"Psychological Assessment of Torture Survivors:
Essential Steps, Avoidable Errors, and Helpful Resources"
Abstract: 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.
PLEASE NOTE: This article appears in the International Journal of Law and Psychiatry,vol. 35(5-6), pages 418-426.© 2013 Elsevier
Torture is widely prohibited--and widely practiced. Major documents prohibiting torture include Article 55 of the Universal Declaration of Human Rights, adopted December 10, 1948; Article 7 of the International Covenant on Civil and Political Rights, adopted by the U.N. on December 18, 1966; and the Declaration on the Protection of All Persons from Being Subjected to Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, adopted unanimously by the U.N. General Assembly on December 9, 1975.
The United Nations Convention Against Torture, adopted by the U.N. General Assembly on December 10, 1984, and ratified by 147 countries, holds that "Each State Party shall take effective legislative, administrative, judicial or other measures to prevent acts of torture in any territory under its jurisdiction." Nothing justifies exceptions: "No exceptional circumstances whatsoever, whether a state of war or a threat of war, internal political instability or any other public emergency, may be invoked as a justification of torture."
Unfortunately, despite these and other explicit prohibitions, torture is widespread. The U.N. Special Rapporteur on Torture stated that "torture was practiced in most countries of the world" (United Nations, 2010). Amnesty International (2011) has documented torture and ill treatment in 98 countries.
Working in the context of tension between the widespread prohibition and practice of torture, those who conduct psychological assessments of people who have been tortured face complex challenges in reaching conclusions that are valid and useful. This article offers information and ideas that may be helpful to evaluators of this very vulnerable population. The information and ideas fall into three sections: essential steps, avoidable errors, and helpful resources.
Essential steps in conducting a psychological assessment of someone who has been tortured include 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 Examiner's Competence
Competence is as crucial in assessing torture victims as it is in other professional endeavors but it takes on added layers of complexity. Maintaining competence requires knowledge of this highly specialized area. For example, the examiner should be familiar with useful guides such as Examining asylum seekers: A health professional's guide to medical and psychological evaluations of torture (Physicians for Human Rights, 2001), Caring for Torture Survivors Free Online Course (Boston Center for Refugee Health and Human Rights, 2009), and Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment ["Istanbul Protocol, Rev 1"] (UN Office of the High Commissioner for Human Rights, 2004).
Understanding the legal context can also be key. For example, Herlihy, Ferstman, and Turner (2004) emphasize the importance, when working with asylum-seekers and refugees, of appreciating the legal context that defines their standing and prospects. "After all, it is this context in which their status is defined and through which they have to journey in a search for sanctuary" (p. 641).
Examiners should be familiar with the emerging general research in this area (e.g., Basoglu, 2009; Gola et al, 2012; Green, Rasmussen, & Rosenfeld, 2010; Hárdi & Kroó. 2011; Johnson & Thompson, 2008; Maercker & Forstmeier, 2011; Rasmussen, Crager, Keatley, Keller, & Rosenfeld, 2011; Schubert & Punamäki, 2011; Shrestha, 1998; Steel et al., 2009) as well as the research addressing the specific purpose, person, and situation at hand. If the assessment involves standardized tests, inventories, or similar instruments, examiners must be abreast of the current research involving these instruments and possess competence in using each instrument.
But beyond this knowledge-base and set of skills, the examiner must maintain "emotional competence" (Pope & Vasquez, 2011). Torture victims have survived horrific experiences and the examiner must be able to listen openly and carefully to accounts of these experiences, to explore them, and to assess their effects on the survivors. Some potential examiners may not be prepared for the immediacy and intensity of these accounts and the brutality they describe. Torture takes many forms and uses many tools. Physical torture can involve applying acid or electric shocks; beating; blinding; breaking bones; burning; cutting; dislocating joints; drugging or poisoning; forcing body parts into icy or boiling water; hanging (e.g., by the thumbs or feet); holding the person under water or otherwise preventing access to air or forcing water into the lungs; kicking; leaving the person in a very small box or cage; mutilating; puncturing ear drums; removing body parts; stabbing; starving; subjecting the person to live in extremely hot or cold conditions; tying the person into a painful position for hours or days; using loud, sometimes deafening, sounds; and so on.
Although all forms of physical torture are likely to have psychological aspects and consequences, some forms of torture are primarily psychological. Torturers may force someone to watch a relative or friend being tortured, may describe (accurately or falsely) the torture, death, or betrayal of loved ones, or may pronounce a fake death sentence, perhaps followed by a fake execution (e.g., placing an unloaded gun to the person's head and pulling the trigger). They may tell victims that no one remembers them, let alone thinks of them or cares about them. They may persuade them that even if they survive, no one will believe what happened to them. Sexual torture involves both physical and psychological aspects.
The psychological horrors of torture can vary from the dreaded inevitability of an inflexible schedule to the terrors of never knowing what will happen next. Jacobo Timerman, editor and publisher of the Argentinean newspaper La Opinion until his arrest by the military, described this inability to anticipate or prepare for what would happen next during his years in prison in Prisoner Without a Name, Cell Without a Number:
[W]henever someone was being prepared for transfer, his eyes blindfolded, his hands tied behind him, thrown on the ground in the back of a car and covered with a blanket, he would have preferred to remain in the clandestine prison. You never knew whether you were being led to an interrogation, torture, death, or another prison... (p. 159).
Torturers may force victims into active participation, telling them to decide which family members, friends, or fellow prisoners will be tortured or murdered. They may direct victims to use torture instruments on themselves or on fellow prisoners. They may ask victims what form of torture they prefer or what body parts they can most easily do without. They may threaten to torture or murder fellow prisoners in the same room unless victims give up names, locations, habits, vulnerabilities, and other information about people the torturers want to capture.
In her Commencement Address at Harvard University, author J. K. Rowling (2008) described how one of her earliest jobs affected her. She was working in the London offices of Amnesgty International where she encountered many victims of torture and their relatives. "I began to have nightmares, literal nightmares, about some of the things I saw, heard..." Here is one of her experiences: "And as long as I live I shall remember walking along an empty corridor and suddenly hearing, from behind a closed door, a scream of pain and horror such as I have never heard since. The door opened, and the researcher poked out her head and told me to run and make a hot drink for the young man sitting with her. She had just given him the news that in retaliation for his own outspokenness against his country's regime, his mother had been seized and executed...."
Examiners must be emotionally prepared to encounter such experiences while remaining alert to any possibility that what they are hearing is evoking reactions in them that impair their work. Pope and Garcia-Peltoniemi (1991) highlighted some of the common reactions of clinicians, including:
1) an almost phobic reaction to the horrors endured by the torture victim, so that the clinician consciously or unconsciously attempts to avoid hearing the most painful aspects
2) an almost voyeuristic or obsessive personal curiosity, resulting in the clinician pressing for and focusing on the most graphic details
3) a tendency to see the person solely as a "torture victim," with the label obscuring all personal or human characteristics that the clinician does not associate with a particular stereotype of torture victim
4) a tendency for the clinician's political beliefs or personal agenda to interfere with the ability to listen carefully and accurately to the person who has been tortured
5) a fear that the clinician may be at risk for negative consequences in some way from working with a torture survivor who is the target of widespread prejudice in the clinician's home country or who may still be hunted by those who perpetrated the torture
6) some form of survivor guilt.
Bustos, (1990), Danieli (1980), and Kinzie and Engdahl (2001) provide additional descriptions of common clinician reactions.
A Clear Purpose
Victims of torture may be evaluated for diverse reasons: To prepare for a hearing to request asylum; to prepare for a criminal, civil, or other legal action against those who perpetrated the torture; to help in adjusting to a new setting as a refugee; to receive treatment for symptoms resulting from (or in some cases independent of) the torture; to name but a few. Only if examiners know the purpose of the evaluation can they ensure that they gather the required information.
Moreover, only if examiners understand clearly the purpose of the evaluation can they ensure that the person to be assessed adequately understands the purpose and can provide appropriate informed consent. Simply showing up for an evaluation is no guarantee of understanding the purpose. An attorney, a member of the clergy, a counselor at a center for victims of torture, an internist, a family member, or a friend may have made the appointment and given the prospective evaluatee a vague explanation along the lines of "here's something you need to do," "this is the next step," or "you'll find that this will be helpful."
Both examiners and evaluatees need to understand clearly:
1) who scheduled the assessment,
2) why it was scheduled,
3) what will be involved in the assessment,
4) what feedback will be given to the evaluatee and who will provide it,
5) where else the results may be presented,
6) any limits to confidentiality, and what impact the results may have on the evaluatee's life.
Examiners bear a significant responsibility to confirm that the individual not only understands an assessment's purpose and implications but also has freely given consent.
There is no one-size-fits-all approach to evaluating people who have been tortured. Assessment methods must be selected that fit the individual, the purpose, and the context. It is often tempting to look for tests that can always be used because they always demonstrate high validity and high reliability. But even for the most useful tests, there is no universal validity and reliability. Validity and reliability can only be demonstrated for specific purposes (e.g., identifying cognitive deficits, revealing attempts to malinger, predicting response to group therapy), specific populations (e.g., people proficient in Spanish, airline pilots, children ages 5-11), and specific settings (schools, medical inpatient facilities, prisons). Evaluators must select assessment methods that are appropriate for the assessment at hand.
Psychological evaluations of people who have been tortured often involved standardized tests. Such tests gain their power from their standardization. Norms, validity, reliability, specificity, sensitivity, and similar measures emerge from an actuarial base: a well-selected sample of people providing data (through answering questions, performing tasks, etc.) in response to a uniform procedure in (reasonably) uniform conditions. When we change the instructions, the test items, or how we administer or score the items, we lose that standardization and the power it gives.
Evaluators must attend carefully not only to the ways in which they administer, score, and interpret tests but also to the many factors than can also interfere with the principles of standardization through which which standardized tests produce valid results. For example, tests requiring the person to read the questions may be normed on people who can see adequately. But the person being assessed may have forgotten to bring reading glasses, or have borrowed someone else' glasses, or have taken medication that impairs vision. If the person cannot see adequately and must squint and guess at some of the words, the test results may not be valid.
Characteristics of the examiner can also drain the power of standardization. Again, competence is a vital key. Examiners must be competent to administer, score, and interpret each test. Attempts to administer a test before achieving competence can lead to significant mistakes that depart from standardization and produce invalid results.
Characteristics of the assessment situation itself can affect the validity of the results. For example, as discussed in a subsequent section, the presence of a third party or recording device can affect an assessment. Loud noises (e.g., construction work nearby or banging doors up and down the hall), lack of privacy, and frequent interruptions can also affect attention and concentration.
It is not uncommon to make adjustments in the administration and other aspects of assessment methods or to make other reasonable accommodations for a person who has been tortured. Discussing accommodations for assessing people with disabilities, Lee, Reynolds, and Willson (2003) suggest principles that are also applicable to reasonable accommodations for victims of torture:
The 1999 Standards for Educational and Psychological Testing adopted by AERA, APA, and NCME requires examiners to make reasonable accommodations for individuals with disabilities when administering psychological tests to such persons. Changes in test administration may be required, but the Standards also require the examiner to provide evidence associated with the validity of test score interpretation in the face of such changes in administration. Departures from standard procedures during test administration may change the meaning of test scores, because scores based on norms derived from standardized procedures may not be appropriate; error terms and rates may also be affected. (p. 55)
Examiners bear a significant responsibility to evaluate whether their administration, scoring, and interpretation of standardized assessments meets the basic conditions of standardization. Fulfilling this responsibility includes constant alertness to and active searching for any factors that could affect the assessment's validity. The assessment report should identify and discuss those factors, if any.
Culture and Language
The evaluator and the person who has been tortured may come from different cultures and may not even speak the same language. If a translator is needed, it is often best to use a trained translator. A person who has been tortured may be hesitant to speak with complete openness and frankness if a family member or friend serves as translator. Ideally, the translator has been trained in mental health issues, knows the terminology likely to be used in the evaluation, and understands issues of confidentiality and trust. Wenk-Ahnson and Gurris (2011) note that "the interpreter has to be fluent in both languages, respectful and of a controlled empathetic posture. The role of the interpreter has to be clear to all involved" (p. 184). Van der Veer (1998) discusses some of the potential costs and benefits of using an interpreter:
Adding a third person will make it more difficult for the refugee to express thoughts he considers as childish, shameful or evil. On the other hand, the interpreter can be experienced by the refugee as a great help in expressing himself. Some withdrawn refugees actually cheer up when the interpreter arrives. (p. 81)
Searight and Searight (2009) provide useful suggestions for working with interpreters.
Even when both evaluator and victim of torture speak the same general language, issues of dialect, regional slang, and different cultural meanings can still interfere with clear communication and cause significant problems. Pope and Vasquez (2011) discussed an episode in which a woman born in Puerto Rico looked into her office and saw someone looking through her purse. The woman confronted the potential thief, things flared up (though no one was touched), and the potential thief ran away. In describing this event to a social worker who had been born in Cuba, the woman used the term asalto. She meant there had been a confrontation. The social worker, more used to Cuban Spanish than to Puerto Rican Spanish, (mis)understood the term to mean a physical assault.
Cultural meanings can hold the key to an evaluation. Nudity and other forms of sexualized shame, embarrassment, and humiliation can play a role in extreme or enhanced interrogations. In some cultures these forms of coercion may violate sacred religious beliefs or cultural mandates. The survivor of unwanted sexual touching, abuse, or assault by opposite- or same-sex interrogators may feel irrevocably bound by religious or cultural proscriptions against openly acknowledging such events. In some cultures, acknowledging certain forms of sexual victimization may bring ostracism or more extreme penalties.
Perlin and McClain (2009) discuss the influence of culture on the selection of standardized tests: "Most standardized tests used by Western clinicians have been designed for use in Caucasian populations and those with Euro-American backgrounds (on potential bias of personality tests, see McCurley, Murphy, & Gould, 2005; on one court's criticism of over-reliance on test results (in the context of a parenting capacity case), see In re B.M., 1996; on how the use of such tests must meet the prevailing legal evidentiary standards for admissibility, see Kavanaugh et al., 2006). Considering the application of these tests in clients with non-Western cultural backgrounds at all requires caution and discretion."
In many instances, the culture of the examiner may be at least as important as the culture of the person who has been tortured. Recognizing how our own cultural background, assumptions, and customs affect the assessment can pose significant challenges. The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures (Fadiman, 1997) documents the tragic costs of overlooking the cultural assumptions of both clinicians and those who come to them for help. Clinicians at a U.S. hospital tried to treat a Hmong girl, a member of a Laotion refugee family. Both the Laotian family and hospital staff attempted to work together to help the child, whom the U.S. doctors had assessed as suffering from epilepsy, but the results were disastrous. Medical anthropologist Arthur Kleinman, as quoted in the book, stated:
As powerful an influence as the culture of the Hmong patient and her family is on this case, the culture of biomedicine is equally powerful. If you can't see that your own culture has its own set of interests, emotions, and biases, how can you expect to deal successfully with someone else's culture? (p. 261)
Recordings and Third Party Observers
Recording a session or allowing an observer to be present can affect an evaluation. Constantinou, Ashendorf, and McCaffrey (2002) reported that "in the presence of an audio-recorder the performance of the participants on memory tests declined. Performance on motor tests, on the other hand, was not affected by the presence of an audio-recorder" (p. 407).
Horwitz and McCaffrey (2008) reported that "performances on semantic fluency and TPT-localization were most strongly associated with observation and trait anxiety, with performance being poorer in the presence of a third party observer" (p. 409).
Gavett, Lynch, and McCaffrey (2005) noted that "third party observers have been found to significantly impair neuropsychological test performance on measures of attention, verbal memory, verbal fluency, and cognitive symptom validity" (p. 49; see also Constantinou, Ashendorf, & McCaffrey, 2005; Duff & Fischer, 2005; Kehrer et al., 2000; Lynch, 2005; Lynch & McCaffrey, 2004; McSweeney et al., 1998; Yantz & McCaffrey, 2005).
Policy statements in this area include the American Academy of Clinical Neuropsychology's "Policy Statement on the Presence of Third Party Observers in Neuropsychological Assessment" (2001), and Axelrod and colleagues' "Presence of Third Party Observers During Neuropsychological Testing: Official Statement of the National Academy of Neuropsychology" (2000).
Howe and McCaffrey (2010) discuss "the scientific, ethical, and pragmatic (i.e., test security and coaching) reasons to not allow third party observation" (p. 518). They also provide resources that can be appended to legal motions and used to educate others about issues with recording or allowing a third party to observe an assessment.
Similarities, Echoes, and Triggers
Examiners must remain alert to and prepared to deal with ways in which the assessment process may trigger traumatic memories of the torture situation. Even just the asking of questions during a psychological evaluation may stir memories of having been interrogated.
The dyadic therapeutic situation itself may be evocative of certain aspects of the torture experience: for example, two people, one of whom is licensed by or a representative of the state or larger society and the other of whom is vulnerable and in need, meeting privately in a room; the questioning of extremely personal matters, a process often experienced as intrusive...; the discrepancy in power; and the intensity of emotion usually evoked by the process. (Pope & Garcia-Peltoniemi, 1991, p. 271)
Torture may focus on finding out information that the individual does not want to reveal. During a psychological assessment, the evaluator may ask about matters that the individual is reluctant to talk about. Westermeyer et al. (2010), for example, note that "Refugees are often reluctant to divulge past and ongoing traumatic experiences" (p. 1132; see also Westermeyer, 1989; Westermeyer & Wahmanholm, 1989). Similarly, Herlihy and Turner (2010) review studies showing that a "major problem for those claiming asylum is the necessity to disclose the most personal and distressing material, including sexual assault histories" and the "high levels of avoidance" that must be overcome (p. 6; see also Bogner, Brewin, & Herlihy, 2009; Bogner, Herlihy, & Brewin, 2007).
In some cases, a psychiatrist (or other physician) or psychologist may have been involved in administering the torture. There is a substantial literature on the involvement of physicians and psychologists in torture and what are sometimes euphemistically called "enhanced" or "extreme" interrogation methods, both historically and in current situations (e.g., Augustin, et al., 2011; Burton & Kagan, 2007; Hall, 2011; Hoffman, 2011; Jesper, 2008; Lee, Conant, & Heilig, 2005; Guteman & McKee, 2012; Lifton, 1996, 2004; Miles, 2008; Mostad & Moati, 2008; O'Connor 2009; Polatin, Modvig, & Rytter, 2010; Pope & Garcia-Peltoniemi, 1990; Pope, 2011; Singh, 2008; Sold & Olson, 2008; Speers et al., 2008; Yudkin, Ziv, & Menuchin, 2010; Weschler, 1990; Zarocostas, 2009). If the assessment is conducted by someone of the same or similar profession, this too may cause the assessment to evoke echoes of the torture.
Beyond the potential structural similarities of the two situations, of course, is the content of the assessment. Describing the physically and psychologically painful experiences of being tortured can itself be an exceptionally painful and overwhelming process. Jarason et al. (2001) note that "a major difficulty in conducting a diagnostic interview with a survivor of torture is that it can stimulate memory of traumatic events or reactivate PTSD symptoms" (p. 252). Memories of being tortured may have a different quality than those of routine episodic memory. Very diverse methods of physical or psychological torture
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. (Elbert et al., 2011, p. 167)
It may be helpful for those conducting assessments to remember Primo Levi's statement that "the memory of a trauma suffered or inflicted is itself traumatic because recalling it is painful or at least disturbing" (p. 24).
Dissimilarities, Misleading Expectations, and Limited Experiences
For the torture survivor, the assessment situation may call up similarities to the torture situations. However, for the evaluator, the dissimilarities between the evaluator's knowledge base, expectations, and experiences may—unless recognized and addressed—lead to a flawed assessment. For example, a torture survivor may show cognitive impairment and report headaches. A routine medical examination having shown no cause for the impairment and headaches, the psychological examiner may conclude that they result from post-traumatic stress caused by the torture. However, the symptoms might be caused by a disease like neurocysticercosis (a CNS infection resulting from Taenia solium tapeworms) which is not endemic to the United States and many other countries. O'Neal et al. (2012) found that "exposure to T. solium parasitic infection is common among refugees from Burma, Laos, Burundi, and Bhutan who resettled to the United States." They emphasized the significant "clinical and public health implications" because in the United States "many clinical providers are not familiar with the disease manifestations, diagnosis, or treatment."
On a very different level, clinicians may not be adequately alert to instances in which a child may have been tortured. The research on people who have been tortured, the development of theory, and studies of the psychometric properties of standardized tests used with people who have been tortured have tended to focus on adults. However, torturers may target children.
In all areas of the world, children have been subjected to forms of physical, psychological, and sexual torture. [Amnesty International] has documented the prevalence of child torture and referred to it as "a hidden scandal" because it receives so little attention. For many groups and individuals engaging in torture, children may make especially inviting targets because of their relative lack of size and strength, their tendency—especially when very young—to be dependent on adult authority, and the belief that children are more likely to be dismissed as unreliable witnesses whose accounts of torture will not be believed. (Pope, 2001, p. 957)
Sometimes descriptions of torture that actually occurred can seem so extreme, so inhumane, and so far beyond the evaluator's frame of experience and reference, that they must certainly be false.
Actively searching for relevant information and contexts outside our personal experience and expectations may save an evaluation from false assumptions and misleading conclusions.
AVOIDING ERRORS IN PSYCHOLOGICAL ASSESSMENT
Five common errors can plague psychological testing and assessment. They are: 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.
No test works well for all tasks with all people in all situations. A well-validated checklist may help us understand torture survivors from certain cultures; those from other cultures, however, may not be familiar with, understand, or think in terms of the checklist's concepts, terms, and descriptions. An intelligence test and other assessment methods may demonstrate exceptional validity in various studies and yet produce misleading results when examiner and examinee are from different races, ethnic groups, or cultures.
Gordon Paul's classic 1967 article moved us away from the oversimplified search for effective therapies toward a more difficult but meaningful question: "What treatment, by whom, is most effective for this individual with that specific problem, and under which set of circumstances?" (p. 111).
Keeping in mind such variables can be crucial in assessing victims of torture. Selecting assessment methods—including psychological tests, rating scales, and inventories—requires addressing similar questions, such as: "Has research established adequate reliability and validity (as well as sensitivity, specificity, and other relevant features) for this test, with an individual from this population, for this task (i.e., the purpose of the assessment), in this set of circumstances?"
We tend to search out, recognize, and value information that fits our attitudes, beliefs, and expectations. Forming an initial diagnostic impression, we may value and focus on findings that support that impression, and discount, ignore, or find ways to explain away data that don't fit. For example, upon hearing an interviewee report nightmares, we may jump to the conclusion that the nightmares resulted from torture. During the rest of the interview and while examining prior records and relevant documents, we may actively look for, be exceptionally open to, or expect any information that might confirm our hasty conclusion, while overlooking evidence to the contrary. However, the nightmares may have begun long before the torture or be a consequence of more recent causes unrelated to the torture.
Guarding against confirmation bias requires keeping an open mind during the data-gathering process and, if we start forming theories early on, actively searching for disconfirming data and alternative explanations.
Confusing Retrospective & Predictive Accuracy (Switching Conditional Probabilities)
An example of predictive accuracy begins with a person's assessment results and asks: What is the likelihood, expressed as a conditional probability, that a person with these results has been tortured? Retrospective accuracy looks from the other direction and asks: What is the likelihood, expressed as a conditional probability, that a person who has been tortured will show these test results?
Confusing the "directionality" of the inference causes many errors. This mistake of confusing retrospective with predictive accuracy often resembles the affirming the consequent logical fallacy:
People who have been tortured are overwhelmingly likely to have had some symptoms of post-traumatic stress;
Person Y has had symptoms of post-traumatic stress;
Person Y is overwhelmingly likely to have been tortured.
One key to avoiding this mistake is to focus not on the fact that two variables are associated but rather on the direction of the association (i.e., which variable or set of variables predicts the other variable or set of variables).
Ignoring the Effects of Low Base Rates
Imagine you've been commissioned to develop an assessment procedure that will reliably identify refugees who claim to have been tortured but are faking (i.e., were not tortured). It's a difficult challenge, in part because only 1 out of 500 refugees in this hypothetical sample is not truthful.
You pull together all the actuarial data you can locate and find that you are able to develop a screening test for faking claims of having been tortured based on a variety of characteristics, personal history, and test results. Your method demonstrates an impressive 90% accuracy rate.
Using your method to assess the next 5,000 refugees claiming to have been tortured, there might be 10 refugees who are not telling the truth (because 1 out of 500 is not truthful). A 90% accurate screening method will identify 9 of these 10 refugees as not telling the truth and one as telling the truth.
So far, so good. The problem is what the test does to the 4,990 honest refugees. Because the method is wrong 10% of the time, and the only way for the screening to be wrong about honest refugees is to identify them as not telling the truth, it falsely classifies 10% of the honest refugees as making false claims about having been tortured. Sadly, this screening method will incorrectly classify 499 of these 4,990 honest refugees as never having been tortured.
In sum, out of the 5,000 refugees who were screened, the 90% accurate test classified 508 of them as making false claims (i.e., 9 who actually made false claims plus the 499 who were telling the truth about having been tortured). The method tends to be right only 9 times out of every 508 times the screening method indicates that someone is making false claims about having been tortured. Tragically, it has falsely branded 499 honest refugees as not having suffered the torture they reported.
Low base rates should always raise a red flag in assessments. They warrant careful analysis, such as they one above, of how they affect a specific assessment method in regard to a particular population, even if only general estimates are available.
Misinterpreting Dual High Base Rates
Imagine that you travel to another country to assist their center for victims of torture. Examining the center's records, you see that of 200 people who have come to the center for help because they had been tortured, the vast majority—162—are of a particular religious faith and have been diagnosed by the center as suffering from PTSD as a result of torture.
It seems almost self-evident that there is a strong association between that particular religious faith and developing PTSD as a result of torture: 81% of the people who came to the center were of that religious faith and had developed PTSD. This link between a particular religion and PTSD in most of the people who come to the center might suggest that this faith makes people vulnerable to PTSD resulting from torture. Or it might suggest a more subtle association: perhaps this faith makes it easier for people who have been tortured and developed PTSD to seek help at the center.
However, there is no actual link between that religion and developing PTSD as a result of torture: religious faith and the development of PTSD as a result of torture in this sample are independent factors.
The dual high base rates of that particular religion and of PTSD creates the illusion of an association.
The sample of 200 people included 162 people who were of that particular religion who developed PTSD and 18 of that particular religion who did not develop PTSD. The percentage of people of that particular religion who developed PTSD was 90%. The sample also included another 20 people not of that religion, 18 of whom developed PTSD and the remaining 2 of whom did not develop PTSD. The percentage of people of another religion who developed PTSD was identical: 90%. Religion was unrelated to whether someone in this sample developed PTSD.
When conducting a psychological assessment of or providing other services to people who have been tortured, a common challenge is quickly finding resources that fit the individual and the situation. Below are resources on the web that people working with torture survivors, refugees, and asylum-seekers may find helpful. They include 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, and other diverse resources. Please note: Links to each of these resources are gathered on the following web page: <http://kspope.com/torvic/torture.php>.
Advocates for Survivors of Torture & Trauma
Amani Community-based Care of Survivors of Torture and Organised Violence
AMCHA Israeli Center for Holocaust Survivors
American Association for the Advancement of Science Human Rights Action Network
Amnesty for Women
Amnesty International Canada
Amnesty International Online
Amnesty International UK
Amnesty International USA
Asian Human Rights Commission
Association for Prevention of Torture
Association for Services to Torture and Trauma Survivors
Association for Solidarity With Asylum Seekers & Migrants
Asylum Seekers Resource Centre for Australia
Bellevue/NYU Program for Survivors of Torture
Berlin Center for Treatment of Torture Victims
Boston Center for Refugee Health & Human Rights
Canadian Centre for Victims of Torture
Canadian Council for Refugees
Caring for Refugees and Survivors of Torture: A Free Online Course
Center for International Human Rights, Northwestern Law School
Center for Justice and Accountability
Center for Survivors of Torture, Dallas
Center for Survivors of Torture & War Trauma, St. Louis, Missouri
Center for Victims of Torture, Minneapolis
Center for Victims of Torture, Nepal
CINAT: Coalition of International NGOs against Torture
Citizenship & Immigration Canada
Combating Torture: A Manual for Judges and Prosecutors
Community Legal Services & Counseling Center: Asylum, VAWA, U-Visa, T-Visa; Cambridge, MA
Derechos Human Rights
Detained LGBT Asylum Seekers: Online Know Your Rights Manual
Detained Torture Survivor Legal Support Network
Detention Watch Network
Edmonton Center for Survivors of Torture and Trauma
Electronic Immigration Network, U.K.
Episcopal Migration Ministry Serving Refugees & Immigrants
European Committee for the Prevention of Torture
European Council on Refugees in Exile
Examining Asylum Seekers: A Health Professional's Guide to Medical & Psychological Evaluations of Torture
Florence Immigrant & Refugee Rights Project
Florida Center for Survivors of Torture
Florida Immigrant Advocacy Center
Foundation House: Victorian Foundation for the Survivors of Torture
Global Lawyers and Physicians for Human Rights
Guide to International Refugee Law Resources on the Web
Health for Asylum Seekers & Refugees Portal
Health Professional's Guide to Medical and Psychological Evaluations of Torture
Hebrew Immigrant Aid Society
Human Rights Clinic
Human Rights First
Human Rights Hotline
Human Rights Internet
Human Rights Watch
Huridocs Human Rights Information and Documentation Systems, International
Immigration Legal Defense Services
Immigration Resource Directory
International Center for the Protection of Human Rights
International Committee of the Red Cross
International Detention Coalition
International Federation of Action by Christians Against Torture (FIACAT)
International Federation of Red Cross and Red Crescent Societies
International Helsinki Federation for Human Rights
International League for Human Rights
International Network for People Affected by Organized Violence
International Refugee Rights Initiative
International Rehabilitation Council for Torture Victims
International Rescue Committee
International Service for Human Rights
Irish Refugee Council
Istanbul Protocol: International Guidelines for the Investigation & Documentation of Torture
Know Your Rights Manual for Detained LGBT Asylum Seekers
Kwazulu-Natal Programme for Survivors of Violence
Lawyers Committee for Human Rights (see Human Rights First)
Lawyers Without Borders
Los Angeles Program for Torture Victims
Lutheran Immigration & Refugee Service
Medact Refugee Health Network
Medical Evaluations of Asylum Seekers
Medical Foundation for the Care of Victims of Torture
Medical Justice: Seeking Basic Rights for Detainees
NAPSM Asylum Documentation Project
National Asylum Partnership on Sexual Minorities: Defend the Rights of Lesbian, Gay, Bisexual, Transgender, & HIV-Positive Immigrants
National Center for PTSD
National Immigration Justice Center: You Have Rights
National Immigration Law Center
National Network for Immigrant and Refugee Rights
North Virginia Family Services: Survivors of Torture & Severe Trauma
Norwegian Refugee Council
Organization for Aid to Refugees, Prague, Czech Republic
Organization for Defending Victims of Violence
Pennsylvania Immigration Resource Center
Physicians for Human Rights
PILOTS: Searchable database of published literature on PTSD
Preventing Torture Through Investigation & Documentation
Queensland Program of Assistance to Survivors of Torture and Trauma
Refugee Council, U.K.
Refugee Immigration Ministry
Rehabilitation and Research Centre for Torture Victims
Responding to Victims of Torture: Clinical Issues, Professional Responsibilities, & Useful Resources
RIVO: Intervention Network for People Having Been Subjected to Organized Violence
Rocky Mountain Survivors Center
Scholars at Risk Network
Service Dogs For Victims of Assault (Note: Only survivors of specific types of torture will qualify)
Shedding light on a dark practice Using the Istanbul Protocol to document torture (International Rehabilitation Council for Torture Victims)
Sprog Center Denmark (language courses for traumatized refugees or survivors of torture)
Survivors of Torture International
Torture (chapter published by Academic Press)
Tortura Nunca Mais
Torture Abolition and Survivors Support Coalition
Torture & Its Neurological Sequelae
Torture Reporting Handbook
Torture and War Trauma Survivors in Primary Care Practice
U.S. Committee for Refugees
U.S. Conclusions and Recommendations of the Committee against Torture
U.S. Department of State Bureau of Population, Refugees, and Migration
U.N. Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment
U.N. Declaration on the Right and Responsibility of Individuals, Groups and Organs of Society to Promote and Protect Universally Recognized Human Rights
U.N. Human Rights
U.N. Principles of Medical Ethics relevant to the Role of Health Personnel, particularly Physicians, in the Protection of Prisoners and Detainees against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment
U.N. Universal Declaration of Human Rights
Unrepresented Nations & Peoples Organization
Vancouver Association for Survivors of Torture (VAST)
Victoria Coalition for Survivors of Torture (VCST)
Victorian Foundation for the Survivors of Torture
Wellington Refugees As Survivors, New Zealand
Women's Refugee Commission
World Legal Information Institute
World Organization Against Torture
Professionals who evaluate torture victims bear an enormous responsibility. A life may hang in the balance. Evaluations of torture victims may determine whether someone finds safe refuge, is accorded some degree of justice, gains access to vital medical care and other services, or is reunited with their family. Torture victims have endured horrors and have much at at stake. We must conduct psychological assessments with the greatest care, taking each essential step, avoiding common pitfalls, and remaining aware of the full range of resources.
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