Screening for Torture: A Narrative Checklist Comparing Legal Definitions in a Torture Treatment Clinic

Beyond torture checklists: an exploratory study of the reliability and construct validity of the Torturing Environment Scale (TES)

Background

Torture methods have traditionally been quantified using checklists. However, checklists fail to capture accurately both the almost infinite range of available methods of torture and the victims’ subjective experience. The Torturing Environment Scale (TES) was designed as a multidimensional alternative that groups torture methods according to the specific human function under attack. This study aims to do an exploratory assessment of the internal consistency reliability and discriminatory validity of the TES as part of a construct validity assessment in a sample of Basque torture survivors.

Methods

We applied the TES to a sample of 201 torture survivors from the Istanbul Protocol Project in the Basque Country Study (IPP-BC) to profile torturing environments in detention. To estimate the internal consistency reliability of the scale, categorical omega values were obtained for each subscale of the TES. To assess its discriminatory validity, the “known groups” method was used comparing mean scorings by gender, state security forces involved in the detention, and decade (the 1980s to the present) when the events took place.

Results

Men reported more physical pain, while women reported more attacks on self-identity and sexual integrity. The TES also showed significant differences as regards the security forces involved in the detention: Civil Guard (a militarised police) used more manipulation of the environment, threats, fear, pain and extreme pain, as compared to national and regional corps. Finally, although patterns of torture remained mostly unchanged across decades, more recent detentions included more emphasis on psychological attacks: context manipulation, humiliation linked to sexual identity, and attacks to meaning and identity. For all subscales of the TES, categorical omega values ranged from 0.44 to 0.72.

Conclusion

The TES may be a useful tool in profiling torturing environments. Its sensitivity to key contextual variables supports the discriminatory validity of the scale. While some of the subscales showed an acceptable degree of internal consistency, others require further analysis to improve reliability. The scale provides unique insights into the profile of contemporary torture. It will allow for future quantitative research on the relationship between different torturing environments and the medical and psychological consequences thereof.

Chronic pain diagnosis in refugee torture survivors: A prospective, blinded diagnostic accuracy study

BACKGROUND

An estimated 87% of torture survivors experience chronic pain such as brachial plexopathy from upper extremity suspension or lumbosacral plexus injury from leg hyperextension. However, a vast majority of pain is undetected by evaluators due to a lack of diagnostic tools and confounding psychiatric illness. This diagnostic gap results in exclusive psychological treatment rather than multimodal therapies, substantially limiting rehabilitation. We hypothesized that the United Nations Istanbul Protocol (UNIP) would have a sensitivity of approximately 15% for pain detection, and that the use of a validated pain screen would improve its sensitivity by at least 29%, as compared to the reference standard (pain specialist evaluation).

METHODS AND FINDINGS

This prospective blind-comparison-to-gold-standard study of survivors of torture, as defined by the World Medical Association, took place at Weill Cornell Medicine between February 1, 2017, and June 21, 2019. 11 women and 9 men, for a total of 20 participants, were included in the analysis. Five participants received 2 UNIP evaluations, for a total of 25 unique evaluations included in the analysis. Participants were representative of a global population, with home countries in Africa, Central America, South Asia, the Caribbean, and the Middle East. Methods of torture experienced were homogeneous, following the predictable pattern of systematic torture. Participants first received the standard evaluation protocol for torture survivors (UNIP) by a trained evaluator, and subsequently received a validated pain screen (Brief Pain Inventory-Short Form [BPISF]) followed by a noninvasive examination by a pain specialist physician (reference standard). The primary outcome was the diagnostic and treatment capability of the standard protocol (index test) versus the validated pain screen (BPISF), as compared to the reference standard. Trained evaluators performing the initial assessment with the UNIP (index test) were blinded to the study, and the pain specialist physician (reference standard) was blinded to the outcome of the initial UNIP evaluation and the BPISF; data from the initial UNIP assessment were not gathered by the principal investigator until all other study procedures were completed. Providers using only the UNIP captured pain in a maximum of 16% of evaluations, as compared to 85% of participants being diagnosed with pain by the reference standard. When employed, the validated pain screen had a sensitivity of 100% (95% CI 72%-100%) and a negative predictive value of 100%, as compared to a sensitivity of 24% (95% CI 8%-50%) and a negative predictive value of 19% (95% CI 5%-46%) for the index test. The difference in the sensitivity of the UNIP as compared to the BPISF was significant, with p < 0.001. No adverse events owing to participation in the study were reported by participants. Limitations of the study include small sample size, its single-site nature, and the exclusion of individuals who did not speak 1 of the 5 study languages.

CONCLUSIONS

These data indicate that a validated pain screen can supplement the current global standard assessment of torture survivors, the UNIP, to increase the accuracy of pain diagnosis.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03018782.

Primary Care Screening Methods and Outcomes for Asylum Seekers in New York City

Effective screening in primary care among asylum-seekers in the US is critical as this population grows. This study aimed to evaluate disease prevalence and screening methods in this high-risk group. Two hundred ten new clients from 51 countries, plus Tibet, who were accepted into a program for asylum seekers from 2012 to 2014 were included. Screening rates and outcomes for infectious, non-communicable, and mental illnesses were evaluated. Screening rates were highest for PTSD, depression, hepatitis B, and latent tuberculosis. Seventy-one percent of clients screened positive for depression and 55 % for PTSD, followed by latent tuberculosis (41 %), hypertension (10 %), hepatitis B (9.4 %), and HIV (0.8 %). Overall screening rates were high. Point of care testing was more effective than testing that required a repeat visit. A large psychiatric and infectious disease burden was identified. These findings can inform future primary care screening efforts for asylum seekers in the US.

Psychological assessment of torture survivors: essential steps, avoidable errors, and helpful resources

This article provides ideas, information, and resources that may be helpful in conducting psychological evaluations of people who have been tortured. The first section discusses essential steps, including achieving competence; clarifying the purpose; selecting methods appropriate to the individual, the purpose, and the situation; addressing issues of culture and language; maintaining awareness of ways in which the presence of third parties and recording can affect the assessment; attending carefully to similarities, echoes, and triggers; and actively searching for ways to transcend our own limited experiences and misleading expectations. The second section discusses avoiding five common errors that undermine these evaluations: mismatched validity; confirmation bias; confusing retrospective and prospective accuracy (switching conditional probabilities); ignoring the effects of low base rates; and misinterpreting dual high base rates. The third section identifies resources on the web (e.g., major centers, legal services, online courses, information about asylum and refuge, networks of torture survivors, human rights organizations providing information and services, guides to assessment) that people working with torture survivors, refugees, and asylum-seekers may find helpful.

The Tortured Brain

Traumatic stressors such as water boarding, electric shock, or false execution all activate similar bodily, affective, and cognitive responses even when they are quite different from one another. As a result, the memory traces merge into a “trauma network” that includes sensory memories but becomes detached from the particular episodic memory; that is, the trauma network has no time or place. As, with increasing traumatic experiences, more and more cues become integrated in the network, the threshold for excitation is continually lowered and the individual is likely to show frequent alarm and other defense responses to reminders of the trauma. Neuroplastic mechanisms determine subsequent reorganization of brain circuitry in order to adapt to a presumed permanent need for defense.

We hypothesized that aversive pictorial material is differentially processed in visual as well as frontal and limbic areas of the traumatized brain. We used Rapid Serial Visual Presentation (three pictures per second) to present aversive, neutral, and appetitive pictorial stimuli. Event-related magnetic fields were recorded in 41 survivors of torture and organized violence who suffered from posttraumatic stress disorder (PTSD) as well as 43 controls with a comparable ethnic background. Traumatized individuals showed an early shift in the processing of aversive pictures from sensory visual areas to fronto-temporal areas and the amygdala compared to controls without trauma-related symptoms. For survivors, as opposed to controls, these stimuli automatically activate aspects of the defense cascade and thus lead to an excitation of action-related neural activity. We conclude that an enlarged fear network in survivors of organized violence has a low excitation threshold, thus leading to prominent PTSD symptoms. A disintegration of the fear network by reconnecting its elements to the respective episodic memory or by some form of inhibition of the network may bring relief.