You are on page 1of 49

Giving Voice

Using Testimony as a Brief Therapy Intervention in Psychosocial Community Work for Survivors of Torture and Organised Violence

Report from a Pilot Training Project with: Peoples Vigilance Committee for Human Rights (PVCHR) Varanasi, India
Phase One of the Capacity Building Project:

Brief Therapy Interventions Among Human Rights Organisations In Crisis Affected or Developing Countries

Draft Final Report July 2008

Inger Agger, PhD Rehabilitation and Research Centre for Victims of Torture (RCT), Copenhagen, Denmark

Table of Contents
ABBREVIATIONS................................................................................................................... 4 EXECUTIVE SUMMARY....................................................................................................... 5 1. CHOICE OF TESTIMONY METHOD........................................................................................ 5 2. PROJECT OUTPUTS................................................................................................................ 5 3. THE M&E COMPONENT........................................................................................................ 6 1. INTRODUCTION................................................................................................................. 7 2. DEVELOPMENT OF THE TESTIMONY METHOD..................................................... 9 2.1 ADDING MINDFULNESS TO THE TESTIMONY METHOD............................................... 12 3. THE WORKSHOP............................................................................................................. 14 3.1 CONTENT OF WORKSHOP.................................................................................................. 14 3.2 WORKSHOP PARTICIPANTS............................................................................................... 17 3.3 THE TWENTY-THREE SURVIVORS WHO GAVE THEIR TESTIMONIES..............................18 3.4 THE DELIVERY CEREMONY AND POLITICAL DEMONSTRATION.....................................19 3.5 DEVELOPING THE MANUAL............................................................................................... 19 4. REVIEW OF THE M&E COMPONENT BY PETER POLATIN, MD, HEALTH PROGRAM MANAGER....................................................................................................... 20 4.1 ASSESSMENT OF M&E QUESTIONNAIRE: PROBLEMS TO BE REMEDIED........................ 20 4.2 PRELIMINARY STATISTICAL DATA GENERATED............................................................. 22 4.3 PRELIMINARY CONCLUSIONS BASED ON INITIAL EVALUATION OF THE M&E............. 23 4.4 CONCLUSIONS AND RECOMMENDATIONS......................................................................... 24 ANNEX I. TERMS OF REFERENCE................................................................................. 26 ANNEX II. MEMORANDUM OF UNDERSTANDING.................................................... 30 ANNEX III. M&E METHODOLOGY, BY PETER POLATIN, MD. HEALTH PROGRAM MANAGER....................................................................................................... 34

ANNEX IV. PILOT QUESTIONNAIRE, BY PETER POLATIN, MD, HEALTH PROGRAM MANAGER....................................................................................................... 38 ANNEX V. PROPOSAL FOR FURTHER COLLABORATION PVCHR/RCT............. 43 ANNEX VI. PVCHR PRESS ANNOUNCEMENT ABOUT WORKSHOP, CEREMONY AND DEMONSTRATION ........................................................................... 45

Abbreviations
ICF MBCT MBSR M&E NET PTSD PVCHR RCT TOV UN WHO International Classification of Functioning and Disability Mindfulness-based Cognitive Therapy Mindfulness-based Stress Reduction Monitoring and Evaluation Narrative Exposure Therapy Post-traumatic Stress Disorder Peoples Vigilance Committee on Human Rights Rehabilitation and Research Centre for Torture Victims Torture and Organised Violence United Nations World Health Organisation

Executive Summary
From 15 April to 15 June 2008, RCT funded a collaborative pilot training project with Peoples Vigilance Committee on Human Rights (PVCHR) in Varanasi, India on Testimony as a Brief Therapy Intervention. The project involved four weeks of training of PVCHR staff in May by the RCT Psychosocial Consultant, Inger Agger. The RCT Health Programme Manager, Peter Polatin, was responsible for the M6E component of the project. The pilot project constituted phase one of a larger capacity building project: Brief Therapy Interventions Among Human Rights Organisations in Crisis Affected or Developing Countries. While the overall objective of the capacity building project is to develop new knowledge about how to alleviate human suffering and consequences of torture, the specific objectives of the pilot project were as follows: 1. To develop a context specific manual for training in the use of the Testimony Method; 2. To build the capacity of the staff at PVCHR through a training workshop; 3. To enhance the psychosocial wellbeing of a number of survivors of TOV who were clients of PVCHR; 4. To summarise and analyse the results; 5. Informally, to evaluate the possibilities for further collaboration between RCT and PVCHR. 1. Choice of Testimony Method Testimony therapy, which originated in Chile during the military dictatorship has been used in different variations for more than 25 years in a number of cultural and political contexts: for refugees in Denmark, the Netherlands, Germany, Bosnia, Kosovo and USA; for survivors of civil war in Mozambique; for humanitarian aid workers in Iraq; and for Sudanese refugees in Uganda. The testimony method was chosen for several reasons: (1) Indian human rights organisations, which often use justice (not health) as their entry point had shown an interest in it; (2) it was in line with previous RCT work in India (a study of psycho-legal counselling); (3) it was adaptable for a context with few professional mental health staff resources; (4) it could be adapted for use as a brief therapy intervention; (5) the RCT psychosocial consultant had many years of experience with the method. A Mindfulness meditation component was added to the testimony method with good results. 2. Project Outputs The pilot project was very succesful and the following outputs were produced: A manual for community workers and human rights defenders was developed: Giving Voice: Using testimony as a Brief Therapy Intervention in Psychosocial Community Work for Survivors of Torture 5

and Organised Violence (June 2008). The manual has been distributed to a large number of human rights organisations in PVCHRs network and has also been posted on the RCT international website. The Manual will be translated into Hindi and published in English in the RCT Praxis Paper series. 12 community workers and human rights defenders from PVCHR were trained in the Testimony Method, Mindfulness and M&E through a twoweeks workshop in which the first week was devoted to theory and practical training, while the trainees in the second week made testimonies and filled in M&E questionnaires of 23 survivors under supervision. 23 survivors received two sessions of testimony therapy. A third session in the form of a political action and delivery ceremony was held in front of the District Government Headquarter of Varanasi where fourteen testimonies were read out in public and delivered to the survivors who were also honoured with a cotton shawl (a symbol of honour in India) and a speech which praised their bravery and encouraged them to continue fighting for justice. The results from this pilot project with PVCHR were promising and invited for further collaboration between PVCHR and RCT. PVCHR has proposed a one-year follow-up training project in collaboration with RCT, starting from August 2008. The project involves follow-up supervision of PVCHR staff, training of other human rights organisations, as well as a Consultative Meeting and a two-day conference.

3. The M&E Component A database has been constructed at RCT International Department and the data from the M&E questionnaires have been entered and analysed. The Health Programme Manager has the following conclusions and recommendations on basis of the pilot phase of the project: Continuation of the PVCHR Testimonial Project so as to increase the N for the study, as well as to increase the number of beneficiaries and expand the capacity of the organization to provide this brief therapy. Expansion of the project by offering capacity building to other human rights organizations. This should include an M&E system. Modification of the questionnaire to elicit more consistency in the responses and generate information that is more consistent with the actual realities of the beneficiaries. Dedication of more resources to expanding M&E capacity in the international work of the RCT. This will require expertise in the International Department at RCT.

1. Introduction
RCTs mission includes the contribution of new knowledge about how to alleviate human suffering and consequences of torture 1. The present partner organisations of RCT undertake various counselling interventions to assist victims of torture, but the concept of counselling has different meanings for different organisations, and there is a lack of knowledge about the most useful psychosocial interventions2. Therefore, a number of projects have been developed to deepen the knowledge about best practices. A fact-finding mission to India from 26 March 3 April 2007 3 with visits to several Indian human rights organizations found that short-term counselling seemed to be the rehabilitation method of choice for organizations visited. Most of the counselling methods observed were, in fact, variations of psycholegal counselling, which has been the subject of an in-depth study by RCT and the Indian human rights organization, Jananeethi 4, from November 2006 January 2007. In psycho-legal counselling, justice constitutes the therapeutic entry point and is an important element in the healing process. It would therefore seem natural to introduce the testimony method in India, as this method is mostly brief and can be used both in individual and community interventions. In the testimony method justice is mostly considered an important healing element, although the method as explained below - has also been seen as psychodynamic, existential, cognitive-behavioural, or narrative. Two of the organizations visited during the RCT fact-finding mission to India in March-April 2007 (Swanchetan in New Delhi, and Peoples Vigilance Committee for Human Rights (PVCHR) in Varanasi) expressed the wish to strengthen their counselling capacity by receiving training through RCT in the use of the Testimony Method as a Therapeutic Tool. Following a third fact-finding mission to India, which occurred from March 23 -30, 2008, it was decided by RCT to start a capacity building project in India RCT (September 2004). RCT Policy: RCT Challenges and Targets in a Changing World. Copenhagen: RCT. 2 Olesen, J.S., Haagensen, J.O., Madsen, A-G. & Rasmussen, F. (2006). From Counselling to Psycho-Social Development. Copenhagen: Rehabilitation and Research Centre for Torture Victims. 3 Haagensen, J.O., Wendt, E. % Agger, I. (2007). Fact-finding Mission to India. Copenhagen: RCT, Report. 4 Agger, I., Ansari, F., Suresh, S. & Pulikuthiyil, G. (2008). Justice as a Healing Factor: Psycho-legal Counselling for Torture Victims in an Indian Context. Peace and Conflict: Journal of Peace Psychology, Vol. 14 (3).
1

and possibly expand it to other countries: Brief Therapy Interventions Among Human Rights organisations in Crisis Affected or Developing Countries. Phase One of this project was a pilot training project with PVCHR on the testimonial method 15 April 15 June 2008. Phase Two of the capacity building project is expected to start on 15 August 2008 and include a larger training project with PVCHR, as well as training of other NGOs in India, and in Sri Lanka and the Philippines (and possibly in other locations).

2. Development of the Testimony Method


In 1983 two Chilean therapists described, for the first time, the use of testimony5 as a therapeutic technique with torture victims and with relatives of victims. The testimony was tape-recorded by the therapist and revised jointly by therapist and patient into a written document, and the aim of the testimony was to facilitate integration of the traumatic experience and restoration of selfesteem. However the authors note that, communication of traumatic events through testimony may also have been usefulbecause it channelled the patients anger into a socially constructive action production of a document that could be used as an indictment against the offenders. The possibility of putting their experiences to use resulted in the alleviation of guilt (p. 50). The method was further described in 19906 as a ritual both of healing and of condemnation of injustice, and that the concept of testimony would seem to be universal phenomenon: when political refugees give testimony to the torture to which they have been subjected, the trauma story can be given a meaning, can be reframed: private pain is transferred into political dignity (p. 115). In a textbook from 1992 on counselling and therapy with victims of war, torture and repression7, the testimony method was recommended as a brief psychotherapy with motivated clients, or as a more flexible supplement to other approaches when the client has many other problems besides the TOV. In 1994 the testimony method was used in a research project about the psychotherapeutic treatment of women victims of sexual torture 8, and in 1996 it was explored in a Chilean context as a therapeutic tool developed in the political framework of an active human rights movement 9. In 1998 the testimony method was studied in a South African context where public testimony constituted the central mechanism in the South African Truth and Reconciliation Commission (TRC) process10. The authors locate the testimony method within the broad framework of social constructionism and Cienfuegos, A.J. & Monelli, C. (1983). The Testimony of Political Repression as a Therapeutic Instrument. Amer. J. Orthopsychiat. 53 (1), 43-51. 6 Agger, I. & Jensen, S.B. (1990). Testimony as Ritual and Evidence inPsychotherapy for Political Refugees. Journal of Traumatic Stress, 3 (1), 115-130. 7 Van der Veer, G. (1992). Counselling and Therapy with Refugees: Psychological Problems of Victims of War, Torture and Repression. West Sussex, UK: John Wiley & Sons Ltd. 8 Agger, I. (1994). The Blue Room. Trauma and Testimony Among Refugee Women a Psychosocial Exploration. London: Zed Books. 9 Agger, I. & Jensen, S.B. (1996). Trauma and Healing Under State Terrorism. London: Zed Books. 10 De la Rey, C. & Owens, I. (1998). Perceptions of Psychosocial Healing and the Truth and Reconciliation Commission in South Africa. Peace and Conflict: Journal of Peace Psychology, 4 (3), 257-270.
5

they find that thematic analysis revealed that overall, the narratives affirmed the therapeutic value of the testimony method, and the connectedness between individual healing and national reconciliation (p. 257). The same year, the testimony method was also studied in a Bosnian context 11 where the method was used with a group of traumatized Bosnian Refugees and provided preliminary evidence that testimony psychotherapy may lead to improvements in PTSD and depressive symptoms, as well as to improvement of functioning in survivors of state-sponsored violence (p. 1720). In 2002 Narrative Exposure Treatment, integrated by components from the testimony method and cognitive behaviour therapy, was applied to a severely traumatized Kosovar refugee12. This case study indicates that Narrative Exposure is a promising and realistic approach for the treatment of even severely traumatized refugees living in camps. In addition, it can provide valid testimonies about human rights violations without humiliating the witness (p. 205). In the Netherlands, the testimony method has been applied in the treatment of traumatized asylum seekers and refugees13. The therapy, consisting of 12 sessions, is in 2003 described step-by-step and the working mechanisms of the testimony method are reframed in cognitive-behavioural terms as exposure to the traumatic memories, as well as the adjustment of inadequate cognitions (p. 368-369). In 2003 in Germany, a testimony project for traumatized Bosnian refugees living in legal limbo for many years was carried out where the testimony method was used in combination with supportive therapy and advocacy 14: By giving testimony, survivors benefited psychologically and became better able to cope with the difficult present. Feelings of self-worth and dignity could be regained and a trusting relationship between the survivor and the listener facilitated the therapeutic process. The testimony material documented human rights abuses both in the country of origin and in exile, helped us to perform informed advocacy for this group and informed a larger public on the psychological costs of refugee resettlement policies (p. 393). In 2004 the effectiveness of the testimony method was explored in a rural Weine, S.M., Kulenovic, A.D., Pavkovic, I. & Gibbons, R. (1998). Testimony Psychotherapy in Bosnian Refugees: A Pilot Study. The American Jounal Of Psychiatry, 155 (12), 1720-1726. 12 Neuner, F., Schauer, M., Roth, W.T. & Elbert, T. (2002). A Narrative Exposure Treatment as Intervention in a Refugee Camp: A Case Report. Behavioural and Cognitive Psychotherapy, 30, 205-209. 13 Van Dijk, J.A., Schotrop, M.J.A. & Spinhoven, P. (2003). Testimony Therapy: Treatment Method for Traumatized Victims of Organized Violence. American Journal of Psychotherapy, 57 (3), 361-373. 14 Luebben, S. (2003). Testimony Work with Bosnian Refugees: Living in Legal Limbo. British Journal of Guidance & Counselling, 31 (4), 393-402).
11

10

community in Mozambique with survivors of prolonged civil war 15. The study included an intervention group (n=66) and a control group (n=71) and trauma symptoms were measured during a baseline assessment, post-intervention and at an 11-month follow-up. A simple version of the testimony method was applied (only one session for most participants). It is concluded in the study that, a remarkable drop in symptoms could not be linked directly to the intervention. Feasibility of the intervention was good, but controlling the intervention in a small rural community appeared to be a difficult task to accomplish (p. 251). Concerning clinical implications of the study, the authors find that the introduction of the testimony method in a relatively small and isolated rural community was feasible and associated with the decrease of reported psychiatric symptoms (p. 257). In the same year, testimonial psychotherapy was used with traumatised Sudanese adolescent refugees in the United States who lacked experience with or interest in psychiatric care16. Testimonial psychotherapys unique focus on transcribing personal, traumatic events for the altruistic purpose of education and advocacy make it an acceptable interaction by which to bridge the cultural gap that prevents young refugees from seeking psychiatric care (p. 31). Also in 2004 a study was published comparing Narrative Exposure Therapy (NET) with supportive counselling and psycho-education for the treatment of Sudanese refugees living in a Uganda refugee settlement 17. The results indicated that was a promising approach for the treatment of PTSD for refugees living in unsafe conditions. In 2005 the testimony method was also used for injured humanitarian aid workers who had survived the bombing of the UN Headquarters in Iraq 18. The method was found to be an effective tool: The testimony method provided a safe structure to recall the traumatic event, while assisting in the reconstruction of the traumatic memories and associated emotions, and offered an acceptable motivation to do so (p. 57).

Igreja, V., Kleijn, Wim, C., Schreuder, B. J. N., van Dijk, J. & Verschuur, M. (2004). Testimony Method to Amliorate Post-traumatic Stress Symptoms: Community-based Intervention Study with Mozambican Civil War Survivors. British Journal of Psychiatry, 184, 251-257. 16 Lustig, S.L., Weine, S.M., Saxe, G.N. & Beardslee, W.R. (2004). Testimonial Psychotherapy for Adolescent Refugess: A Case Series. Transcultural Psychiatry, 41 (1): 31-45. 17 Neuner, F., Schauer, M., Klaschik, C., Karunakara, U. & Elbert, T. (2004). A Comparison of Narrative Exposure Therapt, Supportive Counseling, and Psychoeducation for Treating Posttraumatic Stress Disorder in an Africal Refugee Settlement. Journal of Consulting and Clinical Psychology, 71 (4), 579-587. 18 Curling, P. (2005). Using Testimonies as a Method of Early Intervention for Injured Survivors of the Bombing of the UN Headquarters in Iraq. Traumatology, 11 (1), 5763).
15

11

Also in 2005, testimony therapy is reframed 19 as an African-centred therapy that focuses on the personal stories of those who consult with the therapist, as well as the collective stories of the African experience in the United States (p. 5). In this narrative approach testimony therapy emphasises the person within community and is social constructionist in its outlook (p. 5). The same year, Schauer, Neuner and Ebert (2005) publish a systematic analysis and manual for how to use testimony in Narrative Exposure Therapy (NET)20 giving an overview of the theoretical background for understanding traumatic stress, and the cognitively oriented therapeutic approach of NET. In an Indian context it would seem useful and interesting to take the point of departure in the research described above by Igreja, Kleijn, Wim et al., (2004) where they used the testimony method in a community-based intervention study with Mozambican Civil War Survivors. The authors of that study find that the testimony method is valuable in circumstances where there is a lack of mental health care resources. They also emphasise that it is relatively easy to master, brief and does not require sophisticated materials. Another important inspiration for the training and the Indian manual produced in our pilot project was the manual of NET by Schauer, Neuner and Ebert (2005). 2.1 Adding Mindfulness to the Testimony Method The consultant decided to add a mindfulness meditation component to the testimony method, in order to further reduce stress, anxiety and depressive thoughts. Mindfulness-based stress reduction (MBSR) 21 and mindfulnessbased cognitive therapy (MBCT)22 have developed over the last twenty years, and have god empirical support for their effectiveness Mindfulness is defined by Kabat-Zinn23 as: paying attention in a particular way: on purpose, in the present moment, and non-judgmentally (p. 4). MBSR and MBCT are inspired by Eastern traditions such as Buddhist meditation and yoga and would therefore seem especially applicable in an Indian context. In relation to the testimony method (as well as NET), Mindfulness has proved effective for narrative integration, the process whereby the life story is weaved together in a process of reflection and neural integration (p. 309-

Akinyela, M.K. (2005). Testimony of hope: African Centred Praxis for Therapeutic Ends. Journal of Systemic Therapies, 24 (1), 5-18. 20 Schauer, M., Neuner, F. & Elbert, Th. (2005). Narrative Exposure Therapy: A Short-Term Intervention for Traumatic Stress Disorders after War, Terror, or Torture. Gottingen: Hogrefe Verlag. 21 Kabat-Zinn, J. (1990). Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. New York: Dell Publishing. 22 Segal, Z.V., Williams, J.M.G. & Teasdale (2002). Mindfulness-Based Cognitive Therapy for Depression: A New Approach to Preventing Relapse. New York and London: The Guilford Press. 23 Kabat-Zinn, J. (1994). Whereever you go, there you are: Mindfulness Meditation in Everyday Life. New York: Hyperion.
19

12

310)24.

Siegel, D.J. (2007). The Mindful Brain: Refelction and Atunement in the Cultivation of Well-Being. New York and London: W.W. Norton & Company.
24

13

3. The Workshop
3.1 Content of Workshop The workshop ran over a two-week period with a theoretical part in the mornings and a more practical part during the afternoons. See below the contents of the training program developed for community workers and human rights defenders: Week One
Day One Morning (Theory)

WORKSHOP ON TESTIMONIAL THERAPY


(1) Psychological trauma (2) Testimony as a psychological healing process

Afternoon (Practise) Day Two Morning (Theory)

(1) Mindfulness meditation (2) Communication and active listening (role-plays) (1) Psychosocial community work (2) Assessment of mental health problems: M&E questionnaire Lunch

Afternoon (Practise) Day Three Morning (Theory) Afternoon (Practise) Day Four Morning (Theory) Afternoon (Practise) Day Five Morning (Theory)

(1) Mindfulness meditation (2) Communication and active questionnaire (role plays) Procedures for taking a testimony Lunch

listening:

using

the

(1) Mindfulness meditation (2) Exercises in taking testimonies (role plays) Experiences and problems from role plays yesterdays Lunch (1) Mindfulness meditation (2) Testimony exercises continued (role plays) Peer group support and issues from the preceding days Lunch

Afternoon (Practise)

(1) Mindfulness meditation (2) Peer group support (role plays) (3) Summing up

14

Week Two
Day One Morning

WORKSHOP ON TESTIMONIAL THERAPY


(1) Mindfulness meditation (2) Preparation meeting: Division of participants in pairs (one is interviewer and the other note-taker). Each pair will provide two sessions of testimony therapy to a survivor in the afternoon. Two sessions of testimonies taken with first group of survivors Interviewers testimonies and note-takers correct and write the

Afternoon Evening Day Two Morning

(1) Mi9ndfulness meditation (2) Supervision and process analysis meeting: Each pair reports experiences and problems from the day before: what went well and what were the problems encountered Two sessions of testimonies taken with second group of survivors Interviewers testimonies and note-takers correct and write the

Afternoon Evening Day Three Morning

(1) Mindfulness meditation (2) Supervision and process analysis meeting: Each pair reports experiences and problems from the day before: what went well and what were the problems encountered Two sessions of testimonies taken with third group of survivors Interviewers testimonies and note-takers correct and write the

Afternoon Evening Day Four Morning

(1) Mindfulness meditation (2) Supervision and process analysis meeting: Each pair reports experiences and problems from the day before: what went well and what were the problems encountered Two sessions of testimonies taken with fourth group of survivors Interviewers testimonies and note-takers correct and write the

Afternoon Evening Day Five Morning

(1) Mindfulness meditation (2) Supervision and process analysis meeting: Each pair reports experiences and problems from the day before: what went well and what were the problems encountered Plans made for a delivery ceremony: where will it take place and how will it be done (privately, in a public space, in a community meeting?) Summing up, feed-back and closure

Afternoon

15

16

3.2 Workshop Participants There were 12 participants in the workshop. Below follows a summery of their personal data and professional backgrounds: Name Ag e 38 Mal e X Femal Education e BA in Ayurveda, Medicine & Surgery, State Ayurvedic Medical College, Haridwar Englis h good X Englis h some Englis h none Work

Lenin

Shruti

33

BA Sociology

Anupam (sister of Shruti)

31

BA Hindi and Sanskrit

Upendra

24

MA in Social Work X MA in Social Work MA

Shabana

28

Karman

28

Founder & Director of PVCHR Human rights of lowercaste people: Dalit ideologue, access of voiceless to constitutional rights Managing Trustee of PVCHR, Community human rights work: Dalit rights, womens rights, child rights Core Team Member of PVCHR, Community HR work: teacher, health supervisor Project Coordinator, Community HR work Translator, Community HR Work Associate.

17

ya

Sociology

Anjana

25

MA in Social Work

Vijay

36

Intermedia te

Niraj

28

MA in Human Rights

Anand

31

MA in Ancient Histroy High school

Daya

36

Male

35

Documentati on, advocacy, reporting. HR activist Intern, Community HR Work: Health work (TB), worker education, rural development, gender Core Team Member of PVCHR, Dalit Rights activist, educator, Community HR Work Associate, Journalist, editor, works with police torture Activist, teacher, Community HR work HR EU monitor, community HR work: children Activist, Community HR work

The age of the participants ranged from 24 38 years. 6 of them were male, and 4 were female. 6 of the participants had an MA degree (in social work, sociology, history or human rights); 3 had a BA (in ayurvedic medicine, sociology or Hindi); and 3 had only an intermediate school education. 7 understood English, and 3 spoke it well. 2 did not understand any English. 3.3 The Twenty-three Survivors who gave their Testimonies The 23 survivors who gave their testimonies were known to PVCHR. They

18

had all previously given legal testimonies for use in court cases against the perpetrators. They were selected out of a group of approximately 80 clients of PVCHR because they had shown evidence of psychological distress. 19/23 were male, and 2 belonged to the upper castes, while 13 belonged to the backward castes and 8 to the scheduled castes. 21/23 were Hindus, while 1 was a Muslim and another was a Buddhist. There were 17 primary victims, and 6 secondary victims. See Chapter 4 for further information about the mental health status of the survivors. 3.4 The Delivery Ceremony and political demonstration The training was concluded by a ceremony held in front of the District Government Headquarter of Varanasi where 14 of the 23 testimonies were read out in public and delivered to the survivors who were also honoured with a cotton shawl (a symbol of honour in India) and a speech which praised their bravery and encouraged them to continue fighting for justice. The eyes of all the survivors and their family members were wet after hearing the testimonies and they were feeling very happy and good inside. Mrs. Chanda Mushar started crying while she was honored with the testimony. The whole testimony process and ceremony was very successful. At the end of the ceremony all the survivors united and sat in a circle and interacted with each other about their testimonies as if they had known each for a long time. The ceremony also drew the attention of many people who were sitting in the District Government Head Quarter square and everyone was curious to know more about the testimony method. The ceremony was transmitted by local TV networks and written about by the press, including the Times of India (from the press anouncement sent out by PVCHR to its network after the ceremony). 3.5 Developing the Manual The manual: Giving Voice: Using testimony as a Brief Therapy Intervention in Psychosocial Community Work for Survivors of Torture and Organised Violence was developed in cooperation with the trainees during the workshop. The manual has been distributed to a large number of human rights organisations in PVCHRs network and has also been posted on the RCT international website. It is the plan to translate the manual to Hindi, include illustrations or photographs, and print it in English and Hindi. The English version will be published in RCTs Praxis Paper series.

19

4. Review of the M&E Component by Peter Polatin, MD, Health Program Manager
The questions that constituted the M&E were derived from certain standardized instruments (WHO 5 and Pain Analog), from application of ICF Activities &Participation categories, and from utilization of items from standardized questionnaire information already in use by PVCHR. The experiences of the RCT epidemiologic field study in Bangladesh, recently conducted by Dr. Sharlenna Wang, were also reviewed. The M&E questionnaire was formulated in Copenhagen, but translated and contexualized in Varanasi. However, it was not field tested prior to use in the Pilot Study. Essentially, the Pilot Study WAS the field test for the finalized M&E questionnaire, and it revealed certain problems with the questionnaire, which are summarized below. 4.1 Assessment of M&E Questionnaire: Problems to be remedied Question # or Descriptor 5- Name Code 11- Caste 12- Name of Caste 14- Education 14a- years spent in school 15-Occupation 15a-Occupation other 16-Activities 16a- Activities other Nature of the Problem Gives the participants real name- no anonymity No responses Specific to Varanasi, but what about elsewhere? missing response-3 other response-1 No consistent response other response- 14 5 responses: rickshaw puller(1), tea stall(1), making plates(1), landless laborer(2) no activities-16, other-4 4 responses: karma dancer(1), religious, political, and humanitarian(1), trade union, political, religious(1), religious, humanitarian(1) Range 0-20, Mean 7.78, S.D. 4.8 Suggestions for Modification Introduce a coding scheme and remove the real names Eliminate the question Research whether applicable elsewhere in India, probably not applicable anywhere else Re-evaluate the questionshould other terms be included? Redo the entire education questionnaire Same as above Should these categores be included in Occupation, or should some inclusive term be used instead of other? Question needs to be rewritten Re-write question 16 to include humanitarian, religious, political and trade union in various combinations

22-WHO 5 Total Score

Small sample, invalid statistic, but a pathologic score for the mean : It is recommended to

20

All ICF questions (716)

invalid response as a category

12-998a: S/he spends time with his/her friends 13-998b: S/he goes to community and social events 14-998c: S/he attends religious services 15-940a: S/he attends political meetings 16-940b: S/he participates in political rallies, marches, demonstrations, strikes 20- S/he believes that s/he has certain rights as a human being that cannot be taken away by anyone. Perpetrator of torture # of torture episodes Duration of the torture (add on question because of

3 invalid responses 5 3 14 14

administer the Major Depression (ICD-10) Inventory if the raw score is below 13 or if the patient has answered 0 to 1 to any of the 5 items- Need to run correlation coefficients with the various psychological symptoms solicited later on in the questionnaire invalid means not valid and doesnt mean disabled. Assigning it a value of 9 serves to elevate the standard deviation to indicate lack of significance if invalid is the response.. Is the question understood? It needs to be rewritten and/or re-contextualized

15/23 said NO!!!!

21/23-police not specified- 9 0- 2 3 responses

Is there a problem with the question, the way it was asked, or is it true that most of these people do not believe they have any Human Rights? Confirms a trend of which we are aware Was there a problem with the question or with the asking of the question? If there had been 9 responses, it would have taken care of the problem 21

response to above)

# of injured body parts Other injured body parts (add on) Types of torture

not specified-3 0- 2 2 responses none-1

# of types of physical injuries Burns Other injury descriptors (add on) Evaluation after torture Treatment after torture

not specified-3 0- 1 0 2- swelling All had at least 1 Only one had xrays or blood tests No none, but 0 for private hospital, surgery, or physiotherapy 2- fear All said lawyer

immediately above, but clearly it didnt. It suggests that the question needs to be rewritten and recontextualized Was it the question, or how it was asked? Were these people tortured, or not? Expand the above question to include these other categories Was this person NOT tortured , or didnt understand the question, or was a secondary victim Was the question not asked clearly? Should the question continue to be asked? Add swelling to the Injury Descriptor question Since there were more than one case of fracture, was the right information obtained? Or was it lack of quality care. Consistent with above. These torture victims did not necessarily receive quality medical care Add fear to the Psychological Symptom question Since all of the participants were at PVCHR, could we assume that they would all have seen a lawyer or paralegal? Do we need to ask the question? Does this mean that they had already had a testimonial before the testimonial therapy? Or was there a problem with asking the question?

Other psychological symptoms (add on) Interventions before testimonial therapy

Interventions before testimonial therapy

All said testimonial

4.2 Preliminary Statistical Data Generated In spite of these problems, valuable information can be obtained from a review of the data. A list of derived means from questions of particular interest is reviewed below, and also demonstrates items that yield problematic 22

results.

Question ICF: (0-3 active categories; 9 is invalid> high mean and variance) Function under stress d240 Family function d760 Human rights-political meetings d940 Human rights-demonstrations d940 Making a living now d870 Making a living before torture d870 Making a living immediately after torture d870 Socialization- with friends d998 Socialization-community activities d998 Socialization- religious activities d998 Number of psychological symptoms (05) Torture dose (empirical scale 0-3, derived from the questionnaire) Torture injury amount (empirical scale 03, derived from the questionnaire) Pain Analog (0-5 scale) WHO 5 Total Score (0-25)

Mean Variance S.D.

comment

2.18 1.3 5.8 5.5 1.69 1.0 2.26 2.3 2.4 2.0 3.3 1.95 1.76 2.45 7.78

3.10 3.67 16.8 18.9 1.4 1.18 1.019 8.3 13.2 9.09 2.4 1.04 1.39 3.68 23.1

1.76 1.9 4.1 invalid 4.3 invalid 1.18 1.08 1.009 2.88 3.6 3.01 1.55 1.02 1.179 1.92 4.8 invalid invalid invalid invalid

4.3 Preliminary Conclusions Based on Initial Evaluation of the M&E Statistical significance is difficult to achieve with such a small sample size (n=23). It is possible, however, to derive some information from this initial review of the preliminary data (post treatment data are yet to be derived). The individuals who participated in this pilot study were mostly primary victims of torture. The perpetrators were almost always the police. The participants ranged in age from 18 to 70 and were predominantly of secondary level education or less. The majority were Hindu, and all were members of a caste. They work at lower occupational levels, and do not consider themselves political activists. Most of them are having current difficulties functioning under stress. Many are able to work and support themselves now with mild to moderate difficulty, but all were doing better before they were tortured, and had much more difficulty with income generating activities immediately after being tortured. Quite a few of them have residual pain, and a low sense of wellbeing. Many of them have three or more residual psychological symptoms subsequent to the torture event. Many do not understand the issue of basic human rights, or could not appropriately answer questions about issues related to politics and human rights. Most of them received very low levels of health care after they had been tortured, although many of them had fairly extensive physical injuries. All had seen an

23

attorney, reflective of the fact that they were involved with the PVCHR. 4.4 Conclusions and Recommendations This project has been a pilot in many different ways. Developing a meaningful M&E database is a challenge that must be met so as to assess positive or negative effect of an intervention, which will point to the need for modification of the interventional component. With regard to this pilot project, and for RCTs continuation of Brief Therapies Projects as a Health Product to be offered to partners in the future, certain things must be done: 1. Continuation of the PVCHR Testimonial Project so as to increase the N for the study, as well as to increase the number of beneficiaries and expand the capacity of the organization to provide this brief therapy. 2. Expansion of the project by offering capacity building to other human rights organizations. This should include an M&E system. 3. Modification of the questionnaire as outlined above to elicit more consistency in the responses and to therefore generate information that is more consistent with the actual realities of the beneficiaries. 4. Dedication of more resources to expanding M&E capacity in the international work of the RCT. This will require expertise in the International Department at RCT that will: Assist in the construction of M&E systems for specific projects with partner organizations. Collaborate with the partners in contextualizing questionnaires so to ensure that they are understood and accurately answered by the beneficiaries of interventions Train partners to analyze the information derived in ways that allow meaningful assessment of projects effectiveness and lead to new knowledge.

24

25

Annex I. Terms of Reference


PROJECT INCEPTION MISSION TESTIMONIAL THERAPY PILOT CAPACITY BUILDING PROJECT, PVCHR, VARANASI, INDIA 15 April 15 June 2008 Background The third fact finding mission to India, which occurred from Mar. 23-30, 2008, reconfirmed that in Uttar Pradesh, and elsewhere in India, torture is used as standard procedure in police stations for extracting information, forcing confessions, and obtaining bribes from the persons who are entrapped. The phenomenon of torture is closely interrelated with poverty and low social status. Scheduled Castes and Tribes are overrepresented among the tortured compared to other castes. Peoples Vigilance Committee on Human Rights (PVCHR) works on a wide range of Human Rights Issues, and interacts directly with communities of traumatised survivors of torture and other forms of organized violence. However, while community empowerment and individual advocacy are major activities of this organization, direct health care, psychosocial services, and rehabilitation are not provided at the present time. RCT efforts will concentrate on building capacity and organising training in the testimonial method for Indian psychosocial organizations, beginning with a pilot project with PVCHR. A suitable strategy for RCT intervention in India would combine support for preventive as well as rehabilitative activities. This means a two pronged approach supporting service delivery along with advocacy for reform. The Testimonial Method represents a form of brief psychological therapy which elicits a detailed self report of events of torture or other traumatic experience endured by a survivor. The process of obtaining the document represents a form of narrative exposure therapy, and prior studies have confirmed mitigating effects of this therapy on residual stress symptoms such as PTSD. Additionally, the therapy results in the production of a document that can serve as a basis for advocacy and indemnity for the affected individual, as well as a broader chronicle of torture and organized violence to be brought to the attention of international regulatory bodies working to ensure protection of human rights. PVCHR has expressed an interest in developing a capacity in the testimonial method, and has requested that RCT provide training and supervision to achieve this capacity. During the third mission, the RCT Health Program Manager (HPM) assessed the suitability of PVCHR to participate in such a project. While there are no fully trained psychologists within the organization, there is a depth of psychosocial experience among the community empowerment workers, who regularly visit designated villages in which torture and oppression occurs. There are three social workers with some psychological training and a genuine interest in upgrading their skills. There is data collection and storage as an ongoing component of the advocacy work performed by PVCHR. Finally, there is bilingual capacity in many of the members of the 26

organization, which will facilitate working with an English speaking psychosocial consultant. RCT is fortunate to have available a psychosocial consultant who is an acknowledged international expert in the testimonial method. Dr. Inger Agger (IAG) has published extensively about the application of this method in different post conflict societies, and recently completed a pilot project in another part of India. She is, therefore, the ideal person to be hired as a consultant and trainer for this project. Objectives This mission is to be considered a pilot project which will serve as a spring board for other missions to expand therapeutic capacity in Human Rights organizations working with torture victims. It will accomplish the following objectives: -To produce a contextually specific training manual for the application of the testimonial method in Uttar Pradesh, India. -To train approximately ten members of PVCHR in the use of the testimonial method, and to provide supervision to their application of this therapy. -To select and start treatment of approximately 20-30 individuals who have undergone torture and are suffering from significant emotional sequellae. Additional criteria for participation of these individuals will include adult status and mental competence. -To introduce a Monitoring and Evaluation methodology to PVCHR which will enable the organization to monitor their therapeutic interventions. This will include some brief standardized instruments as well as ICF categories to provide functional measures. It will also serve as a data base for follow up of the project.

Outputs -A cadre of trained personnel who will have demonstrated competency in the testimonial method and will be able to provide this service to clients of PVCHR who are in need of psychotherapy. -The treatment of a group of approximately 30 victims of torture with emotional distress symptoms, who will demonstrate improvement in function -A monitoring and evaluation questionnaire which may be utilized by PVCHR to document its impact in the provision of psychotherapeutic treatment services to needy clients. -A database for patients who have completed the testimonial therapy which will include socio-demographic information and details of the torture experience, as well as before and after indices of general well being, pain level, and functional activities and participations. -The planning of a broader psychotherapy project for PVCHR and the application of a similar project to other organizations servicing torture victims in other parts of India. Time Frame and Methodology

27

The psychosocial consultant will be hired on a two month contract (44 working days, effective on April 15, 2008. From 15 30 April will be in Copenhagen, where the consultant will develop a draft training manual and the HPM will develop a questionnaire and a data collection methodology which will serve as the basis for the projected monitoring and evaluation system. The HPM, with assistance from the Research Department, will construct a data base format which can be used for data entry, either in the field or in Copenhagen. The month of May (1 30 May) will be in Varanasi, where the consultant will work with the personnel of PVCHR to 1.) refine and translate the training manual, 2.) refine and translate the M&E questionnaire, 3.) train and supervise the identified personnel of PVCHR in the application of the testimonial method, and 4.) train and supervise the personnel in the use of the M&E questionnaire. Finally, the consultant will return to Copenhagen from 1 15 June during which she will compose a full report and synthesis of the project (maximum 20 pages + attachments), including assessments of the success of the training, the applicability of the M&E questionnaire, and trends observed after start of the therapy. Lessons learned will be particularly applicable recommendations for future projects of this nature, as well as continued cooperation with PVCHR. The HPM will process and analyze the pre-testing data, with the assistance of the Research Department. Division of Responsibilities The psychosocial consultant will be responsible for the Testimonial Project. These functions include the development of the training manual, the translation and contextual adjustment of the training manual in India, the training of approximately ten staff members of PVCHR in the administration of the testimonial method, and the initial supervision of these personnel in their use of the testimonial method. She will also introduce the M & E questionnaire, have it translated, train and supervise the trainees in its application and use. This will include their collection and recording of information for the instrument in the field and at the PVCHR office. Before departure to India of the consultant, the HPM will construct the M & E Questionnaire, produce a data collection methodology, and set up an electronic data spread sheet for data collection and storage. The consultant will bring electronic copies of these three documents to India. After the return of the consultant, the HPM will oversee the analysis of the data from the pre-testing, which will be sent to him from India by the consultant (with the assistance of the Research Department). This analysis will be available to the consultant for her report writing in June. It remains to be determined after the visit of the consultant to PVCHR how the posttesting data will be transferred to RCT, and how the further supervision and M&E process with PVCHR will be carried out. The HPM will also maintain close contact with the Psychosocial Consultant while she

28

is in the field, and provide logistical support.

29

Annex II. Memorandum of Understanding MEMORANDUM OF UNDERSTANDING (MOU) Between Rehabilitation and Research Centre for Victims of Torture And Peoples Vigilance Committee on Human Rights
This is an agreement between Rehabilitation and Research Centre for Victims of Torture, hereinafter called RCT and Peoples Vigilance Committee on Human Rights, hereinafter called PVCHR

I. PURPOSE & SCOPE


The purpose of this MOU is to clearly identify the roles and responsibilities of each party as they relate to the pilot project: TESTIMONIAL THERAPY PILOT CAPACITY BUILDING PROJECT In particular, this MOU is intended to ensure a concrete working relationship between RCT and PVCHR. The basis for the working relationship is found in the RCT Fact Finding Report II + III from visits in year 2007 and 2008 to PVCHR in Varanasi, Uttar Pradesh. II. BACKGROUND PVCHR was started in 1996 and is a human rights organisation working to ensure basic rights to vulnerable groups and a human rights culture based on democratic values. PVCHR is engaged in organization building from the village level to the national level by working in districts of U.P., M.P. and Bihar on the issues of human rights, torture victims. PVCHR has an advisory committee including Justice V.S. Malimath, Former Chief Justice of Kerala, Karnataka & Ex-Member-NHRC. RCT was started in 1982 and is a human rights organisation with particular focus on rehabilitation and prevention of torture and organised violence. RCT is working in Denmark and together with a number of partner organisations around the world. RCT is governed by a board comprising members of key research institutions and universities.

30

In year 2007 and 2008 RCT conducted two fact finding missions to India. The two missions reconfirmed that in Uttar Pradesh, and elsewhere in India, torture is used as standard procedure in police stations for extracting information, forcing confessions, and obtaining bribes from the persons who are entrapped. RCT efforts will concentrate on building capacity and organising training in the testimonial method for Indian psychosocial organizations, beginning with a pilot project with PVCHR. The Testimonial Method represents a form of brief psychological therapy which elicits a detailed self report of events of torture. PVCHR works on a wide range of Human Rights Issues, and interact directly with communities of traumatized survivors of torture and violence. However, while community empowerment and individual advocacy are major activities of this organization, direct health care, psychosocial services, and rehabilitation are not provided at the present time. PVCHR has expressed an interest in developing a capacity in the testimonial method, and has requested that RCT provide training and supervision to achieve this capacity. By their joint signatures on the MOU the two parties recalls that the current/historical ties between RCT and PVCHR are a shared vision on a world free of torture and organised violence. The cooperation is guided by mutual trust and sharing of resources as to ensure successful implementation of the Testimonial project.

III. [PVCHR] RESPONSIBILITIES UNDER THIS MOU


PVCHR shall undertake the following activities: o Support the Testimonial Pilot project in accordance with the objectives outlined in the LFA Matrix (see Annex I) o Provide logistic support for the pilot project (office and training space, office supplies and other necessary practical support such as access to internet, photocopying, printing etc.) o Recruit a qualified interpreter for ensuring effective translation during the training course o Identify the participants for the training and compose a mixed group of male and female participants o Ensure that the participants are released from other PVCHR duties and will be able attend the training course during its full period o Support the RCT consultant in the timely implementation of the training schedule in accordance with the proposed day to day training plan (see Annex II)

31

o Organise food, snacks and drinks for the participants during the duration of the training o Organise transportation of participants for the field work o Identify and prepare the torture survivors who will participate in the testimonial therapy during the time of field work o Maintain testimonial records obtained from the torture survivors and provide these records in copy to RCT o Evaluate the training course during and after its completion and give valuable learnings and recommendations back to RCT

IV. [RCT] RESPONSIBILITIES UNDER THIS MOU


RCT shall undertake the following activities: o Recruit an expert consultant in the Testimonial Therapy, who will have the professional responsibility for the project, and cover all costs of the consultant (fee, per diems, insurance, travel, and other costs) o Ensure that the expert consultant will deliver her services timely and in accordance with the LFA Project Matrix and the training schedule as covered under this MOU agreement o Provide financial support to PVCHR as to cover all basic administrative and project related costs in connection with the implementation of the pilot project (see Annex III) o Ensure that RCT will share learnings and experiences with PVCHR related to the evaluation of the pilot Testimonial project o Analyse and share all relevant materials and testimonial records from the pilot field work with PVCHR o Provide professional backup and advice by the RCT Health Manager and the RCT Project Manager for Asia should the need occur during the implementation of the project

V. IT IS MUTUALLY UNDERSTOOD AND AGREED BY AND BETWEEN THE PARTIES THAT:


1. Modification The MOU or the activities covered by the MOU may be modified by mutual agreement between the two parties

32

2. Termination The MOU may be terminated by giving notice by one of the parties signing the MOU

VI. FUNDING
This MOU does include the reimbursement of funds between the two parties. The individual payment for services (see Annex III) will be done by the RCT consultant and follow the fulfilment of the assigned task as these have been verified by the RCT consultant. The final accounts for the pilot project following the layout in the detailed budget with all original vouchers attached will be verified by RCT consultant and all original vouchers related to this pilot project shall be handed over to RCT.

VII. EFFECTIVE DATE AND SIGNATURE


This MOU shall be effective upon the signature of RCT and PVCHR authorized Officials. It shall be in force from May 1, 2008 to May 30, 2008. RCT and PVCHR indicate agreement with this MOU by their signatures. Signatures and dates Dr. Jan Ole Haagensen Dr. Lenin Raghuvanshi

_____________________________ _____________________________
Date Date

33

Annex III. M&E METHODOLOGY, by Peter Polatin, MD. Health Program Manager
What is the purpose of an M&E? When a therapy is administered to an individual, it is important to have information about him or her beforehand, and to be able to document and analyze change after the intervention. It is only by comparing certain characteristics of the individual before and after the therapeutic process that the benefit of the intervention can be determined. This, in turn, helps clinicians to decide whether or not to continue administering the therapy, and what changes need to be made to improve its effect. These records are very important, and should be stored in a secure place. Confidentiality should be ensured. The forms have been constructed in such a way that the information can be transferred to a digital data base for subsequent analysis and study as part of later projects.

The PVCHR M&E Questionnaire consists of four parts: I. II. III. IV. History and Demographic Information Pre and post therapy testing Post therapy assessment Information about therapy and coping assessment

Part I: History and Demographic Information This section elicits relevant information about age, sex, address, caste, religion, education, work experience, and political activities. It largely follows the format of the larger PVCHR questionnaire. Assuming that the PVCHR questionnaire has already been completed, the information can be transferred to this shorter form. Otherwise, it can easily be completed in direct interview within a few minutes. It deliberately excludes any information about experiences with torture, which are felt to be better elicited after the actual testimonial intervention. Part II: Testing before and after the testimonial therapy intervention This section is designed as a simple checklist which can be completed by either the subject or an interviewer. It is anticipated that in almost all cases the questionnaire will be administered by a health worker. The questions have between 2 and 6 qualitatively arranged answers. It is to be administered to the treatment candidate immediately before and one month after the testimonial therapy experience, so as to document changes in well being, pain, and functional activities and participations. There are 21 questions. The first 5 questions constitute the WHO5, which is a standardized test measuring quality of life. The raw score for this test is calculated by totalling the figures of the five answers. The raw score ranges from 0 to 25, in which 0 represents the worst possible and 25 represents the best possible quality of life. A raw score below 13 indicates poor wellbeing and is an indication for depression. To obtain a percentage score ranging from 0 to 100, the raw score is multiplied

34

by 4. A percentage score of 0 represents the worst possible quality of life, whereas a score of 100 represents the best possible quality of life. In order to monitor possible changes in wellbeing, the percentage score is used. A 10% difference indicates a significant change. Question 6 is a pain analogue. The interviewee expresses his level of pain as a function of time, ranging from pain all the time (5) to no pain at all (0). Pain is frequently seen in individuals who have been tortured, and therefore it is important to document its presence. In many cases, pain decreases when well being increases, so that an improvement in the WHO5 may be associated with a decrease in pain level, and in association with a beneficial effect from the therapeutic intervention. Questions 7-16 have been derived to measure specific activities and participations (D categories) as classified under the ICF. These categories have been selected as particularly relevant, as the result of an extensive prior M&E project undertaken by RCT with its Partners in the South which included three international workshops and the collaboration of an RCT psychosocial consultant with most of the Partners during 2007(see Strengthening of Psychosocial Intervention Practices Among RCT Partners: ICF Follow-up Missions to Seven Partner Organisations,Synthesis Report, Draft Final Report, December 2007, Inger Agger, PhD, Psychosocial Consultant). The qualifiers used are the same as the modified qualifiers decided upon by the RCT project.; i.e., 4 degrees from 3 (complete difficulty) to 0 (no difficulty). For the purpose of later review of information, however, the not specified and not applicable categories suggested by the original RCT project have been lumped into a single new invalid category, with a high numeric score which would serve to identify invalid responses as outliers. The actual phrasing of the questions was done by the RCT Health Program Manager, Dr. Polatin, in consultation with other ICF experts and researchers. Question 7 asks about D240 (handling stress and other psychological demands) and elicits separate opinions from the interviewee and the interviewer. This is very important, because the interviewer, who is a health worker, is being asked to record his or her own judgement about the interviewees ability to function under psychological demands. While he will ask the question of the interviewee for the first part of the question, he will answer the second part silently from his own opinion. Question 8 asks about D 760 (family relationships). Questions 9-11 ask about D870 (economic self sufficiency) at three different times: the present time, before the torture event, and immediately after the torture event. It is of interest to document the impact of torture on economic self sufficiency, as well as to document a change in economic self sufficiency after treatment (question 9). Only the answer to question 9 should change after treatment. It is expected that the answers to questions

35

10 and 11 will remain the same at each administration, but if there are changes in these answers, it will raise issues of validity. Questions 12-14 ask about D998 (community, social, and civic life), including friendships (12), socialization (13), and religious participation (14). An inclusive category was deliberately chosen over more selective categories which focused on single aspects of this particular activity (D750, D910, D930, etc.). Questions 15-16 ask about D940 (human rights), but are structured fairly openly to elicit political activites and degrees of participation. Questions 17-21 elicit either a yes or no response. Questions 17 and 18 inquires about political commitment. Question 19 inquires about ideologic beliefs in human rights. Questions 20 and 21 elicit information about recent events that might influence well being independent of treatment effect. Part III: Assessment after Therapy This section elicits information about the torture experience. It is possible that much of it can be completed from information derived during the actual testimonial therapy, but it should be completed even if additional information must be solicited. It is to be filled out after the therapy for very specific reasons: 1.) inquiring about this information too early may cause retraumatization and unnecessary emotional upset which might interfere with the progression of therapy 2.) the information may already have been elicited during the therapy itself, and can be recorded from the testimonial record, without upsetting the client further Part IV: Information about the therapy and the therapists assessment of coping abilities This final section records details about the therapy: number of sessions, future uses of the testimonial document, and other treatments provided. It also asks that the therapist make a final assessment of the abilities of the interviewee to function under stress and other psychological demands.

This is a pilot project which will enable PVCHR to develop the capacity to treat survivors of torture with the testimonial method of therapy. It is expected that this treatment will improve the well being and functional abilities of those individuals who complete the therapy. It is very important that a comprehensive record be created and maintained to ensure that 1.) detailed information about the treatment candidates is understood, 2.) the therapy is delivered in a standardized manner so that it can be reproduced as

36

exactly as possible, and 3.) health and functional information about the treatment group is accurately collected and stored for later reevaluation. A careful and comprehensive M&E is as important as the therapeutic process, because it confirms health benefits and therefore justifies application for further funding and extension of treatment services.

37

Annex IV. Pilot Questionnaire, by Peter Polatin, MD, Health Program Manager
(Text in red represents changes made following suggestions by PVCHR)

PVCHR TESTIMONY THERAPY PROJECT

38

I.

HISTORY AND DEMOGRAPHIC QUESTIONNAIRE (to be administered before testimony therapy)

DATE_________________________
NAME OF COMMUNITY WORKER TAKING THE TESTIMONY__________________________

NAME OF SURVIVORS VILLAGE________________________________

ADDRESS ____________________________________________________________ NAME (code designation)_________________________________________________________________

SEX

Male _____ Female ________

PRIMARY VICTIM_____ SECONDARY VICTIM (Relation to primary victim): Son____ Daughter____ Father_____ Mother _____ Husband ____ Wife ____ Other ______ AGE_____________________ CASTE No caste:_____ Does not believe in caste______ No answer______

NAME OF CASTE (if applicable)____________________________

RELIGION Other_____

Hindu____ Buddhist_____ Muslim______ Christian______ Atheist_____

39

EDUCATION None_____ Primary_____ Secondary_____ BA_____ MA_____ Religious school only_____Other_________________________________________________

OCCUPATION Not working___ Household work____ Agriculture____ Animal husbandry ____ fishing_____ Business____ Government or political position ____ Public service, journalism, teacher____ Lawyer, doctor____ Other_______________

ACTIVITIES Trade union____ Political____ Religious____ Humanitarian/solidarity____ Press____ No activities _____ Other____

II: PRE AND POST TESTIMONY TESTING (to be administered before testimony therapy and one month after therapy)
Categoryof instrument W H O / 1 2 3 4 All the time Most of the time More than half of the time 3 3 3 3 Less than half of the time 2 2 2 2 Someof the time 1 1 1 1 At no time

Over the last two weeks


S/he has felt cheerful and in good spirits S/he has felt calm and relaxed S/he has felt active and vigorous S/he woke up feeling fresh and rested His/her daily life has Been filled with things that interest him/her S/he has had persistent Pain

5 5 5 5

4 4 4 4

0 0 0 0

5 5 Complete difficulty

4 4 Moderate to severe difficulty

3 3 Mild difficulty

2 2 No difficulty 1

0 0 Invalid

Pain Analogue

ICF A&P D-240

D-760

D-870

S/he can get everything done that is important for him/her to do, even when s/he is nervous, depressed, tired, angry, or in pain S/he gets along with the people In his/her family and spend time with them S/he is able to earn enough money to support him/herself and the people who depend on him/her Before s/he was tortured, s/he was able to earn enough money to support him/herself and the people who depend on him/her

1 0

40

1 1 D-998 1 2 1 3 1 4 D-940 1 5 1 6 1 7

Immediately after s/he was tortured, s/he was able to earn enough money to support him/herself and the people who depend on him/her S/he spends time with his/her friends S/he goes to community and social events S/he attends religious services

3 S/he attends political meetings 3 S/he participates in political rallies, marches, demonstrations, strikes S/he is a member of a political party

1 YES

0 NO

1 8 1 9

S/he actively works for a political party 1 YES YES 0 NO NO

Is s/he member of the human rights movement

2 0 Recent Events 2 1 2 2

S/he believes that s/he has certain rights as a human being that cannot be taken away by anyone. A good thing has happened to him/her that has made him/her feel happy A bad thing has happened to him/her that has made him/her feel much worse

1 YES 1 YES _ 1 YES

2 NO 0 NO 0 NO

III.

POST THERAPY ASSESSMENT (to be completed after the testimonial, and derived from that document. If the survivor interviewed is a secondary victim all items should refer to his or her physical and mental state)

DATE OF MOST STRESSFUL EVENT___________________________

IDENTITY OF PERPETRATOR (S) Police____ Intelligence service____ Armed forces____ Paramilitary____ Prison official____Other____________________________

NUMBER OF EPISODES OF TORTURE__________ NOT TORTURED________

TYPES OF HUMAN RIGHTS VIOLATIONS Physical torture______ Psychological torture ______ Sexual torture _____ Custodial death of primary Victim_______ Extra-judicial killing of primary victim ________ Other types________________________________

41

INJURED PARTS OF BODY Head___ Face___ Eyes___ Neck___ Arm___ Both arms___ Chest___ Breasts___ Abdomen___Genitalia___ Back___ Leg___ Both legs___ Foot___ Both feet___ Not injured______

NATURE OF INJURY

Bruise____ Open wound____ Burn____ Deformity___ Fracture____ Amputation___

Loss of strength____ Loss of sensation____ Loss of function____ Pain____ Not injured_______

PSYCHOLOGICAL SYMPTOMS

Nightmares___ Memories___ Fear of going out___ Self isolation____ Panic attacks____

Anxiety____ Depression____ Suicidal thoughts____Cant sleep____ No symptoms______

EVALUATION AFTER HUMAN RIGHTS VIOLATION None___ Doctor visit___ Xrays____ Blood tests____ lawyer or human rights organization______

TREATMENT BEFORE TESTIMONY THERAPY None___ Private hospital___ Public hospital___ Surgery___ Medication____ Physiotherapy____ Counseling____ Legal aid______ Testimony before tribunal______

IV. POST-THERAPY TESTING (to be completed one month after testimonial therapy has been done)
NUMBER OF TESTIMONY SESSIONS _____

WILL THE TESTIMONY BE PUBLISHED OR USED FOR HUMAN RIGHTS WORK? Yes___No___

OTHER INTERVENTIONS (BY PVCHR OR OTHER ACTORS) : Medical____ Social____ Legal_____Reading of testimony at Folk School Meeting______ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _________________________

42

Complete difficulty Community workers assessment of the capacity of the survivor to manage stress and other psychological demands

Moderate to severe difficulty 2

Mild difficulty

No difficulty

Invalid

Annex V. Proposal for Further Collaboration PVCHR/RCT


DRAFT PROPOSAL TRAINING IN TESTIMONY THERAPY FOR COMMUNITY WORKERS AND HUMAN RIGHTS DEFENDERS A TRAINING-OF TRAINERS PROJECT

PEOPLES VIGILANCE COMMITTEE ON HUMAN RIGHTS (PVCHR) & REHABILITATION AND RESEARCH CENTRE FOR TORTURE VICTIMS (RCT) 1. Background From April to June 2008, RCT funded a collaborative pilot training project with PVCHR on Testimony as a Brief Therapy Intervention. The project involved four weeks of training of PVCHR staff by an RCT psychosocial consultant, as well as the production of a manual for community workers and human rights defenders: Giving Voice: Using testimony as a Brief Therapy Intervention in Psychosocial Community Work for Survivors of Torture and Organised Violence (June 2008).

43

The success of this pilot training project invited for further continuation of the collaboration between PVCHR and RCT. Before her departure from Varanasi, the RCT consultant discussed various possibilities for future collaboration with Dr. Lenin, Convener of PVCHR, and they agreed on proposing a follow-up to the pilot project, as well as a Training-of-Trainers project for community workers and human rights defenders in other human rights organisations, which PVCHR are networking with. 2. Proposed timeframe 12 Months starting 1 August 2008. 3. Follow-up activities of pilot project Third session: Delivery ceremonies in the communities for the seven survivors who did not participate in the Varanasi ceremony (by beginning of July): Fourth session with 23 survivors: Concluding the M&E of the 23 survivors who have been treated (by end of July); Translation of Manual to Hindi (August); Illustration of Manual by drawings or photographs (August); Supervision (3 days) by psychosocial consultant in Varanasi to follow up of pilot training (September); Consultation meeting with national and state human rights institutions, human rights groups, media, mental health professionals - including Nimhans (September-October); Possible revision of Manual on basis of comments received at the Consultation (October); Printing of Manual in Hindi and English (by end of October).

4. Training-of-Trainers project 4.1 Activities First training (two weeks): November 2008 in Varanasi for 10-15 human rights defenders from different organisations in UP, Bihar and Madhya Pradesh; Second training (two weeks): February 2009 in Ranchi (capital of Jharkhand) for 1015 human rights defenders from Manipur, Jharkand and Chhatisgarh;

44

Two-day conference in New Delhi (April 2009): 1. On the first day: Discussion of psychosocial work, psychological rehabilitation survivors of TOV and the effect of the testimony method with professionals, selected survivors, participants in the training courses, human rights institutions, human rights groups, and the media. 2. On the second day: A core team is formed for the future strategy for using the testimony method in the political campaign against torture. Evaluation of project by external consultant; Writing of articles analysing the results. 4.1 Staff resources needed Four PVCHR staff act and are employed as supervisors in testimony therapy in the field and coordinate all activities (From August): Two trainers for the ToT training: Dr. Lenin and Dr. Agger Good translator.

26 June 2008/Inger Agger, Psychosocial Consultant

Annex VI. PVCHR Press Announcement about Workshop, Ceremony and Demonstration

TESTIMONY: A SOCIAL MOVEMENT


A lot of political and lawful struggle against police torture and other organized types of violence are happening. However, in the human rights organizations of India resources have been scant for providing short-term psychosocial assistance to survivors suffering from psychological problems. This type of assistance has mostly been provided by trained psychologists or psychiatrists in medical centers. It is, therefore, necessary for the organizations working on the grass-roots level to develop their capacity for this type of brief therapy assistance, which can be carried out by non-professional staff. Testimony therapy has been used for survivors of human rights violations in different parts of the world during the last 25 years starting in Chile, Latin America. By giving testimony about the torture - telling the self

45

suffering story - to an empathic listener who records the story, the survivor can heal his or her trauma and also use the testimony document in the struggle for justice. In this way the private pain becomes political and the survivor is empowered. Steps in testimony THERAPY: 1. During two sessions, the survivor tells the story of his or her suffering to a community worker or human rights defender who helps the survivor remember the suffering and feel the emotions at that time and in the present. One community worker acts as the interviewer while the other acts as a note-taker. Together with the survivor they create a coherent story about the human rights violations suffered by the survivor. 2. In the beginning of the second session, the story is read out in front of the survivor as an autobiography and corrections are made if the survivor wants to add or change something in the story. 3. At the end of each session, the interviewers and the survivor sit for ten minutes in a mindfulness meditation experience with focus on the awareness of the breath and the thoughts going through the mind. 4. For the third and last session, the testimony is prepared in colorful and attractive paper with the signature of the survivor and the interviewer. An honor ceremony is organized where the testimony is handed over to the survivor. If the survivor agrees this ceremony can be public and the testimonies of several survivors might be handed over on the same occasion. A copy of the testimony will be used for further advocacy with the acceptance of the survivor. 5. The testimonies of survivors can also be used in folk school meetings, community meetings, programs related to human rights, as part of a peoples movement and in workshops for the police to prevent torture. In this context a workshop on testimonial therapy was organized with the joint collaboration of the Rehabilitation and Research Centre for Torture Victims (RCT) Denmark and Peoples Vigilance Committee on Human Rights (PVCHR) from 12th May, 2008 to 23rd May, 2008. In the workshop 12 human rights defenders from PVCHR were trained in Testimony Therapy by Dr. Inger Agger, Psychologist from RCT,
46

Denmark and the participants thereafter took the testimonies of 23 survivors under the supervision of Dr. Agger. During the workshop a special manual for the use of Testimony Therapy in India was created. The title of this manual is Giving Voice. The manual will be translated into Hindi. The workshop was followed by a ceremony of honor, in which 14 of the survivors who had given their testimonies received their testimony documents. The ceremony took place on 27th May, 2008 at 11 am to 14 pm where the 14 survivors gathered in front of the District Government Head Quarters of Varanasi. The names of the honored survivors were Mr. Kaju, Ms. Anita (not real name), Mr. Ajay Singh, Ramu (not real name), Mr. Jaswant, and Mrs. Munni Devi, Mr. Ram Prasad Bharti, Mr. Devnath, Mr. Ram Lal, Mr. Pahalu Mushar, Mrs. Chanda Mushar, Mr. Hub Raj Mushars, Mr. Banshi Rajbhar, Mr. Satendra Yadav.

Group photo with the survivor and Dr. Inger Agger RCT, Denmark The ceremony started with a brief introduction where the Testimony Therapy was explained. Thereafter, the testimonies of 12 of the survivors were read out to the public by the interviewers who took the testimonies, and the survivors were honored by giving them a flower garland, a white shawl and the testimony document.

47

The testimony is read out by the Human Rights Defender The eyes of all the survivors and their family members were wet after hearing the testimonies and they were feeling very happy and good inside. Mrs. Chanda Mushar started crying while she was honored with the testimony. The whole testimony process and ceremony was very successful. At the end of the ceremony all the survivors united and sat in a circle and interacted with each other about their testimonies as if they had known each for a long time. The ceremony also drew the attention of many people who were sitting in the District Government Head Quarter square and everyone was curious to know more about the testimony method. The ceremony was also transmitted by local TV networks and written about by the press, including the Times of India.

48

The testimony document is delivered to the survivor Dr. Inger Agger, who has worked internationally with Testimony Therapy for many years and published books and articles about it, was very satisfied with the process. She felt it had been an extremely creative experience to work together with PVCHR and develop an Indian version of the Testimony Method. It was also very moving for her to attend the ceremony where the results of the training and the Testimony Therapy were developed into social action.

49