2013. Vol.4, No.5, 472-482
Published Online May 2013 in SciRes (
Copyright © 2013 SciRes.
The Mental Health Effects of Torture Trauma and Its Severity: A
Replication and Extension*
Ibrahim A. Kira1#, Jeffery S. Ashby2, Lydia Odenat3, Linda Lewandowsky4
1Center for Cumulative Trauma Studies, Stone Mountain, USA
2Georgia State University, Atlanta, USA
3Emory University, Atlanta, USA
4University of Massachusetts, Amherst, USA
Received February 23rd, 2013; revised March 25th, 2013; accepted April 22nd, 2013
Copyright © 2013 Ibrahim A. Kira et al. This is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the
original work is properly cited.
To clarify the effects of torture trauma and its components on PTSD and other mental health conditions,
we investigated the relationship between measures for PTSD, Cumulative trauma disorders CTD, cumula-
tive life trauma, torture and torture severity in a sample of 326 torture survivors. Hierarchical multiple re-
gressions found no significant association between torture and PTSD. However, when we examined the
effects of different types of torture we found witnessing and sexual tortures were significant predictors of
PTSD and CTD. Path analysis results found that torture trauma and its severity may not be predicative of
PTSD; but it is highly predictive of the more complex syndromes of CTD. The implications of the re-
sults for treating torture survivors were discussed. One of the important findings is the potential effects of
torture on decreased re-experiencing and emotional numbness. Torture trauma may be too emotionally
and physically painful experience that tends to be suppressed decreasing re-experiencing and increasing
Keywords: Torture Trauma; Cumulative Trauma Disorders; PTSD; Cumulative Trauma
Torture is a complex multilateral trauma as it consists of dif-
ferent trauma types that are focused on humiliating or anni-
hilating the person’s personal and collective identities (for a re-
view of torture definitions, see, Quiroga, & Jaranson, 2005). It
is the intentional infliction of psychological, physical, and/or
emotional pain or deprivation. It is a practice commonly used in
substantial array of societies for purposes of punishment, in-
timidation, interrogation, and coercion (Pope, 2001). Torture is
directed towards instilling and reinforcing a sense of power-
lessness and terror in victims and their perspective communities,
and/or political or religious groups. In this way, torture may be
characterized as inter-group victimization with negative effects
that go beyond individuals to families and communities.
The negative effects of torture on health, especially on ne-
urological systems, for example, closed head and physical inju-
ries, are well documented (e.g., Kira et al., 2006, Vorbrüggen &
Baer, 2007). However, the negative mental health effects of
torture and its dynamics are not completely understood, which
confuse clinicians who want to design appropriate interventions
to this type of traumas. A meta-analysis of 181 surveys on tor-
tured populations from 40 countries found that rates of PTSD
and depression showed large variability (0% - 99% for PTSD
and 3% - 85.5%, for depression) (Steel, Chey, et al., 2009). An-
other meta-analysis (Johnson & Thompson, 2008) concluded
that most epidemiologically-sound studies found relatively low
rates of PTSD following torture. However, Steel and collea-
gues’ (2009) meta-analysis found that reported torture emerged
as the strongest factor associated with PTSD, followed by cu-
mulative exposure to potentially traumatic events (PTE). How-
ever, most studies of the effects of torture have not controlled
for the potentially confounding effects of other life traumas that
happened before and after the torture. There is good evidence
supporting a dose-response relationship between cumulative
trauma and development and maintenance of PTSD in torture
survivors (e.g., Johnson & Thompson, 2008; Mollica, McInnes,
Poole, & Tor, 1998). In two large community studies of Iraqi
refugees, torture did not predict the elevation of symptoms of
PTSD, after controlling for the effects of traumas occurring
before and after torture, (Kira et al., 2006). Recent study by
Hollifield, Warner, & Westermeyer, 2011, replicated these re-
Hooberman, Rosenfeld, et al. (2007), found that witnessing
torture of others or of family members, and deprivation or pas-
sive torture were not associated with PTSD, anxiety, or de-
presssion symptoms, and the only factor associated with these
symptoms was the torture rape. However, Basoglu (2009)
found that while physical torture did not predict PTSD, psy-
chological torture did. Similar results of Basoglu’s were found
in a study of tortured ex-prisoners who presented with elevated
risk of poor health outcomes after exposure to psychological
torture (Punamaki, Qouta, & Sarraj, 2010). Rasmussen, Rosen-
*Disclosure and acknowledgements: All authors report no competing inter-
#Corresponding author.
feld, Reeves, & Keller (2007) found that chronic injuries re-
sulting from torture mediated the path between torture and
PTSD. They also found that injuries, but not torture, were asso-
ciated with major depression, and that injuries did not moderate
the relationship between major depression and torture.
Other variables, such as gender, ethnicity, and age, have also
been identified as significant risk factors in the development of
PTSD and may overlap with torture’s effects among refugee
populations. Gender discrimination, defined as the assignment
of values to real or imagined differences between genders, has
been found to be associated with PTSD and cumulative trauma
related disorders (CTD) (complex PTSD)in female torture sur-
vivors (Kira, Smith, Lewandowski, & Templin, 2010). With
regard to age, torture survivors from Kosovo who were over the
age of 65 were found to be at increased risk of PTSD as com-
pared to their younger counterparts (Johnson & Thompson,
2008). Finally, the experience of discrimination among refugee
torture survivors has been associated with PTSD and CTD (e.g.,
Kira, Lewandowski, et al., 2010),
The goal of the current study was to clarify the relationship
of torture trauma and its severity to PTSD and cumulative
trauma related disorders (CTD). In addition, this study was
designed to further explore which components of torture are
related to different negative mental health outcomes after con-
trolling for all other traumas that occurred before and after the
torture. The objective is to further our understanding of the dy-
namics of torture to help identify the effective interventions.
While the focus of the study is on the effects of torture, the
interventions that may be effective, giving the outcome of the
study will be discussed, in detail in its last part.
Hypothesis 1) Torture trauma will not predict PTSD sym-
ptom clusters but will predict the more severe CTD syndromes
after controlling for the effects of all other life time traumas.
Hypothesis 2) Some extreme torture components, i.e., anal
rape, suffered gunshot and/or electric shock during torture, will
be more associated with PTSD and CTD symptoms.
The study was conducted on an existing clinical database
developed by a center in US that provides wraparound ser-
vices exclusively to torture survivors and gathers mental health
data from all its clients. The instruments used for data collec-
tion were designed by the center psychologists. The instruments
included a comprehensive intake that comprises detailed torture
assessment, in addition to mental health screening that included
measures for PTSD, cumulative trauma related disorders (CTD),
and a cumulative life trauma measure that assesses the occur-
rence of different trauma types, including gender discrimination.
Additionally, a comprehensive assessment of torture experience
was part of intake. The data collection was conducted through
face to face interviews by the center qualified professional and
paraprofessional bi-lingual staff, usually in two sessions. The
procedures in the clinic met all HIPPA regulations concerning
clients’ protection and include consent for use of the collected
data in anonymous research. The study was approved by Geor-
gia State University Institutional Review Board.
The study utilized a data base of a center that served refugee
torture survivors in the Midwest region of USA contained 395
clients that include adults and adolescents. We excluded ado-
lescents as they were relatively small number. Clients included
in the study were 326 that comprise 200 primary and 126 sec-
ondary torture survivors (primary torture survivor is the person
that had been subjected directly to torture, while secondary
torture survivor is one of his/her family members, i.e., spouse,
children, and/or parents). All participants were refugees who
have legal status in US. Most of them have been referred to the
program, in the first three months upon arrival for being suf-
fered of torture in their own country and need assessment for
service needs. Being tortured abroad for political reasons was
the only eligibility criteria for admission. Participants were ad-
mitted between April 2008 and September 2009. They were not
necessarily mental health clients; however, about 40% were
referred to mental health services either for intervention or pre-
vention. They came from 30 countries with the top four source
countries being Burma (n = 86), Iraq (n = 85), Bhutan (n = 73),
and Somalia (n = 27). Participants include 37 from other 13
African countries (Zimbabwe, Uganda, Togo, Sudan (Darfuri),
Rwanda, Nigeria, Liberia, Ivory Coast, Ethiopia, Eritrea, Congo,
Chad, & Burundi). The rest (18 participants) came from differ-
ent countries in Asia, South America, and Europe (e.g., Afgha-
nistan, Vietnam, Russia, Iran, Cuba, Colombia, and China).
Participants included 185 (56.7%) males and 141 (43.3%) fe-
males. While gender representation in some sub-groups was
almost balanced (Iraqi 52% males, 48% females, Bhutanese
45.6% males and 54.4% females), it was lopsided either way in
the other sub-groups (Burmese: 67.7% males, 32.3% females,
Somali: 32.3% males and 67.7% females; other African coun-
tries: 64.9% males and 35.1% females; other non-African coun-
tries: 72.2% males and 27.8% females). Age ranged from 18 to
76 (mean = 38.55, SD = 11.59).
Twenty percent of the clients was identified as illiterate,
24.4% completed primary school, 34.9% high or secondary
school, 16.3% technical/vocational school, 1.2% had college de-
grees and 3.2% had post graduate degrees. With regard to ma-
rital status, 64.5% of them were married and living together
with their spouse, 16.0% were single (never married), 2.3%
divorced, 8.3% widowed, 1.6% identified their spouse as miss-
ing, 5.7% had spouses living in native country, 0.7% were se-
parated by choice, and 0.9% were living with a partner.
Construction and Tran sl ation of Meas ures in the
Data Base
The intake protocol and other measures utilized in the center
were first constructed in English and subsequently translated
into refugee major languages (Arabic, Bhutanese, and Burmese)
by bilingual professionals. Measures were then back-translated
by another fluent professional and reviewed for accuracy. After
confirmation of the accuracy of the translations, the measures
were pilot tested in focus groups. Previous studies have sup-
ported the psychometrics of the translated instruments with
Iraqi refugees (Kira et al., 2006, 2008). For clients who speak
only dialects or other languages, an interpreter translated the
questionnaire directly to them.
PTSD MeasureClinician-Administered Posttraumatic Stre ss
Copyright © 2013 SciRes. 473
Scale (CAPS-2) (18 items) (Blake et al., 1990) is widely used to
assess PTSD. It is a structured clinical interview that assesses
17 PTSD symptoms rated on frequency and severity on a
5-point scale. It has demonstrated high reliability with a range
from 0.92 - 0.99 and showed good convergent and discriminant
validity. The center used its frequency sub-scale that is cur-
rently widely used in psychiatric literature. It has, in this mixed
sample, Cronbach alpha reliability coefficient of 0.94 for all
participants, which indicates a good reliability. The scale has
four sub-scales: re-experiencing, avoidance, arousal and emo-
tional numbness/dissociation. Reliability of the four sub-scales
in our sample are adequate to high (alphas are 0.96, 0.92, 0.89
and 0.85 respectively). Further the alpha coefficients were high
across all national origin groups (Bhutanese = 0.92, Burmese =
91, Iraqi = 0.85, Somali = 0.96, others = 0.97.
Cumulative Trauma related Disorders Measure CTD (15
items) (Kira et al., 2012a). The CTD was developed on five
community and clinic samples of adult and adolescent Iraqi
refugees, Arab Americans, and African Americans. It is de-
signed to assess 13 different symptoms: depression, anxiety, so-
matization, dissociation, auditory and visual hallucinations,
avoidance of being with people, paranoid ideations, concentra-
tion and memory deficits, loss of self-control, feeling too harsh
with family and with people in general, feeling suicidal, and
feeling like hurting self. Exploratory and confirmatory factor
analyses offered support for four factors: Executive function
deficits, suicidality, psychosis/dissociation, and depression/an-
xiety interface. The CTD scale has shown good internal con-
sistency reliability (alphas ranging from 0.85 to 0.98). Test-re-
test reliability in a 6 week-interval was 0.76. Several studies
also offer support for the CTD predictive validity. In the current
diverse sample the Cronbach alpha reliability coefficient for the
overall scale was 0.98. Reliability of the four sub-scales was
found to be high (0.95, 0.97, 0.98, and 0.96 respectively). Coef-
ficients alpha were high across all groups (Bhutanese = 0.93,
Burmese = 94, Iraqi = 0.94, Somali = 0.89, others = 0.94.
CTS Cumulative Trauma Scale (32 items) short form: The
CTS is designed to screen for the occurrence and frequency of
traumas and stress across one’s life time. The measure was
developed based on development-based taxonomy of traumatic
stressors. A number of studies with Iraqi refugees have offe-
red support for the scale’s reliability, and construct, divergent,
convergent, and predicative validity (Kira et al., 2008, Kira et
al., 2011, Kira, Fawzi, & fawzi, 2012). The measure included six
main subscales (attachment, personal identity, collective identity,
and family, secondary, and survival traumas). Different sub-cate-
gories were further added, e.g., gender discrimination, and tor-
ture. The total score represents the cumulative trauma load that
the individual has endured across the life span. The measure
has, in this mixed sample an adequate alpha reliability coef-
ficient of 0.81. Alpha reliabilities for the sub-scales in the pre-
sent data are as follows: Torture = 0.89 (2 items scale), gender
discrimination, GD (2 items scale) = 0.68, survival trauma (3
items scale) = 0.69, secondary traumas (3 items scale) = 0.66,
personal identity traumas (15 items scale) = 0.72 and collective
identity traumas (6 items scale) = 0.68. Some reliability coeffi-
cients of the sub-scales can be relatively questionable but are
usually acceptable for short sub-scales with binary response
questions (e.g., Schmitt, 1996).
Further the alpha coefficients for CTS (the total scale) were
adequate across all national origin groups (Bhutanese = 0.86,
Iraqi = 0.80, Somali = 0.70, others = 0.80).
Torture severity scale: The measure developed in this study
is based on the questions in the intake that include detailed
information about torture experience and story. It comprises 61
stressors for the torture experience that include the duration of
the torture event and the different exposure to physical torture,
psychological or indirect torture, sexual torture, and prison
conditions, with 0 assigned for each torture event that has not
been experienced and 1 for each torture event that has been
experienced. The total number of all torture stressors experi-
enced in the first torture episode was used as a measure of “ob-
jective” torture severity. The higher score indicated higher ex-
posure to torture events and vice versa. The measure has a
Chronbach of alpha of (0.87).
Principal component factor analysis of all torture stressors,
(factor extraction was based on Eigen value greater than 1.00
and scree plot with varimax rotation) yielded eight factors that
accounted for 54.26% of the variance and included: general
factor, witnessing, environment restriction, physical and formal
accusations, sexual torture, for example beating on genitals,
physical torture, extreme exposure to heat or cold, and sexual
rape. On previous factor analysis study on torture component,
Hooberman, Rosenfeld et al., 2007, found similar structure.
Accordingly, seven torture severity sub-scales were constructed
and the last eighth factor was dropped as its coefficient alpha
was too low. The followings are the constructed sub-scales:
1) Torture General Factor sub-scale included 21 items that
comprised different torture stressors that compose most of the
different torture types. Coefficient alpha of this factor was 0.95
2) Witnessing (psychological torture) sub-scale included 7
items that focused mostly on seeing or hearing torture, seeing
rape, dead bodies, seeing killing, witnessing torture of family
members. Coefficient alpha of this factor was 0.84.
3) Deprivation (passive torture) sub-scale Included 4 items
that focused on climate control, no windows, no bed. Coeffi-
cient alpha of this factor is 0.88.
4) Aggressive accusations and Legal procedures sub-scale
Included 10 items and focused on forced accusations and pres-
sures to confess through several means, Coefficient alpha of
this factor was 0.74.
5) Sexual torture sub-scale Included 3 items that focused on
sexual torture, e.g., beating on genital and forced nudity. Coef-
ficient alpha of this factor was 0.99.
6) Physical torture sub-scale included 6 items and focused
on physical torture, e.g., burnt, electrocuted, suspended, forced
experiments. Coefficient alpha of this factor was 0.70.
7) Aggressive environmental control included five items and
focused on exposure to extreme heat or cold, and exposure to
light Coefficient alpha of this factor was 0.64.
Additionally we used five single items: Anal rape, vaginal
rape, suffered gunshot, electric shock, solitary confinement, and
exposure to extreme cold, as single item measures for specific
extreme torture experiences that stand alone.
Data Analysis
Analyses included partial correlation between torture var-
iables and PTSD, and CTD and their symptom clusters. ANOVA
explored the differences between the cultural and national ori-
gin groups, in PTSD, CTD, torture severity, trauma types, and
cumulative trauma using Bonferroni post hoc test. Hierarchical
multiple regressions explored the relationships of PTSD and
CTD and their sub-scales as dependent variables, and torture
Copyright © 2013 SciRes.
sub-scales, and other trauma types and demographics as inde-
pendent variables to determine which the significant predictors
are. Path analyses tested different plausible path models for the
effects of torture and torture severity as well as all other trauma
types, using AMOS 19 software, (Arbuckle, 2006). Bootstrap
with bias-corrected confidence intervals tested the significance
of the direct and indirect effects and confidence interval of each
variable. Bootstrapping is often used to get a better approxima-
tion of sampling distribution of a statistic than its theoretical
distribution provides, when assumption of normality is violated.
Participants’ Torture Experiences
For primary torture survivors (n = 200), over 90% reported
that they had been severely beaten, over 84% had been threat-
ened or received a death threat, and over 69% indicated their
relatives had been threatened. Over 11% of them reported hav-
ing been stabbed, over 32% had suffered crushing injury, and
one had his leg amputated. Over 13% reported having been
burnt, over 26% having been suspended upside down, 8% had
suffered gunshot, and over 12% had been electrocuted. Over
58% of them reported that they had been shackled, over 4%
suffered forced experiments, over 7% had their body parts
stretched, over 13% had been exposed to extreme heat, or to
extreme cold or both, and over 20% forced to walk on their
knees. Over 34% reported that they had been subjected to
forced labor. Over 47% reported that they had seen dead bodies,
and over 73% had to witness others severely tortured. Over
16% had been in solitary confinement. Over 30% reported to
witnessing killing, and over 3% reported witnessing mock exe-
cutions. Over 25% reported that they forced to confess, over
10% forced to accuse others, over 35% had been falsely ac-
cused, and over 22% forced to sign papers. Over 6.5% re-
ported that they had been raped either vaginally or anally or
both, and over 55% had been suspended by testicles, or had
penis intrusion or both. Over 21% reported that they witnessed
rape. Over 65% reported inappropriate toilet, bath, food, sleep,
medical care, and overcrowded cells.
Differences between National Groups in Trauma
Load, Types, and Profiles
The mean number of trauma types occurrence (cumulative
trauma) endured for all sample participants was 10.89 with SD
of 4.18, with the highest trauma load was among the African
group (mean of 12.85, with SD of 5.79 ) and the least was
among the Burmese group (mean of 9.149, with SD of 2.85).
The differences between African group and Burmese, Bhutan-
ese and Iraqi and between Somali and Burmese groups were
significant. For trauma types while there was no significant
differences between group in attachment trauma with low oc-
currence for all, as family and cultural values minimize parents
abandonment of their children. There were, also, no significant
differences between these generally patriarchic cultures in the
level of gender discrimination. Additionally, there were no dif-
ferences between the groups in collective identity trauma (e.g.,
discrimination and oppression), which is the highest occur-
rence compared to other trauma types and seem to be the core
trauma for all groups along with torture. For personal identity,
survival, and secondary traumas, Somali, Iraqi and African
groups had significantly higher loads in these trauma types than
Burmese and Bhutanese groups. For role identity trauma, Iraqi
group scored the highest among all the other groups and the
differences between them and all other groups were significant.
This may be related to the relatively higher level of education
which made them less employable for jobs equal to their quali-
fication in the US.
Concerning torture severity the Somali group scored the
highest in torture severity (mean of 15.42, with SD of 11.96),
while the Burmese group scored the lowest (mean of 8.58, with
SD of 9.52). The differences between Somali and Burmese
groups were statistically significant; otherwise there were no
significant differences between the other groups in torture se-
verity. The between group differences in all variables, except
for torture severity, attachment trauma, gender discrimination
and collective identity, were significant.
Partial Correlation Results
Partial correlation between torture trauma and other trauma
types (controlling for age, marital status, education and gender)
indicated that torture trauma was highly associated with sur-
vival trauma (0.39***), personal identity trauma (0.38***), and
secondary traumas (0.20***). It was negatively associated with
role identity or achievement traumas (0.18***), which may
indicate that torture survivors are mostly achievers. Partial cor-
relation between torture trauma, torture severity and its seven
factor analysis based sub-scales and PTSD, CTD and their
sub-scales indicated that while torture trauma was not associ-
ated with PTSD or CTD, it was significantly associated with
PTSD arousal and CTD Psychoticism/dissociation sub-scales.
Witnessing torture sub-scale was associated with PTSD and
CTD. It was associated with all PTSD four sub-scales. Sexual
torture sub-scale was associated with CTD (but not with PTSD),
It was associated with depression/anxiety comorbidity, suici-
dality, and emotional numbness/dissociation sub-scales. Anal
rape with associated with psychoticism/dissociation, and emo-
tional numbness/dissociation sub-scales. Vaginal rape was as-
sociated with executive functions deficits. Suffered from gun-
shot during torture was significantly associated with CTD Psy-
chosis/dissociation sub-scale and PTSD arousal and emotional
numbness/dissociation sub-scales. Electrocution and solitary
confinement were associated with PTSD emotional numbness/
dissociation sub-scale. Exposure to extreme cold was negatively
associated with CTD and CTD depression/anxiety comorbidity,
executive function deficits sub-scale, and with PTSD re-ex-
periencing and avoidance sub-scales. The results concerning
exposure to extreme cold warrant further discussion. Table 1
details these results.
Hierarchical Multiple Regression A nalyses Resu l ts
For all regression analyses that we conducted, we tested for
multi-colinearity. VIF (variance inflation factor) for all predic-
tor variables ranged between 1.00 and 1.40, which indicated
low colinearity (the recommended cut off score for multi-
colinearity is 5.00, e.g., O’Brien, 2007). In the first round of
hierarchical multiple regression analyses, we tested the effects
of torture and torture severity on PTSD and CTD. To control
for age, gender, education, marital status and cumulative trau-
ma excluding torture trauma, with PTSD and CTD as depend-
ent variables and age, gender, education and marital status as
independent variables in the first step, and added torture
Copyright © 2013 SciRes. 475
Copyright © 2013 SciRes.
Table 1.
Partial correlations between torture, torture severity factors and mental health variables.
Torture scale 0.07 0.10+ 0.025 0.10+ 0.15* 0.05 0.03 0.08 0.17** 0.10+
Torture severity scale 0.05 0.08 0.07 0.11+ 0.08 0.001 0.06 0.09 0.07 0.07
General factor of torture 0.01 0.07 0.03 0.08 0.03 0.003 0.05 0.09 0.06 0.05
(psychological torture) 0.13* 0.15* 0.11+ 0.10+ 0.09 0.09 0.12* 0.13* 0.13* 0.14*
(passive torture) 0.04 0.03 0.01 0.09 0.004 0.08 0.01 0.04 0.06 0.02
Formal accusation and
procedures 0.01 0.02 0.04 0.01 0.02 0.05 0.01 0.05 0.02 0.01
Sexual torture 0.11+ 0.08 0.12* 0.11+ 0.06 0.13* 0.07 0.05 0.03 0.13*
Physical torture 0.003 0.06 0.04 0.07 0.07 0.07 0.05 0.01 0.08 0.04
environmental control 0.05 0.10+ 0.06 0.06 0.001 0.12+ 0.11+ 0.11+ 0.09 0.03
Anal rape 0.14* 0.18** 0.12+ 0.069 0.21*** 0.01 0.15* 0.13+ 0.16* 0.18**
Vaginal rape 0.06 0.05 0.12* 0.06 0.04 0.001 0.07 0.06 0.02 0.02
Gunshot 0.13+ 0.13+ 0.078 0.13+ 0.28*** 0.12+ 0.075 0.12+ 0.14* 0.16*
Electric shock 0.089 0.13+ 0.028 0.073 0.092 0.056 0.073 0.051 0.12+ 0.19**
Solitary confinement 0.08 0.09 0.11+ 0.12+ 0.013 0.013 0.050 0.008 0.087 0.14*
Exposure to extreme cold 0.15* 0.10 0.19** 0.14* 0.11 0.08 0.14* 0.16* 0.083 0.017
Note: CTD = Cumulative Trauma related Disorders, PTSD = Post-Traumatic Stress Disorders, CTD-D = CTD Depression and Anxiety comorbidity, CTD-E Executive
Functions Deficits, CTD-P= Psychoticism/Dissociation; CTD-S = Suicidality; PTSD-R = Re-experiencing; PTSDAV = Avoidance; PTSD-A = Arousal; PTSD-N = Emo-
tional Numbness/Dissociation *p < 0.05. **p < 0.01. +p < 0.10. Two-tailed.
trauma, torture severity, anal rape and vaginal rape in the sec-
ond step and added Cumulative Trauma Excluding Torture in
the Third step. In the final regression model, only cumulative
trauma excluding torture, marital status and anal rape showed
significant prediction of PTSD. Cumulative trauma excluding
torture, and vaginal rape showed significant prediction of CTD.
Table 2 describes these results.
Path Analys i s Results
We checked the different plausible models for the association
between torture trauma, torture severity, all other trauma types
and PTSD and CTD and their sub-scales. The models we tested
replicated or did not go far from regression results, but high-
lighted the severe effects of torture that go beyond simple
PTSD. The first model we present has torture trauma, torture
severity, and all other cumulative traumas as independent vari-
ables, and PTSD four factors as dependent variables. The
model has good fit with the data (Chi Square = 3.690, d.f. = 7, p
= 0.815, CFI = 1.00, RMSEA = 0.000). In the model, Cumula-
tive traumas (other than torture) have highly significant direct
effects on re-experiencing, direct and direct effects on arousal,
and avoidance, and indirect effects on emotional numbness/disso-
ciation. On the other hand, torture trauma has close to signifi-
cant negative effects on all PTSD components. However, tor-
ture severity, have significant effects on increased arousal and
numbness/dissociation. Figure 1 and Table 3 present the model.
The second model we present has torture trauma, torture se-
verity, and all other cumulative traumas as independent vari-
ables, and CTD four syndromes as dependent variables. The
model has good fit with the data (Chi Square = 9.474, d.f. = 6, p
= 0.149, CFI = 0.995. RMSEA = 0.004). In the model all other
life traumas have significant direct and indirect effects on de-
pression/anxiety comorbidity, executive function deficits, and
psychosis/dissociation syndromes, as well as indirect signifi-
cant effects on suicidality. Torture trauma, on the other side has
direct and indirect effects on executive function deficits, and
significant indirect effects on depression/anxiety comorbidity,
suicidality and psychosis/dissociation syndromes. Additionally,
torture severity, has direct effect on executive function deficits,
and indirect effects on depression/anxiety comorbidity syn-
dromes. Torture seems to have more severe mental health ef-
fects than PTSD. Figure 2 and Table 4 present the model.
The results of the study generally confirmed study hypoth-
eses and replicated findings from some previous studies. They
also offer some possible explanations that identify some of the
dynamics of the effects of torture. Partial correlation and hier-
archical regression results found that torture trauma and torture
severity were not significant predictors of PTSD, other cumula-
tive life traumas that happened before and after torture were the
highly significant predictors. These results replicated previous
findings of Kira et al., 2006; and Hollifield et al., 2011. Path
analysis results indicated that torture predicted as hypothized
the more severe symptoms of CTD (Complex PTSD).
For torture types, while physical torture did not predict
PTSD or CTD, witnessing or psychological torture predicted
CTD, and PTSD, replicating Basoglu et al.’s (2009) findings.
Table 2.
Hierarchical Regression analyses with PTSD and CTD as Dependent Variable and Age, Gender, Education and Marital status as independent vari-
ables in the first step, and added torture Trauma, Torture Severity, Anal rape and Vaginal rape in the second step and added Cumulative Trauma Ex-
cluding Torture in the Third step.
Dependent sariables PTSD CTD
Predictors sntered B SE (B) β R² (Change) B SE (B) β R² (Change)
Fist step
Age 0.19 0.08 0.13* 0.048* 0.14 0.05 0.15** 0.039*
Gender 1.67 1.89 0.05 0.72 1.25 0.03
Education 0.28 0.79 0.02 0.11 0.53 0.01
Marital status 1.35 0.49 0.15** 0.68 0.33 0.12*
Second step
Age 0.15 0.08 0.11+ 0.075
(0.028+) 0.118 0.054 0.13* 0.062 (0.023)
Gender 3.07 2.21 0.09 1.24 1.46 0.06
Education 0.18 0.80 0.01 0.150 0.53 0.02
Marital status 1.23 0.49 0.14** 0.61 0.33 0.11
Torture srauma 1.84 1.21 0.10 0.87 0.80 0.07
Torture severity 0.09 0.09 0.06 0.07 0.06 0.07
Anal rape 18.13 9.38 0.11* 9.17 6.23 0.08
Vaginal rape 6.16 5.43 0.06 5.55 3.61 0.09
Third step
Age 0.10 0.07 0.07 0.274 (0.198***)0.083 0.049 0.09+ 0.254
Gender 2.98 1.96 0.09 1.18 1.31 0.05
Education 0.14 .71 0.01 0.17 0.47 0.02
Marital status 0.86 0.44 0.10* 0.36 0.30 0.06
Torture srauma 0.32 1.10 0.012 0.53 0.74 0.04
Torture severity 0.04 0.08 0.03 0.039 0.052 0.04
Anal rape 16.48 8.33 0.10* 8.09 5.57 0.07
Vaginal rape 6.94 4.82 0.07 6.05 3.22 0.10*
Cumulative trauma excluding
torture 1.94 0.22 0.47*** 1.26 0.15 0.46***
Note: All regression models were significant (p < 0.000) *p < 0.05. **p < 0.01. +p < 0.10. Two-tailed.
Anal rape was associated with PTSD and CTD. Vaginal rape
predicted CTD. These results replicated Hooberman et al., 2007,
and Punamaki et al., 2010 findings on the development of
PTSD symptom following sexual torture.
One of the important findings is the potential effects of tor-
ture on decreased re-experiencing and emotional numbness.
Torture trauma is too emotionally and physically painful ex-
perience that tends to be suppressed decreasing re-experiencing
and increasing dissociation. Recent longitudinal study found
persistent dissociation among ex-prisoners of war (Zerach et al.,
2013). That may explain the disappointing results of some pre-
vious studies that focused on torture effects on PTSD. This may
explain why traditional exposure therapy is not recommended
for torture survivor.
Another alternative explanation to this finding is the attrib-
ution of causes of torture, as a politically motivated inter-group
violence. Fundamental attribution to external causes, for exam-
ple, out-group or the enemy, who bears the responsibility for vi-
ctimization and is less stable and less important than in-group, is
less taxing than attribution to internal causes that denigrate self-
esteem and self-efficacy and produce more stress and reexperi-
encing. Such fundamental attribution process may increase feelings
of personal and collective self-esteem, instead, as he/she suffers
for or to protect his/her group or/and its fundamental causes. The
attribution process, in other personal identity trauma types, may
have more internal locus of causation and self blame. Self-per-
ceptions will strongly influence the ways in which people in-
terpret their sufferings. Internalized vicarious group identity
attributions buffer against decreased self-esteem associated with
other traumas and gave them meaning to their suffering.
Another alternative or added explanation is the use of coping
strategies and behaviors among torture survivors. Among study
Copyright © 2013 SciRes. 477
Chi Square = 3.690, d.f.= 7, p = 0.815
CFI = 1.000
RMSEA = 0.000
Figure 1.
Path Diagram for the Direct Effects of Torture, Torture severity and Other Life Traumas on
PTSD Four Factors.
Table 3.
Decomposition of standardized direct, indirect, total effects and confidence intervals (95%) of Torture, torture severity and other cumulative life
traumas on PTSD Four Factors.
Endogenous variables
Causal variables Re-experiencing Avoidance Arousal Emotional numbness/Mild
Torture trauma
Direct effects 0.069
(0.162/0.029) 0.000 0.000 0.000
Indirect effects 0.000 0.052
Total effects 0.069
Cumulative trauma excluding torture trauma
Direct effects 0.472**
Indirect effects 0.000 0.357**
Total effects 0.472**
Torture Severity
Direct effects 0.000 0.000
(0.008/0.135) 0.000
Indirect effects 0.000 0.000 0.000 0.039*
Total effects 0.000 0.000
Squared R 0.207 0.671 0.518 0.547
Note: *p < 0.05. **p < 0.01. +p < 0.10. Two-tailed.
sample, 71% attributed their survival to religious beliefs, 53%
to family support, 41% to fate, 32% to will to survive, 4% to
party and community support, and 3% to forgiveness. Primary
torture survivors, compared to secondary torture survivors,
were significantly attributing will to survive and community
nd political party support as factors in their survival compared a
Copyright © 2013 SciRes.
Chi Square = 9.474, d.f.= 6, p=0.149
CFI = 0.995
RMSEA = 0.040
Traum a
Comor bidit y
Figure 2.
Path diagram for the effects of torture, torture severity and other life traumas on PTSD
four factors.
to secondary torture survivors. They express significantly less
anger from God because what happened to them compared to
secondary survivors. This may indicate more inner resiliency
and post-traumatic growth. Previous study (Isakson, Jurkovic,
2013) concluded that reliance on belief and value systems, safe-
ty measures, and social support, despite continuing psychologi-
cal and physical symptomatology, enabled the moving-on pro-
cess for torture survivors.
The results of path analysis highlighted another potential or
added explanation. While torture may be negatively associated
with some of PTSD symptoms, it is associated with the more
severe symptoms of dissociation, psychosis, and executive func-
tion deficits. Path analysis results showed small size significant
effects of torture on depression/anxiety comorbidity and execu-
tive function deficits, and small indirect, but significant effects
on dissociation/psychosis (0.005*), and suicidality (0.003*). Tor-
ture severity showed medium size direct effects on executive
function deficits and depression/anxiety comorbidity.
Implications for torture treatments
By mapping the full blueprint of the torture effects, we hope
the information will eventually lead to the development of more
targeted interventions. One of the important findings of current
study is that the highest and core trauma for all the cultural
groups in current study was collective identity trauma (inter-
group traumas). The political nature of torture as part of in-
ter-group violence, contrasted by interpersonal violence should
help develop targeted interventions more appropriate to this
core trauma type. The potential effects of torture on decreased
re-experiencing may help explain why clinicians report that
traditional exposure therapy may be contraindicated with tor-
ture survivors and victims of severe trauma in general (e.g.,
Gleiser, Ford, & Fosha, 2008; Kira, 2010). Intervention based
on PTSD model and re-experiencing (e.g., traditional exposure
therapy) may not be effective for some of them as their symp-
toms may be more severe. Force re-experiencing, can be re-trau-
matizing, worsening their condition, or force them to drop out.
Systematic review of treatment modalities for PTSD in ref-
ugee populations found that no treatment modality was firmly
supported, but there was evidence for the effectiveness of nar-
rative exposure therapy and cognitive-behavioral therapy (e.g.,
Crumlish, & O’Rourke, 2010, Robjant, & Fazel, 2010; Neuner
et al., 2009). There is an empirical evidence of the effectiveness
of trauma-focused CBT on refugees (e.g., Kruse, Joksimovic,
Cavka, et al., 2010).
Working with complex traumas, such as torture, needs new
framework for trauma recovery (e.g., Courtois, Ford, Herman,
& van der Kolk, 2009). One of the other promising intervene-
tions, is the Trauma Adaptive Recovery Group Education and
Therapy (TARGET; Courtois & Ford, 2009; Ford & Russo,
2006). TARGET views recovery from trauma as a shift from
living in survival mode to focusing on personal growth and
effectiveness in family, friendship, intimate, work, and commu-
nity relationships. TARGET is a non-exposure therapy that uses
skills building and experiential exercises in a group therapy for-
mat to address topics that include self-esteem, anger, grief, shame,
guilt, relationships, revictimization, and spirituality.
An integrated model of recovery that combines individual
and ecological approaches to recovery may be more indicated
especially for those complex traumas that have political and in-
ter-group components. It was suggested that adding cultural and
the ecological considerations will reduce the limitations of the
individual model of recovery and counter the confines of the
medical model of services (e.g., Kira, 2010; Summerfield,
2004). Individual models of recovery (e.g., Herman, 1997) and
Copyright © 2013 SciRes. 479
Table 4.
Decomposition of standardized direct, indirect, total effects and confidence intervals (95%) of torture, torture severity and other cumulative life trau-
mas on CTD four factors.
Endogenous variables
Causal variables Depression and anxiety
comorbidity syndrome Executive function deficitsSuicidality Psychotic features and
Torture trauma
Direct effects 0.000 0.068*
(0.027/0.138) 0.000 0.000
Indirect effects 0.017*
Total effects 0.017*
Torture Severity
Direct effects 0.032
(0.005/0.154) 0.000 0.000
Indirect effects 0.021*
Total effects 0.053
Cumulative Trauma (Exc luding Torture)
Direct effects 0.314**
Indirect effects 0.089**
Total effects 0.403**
Note: *p < 0.05, **p < 0.01, +p < 0.10. Two-tailed.
ecological models of recovery that have been suggested for in-
terpersonal traumas (e.g., Harvey, 1996) needed to be adapted
and adjusted to work with victims of torture and political vio-
lence (e.g., Miller, 1999). Holistic, interdisciplinary torture re-
habilitation models emerged early on (by 1984) in Copenha-
gen by RCT group (e.g., Ortmann, Genefke, Jakobson, & Lunde,
1987). Variants and expansions of the model have been emer-
ged and further developed, for example, the wraparound ap-
proach for psycho-social rehabilitation of torture survivors (e.g.,
Silove, Tarn, Bowles, & Reid, 1991; Kira, 2002, 2010), ecolo-
gical group therapy models that focus on community healing
(Kira, Ahmed et al., 2012b), post-disaster ecological recovery
model, (Abramson et al., 2010). While such models have social
and ecological validity as inherent programmatic feature, empi-
rical evidence of its effectiveness is not yet established through
controlled double blind studies. However, there is strong em-
pirical evidence for the effectiveness of some of their variants
(e.g., Abramson et al., 2010). There is some empirical evidence
of the effectiveness of multi-component multi-systemic wrap-
around torture rehabilitation approach (e.g., McColl et al.,
2010). There is need to develop or adopt such a multi-systemic,
multi-component, multi-modal Therapies (MSMCT) that include
individual, family, and community healing (c.f., e.g., Alexander,
2004, Kira, 2001, 2010 ). Community-based interventions that
go beyond home-based family sessions have shown evidence of
enhancing the generalizability and durability of treatment bene-
fits (Kazdin & Weisz, 1998).
Working with torture survivors, clinician should adopt mu-
ltifocal conceptual lens that help widen the socio-political and
cultural context that is usually missing in the therapeutic en-
counter with torture survivors. It is importance of having a
working alliance that is characterized by a non-neutral attitude
toward the core traumas of the patient. This highlights the
“bond of commitment” required of therapists and the relevance
of political affiliations and advocacy in these processes. This
bond of commitment seeks to depathologize, demedicalize and
normalize the survivor experiences and resulted symptoms (e.g.,
Becker, Lira et al., 1990).
One limitation of the study was its cross-sectional nature,
which only allowed investigators to draw probabilistic causality
from the results. We realize the limitation of regression and
path analyses with unobserved confounding variables that can
distort statistical inference. It may be impossible to eliminate
their effects in observational studies. However, in the cases where
one cannot conduct experimental studies, regression and path
analyses are powerful tools of analysis.
Further, several analyses were conducted which may increase
the risk for type I errors. Caution should be exercised in inter-
preting the results that are not highly significant.
Another limitation of the study is that the measurement of
cumulative trauma was based on participants’ self-report which
could be subject to bias of under or over-reporting of events
due to current symptoms, embarrassment, shame, and social
desirability. Despite these limitations, results provide associa-
Copyright © 2013 SciRes.
tions that help in the prediction and formulation of hypotheses
for subsequent controlled designs, if possible. Plausible theo-
retical analysis and previous empirical studies suggest a prob-
abilistic directionality of the effects.
Arbuckle, J. L. (2006). Amos 7.0 user’s guide. Chicago: SPSS.
Abramson, D. M., Stehling-Ariza, T., Park, Y. S., Walsh, L., & Culp, D.
(2010). Measuring individual disaster recovery: A socioecological
framework. Disaster Medicine and Public Health Preparedness, 4,
46-54. doi:10.1001/dmp.2010.14
Alexander, J. C. (2004). Toward a theory of cultural trauma. In J. C.
Alexander, R. Eyerman, B. Giesen, N. J. Smelser, & P. Sztompka
(Eds.), Cultural trauma and collective identity (pp. 1-30). Berkeley:
University of California Press.
Başoglu, M. (2009). A multivariate contextual analysis of torture and
cruel, inhuman, and degrading treatments: Implications for an evi-
dence-based definition of torture. American Journal of Orthopsy-
chiatry, 79, 135-145. doi:10.1037/a0015681
Becker, D., Lira, E., Castillo, M. I., Gómez, E., & Kovalskys, J. (1990).
Therapy with victims of political repression in Chile: The challenge
of social reparation. Journal of Social Issues, 4 6, 133-149.
Blake, D. D., Weathers, F. W., Nagy, L. M., Kaloupek, D. G., Klaumin-
zer, G., Charney, D. S., & Keane, T. M. (1990). A clinician rating scale
for assessing current and lifetime PTSD: The CAPS-1. The Behavior
Therapist, 13, 187-188.
Courtois, C., Ford, J., Herman, J., & van der Kolk, B. (2009). Treating
complex traumatic stress disorders: An evidence-based guide. Guil-
ford: Guilford Press.
Crumlish, N., & O’Rourke, K. (2010). A systematic review of treat-
ments for post-traumatic stress disorder among refugees and asylum-
seekers. Journal of Nervous and Mental Disorders, 198, 237.
Ford, J., & Russo, E. (2006). Trauma-focused present-centered emo-
tional self-regulation approach to integrated treatment for posttrau-
matic stress and addiction: Trauma adaptive recovery group education
and therapy (TARGET). American Journal of Psychotherapy, 60,
Gleiser, K., Ford, J., & Fosha, D. (2008). Contrasting exposure and ex-
periential therapies for complex PTSD. Psychotherapy: Theory, Re-
search, Practice, Training, 45, 340-360. doi:10.1037/a0013323
Harvey, M. (1996). An ecological view of psychological trauma and
trauma recovery. Journal of Traumatic Stress, 9 , 3-23.
Herman, J. (1997). Trauma and recovery. New York: Basic Books.
Hollifield, M., Warner, T., & Westermeyer, J. (2011). Is torture reliably
assessed and a valid indicator of poor mental health? Journal of
Nervous & Mental Disease, 199, 3-10.
Hooberman, J., Rosenfeld, B., Lhewa, D., Rasmussen, A., & Keller, A.
(2007). Classifying the torture experiences of refugees living in the
United States. Journal o f Interpersonal Violence, 22, 1-16.
Isakson, B. L., &. Jurkovic, G. (2013). Healing after torture: The role of
moving on. Qualitative Health Research, 23, 749-761.
Johnson, H., & Thompson, A. (2008). The development and mainte-
nance of post-traumatic stress disorder (PTSD) in civilian adult sur-
vivors of war trauma and torture: A review. Clinical Psychology Re-
view 2008, 28, 36-47. doi:10.1016/j.cpr.2007.01.017
Kazdin, A. E., & Weisz, J. R. (1998). Identifying and developing em-
pirically supported child and adolescent treatments. Journal of Coun-
seling and Clinical Psychology, 66, 19-36.
Kira, I. (2001). Taxonomy of trauma and trauma assessment. Trauma-
tology, 2, 1-14.
Kira, I. (2002). Torture assessment and treatment: The wraparound
approach. Traumatology, 8, 23-51.
Kira, I. (2010). Etiology and treatments of post-cumulative traumatic
stress disorders in different cultures. Traumatology: An International
Journal, 16, 128-141.
Kira, I., Templin, T., Lewandowski, L., Ashby, J. S., Oladele, A., & Ode-
nat, L. (2012a). Cumulative trauma disorder scale: Two studies. Psy-
chology, 3, 643-656. doi:10.4236/psych.2012.39099
Kira, I., Ahmed, A., Wassim, F., McAdams-Mahmoud, V., Clorain, J.,
& Rai, D. (2012b). Group therapy for refugees and torture survivors:
Treatment models innovations. International Journal of Group Psy-
chotherapy, 62, 63-83. doi:10.1521/ijgp.2012.62.1.69
Kira, I., Fawzi, M., & Fawzi, M. (2012). The dynamics of cumulative
trauma and trauma types in adults patients with psychiatric disorders:
Two cross-cultural studies. Traumatology, Advanced online Publica-
Kira, I., Templin, T., Lewandowski, L., Ramaswamy, V., Bulent, O.,
Abu-Mediane, S., Mohanesh, J., & Alamia, H. (2011). Cumulative
Tertiary appraisal of traumatic events across cultures: Two studies.
Journal of Loss and Trauma: International Perspectives on Stress &
Coping, 16, 43-66. doi:10.1080/15325024.2010.519288
Kira, I., Ahmed, A., Mahmoud, V., & Wassim, F. (2010). Group thera-
py model for refugee and torture survivors. Torture: An International
Journal, 20, 108-113.
Kira, I., Smith, I., Lewandowski, L., & Templin, T. (2010). The effects
of perceived gender discrimination on refugee torture survivors: A
cross-cultural traumatology perspective. Journal of the American
Psychiatric Nurses Association, 16, 299-306.
Kira, I., Lewandowsi, L., Templin, T., Ramaswamy, V., Ozkan, B., &
Mohanesh, J. (2010). The effects of perceived discrimination and
backlash on Iraqi refugees’ physical and mental health. Journal of
Muslim Mental Health, 5, 59-81. doi:10.1080/15564901003622110
Kira, I., Lewandowsk, L., Templin, T., Ramaswamy, V., Ozkan, B., &
Mohanesh, J. (2008). Measuring cumulative trauma dose, types and
profiles using a development-based taxonomy of trauma. Traumato-
logy, 14, 62-87. doi:10.1177/1534765608319324
Kira, I., Hammad, A., Lewandowski, L., Templin, T., Ramswamy, V.,
Ozkan, B., & Mohanesh, J. (2007). The health and mental status of
Iraqi refugees and their etiology. Ethnicity & Disease, 17, 79-82.
Kira, I., Templin, T., Lewandowski, L., Clifford, D., Wiencek, E., Ham-
mad, A., Al-Haidar, A., & Mohanesh, J. (2006). The effects of tor-
ture: Two community studies. Peace and Conflict: Journal of Peace
Psychology, 12, 205-228. doi:10.1207/s15327949pac1203_1
Kruse, J., Joksimovic, L., Cavka, M., Wöller, W., & Schmitz, N. (2010).
Effects of trauma-focused psychotherapy upon war refugees. Journal
of Traumatic Stress, 22, 585-592.
McColl, H., Higson-Smith, C., Gjerding, S., Omar, M., Rahman, B.,
Hamed, M., et al. (2010). Rehabilitation of torture survivors in five
countries: Common themes and challenges. International Journal of
Mental Health Systems, 4 , 16. doi:10.1186/1752-4458-4-16
Miller, K. E. (1999). Rethinking a familiar model: Psychotherapy and
the mental health of refugees. Journal of Contemporary Psychother-
apy, 29, 283-306. doi:10.1023/A:1022926721458
Mollica, R., McInnes, K., Poole, C., & Tor, S. (1998). Dose effect
relationship of trauma to symptoms of depression and PTSD among
Cambodian survivors of mass violence. British Journal of Psychiatry,
173, 482-488. doi:10.1192/bjp.173.6.482
Neuner, F., Kurreck, S., Ruf, M., Odenwald, M., Elbert, T., & Schauer,
M. (2009). Can asylum seekers with posttraumatic stress disorder be
successfully treated? A randomized controlled pilot study. Cognitive
Behavior Therapy, 34, 1-11.
O’Brien, R. M. (2007). A caution regarding rules of thumb for variance
inflation factors. Quality and Quantity, 41, 673-690.
Ortmann, J., Genefke, I., Jakobsen, L., & Lunde, I. (1987). Rehabilita-
tion of torture victims: An interdisciplinary treatment model. Ame-
rican Journal of Social Ps yc h i a t r y , 7, 161-167.
Pope, K. S. (2001). Torture. In J. Worrell’s (Ed.), Encyclopedia of
women and gender: Sex similarities and differences and the impact
of society on gender (pp. 1-1256). San Diego, CA: Academic Press.
Copyright © 2013 SciRes. 481
Copyright © 2013 SciRes.
Punamäki, R., Qouta, S. R., & EI Sarraj, E. (2010). Nature of torture,
PTSD, and somatic symptoms among political ex-prisoners. Journal
of Traumatic Stress, 23, 532-536. doi:10.1002/jts.20541
Quiroga, J., & Jaranson, J. (2005). Politically-motivated torture and its
survivors: A desk study review of the literature. Torture, 15, 1-111.
Rasmussen, A., Rosenfeld, B., Reeves, K., & Keller, A. S. (2007). The
effects of torture-related injuries on long-term psychological distress
in a Punjabi Sikh sample. Journal of Abnormal Psychology, 116,
734-740. doi:10.1037/0021-843X.116.4.734
Robjant, K., & Fazel, M. (2010). The emerging evidence for narrative
exposure therapy: A review. Clinical psychology review, 30, 1030-
1039. doi:10.1016/j.cpr.2010.07.004
Schmitt, N. (1996). Uses and abuses of coefficient alpha. Psychological
Assessment, 8, 350-353. doi:10.1037/1040-3590.8.4.350
Steel, Z., Chey, T., Silove, D., Marnane, C., Bryant, R. A., & van Om-
meren, M. (2009). Association of torture and other potentially trau-
matic events with mental health outcomes among populations ex-
posed to mass conflict and displacement: A systematic review and
meta-analysis. Journal of the American Medical Association, 302,
537-549. doi:10.1001/jama.2009.1132
Summerfield, D. (2004). Cross-cultural perspectives on the medicaliza-
tion of human suffering. In G. M. Rosen (Ed.), Posttraumatic stress
disorder: Issues and co ntroversies (pp. 233-245). New York: Wiley.
Vorbrüggen, M., & Baer, H. U. (2007). Humiliation: The lasting effect
of torture. Military Medicine, 172, S29-S33.
Zerach, G., Greene, T., Ginzburg, K., & Solomon, Z. (2013). The Rela-
tions between posttraumatic stress disorder and persistent dissocia-
tion among ex-prisoners of war: A longitudinal study. Psychological
Trauma: Theory, Research, Practice, and Policy. Advance online