therapists, lawyers and social adults, the outpatient clinic for children and workers is necessary. Integrated and well- youth, a day clinic and a specialized service coordinated social support fostering the for traumatized women. In order to meet the patient’s autonomy and inclusion into the higher influx of refugees to Germany from host society is necessary for treatment and 2013 onwards and to offer specialized care rehabilitation measures to have an effect to persons with an immediate and high need (Brandmaier & Ahrndt, 2012; Gissendanner, of care and treatment, the outpatient clinic Callies, Schmid-Ott, & Behrens, 2013; for adults developed an acute treatment Wenk-Ansohn, Weber-Nelson, Hoppmann, program for newly arrived traumatized & Ahrndt, 2014). This approach not only refugees. It was hypothesized that the aims at alleviating symptoms, but also at early access to adequate care can reduce supporting the rehabilitation process and the symptom severity and also the risk of in order to include the refugees as best as chronification of trauma-related disorders. possible in the host society. The acute program focuses on stabilizing and supporting patients in the particularly Treatment programs at Center ÜBERLEBEN vulnerable period after their arrival with according to individual indication a short-term multimodal approach of The center is a specialized non- up to six months as outlined below. For governmental organization for the treatment refugees who already lived in a more and rehabilitation for survivors of torture stable context (e.g. secure residence status, and war-related violence. Treatment living conditions), but who suffered from follows the aforementioned multimodal complex and mostly chronic posttraumatic approach including culturally sensitive symptoms, the outpatient clinic continued medical, psychiatric, psychotherapeutic to offer a long-term multimodal treatment and social treatment services. If indicated, and rehabilitation program. The long- supplementary body and creative therapeutic term program focuses on trauma- modules are integrated (Wenk-Ansohn et al., oriented psychotherapy in combination TORTURE Volume 28, Number 2, 2018 2014). The psychotherapists at the center with integrated clinical social support have a medical or psychological background and lasts on average 1.5 years (Wenk- and are trained as psychotherapists in a Ansohn et al., 2014). A recent evaluation cognitive-behavioral, psychodynamic or demonstrated that the long-term program systemic approach. In addition, they received was accompanied by a significant decrease trauma-therapeutic trainings. Therapy in trauma-related psychological symptoms sessions are conducted with the help of and an increase in subjective quality of professional interpreters who are specially life (Stammel et al., 2017). After-care is trained for psychotherapeutic settings (i.e. available for patients after discharge from technically and psychologically) and who either program. 104
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First consultation and acute short-term specialized interpreter. It covers the client’s treatment program symptoms, overview of the personal history, Treatment-seeking refugees are mostly needs (psychosocial, psychiatric and referred to the center through their refugee psychotherapeutic), and her/his motivation shelters, through hospitals or through to take part in therapy. At the end of this lawyers or they learnt about the center initial interview, it is determined whether and its services through their community. there is an indication for further diagnostics Refugees who are interested to enter a and treatment in the center and which of the therapy program at Center ÜBERLEBEN support programs will be offered. In case of can arrange appointments for a personal non-admission to the treatment services, a interview in a weekly telephone consultation referral to the public healthcare system or hour. During the telephone consultation, the network of NGOs for psychosocial and a first screening takes place to assess legal support is offered. Usually the therapy whether the treatment-seeking person requests exceed the center’s capacities by is likely to fulfil the eligibility criteria at far, so that only persons who are severely Center ÜBERLEBEN (victims of war and/ affected will be admitted to the programs. or torture, trauma-related psychological Inclusion criteria for the acute problems, need for treatment with multimodal treatment program requires interpreters). If the person is likely to patients to be newly arrived in Germany fulfil these eligibility criteria, and if there (weeks or a few months), to show acute is capacity for intake, an extensive initial trauma- and stress-related symptomatology clinical interview is offered (see Table and to have a current unstable context with 1). This interview is conducted with a regard to the asylum procedure and/or living psychotherapist, a social worker and a conditions. Most of the patients admitted to
Table 1: Steps before, during and after the initial interview with a specialized interpreter
Before interview Telephone consultation to register, clarify symptoms, and if appropriate refer to other external offers. During interview Current Symptoms. Biographical background and potentially traumatic experiences (overview). Current stressors. Social situation and asylum status, lawyer. Motivation for treatment. Prior diagnostics and treatment. At the end of Preliminary diagnoses; in cases of no diagnoses, consultation on whether other interview problems present, e.g. main emphasis on current unstable life situation or other external factors. Motivation for therapy. Indication for treatment.
Decision Which measures/treatments are indicated? Which measures can be offered, which cannot? (where applicable: concluding counselling and referral). Decision whether acute intervention or a long-term psychotherapeutic treatment process is indicated. If admitted to the acute program treatment, it starts as soon as possible after the initial interview. TORTURE Volume 28, Number 2, 2018 Volume TORTURE 105
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Table 2: Elements and steps in the acute acute program, patients commonly required short-term program support with their asylum application, accommodation and with restoring contact with lost relatives. Later, help was needed In case of admission to the acute treatment program: to access language courses, vocational 1. Clinical diagnostic phase—if applicable: preparation courses, or job opportunities documentation of somatic injuries, and in general. After a successful asylum if needed preparation of a professional application, support might have been needed psychotherapeutic statement for the asylum during the family reunification process. Also, process. 1. Psychological standardized assessment more psychiatric differential diagnostics (T1). (e.g. to exclude psychosis, dissociative 2. Up to 25 individual therapy sessions states, suicidal ideation) and treatment (psychiatric, psychotherapeutic, social with an anti-depressive medication with therapy). sleep-inducing properties was prescribed 3. If indicated, in addition—up to 12 group therapy sessions (psychoeducation and body in many cases, although taken largely only therapy). temporarily in the first moths after intake. 4. Along the therapeutic process, integrated In many cases, crisis interventions were autonomy promoting social work. needed in situations of overwhelming 5. If children accompanied patients, initiation current stressors, such as a negative decision of appropriate help for the children (child- monitoring). concerning the asylum application, or 6. Psychological standardized assessment at confrontations with trauma-associated the end of the program (T2). triggers in the accommodation. Likewise, 7. If necessary: after-care. news about renewed conflict at home, where > the modules are applied in a flexible family members might be in danger, often manner according to the individual’s needs. caused major crises. In some patients, these experiences triggered suicidal tendencies the acute program at intake lived in mass- and a temporary admission to a psychiatric housings or provisory shelters. hospital became necessary. Table 2 provides an overview of Though patients benefitted from group the elements applied within the acute therapy, they also reported that individual multimodal short-term treatment program. psychotherapy sessions were of central The case example further exemplifies the importance to them. Individual sessions first consultation. focused on stabilizing and resource-oriented
interventions as well as grief counselling. TORTURE Volume 28, Number 2, 2018 Reflections by the therapeutic team Furthermore, a narrative approach formed Practical experience with the acute program an integral part of the acute program was gathered in team workshops in order (testimonial therapy; Agger, Raghuvanshi, to adjust our procedures to the challenge Shabana, Polatin, & Laursen, 2009), which of delivering a type of service that was aimed at reconstructing the biography new to us. We observed that newly arrived including traumatic experiences. In many asylum seekers had a higher need for legal cases, the life line method (manualized by counseling provided by social workers Schauer, Neuner, and Elbert (2011)) was compared to patients in the long-term used to identify traumatic as well as positive therapy program. In the early stages of the life events without going into in-depth 106
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Case example and reflections by the therapeutic team
Case study (part I) trapped and that sometimes he had Mr. A. arrives for a first consultation even considered ending his own life. at the Berlin Center ÜBERLEBEN. When asked about difficult experiences He reports that he is 32 years old in Syria, he discloses that he had been and arrived from Syria two months imprisoned in Damascus for two years ago. Currently he suffers from sleep and that a number of his political friends disturbances such as trouble falling and had died during incarceration and that staying asleep. He describes nightmares, he also has scars from torture. During where scenes of torture and bombing the first consultation he does not want occur, with accompanied feelings of to go into further details about his fear and arousal. He reports that, in experiences during his imprisonment. his dreams, he also sees his wife and He reports that his family paid money son yelling for help in their bombed- to get him released from prison. Also, out home, a scene he had not directly that he witnessed bombings and that witnessed. He reports being restless and he transported injured persons with irritable, whilst experiencing hopelessness his van. When asked about the course and feelings of increasing tiredness, guilt of his symptoms, Mr. A. mentions and uselessness in combination with having nightmares since release from worries that he might not be able to prison, albeit more severe since arriving bring his family to Germany. He reports in Europe and that he feels hopeless that he had taken the overland route and and without energy (he begins to had been arrested, beaten and registered cry). He’s currently living in a refugee by the Bulgarian border police. Now shelter and feels ashamed because he he faces the threat of deportation to screams in his dreams. Due to his acute Bulgaria due to the ‘Dublin procedure’. symptomatology and his ongoing unsafe He describes the living conditions for and stressful situation, he is admitted to a refugee family in Bulgaria as being the acute program where support will inhumane. He mentions that he feels start immediately.
exposure. The life-line method focuses on with the narrative approach, the traumatic bringing life experiences into a coherent experience is disclosed as far as possible in narrative and providing some cognitive the actual psychological status, allowing the restructuring inputs or interventions therapist in later stages of the therapeutic concerning psychodynamic aspects. Patients process to expand on it when working evaluated the possibility of communicating with individual triggers, on contents of their experience to an empathic and neutral nightmares, and feelings of powerlessness, listener, who set a framework and limited shame and guilt (Boos, 2005). the amount of the exposure to a bearable We were able to discharge most of the limit, as helpful and relieving. By working participating patients within the six-month TORTURE Volume 28, Number 2, 2018 Volume TORTURE 107
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period of the acute program, whereas only program by examining changes in PTSD, a minority of the patients indicated a need anxiety and depression symptom severity in and motivation to continue therapy in the the course of treatment. We hypothesized scope of the trauma-oriented long-term that patients even in this early phase of their therapy program. The majority reported asylum process and under conditions of that after having received intensive support ongoing post-migration stressors can benefit in the early stage after flight from the acute from a multimodal treatment approach by program, they then felt sufficiently stabilized showing a decrease in PTSD, anxiety and to manage their daily life in exile. They had depressive symptoms, thus enabling them to become more active and started to visit better manage their life in exile. language or professionalizing courses. Many During the diagnostic phase at of those who had gone through the acute the beginning of the acute program, a program, especially those who were still psychological standardized assessment was waiting to hear about their asylum claim, or carried out assessing exposure to traumatic ongoing worries about their family in their events and symptom severity of PTSD, country of origin made use of low frequency depression and anxiety (T1). Exclusion appointments or crisis interventions on criteria for the standardized assessment were demand within our after-care offer. acute suicidality, severe dissociative disorder Working with newly-arrived, severely or psychotic symptomatology. Following traumatized refugees was highly demanding completion of the acute program after for the team of the outpatient clinic. The approximately six months (M = 201 days; therapists and interpreters had insights into SD = 83), a second standardized assessment the atrocities the patients had gone through. was carried out (T2). The team was often confronted with critical The data included in the present study states, dissociative fits and suicidal tendencies were collected between February 2015 and of their patients. To reduce the strain of the May 2017. During that period, 1,484 persons team and prevent compassion fatigue (Figley, made use of the telephone consultation 1995), multidisciplinary case conferences seeking advice or a place for treatment. Based and external supervisions of all persons on this consultation, an initial interview for involved in the care setting was necessary. 359 people was carried out at the outpatient Also, the option to debrief after a particularly clinic for adults, thereafter 169 persons were straining session was important for the team assigned to the short-term acute treatment members working in the acute program. approach as they fulfilled the inclusion
Without the option to share and discuss as criteria. Moreover, 190 persons were either TORTURE Volume 28, Number 2, 2018 well as supporting each other, therapists and assigned to the long-term treatment approach interpreters were at a high risk of burnout, of the center or referred to other internal or whereas sharing and also communicating external offers. Of the 169 persons assigned successes helped to alleviate the strain and to the short-term acute treatment approach, brought energy and job satisfaction. 92 persons completed the standardized mental health assessment by filling in the Method questionnaires. 77 persons were excluded The purpose of the present study was to from the standardized assessment due to evaluate the progress of patients participating fulfilling one the exclusion criteria (see in the short-term multimodal acute treatment above). In most cases, the questionnaires (i.e. 108
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Case study (part II) Overall, at the end of the acute Upon admittance, Mr. A. showed program, the depressive and PTSD- symptoms related to PTSD after a series symptoms had significantly decreased, of sequential traumatic experiences the PTSD symptoms still being above while simultaneously suffering from the cut-off point. Mr. A. did not accept a depressive syndrome as a result of the offer to continue his treatment in the current ongoing stressful situation. terms of a long-term trauma-oriented Due to his depressive symptoms and psychotherapy. He was at the point in order to alleviate his sleep problems, of prioritizing his practical life in he was prescribed an anti-depressive Germany. He provided the feedback medication (Mirtazapine 30mg), that the program had helped him which he took for only three months. immensely, and that he also learned The social worker organized Mr A.’s that therapeutic conversations worked. participation in a German language He asked if he could report back to us course and recommended a lawyer if the symptoms persisted or became for the asylum process. Subsequently, worse. To support his desire to start Mr. A. was willing to talk about his working as soon as possible, the social experiences during his imprisonment. worker was able to organize a vocational Scars from injuries where documented preparation course. according to the Istanbul Protocol Mr. A. returned twice in the frame (United Nations High Commissioner for of aftercare requiring assistance in Refugees, 2001) and a comprehensive managing crisis situations. The family professional statement was prepared. reunification request took time and Additionally, the patient took part in a during both crises bombing in Syria psychoeducative group. A major topic caused the telephone connection to in the individual psychotherapeutic disconnect. Both times, Mr. A. despaired sessions was his feeling of guilt towards and even considered going back to his family, whom he had to leave behind Syria. After approximately six months, during his flight, and towards the fellow he arrived at the center without an inmates in prison, some of whom died appointment. He was radiant with joy during incarceration. and had his wife and two kids (a girl, 10 The Federal Office for Immigration years of age, and a boy, 5 years of age) and Refugees (BAMF) decided not with him. We had a small celebration to activate the Dublin procedure and together. However, his wife reported processed his request for asylum in that her daughter often screamed in her Germany. He was granted asylum sleep and was overly introvert. Thus, we according to the Geneva Refugee organized a first consultation with an Convention, which relieved him Arabic speaking children and adolescent immensely, especially since he was now psychiatrist for diagnostic and parental able to request a family reunification counselling (child monitoring makes with the support of the social worker. part of the program). TORTURE Volume 28, Number 2, 2018 Volume TORTURE 109
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T1 and T2) were carried out via face-to-face Davis, Witte, & Domino, 2015). Items are interviews with clinical psychologists and rated on a five-point Likert scale ranging interpreters while some patients filled out from 0 “not at all” to 4 “extremely”. A the questionnaires in their own homes by preliminary cut-off of 33 suggested to themselves. Informed consent was obtained indicate a severity of PTSD symptoms at from every participant at T1. a clinical level (Weathers et al., 2013). The PCL-5 shows good psychometric properties Instruments (Blevins et al., 2015). In the current sample, Sociodemographic information included Cronbach’s alpha was .82. gender, age and country of origin. The number of either psychotherapy, social Depression and Anxiety: The Hopkins work, group therapy and psychiatric Symptom Checklist-25 (HSCL-25) is a 25- treatment sessions the patient had received item questionnaire based on self-report data was noted according to our digital containing two subscales which measure patient documentation. These included symptoms of anxiety (items 1 – 10) and questionnaires (described below) which depression (items 11 – 25) (Derogatis, 1974). were translated into Arabic, Farsi, Turkish It is a well-established screening instrument and Russian and then back-translated by and has been widely used in a number of an interpreter unfamiliar with the original different cultural contexts (Ventevogel et version. Discrepancies between translation al., 2007). Each item is ranked on a four- and back-translation were discussed point Likert scale from 1 “not at all” to until a final version was agreed upon 4 “extremely”). To interpret the results, following a rigorous translation process as the mean value of each of the subscales recommended for cross-cultural research is calculated and a cut-off value of >1.75 (Guillemin, Bombardier, & Beaton, 1993). is suggested to identify clinically relevant symptomatology. Current evidence supports Traumatic Events: Traumatic events were the construct validity and reliability of the assessed using an adjusted list based on Arabic version of the instrument (Selmo, two standardized instruments, the Harvard Koch, Brand, Wagner, & Knaevelsrud, 2016). Trauma Questionnaire (Mollica et al., 1992) Cronbach’s alpha in this sample was α=.85 and the Posttraumatic Diagnostic Scale for anxiety and α=.86 for depression. (Foa, Cashman, Jaycox, & Perry, 1997). Therefore, 24 traumatic events were assessed Participants altogether, including one item allowing The total sample at T1 consisted of N = TORTURE Volume 28, Number 2, 2018 participants to indicate an additional 92 participants. Approximately 80 per cent traumatic event. Participants were asked were male (81.5%; n = 75). The sample had whether they had personally experienced, a mean age of M = 31.25 years, SD = 9.05 witnessed, or heard/learnt of the event. (range: 18-55). The majority of participants came from Syria (n = 48, 52.2%), 12.0% PTSD: The Posttraumatic Stress Disorder (n = 11) from Afghanistan, 7.6% (n = 7) Checklist for DSM-5 (PCL-5) is a screening from Iraq, and 7.6% (n = 7) from Turkey, instrument for PTSD including 20 items others came from Iran, Iraq, Pakistan, that correspond to the diagnostic criteria Egypt, Chechnya, Somalia, Eritrea, Libya or of PTSD of the DSM-5 (Blevins, Weathers, Lebanon (Palestinians). 110
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Data for exposure to traumatic events of 3.03 (SD = 0.62). Finally, 93.5% (n = were available for only 77 participants. 86) of the patients scored above the cut-off The most frequently reported personally for anxiety with a mean symptom severity of experienced traumatic events were “being 2.92 (SD = 0.71). close to death” (n=68, 87.2%), “exposure to combat situation” (78.9%, n= 60) and Patients with pre-post test diagnostics (n = 44) “assault by a stranger” (76.9%, n= 60). For pre-post comparisons, data were available Torture (as defined by UNCAT) was for n = 44 participants (n=35 (79.5%) male; reported by 70.1% (n=54) on the traumatic age M = 30.64, SD = 9.46). In total, 48 events list. Of the 92 patients who completed participants did not fill out the post assessment T1, 44 completed T2 assessments. (T2) due to several reasons: several patients were released from treatment earlier than three Statistical Analyses months after T1 or dropped out of treatment, Missing data were analyzed for systematic one patient was deported to Spain under the patterns. Missing data in the pre-post Dublin procedure; some were discharged comparison (n=44) were missing completely after six months without a final assessment at random (MCAR) and were replaced after having missed the appointment for the separately for pre and post data using final testdiagnostic assessment repeatedly, Estimation Maximation methods (Tabachnick seven patients with ongoing difficulties in & Fidell, 2001). T-tests and the chi-square managing a day-to-day structure were referred test were applied to test whether completers to intensive daily care at the day clinic or the and non-completers differed in terms of women’s housing program of the center and sociodemographic variables or symptom about 20% of patients initially admitted for the severity of PTSD, depression, and anxiety. acute program were transferred to the long- For pre-post comparison, completer analyses term treatment program. However, completers were conducted. Paired sample t-tests were and non-completers did not differ from each individually performed for PTSD and each other in any of the sociodemographic variables of the PTSD symptom clusters, anxiety, and age (t(90) = 0.62, p = .54) or gender (χ2 = depression. Cohen’s d was calculated as a .22, p = .64), nor the severity of symptoms measure for the respective effect sizes (d = of PTSD (t(90) = 0.16, p = .87), depression .20: small effect, d = .50: medium effect, d = (t(90) =-0.79, p = .43) and anxiety (t(90) = .80: large effect, according to Cohen (1988)). -0.26, p = .80) at the initial assessment (T1). All statistical analyses were conducted using At the beginning of treatment (T1), SPSS, version 24. four of the 44 participants (9.1%) had been granted asylum, while 31 (70.5%) were still Results in the asylum process. The remaining nine Severity of symptoms at T1 (N = 92) patients had either been denied asylum Of the entire sample (N = 92), 95.7% (n (n=1), were temporarily protected from = 88) fulfilled the criteria for PTSD as deportation (n=1), or were undergoing the measured with the PCL-5 with a mean Dublin regulation (n=7). severity of symptoms of M=54.25 (SD = At T2, 13 (29.5%) had been granted 11.79). Similarly, 95.7% (n = 88) scored asylum and 23 (52.3%) were still in the above the cut-off of 1.75 for depression on asylum process. From the remaining
TORTURE Volume 28, Number 2, 2018 Volume TORTURE the HSCL-25 with a mean symptom severity patients, six (13.6%) where temporarily 111
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protected from deportation, and two (4.5%) significant decrease in symptom severity for still faced the Dublin regulation. depression, anxiety, and overall PTSD. While All patients received psychotherapy and the PTSD symptom clusters ‘intrusion’, at T2, patients had received an average of ‘changes in mood,’ and ‘cognition,’ and 14 individual sessions of psychotherapy ‘alterations in arousal and reactivity’ show (M = 13.68, SD = 8.22). 63.4% (n = 28) a significant decrease in severity, the cluster also received psychiatric sessions (about ‘avoidance’ increased slightly, however to 4 sessions on average (M = 3.86, SD = a non-significant degree. Effect sizes for 3.45) but not all of those were treated with reductions of depressive and overall PTSD a medication. The majority of patients symptomatology, PTSD intrusions, PTSD received social work (n = 38, 86.4%) and alterations in arousal and reactivity can be had an average of four sessions of social classified as large, whereas the effect size work (M = 4.48, SD = 2.84). About half for the reduction of anxiety symptoms and of the patients had participated in group PTSD changes in mood and cognition can therapy (n = 24, 54.5%) and received be classified as medium according to the on average six sessions of group therapy conventions of Cohen (1988). (including psychoeducation and body work; While at the beginning of treatment M = 5.58, SD = 3.48). (T1), 97.7% (n=43) fulfilled diagnostic criteria for each PTSD and depression, Pre-Post comparison (n = 44) and 95.5% (n=42) for anxiety, at T2, Table 3 presents pre- and post-comparison 70.5% (n=31) still fulfilled the criteria for data and results of the dependent t-test for clinically relevant PTSD, 79.5% (n=35) for all symptom clusters. Results indicate a depression and 70.5% (n=31) for anxiety.
Table 3: Means and standard deviation for pre and post data (n=44)
T1 T2 T (df) p Cohen’s d [95% CI] M (SD) M (SD)
PTSD 54.04 (11.65) 42.19 (15.20) 5.32 (43) <.001 0.88 [0.26–1.49]
Intrusion 15.39 (3.44) 11.50 (4.71) 5.08 (43) <.001 0.94 [0.32–1.57]
Avoidance 4.71 (2.65) 5.55 (2.32) -1.66 (43) .10
Changes in 18.11 (5.59) 14.10 (6.09) 3.98 (43) <.001 0.69 [0.08–1.29] TORTURE Volume 28, Number 2, 2018 mood and cognition
Alterations in 15.83 (4.14) 11.04 (6.00) 5.75 (43) <.001 0.93 [0.31–1.55] arousal and reactivity
Anxiety 2.94 (0.68) 2.41 (0.88) 3.86 (43) <.001 0.67 [0.07–1.28]
Depression 3.08 (0.55) 2.53 (0.76) 4.40 (43) <.001 0.83 [0.21—1.45]
Note: abbreviations: df= degrees of freedom CI= Confidence Interval, M= mean, SD= standard deviation, T= t-test, p = significance level 112
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Discussion need for treatment were admitted to the The aim of the study was to evaluate treatment, so that patients had on average the short-term multimodal acute very high symptom loads at the beginning treatment at the outpatient clinic at of treatment. An earlier meta-analysis has Center ÜBERLEBEN. The results show shown that high pre-treatment PTSD a significant decrease in symptomatology severity was predictive of smaller treatment between pre- and post-treatment effects than moderate symptom severity measurement for overall PTSD, anxiety, at intake (Haagen, Smid, Knipscheer, and depression. Despite the extremely & Kleber, 2015). Second, refugees are high symptom load at the beginning of confronted with a wide range of ongoing treatment, the uncertainties regarding stressors. After discharge from our acute residence status, and the often ongoing program, more than half of our patients were difficult living conditions in refugee still waiting for an asylum decision or for accommodation, patients seem to benefit family reunification, and most of the patients from the multimodal short-term treatment. were still living in refugee accommodation. Large effect sizes were found with regard to These factors may have substantially reductions in overall PTSD and depression contributed to an increased symptom and a medium effect size was found for severity (Nickerson, Steel, Bryant, Brooks, & reductions in anxiety symptoms. This adds Silove, 2011; Schock et al., 2016). to previously inconsistent findings on the The long-term course of the wellbeing efficacy of multimodal treatment which in of traumatized refugees not only depends some cases has not found any changes in on successful therapeutic and psychosocial PTSD, depression and anxiety between interventions but to a large part on the pre- and post-treatment assessments (Birck, safety, living-conditions and social openness 2004; Carlsson, Mortensen, & Kastrup, of the country of exile. Therefore, part of 2005; Mollica et al., 1990), while other our acute program was to document their studies have found significant reductions history and write expert opinions for the in symptom severity (Arcel et al., 2003; asylum procedure. Patients who still suffered Brune, Eiroa-Orosa, Fischer-Ortman, & from reactive psychological symptoms at Haasen, 2014; Palic & Elklit, 2009; Stammel or following the end of the acute program, et al., 2017). However, assessments at T2 could attend the aftercare program of showed that after treatment, about 70% of the outpatient clinic that offered further the patients still scored above the cut-off support with low frequency sessions or crisis for PTSD and anxiety and about 80% for interventions, when necessary. depression. Previous research shows that Results further showed that while refugees often still suffer from high rates symptom severity in the PTSD symptom of psychopathology, after treatment (de clusters ‘intrusions’, ‘changes in mood and Heus et al., 2017; Schock, Böttche, Rosner, cognition’, and ‘alterations in arousal and Wenk-Ansohn, & Knaevelsrud, 2016; reactivity’ significantly decreased, the mean Stammel et al., 2017). There are several symptom severity in ‘avoidance’ did not reasons why refugees may benefit less from change. This finding may be explained by psychotherapy compared to non-refugee the fact that the acute short-term treatment patients. First, with respect to this study, program, primarily focused on supporting
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symptoms, and trauma-associated triggers, First, this study was conducted without a an approach that may not be sufficiently control group. It is therefore not possible effective to treat avoidant behavior in to state whether the effects found can be PTSD. In personal feedback, some patients attributed to the intervention itself or rather revealed that when responding to the to spontaneous remission of symptoms, or questionnaire they had indicated avoidance to the effects of attention received by the because they had improved their ability to patients within the therapeutic relation. control trauma-related triggers consciously. However, due to the ongoing stressors For example, they would not watch news and uncertainties regarding residence and about war-related developments in their housing situation, substantial changes in home country late at night anymore, the symptom load without therapeutic which in turn had resulted in better sleep interventions cannot be expected. As many and a reduction in nightmares. A trauma- patients were male family fathers whose focused approach, that in various studies families were still in the conflict-affected was demonstrated to be an efficacious regions, having a regular appointment approach to treating PTSD in war-exposed with a supportive listener may have been refugee populations (see meta-analysis by particularly effective in dealing with feelings Lambert & Alhassoon, 2015), was not the of guilt, hopelessness and loneliness. primary focus of this program. The reason Although it would be advisable for future behind not primarily conducting a trauma- research to use control groups to measure focused approach was that not only war- or the efficacy of multimodal interventions flight-related trauma were the cause for the as compared to a waiting list, it has to be patients’ symptomatology, but also post- noted that for ethical reasons, it is difficult migration stressors such as uncertainty to have a waiting list for a period of six regarding residence status in the host months when offering therapeutic support country and worries about family members for traumatized persons in an acutely who were still exposed to war in their home stressful situation. countries (Miller & Rasmussen, 2010), or Second, for a variety of reasons, about even wounded, killed or missing. An in- half of the patients assessed at T1 did not depth processing of traumatic memories participate in the second assessment. Thus, during the phase of acute stressors was not we cannot rule out the possibility that a indicated in this early period of migration selection bias occurred in the sense that since the traumatic process the patients only those patients who benefitted from were in was still ongoing (Flatten et al., therapy were assessed at the second time TORTURE Volume 28, Number 2, 2018 2011). Although the acute program only point. However, patients did not differ from allowed a mild trauma-focused approach, each other with regard to sociodemographic pre to post treatment assessment indicated data or symptom severity at T1, so that a a significant reduction of symptoms systematic reason for the dropout from the including PTSD even after the relatively second assessment could not be identified short treatment period of six months. in this regard. Furthermore, we performed a completer-analysis, which generally shows Limitations of the study larger effects than intention-to treat analysis Several limitations of the study should be and is therefore at risk of overestimating the considered when interpreting the results. treatment effect. 114
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Third, the interventions applied were methodological shortcomings, this study adds not standardized but therapeutic modules further preliminary evidence to the efficacy were applied in a flexible way. Thus, the of multimodal treatment and shows that evaluation at hand does not allow conclusions improvements in symptom severity can be about effective components responsible achieved even within the vulnerable period for improvements in symptomatology. The after arrival in the host country. current analysis was conducted in a natural setting with the primary objective to provide Acknowledgements multimodal treatment tailored to the needs We would like to thank Benedikt Taud of these patients. The scientific objective was for the translations and Maike Stolz for only secondary and the data should therefore the preliminary analyses. We would like be seen as preliminary and explorative. to express our gratitude towards the Fourth, we used different language versions specialized interpreters at our center of each questionnaire, which might result in for their support in collecting the data. a bias in responsiveness. However, we used Furthermore, we thank our patients who the recommended procedure for translating agreed to take part in this study. questionnaires to ensure a rigorous translation process. References Agger, I., Raghuvanshi, L., Shabana, S., Polatin, P., & Laursen, L. K. (2009). Testimonial therapy. A Conclusions pilot project to improve psychological wellbeing This study evaluated an acute short-term among survivors of torture in India. Torture multimodal treatment program for newly- 19(3), 204-217. arrived traumatized asylum seekers and Arcel, L. T., Popovic, S., Kucukalic, A., Bravo- provided reflections on the experiences Mehmedbasic, A., Ljubotina, D., Pušina, J., & Šaraba, L. (2003). The Impact of within this program. Our results suggest that Short-term Treatment on Torture Survivors. the early access to this type of treatment The Change in PTSD, Other Psychological seems to result in significant decreases in Symptoms and Coping Mechanisms after trauma-related symptoms. So far, the results Treatment. In: Treatment of torture and trauma survivors in a post-war society. Association for of the acute program have been promising: Rehabilitation Torture Victims; Center for On admission, all patients who took part in Torture Victims, Sarajevo. the survey were severely strained and more Birck, A. (2004). Symptomatik bei kriegs-und than 95% of patients were suffering from folterüberlebenden Flüchtlingen, mit und ohne Psychotherapie. Zeitschrift für Klinische Psychologie severe symptoms of PTSD, anxiety and und Psychotherapie; Forschung und Praxis, depression. Results show that within the 33(2), 101-109. http://doi.org/10.1026/0084- six-month period of the acute program, it 5345.33.2.101 seems possible to stabilize the majority of Blevins, C. A., Weathers, F. W., Davis, M. T., Witte, T. K., & Domino, J. L. (2015). The posttraumatic patients. However, we do not yet know if the stress disorder checklist for DSM‐5 (PCL‐5): reduction of symptom levels is stable over Development and initial psychometric evaluation. time and if the program helped patients in Journal of Traumatic Stress, 28(6), 489-498. http:// their participation in the host society. We doi.org/10.1002/jts.22059 Bogic, M., Njoku, A., & Priebe, S. (2015). Long- assume that some participants of the acute term mental health of war-refugees: a systematic treatment program will later on sign up for literature review. BMC International Health and further trauma-oriented psychotherapy due Human Rights, 15(1), 29. http://doi.org/10.1186/ s12914-015-0064-9
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Boos, A. (2005). Kognitive Verhaltenstherapie nach Health and Health-Related Quality of Life chronischer Traumatisierung: Ein Therapiemanual. in Tortured Refugees in Multidisciplinary Göttingen: Hogrefe Verlag. Treatment. Journal of Nervous and Mental Disease, Bozorgmehr, K., & Razum, O. (2015). Effect of 193(10), 651-657. http://doi.org/10.1097/01. Restricting Access to Health Care on Health nmd.0000180739.79884.10 Expenditures among Asylum-Seekers and Chung, M. C., Shakra, M., AlQarni, N., AlMazrouei, Refugees: A Quasi-Experimental Study in M., Al Mazrouei, S., & Al Hashimi, S. (2018). Germany, 1994–2013. PloS One, 10(7), e0131483. Posttraumatic Stress Among Syrian Refugees: http://doi.org/10.1371/journal.pone.0131483 Trauma Exposure Characteristics, Trauma Brandmaier, M., & Ahrndt, A. (2012). Neue Centrality, and Emotional Suppression. Perspektiven–Klinische Sozialarbeit mit Psychiatry, 1-17. http://doi.org/10.1080/0033274 traumatisierten Flüchtlingen [New Perspectives— 7.2017.1354620 Clinical social work with traumatized refugees.] CIR Rifugiati. (2017). Time for needs: Listening, In S. Gahleitner & G. Hahn (Eds.), Übergänge healing, protecting. https://www.ueberleben.org/wp- gestalten, Lebenskrisen begleiten (pp. 305-323). content/uploads/2017/10/Report_TIME-FOR- Bonn: Psychiatrie Verlag. NEEDS_CIR.pdf Brewin, C. R., Cloitre, M., Hyland, P., Shevlin, M., Cohen, J. (1988). Statistical power analysis for the behav- Maercker, A., Bryant, R. A., . . . Reed, G. M. ioral sciences (2nd ed.). New York: Academic Press. (2017). A review of current evidence regarding de Heus, A., Hengst, S. M. C., de la Rie, S. M., the ICD-11 proposals for diagnosing PTSD Djelantik, A. A. A. M. J., Boelen, P. A., & and complex PTSD. Clinical Psychology Review, Smid, G. E. (2017). Day patient treatment for 58(Supplement C), 1-15. http://doi.org/10.1016/j. traumatic grief: Preliminary evaluation of a cpr.2017.09.001 one-year treatment programme for patients with Brune, M., Eiroa-Orosa, F. J., Fischer-Ortman, multiple and traumatic losses. European Journal of J., & Haasen, C. (2014). Effectiveness of Psychotraumatology, 8(1). http://doi.org/10.1080/2 psychotherapy for traumatized refugees without 0008198.2017.1375335 a secure residency status. International Journal of European Union. (2013). Directive 2013/33/EU of the Migration, Health and Social Care, 10(1), 52-59. European Parliament and the Council of 26 June http://doi.org/10.1108/IJMHSC-07-2013-0022 2013. Brussels: Official Journal of the European Bundesamt für Migration und Flüchtlinge [German Union, 29.6.2013 (L 180/96) Federal Agency of Migration and Refugees]. Fazel, M., Wheeler, J., & Danesh, J. (2005). Prevalence (2017). Das Bundesamt in Zahlen 2016. Asyl of serious mental disorder in 7000 refugees [The Federal Office in figures 2016. Asylum]. resettled in western countries: a systematic review. https://www.bamf.de/SharedDocs/Anlagen/ The Lancet, 365(9467), 1309-1314. http://doi. DE/Publikationen/Broschueren/bundesamt-in- org/10.1016/S0140-6736(05)61027-6 zahlen-2016.pdf?__blob=publicationFile Figley, C. R. (1995). Compassion fatigue: Toward Bundesweite Arbeitsgemeinschaft der psychosozialen a new understanding of the costs of caring. Zentren für Flüchtlinge und Folteropfer (BafF In Secondary traumatic stress: Self-care issues for e.V) [German Network of Rehabilitation Centres clinicians, researchers, and educators. (pp. 3-28). for Refugees and Survivors of Torture]. (2016). Baltimore, MD, US: The Sidran Press. Versorgungsbericht zur psychosozialen Versorgung von Flatten, G., Gast, U., Hofmann, A., Knaevelsrud, Flüchtlingen und Folteropfern in Deutschland (3. C., Lampe, A., Liebermann, P., Maercker, Auflage) [Report on the Psychosocial Care of Refugees A., Reddemann, L., Wöllern, W. (2011). S3– TORTURE Volume 28, Number 2, 2018 and Torture Victims in Germany]. http://www. LEITLINIE Posttraumatische Belastungsstörung baff-zentren.org/wp-content/uploads/2017/02/ ICD-10: F43. 1 [S3–Guidelines Posttraumatic Versorgungsbericht_3-Auflage_BAfF.pdf stress disorder ICD-10: F43.1]. Trauma und Butollo, W., & Maragkos, M. (2012). Gutachterstelle Gewalt, 5(3), 202-210. zur Erkennung psychischer Störungen bei Foa, E. B., Cashman, L., Jaycox, L., & Perry, K. Asylbewerbern [Auditor for the detection of (1997). The validation of a self-report measure of mental disorders in asylum seekers.] http:// posttraumatic stress disorder: The Posttraumatic www.pgasyl.de/cms/images/stories/PGAsyl/ Diagnostic Scale. Psychological Assessment, abschlussbericht%20lmu%20endfassung%20 9(4), 445-451. http://doi.org/10.1037/1040- 17.12.2012.pdf 3590.9.4.445 Carlsson, J. M., Mortensen, E. L., & Kastrup, Führer, A., Eichner, F., & Stang, A. (2016). M. (2005). A Follow-Up Study of Mental Morbidity of asylum seekers in a medium-sized 116
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German city. European Journal of Epidemiology, Leisering, B. (2018). Geflüchtete Menschen mit 1-4. http://doi.org/10.1007/s10654-016-0148-4 Behinderungen: Handlungsnotwendigkeiten für eine Gäbel, U., Ruf, M., Schauer, M., Odenwald, bedarfsgerechte Aufnahme in Deutschland [Refugees M., & Neuner, F. (2006). Prävalenz der with disabilities: Need for action for needs-based Posttraumatischen Belastungsstörung (PTSD) admission in Germany]. https://www.institut- und Möglichkeiten der Ermittlung in der fuer-menschenrechte.de/fileadmin/user_upload/ Asylverfahrenspraxis [Prevalence of posttraumatic Publikationen/POSITION/Position_16_ stress disorder (PTSD) and ways of identification Gefluechtete_mit_Behinderungen.pdf in asylum procedures practice]. Zeitschrift für Maier, T., & Schnyder, U. (2007). Psychotherapie mit Klinische Psychologie und Psychotherapie, 35(1), 12- Folter-und Kriegsopfern: Ein praktisches Handbuch 20. http://doi.org/10.1026/1616-3443.35.1.12 [Psychotherapy with Torture and Victims of War: A Gissendanner, S., Callies, I., Schmid-Ott, G., & Practical Handbook]. Bern: Hans Huber/Hogrefe. Behrens, K. (2013). Migrantinnen und Migranten Miller, K. E., & Rasmussen, A. (2010). War zwischen Trauma und Traumabewältigung. exposure, daily stressors, and mental health Implikationen aus Migrationssoziologie in conflict and post-conflict settings: Bridging und interkultureller Psychotherapie für the divide between trauma-focused and die psychiatrische, psychosomatische und psychosocial frameworks. Social Science and psychotherapeutische Behandlungspraxis Medicine, 70(1), 7-16. http://doi.org/10.1016/j. [Migrants between trauma and trauma coping. socscimed.2009.09.029 Implications of migration sociology and Mollica, R. F., Caspiyavin, Y., Bollini, P., Truong, intercultural psychotherapy for psychiatric, T., Tor, S., & Lavelle, J. (1992). The Harvard psychosomatic and psychotherapeutic treatment Trauma Questionnaire: Validating a cross- practice]. In R. E. Feldmann & G. H. Seidler cultural instrument for measuring torture, (Eds.), Traum(a) Migration. Aktuelle Konzepte zur trauma, and posttraumatic-stress disorder in Therapie traumatisierter Flüchtlinge und Folteropfer Indochinese refugees. Journal of Nervous and (pp. 61-80). Gießen: Psychosozial-Verlag. Mental Disease, 180(2), 111-116. http://doi. Guillemin, F., Bombardier, C., & Beaton, D. (1993). org/10.1097/00005053-199202000-00008 Cross-cultural adaptation of health-related Mollica, R. F., Wyshak, G., Lavelle, J., Truong, T., Tor, quality of life measures: Literature review S., & Yang, T. (1990). Assessing symptom change and proposed guidelines. Journal of Clinical in Southeast Asian refugee survivors of mass Epidemiology, 46(12), 1417-1432. http://doi. violence and torture. The American Journal of org/10.1016/0895-4356(93)90142-N Psychiatry, 147(1), 83-88. http://doi.org/10.1176/ Gurris, N. F., & Wenk-Ansohn, M. (2013). ajp.147.1.83 Folteropfer und Opfer politischer Gewalt National Institute for Health and Care Excellence [Victims of torture and victims of political (NICE). (2005). Post-traumatic stress disorder: Man- violence.] In: A. Maercker (Ed.), Posttraumatische agement. Clinical guideline. (Vol. cg26). London: Belastungsstörungen (4th ed., pp. 525-574). Berlin National Institute for Health and Care Excellence. & Heidelberg: Springer. Nickerson, A., Schick, M., Schnyder, U., Bryant, Haagen, J. F. G., Smid, G. E., Knipscheer, J. R. A., & Morina, N. (2017). Comorbidity of W., & Kleber, R. J. (2015). The efficacy of Posttraumatic Stress Disorder and Depression in recommended treatments for veterans with Tortured, Treatment‐Seeking Refugees. Journal PTSD: A metaregression analysis. Clinical of Traumatic Stress, 30(4), 409-415. http://doi. Psychology Review, 40, 184-194. https://doi. org/10.1002/jts.22205 org/10.1016/j.cpr.2015.06.008 Nickerson, A., Steel, Z., Bryant, R., Brooks, R., & Herman, J. L. (1992). Complex PTSD: A syndrome Silove, D. (2011). Change in visa status amongst in survivors of prolonged and repeated trauma. Mandaean refugees: relationship to psychological Journal of Traumatic Stress, 5(3), 377-391. symptoms and living difficulties. Psychiatry doi:10.1002/jts.2490050305 Research, 187(1), 267-274. doi:10.1016/j. Inter-Agency Standing Committee. (2007). IASC psychres.2010.12.015 Guidelines for mental health and psychosocial support Pabst, A., Gerigk, U., Erdag, S., & Paulsen, in emergency settings. G. (2013). Ein multiprofessionelles Lambert, J. E., & Alhassoon, O. M. (2015). Trauma- Behandlungsangebot für psychisch erkrankte focused therapy for refugees: Meta-analytic Flüchtlinge [A multiprofessional treatment findings. Journal of Counseling Psychology, 62(1), program for mentally ill refugees.] In: R. E. 28-37. http://doi.org/10.1037/cou0000048 Feldmann & G. H. Seidler (Eds.), Traum(a) TORTURE Volume 28, Number 2, 2018 Volume TORTURE 117
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Migration. Aktuelle Konzepte zur Therapie Amongst Iraqi Refugees Located in Western traumatisierter Flüchtlinge und Folteropfer. (pp. 115- Countries. Journal of Immigrant and Minority 136). Gießen: Psychosozial-Verlag. Health, 17(4), 1231-1239. http://doi.org/10.1007/ Palic, S., & Elklit, A. (2009). An explorative outcome s10903-014-0046-3 study of CBT-based multidisciplinary treatment Stammel, N., Knaevelsrud, C., Schock, K., in a diverse group of refugees from a Danish Walther, L. C. S., Wenk-Ansohn, M., & treatment centre for rehabilitation of traumatized Böttche, M. (2017). Multidisciplinary refugees. Torture 19(3), 248-270. treatment for traumatized refugees in Priebe, S., Giacco, D., & El-Nagib, R. (2016). a naturalistic setting: symptom courses Public health aspects of mental health among and predictors. European Journal of migrants and refugees: A review of the evidence on Psychotraumatology, 8(sup2), 1377552. http:// mental health care for refugees, asylum seekers and doi.org/10.1080/20008198.2017.1377552 irregular migrants in the WHO European Region. Steel, Z., Chey, T., Silove, D., Marnane, C., Bryant, Richter, K., Lehfeld, H., & Niklewski, G. (2015). R. A., & van Ommeren, M. (2009). Association Warten auf Asyl: Psychiatrische Diagnosen of torture and other potentially traumatic events in der zentralen Aufnahmeeinrichtung in with mental health outcomes among populations Bayern [Waiting for asylum: Psychiatric exposed to mass conflict and displacement: A diagnosis in Bavarian admission center]. systematic review and meta-analysis. JAMA, Gesundheitswesen, 77(11), 834–838. http://doi. 302(5), 537-549. http://doi.org/10.1001/ org/10.1055/s-0035-1564075 jama.2009.1132 Schauer, M., Neuner, F., & Elbert, T. (2011). Tabachnick, B. G., & Fidell, L. S. (2001). Missing Narrative exposure therapy: A short-term treatment data. In B. G. Tabachnick & L. S. Fidell (Eds.), for traumatic stress disorders (2nd ed.). Cambridge: Using multivariate statistics (pp. 62-72). Boston: Hogrefe Publishing & Huber Publishing. Pearson Education. Schock, K., Böttche, M., Rosner, R., Wenk-Ansohn, Tinghög, P., Malm, A., Arwidson, C., Sigvardsdotter, M., & Knaevelsrud, C. (2016). Impact of E., Lundin, A., & Saboonchi, F. (2017). new traumatic or stressful life events on pre- Prevalence of mental ill health, traumas and existing PTSD in traumatized refugees: results postmigration stress among refugees from Syria of a longitudinal study. European Journal of resettled in Sweden after 2011: a population- Psychotraumatology, 7(1), 32106. http://doi. based survey. BMJ Open, 7, e018899. http://doi. org/10.3402/ejpt.v7.32106 org/10.1136/bmjopen-2017-018899 Schweitzer, R., Melville, F., Steel, Z., & Lacherez, UNHCR. (2016). Global Trends. Forced Displacement in P. (2006). Trauma, post-migration living 2015. http://www.unhcr.org/576408cd7.pdf difficulties, and social support as predictors of Weathers, F. W., Litz, B. T., Keane, T. M., Palmieri, psychological adjustment in resettled Sudanese P. A., Marx, B. P., & Schnurr, P. P. (2013). The refugees. Australian and New Zealand Journal of PTSD Checklist for DSM-5 (PCL-5). Bosten, MA: Psychiatry, 40(2), 179-187. doi:10.1111/j.1440- National Center for PTSD. 1614.2006.01766.x Wenk-Ansohn, M. (2017). Akutversorgung und Selmo, P., Koch, T., Brand, J., Wagner, B., & traumaorientierte Langzeitbehandlung bei Knaevelsrud, C. (2016). Psychometric traumatisierten und psychisch belasteten properties of the online Arabic versions of Geflüchteten [Acute care and trauma- BDI-II, HSCL-25, and PDS. European Journal oriented long-term treatment in traumatized of Psychological Assessment, 0(0), 1-9. http://doi. and psychologically disstressed refugees]. In TORTURE Volume 28, Number 2, 2018 org/10.1027/1015-5759/a000367 A. Liedl, M. Böttche, B. Abdallah-Steinkopf, Silove, D., Ventevogel, P., & Rees, S. (2017). The & C. Knaevelsrud (Eds.), Psychotherapie contemporary refugee crisis: an overview of mit Flüchtlingen, Neue Herausforderungen, mental health challenges. World Psychiatry, 16(2), spezifische Bedürfnisse, das Praxisbuch für 130-139. http://doi.org/10.1002/wps.20438 Psychotherapeuten und Ärzte (pp. 147-162). Sjölund, B. H., Kastrup, M., Montgomery, E., & Stuttgart: Schattauer. Persson, A. L. (2009). Rehabilitating torture Wenk-Ansohn, M., Weber-Nelson, C., Hoppmann, survivors. Journal of Rehabilitation Medicine, 41(9), F., & Ahrndt, A. (2014). Behandlung und 689-696. http://doi.org/10.2340/16501977-0426 Rehabilitation von Folterüueberlebenden Slewa-Younan, S., Uribe Guajardo, M. G., Heriseanu, und Kriegstraumatisierten [Treatment and A., & Hasan, T. (2015). A Systematic Review of rehabilitation of torture survivors and individuals Post-traumatic Stress Disorder and Depression traumatized by war]. Psychosozial, 37(4), 55-74. 118
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Satisfaction of trauma-affected refugees treated with antidepressants and Cognitive Behavioural Therapy
Caecilie Böck Buhmann, MD, PhD*, Jessica Carlsson MD, PhD*, Erik Lykke Mortensen, MSc**
satisfaction score was developed based Key points of interest: on the questionnaire, and predictors of •• A western model based on cognitive satisfaction were analysed in regression behavioral therapy was found models. Telephone interviews were satisfactory by bi-cultural patients, conducted with patients dropping out who have lived in Denmark for of treatment before the end of the trial. more than a decade. Results: In total, 193 trauma-affected •• Satisfaction was not associated refugees with PTSD were included in with treatment outcome, but with the study. Patients were overall satisfied the patients’ own interpretation with flexible CBT including exposure of whether their condition had treatment in cases where this was part of improved due to treatment. the treatment. There was no statistically significant association between treatment Abstract outcome and satisfaction and satisfaction Purpose: This study seeks to evaluate the and treatment efficacy were independent satisfaction of trauma-affected refugees of each other. The results showed that after treatment with antidepressants, bi-cultural patients who had lived in psycho-education and flexible Cognitive Denmark for more than a decade were Behavioral Therapy (CBT) including satisfied with the treatment based on a trauma exposure. Material and western psychotherapy model. Discussion: methods: A treatment satisfaction Treatment with selective serotonin questionnaire was completed by patients reuptake inhibitor and flexible CBT, at the end of a randomised controlled including trauma exposure, is acceptable trial (RCT) comparing treatment with for trauma-affected refugees. More studies CBT and antidepressants. A patient are needed to evaluate patient satisfaction with western psychotherapy models in refugee patients who have recently arrived *) Competence Centre for Transcultural Psychiatry, and to compare satisfaction with alternative Mental Health Centre Ballerup, Denmark treatment models. **) Department of Public Health and Center for Healthy Aging, University of Copenhagen, Keywords: PTSD, trauma, refugee, cognitive Denmark Correspondence to: behavioural therapy, treatment-satisfaction,
TORTURE Volume 28, Number 2, 2018 Volume TORTURE [email protected] anti-depressants 119
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Background and aims (Silove et al., 1997; Vincent, Jenkins, Larkin, There are an estimated 60 million refugees & Clohessy, 2013). Two qualitative studies and internally displaced persons worldwide have examined the meaning of illness and in 2015, UNCHR estimated that 3.5 and expectations for treatment amongst million of these are in Europe. Refugees trauma-affected refugees (Maier & Straub, and asylum seekers suffer from diverse 2011; Vincent et al., 2013), but no studies mental health problems such as PTSD specifically investigate the patient satisfaction and depression (Steel et al., 2009). with TFCBT offered in a Western setting. Recommended treatments of these trauma- Evaluating patient satisfaction is further related conditions are Selective Serotonin complicated by the lack of consensus of a Reuptake-Inhibitors (SSRI) and Trauma- theoretical framework on patient satisfaction Focused Cognitive Behavioural Therapy (Batbaatar, Dorjdagva, Luvsannyam, (TFCBT) (Bisson, 2009; Stein, 2009). Savino, & Amenta, 2017). In the absence Nevertheless, only a few evaluations of of actual patient satisfaction studies, drop- the effect of these standard treatments out rates can be examined, but drop-out for trauma-affected refugees have been rates are generally reported inconsistently carried out (Crumlish & O’Rourke, 2010; in studies of trauma-focused treatment Nickerson, Bryant, Silove, & Steel, 2011; (Schottenbauer et al., 2008). This is also the Palic & Elklit, 2011). TFCBT involves case in studies on the treatment of trauma- the use of prolonged exposure, which is affected refugees where drop-out rates vary when the patient assisted by the therapist from 0% in small studies to 30% in others and in homework, repeatedly recounts the (Palic & Elklit, 2011). The physiological traumatic events or listens to a recorded response to pharmacological treatment narrative of the traumatic event (Foa, may also be different among patients with Hembree, & Rothbaum, 2007). This different ethnic backgrounds as there is treatment has received some attention evidence of diversity on pharmacokinetics in qualitative studies describing the and pharmacodynamics (Noerregaard, 2012; patient experience of the treatment and Sonne, Carlsson, Bech, & Mortensen, 2016). its acceptability. The studies suggest that The aim of the present study was to examine prolonged exposure is as acceptable as satisfaction with the treatment offered treatment with sertraline (Chen, Keller, among trauma-affected refugees and to Zoellner, & Feeny, 2013) and in some identify predictors of treatment satisfaction. cases preferred over sertraline (Kehle- The treatment offered consisted of CBT
Forbes, Polusny, Erbes, & Gerould, 2014). including trauma exposure, psychoeducation TORTURE Volume 28, Number 2, 2018 However, it is a challenge to ensure patient and sertraline. Our hypothesis was that compliance with treatment (Shearing, Lee, satisfaction may be influenced by the & Clohessy, 2011) even in non-refugee patients’ country of origin and religion as patient samples (Schottenbauer, Glass, proxies for their cultural background. In Arnkoff, Tendick, & Gray, 2008). Only a addition, we hypothesised that the need of few studies have examined acceptability of translation and the use of exposure during these treatments amongst trauma-affected treatment might affect satisfaction. refugees and asylum seekers despite the The satisfaction study was conducted as challenge of applying psychotherapy to part of a RCT evaluating the effectiveness patients with diverse cultural backgrounds of the administered treatments on PTSD in 120
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a population of trauma-affected refugees in according to the UNCAT definition of Denmark. The RCT showed no effect on torture. Additionally, the participants had PTSD symptoms, no effect of psychotherapy to be motivated to receive treatment and to and no interaction between psychotherapy give written, voluntary informed consent. and medicine. A small but significant effect Potential participants were excluded if they of treatment with antidepressants and had a severe psychotic disorder (ICD-10 psychoeducation was found on depression diagnosis F2x and F30.1-F31.9), were (Buhmann, Nordentoft, Ekstroem, Carlsson, addicted to psychoactive substances (ICD- & Mortensen, 2016). 10 F1x.24-F1x.26), had a need of somatic or psychiatric hospitalisation, or were Method pregnant or breastfeeding. Trial design All data were collected at the The satisfaction survey was a part of a Competence Centre for Transcultural pragmatic randomised controlled 2x2 Psychiatry (henceforth called CTP), which factorial trial. Randomisation meant that is part of the public mental health care the treatment received did not reflect services of the greater Copenhagen area in patient preferences. Patients were allocated Denmark. CTP offers outpatient treatment to treatment with psychoeducation and specifically to immigrants and refugees with antidepressants, or CBT with a trauma mental health problems and specialises in exposure component, or a combination of treating patients with trauma related to war, psychoeducation, CBT and antidepressants torture or persecution (Carlsson, Sonne, & or to a waiting list. Patients randomised Silove, 2014). The trial ran from June 2009 to the waiting list received a combination until December 2012. In total, 380 patients treatment after waiting for six months and were screened, 280 patients were included completed the satisfaction survey afterwards. in the trial and 217 completed the trial, Thereby, the patients who participated in and of these, 193 answered the satisfaction this study all received treatment with either questionnaire and were included in the medicine, CBT or a combination of the two, current analyses. Translation services but some of the patients had been waiting were provided during assessment and six months before they started treatment treatment consultations on an as-needed (Buhmann et al., 2016). basis (which was the case for 54% of the patients). All of the interpreters were Participants associated with CTP and had experience in Participants had to be 18 years or older translating rating scales, psychotherapy and and had to be refugees or a family member psychoeducational sessions. reunified with a refugee. Furthermore, participants had to have PTSD according to Interventions the ICD-10 research diagnostic criteria, and Psychopharmacological treatment consisted to have a history of war-related psychological of sertraline in doses of 25-200 mgs. For trauma such as imprisonment, torture, patients reporting problems sleeping, inhuman and degrading treatment or the pharmacological treatment was punishment, organised violence, prolonged supplemented with mianserin in doses political persecution and harassment or of 10-30 mgs at night. Psychoeducation
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covered the illness, treatment, sleep, life-style 2001; Mollica et al., 1992; Mollica et al., (including relaxation-exercises), physical 1987; Oruc et al., 2008). activity and social relations, pain, cognitive •• Blinded observer-rated symptoms of function, and the influence of the illness depression and anxiety (Hamilton on the family. The CBT was manualised depression and anxiety scales, Ham-D & and included core CBT methods, methods Ham-A) (Hamilton, 1959, 1960). from acceptance and commitment therapy •• Self-rated somatic symptoms (Symptom (ACT), mindfulness exercises and in- Check List-90, SCL-90) (Derogatis, vivo and visualised exposure (TFCBT). 1994). The psychotherapy methods were flexibly •• Pain (visual analogue scales, VAS, for applied from the manual and not all headache, backache, pain in the arms and methods were used with all patients. We pain in the legs (Olsen, 2007), which were have therefore chosen to use the term combined to a composite pain-score. “flexible CBT” to describe the treatment. •• Self-rated level of functioning Of the 193 participants in the study, only 37 (Sheehan Disability Scale, SDS) (Lam, participants received treatment with trauma- Michalak, & Swinson, 2005; Sheehan focused exposure (either interoceptive & Sheehan, 2008). exposure or visualised exposure). The •• Self-rated quality of life (WHO-5) trauma-focused exposures were repeated on (Bech, 2012). average twice and therefore did not amount The ratings have been described in detail to a sufficient number of repetitions for it elsewhere (Buhman et al., 2014; 2015; to be termed “prolonged exposure”. The 2016). Ratings were completed at pre-trial patient population at CTP is multicultural, assessment and at the end of treatment. All and it was therefore not feasible to make self-report questionnaires were available in specific cultural adaptations in the manual. the six most common languages at CTP However, the manual allowed for flexible (Arabic, Farsi, Bosnian/Serbo-Croatian, use of methods and the cultural background Russian, Danish and English), which of the individual patient was taken into included the languages of 85% of patients. consideration in the individualised version of If no translation was available, an interpreter psychotherapy. The psychotherapy has been translated the official version into the described in detail elsewhere (Buhmann, et language of the patient. al., 2015). The patient satisfaction questionnaire: A
Outcome measures questionnaire exploring the patients’ view of TORTURE Volume 28, Number 2, 2018 The outcome measures of the trial included: the treatment and the centre was developed •• Self-rated PTSD severity (Harvard specifically to be used at CTP. There is no Trauma Questionnaire’s symptom accepted gold standard for the content of part IV, HTQ) (Kleijn, Hovens, & satisfaction surveys. When developing items Rodenburg, 2001; Mollica et al., 1992; for the present satisfaction questionnaire, Mollica, Wyshak, de, Khuon, & Lavelle, we were inspired by literature on the topic, 1987). a template for a satisfaction survey used •• Self-rated symptoms of depression elsewhere in Danish mental health care as and anxiety (Hopkin’s Symptom well as our clinical experience working with Checklist-25, HSCL-25) (Kleijn et al., trauma-affected refugees. The questionnaire 122
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was constructed to reflect the patient’s asked about the reasons for dropping out. treatment experience with a broad focus The choice of interviewer was deliberately on the content of the service provided, the to prevent patients feeling pressured to service providers as well as the cultural give positive responses to a therapist they understanding in the clinic. Of all the knew. Formal answer categories included items in the questionnaire, only 10 items lack of effect of treatment, inconvenience, were specifically related to satisfaction. The transport costs, cultural differences, other questions covered the patient’s satisfaction obligations, lack of energy, lack of respect, with the contact to the medical doctor, social psychotherapy or medicine unacceptable, worker and psychologist at CTP, satisfaction feeling better, leaving the country or other with the different treatment modalities reasons. Patients who dropped out were and satisfaction with the understanding of also encouraged to fill out the satisfaction the patient’s cultural background at CTP. questionnaire, which was mailed to their The ten items were used to construct a home address with a stamped return satisfaction score. Each question was of a envelope, but none were returned. 1- 4 Likert type format (see Table 2). Score 1-2 were “not at all” and “only to some Data analysis degree” and score 3-4 were “to a certain The association between satisfaction degree” and “to a high degree”. Thereby the score and the change from pre- to post- total of the satisfaction score ranged from treatment (difference scores) was analysed 10–40. Missing items were assigned the by univariate linear regression models (see participant’s mean value of the other items Table 3). Following this, a linear regression of the scale. Cronbach’s alpha for the scale model was generated with the satisfaction was 0.88. The questionnaire was completed score as outcome and including difference at the end of treatment without the presence scores for ratings that were significantly of a therapist or medical doctor from CTP. associated with satisfaction in the univariate Patients were encouraged to complete the models as predictors in addition to other questionnaire before leaving CTP at their potential predictors of satisfaction (age, last appointment. The questionnaire was gender, trauma exposure in treatment, translated to the same six languages as the religion, country of origin and the need outcome ratings and if needed, translation of translation). All analyses were made in was provided in person. If patients did not STATA 12 & 13 (StataCorp LP, College show up for their last appointment, the Station, TX, USA). questionnaire was mailed with a stamped return envelope. Results Description of patient sample Drop-out interviews Of the 217 trial patients, 193 patients Of the 280 patients included in the trial, responded and completed the satisfaction 63 patients did not finish the trial. Of questionnaire. Differences between these, 43 were withdrawn as they did not respondents and non-respondents with continue to meet the inclusion criteria regard to age, gender, religion, country of and 20 patients dropped out. If patients origin, trauma, use of trauma exposure in dropped out of treatment, they were treatment and score on outcome ratings at
TORTURE Volume 28, Number 2, 2018 Volume TORTURE contacted by a secretary by phone and baseline and follow-up were analysed with 123
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paired t-tests and chi2-test. The responders Patient satisfaction were slightly older and had a slightly better The responses to the 10 questions in the level of functioning measured on SDS, but satisfaction score are summarised in Table otherwise there were no differences between 2. The sum of the scale was 34.0 (SD 5.7). responders and non-responders. A summary The theoretical maximum was 40. The mean of the socio-demographic information and score on each item ranged from 2.9 to 3.7 information about the treatment of the on a scale from 1 to 4 with 4 corresponding participants is presented in Table 1. to most satisfied. When condensing the
Table 1: Baseline description of patients (N=193 unless otherwise specified)
Background N (%) or N (%) or Mean (sd) Mean (sd) Sex (male) 113 (59) Previous psychiatric treatment
Country of origin Any prior psychiatric treatment 155 (80) Iraq 68 (35) Needs translation for treatment 105 (54) Iran 26 (13) Mean (sd) Lebanon 22 (11) Age 45 (9) Ex-Yugoslavia 31 (16) Years since arrival in Denmark 15 (6) Afghanistan 19 (10) Treatment Other 27 (14) Duration of treatment (months) 6.0 (1.3) Religion (Muslim) (N=184) 141 (77) No. of sessions with psychologist 9 (6) Trauma history Randomization group N (%) Torture (N=190) 80 (42) Antidepressants and CBT 91 (47) Ex-combatant (N=191) 46 (24) Antidepressants 54 (28) Socioeconomic CBT 48 (25) Currently employed (N=121) 17 (14) Psychopharmacological treatment Never employed (N=172) 33 (19) Sertraline 136 (70) No education (N=185) 6 (3) Mianserin 121 (63)
Married (N=187) 100 (53) Psychotherapy TORTURE Volume 28, Number 2, 2018 Has children (N=187) 163 (87) Have been treated with exposure 37 (19) Mental health condition Discomfort due to therapy 13 (7) Depression 181 (94) Patient perceived outcome of treatment (N=111) Personality Change after 55 (29) Condition improved due to 97 (87) Catastrophic Events (F62.0) treatment Psychotic during treatment 16 (8) Condition worsened due to 1 (1) treatment In treatment for somatic 75 (39) Condition improved due to other 13 (12) symptoms factors than treatment 124
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Table 2: Treatment satisfaction score items
Scale item N Mean (sd) Satisfied (1-4) N (%) Were you satisfied with the contact with the administrative staff? 189 3.7 (0.6) 182 (96) Did you receive the information about your illness and 184 3.4 (0.8) 158 (86) the treatment that you needed? Were you generally satisfied with the contact with the 188 3.7 (0.6) 181 (96) doctor at CTP? Were you generally satisfied with the contact with the 175 3.7 (0.6) 169 (97) psychologist at CTP? Were you generally satisfied with the contact with the 174 3.5 (0.7) 158 (91) social worker at CTP? Were you satisfied with the influence you had on your 176 3.4 (0.8) 157 (89) treatment at CTP? Do you feel there was an understanding of your cultural 168 3.4 (0.8) 149 (89) background at CTP? Were you satisfied with the psychotherapy treatment? 167 3.3 (0.8) 142 (85) Were you satisfied with the drug treatment? 154 2.9 (1.0) 106 (69) Did you find the treatment at CTP worth your time and efforts? 167 3.1 (1.0) 135 (81) Sum score satisfaction score (10-40) 34.0 (5.7)
response scale by combing categories 1 and predictors, a significant association between 2 (“not at all” and “only to some degree”) being Muslim and lower satisfaction scores and categories 3 and 4 (“to a certain degree” (reg. coeff.=-3.1, p=0.02) was found, and “to a high degree”) to “not satisfied” whereas the difference scores did not remain vs. “satisfied”, the vast majority of patients significant in this model. If the patient’s self- were satisfied with the treatment. The range evaluated perceived outcome of treatment of satisfaction was from 69% satisfaction was included in the model, the effect of with pharmacological treatment to 96-97% being Muslim was no longer significant satisfaction with the medical doctor, the (reg. coeff.=-2.4, p=0.07), whereas a self- psychologist and the administrative staff. evaluated positive outcome was significantly There was a high rate of satisfaction (89%) associated with satisfaction (reg. coeff=-3.9, with the understanding of the patient’s p<0.01). We did not find a significant cultural background. In the univariate linear association between satisfaction and the use regression models, a small but significant of trauma exposure in treatment or between association was found between satisfaction satisfaction and the need for translation or and difference score on HTQ, HSCL- country of origin. 25, SDS and VAS-score (see Table 3) and between the patient’s self-rated evaluation Drop-out interviews of treatment effect and satisfaction. In Of the 20 patients who dropped out of the linear regression model, including the treatment, 14 were interviewed about their
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Table 3: Change in outcome ratings from baseline to post-treatment and results of univariate linear regression models of satisfaction score and change in rating
Rating N Mean change in score Linear regression coefficient p-value pre- to post-treatment (95%-confidence interval) (SD) HTQ 181 0.1 (0.6) -1.7 (-3.0 to -0.5) <0.01 HSCL-25 181 0.1 (0.7) -1.4 (-2.6 to -0.2) 0.03 Ham-D 164 0.7 (6.5) -0.1 (-0.2 to 0.0) 0.10 Ham-A 157 0.4 (8.5) -0.0 (-0.1 to 0.1) 0.45 SCL-90 177 -0.1 (0.8) -0.8 (-1.8 to 0.3) 0.16 SDS 176 0.1 (2.2) -0.5 (-0.9 to -0.2) <0.01 WHO-5 177 3.8 (18.5) 0.0 (0.0 to 0.1) 0.78 VAS pain score 176 0.5 (7.8) -0.1 (-0.2 to 0.0) 0.01
mentioned for drop-out were inconvenience in the treatment. In the linear regression (4 patients), lack of energy (4 patients), model, we found an association between other obligations (4 patients), lack of satisfaction and being a Muslim (compared treatment effect (2 patients), transportation to non-Muslims), although this effect difficulties (2 patients) and having left the disappeared when self-evaluated treatment country (2 patients). When asked directly, outcome was included in the model. No no patient confirmed that psychotherapy, association between country of origin or pharmacological treatment, lack of respect the need of translation and satisfaction or lack of understanding of their culture had was found. Patients were generally very influenced their choice to leave treatment. satisfied with the medical as well as the The 43 patients who did not complete psychotherapeutic treatment, and no treatment because they were withdrawn association between satisfaction and the use from the trial were not interviewed. They of trauma exposure in treatment was found. were withdrawn because the patient did not Although we found limited effect of treatment meet the inclusion criteria. on PTSD in the original trial as measured by the outcome variables (C. B. Buhmann et al.,
Discussion 2016), the patients were generally satisfied TORTURE Volume 28, Number 2, 2018 In this quantitative study of patient with the treatment they received. satisfaction amongst trauma-affected A striking result is that patients were refugees in treatment with flexible CBT satisfied despite relatively small treatment and antidepressants, we found high general effects in the trial. Satisfaction was not satisfaction with the treatment. Furthermore, associated with changes in self-report rating 89% of patients reported that they were scales on symptoms, quality of life and level satisfied with the cultural understanding they of functioning, including the HTQ primary had encountered at CTP and no patients outcome variable, or on observer ratings, dropped out of treatment because they felt including the Hamilton scales. Nevertheless, their culture was not considered sufficiently satisfaction was associated with the patient’s 126
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self-evaluated positive or negative effect of the psychotherapy was only culturally treatment (when asked directly whether adapted to the extent that the flexible they experienced that their condition had manual allowed general adjustment of improved and whether this was associated therapy to the individual patient’s problems with treatment or other factors). This could and understanding. However, although indicate that satisfaction is an independent the direct answers in the satisfaction outcome in itself. The results may be questionnaire suggest that patients did not influenced by the trial excluding patients experience culture as a barrier, they may who were openly not interested in receiving have underreported dissatisfaction out of treatment. However, most studies require politeness. In addition to this, we found informed consent and would therefore lower satisfaction amongst Muslims, which exclude patients, who did not wish to receive could also suggest that the treatment is more a given treatment. In our case, only five out suited for people of Western background. of 380 patients screened for the trial were On the other hand, patients had been in deemed not motivated. Denmark on average 14 years at the time of One of our aims was to examine whether the study and therefore cultural differences sociodemographic factors like country of may play a smaller role than in newly arrived origin, need for translation, and religion refugees, because participants could have were associated with satisfaction with adapted to Danish culture to some extent. treatment. When working with patients from Despite this, half of the patients needed a different cultural context, it cannot be translation, which points to cultural isolation expected that treatment to be as acceptable given the long period they have been staying as in studies with non-refugee patients in the country. from a Western country of origin. There The results do not confirm that trauma is therefore an urgent need to explore the exposure in treatment influences patient acceptability of standard PTSD treatments satisfaction. However, the study may not in transcultural patient populations. have been able to evaluate the satisfaction Few studies have looked specifically at with trauma exposure therapy properly, satisfaction amongst trauma-affected refugee as only 27% of patients in psychotherapy patients in a Western treatment setting. An received trauma exposure therapy of any kind Australian study comparing satisfaction and only 20% of patients received trauma- among refugees with general mental health focused exposure. Although the reasons for services and specialised services for trauma- this have not been systematically studied, affected refugees found that there was an the psychologists’ impression was that this overall higher satisfaction with specialised was mostly due to resistance towards the services, but also that patients who were treatment amongst the patients. In other more fluent in English were less satisfied populations, whilst it has been difficult to with treatment in either treatment setting motivate patients to have trauma exposure (Silove et al., 1997). Another study has treatment, those who have experienced found that language is the most important trauma exposure seem to be satisfied with barrier to treatment (Maier & Straub, the treatment, and effect studies on other 2011). Our results point in a different populations show that this is the most direction. Culture was not mentioned as effective treatment for trauma-related
TORTURE Volume 28, Number 2, 2018 Volume TORTURE a reason for drop-out despite the fact that disorders. For example, despite prolonged 127
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trauma exposure being the recommended that answers did not have to be positive. treatment in the department of Veteran Another limitation of the study is the lack Affairs in the U.S., only 1.5% of the patients of a qualitative element to elaborate on undergo a full trauma exposure treatment the findings, which makes it more difficult (Shiner, 2012). Studies have found that to interpret the results. It is furthermore the therapeutic relationship and proper unknown whether all patients understood preparation of the trauma exposure in the questions in the questionnaire, especially therapy, including explaining the method those who completed it without the help to the patients and positive previous of an interpreter at home. Although our patient experience with trauma exposure, results indicate few differences in baseline is important (Chen et al., 2013; Kehle- characteristics and outcome between Forbes et al., 2014; Shearing et al., 2011). patients who completed the questionnaire Satisfaction scores are often related more to and those who did not, we cannot rule out patients’ appreciation of the therapists and that non-respondents and drop-outs were nonspecific aspects of treatment than they are less satisfied with treatment. The sample is to any demonstrated gains from treatment small, which may have affected the predictor (Batbaatar et al., 2017). This may explain analyses as weak associations would have why patients were generally very satisfied with been difficult to detect. Finally, the scale is treatment although the gains were limited on newly developed and has not been validated outcome measures in the trial. in other patient samples. Fewer patients were satisfied with In conclusion, trauma-affected pharmacological treatment than with refugees were overall satisfied with the psychotherapy in the satisfaction standard treatment for PTSD. The need questionnaire. The difference in satisfaction of translation, country of origin or the use between psychotherapy and medicine is of trauma exposure in treatment were all limited. The difference could be explained unrelated to satisfaction, but an association by side effects as there was a high prevalence was found between satisfaction and religion. of side effects in the study population, and However, satisfaction may be influenced by a significant proportion of patients (23%) factors that were not assessed in this study had to stop treatment with sertraline or and the answers given by the patients could mianserin before the end of the trial due have been influenced by politeness towards to side effects (Buhmann et al., 2016). the clinic. This needs to be further explored. This could reflect ethnic differences in pharmacodynamics (Noerregaard, 2012; Acknowledgements TORTURE Volume 28, Number 2, 2018 Sonne et al., 2016). We would like to thank all therapists and The study had several limitations, which research workers at the CTP, who have may also have influenced the results. Patients made this paper possible and Sarah Musoni may have been biased by their relationship for proof reading. with the staff at CTP and the fact that an interpreter was sometimes present. For this Declaration of interests reason, they might have rated higher levels The study was supported by the Mental of satisfaction out of politeness. This could Health Services of the Capital Region of have been addressed by further stressing Denmark and the Tryg Foundation. The that the questionnaire was voluntary and authors report no conflicts of interest. The 128
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authors alone are responsible for the content [doi];00005053-201004000-00001 [pii] and writing of the paper. Derogatis, L. R. (1994). SCL-90-R: Symptom Check- list-90-R. Administration, scoring and procedures manual (3rd ed.). Minnesota, USA: National References Computer Systems. Batbaatar, E., Dorjdagva, J., Luvsannyam, A., Savino, Foa, E. B., Hembree, E. A., & Rothbaum, B. O. M. M., & Amenta, P. (2017). Determinants (2007) Prolonged Exposure Therapy for PTSD: of patient satisfaction: a systematic review. Emotional Processing of Traumatic Experi- Perspect Public Health, 137(2), 89-101. https:// ences, Therapist Guide. Oxford, UK: Oxford doi:10.1177/1757913916634136 University Press. Bech, P. (2012). Clinical psychometrics. Oxford: Hamilton, M. (1959). The assessment of anxiety Wiley Blackwell. states by rating. Br J Med Psychol, 32(1), 50-55. Bisson, J., Andrew, M. (2009). Psychological treat- Hamilton, M. (1960). A rating scale for depression. ment of post-traumatic stress disorder (PTSD). J Neurol Neurosurg Psychiatry, 23, 56-62. http:// Cochrane Database of Systematic Reviews 3. https:// dx.doi.org/10.1136/jnnp.23.1.56 doi.org10.1002/14651858. CD003388.pub4 Kehle-Forbes, S. M., Polusny, M. A., Erbes, C. R., & Buhman, C., Mortensen, E. L., Lundstrom, S., Ry- Gerould, H. (2014). Acceptability of prolonged berg, J., Nordentoft, M., & Ekstrom, M. (2014). exposure therapy among U.S. Iraq war veterans Symptoms, quality of life and level of functioning with PTSD symptomology. J Trauma Stress, of traumatized refugees at psychiatric trauma 27(4), 483-487. https://doi:10.1002/jts.21935 clinic in Copenhagen. Torture, 24(1), 25-39. Kleijn, W. C., Hovens, J. E., & Rodenburg, J. J. Buhmann, C., Andersen, I., Mortensen, E. L., Ry- (2001). Posttraumatic stress symptoms in refu- berg, J., Nordentoft, M., & Ekstrom, M. (2015). gees: assessments with the Harvard Trauma Cognitive behavioral psychotherapeutic treatment Questionnaire and the Hopkins symptom at a psychiatric trauma clinic for refugees: de- Checklist-25 in different languages. Psychol. scription and evaluation. Torture, 25(1), 17-32. Rep., 88(2), 527-532. https://doi.org/10.2466/ Buhmann, C., Mortensen, E. L., Nordentoft, M., pr0.2001.88.2.527 Ryberg, J., & Ekstrom, M. (2015). Follow-up Lam, R. W., Michalak, E. E., & Swinson, R. P. study of the treatment outcomes at a psychiatric (2005). Assessment scales in depression, mania and trauma clinic for refugees. Torture, 25(1), 1-16. anxiety. London: Taylor & Francis. Buhmann, C. B., Nordentoft, M., Ekstroem, M., Maier, T., & Straub, M. (2011). “My head is like Carlsson, J., & Mortensen, E. L. (2016). The ef- a bag full of rubbish”: concepts of illness and fect of flexible cognitive-behavioural therapy and treatment expectations in traumatized mi- medical treatment, including antidepressants on grants. Qual Health Res, 21(2), 233-248. https:// post-traumatic stress disorder and depression in doi:10.1177/1049732310383867 traumatised refugees: pragmatic randomised con- Mollica, R. F., Caspi-Yavin, Y., Bollini, P., Truong, trolled clinical trial. Br J Psychiatry, 208(3), 252- T., Tor, S., & Lavelle, J. (1992). The Harvard 259. https://doi:10.1192/bjp.bp.114.150961 Trauma Questionnaire. Validating a cross-cultural Carlsson, J., Sonne, C., & Silove, D. (2014). From instrument for measuring torture, trauma, and pioneers to scientists: challenges in establishing posttraumatic stress disorder in Indochinese evidence-gathering models in torture and trauma refugees. J Nerv Ment Dis, 180(2), 111-116. mental health services for refugees. J Nerv http://psycnet.apa.org/doi/10.1097/00005053- Ment Dis, 202(9), 630-637. https://doi:10.1097/ 199202000-00008 NMD.0000000000000175 Mollica, R. F., Wyshak, G., de Marneffe, D., Khuon, Chen, J. A., Keller, S. M., Zoellner, L. A., & Feeny, F., & Lavelle, J. (1987). Indochinese versions of N. C. (2013). “How will it help me?” Reasons the Hopkins Symptom Checklist-25: a screening underlying treatment preferences between ser- instrument for the psychiatric care of refugees. traline and prolonged exposure in posttraumatic Am.J.Psychiatry, 144(4), 497-500. https://doi. stress disorder. J Nerv Ment Dis, 201(8), 691-697. org/10.1176/ajp.144.4.497 https://doi:10.1097/NMD.0b013e31829c50a9 Nickerson, A., Bryant, R. A., Silove, D., & Steel, Crumlish, N., & O’Rourke, K. (2010). A system- Z. (2011). A critical review of psychological atic review of treatments for post-traumatic treatments of posttraumatic stress disorder stress disorder among refugees and asylum- in refugees. Clin Psychol Rev, 31(3), 399-417. seekers. J.Nerv.Ment.Dis., 198(4), 237-251. doi:10.1016/j.cpr.2010.10.004 https://doi:10.1097/NMD.0b013e3181d61258 Noerregaard, C. (2012). Kultur og biologi ved psyko- TORTURE Volume 28, Number 2, 2018 Volume TORTURE 129
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farmakologisk behandling af etniske minoriteter. gees with trauma-related disorders: What do we [Culture and biology in psychopharmacological know today? Transcult Psychiatry, 54(2):260-280. treatment of ethnic minorities.] Ugeskrift for lae- https://doi:10.1177/1363461516682180https:// ger, 6, 337–340. doi:10.1177/1363461516682180 Olsen, D. R., Montgomery,E., Boejholm,S., Steel, Z., Chey, T., Silove, D., Marnane, C., Bry- Foldspang,A. (2007). Prevalence of pain in the ant, R. A., & van, O. M. (2009). Association of head, back and feet in refugees previously ex- torture and other potentially traumatic events posed to torture: A ten-year follow-up study. Dis- with mental health outcomes among popula- ability and Rehabilitation, 29(2), 163-171. https:// tions exposed to mass conflict and displacement: doi.org/10.1080/09638280600747645 a systematic review and meta-analysis. JAMA, Oruc, L., Kapetanovic, A., Pojskic, N., Culhane, M., 302(5), 537-549. https://doi.org/doi:10.1001/ Lavelle, J., Miley, K., Forstbauer, S., Mollica, RF jama.2009.1132 & .Henderson, D.C. (2008). Screening for PTSD Stein, D. J., Ipser,J.C., Seedat,S. (2009). Phar- and depression in Bosnia and Herzegovina: vali- macotherapy for post traumatic stress dis- dating the Harvard Trauma Questionnaire and order (PTSD) Cochrane Database of Sys- the Hopkins Symptom Checklist. Int.J.Culture tematic Reviews1: CD002795. https://doi. Ment.Health, 1(2), 105-17-133116. org/10.1002/14651858.CD002795.pub2 Palic, S., & Elklit, A. (2011). Psychosocial treat- Vincent, F., Jenkins, H., Larkin, M., & Clohessy, S. ment of posttraumatic stress disorder in adult (2013). Asylum-seekers’ experiences of trauma- refugees: a systematic review of prospective focused cognitive behaviour therapy for post- treatment outcome studies and a critique. J Af- traumatic stress disorder: a qualitative study. fect Disord, 131(1-3), 8-23. https://doi:10.1016/j. Behav Cogn Psychother, 41(5), 579-593. https:// jad.2010.07.005 doi:10.1017/S1352465812000550 Schottenbauer, M. A., Glass, C. R., Arnkoff, D. B., Tendick, V., & Gray, S. H. (2008). Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations. Psychiatry, 71(2), 134-168. https://doi:10.1521/ psyc.2008.71.2.134 Shearing, V., Lee, D., & Clohessy, S. (2011). How do clients experience reliving as part of trauma- focused cognitive behavioural therapy for post- traumatic stress disorder? Psychol Psychother, 84(4), 458-475. https://doi:10.1111/j.2044- 8341.2010.02012.x Sheehan, K. H., & Sheehan, D. V. (2008). Assess- ing treatment effects in clinical trials with the discan metric of the Sheehan Disability Scale. Int.Clin.Psychopharmacol., 23(2), 70-83. https://doi:10.1097/YIC.0b013e3282f2b4d6 [doi];00004850-200803000-00002 [pii] Shiner, B., D'Avolio L.W., Nguyen, T.M., Zayed, M.H., Young-Xu, Y., Desai, R.A., & Watts, B. TORTURE Volume 28, Number 2, 2018 (2013). Measuring use of evidence based psycho- therapy for posttraumatic stress disorders. Ad- ministration and Policy in Mental Health, 40, 311- 318. https://doi: 10.1007/s10488-012-0421-0 Silove, D., Manicavasagar, V., Beltran, R., Le, G., Nguyen, H., Phan, T., & Blaszczynski, A. (1997). Satisfaction of Vietnamese patients and their fam- ilies with refugee and mainstream mental health services. Psychiatr Serv, 48(8), 1064-1069. https:// doi.org/10.1176/ps.48.8.1064 Sonne, C., Carlsson, J., Bech, P., & Mortensen, E. L. (2017). Pharmacological treatment of refu- 130
CASE REPORT
Case report: The impact of torture on mental health in the narratives of two torture survivors
Simone M. de la Rie,*,** Jannetta Bos,*,** Jeroen Knipscheer, *,**,***, Paul A. Boelen**,***
which in turn, are related to severity of Key points of interest: psychological complaints. Results: Both •• The effects of NET may be patients have experienced an accumulation improved by tailor-made or of traumatic events. The psychological culturally sensitive interventions and physical torture they experienced lead that address shame, guilt, disgust to increased anticipation anxiety, loss of and cognitions about safety, trust, control and feelings of hopelessness, as power, self-esteem, and intimacy. well as overaccommodating cognitions •• Building trust and taking time regarding self and others. Conclusions: to pace the therapeutic process Cognitions, culture and beliefs, as well as is particularly important when issues of confidence and a more long-term treating survivors of torture. perspective affect therapeutic work. Building trust, pacing the therapeutic process, and Abstract applying tailor-made interventions that focus Introduction: Torture survivors risk on cognitions regarding self-esteem, trust in developing Posttraumatic Stress Disorder relationships, as well as safety and control (PTSD) as well as other mental health are warranted. problems. This clinical case study describes the impact of torture on two survivors who Keywords: Refugees, torture, PTSD, trauma, were treated for their PTSD with Narrative narrative exposure therapy Exposure Therapy. Method: The reports of the narratives of two torture survivors were Introduction qualitatively analyzed. It was hypothesized It was so frightening to hear the footsteps that torture yields overaccommodating from the guards in the corridor. What cognitions, as well as mental defeat, would happen? Who would be selected? We all shivered at the moment we heard these footsteps and the key turning in the lock. The account of Ahmed, a 40-year-old man *) Foundation Centrum '45, Partner in Arq, Die- from an Arab country in the Middle East, men, The Netherlands on his traumatic experiences in prison, is **) Arq Psychotrauma Expert Group, Diemen, The only one example of the horrific events Netherlands ***) Department of Clinical Psychology, Utrecht recurring in the nightmares and intrusive
TORTURE Volume 28, Number 2, 2018 Volume TORTURE University, Utrecht, The Netherlands memories that torture survivors need to deal 131
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with everyday. Torture1 is found to have a in individuals as it deliberately attempts to long-lasting effect on physical, psychological, “break someone’s will” (Perez-Sales, 2017a). and social areas of life. Physical as well as The fear- and helplessness-inducing effects psychological symptoms are documented of captivity determines the perceived severity (Peel Lubell, & Beynon 2005; Quiroga & of torture and psychological damage in Jaranson, 2005; Rasmussen, 2006; Skylv, detainees (Başoğlu et al., 2009; 2017). 1992). The most common mental health disorders documented as an effect of torture Treatment were posttraumatic stress disorder (PTSD) Torture survivors benefit from treatment and depression, which often co-occur only moderately (Patel, Kellezi, & Williams, (Nickerson, Schick, Schnyder, Bryant, & 2014; Perez-Sales, 2017b). A promising Morina, 2017). type of treatment is Narrative Exposure Torture survivors are at an increased risk Therapy (NET). NET is an evidence- of a shattered sense of control and cognitive based, short-term intervention for trauma understanding about the self and others. victims, designed for use in patients from Several studies have shown that when the all cultural backgrounds, in particular event was perceived as uncontrollable, mental people who experienced multiple or defeat (i.e. perceived loss of oneself as an complex traumatic events (Gwozdziewycz autonomous person) during trauma may & Mehl-Madrona, 2013; Lambert & inflate symptom severity (Ehlers, Clarck, Alhassoon, 2015; Robjant & Fazel, 2010; Dunmore, Jaycox, Meadows & Foa et al., Schauer, Neuner, & Elbert, 2011). During 1998, Ehlers & Clark, 2000; Wilker, Kleim, NET, therapist and patient collaboratively Geiling, Pfeiffer, Elbert, & Kolassa, 2017). develop a narrative of the patient’s life by In a study on traumatized women, Iverson identifying the most meaningful (positive et al. (2015) stated that assimilated or and negative) life events, symbolized overaccommodated thoughts regarding safety, by “flowers” and “stones”, respectively. trust, power, esteem, and intimacy as opposed The therapist supports the patient in to realistic, “accommodated” thoughts, constructing a chronological narrative of his/ may interfere with recovery from treatment. her whole life. Exposure to each traumatic Assimilation refers to hindsight bias, self- event in a chronological order aims to blame, undoing, minimizing, and denial of reconnect fragmented traumatic memories the event. Overaccommodation refers to with the autobiographical memory in order modifying one’s beliefs in such a way that to diminish trauma related complaints overgeneralizations emerge, e.g. about the (Schauer, Neuner & Elbert, 2011). All TORTURE Volume 28, Number 2, 2018 self (e.g., “I am a worthless person”), others trauma-related sessions are documented in (e.g., “No one can ever be trusted”), and the a written narrative which is handed to the world (e.g., “The world is a dreadful place”). patient at the end of treatment. Torture may induce these types of cognitions Aims The current study examines the narratives of two torture survivors who underwent NET. 1 Following the definition of torture from Article This intervention was offered as an individual 1 of the United Nations Convention Against therapy embedded in a phased day treatment Torture and other Cruel, Inhuman or Degrading Treatment or Punishment (UNCAT, 1984). program for refugees (Figure 1). Their trauma 132
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Figure 1: Day treatment program for refugees, Centrum ‘45*
Time Phase 1 (4 months) Phase 2 (4 months) Phase 3 (4 months)
10.00 Welcome
10.15 Group Creative Therapy Psychomotor Therapy Psychotherapy
11.30 Creative Therapy/ Narrative Exposure Societal Orientation Psychomotor Therapy Therapy
12.45 Lunch
13.15 Sociotherapy Psychomotor Therapy Consultation Hour
14.30 Consultation Hour Consultation Hour
Group-based, phase Group-based, separate Individual 1, 2 & 3 combined for each phase
*The day treatment program for refugees was developed by the first author in collaboration with the multidisciplinary team as a phased-based day treatment; each phase having a duration of four months. The first phase focuses on building trust, enhancing understanding of the complaints and improving coping, emotion regulation, and sleeping. The second phase focuses on processing the traumatic memories, by means of individual NET. The third phase focuses on personal and societal rehabilitation. Throughout the entire program, patients can consult any of the other practitioners (psychiatrist, psychotherapist, social worker, socio-therapist, creative therapist, psychomotor therapist) when needed.
history, the appraisal of torture experiences, the NET therapist) before and after and their impact on perceived mental health NET. The score reflects an individual’s are examined by labelling the cognitions as occupational, psychological, and social being either accommodating, assimilating, functioning on a continuum ranging from over accommodating cognitions or mental poor to excellent functioning (Startup, defeat. We hypothesized that torture yields Jackson, & Bendix, 2002). over-accommodating cognitions, as well as mental defeat, which in turn, are related to Analysis the severity of psychological complaints. The therapist actively asks for cognitions and emotions in response to life threatening Methods situations as part of exposure sessions of Assessment NET. The therapist asks about cognitions At intake, criteria from the DSM 5 “back then” and “here and now. “ A report (Diagnostic and Statistical Manual of Mental is written of each session which results Disorders) were assessed. The Clinician- in a reconstruction of the life history of Administered PTSD Scale (CAPS)—a the patient at the end of treatment. The clinician rated interview—was used to assess NET reports of two torture survivors are the severity of PTSD symptoms before and analyzed. Their cognitions—which are the after NET (Weathers et al., 2017). sections which are not italicized in the Global Assessment of Functioning descriptions below—are, when possible,
TORTURE Volume 28, Number 2, 2018 Volume TORTURE (GAF) was rated by the clinician (not labelled as being either assimilating, 133
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accommodating, over-accommodating has experienced severe and multiple traumas. cognitions or mental defeat. He is able to discuss these events in detail with the therapist and to complete NET, Results although treatment duration exceeds the The narratives of Ahmed and Morteza2 time scheduled. The case of Ahmed Ahmed is a 40-year-old Arab-speaking Ahmed’s narrative on torture: The fourth patient originating from a Middle Eastern period in the life of Ahmed in which he has country, who fled to the Netherlands when experienced multiple trauma, was during his he was 30 years old. At intake he reports imprisonment, as follows:3 that he is suffering from posttraumatic stress “After my arrest I had to follow them into and severe depressive symptoms. He also a small room, somewhere down below. The reports somatic complaints, his body hurts; walls were thin. I could hear other people especially his hands, feet and shoulders for screaming. They started questioning me. I had which he has needed medical treatment. He no clothes on. They beat me. They used an has no job and avoids contact with other electric wire. They hit me on my head, legs, people as much as possible. hands, back, stomach, and genitals. I was As a child he felt rejected by his mother. tied up on a chair, blindfolded. After every He reports bad memories of his childhood. answer, they were hitting me. I thought: ‘I As an adult he has been imprisoned for will die’. I smelled my flesh; it was burning several years because of political activities. because of the electric wire. I felt nauseous. He fled the country as soon as he was I lost consciousness. Afterwards they threw released from prison, but the memories me in a bath with very cold water. That was are recurring in his nightmares or in broad also hurting me a lot. I thought that I would daylight. His asylum procedure is an ongoing drown. I still have a lot of scars on my body. stress factor in his life. He is diagnosed They hanged me for 7-8 hours, with my legs with PTSD and Major Depressive Disorder upward and my head down. That was so (MDD). His score on the CAPS before NET difficult and very painful. I was so terribly is 46. His GAF score is 51. scared. They were laughing. I was blindfolded and taken to a secret prison.” Treatment process: Ahmed participates in the “Most people with whom I shared the day treatment program (Figure 1). He is cell were tortured. The torturing lasted more reluctant to share anything, but participates than a year. Sometimes one person was in group therapies when invited. He builds torturing me, another time 3 or 5 men. One TORTURE Volume 28, Number 2, 2018 trust in the therapist whom he already got to day they chose me, the other day one of my know before the start of the day treatment fellows. It was so frightening to hear the program. At phase 2 he starts with NET. He footsteps from the guards in the corridor. refers to five periods in his life in which he What would happen? Who would be chosen? We all shivered at the moment we heard these footsteps and the key turning in the lock. It was dark in the cell. We were 2 Written consent concerning the narrative has been obtained from both patients. The narratives of the torture survivors are anonymized—i.e. names have been changed. 3 Cognitions are in normal font. 134
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with many prisoners in one cell. I saw their these stressors. The CAPS score decreased, injuries. Some never returned. During the albeit, marginally, from 46 to 45 and the torturing, legs, and arms could be broken. GAF score from 51 to 45. They broke my wrist. A lot of people died, due to the beating or the electricity, or The case of Morteza because they fell ill, or were not treated for Morteza is a 48-year-old man, born their diabetes, their heart disease. People also in Teheran, Iran. At intake he reports died due to the very bad food and the hunger. severe PTSD complaints, having Sometimes the guards were quiet, sometimes recurrent nightmares and flashbacks of not, depending on the amount of alcohol his imprisonment in Iran. He suffers they had been drinking. We were all punished from intrusions: thoughts, images and when someone talked too loudly. Then we scents. He has problems falling asleep, were chased out of our cell and we had to and he ruminates a lot. He has problems stand in the hall for hours in our underwear. with concentration, anger outbursts, and I felt so tired, I could hardly stand on my avoids reminders of the past. He also feet. I had to prevent that I would collapse. reports severe somatic complaints, chronic Collapsing meant that the beating would pain in chest and shoulders, recurrent start again.” headaches. He failed to finish education “I knew they could do things like this. in the Netherlands and was never able The people who did this to us were drinking to work. He is currently living alone in a a lot of alcohol. I could smell it. They were small apartment, after having wandered also using drugs. I was blindfolded. They on the streets for years, using drugs. In were with three to five people. One was his childhood he experienced multiple lashing my back. The others were pushing traumatic experiences during the Iran-Iraq me to the wall. They pushed me down. I am war. He managed to finish high school often thinking: ‘I want to die’ when this education and before his imprisonment he memory is coming up. I feel disgusted. was a university student. He was arrested (Note from therapist: at this point of the because of political activities at university story patient can’t sit, is jumping up and four times. He escaped the fourth time restless. He wants to vomit. Sweat is all over and fled the country. He is also feeling his face. He is trembling all over.) They depressed, detached and isolated. He is raped me, one by one. They are laughing diagnosed with PTSD and MDD. The loudly. I could smell his body, the alcohol. It severity of his PTSD complaints as assessed was so painful. I could only think: ‘I want by CAPS prior to treatment was 48. His to die’ I still can feel these people inside me. GAF score was 45. I feel dirty until now. Some people killed themselves. They hanged themselves. I Narrative Exposure Therapy: At the start survived. I don’t know why.” of the day treatment program Morteza is reluctant to enter treatment. He fears the The completion of NET: After NET was idea of talking about his past experiences completed, other complaints were aggravated which he has avoided so far His coping skills due to current life stressors related to the to handle his emotions are not sufficient and asylum procedure. Additional treatment was during Phase 1 of the day care treatment
TORTURE Volume 28, Number 2, 2018 Volume TORTURE offered to support Ahmed in dealing with program—prior to the NET—the focus was 135
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on handling these emotions. No-show is Now I’m afraid of the police, afraid they’re high. Nevertheless he agrees to start NET going to get at me, despite knowing that’s not in Phase 2 and is able to describe several happening here. I’m afraid people do not traumatic events in his life line, but is very believe me, they think I’m lying. I feel scared of saying too much. He needs time insecure now too. The pain was bad, but to build trust in the therapist. The process what was worse was that I could think of of treatment is hampered because Morteza nothing else all day long. I was constant in frequently does not show up for his sessions. fear that they came to take me away again This has been discussed and as therapy and that they would hurt me again. It was continues he learns to trust the therapist terrible. I thought, “they are worse than I and opens up. He discloses several other ever could have imagined.” traumatic events during imprisonment which “After my first imprisonment, I was no he did not dare to share before because longer the person I used to be. I often of shame. Although treatment duration of got negative thoughts that I felt ashamed NET is longer than expected, he is able to of. I felt bad and worthless. I ruminated complete NET. a lot and stayed at home often. After half a year I was arrested again, and I was detained Morteza’s narrative: After several childhood for six months this second time. The first few events have been addressed by means months I was tortured a lot, once a week. of exposure, he mentions that the most You never knew when they would come. debilitating events were yet to come. So you were always scared. I ruminated The accounts of his experiences during a lot. Would they come for me? When imprisonment are as follows:4 they summoned me to follow them, they “I was taken to prison and pushed into a blindfolded me before taking me to a room. I small isolation cell. It was white, the walls was scared what would happen again. Would were filthy and written on. There was a I die? Could I keep it up? The room had small window through which I could talk white, dirty walls, filled with torture tools. with guards. I could hear others in the Then I was afraid they would use that. corridor. The first two months were the These thoughts went through my mind. I was worst. I had little sleep and was taken away afraid to be a coward. First, they tied me for questioning at unexpected moments, to a chair. They were usually two men. Then sometimes even in the middle of the night. they asked questions. They beat me, with their The interrogators were aggressive, threatening, hands and legs, but also with a whip. They
mean, and scolded at me. I was beaten with said I was lying. I was sometimes pulled up TORTURE Volume 28, Number 2, 2018 fists, but also with a whip. That was very by my legs, then they hit me on the soles of painful. Sometimes they tied my hands on the feet and forced me to walk. Or they would my back and hit me on my back, on my legs, hang a stick under my knees and tied with but also on my soles. Then they forced me to my hands against each other. They hung walk. I felt so much pain. I cried, I shouted. the stick on two tables and then I waved Whenever they thought you’d lied, they beat upside down. They hit me in many places. It you even harder. I could not do anything. was unbearable. I had no control over my thoughts, they hit me all over my body, I forgot about where I was, who I was. I 4 Cognitions are in normal font. can still feel pain in my arms and legs. 136
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I could not bear it, I felt different kinds earth. I once again fell unconscious. I only of pain. I cried and screamed because of the have patches of memory. When I woke up pain. What I found terrible was that they I felt worthless and saw no future. I was hung me on the ceiling with my hands in afraid and wanted to escape.” handcuffs. That was awfully painful, just electricity. In retrospect, I think I was lucky The completion of NET: At the last session too. There were moments I thought if it of NET he feels he has been able to discuss continues, I’ll tell everything. After a few his life in more detail than ever before. months, they stopped, they knew everything However, several comorbid complaints and we were brought to court.” remain. His CAPS score after NET is 38 “The fourth time I was arrested and and his GAF score is 50. Although he felt was in prison was the worst of all. It was some improvement in daily functioning a tough time, many people were executed. and less overwhelmed by flashbacks, several The tortures were violent, many people complaints remained. He has been referred started talking. When the guards discovered for further treatment for his other complaints. that I had lied, they got very angry and the torture aggravated. They threatened Discussion me with everything, with rape, with The narratives of Ahmed and Morteza execution. They said I was dirty, worthless. illustrate the tremendous psychological, I was afraid, feeling little. I thought, physical, and social toll of torture for I’ll never come out, I’ll die. I felt individuals and the long-lasting impact. worthless. Life is nothing anymore, many people were killed. I expected to die. Psychological torture Everything could happen. During earlier In their narratives, both Ahmed and imprisonments the rules were more clear: they Morteza described how they experienced finished torturing when they assumed they a lack of control. The unpredictability of had all the information they needed. But the experiences, hearing other people being now there were guards who continued with tortured or never seeing them return to their torture and seemed to enjoy the pain. I felt cell induced fear and contributed to their hate, but then at some point I thought: hopelessness, and later on, in the loss of self- it’s over. I had no control whatsoever. I worth—most evident in the story of Morteza. gave up. Now I have sometimes the same Psychological torture during captivity feeling, as if everything is hopeless and I induced a sense of fear and helplessness, as feel worthless.” stated by Başoğlu (2009). This psychological “But the worst of the worst torture is torture appears to be detrimental for the rape. I can not say or believe this has ability to cope with these overwhelming happened, but I heard a lot of others. experiences. The constant threat that torture During the torture I often felt unconscious. could be repeated reinforced the impact of One day I was beaten and threatened. I the memories. The accounts of both Ahmed fell unconscious. There were three men. A and Morteza refer to anticipation anxiety, stranger grabbed me by the arm and pulled a constant free-floating anxiety while in me to the ground. I was in a room, the light prison due the process of dehumanization was dimmed. I laid on the ground. The and humiliation. The uncertainty and
TORTURE Volume 28, Number 2, 2018 Volume TORTURE ground was cold and I sensed the smell of unpredictability aggravated the anxiety and 137
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resulted in a generalized free-floating anxiety, witnessed by the therapist when Ahmed even up to the present as if these events could recalled memories. It is important to note happen again at any time. These anxious that a neurocognitive overlap of social and expectations are related to the severity of the physical pain has been found (DeWall et al., anxiety complaints. 2010; Eisenberger & Lieberman, 2005).
The appraisal of torture events Implications for treatment The cognitions regarding the torture events In the case of both Ahmed and Morteza, of both Ahmed and Morteza revealed that a constant feeling of threat and the over-accommodating thoughts are provoked accumulation of different type of traumatic by both physical and psychological torture events during captivity called for a pacing which affected their level of distress. In of the therapeutic process to disentangle particularly the devaluating, stigmatizing, the traumatic events as distinct “events” in degrading remarks, laughing and shouting as order to reconstruct the narrative. At first, well as the deliberate violation of culturally some “stones” were not named or even sensitive taboos (by means of rape), induced mentioned at all, because of shame. The thoughts that you are ‘a nobody’ and feelings chronological reconstruction required to of shame, guilt and disgust. Emotions such take one step at a time. as shame, guilt and humiliation attack Building trust within the therapeutic dignity which can aggravate the breaking alliance and taking time by pacing the assumptions on self, the others and the therapeutic process with patience was world (Perez-Sales, 2017a). particularly important. It was important to Mental defeat, the complete lack of be aware of accumulation of trauma and control during the traumatic event, did (the interplay of) physical and psychological contribute to the belief that “everything harm, and the notion that shame may is hopeless and there won’t be a future.” prevent sharing of the most painful or The analysis of the narrative of Morteza shameful events recurring in nightmares and illustrates this. As he felt a total loss of flashbacks. Recalling memories once again control or was unable to anticipate anything induce feelings of shame and humiliation that happened to him during his last and the loss of dignity. The reluctance to imprisonment, he expected to die and felt say this and to show up at appointments totally demoralised and hopeless. They both at the beginning of the process can be at some point expected to die. understood as avoidance. Trust developed
gradually within the therapeutic relationship, TORTURE Volume 28, Number 2, 2018 Interplay of physical and psychological torture which eventually facilitated both Ahmed The interplay between physical and and Morteza to open up about even the psychological consequences of torture was most painful memories. An open, respectful, evident. Physical torture induced anxiety for patient, empathic attitude of the therapist pain and the physical harm was a constant and calmness when listening to their horrific reminder of the pain which reinforced stories while validating the emotional impact anxiety. Both Ahmed and Morteza reported of these experiences appears to be helpful in that daily pains trigger flashbacks about achieving a solid therapeutic alliance. the traumatic events. Furthermore, the The moderate effects of NET may be flashbacks are also triggering pain as was improved by more tailor-made or culturally 138
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sensitive cognitive behavioural interventions References that address shame, guilt, disgust and American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th cognitions about safety, trust, power, self- ed.). Washington, DC. esteem, and intimacy (Ehlers, A., Clark, D. Başoğlu, M. (2009). A multivariate contextual analy- M., Dunmore, E., Jaycox, L., Meadows, sis of torture and cruel, inhuman, and degrading E., & Foa, 1998, 2000; Iverson, King, treatments: Implications for an evidence-based definition of torture. American Journal of Or- Cunningham, & Resick, 2015; Perez-Sales, thopsychiatry 79 (2), 135-145. https://doi. 2017). Interventions that address core org/10.1037/a0015681 cognitions as those applied in schema therapy Başoğlu, M. (Ed.). (2017). Torture and its definition may be useful for the long-lasting impact of in international law: An interdisciplinary approach. New York: Oxford University Press. torture on the cognitions regarding self—"I Campbell, T. A. (2007). Psychological assessment, am worthless, I have no control"—and diagnosis, and treatment of torture survivors: a others—"No one can be trusted. People may review. Clinical Psychology Review, 27(5), 628-641. hurt me again"—(Young, Klosko & Weishaar, https://doi.org/10.1016/j.cpr.2007.02.003 DeWall, C. N., MacDonald, G., Webster, G. D., 2003). This may contribute to alleviating the Masten, C. L., Baumeister, R. F., Powell, C., Ei- symptoms, and patients may feel empowered senberger, N. I. (2010). Acetaminophen reduces to be more in control of their emotions while social pain: Behavioral and neural evidence. the process progresses. Psychological Science, 21(7), 931–937. https://doi. org/10.1177/0956797610374741 Although both torture survivors were Eisenberger, N. I., & Lieberman, M. D. (2005). Why able to complete NET, learned to trust the it hurts to be left out: the neurocognitive over- therapist, and showed some improvements, lap between physical and social pain. In: K. D. Williams, J. P. Forgas, & W. von Hippel (Eds.), the results were limited in terms of The Social Outcast: Ostracism, Social Exclusion, improvements in PTSD and GAF scores. It Rejection, and Bullying (pp. 109-127). New York: is remarkable that several positive changes Cambridge University Press. could be observed in the patients, but not Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behavior Re- so much in terms of diminishing PTSD search and Therapy, 38 (4), 319–345. https://doi. complaints. The ongoing asylum procedure org/10.1016/S0005-7967(99)00123-0 and the fear of being sent back to his Ehlers, A., Clark, D. M., Dunmore, E., Jaycox, L., country and to be imprisoned and tortured Meadows, E., & Foa, E. B. (1998). Predicting response to exposure treatment in PTSD: The again had a detrimental impact on Ahmed, role of mental defeat and alienation. Journal of because of which he had difficulties in Traumatic Stress, 11 (3), 457–471. benefiting from treatment. Ehlers, A., Maercker, A., & Boos, A. (2000). Post- It is important to look beyond physical traumatic stress disorder following political imprisonment: The role of mental defeat, aliena- and psychological symptoms, to broader tion, and perceived permanent change. Journal of adaptive functioning in terms of the Abnormal Psychology, 109 (1), 45–55. https://doi. individual’s ability to feel confidence in their org/10.1037//0021-843X.109.1.45 own capacities, in the predictability of the Gwozdziewycz, N. M. A. & Mehl-Madrona, L. (2013). Meta-Analysis of the Use of Narrative world, and the trustworthiness of the human Exposure Therapy for the Effects of Trauma community (Campbell, 2007; Hocking, Among Refugee Populations. Permanente Kennedy & Sundram, 2015; Jaranson Journal, 17 (1), 70-76. https://doi.org/10.7812/ TPP/12-058 & Popkin, 1998; Kirmayer, Rousseau & Hocking, D. C., Kennedy, G. A., & Sundram, S. Measham, 2010; Steel et al., 2009). This (2015). Mental disorders in asylum seekers: may help torture survivors to feel more in The role of the refugee determination process and employment. Journal of Nervous and Mental
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Disease, 203(1), 28–32. https://doi.org/10.1097/ ture. 2nd, expanded edition, Göttingen: Hogrefe & NMD.0000000000000230 Huber Publishers. Iverson, K.M., King, M., Cunningham, K.C., & Re- Skylv, G. (1992). The physical sequelae of torture. In: sick, P.C. (2015). Rape survivors’ trauma-related Başoğlu, M. (ed), Torture and its consequences: cur- beliefs before and after Cognitive processing rent treatment approaches (pp 38-55). New York: therapy: Associations with PTSD and depression Cambridge University Press. symptoms. Behaviour Research and Therapy 66, 49- Startup, M., Jackson, M. C., & Bendix, S. (2002). 55. https://doi.org/10.1177/0886260515592618 The concurrent validity of the Global Assess- Jaranson, J., & Popkin, M. (Eds.). (1998). Caring for ment of Functioning (GAF). British Journal of Victims of Torture. Washington, DC: American Clinical Psychology, 41 (4), 417-422. https://doi. Psychiatric Press. org/10.1348/014466502760387533 Kirmayer, L. J., Rousseau, C., & Measham, T. (2010). Steel, Z., Chey, T., Silove, D., Marnane, C., Bryant, Sociocultural considerations. In D. Benedek & G. R. A., & van Ommeren, M. (2009). Association H. Wynn (Eds.), Clinical manual for the manage- of torture and other potentially traumatic events ment of posttraumatic stress disorder. Washington: with mental health outcomes among populations American Psychiatric Publishing, Inc. exposed to mass conflict and displacement: a sys- Kross, E., Berman, M. G., Mischel, W., Smith, E. E., tematic review and meta-analysis. Journal of the & Wager, T. D. (2011). Social rejection shares American Medical Association, 302 (5), 537-549. somatosensory representations with physical pain. https://doi.org/10.1001/jama.2009.1132 Proceedings of the National Academy of Sciences, United Nations (1984). Convention against Torture 108(15), 6270–6275. and Other Cruel, Inhuman or Degrading Treat- Lambert, J. E. & Alhassoon, O. (2015). Trauma- ment or Punishment. Focused Therapy for Refugees: Meta-Analytic Weathers, F. W., Bovin, M. J., Lee, D. J., Sloan, D. M., Findings. Journal of Counseling Psychology, 62(1), Schnurr, P. P., Kaloupek, D. G., & Marx, B. P. 28–37. https://doi.org/10.1037/cou0000048 (2017). The Clinician-Administered PTSD Scale Nickerson, A., Schick, M., Schnyder, U., Bryant, A.E. for DSM–5 (CAPS-5): Development and initial & Morina, N. (2017). Comorbidity of psychometric evaluation in military veterans. Psy- Posttraumatic Stress Disorder and Depression in chological Assessment, 30(3), 383-395. Tortured, Treatment-Seeking Refugees. Journal of Wilker, S. Kleim, B., Geiling A., Pfeiffer A., Elbert, Traumatic Stress, 30 (4), 409–415. http://dx.doi. T. & Kolassa I.T. (2017). Mental defeat and org/10.1002/jts.22205 cumulative trauma experiences predict trauma- Patel N., Kellezi B., & Williams A.C.D.C. (2014). related psychopathology: Evidence from a post- Psychological, social and welfare interven- conflict population in Northern Uganda. Clinical tions for psychological health and well-being Psychological Science, 5(6),974–984. https://doi. of torture survivors. Cochrane Database of org/10.1177/2167702617719946 Systematic Reviews, Issue 11. https://doi. Young, J. E; Klosko, J. S; Weishaar, M. E. (2003). org/10.1002/14651858.CD009317 Schema therapy: a practitioner’s guide. New York: Peel, M., Lubell, N., & Beynon, J. (2005). Medi- Guilford Press. cal Investigation and Documentation of Torture. A Handbook for Health Professionals. Human Rights Center: University of Essex. Pérez-Sales, P. (2017a). Psychological torture: Definition, evaluation and measurement. London: Routledge. TORTURE Volume 28, Number 2, 2018 Pérez-Sales, P. (2017b). Psychotherapy for torture survivors – Suggested pathways for research. To r - ture, 27(1), 1–12. Quiroga, J. & Jaranson, J.M. (2005) Politically- motivated torture and its survivors: A desk study review of the literature. Torture, 15,(2-3) Rasmussen, O. V. (2006). The medical aspects of the UN Convention against Torture. Torture, 16(1), 58–64. Schauer M, Neuner F, Elbert T. (2011). Narrative Exposure Therapy. A Short-term Intervention for Traumatic Stress Disorders after War, Terror or Tor- 140
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that governments need to be consulting Building survivor survivors, who are the experts, rather than activism: An the top-down method. But, survivor activism can mean many things, and there are organisational view questions over how it can best be carried out in an environment already plagued by a lack Shameem Sadiq-Tang,* of resources. At Freedom from Torture, we distinguish survivor activism from the work Introduction we also do to engage service users in our The purpose of this paper is to share how own organisation. We see survivor activism different models of survivor activism can be as amplifying the voices of survivors of built in a clinical charity with a human rights torture in discussions and debates in spaces ethos and to set out the value that has come of influence and decision- making fora. It from growing survivor activism organically, must go beyond tokenism or consultation. based on experiences at Freedom from To me, this means that survivors voices, Torture. The work was formally established words and narratives are aimed at shaping as survivor activism eight years ago and changing policy and practice on although it began years before. Since then torture and its impact. It means formally it continues to evolve and, as a result, recognising survivor activism as a body of there is a strong programme based on work and allocating resources to support collaborative approaches and good practice survivors to meaningfully engage in activism. for safe and informed engagement. From an Our survivor activism has not developed organisational perspective, it is possible to in response to research findings based on highlight risk reduction, empowered spaces samples or methodologies, but a genuine and enabling survivors of torture to be their belief amongst service users and staff in own agents of change as key factors in a the value of activism by those with lived successful survivor activism programme. experience of torture. It is based on years of It is widely acknowledged that survivor working in collaboration with survivors of involvement is important, not only in torture and getting their positive feedback, shaping the rehabilitation and other services and simply getting out there and doing and they receive but also in advocating for learning along the way. positive change in the wider world. Juan In a climate of limited funding, Mendez, former UN Special Rapporteur organisations have to make difficult on Torture,1 amongst others, has indicated decisions about where to invest resources. Freedom from Torture is one of the larger torture rehabilitation centres but
1 https://www.freedomfromtorture.org/survivor_ we still face these dilemmas. However, activism a commitment to putting survivors of torture at the heart of everything we do *) Survivor Activism Manager, Freedom from Tor- including in our external influencing work ture, UK. Shameem has led the Survivor Activ- is embedded in the organisational strategy ism team for eight years. at Freedom from Torture, so we have been Correspondence to: lucky enough to have ring-fenced resources [email protected]
TORTURE Volume 28, Number 2, 2018 Volume TORTURE (Also to find out more about survivor activism). for a number of years. 141
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Activism groups and activists centres (London & South East, Glasgow, Survivor activists in Freedom from Manchester, Newcastle and Birmingham). Torture projects are men, women and Recently, their work has focused on direct young people who have been tortured advocacy with domestic and international and are either asylum applicants or decision makers like the UK Home Office, refugees in the UK. They are all current the Foreign and Commonwealth Office and or former clients of Freedom from cross-party governmental scrutiny bodies, Torture. They are supported by a team but its members also speak at events in of volunteers and staff and together we the UK and abroad including at colleges have grown survivor activism into an and universities, in Parliament, and to the area of work that is now acknowledged United Nations, to raise awareness and within the organisation as an important press for change. part of the rehabilitative journey for The group speaks as a network of survivors of torture. The three groups, survivors with one voice. This strengthens two adult and a third being set up for their message but also supports their own young people, focus on promoting personal well-being. A driving philosophy survivor-led or supported interventions of their work is to let people know that as in public spaces, policy debates and survivors of torture, they are not simply practice about torture, but they all have a source of testimony but that their lived different ways of working. experience of torture and its impact means they have crucial insights to shape change Survivors Speak OUT (SSO) and create meaningful solutions. “As an activist, I can address some of the Examples of their impact include staff injustices of my past and present. For too long training implemented in the UK Home others told my story but now I am speaking Office’s Asylum Intake Unit about greater for myself and for other torture survivors. We awareness of behaviours and attitudes are taking back control and working hard to on asylum applicants. This training was make sure that we are part of finding and implemented after joint advocacy work shaping solutions about our lives”, Serge by SSO and Freedom from Torture with Eric Yamou, co-founder of SSO, and now the Intake Unit; and the introduction of Trustee at Freedom from Torture a principle in the UK Preventing Sexual Survivors Speak OUT is a survivor-led Violence Initiative’s (PSVI) Global activist network supported by the charity Principles for Action to tackle Sexual but which was in fact initiated by a small Violence in Conflict on empowering TORTURE Volume 28, Number 2, 2018 group of service users2 who had a passion survivors to speak out. to speak out against torture and its As an organisation, we support the impact. The network is now ten years old. network by helping members to access There are more than 30 active members opportunities to influence others. The all of whom have completed treatment process of support is intensive and at one of Freedom from Torture’s five includes capacity building for their public speaking, media training and advocacy skills, preparation through workshops to support them to develop policy positions 2 A user of Freedom from Torture’s rehabilitation services and key messages, help to write speeches 142
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and articles, work to develop and Write to Life,3 our creative writing and promote their brand as a network, and more recently performance group, is now 20 also as individual advocates. In addition, years old. The group began as a therapeutic there is a need to develop and manage space based in our clinical department. It safeguarding, good practice around a has now evolved into a group supported range of issues including individual by professional writers who work with security and self-care. Throughout this its members and support them to reach process the focus is always on supporting out to new and previously untapped network members to develop their audiences through poems, films, music identities as activists so that they are and theatre, most of which the members recognised within their own right. perform themselves. Unlike Survivors Speak SSO has taught us the power of OUT, members of Write to Life are both speaking with a collective voice. This current and former service users. Again, an approach sometimes stops survivors important principle for the group is that being included in discussions and debates they do not recount torture experiences but because those reaching out to the group are find creative and engaging ways to tell their interested only in testimony about specific versions of their stories, whatever that may torture experiences. But this model has be, on their terms. allowed us to help the Survivors Speak One of Write to Life’s key achievements OUT network to develop collaborative has been through transforming stories policy positions which helps to reduce and words into artistic forms of self- the risk of personal credibility attacks and expression that has enabled new audiences protects the network from claims of bias in to be reached that might not otherwise be relation to a country or an issue. We have interested in torture and its’ impact. An also taken partners along with us on this example of this is the play, Souvenirs, that journey—for example, we convinced the was written and performed by members of UK Foreign & Commonwealth Office that the group (all survivors of torture) which survivors could contribute more than their toured theatres to packed-out audiences. stories. The coordinator of the network now One audience member said, “Souvenirs serves on the ministerial steering group burned itself on my soul. Not in any way for the UK’s Preventing Sexual Violence bleak or sympathy stealing. It felt like a true in Conflict Initiative. This approach also human connection between audience and enables survivor perspective on human performers. This is the most important thing rights issues to inform the influencing I have seen a theatre do.” programmes and policy positions of Appropriate safeguards to reduce Freedom from Torture. risks and respond to incidents that might impact mental health must continuously Write to Life be developed, improved and implemented. “Writing to me is activism—it makes Another current focus is promoting me feel who I am”… “I write to empty collaborative approaches between group myself of my memories, to choose things to remember and challenge myself to move on”, Quotations from Survivor Activists 3 https://www.freedomfromtorture.org/survivor_
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members and support staff/volunteers. supported by clinical staff. We strive to find a balance in providing Nonetheless, some people see our enough space for the group to nurture its survivor activism work as an important part creative approach that enriches writing of their rehabilitation journey and writing and performance. At the same time, we like that of Write to Life certainly has also look at how their work can support therapeutic benefits. Elif from Write to Life the strategic policy priorities set by the describes how writing enables distance from organisation in collaboration with survivors, a painful past and allows me to focus on the for example through performances for present and the future. advocacy targets or creative projects aligned One important way to support to campaign objectives. engagement in activism is by holding regular group meetings for survivor activists Youth Voices to come together, discuss issues, reach The third group, Youth Voices, is for younger common agreement and generally bond torture survivors aged 16 to 25 who have as a group with a common cause. This is an interest in activism. The purpose of this important because our groups are made group is to create a space for young survivors up of women and men from different to have a more prominent voice and speak backgrounds, cultures, expectations out on issues that impact their lives in the and experiences so taking the time to UK. Young people in the UK experience the understand each other is important asylum system and other services differently It is important to inspire people to and too often their voices are not heard over engage through skill-building workshops that adult interests. The direct engagement phase are relevant to them and that they enjoy. with young people begins in summer 2018. These workshops might involve support to members of our groups to formulate policy What does it take?: Dedicated positions, recommendations for change, resources write speeches or poems. If survivor activists Enabling engagement: When people (survivor are volunteering their time and energy activists) join our groups, it begins with an around initiatives related to deeply personal induction about the group, its members, and traumatic issues, they need to feel the what is involved, a two-way discussion about value of their engagement. expectations, how to make a complaint and People are supported to express a set of policies to support good and safe themselves in their own words, avoiding practice. It is important to be clear that jargon and using simple language. They don’t TORTURE Volume 28, Number 2, 2018 survivor activism is not a clinical group or need to speak the best English but they will a formal part of the therapeutic process have to have some level of English to speak because it is of course essential for group to their audience directly—they may need members to know if they are a therapy client support to do this even though it in itself can for a number of reasons; ethically they need create challenges around authentic voice and to be clear about their relationship with the feelings of frustrations when someone cannot organisation; therapy clients may have access clearly express themselves in the way that to different internal services; and staff in they want or need to. survivor activism are not clinical therapists All of the activities and events we although there are situations where we are help the groups to participate in are 144
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supported by briefings as a group before, People: A dedicated team makes it possible if necessary during, and always after, to build relationships, develop trust and, as a because preparation, preparation and more result, is more effectively able to build know- preparation is essential for impact. This how, appropriate polices, and good practice approach creates confidence and also fosters to monitor the work and ensure that it is an environment for reflection and learning safe and as risk free as it can be for survivor and in turn, progression. Things can and activists to engage. will go wrong so a key part of my role is to A key element of the success of survivor facilitate a process of checking in throughout activism at Freedom from Torture is and supporting the group to make a decision the existence of a dedicated team which together about next steps. supports the work, as well as a ring- Involvement with survivor activists fenced set of organisational resources. means that we develop long-term This commitment is embedded in our relationships through activism, in a organisational strategy to put survivors of way which for obvious reasons is rarely torture at the heart of everything we do experienced in the more boundaried clinical including in decision making. environment. That means that we see the There has been a conscious decision to lasting impact of torture, exile, rehabilitation ensure that this is not extra work tagged on and survival. This unique perspective to that of all or other teams but a body of supports our work with survivor activists work in itself. This is of course important because we often understand the issues and because survivor activists are still potentially the drivers that they prioritise. It also means vulnerable people living with deeply that we learn of, and are sometimes called traumatic pasts and in many instances very on to provide support on legal and welfare difficult present circumstances. They are issues they are experiencing. At Freedom highly motivated to engage in this work from Torture we are fortunate to have for a number of reasons including so that specialist colleagues in house to give legal others do not face what they have had to, advice and/or signpost to welfare support but part of the journey for them, and for us, services, when they have capacity. This is an can involve exploring issues which they may issue we continue to explore internally given not have had cause to address in therapy or limited resources and the need to prioritise other support, for example the potential to those with the most need while also wanting meet a government representative from their to meaningfully support the people we have home country in an international meeting. long-term relationships with. Operational budgets: Activities for the groups can be costly. Realistic and dedicated “Black writing ran wildly around the budgets for the day-to-day running of the page like spiders. All I could see was work are important. Money is needed to the word ‘refusal’. I lost my courage. I bring people together, to pay for skills- could not continue to read. The world building initiatives and to attend conferences had gone blue. My solicitor read out the (e.g. within the charity, homelessness and/ rest”, Extracts from 'The Letter' by or health sector), and provide basic costs Anon from Write to Life to enable practical involvement of activists,
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provisions of childcare. This has significant taking our duty of care in a survivor activism cost implications but also challenges in context seriously. ensuring the implementation and navigation It is important that informed consent is of a transparent system. Despite this, a based on a thorough assessment to support conscious decision has been made not to survivor activists to navigate the risks and replicate the barriers that survivor activists benefits associated with involvement in an face in their day-to-day life because of activity. It should also include information their gender and/or their asylum status. on how to withdraw consent and there We believe this is also essential to move should be a responsibility on the staffer or survivor engagement away from tokenistic facilitator to ensure that they have explained models into meaningful engagement because it clearly, discussed the appropriate risks and it allows for sustained development of benefits, and follow through to make sure an skills, and gives the groups the opportunity individual’s choices are respected. and time to develop thoughtful advocacy Preparation for activities should always positions. In our view, this means that include gathering enough information to we have to break down the barriers that carry out a risk assessment without which prevent meaningful engagement in a the informed part of consent (permission progressive way that leads to up-skilling based on full knowledge and consequences) and growing confidence (as opposed to can’t be given by survivor activists. passive involvement). We are fortunate in Participants need to clearly understand what the UK that, as well as the support of the will happen to the information they share, organisation, there are a number of funders where it might be used and what exposure that share our vision and support this work. it will be subject to including on social media and the internet. Exposure on digital Good practice: The survivors we work with channels opens up other issues to consider are without a doubt incredibly resilient, including issues around stigma, the potential but it is also important to recognise that for their experience to reach a far wider they are also susceptible to setbacks, not audience including in their home country only because of the torture they have with implications for family members survived and its long term impact on wherever they might be, and more. their lives, but also due to the myriad That is why for survivors of torture of challenges faced living as an asylum navigating consent is not about focusing seeker or refugee in the UK. Survivor simply on the present but the future too. The activism by its nature more often involves increasingly hostile efforts of states towards TORTURE Volume 28, Number 2, 2018 exposing survivors and their experiences refugees seeking protection means that we to strangers on platforms in the UK and do not know if they might face return to a internationally. Together these issues can torturing state either on refusal of asylum bring a host of challenges and risks. status or renewal of refugee status. Our Measures need to be in place to ensure responsibility to the well-being and safety of that our day-to-day work is based on safe survivor activists is paramount and overrules practices and guides staff and activists to our need to be relevant in debates or raise respond appropriately when faced with these organisational profile. challenges. It is not about wrapping people Another essential tool is the Critical up in cotton wool but as an organisation Incident Protocol which allows us to 146
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respond to situations that result in survivor control my own narrative and for me, that activists experiencing a serious deterioration is important”, Tracy N’dovi, Survivor of mental health including thoughts of Advocate, SSO suicide, and any child protection issue. This Working with and not just for survivors is might be the result of a particular activity an important principle, especially within or something external to the work. The an organisation with day-to-day contact protocol sets out clear guidance on how to with survivors of torture. Before being spot these signs and respond to situations able to create an opportunity to work both in and outside of working hours for alongside survivors in a meaningful way, an non-clinical staff in the survivor activism environment that supports people to build team. It is as much about supporting the their skills and capacity to engage in activism person experiencing a mental health set-back and feel confident about speaking out needs as it is for the staffer or activist responding to be created. to the incident. Having such a protocol in We do this by putting survivors and the place is essential not only for the well-being impact of their experiences at the centre of of individuals but also as a safeguard for the our approach. This involves working with organisation which may have legal and other people to understand how they process questions to face in such a situation from information, how their experiences of regulatory bodies as well as others. torture impact their engagement, what There are also other policies and the environment needs to feel and look practices implemented to respond to like to enable engagement, whether there other seemingly simple but in reality are barriers that inhibit engagement, more complex issues. This includes how factors like people, gender, status communications within the activism groups and culture influence involvement, and on online platforms such as social media or crucially what needs to be in place to mobile apps where information and video encourage and motivate people to join footage moves around at a rapid pace and discussions and debates. can include graphic and distressing content; Ultimately, the goal is to move to a and approaches between and amongst staff survivor-led approach. This is a long-term and survivor activists to maintain clear aspiration in which investment is put into and professional boundaries in the context supporting survivors to lead on their own of friendships born out of this work often organising, their own facilitation, and their outside of core working hours. own activism whatever that may look like. However, it is important to realise that Strategic development: Survivor- even when survivors have been politically centred to survivor-led active in other contexts, such as their home “I may have lost some dignity and respect countries, this may take time. For example, I was once treated with, but I want to say it is important to explore and understand that in all that you do, always remember the different advocacy spaces given that some words and contributions of women survivors of the survivor activists were human rights of torture. Our pasts may have left us in defenders in their home countries. Looking shock and in pain but we are resilient. I now at cultural differences in influencing public speak out against torture and its impact audiences or decision makers in the UK or
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and finding common ground is a critical after each event; when a group is strong, part of capacity building. individual feedback forms are often not The survivor-led approach is about wanted. Instead, creating a climate of trust supporting people to take more control and and building confidence means that survivor responsibility to deliver the impact that they activists will express themselves when they have identified. In practice, this is resource- need to. And this works two ways in a intensive and involves commitment from the mutually respectful relationship. All of this survivor group together with the skills and information is collated and fed back into the know-how to carry out parts of the day-to- development of the projects. Unfortunately, day work. There are also some more thorny we have not yet had the resources to carry issues of accountability to other group out any clinical evaluations as a result of our members, funders, the host organisation projects. Certainly, for many of the survivor and others. The reality is that ultimately you activists, although anecdotal evidence, they are working with people and not all people report that their involvement has led to conform to a particular approach that might an increase in their skills and confidence, be needed by the organisation. These are and many have since secured employment issues that arise day to day in every work including in engineering, academia, as place and this area of work is no exception. interpreters, writers and authors, and as From experience, we know that this well as organisations like Freedom from approach might not always or consistently Torture. Additionally, Freedom from work; we are grappling with and exploring Torture carried out a survivor-led six month different approaches, and this has value study in 2016 involving over 100 clients in itself. For example, whether to include to explore the meaning of rehabilitation to survivor activist in work behind the scenes survivors. Some clients reported that feeling like workshop design or facilitation, empowered to speak out about what had work closer to delivery stage including happened to them, and advocating for other speech development and delivery, or both survivors with decision makers or to public whilst considering capacity in terms of audiences, was a key part of rehabilitation. availability, time, skills and budget. As an “They said that using their voice empowers organisation it is important to be prepared them and helps restore their confidence. to be flexible about the type and level of This is especially important for people who support that is needed. previously felt unable to use their voice to speak out in public.” (Haoussou, 2018 p. 69)
Learning along the way The number of survivor activists who TORTURE Volume 28, Number 2, 2018 Monitoring and evaluation: Good practice have engaged with us over the years is small should include having mechanisms in in comparison to the number of clients place to evaluate this work both in terms at Freedom for Torture. This reflects that of benefits to survivor activists and shaping survivor activism is still a comparatively new more progressive ways to engage survivors area of work, and the resources we currently in influencing opportunities, but also for have reflect the capacity we have to deliver policy impact. We do continuous evaluation our work safely. through listening to survivor activists at the meetings and workshops mentioned above Recommendations: The wealth of learning but we do not do circulate evaluation forms is not possible to share in its entirety 148
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here but brief issues to highlight for other everyone’s voices are amplified; organisations looking to build similar •• Monitoring and evaluation in models are: collaboration with survivor activists is •• Few, if any, of the survivors now engaged important for progress, learning and in activism came as professional public funders; and speakers, advocates or performers. Yet •• We all need to find ways to share good because of torture, they are now doing practice and embed survivor activism in just that so they need significant support. the anti-torture movement, in keeping Take the time to invest, support and with the human rights principles of build trust; empowerment and participation. •• Support people to control their own narratives. Help them to or directly How to do this work with fewer resources: It is resist requests purely for testimony still possible to support survivor engagement and focus on the messaging and in activism with fewer resources, but be positive action that are important to realistic about what you can and can’t do. survivor activists; The list below are some initial points to think •• Try to secure dedicated resources to about when considering this work for the support survivor activism rather than first time: adding this approach to other posts; •• Have a clear sense of resources including •• Make sure you are able to spot risk staff time, skills in-house and budget; including signs of deteriorating mental •• Have a clear and simple strategy with an health and have the appropriate aim (what do you want to achieve) and safeguards in place to respond objectives (what must happen to help appropriately; you achieve your aim); •• As in all groups that work together and •• You must be able to deliver your strategy can form strong bonds, there will not within existing resources and crucially, always be agreement; sometimes there with buy-in and support from survivor will be falling out. Implement fair and activists and other support staff; appropriate support and responses to •• Develop guidance to support good help navigate out of the situation; practice and at a minimum, be clear •• Don’t let engagement be tokenistic, about gathering ‘Informed Consent’ make it meaningful and when you’re not that includes a thorough risk and safety able to do that, think about if it is fair assessment; and have a plan in place to continue; about how you will respond in the •• Don’t be afraid to give constructive event of an emergency or risk to safety/ feedback when things don’t go to well-being; plan as learning is important. But •• Be clear about what the engagement can consider the individual first and tailor and can’t offer—be realistic; your approach so that they don’t feel •• Start preparing for the activity and put in demotivated. And of course, always practice time before hand; praise when it all goes well; •• Make sure that appropriate support is •• Keep an eye on individual and in place during the activity and debrief organisational egos (we all have them) so afterwards (to survivor activists and
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•• Monitor progress and record well-being and any other risk issues that emerge; •• Consider your plan for next steps including assessing impact; and •• Maintain good boundaries throughout the process.
Conclusions For organisations interested in building similar survivor activism models, this is a small offering of advice based on my personal perspective of what is necessary to consider to move any involvement away from tokenistic participation to a survivor-centred space. There is a lot of hidden work that goes on behind the scenes including constant reflection about how to build on and improve for the future. Of course there are times where we might get it wrong. There are also times where internally our approach might not be in sync with other departments. But this is constant work in progress and our organisation continues to demonstrate its commitment to amplifying survivor voices including through survivor activism where we continue to build on our successes and look to grow over the coming years.
References Haoussou K., (2017) Perspective—The long journey to rehabilitation for torture survivors. Torture 27, (1) 66-74. TORTURE Volume 28, Number 2, 2018 150
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The book is an essential, specialized Evans, III, B. F., Hass, guide for psychologists and clinicians who G. (2018). Forensic work with immigrants. It is an attempt to draw together the authors’ knowledge Psychological about forensic psychology, psychological assessment, traumatology, family processes, Assessment in and national and international political Immigration Court. forces to present an approach to effective and ethical practice of forensic psychological New York: assessment in courts. The book consists of three parts. The Routledge. first part of the book gives an insight into the conceptual background, such as, culture, gender, credibility etc. The second part Edited by Barton offers numerous applications of forensic assessment approaches to common areas of F. Evans III, Giselle immigration law practice. In the third part, A. Hass the use of psychological tests and methods, report writing and expert testimony for the immigration courts are explained. This Published by Routledge. New York. approach leads the reader, via theory to (ISBN-13: 978-1138657731) practical information about carrying out an evaluation and delivering the results to Mari Amos, MA, MPh* both customer as well as the court. Personal reflections and experiences and practical This guidebook by Barton F. Evans III examples about the cases the authors and Giselle A. Hass, published in the US have been dealing with are also included this year, has been written by two experts throughout the book. in the field. Barton F. Evans III, Ph.D, a There are many key messages that the clinical and forensic psychologist as well keen reader can discover and benefit from. as a Clinical Professor of Psychiatry and For example, in Chapter 1, principles Behavioral Sciences, and Giselle A. Hass, of forensic psychology and how they are Psy.D., ABAP, a licensed psychologist relevant to the immigration court (IC) and a diplomate by the American are clarified. In this framework, it stresses Board of Assessment Psychology. Both the fundamental differences between the of the authors have had long-standing forensic assessor and the mental health professional careers in the area of clinician that should be kept in mind. assessments for immigration courts in the The most important difference is that the United States of America. forensic assessor must take an objective, neutral stance in the evaluation which is different from the supportive, accepting, empathic, and confidential relationship *) Current Member of the United Nations Subcom- critical to good clinical treatment. The mittee on Prevention of Torture
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neutral and be able to back-up findings a manual in that, on certain occasions, it with scientific, well-acknowledged tools takes a step-by-step approach. and methods. Chapter 2 explores cross- Table 2.1 is quite inspirational, giving cultural, gender, and language perspectives. a long list of recommendations when using The authors remind us to understand interpreters. At the same time, as the book issues of race, ethnicity and culture. For generally appears to be aimed at those who example, the emotional impact of abuse have at least some knowledge about this and discrimination on account of race, issue, the list could be considered too basic. ethnicity and culture is further aggravated Readers are reminded about when immigrant workers are forced by the importance of the evaluator’s necessity to accept jobs of a lower status professionalism in such proceedings and than they would have in their native Chapter 2 and Figure 2.1 are very helpful countries. One aspect of this issue has to in this regard as they provide an overview do with limited English proficiency and of the main necessary competences as acculturation which, according to the well as a tool for self-reflection for those authors, is unfortunately rarely assessed in who are already active in the area. This forensic assessments. level of detail might in fact attract novices The main value of the book certainly to purport to have more skills than they lies in Part III–Methodology which actually have and follow tools detailed consists of three chapters (Diagnostic in the book without the appropriate Interviewing and Trauma-Specific professional background. Another Instruments in Immigration Evaluations, important, but often neglected area is the Rorschach and Performance-Based need for self-care for evaluators. Supervision, Measures in Immigration Evaluations, and peer-support etc are crucial for working Report Writing and Expert Testimony) fruitfully and efficiently on this field. which are comprehensive, appropriately Despite the aspects to recommend it, the detailed and practical. Chapter 9 book lacks a common approach and style. explains that psychological assessment It mixes personal stories and reflections; instruments include clinical interviews, scientific research in forensic medicine and symptom-specific tests, and comprehensive psychology; lots of statistics, numbers and personality tests. Several tests are facts; overviews and assessments of tools; introduced and described with respect checklists and so on. All three parts of the to their content, usability and value. book are absolutely different—starting
Chapter 10 attempts to highlight how the from a collection of quotations in the first TORTURE Volume 28, Number 2, 2018 Rorschach and other Performance-Based one, ending with very practical tips in the Measures can be used in evaluations in last one. Even the individual chapters are the context of relevant legal issues by the written in an un-unified way. Doubtless, appropriately trained assessor in forensic there is much information available about evaluation in the IC. The section concludes immigration, evaluations, and hardships that with useful practical tips for writing a people who have had to cut their roots are report and presenting it. This being so, facing, but I am not sure all this needs to be Part III is very helpful for those who are included with science, stories and tools. interested in or have to start practising in, This raises the question: who is the or exploring the area. Parts of it act like addressee of this book? It fails to be a 152
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practical guidebook for practitioners precisely because of its lack of systematism After Deportation: and the absence of an easy-to-use format. Ethnographic At the same time, it does not qualify as academic as it does not provide synthesis Perspectives and new approaches. Some parts of the book are written in a well-structured way, whilst other parts use a different style and Edited by Shahram content, with even minor technical things Khosravi like references being put in different ways. Perhaps the real beneficiary of this book Published by Palgrave Macmillan (ISBN-13: is the possible “examinee” who could (by 978-3319572666; ISBN-10: 3319572660). skipping the first theoretical parts) get rather a good idea on how to pass proceedings with “clean records”? Louise Victoria Johansen, PhD, Ass.Prof.*
In After Deportation: Ethnographic Perspectives, thirteen chapters by different authors provide strong accounts of what happens when migrants and rejected asylum seekers are deported from countries in which they have resided for shorter or longer periods. This anthology highlights a phase of deportees’ lives that is seldom ethnographically studied when compared to the much larger interest given to immigration detention and deportation. The ethnographies highlight post deportation phases from different geographic, gendered and social perspectives. Some of the narratives include deportation from EU countries to countries such as Nigeria, Cameroun, Mali and Togo, while other chapters analyze experiences of deportees from the United States to the Caribbean, from Australia to Samoa, or even from Iran to Afghanistan. The authors show how the very different circumstances in which people are deported shape their constraints and possible strategies.
*) Faculty of Law, University of Copenhagen, Denmark
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Many of the contributions cite Natalie approach, following people through Peutz’s call for an ’anthropology of removal’ different phases of their deportation. As a (2007), focusing on spatial and temporal consequence, most studies are multi-sited dimensions of deportation. The authors and use different kinds of communication thus distance themselves from the general technology such as Skype and other internet notion of deportation as a movement from media, underlining how an ethnography of one nation state to another. While politically, deportation cannot just be about ’places’ to deportation is couched as ending migration, study, but also about who to study and how deportation is for many migrants just part of to follow people on the move. a migration cycle in which new possibilities Several of the contributions analyze for migrating will continuously be explored. gendered aspects of post-deportation. For Therefore, the present book argues that instance, gender is crucial to understanding deportation involves longer periods of female sex worker migrants from Nigeria, time, geographical spaces, institutions, and who have been deported from an EU people than perhaps expected. Deportation country. Not all sex workers are victims is seen as a transnational, intercontinental of human trafficking, but they are often and postcolonial phenomenon. Through depicted as such. By accepting this its involvement with individual deportees, categorization, they may gain access to the book shows how they are part of larger some kind of economic support from the sociopolitical and economic agendas. The deporting countries, but at the cost of so-called ‘Global North’ needs labor from having to perform ’the good victim’ as the ‘Global South’ but wishes to regulate entrepreneurs in the country of return. this flow through possibilities of importing The problem of receiving economic and deporting laborers. The authors criticize support in the process of deportation, the official rhetoric surrounding deportation called ’pay-to-go’ models, is also addressed through the use of concepts like ‘home in other chapters of the book. The relative country’, ‘family’ and ‘reintegration’. success or failure of this model is dependent These discourses serve to depoliticize on several issues. A key to success is if deportation which is precisely characterized migrants have had the chance to plan their by separating families in the country of departure. Unfortunately, this is precisely deportation. Similarly, programs of ’assisted not the case for deportees, who are often voluntary returns’ are mostly not voluntary picked up without notice by police and nor are they perceived as a ’return’ by transported directly to migration detention. deportees themselves. The book pinpoints Furthermore, rejected asylum seekers often TORTURE Volume 28, Number 2, 2018 how ‘assisted voluntary returns’ are instead return to countries still at war, making it part of neoliberal governing practices through almost impossible to set up a business or which deportees are perceived as self- the like. These obstacles highlight how pay- governing subjects who are able to handle to-go initiatives are political legitimations decisions about their own deportation. for deporting people, but with little or no Methodologically, most of the chapters positive outcomes for either deportees or use qualitative or mixed methods, receiving countries. One further interesting although the volume of qualitative data perspective put forward in another chapter is varies somewhat from chapter to chapter. the fact that deportees have a better chance The studies often involve a longitudinal of coping with deportation if they have been 154
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imprisoned in the deporting country than Perspectives conveys strong accounts if they have been in immigration detention. of people who experience the period Being in prison may involve access to post-deportation and its consequences education and the possibility of planning on their own lives, their families, and their own deportation. the communities they form part of. A criminal conviction is one of the Nevertheless, it might be interesting to recurring reasons for deportation. Authors pursue further aspects in future post- show how this may have particular deportation studies. For instance, the book negative consequences for deportees analyzes single aspects of gender or age because they have often been long- and their impact on how people experience term legal residents in the country of deportation, but it would be interesting deportation, where they also have families. to analyze in a more in-depth way how As deportees, they feel total estrangement, intersections between race, age, gender and loss, and regret over past actions. At the class influence deportees’ life situations same time, their new community often in different ways. Several chapters meets them with fear and hostility. mention the legal aspects of deportation, Running through all chapters is the for instance, that insufficient knowledge overall description of loss, separation about how to renew a residence permit and failure following deportation. Some may lead to deportation. In addition, the informants describe how it is more ‘externalization’ of border controls by the stigmatizing to be a deportee than to be ‘Global North’ to places of departure is a sex worker because it is perceived as shown to create new criminal categories a sign of downward social mobility. The such as ‘illegal emigration’, and thus economic and social situation may also also new legal norms in ‘Global South’ have changed for the worse in the country countries. These legal and often quite of return, making it extremely difficult for technical aspects of (post) deportation deportees to cope. Deportation is depicted would be rewarding to study further as a life-changing event, placing deportees since they both visibly and covertly shape in strenuous situations of liminality because deportation processes. of their role of being in-between different countries, cultures and communities. The anthology renders detailed portraits of people who live in these post-deportation situations. Each chapter provides different perspectives on their hardships and the coping strategies they develop. Authors as well as informants insist on the fact that deportees are not victims but actors trying to navigate in the new situations they encounter, for instance by developing ’transnational survival strategies’ and using their skills from the ‘Global North’ in their receiving environments.
TORTURE Volume 28, Number 2, 2018 Volume TORTURE As such, After Deportation : Ethnographic 155
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the protection against its use. The great Tainted by Torture: contribution of this report, compared Examining the Use of with previous reviews, is precisely its effort to identify the real translation of the Torture Evidence prohibition into different state models, providing evidence on existing formats Edited and Published by REDRESS and Fair and how they function in practice. Taking Trials.(Free access) on this complex and ambitious task is not only courageous but is also important as Sara Lopez. PhD. Senior Legal Advisor* it provides an evidence-based proposal to limit the judicial legitimation of torture. The In 80 pages, the report Tainted by Torture: proposals and conclusions of the report are Examining the Use of Torture Evidence, a remarkable starting point for undertaking jointly written by Redress and Fair this work. Trials, analyses legislation, jurisprudence The report is divided into several and data on the admission of evidence chapters, dealing with different aspects of obtained under torture. It identifies not the admissibility of evidence obtained under only the different models of regulation torture in the named countries, including in applying Article 15 of the Convention whether: (i) the prohibition is absolute; (ii) against Torture,1 but particularly focuses it extends to other forms of inhuman or on the limitations, both interpretative and degrading treatment or punishment; (iii) it practical, found in this provision. covers evidence obtained from the torture The authors draw on a comparative of a third party; (iv) it covers derivative survey of the law and practice of 17 evidence/’fruits of the poisonous tree’; and (v) countries, namely, Australia, Brazil, China, there are effective legal procedures in place to England and Wales, France, Germany, identify and exclude ‘torture evidence’. Indonesia, Japan, Kenya, Mexico, Spain, Chapter I, “The prohibition on torture South Africa, Thailand, Tunisia, Turkey, and the exclusionary rule”, examines the the United States of America and Vietnam. international regulation on the prohibition of As they explain, this data was used to torture, with a particular focus on the rights examine different ways of implementing and principles to do with the violation of the the prohibition on using evidence obtained exclusionary rule with respect to the use of under torture, to identify challenges in confessions obtained under torture. the course of applying it and any gaps in Chapter II, “The components of the TORTURE Volume 28, Number 2, 2018 exclusionary rule”, analyses the different models, monistic or dualistic, express or implied regimes, which can be adopted *) SiR[a] Center. with respect to the prohibition on Correspondence to: [email protected] ‘torture evidence’ in different countries. 1 Article 15 of the Convention states that, “Each State Party shall ensure that any statement Of particular interest is the study of the which is established to have been made as a balancing act between the system in the result of torture shall not be invoked as evidence Commonwealth and Western Australia. in any proceedings, except against a person ac- The chapter also addresses challenges cused of torture as evidence that the statement was made”. arising from the fact that the prohibition of 156
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torture is not extended to other forms of that operate among defence lawyers are cruel, inhuman and degrading treatment. also discussed, including the fact that they The analysis of the differing national do not believe the court will exclude the implementation of the evidence obtained evidence anyway, are concerned about their by torture of a third party is particularly personal safety or that of their client, and relevant. Similarly, the varying application fear that it will be detrimental to their future of excluding derivative evidence (‘the fruits work. Similarly, the chapter thoroughly of the poisonous tree’ or evidence obtained reviews practical barriers, which include illegally) is also reviewed in detail and with the difficulties in ensuring the protection of considerable cross-national evidence. complainants; the limitations in obtaining Chapter III, “Triggering the procedure”, evidence of the existence of torture; the reviews in detail the different models of obstacles posed by delays in cases where the regulation and procedural practices in complainant is in pretrial detention; and the combating the use of evidence obtained very frequent guilty pleas, which involve the under torture. It examines the different withdrawal of the complaint in exchange for moments in which the illegality of the favourable treatment in application of the evidence may be challenged; it defines the complainant’s punishment. The clarity with standards relating to the right to a fair which these complex practical dilemmas are trial under international law; it verifies the identified in the report successfully lays bare different systems of burden of proof, again the challenges that need to be addressed in with numerous comparative evidence; and this area. considers the different types of evidence Chapter V, “Tackling confessions-based that courts can take into account when criminal justice”, in turn, proposes a clear assessing whether evidence was obtained approach to judicial models based on a by torture. The breadth of the legal, single source of evidence that can easily jurisprudential and practical review of the be obtained under torture. Thus, different chapter provides a clear overview of the proposals for corroborating evidence are advantages and weaknesses of the different reviewed, as are the diverse systems of models analysed. confession given at different stages in the One of the most relevant chapters is proceedings or to different actors within the Chapter IV, “Making the exclusionary rule justice system. Reviewed too is the varied effective in practice”. The absence of official systems of procedural safeguards during data compels the authors to review whether the investigation in different countries. The NGOs and treaty-monitoring bodies are chapter concludes with the need to reinforce reporting instances of ‘torture evidence’ the initiative of Juan Mendez, the former UN admitted in criminal cases. The chapter Special Rapporteur on Torture, to elaborate reviews the major problems for professionals a universal protocol for interrogations. in the justice sector, including the lack of Chapter VI, “Prosecutions and training for judges on the relevant domestic disciplinary sanctions stemming from laws and international standards; and, revelations about torture evidence”, briefly institutional disincentives among judges, addresses the Convention’s requirement such as the weight of work, or the risk of that countries define torture as a specific an adverse public, political or diplomatic offence in their Criminal Codes. It also
TORTURE Volume 28, Number 2, 2018 Volume TORTURE response to a prosecution. The disincentives reviews the major difficulties posed by the 157
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duty to investigate in various countries; and examines some systems of administrative complaint bodies or inspectorates which have the power to investigate and sanction any unlawful conduct. Chapter VII, “Remedies and reparation for victims”, sets out the need for specific forms of reparation for forced confessions and reviews, in turn, the elements of the duty of reparation to victims (restitution, compensation, rehabilitation, satisfaction and guarantees of non-repetition) in the various systems under study, in order to identify the insufficiency of measures in this regard and to define future lines of work. The final chapter, “Conclusions and recommendations”, reviews the proposals made at the beginning of the report, providing suggested resolutions on each of the aspects addressed. The signatory organisations, Redress and Fair Trials, argue that the exclusionary rule should be accorded a more prominent role in the work undertaken to combat torture; it should define a clear focus for advocacy efforts, including by domestic civil society actors. They argue for clarity on the extent to which the exclusionary rule overlaps with derivative evidence and evidence obtained as a result of inhuman or degrading treatment or punishment. The elaboration of approaches which address how the law is operating in practice is proposed, and an increased focus TORTURE Volume 28, Number 2, 2018 on rights-compliant police investigations is recommended. Not least, the report calls for the adoption of reparation measures for victims in accordance with the requirements of General Comment No. 3 of the Committee against Torture. All in all, it is a thorough and geographically broad analysis which is at the same time a reasonable and understandable rallying cry in the name of justice for torture survivors. 158
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does not and must not give free reign for Grotesque image can medical professionals and other to indulge never be forgotten in blatantly unethical and unprofessional practice. It is important that standards are nor forgiven maintained to avoid traumatising or tortuous environments in healthcare settings (Centre An adult male was admitted in Rani for Human Rights and Humanitarian Law Laxmibai Medical College, Jhansi, MP, Anti-Torture Initiative, 2013). India, where his leg was amputated. We feel obliged to speak out particularly Regrettably, the patient’s amputated leg was as this is not the first time that such a practice tucked under his head as a pillow while the has been identified. On this occasion, the patient was recuperating in the emergency matter was highlighted by the press (Hindi section of the hospital. Daily, 2018). Previously, similar situations This situation is clearly professionally have been shown to occur time and again in unethical, promotes medical ostracization, India (Husain, M., Anjum, A, Alshraim, M, creates psychological issues for the victim, Usmani, A, Usmani, J.A., 2012). and works against inherent humanistic values We urge that such practices be stopped and medical progress and accepted norms and counselling should be provided to those of decency. This form of mental torture may hospital employees who are so susceptible not exactly conform to the definition of to stress that they take short cuts without torture in the Convention against Torture. realising that these may cause deep hurt and However, it must certainly be degrading downgrade professional values. treatment, at the very least, and such practices must surely be condemned by Md Mojahid Anwar, MD, Ass Prof., Mohd the medical professional worldwide. In this Asrarul Haque, MD, Ass Prof, Afzal Haroon, case, a non-implantable body part which MD, Ass Prof., Hena Fatima,*, Munawwar has become ‘non-self’ being used as a pillow Husain, MD, Prof.,** is highly likely to seriously detrimentally psychologically affect the patient. Why did this happen? Whilst in a hospital References such incidents should never take place, still Centre for Human Rights and Humanitarian Law Anti-Torture Initiative. (2013) Torture in they do. The problem of lack of resources Healthcare Settings: Reflections on the Special and the increase in patient load has created Rapporteur on Torture’s 2013 Thematic Report. an atmosphere where apparently minor Washington College of Law: Washington, USA. Edward (2005). Principia Ethica. Bames & Noble lapses and unethical practices are often Publishing House. overlooked, or normalised. Additionally, Hindi Daily. (2018). Dainik Jagran, Aligarh, 11th patients find it hard to question the quality March 2018, p.16. of health care as their treatment is going Husain (2001). A proposal to revisit the UN torture definition. Torture, 11 (21-22). on, particularly as they may not consider Husain, Anjum, Alshraim, Usmani, Usmani (2012). healthcare to be their birth right - despite Situation Ethics: How relevant is ‘right’ versus assurances given by the Indian government. ‘useful’ theory in ethical practice? J Indian Justification for incidents such as these is Academy Forensic Med, 34 (2), pp 154-155. UN Convention against Torture and Other often inadequacies in the health care system. Cruel, Inhuman or Degrading Treatment or However, it is our firm view that this context Punishment. A/RES/39/46. TORTURE Volume 28, Number 2, 2018 Volume TORTURE 159 HowLETTER TOto THE support EDITOR Campaign the Torture to reach 3,000 Journal subscribers
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