Torture Volume 26 Number 3 2016

Part I: The Istanbul Protocol Project in the Basque Country Istanbul Protocol Project in the Basque Country Working Group

Part III: 'Five days is enough’: the concept of torturing environments Pau Pérez-Sales, Miguel Angel Navarro-Lashayas, Angeles Plaza Benito Morentin, Oihana Barrios Salinas

Enhancing empathy among humanitarian workers through Project MIRACLE: Development and initial validation of the Helpful Responses to Refugees Questionnaire Miriam Potocky, Kristen L. Guskovict A comparative study of the use of the Istanbul Protocol amongst civil society organizations in low-income countries Tobias Kelly, Steffen Jensen, Morten Koch Andersen, Catrine Christiansen, Jeevan Raj Sharma

Jour nal on Rehabilitation of Torture Victims and Prevention of Torture

TORTURE – VOLUME 26, NO 3, 2016

Part II: Enhanced credibility assessment based on the Istanbul Protocol Pau Pérez-Sales, Benito Morentin, Olatz Barrenetxea, Miguel Angel Navarro-Lashayas

TORTURE 3

Part IV: Psychological and psychiatric consequences of ill-treatment and torture: trauma and human worldviews Miguel Angel Navarro-Lashayas, Pau Pérez-Sales, Gabriela Lopez-Neyra Maitane Arnoso Martínez, Benito Morentin

Online subscription Please sign up to receive an email notification as soon as a new issue is available online at www.irct.org/torture.journal rather than opting for a hard copy.

The IRCT is an independent, international health professional organisation that promotes and supports the rehabilitation of torture victims and the prevention of torture through nearly 200 rehabilitation centres and pro­ grammes around the world.

The objective of the organisation is to promote the provision of specialised treatment and rehabilitation services for victims of torture and to contribute to the prevention of torture globally. To further these goals, the IRCT seeks on an international basis:

•

to develop and maintain an advocacy pro­ gramme that accumulates, processes and disseminates information about torture as

• •

• • •

well as the consequences and the rehabilita­ tion of torture to establish international funding for re­ habilitation services and programmes for the prevention of torture to promote the education and training of relevant professionals in the medical as well as social, legal and ethical aspects of torture to encourage the establishment and main­ tenance of rehabilitation services to establish and expand institutional rela­ tions in the international effort to abolish the practice of torture, and to support all other activities that may con­ tribute to the prevention of torture

ISSN (Online): 1997-3322 ISSN (Print): ISSN 1018-8185

VOLUME 26, NO 3, 2016, ISSN 1018-8185

2016

Incommunicado detention and torture in Spain:

TORTURE Journal on Rehabilitation of Torture Victims and Prevention of Torture Published by the International Rehabilitation Council for ­Torture Victims (IRCT), Copenhagen, Denmark.

TORTURE is indexed and included in MEDLINE. Citations from the articles indexed, the indexing terms and the English abstracts printed in the journal will be included in the databases

Contents

Volume 26, No 3, 2016 ISSN 1018-8185

The Journal has been published since 1991 as Torture – Quarterly Journal on Rehabilitation of Torture Victims and Prevention of Torture, and was relaunched as Torture from 2004, as an inter­national scientific core field journal on t­ orture

Scientific Articles

Editor in Chief Pau Pérez-Sales, MD, PhD Managing Editor Leanne Macmillian Editorial Assistant Nicola Witcombe, MA Editorial advisory board S. Megan Berthold, PhD, LCSW Hans Draminsky Petersen, MD Jim Jaranson, MD, MA, MPH Marianne C. Kastrup, MD, PhD Jens Modvig, MD, PhD Duarte Nuno Vieira, PhD, MSc, MD Önder Özkalipci, MD June C. Pagaduan-Lopez, MD José Quiroga, MD Nora Sveaass, PhD Morris V. Tidball-Binz, MD Language editing Monica Lambton, MA, BA Correspondence to IRCT Vesterbrogade 149, building 4, 3rd floor, 1620 Copenhagen V, Denmark Telephone: +45 44 40 18 30 Email: irct@irct.org Subscription www.irct.org Price: EURO 50 or DKK 375 per year. www.irct.org/Library/torture-journal.aspx.

The journal is free of charge for health professionals.

The views expressed herein are those of the authors and can therefore in no way be taken to reflect the official opinion of the IRCT. Front page: Mogens Andersen, Denmark Printed in Denmark by Scanprint a/s, Horsens, Jylland

Editorial

Pau Pérez-Sales, Editor in Chief

1

Incommunicado detention and torture in Spain: Part I: The Istanbul Protocol Project in the Basque Country

Istanbul Protocol Project in the Basque

Country Working Group 3 Part II: Enhanced credibility assessment based on the Istanbul Protocol

Pau Pérez-Sales, Benito Morentin, Olatz Barrenetxea,

Miguel Angel Navarro-Lashayas 8 Part III: 'Five days is enough’: the concept of torturing environments

Pau Pérez-Sales, Miguel Angel Navarro-Lashayas,

Angeles Plaza, Benito Morentin,

Oihana Barrios Salinas 21 Part IV: Psychological and psychiatric consequences of ill-treatment and torture: trauma and human worldviews

Miguel Angel Navarro-Lashayas, Pau Pérez-Sales,

Gabriela Lopez-Neyra, Maitane Arnoso Martínez,

Benito Morentin 34 Enhancing empathy among humanitarian workers through Project MIRACLE: Development and initial validation of the Helpful Responses to Refugees Questionnaire

Miriam Potocky, Kristen L. Guskovict 46 A comparative study of the use of the Istanbul Protocol amongst civil society organizations in low-income countries

Tobias Kelly, Steffen Jensen, Morten Koch Andersen,

Catrine Christiansen, Jeevan Raj Sharma 60 Debate

Related to 'A comparative study of the use of the Istanbul Protocol amongst civil society orrganizations in low-income countries' pp.60-73 Comment I: Istanbul Protocol in low-income countries - A reply

Rusudan Beriashvili,Vincent Iacopino 74 Comment II: Documentation of torture and justice: 'Bon pour L'Orient?

Önder Özkalıpcı 77 Response by the authors

Tobias Kelly, Steffen Jensen, Morten Koch Andersen,

Catrine Christiansen, Jeevan Raj Sharma 80

Correction: In the printed version of 'Group treatment for survivors of torture and server violence: A literature review' (Volume 26, No 1 2016 p45), the affiliation of Faith Ray should have read National Capacity Building Project at Center for Victims of Torture, St. Paul, Minnesota, USA.

1 EDITORIAL

Editorial – The Torture Journal: A home for all Pau Pérez-Sales, MD, PhD, Psych*, Editor in Chief

*) SiR[a] Centre, GAC Community Action Group and Hospital La Paz, Spain.

deeply affected hundreds of lives and helped fuel radicalism, but has fundamentally challenged democracy. Against this heritage, Donald Trump has recently condoned waterboardingii and has said “the unthinkable” should be carried when it comes to prisoner interrogation.iii Our duty here is to also think the unthinkable and try to react to it; our sector remains more crucial today than it ever has and I hope to ensure that the Torture Journal will continue adding value to this work.

The presence and work of the previous Editor in Chief, Lilla Hárdi, lives on in this issue which is largely a reflection of her work.

The set of papers entitled 'Incommunicado detention and torture in Spain’ was first discussed with Joost den Otter when he was Editor in Chief and has been edited by Lilla Hárdi. The study has been conducted by the Istanbul Protocol Project in the Basque Country Working Group, Benito Morentin, Olatz Barrenetxea, Miguel Angel NavarroLashayas, Pau Pérez-Sales, Angeles Plaza, Oihana Barrios Salinas, Gabriela Lopez-Neyra and Maitane Arnoso Martínez. The study provides an in-depth analysis of how contemporary torture operates in European societies, with Spain and the Basque country as a case

i See Torture Journal Vol.15, No.1 2005 pp66-70; Vol.16, No.1 2006 pp65-66. ii Donald Trump on waterboarding: “Torture works”.

Washington Post. 17 February 2016. iii Trump Amps Up His Call For Torture: ’We’re Going To Have To Do Things That Are Unthinkable’.

Huffington Post. 30 June 2016

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Whilst there are positive developments in the field, the failure of President Obama to close Guantanamo Bay after eight years in power exemplifies the challenges that face us: many Guantanamo detainees were originally captured with the acquiescence of democratic governments; both international and American laws were supposedly circumvented by basing Guantanamo outside America and classifying the detainees as terrorists; the authorities developed a programme of “evidence-based” torture under the supervision of clinicians with connections to the American Psychological Associationi; and, despite the will of President Obama, legal advisors and Congress have prevented Guantanamo’s closure and polls even suggest that a majority of the US population are against its closure. 730 of the detainees have gradually been freed, including 20 prisoners who are to be released before the new President takes office, and these individuals and their families need the care and attention of the rehabilitation sector. Eight have died (allegedly having committed suicide) and ten have been convicted by a military tribunal not recognised by the American justice system. Of the original 779, only 31 detainees have been deemed too dangerous to be released. They are likely to remain at Guantanamo for the rest of their lives as the authorities are unlikely to want the torture practised on them to come to light. This is a human rights catastrophe that has not only

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study. Ill-treatment and torture based on physical pain have been left behind. Patterns of coercion on human freedom have advanced to more complex and efficient ways of breaking the will of the individual. Contemporary torture emphasises attacks on the conscious mind to target the self and identity in a process that, according to the study, needs no more than three to five days to achieve physical and psychological breakdown. The study, conducted over a four-year period by a team of 25 forensic psychiatrists, psychologists and physicians, presents a particular way of using the Istanbul Protocol (IP) for advanced forensic research.

The authors highlight some shortcomings of the IP that they deem important.

The article ‘Enhancing empathy among humanitarian workers through Project MIRACLE: Development and initial validation of the Helpful Responses to Refugees Questionnaire’

by Miriam Potocky and Kristen Guskovict is an unusual and extremely useful work. It proposes a scale to measure empathy in working with victims. The effectiveness of counselling and psychotherapy as part of the rehabilitation of victims of torture depends less on a closed set of tools or methods than on what contemporary psychotherapy calls the non-specific elements of therapeutic work, and specially interviewing skills, empathy and compassion. Furthermore, empathy must permeate the work of all professionals in the rehabilitation team, including non-therapists. The authors propose a brief and innovative scale that allows for pre and post intervention measures, assessing the impact of training workshops on counselling, or even selecting candidates for a team.

On a different but concurrent side of the IP debate, in ‘A comparative study of the use of the Istanbul Protocol amongst civil society organizations in low-income countries', Kelly et al. question the usefulness of the IP due to its excessive complexity for the average human right’s worker. Their argument, based on

EDITORIAL

interviews in three countries, is that in most places were torture is widespread, access to justice is simply impossible and workers face considerable risks when working with individual cases. Frontline workers would demand a simpler and straightforward model.

Experts in the field challenge these findings in the Debate section of the journal. They question who the interviewees were, what their training and experience was, and stress that the IP can be adapted for different purposes and this is part of the training process. It is not acceptable, says Dr Özkalipci, to have two standards of quality for high and low income countries, but it is mandatory to have a high standard and adapt the tool accordingly.

As these debates show, the Torture Journal is the place where our community of scientists, practitioners and survivors can debate with science as a key point of reference, and can hopefully assist in informing public opinion and decision-makers. It must be a home for all.

I would finally like to pay tribute to and thank all the past Editorial Advisory Board members and particularly the previous Editors in Chief, Henri Marcussen, Ole Vedel Rasmussen, Joost den Otter and Lilla Hárdi. They have made the journal the main scientific reference in medical and psychological research in the field of torture.

With respect to the future, the members of the editorial team and the Editorial Advisory Board look forward to sharing some of the key ideas for the next steps in the history of the journal in the next issue. We can also look forward to the IRCT’s Scientific Symposium in Mexico in December with its more than 200 presentations. This is a unique opportunity to get a global picture of the field at this time, as well as reviewing past achievements and ways forward. Lastly and importantly, we wish to express again that we welcome and look forward to your contributions; the Torture Journal must strive to be a home for all.

3 SCIENTIFIC ARTICLE

Incommunicado detention and torture in Spain, Part I: The Istanbul Protocol Project in the Basque Countryi Istanbul Protocol Project in the Basque Country Working Group*

Abstract

There is increasing evidence to show that torture is a serious problem in the Basque Country. Whilst such evidence can be found in reports of international human rights monitoring bodies, sentences of Spanish and international courts, and empirical studies, they are limited in not having followed the Istanbul Protocol (IP) in order to evaluate the reliability of torture. A working group composed of professional associations of psychiatrists, psychologists, physicians and lawyers, in collaboration with the University of the Basque Country, conducted a four-year study on the medical and psychological consequences of torture in incommunicado detainees, including an assessment of credibility in line with the IP. The methodological design included a multi-level peerreviewed blind assessment and input by an external expert (from the Independent Forensic Expert Group facilitated by

Markez, Iñaki (Psychiatrist); Medina Elena (Psychiatrist); Moreno-Pérez Ana (Psychiatrist); Morentin Benito (Forensic Physician), NavarroLashayas Miguel Ángel (Psychologist); Pérez-Sales Pau (Psychiatrist); Plaza Mari Ángeles (Psychologist); Ruiz de Alegría Anabel; (Psychologist); Velasco Teresa (Psychologist); Vidal Luisa (Psychologist); Walther Marc (Psychiatrist); Zalbidea Urko (Psychologist), Zuazua Julene (Psychologist).

Correspondence to: morentin.b@aju.ej-gv.es i

Editor: Lilla Hárdi.

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*) Members: Agirre Inmaculada (Physician); Albi Inmaculada (Psychiatrist); Andueza Oihana (Psychologist); Arana Miren (Physician); Arnoso Maitane (Psychologist); Barrenetxea Olatz.

(Psychologist); Barrios Oihana (Psychologist); Callado LF (M.D., Ph.D.); Gandarias Itziar (Psychologist); García de Eulate Josefina (Psychologist); Gato Elena (Psychiatrist); Ibernia Maitane (Psychologist); Iturralde Matilde (Physician); Jordá Enric (Psychiatrist); Krakenberger Andres (Human Rights Expert); Landa Jon Mirena (Human Rights Expert); Legorburu Ixone (Psychologist); López de Luzuriaga Nagore (Psychologist); López-Neyra G (Psychologist);

International Rehabilitation Council for Torture Victims (IRCT)). A sample of 45 Basque people held in short-term incommunicado detention under anti-terrorist legislation (between 1980 and 2012) in Spain who had reported ill-treatment or torture was selected.

The findings are divided into four papers: the present introductory paper; the second analyses the credibility of the allegations of torture and introduces an innovative methodology that enhances the IP, the Standardized Evaluation Form (SEC); the third provides an analysis of the methods of torture and introduces the concept of Torturing Environments; and, in the last paper, the psychological and psychiatric consequences of incommunicado detention are analyzed. The collection of papers are intended to be useful not only in the documentation of torture in the Basque Country and Spain, but also as an innovative

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example of how the IP can be used for research purposes.

Keywords: Istanbul Protocol, torture, ill-treatment, documentation of torture, Spain

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Torture in the Basque Country

In cases of terrorism, the Spanish Criminal Procedure Code allows incommunicado detention, as provided by Articles 509, 520bis and 527. These provisions set out that the maximum time of detention before presentation to a judge can be prolonged and basic rights of detainees that guarantee the physical integrity of the person under arrest, including the right to communicate with their families, lawyers or doctors of their choice, are curtailed. Far from shortening the period of five days of incommunicado detention as was unanimously demanded by international monitoring bodies, the reform introduced by Law 15/03 dated November 25th 2003 expands this period and includes the possibility of prolonging incommunicado detention for a further eight days in prison after being taken to court. Thus, this can lead to a total of 13 days of incommunicado detention.1 International organizations have expressed their concern about allegations made by detainees of torture and ill-treatment in Spain, especially in the context of incommunicado detention. In 2002, the United Nations Committee Against Torture (UNCAT) expressed concern about NGO reports.2 In 2004, the Special Rapporteur on torture and other cruel, inhuman or degrading treatment or punishment considered that in Spain, “Torture is more than sporadic and incidental.”3 In 2008, the UN Human Rights Committee expressed concern that investigations were not being conducted properly and set out that “incommunicado detention must be abolished.”4 In 2013, the

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European Committee for the Prevention of Torture (CPT) concluded that there were “credible and consistent allegations of ill-treatment.”5 There have been many judgments condemning the Spanish authorities for lack of proper investigation into allegations of torture, including those made by the Spanish High Court, Supreme Court and Constitutional Court, the European Court of Human Rights, the United Nations Committee Against Torture, and the United Nations Human Rights Committee.4, 6-10 They conclude that sufficient guarantees and supervision of incommunicado detention are substantially lacking, and condemn the absence of any effective investigation of complaints raised.

Epidemiological data

There are no official figures on how many people have been held in incommunicado detention and there is no official record of allegations of torture. The Basque NGO Euskal Memoria estimates that there have been approximately 10,000 cases of torture over the last 50 years, most allegations having been silenced and certainly never publicly denounced.11 According to an official report of the Basque Government (1960-2013), there are about 5,500 public allegations of torture (including both judicial complaints and extrajudicial allegations).12 In an empirical investigation, the Basque Government collected information regarding 634 cases of torture complaints during the period 2000-2008.13 Currently the Basque Government, in collaboration with the University of the Basque Country, is undertaking research about torture in the period 1960-2013 as part of the Peace and Coexistence Plan (Plan de Paz y Convivencia).14 Part of this research involves compiling a register of people who have alleged torture, the preliminary results

5 SCIENTIFIC ARTICLE

of which suggested that there were more than 3,000 allegations of torture.15 Despite this evidence, the official position of the Spanish Government has been to deny the existence of torture, claiming that reports of torture were false and made systematically as part of the ETA strategy to undermine the Spanish criminal justice system. According to government figures, and based on cases where a decision has been reached, there are only anecdotal cases and torture cannot be considered an issue in Spain.16 The Istanbul Protocol Project in the Basque Country (IPP-BC)

i ARGITUZ Human Rights Association; Spanish

Association of Neuropsychiatry (AEN); Ekimen Elkartea Association for the Study of Social Problems; GAC Community Action Group, Resource Centre on Mental Health and Human Rights; Jaiki-Hadi, Prevention and Assistance Association; OME Osasun Mentalaren Elkartea. Mental Health and Community Psychiatry Association; SALDE Health Rights Association; Department of Social Psychology, Basque Country University (UPV/EHU).

All of these guidelines were met, as is demonstrated here and in Parts II to IV. For example, the project was approved by the Ethical Committee of Research at the University of the Basque Country and an expert from the Independent Forensic Expert Group, which is facilitated by the International Rehabilitation Council for Torture Victims, advised on the project (see Part II, Table 2).

A group of Basque people who had been held in short-term incommunicado detention under anti-terrorist legislation between 1980 and 2012 in Spain and who had reported ill-treatment or torture (whether or not such allegations were presented in court) was selected through a snowball sampling method using a Latin Square methodology to balance for gender, year of detention and state security force involved. The sample was composed of 45 incommunicado detainees.

The working group conducted a four-year study on medical and psychological consequences of torture in these 45 subjects, including an assessment of the credibility of allegations in line with the IP. Part II includes an analysis of the credibility of the allegations of ill-treatment

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Previous empirical studies have not used evaluations with international scientific tools regarding the reliability of the testimonies of torture in each particular case. With the objective of rectifying this deficiency in mind, a working group was created composed of seven different associations of psychiatrists, psychologists, physicians, lawyers and human rights workers in collaboration with the University of the Basque Country.i The team constituted over 30 professionals, mostly in the field of mental health. The Working Group worked on the basis of the following guidelines: • I nvolve organizations and and a range of scientific groups in the field of health and human rights both locally and internationally.

•C arry out research using internationally

accepted guidelines or forensic tools, validated for the assessment of physical and psychological torture, in line with the professional standards of good practice (the IP) and submit proposals to a Research Ethics Committee.

• Conduct a robust and rigorous methodological design (more than is usual in this type of study) to include an internal cross-validation procedure, scientific monitoring made by external institutions and international experts (see Part II).

• Extend the project to other local and state organizations working in areas of mental health and human rights.

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or torture based on the highest international forensic standards in the field and a modified version of a new tool, the Standardized Evaluation Form (SEC), is proposed that strengthens the IP. Part III presents the data on methods of torture and it is suggested that further categories of psychological torture are needed in the IP. In the final paper, Part IV, data about the psychological and psychiatric consequences of short-term ill-treatment and torture in incommunicado detention is explored. Whilst it is acknowledged that the IP was not designed as a research tool, the findings show that the IP can indeed be very useful, not only in the documentation of torture but also in the field of scientific research.

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Dissemination and implications for the future

The final data for each of the 45 participants were published in.ii Preliminary results were also presented to the press and academic institutions in a workshop held in Madrid on September 18th 2014, as well as various organisations working with torture survivors (Reprive, Redress, Amnesty International in London and the World Organisation Against Torture (OMCT) in Geneva). The Special Rapporteur against torture and other cruel, inhuman or degrading treatment or punishment and the Special Rapporteur for Human Rights have also endorsed the project. The findings were also submitted to the United Nations sub-commitee for the prevention of torture and, in the Spanish political arena, were presented and discussed in the Basque Parliament. Importantly, the findings have also been shared with survivors and their relatives through individual and group meetings.

ii The final data for each of the 45 participants were published in the report “Incommunicado detention and torture. Assessments using the Istanbul protocol� 17

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The experience gained by the professionals who have been involved in this work and the methodology used will be a valuable tool for future study, not least in analysing the data captured by the register of people who have alleged torture in the Basque Country as part of the Peace and Coexistence Plan ('Plan de Paz y Convivencia') commissioned by the Basque Government.14 It is intended that the experiences of a further 200 Basque incommunicado detainees who have alleged torture in the period 1960-2014 will be analysed. Additionally, this collection of scientific papers are intended to be useful, not only in the documentation of torture in the Basque Country and Spain, but also as an innovative example of how the IP can be used for research purposes.

Acknowledgements

The members of the Istanbul Protocol Project in the Basque Country Working Group wish to thank Felicitas Treue as a member of the International Rehabilitation Council for Torture Victims' Independent Forensic Expert Group who assisted with the methodology. Her support and advice was most valued. We also wish to thank Hans Draminsky Petersen who provided insightful comments and enthusiastic support at all stages of the process.

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14. Basque Government, Presidency. Lehendakaritza, Secretaría General de Paz y Convivencia. Plan de paz y convivencia 2013-16 [Peace and Coexistence Plan] Gobierno Vasco, June; 2013.

15. Instituto Vasco de Criminología. Proyecto de investigación de la tortura en Euskadi entre 1960-2010: Informe preliminar sobre diseño y primeros pasos del estudio sobre la tortura.

Donosti 2015. Available from: http://www.nuevatribuna.es/media/nuevatribuna/files/2015/06/26/ informe_estudio_tortura_parlamento_vasco.pdf).

16. Spanish Government answer to CPT ON the Report on its visit dated September 9th to October 1st 2007: CPT/Inf (2011) 12. Available from: http://www.cpt.coe.int/documents/esp/2013-06inf-eng.htm 17. Argituz, AEN, Ekimen Elkartea, GAC, JaikiHadi, OME, OSALDE, Departamento de Psicología Social (UPV/EHU). Incommunicado detention and torture. Assessments using the Istanbul protocol. Bilbao: Ekimen Ed. and Irredentos Libros; 2014. Available from: http:// www.psicosocial.net/images/Tortura/InformeIncomunicacion-tortura-Analisis-protocoloEstambul-Eng.pdf, or can be requested from the corresponding author.

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References 1. Sunderland J. Spain, Setting an Example?: Counter-terrorism Measures in Spain. Human Rights Watch; 2005. [Internet] [Updated 2005 Jan 26] https://www.hrw.org/report/2005/01/26/settingexample/counter-terrorism-measures-spain 2. United Nations Committee against Torture (CAT): Spain. 23 December 2002, CAT/C/ CR/29/3.

3. United Nations Report of the Special Rapporteur on the question of torture: Visit to Spain. 6 February 2004, E/CN.4/2004/56/Add.2.

4. United Nations Human Rights Committee.

María Cruz Achabal Puertas v. Spain, Communication No. 1945/2010, U.N. Doc. CCPR/ C/107/D/1945/2010 (2013).

5. European Committee for the Prevention of Torture (CPT). Special recommendations after the visit of May 30 to June 13, 2011. Available from: http://www.cpt.coe.int/documents/ esp/2013-06-inf-esp.pdf. See also all other reports on Spain available from: http://www.cpt. coe.int/).

6. Sentencia de la Audiencia Nacional de 12 abril de 2010 relativa al denominado “Caso Egunkaria”. Audiencia Nacional, Sala de lo Penal Sección Primera SENTENCIA Núm. 27/2010.

Available from: http://www.berria.eus/dokumentuak/dokumentua599.pdf 7. Sentencia del Tribunal Supremo 483/2011, de 30 de mayo, que revisa en casación un supuesto de colaboración con organización terrorista del año 2009.

8. Tribunal Constitucional (STC 63/2010, de 18 de octubre de 2010). Available from: https:// www.boe.es/diario_boe/txt.php?id=BOEA-2010-17740 9. European Court of Human Rights. Beortegui Martinez v. Spain (no. 36286/14). 31 May 2016.

10. United Nations Committee against Torture (CAT). Communication no. 453/2011. Decision adopted by the Committee at its 48th session, 7 May to 1 June 2012.

11. Arzuaga, Julen, Oso Latza izan da. Tortura Euskal Herrian. [It has been so tough. Torture in the Basque Country] Euskal Memoria, DonostiaSan Sebastian; 2012.

12. Basque Government, Presidency. “Informe-base de vulneraciones de derechos humanos en el caso vasco (1960-2013)” [Base-Report of Human Rights Violations in the Basque Country (19602013)]. Vitoria-Gasteiz, 2013; June.

13. Human Rights Department. Torture: a scientific approach (2000-2008). Basque Government, Vitoria-Gasteiz; 2009.

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Incommunicado detention and torture in Spain, Part II: Enhanced credibility assessment based on the Istanbul Protocoli Pau PĂŠrez-Sales, MD, PhD*, Benito Morentin, MD, PhD**, Olatz Barrenetxea***, Miguel Angel Navarro-Lashayas, PhD***

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Abstract

Background: The Istanbul Protocol (IP) is the key instrument in the documentation of allegations of torture. However, few scientific studies have evaluated its effectiveness as a tool to assess credibility of allegations of ill-treatment or torture. Objective: Present data on the credibility of allegations of torture in a sample of 45 Basque people held in short-term incommunicado detention between 1980 and 2012, using a modified version of the Standard Evaluation Form for Credibility Assessment (SEC), a new tool to assess credibility based on the IP. Method: Each case was evaluated by two psychiatrists, a psychologist and a physician through a layered system of simultaneous, independent assessments, blind audits and peer-review processes. Clinical interviews following the IP were contrasted with psychometric tests and external documentary evidence by independent experts. All available data were structured using the SEC and cases were *) Hospital La Paz, Spain. SiR[a] Centre, GAC Community Action Group and Hospital La Paz, Spain. **) ARGITUZ - Human Rights Association and Section of Forensic Pathology, Basque Institute of Legal Medicine, Spain. ***) Human Rights Section, Spanish Association of Neuropsychiatry.

Correspondence to: pauperez@arrakis.es i

Editor: Lilla HĂĄrdi.

accordingly classified as having Maximum consistency, Highly Consistent, Consistent or Inconsistent. Findings: According to the SEC, 53% of allegations of torture were considered to have Maximum Consistency, 31% Highly consistent, 15% Consistent and 0% Inconsistent. The items that most contributed to the overall credibility assessment came from the psychological evaluation, including the description of alleged torture, emotional reactions, objective functional changes, changes in identity and worldviews and clinical diagnosis. There was little contribution from previous medical reports. Interpretation: When applied competently, the IP is an essential tool in the documentation of torture. Our study shows: (a) evidence that allegations of ill-treatment and torture in the Basque Country are consistent and credible, being ascertained beyond reasonable doubt and aside from any political debate; (b) the wider use of the IP as a tool to assess credibility of allegations of ill-treatment and torture; and, (c) the usefulness of the SEC as a tool. The SEC can help as a tool for documenting torture in contexts where there are political differences and figures are distorted as a result of polarized political debates, and where legal documentation is needed for judicial purposes. Forensic science can help by providing an objective assessment of the credibility of allegations.

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Keywords: Standard Evaluation Form for Credibility Analysis (SEC), torture, forensic science, Istanbul Protocol, incommunicado detention, Spain, Basque Country Introduction

Table 1: Credibility analysis in the Istanbul Protocol: Epistemological basis • Empathy in an open and horizontal setting characterised by listening.

• No time pressure on the interviewee.

• Knowledge of human rights and political context.

External sources of verification.

• Interview focused not on clinical symptoms but on personal biographical history, with data collation by third-party sources.

• Coherence in the events described.

• Consistency between verbal and nonverbal communication.

• Consistency between the events described and the emotion and resonance with which they are expressed.

• Known coping patterns in adverse situations and in the assessed situation.

• Analysis of changes in personality structure.

Plausibility of torture as the likely reason for changes (cause-effect relationship) due to the nature of changes and a likely temporal association. Discarding other causes.

• Complementary test: psychometric measures, image and others.

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The Istanbul Protocol (IP) is the key instrument in the international documentation of ill-treatment or torture allegations.1 Since its beginnings in 1999, the IP has been supported and promoted by the United Nations system that has adopted it as the international standard of reference.2, 3 It has been recognized by human rights bodies as a benchmark with which to measure the quality and effectiveness of the investigation and documentation of torture allegations.4-6 The IP is a tool to assist physicians and psychologists in recognizing, documenting and reporting the evidence of torture. One of the main objectives of the IP is to make a judgment concerning credibility, defined as the evaluator’s impression of the accuracy of the survivor’s statement, and whether or not it leads the evaluator to believe that the events occurred as the survivor claims. The focus, thus, is not on whether the person is telling the truth or not (something that would entail complex moral considerations), but whether the narrative is accurate according to a set of criteria. A credibility analysis uses both objective and clinical criteria to determine whether a person’s claim that he or she has been tortured occurred as he or she states. The IP does not devote a special section to credibility analysis, but there are many helpful ideas throughout the text that have been condensed in Table 1.

The IP does not give clear guidelines on how to make an overall assessment of credibility but suggests that medical symptoms are evaluated according to four possible categories: ‘Not Consistent’ (lack

of consistency between alleged facts and forensic examination), ‘Consistent with’ (nonspecific findings that may have been produced by the events described), ‘Highly Consistent’ (the findings could have been caused by the events described, and there are few other possible causes) and ‘Maximum consistency’ (the findings of the forensic examination could not have been caused in any way other than that described). Although the IP has received UN endorsement, there is a lack of effective implementation of the IP worldwide and very few scientific studies have assessed the usefulness of the IP as a research tool in general,5, 6 and none specifically as a tool for credibility assessment.

Torture is a debated concept in the Basque Country. The main aim of the present study is to assess the credibility of

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allegations of ill-treatment or torture in a sample of people under incommunicado detention (considered as implying the greatest risk of ill-treatment), using the IP as tool of analysis. In order to assess credibility in a consistent way and to standardize the final decisions of the forensic experts, a simplified version of the SEC was used. This is a newly developed tool that enhances the IP with a set of 19 criteria previously used for forensic reports, but not as a research tool.7 As a secondary objective, we therefore intended to test the usefulness of the SEC as a tool for research.

Method

Definition of torture The definition of torture in the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, which is also the definition adopted in the IP, was used.

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Participants

We selected a purposive group of Basque people (N=45) held under short-term incommunicado detention in application of anti-terrorist legislation between 1980 and 2012 in Spain and who had reported ill-treatment or torture (whether or not such allegations were presented in court). The sample was recruited through a snowball sampling method using a Latin Square methodology to balance for gender, year of detention and state security force involved.

Instruments and Procedure

Building Consistency Analysis: A system of blind and independent assessments and peer-review processes and audits The methodology of assessment of each case describing the successive layers of the study and the role of each expert involved is detailed in Table 2.

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The forensic examination was compartmentalized into independent levels with a combined system of blind analysis and peer review processes that involved five different professionals. Briefly, each case was evaluated by two psychiatrists or clinical psychologists (a ‘pair’) who conducted extensive clinical interviews following a semi-structured script based on the IP. The interviews were recorded on video or audio (as chosen by the interviewees) and transcribed. The participants undertook a battery of tests (Vital Impact Assessment Questionnaire (VIVO), Beck Depression Inventory (BDI), Post-traumatic Stress Disorder (PCL-C), and Social Support, Guilt and Forgiveness) (see Part IV). Two psychologists, blind to the forensic assessment, analyzed the results of the tests.

A third group sought and analysed external documentary evidence related to each arrest (see Table 3). With all these data, the two persons responsible for the IP completed the credibility analysis. All examinations were subsequently compared for consistency and cross-checked by a supervisor, a psychiatrist with significant experience in forensic assessment of torture allegations, who additionally supervised the results and overall conclusions of the SEC Scale.

The team put together a final IP report which included the description of torture and ill-treatment, symptoms in relation to torture, psychological and medical examination, results of psychometric tests, psychiatric diagnoses following the tenth version of the International Classification of Diseases (ICD), the SEC (see below) and an official statement of the level of credibility of allegations for legal purposes.

Credibility assessment: a proposal of an extended set of indicators The Istanbul Protocol specifically asserts that one must ‘establish the credibility of

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Table 2: Assessing credibility: independent analysis and audit systems Expert

Role

1. Collecting data

Psychiatrist or psychologists with excellent knowledge of the political history and context from the Basque Country.

Informed consent.

Extensive clinical interview, following a semistructured script based on the Istanbul Protocol.

Psychometric Assessment including Impact on Human Worldviews, Posttraumatic Stress Disorder, Depression, Social Support, Guilt and Forgiveness

2. Contrasting data

Psychiatrists or clinical psychologists from places outside the Basque Country, with experience in the documentation of torture.

External ‘partner’ (or ‘pair’), who acts as a source of contrast. Sometimes he/she would decide to go to the Basque Country and personally attend the interviews. In other cases, he/she worked with recordings and/or transcripts of the testimony and the expert's notes.

3. Draft IP report

The two experts who take part in layers 1 and 2 (‘pair’).

Both were joint signatories of the IP and had the responsibility of establishing a system of agreement in cases of doubt with support from a technical supervisor.

4. Analysis of complementary sources (psychometric)

Two independent psychologists.

Blind analysis of the questionnaires and all psychometric data producing an independent report for each case.

5. Analysis of complementary sources (medical)

Independent group of physicians and forensic doctors.

Blind independent analysis of external documentary information available for each case (see table 3). They produced an expert opinion on credibility using the SEC.

6. Overall supervision.

Experienced Psychiatrist.

Peer Review and Credibility Analysis of all the material arising from steps 1 to 5 on a case-bycase basis, validating the results and proposing criteria of improvement or contrast through several individual and group feedback sessions with each pair of forensic experts. Validates the results of the SEC.

7. Consultation by an independent international source.

Expert from the Independent Forensic Expert Group (a group facilitated by the International Council for the Rehabilitation of Torture Victims (IRCT)).

Meetings in Madrid and Bilbao conducting interviews with some of the examinees, individually and in groups. The expert also collated recordings, met with some of the psychiatrists or psychologists and analysed a random sample of IP.

the person’ and that establishing consistency is a fundamental tool in doing so.2 When the protocol speaks of ‘credibility’ it is not referring to evaluating the person’s honesty, but rather to the credibility of past

and present core facts (Objectively assessed, is all or part of the claimant’s story of torture, which he or she presents as a factual background to their case, accepted as “credible”?). The person’s credibility is

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Layers of the study

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Table 3: Methodology: external sources of data contrasted

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• Documentation presented as part of the judicial procedure arising from the allegations of ill-treatment/torture (in those cases in which there had been legal complaints).

• Testimonies of allegations of ill-treatment/torture provided in judicial complaints, public denunciations or complaints to human rights organizations.

• Rights violations statements made to the Central Instruction Judge.

• Forensic assessments issued during the period of incommunicado detention and any other forensic report in relation to the case.

• Medical and psychological assessments carried out by health centres, hospitals, or prison professionals etc., during or after the arrest. Any other documentation or medical tests that would provide information on the finding of possible injuries or sequels.

• Documentary reports by human rights organizations, or victim associations.

• Interviews of potential witnesses to the facts (relatives, other people detained at the same time etc).

not being analyzed, but rather the set of events that s/he refers to.

In order to assess the credibility of allegations of ill-treatment on objective grounds, a modified version of the SEC was used. The SEC complements the IP, enabling credibility to be assessed in a consistent and reliable way. It helps the evaluator to search for potential sources of credibility and systematize information, to make his or her final decision more objective and to have comparable results among experts and studies. It is based on a set of 19 criteria that includes a consistency analysis, clinical data and analysis, and triangulation of available sources of information.7 The study used a shortened form that included a set of 14 criteria (see Appendix A).i The global assessment of credibility is not derived from a numerical sum-up of criteria. The matrix is

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merely an aid to reaching a final consensual decision. Establishing cut-off points would not be theoretically logical in any event because: (a) some of the criteria depend on the availability of external sources (criteria 11 and 12), or having by-proxy information (criteria 8); (b) not fulfilling certain criteria does not erode credibility, for instance, not having sequels (criteria 5), a clinical diagnosis (criteria 6), or persistent personality changes (criteria 10); and, (c) the conceptual weight of each of the 14 criteria is too dissimilar for a simple sum-up.7 The global assessment of credibility was coded in one of the four categories proposed in the IP and adopted by the SEC. The SEC was filled in for each case according to the data obtained in clinical interviews, psychometric test and external documentation.

Statistical Analysis In addition to descriptive statistics, a Chi-square test was used to assess the differences in the distribution of the three categories of global assessment of credibility, (maximum consistency, highly consistent, and consistent) in relation to gender, age at the time of forensic evaluation and period of detention. The level of significance was set at p < 0.05. All the analyses were performed using the Statistical Package for Social Sciences (SPSS 17.0).

Results

Description of the study population The socio-demographic and socio-political characteristics of the sample are detailed in Table 4. Essentially, the typical examinee is a man (58%) or a woman (42%) between 21 and 30 years of age when detained (69%), with university studies (53%), i A copy of the full SEC scale is available from the corresponding author.

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Table 4: Sociodemographic and socio-political characteristics Description of population (N = 45)

n (%) 26 (58) 19 (42)

Age at the time of arrest

≤ 20 21-30 31-40 ≥ 41

8 (17) 31 (69) 5 (11) 1 (2)

Age in the moment of forensic evaluation

21-30 31-40 ≥ 41

18 (40) 13 (29) 14 (31)

Educational Level

Basic Education Secondary studies University studies

2 (4) 19 (42) 24 (53)

Marital status

Single Cohabitation Married Separated

13 (29) 22 (49) 6 (13) 4 (9)

Children

Yes No

7 (16) 38 (84)

Militancy at the time of arrest

Armed Group Member or collaborator Nationalist Youth Group Member Member of Nationalist political group Member of non-nationalist Social Group or non-specified militancy No link with activism or militancy

2 (4) 17 (38) 19 (42) 6 (13) 1 (2)

Security body responsible for the arrest and interrogation

Guardia Civil Policía Nacional Ertzaintza

24 (53) 14 (31) 7 (15)

Days under Incommunicado detention

1 3 4 5 10

2 (4) 14 (31) 2 (4) 24 (53) 3 (7)

Further Measures

Freedom Without Charges Freedom with Charges Pre-trial imprisonment

4 (9) 4 (9) 37 (82)

Year of Detention

Before 1998 1998-2002 2003-2007 2008 or after

9 (20) 12 (27) 7 (16) 17 (38)

Time between arrest and Forensic assessment

Less than 1 year Between 1 and 2 years Between 2 and 5 years Between 6 and 10 years 11 or more years

4 (9) 9 (20) 6 (13) 15 (33) 11 (24)

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Gender

Male Female

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married or in a joint household situation (62%), with no children. He or she is a member of a nationalist political or social group (80%) with strong collaborative links with the Basque political independence project through militancy (protests or political actions, social mobilization, solidarity and/or support of political prisoners or their relatives, etc.). About half (53%) were arrested by the ‘Guardia Civil’ and were held in incommunicado detention of five days duration and 82% of the subjects were transferred to prison to await trial. The forensic assessment using the IP is generally carried out, on average, between five and 10 years after incommunicado detention.

Credibility assessment and consistency of allegations of torture

The data about overall level of credibility and about each criteria of the SEC can be found in Table 5. About half of the examinees received the highest level of credibility; a third was considered ‘Highly Consistent’and 15% ‘Consistent’. None of the cases were considered ‘Inconsistent’. The criteria that most contributed to the overall decision were: the internal consistency in the description of alleged torture (criteria 1); psychological/psychiatric evaluation, including consistency between narrative, emotions and clinical symptoms (criteria 3 and 4); psychological and functional changes and long-term sequelae after torture (criteria 2, 5

Table 5: Global level of credibility and Level of consistency by credibility criteria Items

Highly consistent

Consistent

Not consistent

N (%)

N (%)

N (%)

N (%)

Global level of credibility

24 ( 53)

14 (31)

7 (16)

0

[1] Torture allegation

16 (36)

18 (40)

11 (24)

0

[2] Expected Psychological Reaction

11 (24)

23 (51)

11 (24)

0

[3] Emotions-facts consistency

11 (24)

24 (53)

8 (18)

2 (4)

[4] Verbal-Nonverbal Consistency

12 (27)

21 (47)

12 (27)

0

[9] Functional changes (work. family...)

12 (27)

19 (42)

14 (31)

0

[10] Persistent personality changes

10 (22)

20 (44)

15 (33)

0

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Maximum consistency

Yes

No

N (%)

N (%)

[5] Consistent sequels

41 (91)

0

[7] Experts agreement

45 (100)

0

[8] Facts contrasted with other informants (family, etc.)

10 (22)

35 (78)

[11] Medical tests or evaluations

6 (13)

39 (87)

[12] Medical assessments

6 (13)

39 (87)

[13] Court sentence in favour of the examinee

1 (2)

44 (98)

[14] Human Rights entity report

8 (18)

0

Not applicable N (%) 4 (9)

37 (82)

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Figure 1: Global level of credibility according to gender, age at the time of the evaluation and period of time in which arrest occurred

Representation of the percentage of each category of the Global Level of Credibility (maximum consistency, highly consistent; and consistent) in relation to socio-demographic characteristics (gender, age at time of evaluation and period of detention). The grey segment of each bar represents the percentage of “maximum consistency”; the black segment those considered “highly consistency”; and the white segment those considered as “consistent”.

Discussion

Documenting torture in Europe is a challenge. Torture is mostly based on psychological methods and methods that do not leave

visible external injuries. In addition, in some countries, as in Spain, official forensic examinations during detention do not follow the proper procedural safeguards.9, 10 The absence of safeguards for the rights of detainees and the inactivity on the part of the courts with respect to the investigation and prosecution of torture-related crimes are also matters of concern.11, 12 Despite the development of the IP, few scientific studies have assessed its effectiveness with regard to the investigation and documentation of torture specifically regarding credibility analysis. In a pioneering study in Mexico,5 39 cases were analyzed that allegedly used the IP, noting important deficiencies that precluded the effective documentation of torture.

The procedure in this study followed IP

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and 6); and, concurrent agreement of experts (criteria 7). The external sources of data available to triangulate information were interviews with relatives or acquaintances (22%), cases previously collected by human rights organizations (18%), medical assessments (13%), medical tests done shortly after the detention (13%), and court sentences (2%). Detailed data for each of the 45 participants are available in the final report.8 We did not find significant differences in the level of credibility by gender, age or period of detention (see Figure 1).

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standards and involved about 30 professionals (psychologists, psychiatrists and medical doctors) in a system of blind audits and peer review processes and contrasted information with external sources when available. Our work shows that, when applied by a multidisciplinary team of experts, the IP is an essential tool in the investigation of torture.

The IP as proof of evidence for judicial procedures The IP puts a strong emphasis on credibility assessment and tries to fill the gap left by the lack of witnesses and physical findings by using, among other things, a rigorous, extensive and intensive psychiatric and psychometric assessment that has forensic probative value. This study shows the importance of the psychological assessment in the evaluation of allegations of torture, as well as the importance of the use of the SEC to evaluate credibility in a consistent manner.

SEC is a tool that clearly enhances the IP in the assessment of allegations of ill-treatment and torture.

In the analysis of credibility, the items that contributed most to the global assessment were psychological, namely, expected psychological reaction, consistency between facts and emotions, consistency between verbal and nonverbal elements, functional changes and persistent personality changes temporally linked to the alleged events (Table 5). This is mainly due to two facts: (a) the methods of torture reported in the Basque Country leave no chronic physical sequels; and (b) the fact that a long time had generally elapsed between alleged torture and the IP evaluation. The blind use of psychometric tests was also an invaluable tool, complementing the clinical interview, especially the measures of impact on identity and human worldviews (see Part IV).

The usefulness of medical documenta-

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tion as an external source of contrast and corroboration in the analysis of credibility was quite poor overall. The IP is not integrated to official medico-legal practice in Spain and forensic doctors do not use a formal protocol in line with the recommendations of the CPT.13 Finally, other external documentation that could be cross-checked, especially police and judicial records, was also deficient, largely due to the difficulties for human right groups in obtaining primary sources.

The findings demonstrate a high level of consistency between the allegations of torture and the result of the assessments made by the forensic experts trained in the IP. It can be concluded that there is ill-treatment and torture during incommunicado detention in Spain and that it is unlikely to be a matter of a few isolated cases.14, 15 We have documented at least 45 cases using basic snowball sampling, and discarding many potential cases to adjust for sociodemographic variables according to the Latin Square procedure.

In contrast to statements made by the Spanish Government affirming that torture does not exist at all, the international institutions that have addressed the reliability of the allegations of police ill-treatment of people arrested under incommunicado detention have concluded that torture claims are credible. For example, after its visit to Spain in 2011,13 the Committee for the Prevention of Torture determined that the allegations of ill-treatment from 10 of the 11 people with whom they had had interviews were credible and consistent. Importantly, a recent court sentence absolved 40 young people who alleged torture during incommunicado detention, of belonging to ETA. The judges were surprised that none of the accused detained in France had made a self-incriminating statement, while most of

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those detained by the Spanish police did.

They also accepted the IP reports of some of the detainees presented in the trial as a forensic probe of ill-treatment and decided not to admit self-incriminating statements.

Limitations of the study

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An official register of Basque people alleging torture during detention is being finalized.

This will allow for a population-based study using random sampling to be carried out in the future, something that was not possible with respect to the current study which involved working with a convenience sample stratified by key socio-demographic variables.

Selection bias and slight variations cannot be ruled out. However, the study does not claim to be epidemiological and provide an estimate of the prevalence of torture allegations among the thousands of Basque people that have undergone incommunicado detention during the last decade. Given the register under development, future studies by the same team will be able to do so.

Considering the poor official medicoforensic documentation and the deficient judicial investigation of torture conducted so far, it would be advisable to investigate allegations of torture using the IP, and more specifically, the SEC. Only then, would it be possible to get a real picture of the magnitude of the problem. To do this, it is mandatory to train professionals in the implementation of the IP in Spain. Likewise, we think that our procedure can provide ideas for other similar contexts in which allegations of torture or ill-treatment are disputed, and that it can help as a tool for the implementation of the IP when credibility is the core aspect to be assessed.

References 1. Ucpinar H, Baykal T. An important step for prevention of torture. Istanbul protocol and challenges. Torture. 2006;16(3):252-67.

2. UN Office of the High Commissioner for Human Rights (OHCHR), Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment - Istanbul Protocol, 2004, HR/P/ PT/8/Rev.1 Available from: http://www.unhchr. ch/ pdf/8istprot.pdf 3. United Nations General Assembly Resolution 55/89, Add 1, 2000 December 4th.

4. Iacopino V, Ozkalipci O, Schlar C. The Istanbul Protocol: international standards for the effective investigation and documentation of torture and ill treatment. Lancet. 1999 Sep 25;354:1117.

5. Moreno A, Iacopino V. Forensic investigations of torture and ill-treatment in Mexico: A follow-up study after the implementation of the Istanbul Protocol. J Leg Med. 2008 OctDec;29(4):443-78.

6. Perera C, Verghese A. Implementation of Istanbul Protocol for effective documentation of torture– review of Sri Lankan perspectives. J Forensic Leg Med. 2011 Jan;18(1):1-5 7. Pérez-Sales P. Standard Evaluation Form for Credibility Analysis. A new tool to assess credibility based on the Istanbul Protocol. In: PérezSales P. Psychological Torture: definition, evaluation and measurement. Do you know the location of the publisher? London-New York: Routledge; 2016. pp. 314-324.

8. Argituz, AEN, Ekimen Elkartea, GAC, JaikiHadi, OME, OSALDE, Departamento de Psicología Social (UPV/EHU). Incommunicado detention and torture. Assessments using the Istanbul protocol. Bilbao: Ekimen Ed. and Irredentos Libros; 2014.

9. Petersen HD, Morentin B, Callado LF, Meana JJ, Hougen HP, Idoyaga MI. Assessment of the quality of medical documents issued in central police stations in Madrid, Spain: the doctor’s role in the prevention of ill-treatment. J Forensic Sci. 2002 Mar;47(2):293-8.

10. Morentin B., Petersen H.D., Callado L.F., Idoyaga M.I., Meana J.J. A follow-up investigation on the quality of medical documents from examinations of Basque incommunicado detainees. The role of medical doctors and national and international authorities in the prevention of ill-treatment and torture. Forensic Sci Int. 2008 Nov 20;182(1-3):57-65.

11. Report of the Special Rapporteur on the promotion and protection of human rights and fun-

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damental freedoms while countering terrorism, 2008. A/HRC/10/3/Add.2, dated 16 December 2008.

12. Amnistía Internacional. La tortura como receta.

De las leyes anti-terroristas a la represión de la primavera árabe, Junio 2011.

13. European Committee for the Prevention of Torture (CPT). Special recommendations after the visit of May 30 to June 13, 2011. Available from: http://www.cpt.coe.int/documents/esp/2013-06inf-esp.pdf. (See also all other reports on Spain available from: http://www.cpt.coe.int/).

14. Terwindt C. Were They Tortured or Did They Make That Up? Ethnographic reflections on torture allegations in the Basque Country in Spain.

Oñati Socio-Leg Ser. 2011;1(2).

15. United Nations Economic and Social Council. Report of the Special Rapporteur on the question of torture. Civil and political rights, including the question of torture and detentions.

Visit to Spain. E/CN.4/2004/56/add.2, 2004.

Available from: http://www.unhchr.ch/Huridocda/Huridoca.nsf/(Symbol)/E.CN.4.2004.56.

Add.2.En?Opendocument.

16. Audiencia Nacional. Sala de lo Penal. Sección Primera. Sentencia nº 26/2014. Available from: http://www.naiz.eus/media/asset_publics/resources/000/089/292/original/ 2014-6-11_Sentencia_SEGI_I.pdf.

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Appendix A Modified version of the Standard Evaluation Form for Credibility Assessment based on the IP.7

Criterion

Coded

1) Description of alleged torture (circumstances, type, methodology, duration, etc.) according to that described in previous reports from the same context by human rights organizations, international organizations, or entities associated with or recognized by United Nations agencies working on preventing or denouncing torture.

1. Maximum consistency 2. Highly consistent 3. Consistent with 4. Not consistent

2) Expected or typical psychological reactions to extreme stress, within the cultural and social context of the examinee.

1. Maximum consistency 2. Highly consistent 3. Consistent with 4. Not consistent

3) Consistency between the description of events and the emotions with which these are expressed.

1. Maximum consistency 2. Highly consistent 3. Consistent with 4. Not consistent

4) Consistency between verbal and nonverbal communication in the statement of events.

1. Maximum consistency 2. Highly consistent 3. Consistent with 4. Not consistent

5) Medium/long term sequelae consistent with the alleged events.

1. Yes 2. No 3. Not applicable

6) At the time of the expert assessment, evalueeâ&#x20AC;&#x2122;s principal clinical diagnosis related to the events is consistent with allegations.

Write codes ICD-11

7) Coincidence of two forensic experts and/or an external evaluator regarding the credibility assessment.

1. Yes 2. No 3. Not applicable

9) Functional changes (in work, studies, personal relationships, etc.) after the events described which are attributable to such events.

1. Maximum consistency 2. Highly consistent 3. Consistent with 4. Not consistent

10) Objective and verifiable personality changes that can be temporally associated with the alleged events.

1. Maximum consistency 2. Highly consistent 3. Consistent with 4. Not consistent

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8) Events and physical and psychological consequences independently 1. Yes contrasted with one or more other informantâ&#x20AC;&#x2122;s testimony (family, friends, 2. No co-detainees or others). Consistent versions from different sources 3. Not applicable regarding the signs and symptoms before and after the events and the hypothetical sequelae.

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11) Tests or medical reports (x-rays, blood tests, or other tests) which are consistent with the alleged events.

1. Yes 2. No 3. Not applicable

12) Previous medical or forensic assessments evidencing sequelae or injuries consistent with the events described.

1. Yes 2. No 3. Not applicable

13) Court sentence in favour of the examinee recognizing degrading treatment, ill-treatment, or torture during the arrest.

1. Yes 2. No 3. Not applicable

14) Case previously described in an independent human rights report.

Congruency between sources.

1. Yes 2. No 3. Not applicable

OVERALL LEVEL OF CREDIBILITY (According to the Istanbul Protocol and external sources of verification).

1. Maximum consistency 2. Highly consistent 3. Consistent with 4. Not consistent

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Incommunicado detention and torture in Spain, Part III: 'Five days is enough’: the concept of torturing environmentsi Pau Pérez-Sales, MD, PhD*, Miguel Angel Navarro-Lashayas, PhD**, Angeles Plaza***, Benito Morentin, MD, PhD****, Oihana Barrios Salinas*****

Abstract

Background: Torture is changing in western societies, evolving from pain-producing torture to more subtle mixed psychological methods that are harder to detect. Despite this, there is not an adequate understanding of the complexities of contemporary psychological techniques used in coercive interrogation and torture. Methods: The interrogation and torture techniques used on 45 detainees held in short-term incommunicado detention in Spain during the period 1980-2012 were analyzed. The list of torture categories set out in the Istanbul Protocol (IP) were assessed quantitatively. Software-aided qualitative analysis of the testimonies was conducted, using both inferential and deductive approaches to deduce a classification of torture techniques from the point of view of the survivor. Findings: The most frequent

Correspondance to: pauperez@arrakis.es i

Editor: Lilla Hárdi.

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*) SiR[a] Centre, GAC Community Action Group and Hospital La Paz, Spain. **) Human Rights Section, Spanish Association of Neuropsychiatry (AEN). ***) GAC - Community Action Group, Resource Centre on Mental Health and Human Rights, Spain. ****) ARGITUZ - Human Rights Association and Section of Forensic Pathology, Basque Institute of Legal Medicine, Spain. *****) Jaiki-Hadi Prevention and Assistance Association.

methods according to the IP categories used against detainees were isolation and manipulation of environment (100%), humiliation (93%), psychological techniques to break down the individual (91%), threats (89%) and forced positions and physical exercises until extenuation (80%). Additionally, with a frequency of between 51 and 70%, mild but constant blows, being forced to witness the torture of others, hooding (mainly dry asphyxia) and unacceptable undue conditions of detention were also frequent. Sexual torture was also widespread with sexual violence (42%), forced nudity (38%) and rape (7%). Qualitative analysis showed that most detainees were submitted to coercive interrogation using a wide array of deceptive techniques. This is often a central part of the torturing process, frequently used in conjunction with many other methods. It was found that giving false or misleading information or making false accusations was most frequently used, followed by maximization of responsibility or facts and giving false information regarding relatives or friends. Different patterns of harsh interrogation, ill-treatment and torture are described that appear to have been tailored to the profile of Basque detainees. Interpretation: The study shows the need to improve the conceptualization of psychological torture suggested by the IP. Key to this view is the idea that we must not concern ourselves with 'torture methods' but

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with Torturing Environments. The concept of Torturing Environments is defined and proposed as a focus for future study.

Keywords: Torture, torturing environments, incommunicado detention, psychological torture, interrogation procedures, deception, Istanbul Protocol.

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Introduction

Historically, torture has been wrongly associated with the production of physical pain.1, 2 Pain is certainly part of an overall process of breaking down the mental state of the person who is being tortured.3 However, contemporary torture, particularly in western societies, is changing in that psychological torture which does not leave marks is increasingly replacing pain-based torture. As torture is generally accepted to be a process of compliance and submission, humiliation and psychological breakdown, psychological torture can be more targeted and efficient, often achieving the desired effect in a shorter time (see statements 1 and 2, Appendix A).4-5 In Spain, anti-terrorist laws allow for incommunicado detention for up to five days, which can be extended to 13 days, during which the right to communicate with family members and have access to lawyers or doctors of the detainee's choice is denied.6 Incommunicado detention has been repeatedly denounced as contrary to international law by different human rights bodies and was even considered as amounting to torture by the United Nations Special Rapporteur on torture and other cruel, inhuman or degrading treatment or punishment.7-12 The Spanish police are trained in the use of the Reid technique, a harsh method of questioning subjects by means of a progressively accusatory process.13 Unlike cognitive interviewing, where the interrogator tries to

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build a positive atmosphere of dialogue and cooperation with the detainee,14 it assumes that the detainee is guilty. The investigator uses an escalation of coercive procedures and deceptive tactics with the aim of self-incrimination. Unsurprisingly, the technique has been reported to produce very high rates of false confessions.15, 16 There are very few contemporary systematic studies on ill-treatment methods in Europe. Studies on incommunicado detention in Spain have been mostly descriptive, only consisted of testimonial reports or provided rough estimates of the frequency of mainly physical torture methods. They offer scant information about the dynamics of modern psychological torture and its consequences. Even the IP arguably lacks detailed guidelines on how to explore and report on psychological torture.5 It is therefore a priority for future research to recognise and focus on how psychological ill-treatment and torture is now being conducted.

The objective of this paper is to describe the ill-treatment and torture techniques used by the Spanish security forces on incommunicado detainees, including the coercive interrogation techniques which make up a torturing environment, as well as providing some methodological reflections on the epidemiology of torture methods for similar studies in the future. The concept of Torturing Environments is presented, a term which allows a more meaningful understanding of the dynamics of interrogation procedures and of the psychopathological consequences of current ill-treatment and torture.

Method

A stratified purposive sample of Basque people (N=45) held under incommunicado detention between 1980 and 2012 in Spain

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who have reported ill-treatment or torture during detention was selected. The participants and the methodology of assessment have been described in Part II. Data were obtained through extensive clinical interviews following a semi-structured script based on the IP conducted by psychiatrists or clinical psychologists. Forensic experts collected, as part of the IP, a detailed account of the conditions of detention and interrogation, and allegations of ill-treatment.

These interviews were recorded on video or audio (as chosen by the interviewees) and transcribed.

Analysis of data

Quantitative analysis Torture techniques according to categories set out in the IP were coded. In order to evaluate if torture methods have changed during the last decade, two periods: 1980 to 2002 and 2003 to 2012 were compared.

Chi-square tests were used to assess differences in the distribution of torture methods for those with a frequency >10% in the two periods. Level of significance was set up at p < 0.05. All the analyses were performed using the Statistical Package for Social Sciences (SPSS 17.0)).

Results

Quantitative analysis: Methods of physical and psychological torture Table 1 shows the frequency of torture techniques. Torture exposure is cumulative and the results show that the detainee is submitted to a large number of physical and psychological methods simultaneously or successively. Most of the survivors reported isolation and manipulation of environment (100%), humiliation (93%), psychological techniques to break down the individual (91%), threats (89%) and positional torture (forced positions and physical exercises) (80%). These could therefore be considered the core torture techniques used in incommunicado detention in Spain. Also widely used, are blows (mild but constant) (69%), forcing the victim to witness torture (67%), hooding (with dry asphyxia on most occasions) (47%), and unacceptable conditions of detention (56%). Sexual torture was also common with reports of sexual violence (42%), forced nudity (38%), and even rape (7%).

In relation to the distribution of the frequencies of torture methods by period of detention (Figure 1), there were not statistically significant differences, except for the electric shocks (most frequently used in the first period), showing that the methods are mainly psychological and remain substantially unchanged.

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Qualitative analysis All 45 IP descriptions of sessions were submitted to content analysis using Atlas. ti.6.0 software for text analysis. Two methodologies were used: (a) I nferential methodology. Through the Atlas.ti analysis, a thesaurus of all the terms related to torture methods that appeared in the statements was obtained. (b) D eductive methodology. Additional codes were generated through an in-depth reading of the 45 testimonies according to theoretical models of conceptualization of torture methods.

The results of (a) and (b) were collated and grouped into conceptual nodes. Nodes were latter interconnected into conceptual families. A final report was produced with the hierarchy of nodes and families and all the quotations for the IP that supported each of them. These data were analysed over a time line in order to elaborate a prototypical process of detention and ill-treatment which helped to understand the dynamics of an interrogation procedure.

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Table 1: Frequency of torture techniques according to IP classification (N = 45) n (%) Blunt trauma, beatings.

31 (69)

Positional torture

36 (80)

Electric shocks and mock electric shocks

7 (16)

Asphyxiation, such as wet (water) and dry (hood, bag) methods

21 (47)

Crush injuries

2 (4)

Forced nudity

17 (38)

Sexual violence

19 (42)

Rape

3 (7)

Conditions of detention

25 (56)

Isolation. Alteration of normal sensory stimulation; sleep, food, water

45 (100)

Deprivation of an adequate medical care

18 (40)

Humiliation, such as verbal abuse, performance of humiliating acts

42 (93)

Threats of death, harm to family, further torture, imprisonment

40 (89)

Mock executions

6 (13)

Psychological techniques to break down the individual, including forced betrayals, ambiguous situations etc

41 (91)

Forced betrayal of someone placing them at risk of harm

12 (27)

Forcing the victim to witness torture or atrocities being inflicted on others, or records of screaming, music, etc.

30 (67)

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Figure 1. Methods of torture in relation to period of detention: Types of torture (%) from 1980 to 2002 (black columns, n = 21) and 2003 to 2012(grey columns, n = 24)

BT = Blunt trauma; PT = Positional torture; ES = Electric shocks; As = Asphyxiation; FN = Forced nudity; SV = Sexual violence; CD = Conditions of detention; Is = Isolation; DM = Deprivation of medical care; Hu = Humiliation; Th = Threats; ME = Mock executions; PTB = Psychological techniques to break down the individual; FB = Forced betrayal; FV = Forcing the victim to witness others torture. * p <0,05.

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Qualitative analysis: Conceptual nodes and families Tables 2 and 3 show the conceptual nodes and families including representative quotations as a way of description. A more detailed account of each one can be found in the final report.17 Coercive interrogation techniques (Table 3) are part of contemporary torture. The core technique in coercive interrogation is deception, defined as the purposive use of misleading threats and questions to obtain information from a detainee.18 Table 4 summarizes the frequency of deceptive mechanisms used in incommunicado detention in Spain. Two out of every three detainees reported maximization of facts, responsibility or consequences, false information about their family being detained or in immediate danger, false accusations (false witnesses or false indictments) or making false promises of leniency.

Cumulative effect The classification in categories does not reflect the fact that techniques were applied simultaneously and that the combined effect is what produces a strong impact in a very short time. Five days was enough to produce a state of confusion and disorientation in which deceptive questions had a major influence (see Appendix A).

(1) Initiation. Two patterns emerged: a. Flooding. The detention is very violent from the outset, using an explosion of ferocity that begins from the very moment of detention or transfer, and cannot be stopped by the detainee whatever he or she does. When the true

(2) Intermediate sessions: The progression of the interrogations changes over time and depending on the detention center. The most frequently used involves the alternative use of long and exhausting interrogations for up to 12 hours (by teams who take turns), combined with periods of isolation that foster anxiety, rumination, fear, disorientation and confusion. In a standard session: • The space is small, the person is partially or fully naked, usually deprived of vision and there are several interrogators acting in a coordinated manner.

• Physical torture (anoxia, repeated and rhythmic beatings, deprivation of food and sleep) are combined with use of deceptive information, humiliation and

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Dynamics of interrogation A prototypical process of detention and ill-treatment in incommunicado detention appeared as follows:

interrogation starts, the detainee is terrorized. The interrogators often make serious charges involving links to terrorist activities that involve long sentences right from the beginning.

The charges are presented as fact and only the ‘correct’ answers are allowed.

False evidence is shown and confirmation, further details and a signature on a written confession is expected. b. In-crescendo. No formal charges are brought at any moment and the detainee does not know the cause of detention. The person is then submitted to open exploratory questions in a soft tone. The aggressiveness of the interrogation increases if the detainee does not progress in the desired direction by the use of verbal assaults coupled with mild but constant physical violence. This usually culminates in humiliations and threats at the end of the second day or beginning of the third.

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Table 2. Classification by nodes (torture methods) and families (categories of torture methods according to its purpose): Examples in the words of the detainees Basic Human Needs (Very Frequent 80%) 1. Physical space: cell and detention conditions. "I remember the cell, very dark, with a concrete cot with a blanket that I think had [remains of] blood on it, it was very dirty and it was stiff."

2. Sleeping and waking rhythm disruptions. "I could hardly sleep, most of the time (the first three days) they left the lights on and went and opened the hatch, or knocked on the door to wake me up."

3. Food and liquid intake. "I had very cracked lips because my lips were very dry and after going to the forensic doctor, the Civil Guard official gave me water. Till then they had not allowed me to drink and it looked as if they withheld it in return for information: «If you want to drink water you have to tell us this».”

4. Physical exhaustion - forced positions - strenuous exercise. “I had to do push-ups up and down, I had to stand upright and then squat, I could not stand up, I fell against the wall, I was dizzy, stunned."

Relationship with the environment and sense of orientation [Very Frequent 60%] 1. Visual manipulation – lighting conditions. "Then the night came. The cell (...) had a light that illuminated it all (...) and a fan on the side, two on the roof. The light stayed on continuously for 4 days, as well as the fan, so there was a constant noise."

2. Auditory manipulation - Noises. ”The music was very loud, so that we could not hear the cries, I suppose,, because in the moments they turned off the music I heard the other detainees screaming."

3. Temperature. "It was spring and the day was hot, so I was dressed in a tank top, but at night it was cold. They wet my arms and opened the window to let in the cold, I was shivering. " 4. Time Manipulation. "You don’t know what time it is or anything. I've never used a watch and after what happened I now always wear a watch, I just cannot not know what time it is now. Before, I did not care «I can always ask » (...) The timing issue is amazing, finally you got disoriented and you don’t know if things take an hour or a day. I had only spent a day and a half and I thought «I must be on the fourth day or so. »".

Need for safety [Very Frequent 80%] 1. Fear of the unknown- Uncertainty. "The worst was fear. (...) It's so surreal that you do not know what to think... what is this? Nobody will believe this. My friends are from the nationalist left and know that torture exists, but you cannot imagine that situation, every minute, for five days. It's surreal."

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2. Waiting for pain. "Imagine how I must have been as I told them, crying, shock me now, shock me now. (...) That situation was ... I don’t know, you can stand physical harm, but before suffering such harm it is the fear, the anticipation of whether he is going to hit me or not? (...) They also realized this, they saw how I was shaking, crying, screaming, I don’t know."

Psychological perception of death – asphyxiation [Frequent 40%] 1. Dry asphyxia (use of bags, hoods and other methods of suffocation). "The use of la bolsa is continuous. First, they pull the bag on you without tightening and they go on questioning you while hitting you, and then they begin to tighten and squeeze until you get to the asphyxiation point. One, two, ten, twenty, thirty, forty times, a hundred times. (...) Then you enter into a fucking stifling situation (…).

And it is like this all the time. All of this while they are screaming at you, asking questions."

2. Mock executions. "During the interrogation, a Civil Guard who was standing behind me, started making a noise with a gun, he told me that he was going to shoot me in the head, that he would kill me. He asked whether I thought he had bullets or not... He put the gun up to my head and fired twice. Both times there was a click. This interrogation was very hard."

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Physical pain 1. L ow intensity rhythmical and constant blows. [Very Frequent 60%] During the interrogation, they spoke to me, they hit me, like a drop of water that keeps on falling, they pounded on you, and pounded on you, until you got a splitting headache. The blows were not really strong, nor were they insignificant, but their cadence BOOM, BOOM, BOOM, all the time.”

2. U se of electric shocks and mock use of electric shocks". [Rare 20%] “And they began to threaten me also with the electrodes. «We're going to put the electrodes on you.»

Then, they approached something sizzling to my ear, like something producing sparks. (…). In the end they attached them to me. On the ears, on the penis and testicles. They were not very strong, but I was terrorised, the fear that caused in me was very big.”

Psychological integrity – self-concept 1.

Attacks on sexual and gender identity: molestation, abuse and rape. [Frequent 40%] "They took me to a place and said «Slut, get undressed, take off all your clothes, you bitch! » At first I said that I didn’t want to, then they started to force me to, and in the end I took them off. At first I didn’t take off my pants but they ordered me to take it all off. And I took them off. I heard laughter. «Ok, it’s done, we've already seen you, we have seen what we had to see. Now get dressed! »” “He passed what I think it was a stick, a rounded thing, between my legs. «I'm getting you hot! » He said, «Here, this bitch is going to come, we're going to make her come. » I thought, «My God how can he say that! » Until he reached the vagina and pushed...

2. Attacks on the self. Attacks on political, social and personal identity. [Very Frequent 60%] Dignity and respect: humiliation, shame and sense of personal value: "Just to be held incommunicado is an outrage, going five days knowing nothing of the outside world is an atrocity.You feel like crap, vulnerable; you're the last shit there. You are between fear... above all fear and helplessness, like an ant among people. You feel that it will never end, that you've lost.”

"Although 10 years have passed since these facts, [I] remember the insults, “Idiot, stupid, slut, bitch, useless twat, martyr, arrogant whore... “. (…). [I] did not react, and did not respond.”

Questioning social identity and militancy: “If I had to describe the hard part, of abuse, rather than the blows that hurt, it is the damage they do to you as a person. They get you to feel like a bug. That you are a normal person and suddenly your feelings are not the same. (...) The blows hurt and leave you marks (…) but the harassment of "I'll kill you, I'll kill you", "I'll rape you" they get you to believe it and say «Well, this is the end, this is as far I've come and I will not stand it any longer. »” Need for affiliation and sense of belonging [Very Frequent 80%] 1. Loneliness – isolation. “But the scariest thing was to go back to the cell, because I had no distraction there. I used to think about things but that... that was hard, I could not rest, all the time thinking about the threats they had made basically against my family. (...) When I went to the cell... going over all that they had told me and I could not get it out of my head, I could not.”

3. Family environment: emotional manipulation and guilt. “At one point they showed a picture of my sister. When I saw that picture I got emotional and began to cry. Then I remember one of them saying: «Now his legs are shaking and he is half crying. » And then they all came and pulled the bag on me.”

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2. Threats to family and environment. " «Poor mother » and in the end it was true, the fear of what might happen to her was tremendous, and «what your relatives are going through because of you», «whatever happens to them will be your fault» And that was all for me, the feeling of guilt; it really is true that my relatives were going through bad times.”

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Table 3: Coercive interrogation techniques: Examples in the words of the detainees Confusion and daze during interrogation. “So, there were times when you said: "I will declare whatever you want and sign whatever you like" and at other times you know that you are in the right and you say: "These guys are going to fuck my life and put me in prison for life by declaring something I don’t know nothing about." It was all the time like the angel and devil speaking in my head. There, in that situation, you're not completely aware of things; it is a matter of living the moment, the present, which is coming, and you just want to get out. There were moments when you think: "but is this real or am I dreaming?" It was really surrealistic.”

Breaking silence and not allowing negative answers. "I was blocked: I didn’t want to talk; (...) besides, this is how they begin: with silly questions, without relevance. You cannot say you do not know the answer. They start with small things and go on playing with that. (...) And then they change their strategy and involve you by asking simple questions you do know the answer to in an ordinary or even pleasant way , to see if you say anything else. (…). But, come on, I thought that I didn’t know what kind of information they wanted from me, which I did not have.”

Contemplation time. "Everything was perfectly organized, they took you out from the cell quickly, the interrogations were long and when they saw that you were tired or that they had said something that had worried you, they got you into the cell and left you there to worry about it, not allowing you to sleep, with music, and very strong lighting.”

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Omnipotence and omniscience. "The second interrogation was the one which did the most damage to me; they started telling me my life since I was twelve until the day I was arrested. What they told me was a lot. They knew everything (...) I was left with the feeling that they knew everything that they had seen or had found out before, but they knew it all. And that's when I went downhill. (...) I felt vulnerable, surprised, they knew everything about me.” "«You'll have the rights that we want you to have » they said. That was it, you were in his hands, that was, what they wanted, exactly what they wanted. At the end I signed, I signed what they wanted.”

Deception. “There were calls from another group of policemen as if they were talking to those in the reserve. One of them yelled and everyone fell silent. Everyone started to comment on «How crazy, that’s too much! » They sat me in a chair and one of them told me that my mother had died.”

"I don’t know how they made me believe that my sister was a detainee in another room. It seemed true because even the voices sounded like hers. And of people close to me... of people very close to me, it was so believable... because you thought that they were being tortured in the cell in front. People of the family who were detained in another room and they made you believe that this was true.”

"At the beginning, or so I was told, I was going to be in prison for a long time; I was going to have a sentence of many years... And suddenly, I was out on bail.”

“I remember he started to carry out tests and in all confidence, I told him that I had been beaten and I asked him to look here [pointing to his neck] because I had taken a lot of beating. Suddenly he said: «Boy, you have complicated everything. » «What do you mean? You are not the forensic doctor?… » and he said no, he was a Civil Guard.”

Sudden change in interrogation style or interrogator. “It was a tone of voice... like reassuring and then suddenly Bang! She hits you! (...) So, it seems you're fine, and then suddenly you are beaten. I don’t know; she would come softly, she would speak softly and then suddenly hit me.”

Emotional Manipulation – empathy with alleged victims and guilt. “In a moralistic tone, they told me about their families, about my family. Other times they wanted to talk about politics or about themselves, about how we called them, about what we do, about the Basque police... When they wanted to talk about these issues, they employed a more relaxed voice, did not scream and even laughed at what I said.

After this interrogation I was defeated. I could not stop crying, I even yelled ...”

"Psychologically they also crush you. Yes, with the family, also with my mother, they made me feel guilty... my mother had committed suicide: they made me feel guilty about that.

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Forced betrayal and prisoner’s dilemma. “They told me that they needed names, because they do not believe that I really didn’t know, and come on ... And then they put the bag over your head until you suffocate, and you give them a name. And then again and again... And you end up telling them about so and so’s friend whose name I knew, and I was aware I was placing him in a tight spot, because I don’t even know whether he is a militant or not. Just to tell them something I'm giving them names of people I don’t know... And that makes you feel guilty.”

"They showed me some pictures (…). They were my best friends, my brothers, and they already knew who they were. (...) they were particularly interested in the incrimination of two of them, and later the two were arrested. One was arrested on the same day as I was, and obviously, the day they arrested the second one my world fell to pieces.”

"It was not to self-incriminate you but to incriminate. But then one came and told you that your colleague had already compromised you, that he had already signed it was you... and this was continuous.”

Absurd orders – submission. “They began to say that I had to do a handwriting test, I didn’t know if it was part of the statement, so we did the calligraphic test. I was scared while I did it because I was writing a text which I didn’t know if it was absurd or if it was going to be used against me...

Table 4: Deception techniques: Types and frequency.

Types

Frequency

Providing false or misleading information to the detainee on a hypothetical charge or conviction

• False accusations for which there is no evidence.

• Suggesting false evidence.

• Revealing false witnesses.

• Alleged indictments made by others.

• Threats with convictions on charges involving twenty or more years in prison.

Very frequent (around 60%)

Maximization

• To exaggerate the importance of the matter under investigation or its consequences, making false extremely serious accusations to instigate self-incrimination of a comparatively lesser crime.

Frequent (around 40%)

Providing false information about the situation in which the detainee’s family is in

• Existence of first-degree relatives detained and / or interrogated.

• Existence of family members (especially couples) tortured in nearby cells (shouts, etc.).

• Family suicides.

• Known or close people detained and interrogated.

Frequent (around 40%)

Making false promises

• Impact of detention on family.

• Promise to call relatives.

• Promise of freedom without charges or with minor charges.

Frequent (around 20%)

Simulations / Staging

• Recordings or screams of other alleged detainees.

• Noises/Sounds of alleged torture to detainees in adjoining rooms.

• Police posing as false allies.

• Police posing as torture victims.

Rare (around 10%)

• Of facts • Of responsibility for the crime • Of consequences

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Deception techniques

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harassment of a sexual nature, emotional manipulation and guilt related to relatives and friends. There is a tailored selection, refinement and progression in the methods used, depending on the perception of the person leading the team of interrogators based on what has the most profound impact on the psychological integrity of the detainee.

(3) Confessions, incrimination and selfincrimination: The interrogations continue until interrogators believe it is possible to make a written statement which must be memorized and repeated word by word before a judge. This is reported to happen between the third and fifth day. If the results are not suitable, the incommunicado detention can be prolonged up to thirteen days.

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(4) C losing post-statement: Several detainees reported a final interview after being presented to the judge, using a friendly tone, indicating that everything is now over and that there was no choice and providing comfort, contact or collaboration.

Four out of every five detainees were later transferred to prison, which was reported by most of them as a liberation. This helps to understand the harsh conditions that detainees must endure during incommunicado detention.

Discussion

This study documented allegations of ill-treatment or torture in 45 persons who have been held in short-term incommunicado detention in the period 1980-2012 in Spain. A comprehensive list of techniques according to the IP categories was obtained and ordered by frequency. The results are

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consistent with data published in previous studies and reports of international bodies showing that detainees are submitted to a large number of physical and psychological methods simultaneously or successively, and that there is a pre-eminence of psychological torture in breaking the detainee.6-12, 19-25 Most police handbooks on interrogation around the world use adaptations of the Reid Manual, written in the USA in the 1960â&#x20AC;&#x2122;s and rewritten and reedited every ten years since then. Interrogation following the Reid technique uses confusion and daze; continuous questioning; not allowing negative answers or breaking the silence; alternating long hours of interrogation with time when the person is left completely alone; calculated use of deceptive techniques; use of omnipotence and omniscience from the interrogator; sudden changes in interrogational style, either by the same interrogator or by two; emotional management of the detainee, playing with feelings of empathy, guilt or shame; use of personal information; forced betrayal, and having to follow absurd and repetitive orders.13 The interrogator asks loaded questions, uses false choices, or shows unproven or manipulated data in a graded process that erodes and manipulates the narrative of the detainee until information or a confession is obtained. Its use has been associated with a high number of false self-incriminations.15-16 Coercive interrogation techniques are illegal and are considered grounds for a conviction to be overturned in the UK or in Germany,26 for example, but are still legal and considered valid investigative practice in countries like the United States, Russia and Spain.27 There are clearly strong commonalities between the methods described here and those described in CIA-led programs practiced by the US government28 and other examples of contemporary torture,29 suggesting shared

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process. The long term effects on the mind can be devastating, as reflected in Part IV. Despite the fact that torture does not have to involve physical pain, psychological torture is often poorly explored and not given the attention it deserves in legal claims and by politicians.

Qualitative approaches, such as the one here, can improve the understanding of the mechanisms of contemporary interrogative techniques and their psychological impact on detainees. Whilst the IP does not purport to provide an exhaustive list of torture methods, we believe that some reformulation is necessary; the increasing variety and complexity of psychological techniques need to be more accurately reflected, and we would therefore commend the use of the concept of Torturing Environments with respect to future research in the area.

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learning and models between western governments.

The present study is limited by the small sample size. It nevertheless suggests that there have not been significant changes in relation to the main methods of torture over time, except for electric shocks which are no longer used (Figure 1). In Tables 2 and 4, the approximations of frequency for each node and family were provided. Exact figures were specifically not provided (as we do for IP categories in Table 1) as this would be misleading; working with qualitative software includes deciding between categories which are not always clear-cut. The frequencies in Tables 2 and 4 are likely to be underestimated because they come from counting quotations derived from Atlas-ti (inferential method). This method allows latent data to emerge and highly increases the reliability of the estimates, but it only offers data on the spontaneous recall of interrogation techniques and thus provides conservative figures.

A Torturing Environment is a milieu that creates the conditions for torture. It is made up of a group of contextual elements, conditions and practices that obliterate the will and control of the victim, compromising the self.5 The creation of a Torturing Environment requires the interaction of several elements: (a) sensorial and temporal disorientation and confusion of the selfreflecting mind; (b) fear and terror that starts from the outset of detention and remains present throughout; (c) humiliations and attacks on identity that contribute to eroding any sense of control; and, (d) tension and beatings that produce physical and emotional exhaustion. The capacity of the victim for proper understanding, retrieval of memories, judgement and reasoning is progressively undermined. The techniques of emotional manipulation and cognitive distortion used during the interrogation complete the

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15. Kassin SM, Drizin SA, Grisso T, Gudjonsson GH, Leo RA, Redlich AD. Police-induced confessions. Law Hum Behav. 2010;34:3–38.

16. Pearse J, Gudjonsson GH. The Identification and Measurement of “Oppressive” Police Interviewing Tactics in Britain. In: Gudjonsson GH, editor. The Psychology of Interrogations and Confessions. A handbook. Wiley and Sons; 2003.

17. Argituz, AEN, Ekimen Elkartea, GAC, JaikiHadi, OME, OSALDE, Departamento de Psicología Social (UPV/EHU). Incommunicado detention and torture. Assessments using the Istanbul protocol. Ekimen Ed. and Irredentos Libros. Bilbao. 2014.

18. Kassin SM, Perillo JT, Appleby SC, Kukucka J. Confessions. In APA Handbook of Forensic Psychology. Vol 2. Criminal Investigation, Adjudication and Sentencing Outcomes. Washington DC; 2015. pp. 245–270.

19. Petersen HD, Jacobsen, P. Psychical and physical symptoms after torture. A prospective controlled study. Forensic Sci Int. 1985;29:179-89.

20. Biurrun JM. Las relaciones de tortura. Iralka editorial. San Sebastian; 1994.

21. Meana, JJ, Morentin B, Callado LF, Idoyaga MI. Prevalence of sexual torture in political dissidents. The Lancet 1995; 345:1307.

22. Arzuaga J. Oso Latza izan da. Tortura Euskal Herrian. [It has been so tough. Torture in the Basque Country] Euskal Memoria, Donostia-San Sebastian; 2012.

23. Torturaren Aurkako Taldea. Annual Reports (2000-2014). Available from: www.stoptortura. org 24. Basque Government Presidency. Torture: a scientific approach (2000-2008). Vitoria-Gasteiz; 2009.

25. Morentin B, Callado LF, Idoyaga MI. A followup study of allegations of ill-treatment/torture in incommunicado detainees in Spain: failure of international preventive mechanisms. Torture 2008;18:87-98.

26. Zander M. The Police and Criminal Evidence Act 1984. Sweet & Maxwell; 2013.

27. Hess JE. Interviewing interrogation for law enforcement. Lexisnexis; 2010.

28. Physicians for Human Rights. Break them down.

Systematic use of psychological torture by US forces. Washington: Physicians for Human Rights; 2005.

29. Busch J, Hansen SH, Hougen HP. Geographical distribution of torture: An epidemiological study of torture reported by asylum applicants examined at the Department of Forensic Medicine, University of Copenhagen. Torture 2015; 2: 12-21.

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Appendix A Statements: Allegations of torture of particular pertinence to the situation in the Basque Country, Spain Case 1.

“They tell you: «We have five days to make you talk. One or two, may be, but three is always enough. You will see… ». And the worst thing is that it was true…five, even three days is enough to break a detainee. They get you mad”.

Case 2.

“On the way to Madrid she [a policewoman] told me: «You'll see when you get there.

There are three phases. You all do the same. At first, you do not want to talk. In the second you're going to tell some lies, you're going to say things that are a lie. And at the end there is the phase in which you will tell the truth. You are going to get there»…”.

Case 3.

"There came a time when I did not think any more, and I was not aware of anything; moments of heavy burdens, madness, crazy ideas.”

Case 4.

“There were moments that I didn’t want to live through… I wanted to get out of there; they were the longest five days of my life. It seemed that they were never ending. There were times when you felt you were going to go crazy, at some point you were so tired that you had no reflexes, they spoke to me and I looked like a zombie, I could not coordinate.”

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Incommunicado detention and torture in Spain, Part IV: Psychological and psychiatric consequences of ill-treatment and torture: trauma and human worldviewsi Miguel Angel Navarro-Lashayas, PhD*, Pau Pérez-Sales, MD, PhD**, Gabriela LopezNeyra,*** Maitane Arnoso Martínez, PhD****, Benito Morentin, MD, PhD*****

Abstract

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Background: Most literature on psychological consequences of torture is related to prolonged detention. Psychological consequences of intensive physical and psychological torture in brief detention have not been investigated. The aim of this study is to analyse the psychological impact of torture in short-term incommunicado detention.

Method: A sample of 45 Basque people who had allegedly been subjected to ill-treatment or torture whilst held in incommunicado detention between two and 11 days in Spain in the period 1980-2012 was analysed. The period between detention and evaluation ranged between two and 12 years. Each case was evaluated by several psychiatrists and psychologists. Clinical interviews which

*) Human Rights Section, Spanish Association of Neuropsychiatry (AEN). **) SiR[a] Centre, GAC Community Action Group and Hospital La Paz, Spain. ***) GAC - Community Action Group, Resource Centre on Mental Health and Human Rights, Spain. ****) University of the Basque Country. *****) ARGITUZ - Human Rights Association and Section of Forensic Pathology, Basque Institute of Legal Medicine, Spain.

Correspondence to: navarro.miwel@gmail.com i

Editor: Lilla Hárdi.

followed the Istanbul Protocol were assessed, as were psychometric tests (Post-traumatic Checklist-Civilian version (PCL-C), Beck Depression Inventory (BDI) and Vital Impact Assessment Questionnaire (VIVO)) and external documentary evidence. A cumulative prevalence of psychiatric diagnosis (ICD-10) from the period of detention was established.

Findings. Post-traumatic stress disorder (PTSD) was the most frequent diagnosis (53%). Enduring personality change after a catastrophic experience was detected in 11% of subjects. Other diagnoses were depressive disorders (16%) and anxiety disorders (9%).

Psychometric evaluation at the time of the study showed symptoms of PTSD in 52% of the subjects (with a tendency for these symptoms to diminish over time) and depressive symptoms in 56%. The VIVO questionnaire discerned two subgroups of survivors: “affected” survivors (36%); and “resilient” survivors (64%).

Interpretation. The data demonstrated two important issues: the undervalued damaging effect of intensive torture in short-term detention and the long lasting psychological damage of the same over time.

Keywords: Psychological torture, incommunicado detention, posttraumatic stress disorder.

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Introduction

Methods

We examined a stratified purposive sample of Basque people (N=45) who reported ill-treatment or torture while held in incommunicado detention for an average of five days between

1980 and 2012 in Spain. The participants and the methods of collecting data were the same as set out in Part I and II. Instruments and procedure

The protocol included a complex system of forensic psychological examinations and psychometric measurements. Each case was assessed by two clinical psychologists or psychiatrists who conducted extensive clinical interviews (following the Istanbul Protocol). The report was then contrasted with psychological tests and external sources of data (i.e. psychiatric, psychological or medical reports) by independent researchers who had not seen the initial findings.

Psychometric tests

The following self-ratings tests were included: Post-traumatic Checklist â&#x20AC;&#x201C; Civilian Version (PCL-C)10 The PCL-C is a 19-item scale that follows the diagnostic criteria for PTSD in DSM-IVR. Each item corresponds to a symptom, which is evaluated in frequency and intensity on a scale from 1 to 4. There are four cut-off points recommended according to the original validation studies:11 Less than 44 points = Absence of PTSD; 45-50= Symptoms of PTSD (or Partial Syndrome); 51-55= Likely Presence of PTSD; More than 55= Diagnosis of full PTSD. Beck Depression Inventory (BDI1)12 The BDI is the most widely used scale for quantifying depressive symptoms. It evaluates primarily clinical symptoms of melancholy and intrusive thoughts present in depression. The test has 21 items on a scale from 0 to 3. The recommended cut-off points are: 0-9 = Absence of depression; 10-16 = Mild depression; 17-29 = Moderate depression; 30-63 = Severe depression.13

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Torture may result in serious long-term psychological sequelae, including permanent changes in identity and worldviews, and clinical sequelae such as post-traumatic stress disorder (PTSD) and depression.1-9 This information is mostly based on studies with survivors who have suffered torture during periods of prolonged detention. The psychological impacts of torture in shortterm detention have received less attention.

At first glance, it might be expected that the consequences of torture in time-limited detention should be milder than in longer periods of detention, but this is not the impression given to organizations working with survivors. Contemporary torture is becoming more psychological in western societies. Clinical research on torture shows that the perceived severity of psychological torture is a better predictor of PTSD than the perceived severity of physical torture.9 Spanish anti-terrorist legislation allows incommunicado detention for a period of five days with the possibility of extending detention to 13 days. As we concluded in Part II, contemporary short-term ill-treatment and torture mostly relies on the use of intensive psychological techniques in combination with physical ones. These methods, applied during a relatively short detention period, are aimed at breaking the resistance of the victim to obtain information or self-incrimination. To our knowledge, there are no studies on the psychological impact of torture in short-term detention and in western settings where torture is mainly psychological.

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Vital Impact Assessment Questionnaire (VIVO)14 This questionnaire assesses the impact of traumatic experiences on the perception of the self, others and the world as well as the impact on the subjectâ&#x20AC;&#x2122;s emotions and beliefs.

It has been validated through a multi-sample collaborative international study conducted in 13 countries, including survivors of torture from Spain, Argentina and Uruguay.

All of the participants filled in the VIVO Questionnaire. PCL-C and BDI were used only when the psychiatrists or psychologists considered it necessary to refine the diagnosis.

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Statistical analysis

Data was processed with SPSS 17 and ATLAS 6.0 statistical software for quantitative and qualitative variables respectively. We used descriptive statistics (means and standard deviations, or numbers and percentages) for all measures. Additionally, the VIVO questionnaire was used to identify resilient versus less resilient survivors according to the severity of symptoms through a SPSS k=2 Cluster Analysis Procedure. The two groups were then compared using a Discriminant Analysis, based on membership of the resilient or less resilient group as the dependent variable and the subscales of VIVO as independent variables. The values of VIVO, PCL-C and BDI were compared over time using chi-square contingency tables for frequencies and Kruskal-Wallis tests for means. Additionally, a qualitative analysis was conducted using a thesaurus of terms derived from the Istanbul Protocol (see Part III).

Results

The sociodemographic and socio-political characteristics of the sample, the assessment of credibility, and the analysis of torture methods were set out in Part II and III.

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Psychiatric diagnoses

Table 1 shows the cumulative prevalence of psychiatric diagnosis (ICD-10) from the moment of detention, according to clinical assessments. The data does not include pre-existing conditions unless there was a clear deterioration in those conditions following arrest.

PTSD (53%) was by far the most frequent diagnosis. In total, 76% of survivors had some kind of stress or adjustment disorder. This was followed by those with depressive disorders (16%); personality disorders (13%); and anxiety disorders (9%) (Table 1).

The most severe diagnosis associated with traumatic experiences in ICD-10 is 'Enduring personality change after a catastrophic experience' (EPCACE, F62.0).

This suggests permanent damage which was not present before the pathogenic experience, with a significant transformation of personality, often associated with rigid and maladaptive behaviour. The diagnosis is essentially based on the presence of a permanent attitude of distrust or hostility towards the world; social isolation; feelings of emptiness or hopelessness; the constant feeling of 'being on edge' as if constantly threatened; or a sense of self-estrangement. In our sample, 11% of the examinees fall into this extreme form of damage.

Symptoms of post-traumatic stress disorder (PCL-C)

29 of the 45 subjects completed the PCL-C. At the time of the forensic examination, approximately a quarter had full or possible PTSD and another quarter had some symptoms of PTSD (Table 2).

Table 2 presents the data organized by the time elapsed since detention and the forensic examination. The data suggests, although unconfirmed by statistical results,

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Table 1: ICD-10 psychiatric diagnosis (N=45)i N (%) Depressive disorder F32.0 Depressive disorder - Mild F32.1 Depressive disorder - Moderate F33.1 Depressive disorder â&#x20AC;&#x201C; Recurrent F33.3 Depressive disorder - Severe (with psychotic symptoms)

7 (16%) 3 2 1 1

Phobic disorders F40.2 Specific (isolated) phobias

1 (2%) 1

Anxiety disorders F41.1 Generalized anxiety disorder F41.2 Mixed anxiety and depressive disorder F41.9 Anxiety disorder, unspecified

4 (9%) 2 1 1

Obsessive-compulsive disorder F42.0 Predominantly obsessional thoughts or ruminations

2 (4%) 2

Reaction to severe stress, and adjustment disorders F43.0 Acute stress reaction F43.1 Post-traumatic stress disorder F43.2 Adjustment disorders F43.9 Reaction to severe stress, unspecified

34*(76%) 3 24 6 2

Somatoform disorders F45.8 Other somatoform disorders F45.9 Somatoform disorder, unspecified

2 (4%) 1 1

Disorders of adult personality and behaviour F60.7 Dependent personality disorder F62.0 Enduring personality change after a catastrophic experience

6 (13%) 1 5

No psychiatric pathology Z65.4 Victim of torture who does not meet criteria for any ICD-10 disorder.

6 (13%) 6

i

Please note: Some people have more than one diagnosis, so the sum of percentages exceeds 100%

(30%)). Probably due to the time elapsed since detention, re-experimentation symptoms were less frequent, which include painful memories, thoughts or images (36%) and having sleep problems/nightmares (34%).

Depression symptoms: BDI

The BDI was completed by 32 subjects (Table 2). At the time of the assessment, depression was rated as mild in a quarter, and as moderate or severe in one third of survivors. The mean BDI values did not change significantly with time (Mean < 2 yrs: 12; 3-8 yrs: 12; > 8 yrs: 13.9; K-W : 0.745;

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that there is an improvement of PTSD symptoms with time. For most people there is a progressive, albeit slow control of traumatic symptoms. (Mean < 2 yrs: 45; 3-8 yrs: 45; > 8 yrs : 35; K-W: 0.182, n.s.).

In Table 3 the frequency of each PTSD symptom is shown with selected quotations from the survivors. The most frequent symptoms were related to the avoidant cluster (feeling bad about remembering the experience (54%), truncated future (33%) and physical reactions recalling the experience (30%) for example); and the hyperreactivity cluster (hyper-arousal or remaining on guard (42%) and restless or startled

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Table 2: Post-traumatic stress disorder (PCL-C), Beck Depression Inventory (BDI) and Vital Impact Assessment Questionnaire (VIVO) scores across time since detention

PCL-C Absence of PTSD Symptoms of PTSD Possible PTSD PTSD BDI

Less than 2 years

Between 3 and 7 years

More than 8 years

TOTAL

N=6

N=8

N=15

N=29

n (%)

n (%)

n (%)

n (%)

1 (17) 3 (50) 2 (33) 0

4 (50) 1 (12) 1 (12) 2 (25)

10 (67) 3 (20) 1 (7) 1 (7)

15 (52) 7 (24) 4 (14) 3 (10)

N=7

N=9

N=16

N=32

n (%)

n (%)

n (%)

n (%)

Absence of depression Mild depression Moderate depression Severe depression

3 (43) 2 (29) 2 (29) 0

5 (56) 3 (33) 0 1 (11)

6 (37) 3 (19) 6 (37) 1 (6)

14 (44) 8 (25) 8 (25) 2 (6)

VIVO

N=13

N=9

N=23

N=45

n (%)

n (%)

n (%)

n (%)

5 (38) 8 (61)

2 (22) 7 (78)

9 (31) 14 (61)

16 (36) 29 (64)

Major affectation Resilient

n.s). The most frequent depressive symptoms were 'changes in sleep patterns' and 'difficulty in concentration' (Table 4).

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Impact on identity and worldview: VIVO questionnaire

The results of the VIVO questionnaire showed that mean values of the VIVO subscales did not differ from normative values in the general population, and that there were dissimilar results among individual survivors. In order to capture this variance and individualize subgroups of survivors, a cluster analysis was performed. Optimal classification was conducted with a twogroup solution ('affected' survivors (n = 16) and 'resilient' survivors (n = 29). The resulting function had a canonical correlation of 0.87, with auto-values of 2.54 and a

Wilks' Lambda coefficient of 2.28 (4 d.f., p <0.000) indicating a robust result.

The subscales of the VIVO that contributed most to explain the differences between groups through a Discriminant Analysis were explored, again using group (Affected vs Resilient) as the independent variable and the dimensions of the VIVO as dependent variables (Table 5). The group of survivors with damaged worldviews had significantly higher scores in 'identity - perception as a victim', 'negative worldview' and 'negative perception of future'. They also perceived less 'support from society' and feelings that they were 'blamed by others' for what happened to them. They tended to report that they felt â&#x20AC;&#x2DC;frozenâ&#x20AC;&#x2122; when something serious happened to them, a greater tendency to ruminate about what happened, to have non-specific fears of

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Table 3. Symptoms of post-traumatic stress disorder (PCL-C) at the time of the study. Quantitative and qualitative data (N = 29) PTSD symptoms

%

Qualitative data

Re-experiencing Painful memories, thoughts or images Repeated nightmares Behaviour or feeling as if the event was happening all over again

36 9 6

"Things happen to me that don’t make any sense, which are like weird, aren’t they? For example, like when I was arrested, I was tied with a bridletype thing. I could not see very well. At the beginning, I did not realize it was because of that, a piece of plastic that doesn’t mean anything, but you realize that it is because of that.”

"Lots of nightmares, even now in some dreams the Guardia Civil come in. More in the first few months.”

Avoidance Feeling bad about remembering the experience Physical reactions recalling the experience Avoid talking or remembering the experience Avoid activities that remind the person of the experience

54 30 27 18

"What is here (referring to his head) forms a block and wants to forget and so there are things I do not remember, right? Because there has been this attempt to want to forget.”

21

"You can be with a hundred people but are alone, which is what happens to me. I can be with a lot of people but I am in my own world, I'm out of it.”

“I do remember that with the passage of time I had things that were not in order, the first time I put some order to them was when I left prison and had to go to a psychologist... As I recounted some disjointed facts, somehow I skipped one day, or one fact, in those five days.”

Emotional anaesthesia Troubles remembering some parts of the experience Loss of interest in things that used to interest him/her Feeling distant from people Emotionally blocked (“numb”) Truncated future

Hyper-arousal Sleeping problems Irritable, angry outbursts Difficulty in concentrating Hyper-arousal or remaining on guard Restless or startled

29 3 33

34 12 3 42 30

“I always look all around me, even when I go into a bar for a coffee, I will never turn my back to the door, I need to control my surroundings.”

"I can hardly sleep, there is a noise and I wake up.

Before… I could fall asleep even if the building opposite my house collapsed; I didn’t care.”

41 29

"So far I've worked in hostelry, in the family bar (...) with clients who you know more or less (...) now I have to relate to all kinds of people (...) and I could hardly think (...) I get very dizzy, I have to do it but don’t know how to.”

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Functional criteria Perceived stress level above 5 (scale 1-10) Level of daily routines affectation above 5 (scale 1-10)

24

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Table 4: Beck Depression Inventory (BDI): main symptoms at the time of the study (N=32).

Item

Severity scale (%) Absent

Mild

Moderate

Severe

Loss of pleasure

47

35

15

3

Self-criticism

35

59

6

0

Agitation

35

56

3

6

Loss of interest

50

41

9

0

Changes in sleeping patterns

29

41

15

15

Irritability

53

35

9

3

Difficulty in concentration

29

47

18

6

Loss of interest in sex

62

18

18

3

Table 5: Vital Impact Assessment Questionnaire (VIVO). Cluster centres. Comparison of mean values between 'affected' and 'resilient' survivors Major affectation (n=16)

Resilient (n=29)

F

SIG

Negative worldview

63

51

28,591

,000

Life lacks meaning

52

47

5,017

,030

Ideological or religious convictions do not help

52

49

2,185

,147

Suicide is an acceptable option

52

49

1,901

,175

Fate is important in life

48

45

1,100

,300

Not tolerating ambiguity and uncertainty

50

50

,014

,907

Search for the logic of facts

45

51

5,455

,024

Sharing the experience is useless

49

45

1,889

,177

Suffering is useless

52

47

4,244

,046

It is not possible to believe in the goodness of people

52

51

,635

,430

Loss of confidence in people

53

46

5,404

,025

Unable to communicate the horror

53

49

2,796

,102

Expression of suffering in dreams

53

48

3,392

,073

Tendency to think about what happened - rumination

55

51

4,337

,043

Frozen sensation during the events

63

51

29,882

,000

Unable to forget

57

55

,634

,430

Worldview

Attitudes towards the world

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Vision of human being

Coping

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Impact of the past Experiences of guilt

55

50

7,394

,009

Loss of self-confidence

53

Unable to learn from the facts.

54

50

1,033

,315

46

13,420

,001

Unable to change their way of being:

47,

Nonspecific fears

57

45

1,203

,279

49

10,517

,002

Negative emotions associated with the events

52

50

,689

,411

Feelings of helplessness

52

50

,737

,395

Rejection of negative feelings

52

46

6,983

,012

Giving social testimony is unimportant

47

48

,273

,604

Communicating what happened is unimportant

39

51

13,907

,001

Lack of empathy - insensitivity to other victims

49

47

,895

,350

Decreased ability to love others

48

46

1,189

,282

Questioning by chance - why me

38

40

,564

,457

Lack of social support

50

42

17,690

,000

Feeling that society blames the victim

55

50

3,698

,061

Negative future - no hope

57

49

17,498

,000

Changes in identity since the facts

56

49

6,266

,016

Changing priorities in life

48

47

,241

,626

Identity â&#x20AC;&#x201C; victimhood determines outlook

57

46

12,086

,001

Emotions

Narrating the experience

Consequences

Identity

Discussion

The results confirm that torture has a significantly destructive power; it involves extreme situations when a person's personal and social identity is confronted. Psychiatric diagnoses associated with or aggravated by torture were or had been present in 87% of the detainees: 53% PTSD; 16% depressive

disorders, 11% enduring personality changes, and 9% anxiety disorders.i High co-morbidity of depression and PTSD is well-documented in traumatized refugees: in the sample, 86% of patients with depressive disorder had also been diagnosed with PTSD. Our findings are consistent with studies showing that the most common symptoms after torture are psychological, and include

i

The categories are not mutually exclusive.

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things they did not have before and to report more frequent feelings of guilt.

Selected examples of the main VIVO categories are also included in Annex 1.

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depression, anxiety, emotional instability, reduced ability to sleep, nightmares, and concentration and memory deterioration.2, 4, 15 A meta-analysis5 of 181 epidemiological studies on tortured populations from 40 countries found that the prevalence of PTSD and depression had large variability: 0% 99% for PTSD and 3% - 85.5% for depression. The average prevalence was 30% for PTSD and for depression. This high variability is largely due to the wide criteria used in the selection of participants and the instruments used for assessment.6 In a second meta-analysis7 of adult survivors of war and torture, the study found a high prevalence of psychological symptoms (anxiety, depression, irritability/aggressiveness, emotional liability, self-isolation/social withdrawal), cognitive symptoms (confusion/ disorientation, memory and concentration impairment, impaired reading ability), and neurovegetative symptoms (lack of energy, insomnia, nightmares, sexual dysfunction),8 but relatively low rates of full PTSD. The present study suggests that people held under incommunicado detention usually recover from the experience of torture, but between 11% (based on ICD-10 diagnosis of Enduring Personality Change) and 36% (according to the cluster analysis of the VIVO questionnaire) have long-lasting damage.

This study is not longitudinal, and thus does not address the subjectâ&#x20AC;&#x2122;s evolution over time. However, considering that torture occurred on average 10 years prior to the assessment, we can conclude that torture has changed the lives of these subjects significantly. Our research does not clarify whether this is due to pre-existing vulnerability, to the experience of torture, or to other factors. The majority of subjects had also experienced other types of trauma before and after their alleged torture, for example (see Part II).

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This included being politically repressed as a Basque dissident as well as persecuted and imprisoned. Further studies are needed to determine the role of each factor in the psychological health of the victim.

At the time of examination, 24% of interviewees were diagnosed with PTSD or possible PTSD using psychometric criteria despite the assessments taking place an average of 10 years after the period of detention. Even without full or possible PTSD, many subjects suffered from partial symptoms, such as feeling bad when recalling the traumatic events, hyperarousal, painful memories, loss of interest in things that they used to enjoy or feelings of truncated future.

Mean PTSD scores decreased with time suggesting that there is a progressive, though slow, improvement of symptoms. On the contrary, mean depressive scores increased with time suggesting a long-standing damage in emotions and affect.

Opponents to the use of PTSD in conjunction with torture victims consider that survivors experience a normal reaction to an abnormal stressor in the context of an abnormal social situation.16 Labelling torture symptoms as a mental disorder can be viewed as medicalizing a socio-political problem and individualizing social suffering.17 The emphasis is then not on symptoms but on the way the survivor reconceptualizes life. For example, how he or she reconsiders priorities in life, provides meaning to a devastating experience, builds a new positive identity and adjusts his or her perceptions of others and of the world. In our sample of 45 survivors, and according to the results of the VIVO questionnaire, about a third of the examinees have serious difficulties in reconceptualizing life.

Our results must be considered with caution. As most studies with torture

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survivors, our sample is small and purposive and the results cannot be extrapolated to other survivors in the Basque Country, especially those who have never spoken of their days under incommunicado detention.

The use of self-report measures also tend to generate higher prevalence rates of PTSD and depression compared to clinical interviews.4, 7 Despite the limitations of this study, the results show two important issues that deserve more detailed investigation: the undervalued damaging effect of intensive torture in short-term detention and the long-lasting psychological damage that can be detected over time.

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12. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh JK. An inventory for measuring depression. Arch Gen Psychiatry. 1961;4:561–71.

13. Beck AT, Steer RA, Carbin MG. Psychometric properties of the Beck Depression Inventory: Twenty-five years of evaluation. Clin Psychol Rev. 1988;8:77–100.

14. Perez Sales P, Eiroa-Orosa FJ, Olivos P, Barbero-Val E, Fernández-Liria A, Vergara M. VIVO Questionnaire. A measure of human worldviews and identity in trauma, crisis and loss. Validation and preliminary findings. Journal of Loss and Trauma; 2012 DOI: 10.1080/15325024.2011.616828.

15. Bașoğlu M, Livanou M, Crnobarić C. Torture vs other cruel, inhuman, and degrading treatment: is the distinction real or apparent? Arch Gen Psychiatry. 2007;64:277–85.

16. Reeler AP. Is torture a post-traumatic stress disorder?. Torture. 1994;4:59–63.

17. Summerfield D. A critique of seven assumptions behind psychological trauma programmes in waraffected areas. Soc Sci Med. 1999;48:1449–62.

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Appendix 1 Content analysis of the VIVO questionnaire. Examples of most salient categories

Worldview

"I feel a little strange in society. (...) I feel people are distant, they don’t understand the context you have suffered (...) maybe I am the strange one... don’t know.”

"The physical aspect, it hurts, there are some days that you cannot walk, but the psychological aspect is one thing that still today I cannot cope with. It’s very hard, very hard.”

Attitudes toward the world

View of humanity

"I think about them, they were psychopaths.

You wonder about who he is, how many people he has done the same thing to, if he has a family and if he goes home quietly, feeling like a hero for doing what he does… I am curious to know who they are and I would like to know their stories.

"I used to be more affectionate now it is hard for me to have physical contact, to show my feelings through physical contact; I used to give hugs and kisses to my friends... Now I cannot, it doesn’t come out of me.”

I see around me that people continue with their lives as if nothing has happened, it brings me a sense of despair. To see that people are like this, that they are so insensitive to certain things that exist.”

Attitudes toward society

"You have to be with a person who has passed through the same thing you've passed through, if not, people just don’t understand you. I can talk and tell you, and explain, but you will never understand what I've been through. That is what happened to us in prison and that is why you have a lot to do with the people there”

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Attitudes toward society

"I have not talked in depth about this, I find it hard... with friends I have spoken about it, with those I trust a lot, but more in the form of facts, like anecdotes, like getting away from myself, as if in third person.”

Coping with facts

"I was afraid of what they could do to me. I was also very nervous, I was blocked, scared and physically hurt and it had started my body aching.”

“They come in and I have not gotten them out of my head."

Social support

"You feel, above all, that society judges you.

The arrest is broadcast on TV and the information they gave didn’t help that happen. In the final analysis, people will always think that you did do something or that you deserve it, and that's hard.”

Future

"Now I take life from day to day, I do not have many goals, now I am content if I'm not getting fired from a job and that’s it. My goal this year is to not lose my job, and that’s how it goes.”

Changes in identity

"There is a before and an after experiencing a traumatic event, something changes inside us, we don’t relate the same, life values change, things that didn’t matter

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before do now, or vice versa, something within changes.”

"Honestly if I feel affected, I’m not denying it, yeah I'm emotionally affected... there has been a change in me and I sincerely believe that I’m paying for what has happened.”

Changes in militancy

"I didn’t know if it was good or bad for me (to develop political activities on torture victims), but the truth is that I had no strength, because I've noticed that I needed to heal, without knowing how and from what, and for a while I was just going to pursue that.”

Posttraumatic growth

“Over time things go on healing, I would rather say that I have quite forgotten them, you give more importance or you look at other things that go on happening to you, then you leave the others back there.”

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Enhancing empathy among humanitarian workers through Project MIRACLE: Development and initial validation of the Helpful Responses to Refugees Questionnairei Miriam Potocky, MSW, PhD*, Kristen L. Guskovict, MS, MSW*,**

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Abstract

Background: Empathy is an important tool needed for service providers working with people who have experienced trauma, such as refugees and torture survivors. However, the high caseloads, rigorous deadlines, and overwhelming circumstances under which humanitarian workers typically operate often make it challenging to employ empathy. The Helpful Responses to Refugees Questionnaire (HRRQ) was developed to measure empathetic responsiveness, a core skill of Motivational Interviewing, among service providers working with refugees, including torture survivors. Methods: The HRRQ was adapted specifically for measuring empathy in refugee contexts, including among asylum-seekers and torture survivors. Face validity and content validity were established by a panel of refugee resettlement experts prior to administration. The instrument was then administered via an online survey to a national sample of refugee service providers

*)School of Social Work, Florida International University, Miami **)KLG Consulting Services LLC, Miami Correspondence to: potockym@fiu.edu i

Editor: Pau PĂŠrez-Sales

(valid N=90). Findings: The HRRQ demonstrated good psychometric properties.

Interpretation: The HRRQ has several potential applications for work with refugees, including torture survivors. It could be used as a supervisory tool to assess service providersâ&#x20AC;&#x2122; skills in this area and provide feedback for improvement, if needed. It could also be used as a screening tool for hiring new staff as part of a comprehensive screening and selection process. Finally, it may be used as a pretest-posttest to evaluate the impact of staff training in motivational interviewing. Limitations of this study and implications for future research are discussed.

Keywords: Refugees, torture survivors, resettlement, motivational interviewing, empathy, Project MIRACLE, HRRQ Introduction

Refugees are defined as people who are forced to live outside their country of origin due to a well-founded fear of persecution based on race, religion, nationality, political opinion, or membership in a particular social group.1 That well-founded fear is often created by traumatic events. The experience of increasing fear, which may include torture, leads to forced migration. These pre-migra-

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tool needed for service providers working people who have experienced trauma.

Empathy is defined as the act of understanding and responding to the emotional state of another.6 The use of empathy enhances providersâ&#x20AC;&#x2122; effectiveness in guiding refugees in building new lives after resettlement.

Although empathy in and of itself is not sufficient to address complex mental health challenges such as PTSD, it is a critical foundation for establishing a working alliance between the service provider and client, an important predictor of outcome.7 Service providers working within the U.S. refugee resettlement program have a very limited timeframe within which to offer services. Once a refugee has arrived in the U.S., or an asylum seeker has been granted asylum, regardless of their torture or trauma history, local refugee resettlement agencies are responsible for providing housing, essential furnishings, food, clothing, community orientation, and referral to other social, medical and employment services.8 This work is to be completed by a resettlement agency within ninety days. Refugee case managers are tasked with ensuring that the basic needs of each of their clients are met within that tight timeframe. In addition, many people working as case managers within refugee resettlement programs are paraprofessionals and former refugees themselves. They are dedicated staff members, but often are not afforded the level of training that their counterparts educated in the helping professions may have. Very few U.S-based resettlement agencies have resources, such as torture treatment programs or refugee mental health programs, which can assist them when they are working with a client whose level of function and problem solving appears to be impaired. The volume of work and lack of resources, along with the pace, leaves little time to remember

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tion traumas, combined with traumas experienced during flight, such as danger and life in refugee camps, and traumas during resettlement, such as acculturative stress, combine to form what is referred to as the triple trauma paradigm.2 The refugee population includes people who have experienced torture. These layers of traumatic events can have significant impacts on a personâ&#x20AC;&#x2122;s general function, including problem-solving skills.

Throughout the world there are currently over 21 million refugees.3 Resettlement is one of three durable solutions identified by the office of the UN High Commissioner for Refugees (UNHCR). However, as refugees, including torture survivors, resettle, they struggle with these accumulated stressors, leading to high rates of mental health concerns. Refugees are at markedly greater risk than the general population of having psychiatric disorders. They have up to ten times the rate of post-traumatic stress disorder (PTSD) as well as higher rates of depression, chronic pain and other somatic complaints, with exposure to torture being the strongest predictor of PTSD symptoms among refugees.4 The present study was conducted in the United States, where up to 35% of resettled refugees are survivors of torture.5 Refugees, including survivors of torture, all receive the same level of support and assistance through the U.S. resettlement process. Individuals who are granted asylum are assisted through the resettlement assistance program.

Furthermore, torture survivors typically do not present their torture-related trauma as the initial presenting problem in an encounter with a caseworker, but rather present the same challenges as other newcomers such as language, employment, and acculturation.

Regardless of whether trauma is articulated or not, empathy is an important

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the challenges that have faced each refugee and the impact that empathy might have on their future. Although refugee service providers cannot change the past experiences of their clients, they can provide the empathy and the quality of service these individuals deserve. The present study was designed to develop an instrument to measure the level of empathy that service providers demonstrate in their responses to common, yet difficult, refugee resettlement case scenarios.

Theoretical/Conceptual Framework This study is the first phase of a larger project, Project MIRACLE: Motivational Interviewing for Refugee Adaptation, Coping, and Life Empowerment, which initiates a novel approach—the application of Motivational Interviewing9 with refugees— with the ultimate goal of improving client outcomes. In brief, Motivational Interviewing (MI) is an evidence-based practice approach that aims to develop a working alliance between practitioner and client in order to resolve client ambivalence about change. MI has been applied in numerous areas of health,10 mental health,11 and social work.12 MI is an exception to the critique that much of counseling is culturally biased.13, 14 MI has been disseminated around the world, demonstrating cross-cultural generalizability.12 The rationale for applying this approach with refugee clients has been presented elsewhere.15 Empathy, as demonstrated by reflective listening, is a core skill of Motivational Interviewing.

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of things that clients in general mental health, addiction, and social service settings might say. After each scenario, providers are encouraged to write a one to two sentence open-ended response indicating what they would say to the imaginary client. Responses are then rated on a five-point scale that assesses depth of reflection and ability to avoid communication roadblocks. The HRQ was originally administered to a sample of 190 social service providers attending a workshop on active listening and crisis intervention skills. The instrument was found to have an inter-rater reliability of .93 and a Cronbach’s alpha of .92. Respondents’ scores following the workshop were significantly improved from before the workshop.

The HRQ has subsequently been employed in pretest-posttest evaluations of MI trainings, with positive results.17-20 HRQ scores have been found to be correlated with actual MI skills in practice.21 The HRQ has been adapted once, for use in correctional settings.22 The authors of that adaptation wrote new scenarios for the scale to address situations common to probation and parole officers. The renamed Officer Responses Questionnaire, consisting of five items, was administered to officers attending MI trainings. Inter-rater coding of 125 questionnaires resulted in an average intra-class correlation of .80. Scores improved significantly from pre- to posttraining. This study demonstrates that the HRQ can be successfully adapted for providers in serving alternative client populations.

Background

The Helpful Responses Questionnaire (HRQ),16 developed by one of the co-founders of Motivational Interviewing, is designed to measure reflective listening (also known as active listening) and by extension, empathic ability. The instrument includes six scenarios

Study Aims The purpose of the present study was to develop a version of the Helpful Responses Questionnaire specific to working with refugees, including torture survivors, and to test its psychometric properties.

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Inter-coder and internal consistency reliabilities were estimated. Face validity and content validity were assessed via the questionnaire development process (described in the method section below). To assess known-groups validity, it was hypothesized that respondents who have (1) higher education levels, (2) education in a helping profession, (3) longer experience working with refugees and in human services, and (4) prior training in MI and/or active listening, would all have higher scores on the Helpful Responses to Refugees Questionnaire, compared to their counterparts.

Methods

Participants and Data Collection The questionnaire was disseminated in January 2015 via an online survey using Qualtrics software. A list of e-mail addresses of administrators of refugee services programs in the United States was compiled from information on the website of the U.S. Office of Refugee Resettlement and links therein. An e-mail inviting survey participation was sent to a total of 435 e-mail addresses, which included all state refugee coordinators, all state refugee health coordinators, administrators of local affiliate programs of the nine national voluntary resettlement agencies that contract with the Office of Refugee Resettlement, and representatives of refugee mutual assistance associations. The addressees were asked to forward the e-mails to their staff members and contacts who worked directly with refugees.

The sample was not random, as it consisted of those electing to participate; as such, this study did not aim to infer the results to a population and therefore the use

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Questionnaire Development In this study, the HRQ was adapted for use with refugee resettlement service providers.

Five new scenarios were written that were reflective of situations typically encountered in work with these clients. In order to establish face validity (i.e., whether the instrument appears to measure what it is supposed to measure) a panel of five refugee and torture survivor service experts (including the two authors) wrote the questionnaire items. The panel members all had extensive experience in practice and scholarship on refugee resettlement, including programs for survivors of torture. Each panel member wrote one questionnaire item.

The questionnaire items intentionally did not identify the national origin or ethnicity of the imaginary refugee in each scenario, because while the nationalities and ethnicities of refugees resettled in the U.S. vary from year to year, the challenges faced by new arrivals tend to remain similar. Thus, the intent was for the questionnaire to be generalizable and remain relevant to future arriving populations, regardless of national origin or ethnicity.

Once written, the five items were

reviewed by all five contributors to assess content validity (i.e., the degree to which the items are relevant to and representative of the concept being measured). As recommended by Haynes, Richard, & Kubany,23 each panel member rated the revised questionnaire on a 5-point scale (ranging from “strongly agree” to “strongly disagree”) on the dimensions of relevance, representativeness, and specificity and clarity. They also provided qualitative feedback on suggested item additions, deletions, and rewordings. Based on these evaluations (described in the results section below), further revisions were made. The final version of the questionnaire, entitled the Helpful Responses to Refugees Questionnaire, is shown in Appendix A.

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of power analysis to determine sample size was not appropriate. The authors aimed to achieve a modest response rate with a targeted sample size of 100. In order to incentivize participation, respondents were promised (and received) a $10 electronic gift card to a national coffee shop chain for completing the survey. 102 responses were obtained within several hours of the e-mail dissemination.

In addition to the five items on the Helpful Responses to Refugees Questionnaire, respondents were asked to provide information about their level of education (in six categories ranging from “completed high school” to “doctorate degree”); professional discipline (write-in response), length of experience in working with refugees and in human services in general (in five categories ranging from “less than 1 year” to “more than 10 years”); and whether or not they had any prior training in MI and in active listening. Finally, respondents were asked to provide their job title (write-in response), in order to further describe the characteristics of the sample.

All survey questions were required to be answered to submit the survey in order to avoid any missing data.

Data Analysis Each response to the five scenarios was independently coded by the two authors.

Following the procedure used in the coding of the original HRQ, the responses to the five items were disarticulated and randomized “to remove possible biases due to … halo effects caused by scoring multiple responses known to be made by the same individual” (p446).16 Coders were also blind to respondent characteristics.

The scoring instructions for the Officer Response Questionnaire were used, as these provide explicit guidelines and examples.

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Per those instructions, a response is given a score of: 1 - if it contains any roadblock response such as ordering, disagreeing, or giving advice without permission; 2 - if it contains a closed question, affirmation, offers of help, or other non-reflective response; 3 - if it contains an open question; 4 - if it contains a “simple” reflection that restates the basic content of the original statement; 5 - if it paraphrases or infers a deeper meaning from the original statement.

If a response contains multiple elements (e.g., open question and simple reflection), it receives the score of the highest elements (4 for the simple reflection), unless it contains a roadblock, in which case it receives a score of 1 (p68).22 The two other write-in responses (professional discipline and job title) were collapsed into major categories and frequencies were recorded.

Statistical analyses were conducted using SPSS software (Version 21). Following the procedures used in the coding of the Officer Response Questionnaire, the raters initially coded five randomly selected questionnaires and an initial inter-rater reliability was computed using the intra-class correlation.

The coders then met to discuss the scoring discrepancies, mutually decide on final codes where discrepancies existed, and clarify and elaborate the coding instructions. This process was repeated two more times (with two new sets of five questionnaires each), until an average intra-class correlation greater than .80 was attained. Subsequently the remaining questionnaires were coded by both coders, who then met and resolved discrepancies. In the process of rating responses, it was recognized that the coding

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instructions should be adapted to reflect responses by refugee service providers while maintaining the intent and integrity of the rating scale. The finalized coding instructions based on the refinements made through this process are shown in Appendix B. Total scores were computed by summing the final codes for each item. To test known-groups validity (i.e., whether a measure discriminates between groups expected to differ on the variable being measured), the previously-mentioned hypotheses were tested by examining the relationships among the total scores and the hypothesized predictors (education levels, education in a helping profession, length of experience working with refugees and in human services, and prior training in MI and in active listening). Because this was not a random sample and the study did not aim to infer results to a larger population, inferential statistics and statistical significance testing were not used. Instead, effect sizes (Spearman’s rho, Cohen’s d) were computed. Attainment of a medium effect size as defined by Cohen24 was considered evidence of support of the relevant hypothesis.

Finally, this study was approved by the Florida International University Institutional Review Board.

person (for example, “I will explain to her that…”). Thus, these were considered invalid responses, resulting in a valid sample size of 90.

The characteristics of the sample are shown in Table 1. The vast majority of respondents possessed either a bachelor’s (44%) or a master’s (38%) degree. The top five fields in which the highest degree was held were business/management (18%), social work (13%), psychology/ counseling (12%), social science (11%) and international relations/intercultural communication (9%). There were no respondents with degrees in a health profession such as medicine or nursing. 30% of the respondents possessed their highest degree in other fields.

Somewhat less than half the respondents worked in direct service positions (44%) or administrative/managerial positions (42%), with the remainder in administrative support or higher education. Most respondents had worked with refugees for two-five years (37%), followed by more than 10 years (20%), five to ten years (18%) and less than one year (16%). Over two-thirds (69%) had worked in the human services for more than five years. Finally, more than half of respondents (55%) had prior training in active listening, and approximately one third (30%) had prior training in Motivational Interviewing.

Results

Descriptive Statistics: The total scores ranged from 5 to 24, with a mean of 10.8 (SD=5.0), and a median of 10.

Instrument Reliability: The average intra-class correlation (a measure of inter-coder reliability) was .78, which is considered to be in the excellent range.22 The Cronbach’s alpha (a measure of internal consistency) was .71, which is considered good for tests of ability.25

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Sample Characteristics 102 people completed the questionnaire.

However, upon reading the responses, it was discovered that 12 respondents did not follow the questionnaire instructions to “write the next thing you might say if you wanted to be helpful.” These twelve respondents wrote what they would do rather than what they would say (for example, “family intervention is needed”), including referring to the refugee in the scenario in the third

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Table 1: Sample Characteristics Characteristic

n (%)

Education High School

1 (1.1)

Some college, no degree

5 (5.6)

Associate degree

6 (6.7)

Bachelor degree

40 (44.4)

Master degree

34 (37.8)

Doctorate degree

4 (4.4)

Degree Business/Management

16 (17.8)

Social Work

12 (13.3)

Psychology/Counseling

11 (12.2)

Social Science

10 (11.1)

International Relations/Intercultural Communication

8 (8.9)

Other

27 (30.0)

None

6 (6.7)

Position Direct Service

40 (44.4)

Adminstration/Management

38 (42.2)

Administrative Support

10 (11.1)

Higher Education

2 (2.2)

Length of Time Working with Refugees Less than 1 year

14 (15.6)

1-2 years

9 (10.0)

2-5 years

33 (36.7)

5-10 year

16 (17.8)

More than 10 years

18 (20.0)

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Length of Time Working in Human Services Less than 1 year

7 (7.8)

1-2 years

5 (5.6)

2-5 years

16 (17.8)

5-10 year

27 (30.0)

More than 10 years

35 (38.9)

Training in Active Listening Yes

50 (55.6)

No

40 (44.4)

Training in Motivational Interviewing Yes

27 (30.0)

No

63 (70.0)

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who possessed degrees in a helping profession (social work and psychology/counseling) had a higher total score (M=13.1, SD=5.9) than respondents who did not (M=10.1, SD=4.5), which was a medium-to-large effect size (Cohen’s d=0.67). There were no correlations between total score and length of experience working with refugees (Spearman’s rho=-.06), or total score and length of experience working in human services (Spearman’s rho=.04). Finally, respondents who had prior training in MI had a higher total score (M=12.5, SD=5.5) than those who did not (M=10.0, SD=4.6), a medium effect size (Cohen’s d=0.52); and those who had prior training in active listening had a higher total score (M=11.3, SD=5.0) than those who did not (M=10.2, SD=5.0), a small effect size (Cohen’s d=0.22). In sum, three of the four hypotheses (1, 2, and 4) were supported, thus providing evidence for the known-groups validity of the instrument.

Discussion

This study has demonstrated the development and initial reliability and validity of an instrument for measuring empathy, a key component of Motivational Interviewing, among service providers working with refugees, including survivors of torture, in resettlement. The study has also demonstrated the feasibility of administering such a measure on-line as opposed to the paperand-pencil format used in prior research.

Practice Applications The Helpful Responses to Refugees Questionnaire may have several potential applications in practice. It could be used as a supervisory tool to assess service providers’ skills in this area and provide feedback for improvement, if needed. It could be used as a screening tool for hiring new staff (as part of a comprehensive screening and selection

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Instrument Validity: As described in the methods section, the questionnaire items have face and content validity as a function of being developed, judged, and refined by a panel of five experts in refugee resettlement/ torture survivor programs. Five original items were written and reviewed by the panelists. All of the panelists strongly agreed that “the questionnaire items are relevant to situations encountered by refugees in resettlement.” Also, they all agreed or strongly agreed that “the questionnaire items are specific and clear to the target audience (practitioners working with refugees).”

However, three of the five panelists disagreed or strongly disagreed that “the questionnaire items represent an appropriate variety and balance of situations encountered by refugees in resettlement.” Specifically, the panelists noted that three of the items were very similar, dealing with the employment and income challenges of male refugees and their feelings about this vis-à-vis their family roles. These panelists suggested replacing the redundant items and made numerous suggestions for alternate topics. Consequently, two of these three items were deleted and replaced with two new items written by the two study authors, incorporating the suggested topics.

Known-groups validity was assessed by testing the four hypotheses regarding the relationships between respondent characteristics and total scores on the questionnaire.

As stated earlier, it was hypothesized that respondents who have (1) higher education levels, (2) education in a helping profession, (3) longer experience working with refugees and in human services, and (4) prior training in MI and active listening, would all have higher scores compared to their counterparts. The Spearman’s rho correlation between education and total score was .30, which is a medium effect size. Respondents

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process). It must be noted that if agencies wish to use the instrument in these contexts, they should first practice scoring the instrument on a pilot sample prior to deploying it for assessment purposes, since the scoring process requires substantial interpretation. Finally, the instrument can be used as a pretest-posttest to evaluate the impact of staff training in motivational interviewing. This is the next step in Project MIRACLE, the larger project of which the current study is the first step; a manuscript reporting the results of this phase of the study is currently under review. By helping them to recognize when they are providing an empathetic response, this tool can help them to support refugees throughout the resettlement process.

It is interesting to note that the largest effect size observed was between total scores on the instrument and possessing an educational degree in a helping profession (social work or psychology/counseling).

However, only a minority of the respondents (25%) possessed such a degree. Refugee resettlement programs are staffed by individuals with a diversity of educational backgrounds, as reflected in this sample.

Sometimes staff members are former refugees themselves, who are hired for their linguistic skills and commonality of experience with clients; the results of this study suggest that these may not be sufficient qualifications for effective helping. It is likely that these former refugees serve a valuable function in modeling successful integration into the new society, but in order to maximize their effectiveness, they should be encouraged and supported to pursue higher education in a helping field. Owen & English26 noted that in the early days of the U.S. refugee resettlement program, special programs assisted these paraprofessionals to obtain training and education, and these

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authors have called for re-establishment of such programs. The findings of this study lend further support to this recommendation. Policymakers and advocates in both resettlement and higher education should explore means of financially supporting this endeavor.

It is also interesting that there was no correlation between total scores and length of work experience either with refugees or in human services in general. This suggests that reflective listening and empathy skills do not naturally improve over time. Further, it suggests that length of work experience should be a less important criterion in hiring than possessing a degree in a helping profession.

Limitations and Implications for Future Research Finally, it is critical to note the limitations of this study and consequent implications for future research. The initial reliability and validity findings of this study should be replicated in future research. Further, although the target respondents for this study were direct service practitioners, 42% of the respondents were administrators/managers and 11% were administrative support staff (e.g. IT personnel). Apparently, some of the administrators/managers who received the e-mail asking them to forward it to their direct service staff did not fully follow the instructions, choosing to answer the questionnaire themselves and/or forward it to support staff. However, upon reflection, the present authors realized that these responses were also important, in as much as administrators/managers should also possess empathic skills in order to model and teach them to the direct service staff whom they supervise.

Moreover, administrative support staff, like all staff, represent the â&#x20AC;&#x153;faceâ&#x20AC;? of the organization; they may occasionally, if not frequently,

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encounter clients on the premises, and they likewise should possess some level of ability to respond to clients appropriately should the situation arise. Nonetheless, future research targeted to direct service staff should incorporate means of excluding non-targeted respondents.

Further, although prior research has demonstrated a correlation between scores on these types of questionnaires and actual skills in practice, such a linkage remains to be determined in the present context. The scoring of written responses is hampered by the inability to observe body language and tone of voice, which are also key to empathic behavior. Future research could examine the correspondence between scoring videotaped responses in role-play scenarios versus scoring written transcripts of those same role-plays. Additionally, this study addressed refugees resettled in the United States; the utility of the instrument for refugees in transit (e.g., in camps), in local integration, and in resettlement in other countries should be assessed. Finally, the most important question remaining is determining the impact of worker reflective listening and empathic responses upon actual client outcomes.

Acknowledgements

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This research was supported by the Lois and Samuel Silberman Grant Fund in The New York Community Trust awarded to Miriam Potocky. The authors thank Sylvia Acevedo, Chak Ng, and Uma A. Segal for serving as expert panelists for this study.

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8. U.S. Department of State. Frequently Asked Questions (FAQ) on Refugee Resettlement Benefits. 2015. Available from: http://photos.state.gov/ libraries/iraq/216651/refugees/FAQ on refugee resettlement benefits.pdf 9. Miller WR, Rollnick S. Motivational Interviewing: Helping People Change. 3rd ed. New York: Guilford; 2012.

10. Rollnick S, Miller WR, Butler C. Motivational Interviewing in Health Care. New York: Guilford; 2008.

11. Arkowitz H, Westra HA, Miller WR, Rollnick S, editors. Motivational interviewing in the Treatment of Psychological Problems. New York: Guilford; 2007.

12. Hohman M, editor. Motivational Interviewing in Social Work Practice. New York: Guilford; 2011.

13. van der Veer G. Counselling and Therapy with Refugees and Victims of Trauma. 2nd ed. West Sussex, England: Wiley; 1998.

14. Sue DW, Sue D. Counseling the culturally diverse: Theory and practice. 7th ed. Hoboken, NJ: Wiley; 2016.

15. Potocky M. Motivational interviewing: A promising practice for refugee resettlement. J of Ethnic and Cultural Diversity in Social Work 2016; 25:247-252.

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16. Miller WR, Hedrick KE, Orlofsky DR. The Helpful Responses Questionnaire: A procedure for measuring therapeutic empathy. J Clin Psychol 1991; 47:444-448.

17. Baer JS, Rosengren DB, Dunn CW, Wells EA, Ogle RL, Hartzler B. An evaluation of workshop training in motivational interviewing for addiction and mental health clinicians. Drug Alcohol Depend 2004;73:99-106.

18. Martino S, Haeseler F, Belitsky R, Pantalon M, Fortin AH. Teaching brief motivational interviewing to year three medical students. Med Educ 2007; 41: 160-167.

19. Miller WR, Yahne CE, Moyers TB, Martinez J, Pirritano M. A randomized trial of methods to help clinicians learn motivational interviewing. J Consult Clin Psychol 2004; 72: 1050-1062.

20. Shafer MS, Rhode R, Chong J. Using distance education to promote the transfer of motivational interviewing skills among behavioral health professionals. Journal of Subst Abuse Treat 2004; 26: 141-148.

21. Miller WR, Mount KA. A small study of training in motivational interviewing: Does one workshop change clinician and client behavior? Behavioural and Cognitive Psychotherapy 2001; 29:457- 471.

22. Walters ST, Alexander M, Vader AM. Officer Responses Questionnaire: A procedure for measuring reflective listening in probation and parole settings. Federal Probation 2008; 72: 67-70.

23. Haynes SN, Richard DCS, Kubany ES. Content validity in psychological assessment: A functional approach to concepts and methods. Psychological Assessment 1995; 7: 238-247.

24. Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2nd ed. Hillsdale, NJ: Erlbaum; 1988.

25. Field A. Discovering Statistics Using IBM SPSS Statistics (4th ed). London: Sage; 2013.

26. Owen CL, English, M. Working together as culture brokers by building trusting alliances with bilingual and bicultural newcomer paraprofessionals. Child Welfare 2005; 84:669-688.

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Appendix A Helpful Responses to Refugees Questionnaire

The following five paragraphs are things that a refugee might say to you. With each paragraph, imagine that a refugee you know is talking to you and explaining a problem that he or she is having. You want to help by saying the right thing. Think about each paragraph. For each paragraph, write the next thing you might say if you wanted to be helpful. Write only one or two sentences for each situation.

1. A 43-year-old resettled male refugee says:

“I can only find part-time low-paying jobs.

Because I cannot speak English, no one wants to hire me. My wife doesn’t mind working cleaning hotels, but there is no respect in that for a man.

My children have to come with me to translate everywhere I go.You know how hard it is to learn English at my age? And how can I support my family? I sometimes feel so angry…no, I don’t want to talk about it…”

2. A 30-year old female refugee says:

3. A 15-year-old refugee girl says:

“I only went to school twice last week because my mother was sick and I had to go with her to the doctor’s, so I could help the doctor understand what was wrong. The week before, my mom got some work, and so I had to stay home from school to watch my little brother while she

4. A 22-year-old refugee woman says:

“My son is 3 years old, and sometimes he does not listen to anything I tell him. I used to hit him with a wire hanger when he wouldn’t listen.

That’s how my mom raised me. But, a woman in the neighborhood told me that my child could be taken from me if I do that again. I just laughed – he is my son, and when he disobeys it is my responsibility to teach him the right way to behave. “ 5. A 38-year-old female refugee says:

“My husband was arrested for hitting me and I don’t understand why. He didn’t kill me, so I don’t know why he’s being punished. Now with him in jail, I’m having a really hard time caring for our four children. They refuse to obey me.

And now we don’t have my husband’s income.

And I don’t drive or speak English – my husband took care of those things. I need my husband back.”

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“I can’t sleep at night – I keep having nightmares of how my brother was dragged out of our home and executed in front of us by the military.

And I miss my big family back home – here, I have no one. I feel very lonely. Counseling? No, that’s for crazy people.”

worked. I've missed so much school I don't think I will pass my classes. It might be best if I just drop out and get a job so I can help my parents pay the bills.”

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Appendix B Scoring the Helpful Responses to Refugees Questionnaire

The Helpful Responses to Refugees Questionnaire (HRRQ) is designed to measure depth of reflective listening. Each response is rated on the depth of reflection and ability to avoid communication roadblocks. The roadblocks, listed below, tend to raise client defensiveness and therefore make change less likely.

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• Ordering or threatening • Persuading with logic, arguing, lecturing • Disagreeing, criticizing, sarcasm, labeling • Patronizing* • Giving false promises or statements about the future* • Judgment of another cultural norm as wrong* • Over-identification* • Giving unsolicited advice, suggestions or solutions (Exception: Provision of factual information that may be new to an incoming refugee, without intent to suggest solutions or persuade with logic) To score the HRRQ, give each response a score from 1-5, based on the following criteria. Participants are asked to provide brief (one-two sentence) responses to each scenario. If participant responses are longer, only the first two lines should be coded.

A score of 1 is given if the response includes a roadblock response, whether or not it contains additional elements. A score of 1 is also given for irrelevant or incomplete responses. Several examples are given for each roadblock, using responses to scenario 1 from the questionnaire.

• You should attend English class every day. (ordering) • Since you are working to support your family, you should find dignity in every job (persuading with logic) • Don’t give up,[this] is a country full of opportunities (persuading) • You are never too old to learn a language (arguing) • You will learn English and advance in your job (false promise) • My mother did it and so can you! (over-identification) • You have to do what you have to do. If it means doing so-called ‘women’s work’, then do it (judgement of the ‘correctness’ of cultural differences) • Go to school in your free time to learn English so you can find a better job (unsolicited advice) • While you are at home watching TV, change to children's channels in English and you'll soon see the difference (suggestion and false promise) A score of 2 is given if the response contains a closed (yes/no/limited option) question. A score of 2 is also given for miscellaneous affirmations, offers of help, or statements of understanding that do not fit into other categories. If the response also contains a roadblock, it receives a score of 1. Examples of items that receive a score of 2 come from responses to scenario 2 from the questionnaire.

• Why don’t we talk about different options to help you (offer to help) • An offer to help differs from a suggestion, which is a road block, in its association to the original scenario.

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• A suggestion includes a specifically identified entity, which is not asked for in the scenario.

• An offer to help is specific to the scenario and often involves a close ended question • Counseling, in this country, is for everybody.

Counseling means that we have a qualified person that understands what we are going through and has the tools to help us. (providing information) • Providing information is different from arguing or lecturing. It normalizes the concern and provides factual information. If the statement had said ‘Counseling is not for crazy people’ it would have been considered to be arguing).

• Would you be interested in connecting with other women that are also refugees? (closed question) •D o you ever talk with your family? (closed question) • I am glad that you are here and safe. (affirmation) • I am sorry that you’re having trouble sleeping (statement of understanding)

• What do you really want to do? (open question) •L et's see if we can come up with some other options before you make the decision to drop out of school (open question) A score of 4 is given if the response repeats the basic content of the original statement.

When multiple responses are made, the

• As a mother you want to make sure that your children do the right thing and obey. (simple reflection, using the same words as are used in the scenario) • Sometimes children tend to misbehave. But let’s consider other ways to discipline (simple reflection, open question) A score of 5 is given if the response paraphrases the original statement, using substantially different language or inferring meaning. When multiple responses are made, the highest level is scored (unless the response contains a roadblock, resulting in a score of 1). Examples of items that receive a score of 5 come from responses to scenario 5 from the questionnaire.

• I understand you love your husband and want your family to be intact. (paraphrase that infers meaning) • It must be difficult handling your 4 children and the finances with your husband not here to help. How about we look at some options to help you while your husband is in jail (paraphrase that infers meaning, open question) *New roadblocks identified in this study.

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A score of 3 is given if the response contains an open question. When multiple responses are made, the highest level is scored (unless the response contains a roadblock, resulting in a score of 1). Examples of items that receive a score of 3 come from responses to scenario 3 from the questionnaire.

highest level is scored (unless the response contains a roadblock, resulting in a score of 1). Examples of items that receive a score of 4 come from responses to scenario 4 from the questionnaire.

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A comparative study of the use of the Istanbul Protocol amongst civil society organizations in low-income countriesi Tobias Kelly, PhD*, Steffen Jensen, PhD**, Morten Koch Andersen, PhD**, Catrine Christiansen, PhD***, Jeevan Raj Sharma PhD*

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Abstract

The Istanbul Protocol (IP) is one of the great success stories of the global anti-torture movement, setting out universal guidelines for the production of rigorous, objective and reliable evidence about allegations of torture and ill-treatment. The IP is explicitly designed to outline ‘minimum standards for States’. However, it is all too often left to civil society organizations to investigate allegations of torture and ill-treatment. In this context, important questions remain as to how and where the IP can be used best by such organizations. These questions are particularly acute in situations where human rights groups may have limited institutional capacity. This paper explores the practical challenges faced by civil society in using the IP in Low-Income Countries. It is based on qualitative research in three case studies: Nepal, Kenya and Bangladesh. This research involved over 80 interviews with human rights practitioners. The conclusions of the paper are that the Istanbul Protocol provides

*) School of Social and Political Science, University of Edinburgh, Scotland **) DIGNITY: Danish Institute Against Torture, Copenhagen, Denmark. *** Independent consultant Correspondence to: toby.kelly@ed.ac.uk i

Editors: Pau Pérez-Sales and Lilla Hárdi.

a useful framework for documentation, but more comprehensive forms of documentation will often be limited to a very small – albeit important - number of legal cases. In many cases, the creation of precise and standardized forms of evidence is not necessarily the most effective form of documentation for redress or accountability.

In the absence of legal systems willing and able to respond effectively to allegations of torture and ill-treatment, there are severe limitations on the practical effectiveness of detailed and technical forms of documentation.

Keywords: human rights documentation, Istanbul Protocol, Low-Income Countries, torture and ill-treatment.

Introduction

The Istanbul Protocol (IP) represents the internationally recognised standard for the documentation of torture and ill-treatment.1 With its origins in the Turkish human rights struggle, the final version was the collective product of over 75 human rights activists, lawyers and health workers from organizations in at least 15 different countries. The aim of the IP is to ‘enable States’ to bring ‘evidence of torture and ill-treatment to light so that perpetrators may be held accountable for their actions and the interests of justice may be served’ (p1). The Protocol describes,

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i For example: OHCHR Resolution 2003/33 of 23 April 2003; UN Special Rapporteur on Torture General Recommendations of 2003; 32nd ordinary session of the African Commission on Human and People’s Rights, October 2002; Guidelines to EU Policy towards Third Countries on Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, General Affairs Council, 2001.

tions to investigate and document allegations of torture and ill-treatment. The most comprehensive forms of documentation set out in the IP are resource-intensive, resources that are often unavailable to many civil society organizations. However, as the introduction to the IP explains, it is not designed as: ‘a fixed protocol’, but rather as flexible ‘minimum standards… and should be used taking into account available resources’ (p2).1 There are therefore important questions about how, in practice, to best to use the forms of documentation set out in the IP. This article is the product of a two-year research project funded by the UK’s Economic and Social Research Council and the Department for International Development, carried out by the University of Edinburgh and Dignity: Danish Institute Against Torture.ii The overall project aims to explore the issues faced by civil society organizations in documenting torture and ill-treatment in Low-Income Countries (as defined by the OECD).13 It examines the aims of civil society organizations in documenting torture, the techniques they use, and the problems they face in doing so. The IP is the most widely recognised human rights instrument used in the documentation of torture, setting international standards. It is therefore important to explore the potential scope and challenges of using the IP in practice. This particular paper asks: What role does the Istanbul Protocol play in the documentation of torture in Low-Income Countries? And what are the challenges and opportunities involved in doing so?

ii ESRC/DfID ES/L005395/1, May 1 2014 - April 30 2016. For more details please see: https:// torturedocumentationproject.wordpress. com/?s=documentst last accessed 16 January 2016.

Include in references

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in great detail, the ‘minimum standards’ for legal investigation and the production of medical and psychological evidence (p2). It recommends obtaining victim statements, preserving evidence (including medical evidence), identifying possible witnesses and obtaining statements, in order to determine ‘how, when and where the alleged incidents of torture occurred’ (p17). More broadly, the experience of human rights activists tells us that torture and ill-treatment are inherently difficult to document.2, 3 Not only can states inflict torture in a way that leaves few marks, but claims of torture are also often met with cultures of denial.5, 6 The IP therefore attempts to address these issues by setting out a clear method through which torture and ill-treatment can be documented in a consistent, effective and impartial manner.

There is no doubt that the IP is one of the great success stories of the anti-torture movement. Since it was adopted by the UN in 1999, it has been recommended by the UN General Assembly, the UN Human Rights Council, the UN Special Rapporteur on Torture and Cruel, Inhuman and Degrading Treatment or Punishment, the African Commission on Human and People’s Rights and the European Union, amongst others.i It has been translated into multiple languages. The IP has also spawned numerous guides and manuals designed to explain and clarify its 76 pages.6-9 The IP is explicitly designed to outline ‘minimum standards for States’. However, it is all too often left to civil society organiza-

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More broadly, the research addresses the challenges raised by attempts at standardisation in human rights work. Any move towards standardisation treads a careful line between principles that help set a general framework but risk becoming too broad to be meaningful in a particular context, on the one hand, and detailed guidelines that become too inflexible to take into account context-specific tactical demands, on the other.14 Much human rights documentation implicitly assumes that more knowledge is of value. If we can produce rigorous evidence about particular incidents of torture, we will be in a better place to hold perpetrators to account. As such, the underlying assumption behind the IP is that production of detailed, objective and reliable legal evidence is central to the fight against torture. This is certainly true. Yet, at the same time, knowledge should always be thought of as a means to an end, rather than an end in itself; it is important because it helps human rights practitioners realise other more substantive goals, such as the eradication of torture. We therefore need to understand the role of particular forms of knowledge in working towards context specific goals. This means asking why civil society organizations use human rights instruments, what they want to achieve, and the issues they face when doing so.

The conclusions of the paper are that the IP provides a useful framework for documentation, but the practical impact of comprehensive forms of documentation will often be limited to a small â&#x20AC;&#x201C; albeit important - number of legal cases. In a context where legal systems are often unresponsive or inefficient, documentation is more likely to be used for advocacy or rehabilitation than legal complaints. In the absence of legal systems willing and able to respond effectively to allegations of torture and ill-treatment, there are severe limitations on the practical

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effectiveness of detailed and technical forms of documentation. The problem is not simply knowledge but also, political will. This paper does not seek to suggest that fear and risk should rule out human rights work. Neither is it suggesting that human rights standards should be lower in Low-Income Countries.

What is being suggested is that, at a very practical level, in the face of a stateâ&#x20AC;&#x2122;s failure to live up to its obligations and in an environment of often scant resources, comprehensive documentation might not always be the most effective way of achieving the broader goals of human rights organisations.

Methods

The project employs three case studies: Kenya, Bangladesh and Nepal. These three countries have been chosen for the following reasons: First, the OECD classifies them all as Low-Income Countries. Second, while they all have past and present histories of state-led violence including torture and ill-treatment, none of the countries are currently experiencing levels of violence that would make the research unfeasible. Third, all three case studies include vibrant human rights communities that struggle to document widespread and long-term abuses, and bring perpetrators to account, often under high levels of political pressure. All three case studies can therefore tell us a great deal about the aims and methods of human rights practitioners with limited institutional capacity, operating in hostile political environments, and their attempts to grapple with the dilemmas of human rights documentation.

In order to ensure that the research addresses the needs and interests of local and international stakeholders, the project was carried out in conjunction with collaborators in each case study, as well as researchers at

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i The Advisory board consists of: Nigel Rodley, University of Essex; Stephanie David, FIDH; Mandira Sharma, Advocacy Forum; Mutuma Ruteere, CHRIPS; Saira Khan, Odhikar; Malcolm Evans, University of Bristol.

Their participation should not be taken as endorsement of the views in this article.

graphic and interpretive interview.15 The interviews were carried out by CC in Kenya, JRS in Nepal and MKA in Bangladesh. In all three case studies, participants were interviewed from nearly all organizations identified as having a direct role in the documentation of torture and ill-treatment. They were identified as playing a central role in commissioning, carrying out or using the documentation of torture and ill-treatment in the organization. In many cases, they were lawyers, but clinicians and other human rights professionals were also included. As above, it was not assumed that it was only lawyers or clinicians who used documentation in practice. We carried out 80 interviews in total, with each interview lasting between one and three hours.

In this part of the larger project, the focus was on the general experiences and perceptions of human rights practitioners involved in the documentation of torture or ill-treatment with the aim of exploring the perception of the main issues and challenges. The interviews were open-ended and addressed broad themes agreed upon for all three case studies, including: the aims of torture documentation, the challenges involved in documenting torture, the instruments people use for documentation and the reasons they are used, and whether and how the IP is used, and by whom. We did not assume prior knowledge of the IP, but sought to examine how, why and where it was used by human rights organizations. Interviews covered the specific expertise of those involved, the instruments and techniques used by the organizations to document torture and ill-treatment, the organizationsâ&#x20AC;&#x2122; objectives when documenting cases of torture and ill-treatment, the interviewees views and experiences around using the IP, and the problems and issues they face when doing so.

In the footnotes we have provided broad

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DIGNITY (Danish Institute against Torture) and the University of Edinburgh. Local partners, including human rights organizations in all three case studies, were involved in research design and implementation, with representatives from these organizations serving on the project advisory board.i In Kenya and Nepal, after an initial mapping of the field carried out in conjunction with our project partners, the main organisations involved in the documentation of torture were invited to stakeholder workshops. At the workshops, the project objectives and methods were explained, and participants provided feedback. The workshops also enabled us to identify other possible actors in torture documentation. In Bangladesh, political tensions at the time of the research meant workshops were not feasible. Bangladeshi interviewees were therefore identified on the basis of existing contacts and recommendations from human rights practitioners.

Throughout the process, it was important to include all groups involved in the documentation of torture and ill-treatment, and not to assume that only formal human rights groups carry out such work. This initial step allowed us to map the organizations, people and bodies which are involved in documenting torture and ill-treatment, including NGOs, journalists, medical doctors, heath workers, lawyers, and paralegals, as well as state officials. We identified 22 organizations in Kenya, 17 organizations in Nepal and 6 in Bangladesh.

The research used in-depth qualitative interviews, in the tradition of the ethno-

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details of the interviewees experience and position, without compromising their anonymity.

It is important to acknowledge the implications and limitations of the interpretive and qualitative methods and framework for analysis used in this article. The data consists of the opinions and views of human rights actors. These are necessarily subject to variation and disagreement, and do not necessarily represent actual practice. We have tried to capture these disagreements, where significant, but given limitations of space, we cannot represent the full range of opinions.

As in all interviews, responses were also conditioned by the encounter between the interviewee and interviewer. It is possible that responses were shaped by, for example, a hope to increase funding. An alternative research strategy would have been to collect direct information on individual cases, but this would raise issues of confidentiality. We used purposive sampling given the small sample size.16 Furthermore, given the size and nature of the sample frame, statistical information would not have been reliable or significant. Whilst it is not possible to generalize the findings to all low-income settings, the results raise issues that might be applicable in other cases. Indeed, generalization is not an aim of this paper, but rather to explore the context-specific use of the IP. Carrying out research in contexts of violence and instability contains very real risks, both for the participants and the researchers. The utmost consideration was therefore given to potential negative repercussions arising from any research for respondents and researchers. The research went through an ethical audit and review by the Research Ethics Committee of the School of Social and Political Science at the University of Edinburgh, procedures in compliance with the Ethical Guidelines of

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the Association of Social Anthropologists.17 This process includes an audit of risk to researchers and participants, confidentiality and handling of data, informed consent and conflict of interest. Interviewees have accordingly been kept anonymous.

Context

In this section we briefly set out the legal and political context in all three case studies.

Such background information is essential to obtain an understanding of the practical challenges in using the IP for more comprehensive forms of documentation.

In Kenya, Articles 25, 26 and 29 of the 2011 Constitution guarantee the right to life and the absolute prohibition of torture.

There is currently no specific legislation criminalizing torture. Human rights organizations report that torture is widely used as an interrogation method in places of detention.18-20, i In addition, al-Shabab activities in Somalia have spread into Kenya, resulting in an often brutal crackdown by Kenyan security forces on terror suspects.

Ethnic Somalis have been particularly vulnerable to the violence of the police and security forces.21 At the time of writing, the government was trying to expand its security powers, and in 2014, new legislation gave the police wide powers over suspects, although key clauses have been suspended by the High Court. There are a large number of organizations in Kenya involved in the documentation of torture and ill-treatment. Key organizations include the Independent

i lawyer and programme advisor for national human rights NGO, Nairobi, 6 August 2014; paralegal, national human rights NGO, Nairobi, 13 August 2014; lawyers and programme directors, national human rights NGO, Nairobi, 19 August 2014; head of field office of international human rights NGO, Nairobi, 28 August 201; lawyer and director of national human rights NGO, 22 September 2014.

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i lawyer and director of national human rights NGO, Nairobi, 22 September 2014. ii See also: Written statement submitted by ODHIKAR Coalition for Human Rights, Twenty-seventh session, Agenda item 4: Human rights situations that require the Council’s attention, 25 August 2014. Available at: http:// odhikar.org/wp-content/uploads/2014/09/StatementWritten_UN-HRC_Odhikar_25-August-14_Eng.pdf, last accessed 20 January 2016.

death, extra judicial killings known as “cross fires” and enforced disappearances are widespread. The second is on-going political tensions between supporters of the Awami League government and its opponents, mainly in the Bangladesh National Party and the Jamaat-e- Islami.24-28 There are three main organizations in Bangladesh involved in the documentation of torture and ill-treatment. Ain o Salish Kendra provides legal aid, documentation and advocacy, and operates in just under a third of Bangladesh’s districts.

BLAST acts as a legal services organization, specializing in women’s and constitutional issues, and operates in under a third of the country’s districts.23 Odhikar specializes in the documentation of torture and extrajudicial killings and has a network of supporters in two thirds of Bangladesh’s districts. Since 10 August 2013, Odhikar has come under increasing political and economic pressure from the Bangladeshi government.29 With the exception of BLAST, human rights organizations rarely have branch offices, and rely on referrals by third parties and volunteer members of human rights networks.iii Human rights workers are usually either lawyers or journalists. Clinicians for medico-legal reports are recruited on a consultancy or voluntary basis.iii It is often difficult to persuade doctors to take up such work.iv In Nepal, the Constitution of 1990, as well as the Interim Constitution of 2007, prohibits torture. The 1996 Torture Compensation Act (TCA) provides formal redress for victims of torture in places of detention.

Besides the TCA, the National Human Rights Commission Act, 2068 (2012),

iii director of investigation unit, national human rights NGO, Dhaka, 9 September 2014. iv director of human rights organisation 24 March 2015, director human rights organisation 11 September 2014.

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Medical Legal Unit (IMLU), Kenya Human Rights Commission, Amnesty International - Kenya and the Kamukunji Paralegal Unit.

IMLU is the only organization that solely works on torture amongst the general Kenyan population. Four organizations offer medical examination and rehabilitation services for torture survivors, and three of these focus on specific populations such as children or refugees. Full-time, paid human rights workers are largely, but not solely, trained lawyers. Clinicians for medico-legal reports are largely recruited on a voluntary or consultancy basis and trained by IMLU. Individual cases are usually identified through media reports or by paralegals working in local communities. The documentation of security-related cases is widely perceived by human rights actors to be a more politically sensitive issue than the documentation of criminal cases.i In Bangladesh, custodial torture became a specific crime in 2013, with the approval of the Torture and Custodial Death (Protection) Act 2013. The Bangladeshi security services have recently proposed amending the law to exclude mental suffering, to omit purposes including punishment, intimidation, coercion and discrimination, and to require that the police carry out the investigation of any complaint.22 Human rights practitioners report that torture and ill-treatment is a product of two processes.ii The first is harassment, extortion and interrogation by police offices.23 Torture, custodial

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Evidence Act, 2031 (1974), and the National Code, 1963 (Muluki Ain, 2020) also contain important provisions against torture. There is no specific legislation that criminalises torture. Human rights practitioners report that torture was widespread during the Maoist insurgency of 1996-2006.30, 31 Since this period, ‘politicised’ torture has generally, but far from completely, declined.32 The police regularly use torture as an interrogation technique. There are a wide variety of organizations involved in the documentation of torture, many of them with roots in human rights work during the insurgency.i Only the Centre for Victims of Torture (CIVICT) specializes in torture, but several others, such as Advocacy Forum, INSEC and Terai Human Rights Defenders Alliance, have made torture a focus of their work.

Other significant organizations involved in the documentation of torture include the National Human Rights Commission, and the Forum for the Protection of People’s Rights. All the above organizations focus on documentation, monitoring, advocacy, psychosocial counseling and legal cases.ii CIVICT, Transcultural Psychological Organization-Nepal, and the Centre for Mental Health and Counselling-Nepal provide rehabilitative services. The identifica-

i head of documentation, national human rights NGO, Kathmandu, 11 June 2014; founder of national human rights NGO, Kathmandu, 2 September 2014. ii interview with head of documentation, national human rights NGO, Kathmandu, 11 June 2014; lawyer and head of national human rights NGO, Kathmandu, 3 June 2014; director, national human rights NGO, Kathmandu, 7 August 2014. iii lawyer, national human rights NGO, Kathmandu, 13 June 2014; programme officer, woman’s rights organization, Kathmandu, 4 August 2014; head of documentation, national human rights NGO, 13 February 2015. iv programme director, children’s rights NGO, Kathmandu, 28 August 2014; director, national human rights NGO, Kathmandu, 7 August 2014.

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tion of cases is largely carried out by district level caseworkers, networks of human rights defenders and journalists.iii Lawyers were initially prominent in the Nepali human rights movement, but an increasing number of therapists are now involved in rehabilitation.iv Clinicians for medico-legal reports are recruited on a consultancy or voluntary basis.v Much of the most detailed documentation of torture takes place in order to produce evidence for litigation under the Torture Prevention Act, with the aim of obtaining compensation and not for the purpose of holding perpetrators accountable.

Results and Discussion

In all three case studies, our interviews suggest that human rights organizations document torture and ill-treatment for a wide range of often overlapping objectives. The reasons for documentation predominantly include, but are not limited to, media advocacy, issuing urgent appeals, developing training and education projects, alternative reports and complaints before regional and international mechanisms.vi Several organizations document solely as a way of identifying the medical needs of survivors.vii Crucially, the eventual end to which documentation will be put is not necessarily known at the start of the process.viii Our interviews also suggest that in all three case studies, levels of awareness about

v

head of documentation, national human rights NGO, Kathmandu, 11 June 2014; programme director, children’s rights NGO, Kathmandu, 28 August 2014. vi lawyer, international NGO, Nairobi, 18 August; lawyer and programme advisor for national human rights NGO, 13 August; 12 August 2014. vii psychologist at international NGO, Nairobi, 26 August; interview with lawyer and director, national human rights NGO, Kathmandu, 18 November 2014. viii medical professional and director of national human rights NGO, Kathmandu, 5 August 2014; director investigation unit, national human rights NGO, Dhaka, 9 September 2014.

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the IP varied amongst human rights practitioners. Awareness was high amongst those organizations that explicitly dealt with cases of torture, and with higher levels of awareness amongst more senior employees. In general, awareness also seems greatest for those with strong relationships with international human rights organizations, as this is the main source of training on the topic.i In Kenya and Nepal, there has been a programme of training in the use of the IP, funded by international donors, and supported by international organizations. ii In Nepal, these training sessions have been aimed at clinicians, lawyers and other human rights workers. In Kenya, organizations report limited training for non-clinicians, apart from that reported by the IRCT.33 There has been virtually no training in Bangladesh.

The general consensus amongst many of the human rights organizations we interviewed was that the IP provides a useful general set of guidelines for their work.

Human rights practitioners also report that medico-legal reports in particular can have a crucial role to play in ensuring accountability and reparations for survivors.iii In those cases that go to court, cases without medico-legal reports will rarely get very far. This is especially the case in Nepal, where the Torture Compensation Act (TCA) provides a framework for civil compensation for people tortured in places of detention. Of the

iv medical professional and director of national human rights NGO, Kathmandu, 5 August 2014. v medical professional and director of national human rights NGO, Kathmandu, 5 August 2014; director, national human rights NGO, Kathmandu, 7 August 2014. vi lawyer and director of national human rights NGO, Nairobi, 27 June 2014; head of documentation, national human rights NGO, Kathmandu, 13 February 2015; medical professional and director of national human rights NGO, Kathmandu, 5 August 2014; Nepal Stakeholder Workshop, 4 September 2014; interview with director of investigation unit, national human rights NGO, Dhaka, 26 February 2015; documentation officer, national human rights NGO, Dhaka, 11 September 2014; director investigation unit, national human rights NGO, Dhaka, 9 September 2014.

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i lawyer and head of national human rights NGO, Kathmandu, 3 June 2014; medical professional and director of national human rights NGO, Kathmandu, 5 August 2014; head of documentation, national human rights NGO, Kathmandu, 11 June 2014. ii head of documentation, national human rights NGO, Kathmandu, 14 August 2014; head of documentation, national human rights NGO, Kathmandu, 11 June 2014; lawyer and head of national human rights NGO, Kathmandu, 3 June 2014. iii lawyer and director of national human rights NGO, Nairobi, 27 June 2014; interview with human rights practitioner, Dhaka, 26 September 2014.

total number of cases of litigation led by one Nepali human rights organization, 32.9% of cases were dismissed due to lack of medical evidence and insufficient documentation.34 Those organizations with a specific focus on torture report that their documentation and screening processes are informed by the IP. However, interviewees also reported that there were severe limitations to using the more comprehensive forms of documentation set out in the IP. As one senior Nepali human rights activist put it "the IP does not work in Nepal without contextualizing it in the Nepali context".iv Interviewees reported that given limitations of time and resources, IP principles have been adapted to ‘local conditions’.v In practice, few interviewees reported that their organisations followed the IP in any level of detail, although it remains a ‘framework’. Interviewees reported four main issues, which are outlined below.

First, in all three case studies, interviewees reported that victims can be extremely reluctant to report their experiences.vi There is a widespread fear of negative, perhaps even violent reprisals for torture survivors.vii In all three countries there are long histories of impunity for police violence, with little protection offered to those making complaints about the police or military.viii The

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director of a Kenyan human rights NGO, for example, reported very high levels of intimidation by perpetrators, with the police routinely threatening to kill or detain survivors if they file an allegation.i A paralegal at a Kenyan human rights NGO based in a slum area similarly reported that in order to lodge an allegation of torture and ill-treatment survivors must report to a police station. They are reluctant to do so, as they have already been victims of police brutality.ii The head of documentation at one Nepali human rights NGO reported several cases where survivors had been tortured again following allegations resulting in a loss of trust amongst survivors with the legal process.iii In such contexts, the interviewees reported that survivors often are extremely reluctant to seek justice through formal

vii lawyer and director of national human rights NGO, Nairobi, 22 September 2014; interview with director of investigation unit, national human rights NGO, Dhaka, 26 February 2015; documentation officer, national human rights NGO, Dhaka, 11 September 2014; director investigation unit, national human rights NGO, Dhaka, 9 September 2014; paralegal, national human rights NGO, Nairobi, 31 July 2014; head of national human rights NGO, Kathmandu, 3 June 2014; national human rights NGO, Kathmandu, 10 February 2015. viii programme director, children’s rights NGO, Kathmandu, 28 August 2014; lawyer and project officer, national human rights NGO, Dhaka, 3 March 2015; independent human rights lawyer, Dhaka, 24 February 2015; independent human rights lawyer, Dhaka, 28 February 2015. i lawyer and director of national human rights NGO, Nairobi, 22 September 2014. ii lawyer and director of national human rights NGO, Nairobi, 27 June 2014. iii head of documentation, national human rights NGO, Kathmandu, 11 June 2014. iv paralegal, national human rights NGO, Nairobi, 6 August; lawyer and programme advisor for national human rights NGO, Nairobi, 13 August 2014; interview interview with lawyer and director, national human rights NGO, Kathmandu, 18 November 2014; interviews with independent human rights lawyer, Dhaka, 24 February 2015; independent human rights lawyer, Dhaka, 28 February 2015.

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mechanisms.iv The director of a Bangladeshi human rights organization reported that torture survivors are often more interested in being released from detention that gaining compensation or accountability, and most survivors do not see remedy as a viable option.v Our interviewees reported that human rights organizations can therefore face great difficulty in persuading people to provide the level of detail that is necessary in order to document torture and ill-treatment according to IP principles.vi Ironically, it is relatively more straightforward to produce a forensic medical report if the victim has died. vii The main reason for this is that victims, and by definition the main witness, can no longer be intimidated.

Second, in all three countries studied the interviewees reported there was a shortage of medical professionals who are willing and able to produce medico-legal reports for human rights organizations. Writing medicolegal reports is seen as carrying limited professional prestige. There can also be high levels of intimidation and fear among medical professionals.viii If doctors write reports, they may be asked to give oral evidence, and therefore become visible to the police. A Nepali human rights activist, for example, reported that medical personnel are under pressure from the police and ‘don’t want to take active steps’.ix Furthermore,

v

director of national human rights NGO, Dhaka, 11 September 2014. vi medical professional and director of national human rights NGO, Kathmandu, 5 August 2014; interview human rights activist, Dhaka, 11 September 2014. vii lawyer and director of national human rights NGO, Nairobi, 22 September 2014. viii director investigation unit, national human rights NGO, Dhaka, 9 September 2014; interview with founder of national human rights NGO, Kathmandu, 2 September 2014. ix director, national human rights NGO, Kathmandu, 7 August 2014.

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many clinicians are directly employed by government-funded hospitals, and therefore fear losing their jobs if they are critical of the state. The director of a Bangladeshi human rights NGO reported that doctors are often reluctant to become involved in lengthy legal cases and fear possible repercussions.i In Bangladesh, Kenya and Nepal, the independence of reports produced by government doctors is widely criticised by human rights organizations.ii One Kenyan paralegal, for example, reported that as prison doctors are also prison employees, they are reluctant to provide critical evidence supporting allegations of torture and ill-treatment.iii For those independent doctors who are willing to write medico-legal reports, it can be very difficult to access the medical records of survivors.iii Third, the interviewees reported that following the IP can be very expensive and time consuming. One Nepali clinician described the IP as a "gold standard", but said that he simply did not have the capacity or the equipment to follow it step by step.iv The expenses involved in documenting cases can be so great that one Nepali human rights organization requires survivors to sign a document stating they will not back out of bringing a legal case.v This finding has been reflected in other work. One unofficial

vi programme director, children’s rights NGO, Kathmandu, 28 August 2014. vii lawyer and programme coordinator, national human rights NGO, Nairobi, 20 August 2014. viii head of field office of international human rights NGO, Nairobi, 28 August 2014; lawyer and project officer, national human rights NGO, Dhaka, 3 March 2015. ix senior lawyer, national human rights organization, Nairobi, 13 August 2014.

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i director of national human rights NGO, Dhaka, 11 September 2014. ii senior investigator, national human rights NGO, Dhaka, 16 September 2014; interview with lawyer, woman’s rights NGO, Nairobi; director, national human rights NGO, Kathmandu, 8 August 2014; interview with interview with lawyer and director, national human rights NGO, Kathmandu, 18 November 2014; interview with medical doctor, Kathmandu, 18 November 2014. iii paralegal, national human rights NGO, Nairobi, 6 August 2014. iv head of documentation, national human rights NGO, Kathmandu, 17 November 2014. v director, national human rights NGO, Kathmandu, 8 August 2015.

estimate puts the time for an IP style examination at seven hours, leading some human rights organizations to develop less time-intensive screening methods that build on the IP, but do not require the same level of detail (p7).11, 12 Fourth, and perhaps most importantly, the interviewees reported that the level of detail in the most comprehensive forms of documentation set out in the Istanbul Protocol is often not needed.vi One Kenyan human rights practitioner commented that detailed documentation was something they did ‘mainly for donors’.vii This is partly because individual legal cases are relatively rare. Only Nepal has signed up to individual complaints under the UN Human Rights Committee monitoring process, and even then only a handful of cases have been able to go forward.35 Domestically, with the partial exception of Nepal, civil or criminal legal cases are also relatively rare. Delays are common in the domestic legal system, meaning that the few cases that do make it to the courts, take years to do so.viii One senior lawyer with a Kenyan human rights organisation reported that many survivors prefer to settle cases out of court as they get frustrated with the long delays.ix A senior lawyer at a Bangladeshi woman’s rights organisation explained that the length of the legal process means that many survivors will prefer to make informal settlements with perpetrators, if at all.x If civil or criminal cases do reach

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court, judges can also be antipathetic to claims of torture, or themselves placed under political pressure.i In Bangladesh, at the time of writing, no one has been convicted under the Torture and Custodial Death (Protection) Act 2013, although several cases of custodial death are pending. Nepal stands in partial contrast, where the Torture Compensation Act has resulted in victims filing relatively large numbers of civil cases in the courts. However these are for compensation and do not include the possibility of holding perpetrators to account. A report published in 2014 by a local human rights organization in Nepal shows that out of 146 cases filed under Torture Compensation Act by the organization since 2003, 31 (21%) were granted compensation, 48 (32.9%) were dismissed, 61 (41.8%) were awaiting decision and 6 (4.1%) were withdrawn.34 In Kenya and Bangladesh, even when cases are won, the government can fail to pay the agreed compensation.ii More broadly, rather than formal legal action, the mobilization of political and economic pressure often seems to be the most practically effective form of accountability for local human rights organizations concerned with addressing perpetration in the absence of the wider rule of law. In Bangladesh and Nepal, for example, human rights practitioners report perpetrators to the UN Department of Peacekeeping Operations (DPKO). Both countries are amongst the

x senior lawyer, woman's rights organization, Dhaka, 25 March 2015. i head of field office of international human rights NGO, Nairobi, 28 August; social worker, national human rights and refugee NGO, Nairobi, 19 August 2014; interview with lawyer and director, national human rights NGO, Kathmandu, 18 November 2014. ii lawyer, international NGO, Nairobi, 18 August 2014; lawyer and director national human rights NGO, Dhaka, 24 March 2015.

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largest contributors of personnel to UN Peacekeeping Missions and the armed forces earn a great deal of income through this work. Crucially, the reports used by human rights organizations in such cases are often very short, and require only a very limited level of detail to be effective. Human rights organizations in Nepal in particular, have used this tactic successfully; resulting in the removal of police and army officers from UN missions.iii At the time of writing, the tactic has not resulted in action against individual police officers in Bangladesh, but has seen an increase in political pressure against human rights organizations.iv More broadly, in Kenya, Nepal and Bangladesh, the most effective forms of documentation help human rights organizations to mobilize political connections, often, but not always, in the shape of lobbying the media and international donors. The director of one Nepali human rights organization, for example, reported that lobbying donors and local politicians was the most effective way to get a response from the Nepali state.v Crucially, this work can be done with relatively limited evidence.

Conclusion

The central objective of the IP is to provide guidelines for States for the effective investigation and documentation of allegations of torture and ill-treatment. In so doing, it is hoped that such documentation will establish facts, identify those responsible, facilitate protection, and/or

iii human rights practitioner, Kathmandu, 19 November 2014. iv Human Rights Watch. World Report 2016: Bangladesh.

Available at: https://www.hrw.org/world-report/2016/ country-chapters/bangladesh. Accessed 21 September 2016. v lawyer and head of national human rights NGO, Kathmandu, 3 June 2014.

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actually being carried out for reasons other than legal redress, such as lobbying international donors, that in practice require less detail. Given that the major obstacles to accountability and redress are political, rather than linked to knowledge and expertise, the impact and role of training around more comprehensive forms of documentation will therefore likely remain limited. The overall problem is not one of professionalized expert knowledge, but of political will. In this context, one possible future avenue is to think systematically about forms of human rights documentation that are not aimed at criminal prosecutions or litigation. Rather than developing universal standards, this could involve sharing the myriad of examples of effective good practice that already exist around the world which can be adopted to local contexts.

The research upon which this is based should be seen as an initial attempt to explore the practical use of the IP in low-income settings. It can possibly be extended in several ways. Studies could move beyond the opinions and views of human rights practitioners, to explore if, when and how the IP is used in the documentation of particular cases, and the factors that impact upon this - although this could raise confidentiality issues. The three case studies could also be compared with other contexts, for example, how relative forms of poverty, institutional capacity, human rights awareness and the rule of law impact on the effective use of the IP. Additionally, the relative impact of certain factors, such as improvements in the rule of law, human rights awareness and training of human rights practitioners amongst other things, could be tracked over time, although causation will be extremely hard to measure.

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obtain redress for victims. In the face of the all too common failure of States to carry out suitable investigations, civil society organizations often take the lead. The questions therefore are what is the best way for civil society organizations to document torture and ill-treatment, and what role can the IP play in this process? If human rights documentation is to be treated as a means to an end, rather than an end in itself, it is important to examine how effective particular forms of documentation are in particular contexts.

Looking at the interviews as a whole, we can infer that several processes have to come into line for comprehensive forms of documentation to be practical and effective: the survivor must have documentable sequelae and be willing and able to make contact with a human rights organization; a trained clinical professional must be willing and able to provide a comprehensive medicolegal report; the survivor must be willing and able to pursue a case over an often lengthy period; and, above all, there must be empowered legal actors who are willing and able to respond to documented allegations of torture and ill-treatment, as well as act against the perpetrators and provide redress to the survivors. In the three countries studied, all these factors were the exception rather than the rule.

This research has potential implications for how the IP is used for documenting torture and ill-treatment in low-income countries. Whilst the IP provides a useful broad framework for torture documentation and sets standards to which States can be held to account, the practical significance of more comprehensive forms of documentation appear restricted to a small â&#x20AC;&#x201C; albeit perhaps strategically important - number of legal cases. High levels of evidence are often of limited practical use, as documentation is

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Acknowledgements

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We wish to thank all the participants and partners in the research for this article, particularly Peter Kiama, Therese Rytter, Jo-Anne Prud’homme, and Adilur Rahman Khan. All errors and omissions are our responsibility alone. The research upon which this article is based was made possible by the generous support of an Economic and Social Science Research Council/Department for International Development Joint Poverty Alleviation Grant (ES/L005395/1, May 1 2014).

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References 1. Office of the United Nations High Commissioner for Human Rights. Istanbul Protocol: Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. New York and Geneva: United Nations; 2004 2. Jensen S, Hapal K, Modvig J. Violence in Bagong Silang. DIGNITY, International Series on Torture and Organized Violence 2, Copenhagen; 2013.

3. Kelly T. This Side of Silence: Torture, Human Rights and the Recognition of Cruelty. Philadelphia; University of Pennsylvania Press; 2012.

4. Rejali D. Torture and Democracy. Princeton: Princeton University Press; 2009.

5. Fassin D. Compassion and Repression: The Moral Economy of Immigration Policies in France. Cultural Anthropology. 2005 20(3): 362387.

6. International Rehabilitation Council for Torture Victims (IRCT). Medical Physical Examination of Alleged Torture Victims: A Practical Guide to the Istanbul Protocol – For Medical Doctors.

Copenhagen: IRCT; 2009a.

7. Peel M, Lubell N. Medical Investigation and Documentation of Torture. Colchester: Human Rights Centre, University of Essex; 2005. [Cited 24 May 2915] Available from: http://www.medekspert.az/fr/chapter3/resources/nouveau%20 manuel%20d'Essex.pdf.

8. International Rehabilitation Council for Torture Victims (IRCT). No date. Model Curriculum on the Effective Medical Documentation of Torture and Ill-Treatment - Educational Resources for Health Professional Students. Copenhagen: IRCT. Available from: http://www.irct.org/resources/irct-electronic-library/trainers-materials/ model-medical-curriculum.aspx 9. Redress. A Practical Guide to the Istanbul Protocol for Lawyers in Georgia. London: Redress; 2004.

10. International Rehabilitation Council for Torture Victims (IRCT). 2009b. Shedding Light on a Dark Practice: Using the Istanbul Protocol to document torture. Copenhagen: IRCT; 2009b.

[Cited 24 May 2014] Available from: http://irct. org/Files/Filer/publications/ipip/shedding_light_ on_a_dark_practice.pdf 11. Oficina de Derechos Humanos del Arzobispado de Guatemala. Consultoría para la ratificación del OPCAT en Guatemala. Recopilación de Informes I Y II. Guatemala City; 2005. Oficina de Derechos Humanos del Arzobispado de Guatemala. See also: http://www.odhag.org.gt/.

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www.blast.org.bd/issues/justice/214-3806of1998.

See also: http://www.blast.org.bd/issues/justice/214 24. Islam S. The State of Governance in Bangladesh 2010-11: Policy, Influence, Ownership. Dhaka: Institute of Governance Studies; 2012.

25. Jahan R. Bangladesh Politics: Problems and Issues. Dhaka: University Press Limited; 2005.

26. Moniruzzaman M. Party Politics and Political Violence in Bangladesh: Issues, Manifestation and Consequences. South Asian Survey 2009 16(1): 81â&#x20AC;&#x201C;99.

27. Alam, Quamrul, Teicher J. 2012. The State of Governance in Bangladesh: The Capture of State Institutions. Journal of South Asian Studies.

35(4).

28. Andersen M K. 2016. Time-Use, Activism and the Making of Future. Journal of South Asian Studies, 39(2): 415-429.

29. Written statement submitted by ODHIKAR Coalition for Human Rights, Twenty-seventh session, Agenda item 4: Human rights situations that require the Councilâ&#x20AC;&#x2122;s attention, 25 August 2014.

30. Von Einsiedel S, Amlone D, Pradhan S (eds.)

Nepal in Transition. Cambridge: Cambridge University Press; 2012 31. Office of the United Nations High Commission on Human Rights (OHCHR), 2012. Nepal Conflict Report: An Analysis of Conflict-Related Violations of International Human Rights Law and International Humanitarian Law between February 1996 and 21 November 2006. Geneva: OHCHR; 2012. [Cited 24 May 2015] Available at: http://www.ohchr.org/Documents/Countries/ NP/OHCHR_Nepal_Conflict_Report2012.pdf 32. Advocacy Forum - Nepal. Nepal: Is the Government Unable to Unwilling to Prevent and Investigate Torture? Kathmandu: Advocacy Forum; 2013. [Cited 2015 24 May] Available from: http://advocacyforum.org/downloads/pdf/publications/torture/26-June-2013-english-version.pdf 33. International Rehabilitation Council for Torture Victims (IRCT). Kenya national materials. Copenhagen: IRCT; no date. Available from: http:// irct.org/resources/irct-electronic-library/countryspecific-materials/kenya.aspx 34. Advocacy Forum - Nepal. Promising Developments and Persistent Problems. Kathmandu: Advocacy Forum; 2014. [Cited 2015 May 24] Available at: http://advocacyforum.org/downloads/ pdf/publications/torture/promising-developmentpersistent-problems.pdf

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12. Mandel L, Worm L. 2006. Implementing the Istanbul Protocol. RCT Praxis Paper. [Cited 24 May 2015] Available at: http://www.dignityinstitute.org/media/407343/praxis%20paper%20 no.%203.pdf. Last Accessed 24 May 2015.

13. Jensen S, Kelly T, Andersen M, Christiansen C, Sharma J. Torture and Ill-treatment Underperceived: Human Rights Documentation and the Poor. Human Rights Quarterly, forthcoming.

14. Alston P, Knuckey S. The Transformation of Human Rights Fact Finding. New York: Oxford University Press; 2016.

15. Spradley J. The Ethnographic Interview. Long Grove: Waveland; 1979.

16. Teddlie C, Yu F. Mixed Methods Sampling: A Typology With Examples. Journal of Mixed Methods Research 2007 January 1: 77-100.

17. Association of Social Anthropologists of the UK and Commonwealth. Ethical Guidelines for good research practice 2011 [Cited 24 May 2015] Available from: http://www.theasa.org/ethics. shtml 18. Independent Policing Oversight Authority. Monitoring Report on Operation Sanitization 2014.

[Cited 23 January 2016] Available from: http:// www.ipoa.go.ke/ipoa-downloads 19. Kenya National Commission on Human Rights, 29 Days of Terror in the Delta: KNCHR Account Into the Atrocities at Tanza Delta (2012), [Cited 20 January 2016} Available from: http://www. knchr.org/Portals/0/Reports/29_Days_Of_Terror_Delta.pdf 20. Independent Medico-Legal Unit (IMLU). Research Report: A Cry for Justice: Torture and ill-treatment of Hawkers and Small Scale Traders in Nairobi City County. Nairobi: IMLU; 2014.

[Cited 2 February 2015] Available from: http:// www.imlu.org/2011-06-30-23-44-4/2015-08-2809-08-23/reports/finish/2-reports/279-tortureand-ill-treatment-of-hawkers-and-small-scaletraders-in-nairobi-city-county/0.html 21. Anderson D, McKnight J. Kenya at War: Al Shabaab and its Enemies in Eastern Africa. African Affairs. 2015 114(1): 1-27.

22. Atlas of Torture: Observing the Situation of Torture Worldwide. Bangladesh: Security services proposed amendments to limit the protection against torture [updated Apr 09, 201; cited 4 Jun 2015;] Available from: http://www.univie.ac.at/ bimtor/news/1765 23. Bangladesh Legal Aid and Service Trust (BLAST). BLAST and others vs. Bangladesh and others: Writ Petition No. 3806 of 1998, High Court Division of the Supreme Court of Bangladesh. [Cited Jun 4 2015] Available from: http://

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D E B AT E

Debatei Related to 'A comparative study of the use of Istanbul Protocol amongst civil society organizations in low-income countries’ by Kelly et al. (pages 60 to 73)

Comment I: Istanbul Protocol in lowincome countries – A reply

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Rusudan Beriashvili, MD, PhD, Vincent Iacopino, MD, PhD

In an article in this issue by Kelly et al. on the use of the Istanbul Protocol amongst civil society organizations in low-income countries, the authors conclude that the significance of the Istanbul Protocol is “limited to a very small – albeit important - number of legal cases” and largely does not apply to low-income countries based on issues such as fear of reprisals, the lack of trained health professionals, and the duration and expense of comprehensive forensic medical evaluations. As clinicians who have participated in the development of the Istanbul Protocol and implementation of Istanbul Protocol standards in many contexts and countries, including low-income countries, we are concerned that the conclusions in the article are not well founded.

During the development of the Istanbul Protocol, the authors were acutely aware of variations in country conditions including the threat of reprisals and limited financial and human resources. While the Istanbul Protocol contains detailed guidelines for the effective legal and medical investigation of torture and ill treatment, it clearly states that

i

Editor: Pau Pérez-Sales

these guidelines are not fixed. The only component of the Istanbul Protocol that is considered universal is the principles on which the Istanbul Protocol is based, namely, the “Istanbul Protocol principles” which are contained in Annex I. Kelly et al. acknowledge in their article that the Istanbul Protocol principles represent minimum standards for the effective legal and medical investigation and documentation of torture and ill treatment. Indeed, the Istanbul Protocol principles for medical evaluations were developed to address the issues of universal application. These are brief, less than half a page, and can be summarized as follows: • Medical evaluators should behave in conformity with the highest ethical standards and obtain informed consent before any examination is conducted.

• Medical evaluations must:

• c onform to established standards of medical practice;

•b e under the control of medical experts, not security personnel; and,

•b e conducted promptly.

• Written reports must be accurate and include the following:

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• identification of the alleged victim and conditions of the evaluation; • a detailed account of allegations including torture methods and physical and psychological symptoms; • a record of physical and psychological findings; • a n interpretation of all findings, an opinion on the possibility of torture and/or ill-treatment, and clinical recommendations; and, • identification and the signature of the medical expert(s).

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These principles were intended to apply to all medical evaluations regarding alleged torture and ill-treatment, not only comprehensive forensic, medical legal contexts, and this is clearly stated in the introduction of the Istanbul Protocol. Most clinicians who use the Istanbul Protocol understand that brief medical evaluations can be conducted in accordance with the Istanbul Protocol principles for many different purposes, for example, in human rights investigations, human rights monitoring, prevention, and advocacy activities, as well as clinical encounters with alleged victims that are not intended to be comprehensive forensic evaluations. The presumption that the Istanbul Protocol requires comprehensive forensic evaluations in all circumstances is, unfortunately, not consistent with the content of the Istanbul Protocol or actual practices.

The reason for this presumption in the article is not clear; the authors did not assess awareness of the Istanbul Protocol or the potential relationship between awareness and attitudes to and opinions on the Istanbul Protocol. It is therefore possible that attitudes and opinions in the article were not consistently based on actual knowledge of the Istanbul Protocol. The authors acknowledged

that in one country, Bangladesh, none of the participants reported having any Istanbul Protocol training. In addition, the inclusion of attitudes to and opinions on medical evaluations by non-clinicians, such as journalists, attorneys and human rights advocates, may also account for the misperception that the Istanbul Protocol requires comprehensive forensic evaluations in all circumstances.

Istanbul Protocol principles and guidelines for medical investigation and documentation of torture and ill-treatment apply to qualified clinicians as medical knowledge is necessary to make a valid interpretation of the consistency between specific allegations of torture and physical and psychological evidence on evaluation. The Istanbul Protocol principles for medical evaluations are not intended for investigation and documentation by journalists and non-clinicians who interview and investigate torture.

Although the authors are careful to state that their methodology does not permit generalization of their findings, they appear to suggest that the concerns expressed by participants are related to low-income status in the three countries included in the study.

Since there were no participants from middle- or high-income countries, this causal inference seems unjustified. In our experience, issues such as fear of reprisal by alleged victims, the availability of qualified health professionals, and the duration and expense of comprehensive medical legal evaluations are not unique to low-income countries. The threat of reprisal, for example, is a common concern throughout the world and is more likely a function of impunity than the economic status of a country.

As mentioned previously, the Istanbul Protocol does not require all medical evaluations to follow the guidelines for comprehensive forensic assessments of physical and psychological evidence. Brief

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medical evaluations can be conducted by qualified medical personnel in a timely, efficient and cost-effective manner. While we agree that comprehensive forensic evaluations require additional expertise and may be time-consuming and expensive, this is not a deficiency of the Istanbul Protocol, but rather the nature of rigorous medical evaluations in legal contexts. In our experience, these very important and practical issues can and should be addressed to enable the conditions for effective investigation and documentation in accordance with Istanbul Protocol principles and guidelines.

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Comment II: Documentation of Torture and Justice ‘Bon pour L`Orient’i? Önder Özkalıpcı, PhD, MD

The study by Kelly et al. on the Istanbul Protocol (IP) was made in three low income countries. It is based on eighty interviews of human rights practitioners who in “many cases… were lawyers, but clinicians and other human rights professionals were also included.” (p63) The study does not provide a breakdown of the individuals interviewed, their professions, or their experience in documentation and specifically medico-legal or IP documentation. The study does not assume interviewees had any prior knowledge of the IP. In addition, health professionals – a key group that implements the IP – do not appear to be well represented among the interview group.ii The study argues that one of the IP’s weaknesses is that it does not lead to precise conclusions, but it does not suggest that more precise methods of documentation are available. The study is also unclear regarding whether any interviewees had knowledge of clinical forensic science and how its conclusions are made.iii Through and even within

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i ‘Bon Pour L’Orient’ was a stamp affixed by French universities to diplomas earned by its Arab colonial subjects. It indicated that the students were not qualified for and did not receive the same level of excellent education as Western students, but an education that was ‘good enough for the Orient’. ii Of the forty-three citations to interviewees, only eight are to health professionals, including six to a medical professional’ in Nepal (possibly the same individual), one to a medical doctor in Nepal, and one to a psychologist in Kenya. iii To put precision in perspective, not even DNA paternity tests offer 100% conclusive results.

the field of forensic science, the IP has increased the ability of practitioners to make stronger and more complete conclusions on torture. This has been achieved by promoting joint medico-legal reports by mental health and medical professionals following a comprehensive evaluation of the history of torture allegations, all physical and psychological symptoms preceding, during, and following alleged torture events, and laboratory test results.

The article argues that IP implementation may be impracticable due to security concerns and limited resources. These are serious challenges, but to justice generally.

These challenges, particularly where the rule of law is weak/impunity is high, affect not only human rights practitioners and health professionals, but judges and prosecutors too. The IP was created as one response to torture denial and impunity – by providing a tool to gather strong and clear evidence and by creating an obligation upon states to do so. The Principles on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment were adopted by the United Nations (UN) General Assembly.1 The Principles provide a legal basis for human rights organisations to challenge the unwillingness of states to investigate torture allegations effectively, impartially, and promptly.

The study argues that “comprehensive documentation might not always be the most effective way of achieving the broader goals

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of human rights organizations” although, it does not identify what those broader goals are. Human rights organisations have numerous strategies available to tackle the problems they face; the IP is just one tool.

However, if the broader goal of human rights organisations is to force states to admit torture, confront it, improve the justice system, enhance the rule of law, and to provide redress to victims, the IP is designed for that purpose, namely, for producing compelling and undeniable evidence of torture. The IP has proven to be effective in achieving that goal in challenging contexts.

Effective investigation and documentation is central to the three pillars of state obligation under the UN Convention against Torture to ensure justice and to prevent and to redress all acts of torture. One perpetrator held accountable under rule of law has the potential to prevent a thousand new instances of torture. The process of documentation is also part of the rehabilitation process and often has an rehabilitative effect on victims.

Where torture is prevalent, providing training and implementing activities on IP has significant value for improving justice.

From our global experience, applying the IP can enhance state investigatory practices, the quality of forensic services, and other justice mechanisms. In states without functional justice systems, IP documentation done today can be important to the future. For this reason, prominent organisations have provided training on IP documentation of torture in conflict and post-conflict states, including the International Rehabilitation Council for Torture Victims (IRCT) in Libya, Burundi, and the Democratic Republic of the Congo2 and Physicians for Human Rights in Afghanistan and Syria.3 In its discussion section, the study provides interesting suggestions to achieve

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accountability for human rights violations, such as reporting perpetrators in Nepal and Bangladesh to the UN Department of Peacekeeping Operations (DPKO) to foil the ability of alleged perpetrators to obtain lucrative jobs serving in UN peace keeping missions abroad. The study notes that, in these instances, only limited ‘proof’ is needed. Human rights practitioners should be congratulated for using all means available to build pressure on perpetrators.

Practitioners should utilise any number of tactics, such as naming and shaming, a strategy that has also been applied in Nepal.4 The study however concludes that lobbying donors and local politicians is more effective than utilising IP medico-legal reports in the judicial system. While these methods for accountability may supplement efforts to achieve justice through rule of law, they should not supplant them; it is unthinkable that human rights organisations only have the broader goal of preventing perpetrators from obtaining lucrative or political jobs and that victims are satisfied with only that.

Whether we succeed or not in our efforts to advance justice and the rule of law, we should not ignore the societal need to strive toward broader goals. The IP is an important tool for doing so.

We should not speak of methods that are ‘bon pour l’Orient’, or accountability that is ‘bon pour l’Africa’, or human rights, or women’s rights, or redress that is merely ‘good enough’ despite all the serious obstacles and challenges before us. Recourse to donor organisations and political leaders can never be a suitable alternative to achieving justice through the rule of law.

Finally, while I have reservations and disagreements with the conclusions of this study, I wish to thank the authors and supporting institutions for undertaking research on the IP. All discussion and

79 D E B AT E

research on the IP is positive; raising awareness of it and the value of high quality medico-legal documentation of torture. Let us continue these explorations into the challenges of documenting torture as the more we continue to discuss how to do it better, the greater chance we have for achieving a better world.

References 1. Principles on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment Recommended by General Assembly resolution 55/89 of 4 December 2000 Available from: http://www.ohchr.org/EN/ProfessionalInterest/Pages/EffectiveInvestigationAndDocumentationOfTorture.aspx 2. IRCT Annual Report [Internet] 2015 Available from: file:///C:/Users/nawirctorg/Downloads/ IRCT-annual+report+2015.pdf 3. Physicians for Human Rights, Forensic Training Institute [Internet] Available from: http://physiciansforhumanrights.org/training/ 4. Sharma JR. Documenting torture. Republica [Internet]. 2016 May 26 [cited 31 October 2016] Available from: http://admin.myrepublica.com/ opinion/story/42817/documenting-torture.html

T O RT U RE Vo lu m e 2 6 , Nu m be r 3 , 2 0 16

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Response by the authors Tobias Kelly, PhD*, Steffen Jensen, PhD**, Morten Koch Andersen, PhD**, Catrine

T O RT U RE Vol u m e 2 6 , N um be r 3 , 2 01 6

Christiansen, PhD*** , Jeevan Raj Sharma PhD*

We would like to thank the editors and the commentators for their comments and the opportunity to respond. We greatly appreciate the time and effort that such experienced and expert practitioners have taken to read our paper.

We think the Istanbul Protocol is a crucially important document in the struggle against torture, and it is therefore very important to think about the ways in which it is used in practice as part of a wider campaign to prevent torture and provide survivors with redress. More broadly, our general aim is to participate in a wider debate about the ways in which human rights organizations can produce effective evidence in the struggle to end impunity and provide justice.

We welcome this opportunity to clear up some misunderstandings that may have arisen.

We do not say in the article that the IP requires comprehensive documentation.

Indeed we say early on in the paper that it is designed as a flexible protocol. It is all the more important therefore to think about how the IP can be best used in practice, given the range of potential options it presents. The article therefore sets out to see if, how and when human rights practitioners use the IP in the context of wider human rights processes. Our conclusion is not that the IP

*) School of Social and Political Science, University of Edinburgh, Scotland **) Dignity: Danish Institute Against Torture, Copenhagen, Denmark. *** Independent consultant

is inapplicable to Low-Income Countries, but the much more limited claim that more comprehensive forms of forensic documentation, as set out in the IP, will be limited to a small, albeit, important number of cases.

The commentators are concerned that we have included the opinions of non-clinicians in our study. We did this deliberately.

Our aim was to examine how documentation is used as part of human rights work.

Journalists and lawyers are certainly not qualified to carry out forensic documentation. However, they are often the ones who use such documentation as part of wider attempts to seek justice. To end the discussion of the IP at what clinicians think would be to ignore the ways in which the IP should be seen as a tool in these broader struggles.

The three countries in which we carried out the study can all be classified as LowIncome. We do not make any causal inferences about the ways in which Low-Income status impacts on human rights work. We of course recognize that impunity is a problem all over the world. At the same time, it is also important to recognize that resource limitations are more acute in some places than in others.

We are certainly not suggesting that human rights aspirations should be low in Low-Income countries, and say so explicitly in the introduction. We do think though that human rights struggles, at a tactical level, do not operate in a vacuum and they therefore need to take the political and legal context into account; it is only by doing so that they can be effective.

TORTURE Journal on Rehabilitation of Torture Victims and Prevention of Torture Published by the International Rehabilitation Council for ­Torture Victims (IRCT), Copenhagen, Denmark.

TORTURE is indexed and included in MEDLINE. Citations from the articles indexed, the indexing terms and the English abstracts printed in the journal will be included in the databases

Contents

Volume 26, No 3, 2016 ISSN 1018-8185

The Journal has been published since 1991 as Torture – Quarterly Journal on Rehabilitation of Torture Victims and Prevention of Torture, and was relaunched as Torture from 2004, as an inter­national scientific core field journal on t­ orture

Scientific Articles

Editor in Chief Pau Pérez-Sales, MD, PhD Managing Editor Leanne Macmillian Editorial Assistant Nicola Witcombe, MA Editorial advisory board S. Megan Berthold, PhD, LCSW Hans Draminsky Petersen, MD Jim Jaranson, MD, MA, MPH Marianne C. Kastrup, MD, PhD Jens Modvig, MD, PhD Duarte Nuno Vieira, PhD, MSc, MD Önder Özkalipci, MD June C. Pagaduan-Lopez, MD José Quiroga, MD Nora Sveaass, PhD Morris V. Tidball-Binz, MD Language editing Monica Lambton, MA, BA Correspondence to IRCT Vesterbrogade 149, building 4, 3rd floor, 1620 Copenhagen V, Denmark Telephone: +45 44 40 18 30 Email: irct@irct.org Subscription www.irct.org Price: EURO 50 or DKK 375 per year. www.irct.org/Library/torture-journal.aspx.

The journal is free of charge for health professionals.

The views expressed herein are those of the authors and can therefore in no way be taken to reflect the official opinion of the IRCT. Front page: Mogens Andersen, Denmark Printed in Denmark by Scanprint a/s, Horsens, Jylland

Editorial

Pau Pérez-Sales, Editor in Chief

1

Incommunicado detention and torture in Spain: Part I: The Istanbul Protocol Project in the Basque Country

Istanbul Protocol Project in the Basque

Country Working Group 3 Part II: Enhanced credibility assessment based on the Istanbul Protocol

Pau Pérez-Sales, Benito Morentin, Olatz Barrenetxea,

Miguel Angel Navarro-Lashayas 8 Part III: 'Five days is enough’: the concept of torturing environments

Pau Pérez-Sales, Miguel Angel Navarro-Lashayas,

Angeles Plaza, Benito Morentin,

Oihana Barrios Salinas 21 Part IV: Psychological and psychiatric consequences of ill-treatment and torture: trauma and human worldviews

Miguel Angel Navarro-Lashayas, Pau Pérez-Sales,

Gabriela Lopez-Neyra, Maitane Arnoso Martínez,

Benito Morentin 34 Enhancing empathy among humanitarian workers through Project MIRACLE: Development and initial validation of the Helpful Responses to Refugees Questionnaire

Miriam Potocky, Kristen L. Guskovict 46 A comparative study of the use of the Istanbul Protocol amongst civil society organizations in low-income countries

Tobias Kelly, Steffen Jensen, Morten Koch Andersen,

Catrine Christiansen, Jeevan Raj Sharma 60 Debate

Related to 'A comparative study of the use of the Istanbul Protocol amongst civil society orrganizations in low-income countries' pp.60-73 Comment I: Istanbul Protocol in low-income countries - A reply

Rusudan Beriashvili,Vincent Iacopino 74 Comment II: Documentation of torture and justice: 'Bon pour L'Orient?

Önder Özkalıpcı 77 Response by the authors

Tobias Kelly, Steffen Jensen, Morten Koch Andersen,

Catrine Christiansen, Jeevan Raj Sharma 80

Correction: In the printed version of 'Group treatment for survivors of torture and server violence: A literature review' (Volume 26, No 1 2016 p45), the affiliation of Faith Ray should have read National Capacity Building Project at Center for Victims of Torture, St. Paul, Minnesota, USA.

Part I: The Istanbul Protocol Project in the Basque Country Istanbul Protocol Project in the Basque Country Working Group

Part III: 'Five days is enough’: the concept of torturing environments Pau Pérez-Sales, Miguel Angel Navarro-Lashayas, Angeles Plaza Benito Morentin, Oihana Barrios Salinas

Enhancing empathy among humanitarian workers through Project MIRACLE: Development and initial validation of the Helpful Responses to Refugees Questionnaire Miriam Potocky, Kristen L. Guskovict A comparative study of the use of the Istanbul Protocol amongst civil society organizations in low-income countries Tobias Kelly, Steffen Jensen, Morten Koch Andersen, Catrine Christiansen, Jeevan Raj Sharma

Jour nal on Rehabilitation of Torture Victims and Prevention of Torture

TORTURE – VOLUME 26, NO 3, 2016

Part II: Enhanced credibility assessment based on the Istanbul Protocol Pau Pérez-Sales, Benito Morentin, Olatz Barrenetxea, Miguel Angel Navarro-Lashayas

TORTURE 3

Part IV: Psychological and psychiatric consequences of ill-treatment and torture: trauma and human worldviews Miguel Angel Navarro-Lashayas, Pau Pérez-Sales, Gabriela Lopez-Neyra Maitane Arnoso Martínez, Benito Morentin

Online subscription Please sign up to receive an email notification as soon as a new issue is available online at www.irct.org/torture.journal rather than opting for a hard copy.

The IRCT is an independent, international health professional organisation that promotes and supports the rehabilitation of torture victims and the prevention of torture through nearly 200 rehabilitation centres and pro­ grammes around the world.

The objective of the organisation is to promote the provision of specialised treatment and rehabilitation services for victims of torture and to contribute to the prevention of torture globally. To further these goals, the IRCT seeks on an international basis:

•

to develop and maintain an advocacy pro­ gramme that accumulates, processes and disseminates information about torture as

• •

• • •

well as the consequences and the rehabilita­ tion of torture to establish international funding for re­ habilitation services and programmes for the prevention of torture to promote the education and training of relevant professionals in the medical as well as social, legal and ethical aspects of torture to encourage the establishment and main­ tenance of rehabilitation services to establish and expand institutional rela­ tions in the international effort to abolish the practice of torture, and to support all other activities that may con­ tribute to the prevention of torture

ISSN (Online): 1997-3322 ISSN (Print): ISSN 1018-8185

VOLUME 26, NO 3, 2016, ISSN 1018-8185

2016

Incommunicado detention and torture in Spain: