torutre and mental health

Mental Health and

Torture

GanesanHuman Rights Counsil

Sri Lanka15th July 2015

What is……..

Amnesty International (Report on Torture 1973)

World Medical Association (Tokyo, 1975)

United Nations Convention Against Torture (CAT, 1984/ 1987)

Physicians for Human Rights (PHR 2005)

DefinitionsAI: Systematic & deliberate infliction of pain and suffering by one person on another

WMA: Deliberate, systematic or wanton infliction of physical or mental suffering for any reason

UN: severe* pain and suffering, intentionally inflicted for any reason by a public official based on discrimination

PHR: ‘‘severe mental pain or suffering’’ caused by the threat of, or actual, administration of ‘‘procedures calculated to disrupt profoundly the senses or personality’’

(* reintroduced to concept of gradations of pain and suffering)

Maltreatment

1971: Used legally for the first time in the European Court of Human Rights

Decision that interrogation of a prisoner while blindfolded and deprived of food and sleep was maltreatment and no torture

Collective violence (WHO, 2002)

The context of violence broadened to include organised violence, such as during war. violent acts within and between countries, organised crime structural violence* that may not be state perpetrated

*Economic, political or social discrimination directed at one or more groups in society

To or Not to - 2 types

Leaving physical evidence on the bodies of the tortured has not troubled those oppressive states where impunity is widespread and the perpetrators have no reason to fear prosecution, let alone condemnation, for following what is de facto state policy.

Other states, have increasingly changed their practices owing to growing accountability or perhaps to moral or other pressures and are thus resorting more and more to coercive psychological methods in their interrogations.

“Reasons” for Torture1) To obtain a confession (“judicial torture”)

2) To obtain information (“interrogational torture”)

3) To punish (“penal torture”)

4) To intimidate or coerce the sufferer or others to act in certain ways (“terroristic” or “deterrent” torture)

5) To destroy opponents without killing them (what we may call “disabling torture”)

6) To please the torturer or others (“recreational torture”)

Bosses of Torturers

Imagined that they were laying the groundwork for a civilization that would last a thousand years-that, far from having to justify themselves for occasional lapses, they would be celebrated by all posterity for their achievement.

Psychological Torture

Sleep and food deprivationIsolationThreatsWitness torture of othersUnpredictabilityNothing to say or do to make it stop

Minor….?constant taunting;verbal abuse;intimidations;insulting the honour of a family member; cultural humiliationspitting in someone’s lunch container;petty humiliations (always linked to cultural values); petty and less petty harassments;repeated exasperation provoked on purpose;enforced artificial light 24 hours a day;lack of privacy exploited purposely to mock sensitivities;verbal threats of further torment

In the head of the interrogated prisoner a haze begins to form. His spirit is wearied to death, his legs are unsteady, and he has one sole desire, to sleep, to sleep just a little, not to get up, to lie, to rest, to forget ... Anyone who has experienced this desire knows that not even hunger or thirst are comparable with it ... I came across prisoners who signed what they were ordered to sign, only to get what the interrogator had promised them. He did not promise them liberty ... [only] uninterrupted sleep! ...

White Nights: The Story of a Prisoner in Russia.Menachem Begin, Israeli Prime Minister (1977–83)

Content

Effects of torture

Mental Health services and torture - reality

Justice and Mental Health

Helping survivors of torture

Effects of Torture

‘‘the worst scars are in the mind’’

Impact of Torture

Question basic human relationshipsDestroy victim’s fundamental assumptions about

safety of the world, positive value of self, meaningful order of creation

Violate autonomy of personShatter sense of connection between individual and community

Experience of Torture

Brutality – deliberate, cruel, inhumane treatment from people in official position of powerIntense fear of harm or deathSubjugation and helplessnessLoss of control over one’s bodyHumiliation/degradationPotential to betray oneself, one’s valuesSense of horrorUtter helplessness, serious injury or the threat of physical injury or death.

Psychological Effects 1

One of the main aims of torture is to destroy the psychological, social integrity and functioning of the victim

All kinds of torture inevitably comprise psychological processes (Kordon et al., 1988)

Torture methods are often designed not to leave physical lesions and physical methods of torture may result in physical findings that either resolve or lack specificity.

Contrary to the physical effect of torture, the psychological consequences of torture are often more persistent and troublesome.

Torture can profoundly damage intimate relationships between spouses, parents, children and other family members, and relationships between the victims and their communities” (Istanbul Protocol, § 235).

Psychological Effects 2

In contrary to the physical effects of torture, the psychological symptoms are much more persistent, as torture is intended to damage the person’s self esteem and destroy the person’s trust in fellow humans. The psychological methods of torture are mostly tailor-made. and will often include induced exhaustion and debility through food, water and sleep deprivationThe victims and their families are threatened with death or they experience sham executions. In other cases the victims witness the torture of another prisoner or of family members.

Resilience

Torture survivors who believe in a cause are often more resilient and tolerant.

However, when trauma accumulates beyond the person’s threshold of resilience, an added mild or moderate trauma can become “the last straw that broke the camel’s back,” causing all previous trauma to come to the forefront.

Disorders

Depression and anxietyPost traumatic stress disorderDissociationSomatic problems – headache, pelvic pain, etc.Organic brain syndromesLoss of sense of predictabilityDisconnectionProblems in adjustmentAlcohol and drug abuse

Enduring personality change

evidence of a definite, significant and persistent change in the individual's pattern of perceiving, relating, or thinking about the environment and him/herself, associated with inflexible and maladaptive behaviours not present before the traumatic experience

Present for at least two years following exposure to catastrophic stress

Personal vulnerability not necessary to explain its profound effect of the personality

This is characterized by a hostile or distrustful attitude towards the world, social withdrawal, feelings of emptiness or hopelessness, a chronic feeling of "being on edge" as if constantly threatened, and estrangement.

Sexual dysfunction

Sexual dysfunction is common among survivors of torture, particularly among those who have suffered sexual torture or rape, but not exclusively. It can be linked to depression and post-traumatic stress disorder, but can be a direct result of an assault. Hypnotics or alcohol abuse can occur in this context.

sexual abuse of men in detention in Sri Lanka

THE LANCET • Vol 355 • June 10, 2000

Of the 184 men,

38 (21%) said they had been sexually abused during their detention.

3 (7%) of the 38 said they had been given electric shocks to their genitals,

26 (68%) had been assaulted on their genitals, and

4(9%) had sticks pushed through the anus, usually with chillies rubbed on the stick first.

One said he had been forced to masturbate a soldier manually,

3 had been made to masturbate soldiers orally, and

one forced with his friends to rape each other in front of soldiers for their “entertainment”.

Content

Effects of torture




Health services and torture - reality

Doctors

Do no harm

special position to uphold human rights

leaders of society - Agents of change

Doctors in Sri Lanka

There was a punishment during the time of the Sinhalese kings, namely, two arecanut posts are erected, the two posts are then drawn toward each other with a rope, then tie each of the feet of the offender to each post and then cut the rope which result in the tearing apart the body. These people also should be punished in the same way.....

MP for Panadura (Dr. Neville Fernando)

“The realists,”

Defend torture because (they say) it is in fact often useful in a world as dangerous as this one. They defend it not as a rare act but as a practice or institution.

Michael Davis

Punishment? Michael Davis

1. punishment presupposes rationality. The insane, children, and other mental incompetents are exempt from (legal) punishment (as least while their incompetence lasts).Torture requires only sentience.

2. punishment recognizes the condemned as retaining certain rights (especially, the right to be treated as a human person).

3. punishment has a limit the condemned knows as well as those who execute sentence. Even someone condemned to be drawn and quartered, for example, knows that he will not be flogged or branded.

4. punishment does not seek to break the condemned (though it may in fact do so). Unlike torture, punishment does not take full advantage of the condemned’s helplessness.

Content

Effects of torture




Introduction

Who scheduled the assessment,

Why it was scheduled,

What will be involved in the assessment,

What feedback will be given to the person

Where else the results may be presented,

Any limits to confidentiality, and what impact the results may have on life.

AssessmentRespect and empathy may help in determining the consistency of allegations.

Attentive listening is more important than asking the right questions when assessing allegations.

Traumatized individuals are often passive, shy and non-assertive. They find it painful to describe their trauma and may therefore, understandably, refrain from a detailed description.

A prisoner who has been subjected to violence may have many reasons not to volunteer this information.

Necessary to establish a secure relationship at the outset

Feelings of self-blame and guilt are common in victims,

Evaluation of the impact of torture on the family system, the family dynamics and on the other members of the family (Kira, 2002).

Assessment 2Because of the nature of trauma symptoms, it cannot be expected that the whole history of the traumatic event, or all the symptoms will be elicited in one interview.

The memories are per definition fragmented, and the impossibility to recollect important details of the event are part of the syndrome.

Also, the strong feelings connected to the memories can cause pain and re-traumatization. When only one interview is possible it is important to realize these limitations.

One should not try to pressure a traumatized person to describe details of the trauma if he/she does not seem up to it, or seems to be in pain.

In a long and detailed monologue on the trauma, the interviewer has the obligation to limit the flow of narration, because such flooding can also cause deterioration.

Istanbul Protocol

• Identification of alleged victim and conditions of evaluation

• Detailed account of allegations, including torture methods and physical and psychological symptoms

• Record of physical and psychological findings

• Interpretation of findings and recommendations

• Identification and signature of the medical expert(s).

Content

Effects of torture




Helping Survivors of Torture

Under-recognition by healthcare workers of torture survivors is the norm,and disclosure occurs in only a minority of cases, and rarely at first meeting.

Crosby SS, Norredam M, Paasche-Orlow MK, et al.

The context of torture, is very important and the meanings of the experience differ enormously among torture survivors, from feelings of defeat and despair to pride

Social, financial, occupational and relational consequences (McFarlane 2012)

Psychiatric assessment and treatment of survivors of torture

Richard M. Duffy, Brendan D. Kelly

BJPsych Advances Mar 2015, 21 (2) 106-115;

• authority figures• electrical

appliances• medical

investigations or procedures

• interviews resembling interrogations

• police officers / military personnel

• people that resemble the torturers in some way

• police cars

• crowded places• staying alone at

home• news about violence• Objects, smells,

tastes, tactile sensations that act as reminders of torture experience

• Feared or distressing situations

Feared or distressing situations in torture survivors

Cognitive Strategies to Block

Reflexively Dismissing All Evidence As Questionable, Incomplete, Misleading, False, Or In Some Other Way Inadequate

Using Euphemism, Abstraction, and other Linguistic Transformations

Turning Away: "I'm not involved," "There is nothing I can do about it," "I have no authority, jurisdiction, power, or influence," "This is no concern of mine," etc.

Negative ResponsesTry to prevent the client from telling

extremely interested and push for details

label as torture victim

It is crucial to address the victim's fear carefully, realistically, and in a way that offers maximum safety and security

Clinicians may feel that they too are in danger because of their work with the victim.

Survivor guilt or a regret at not having previously acknowledged and addressed more actively the practice of torture. These feelings may be intensified when the clinician's government was involved,

clinician's political beliefs or personal agenda to interfere with the ability to listen carefully and accurately Pope and Garcia-Peltoniemi (1991)

Treatment

Trust

Relationship

Cultural factors

Testimonials

Accepting the story, reactions and being very clear of the unacceptability of torture

Relaxation, physiotherapy

Testimonial

Privacy and secrecy of torture not only intensified the psychological pain and isolation of the prisoner but also made easier subsequent reports by the authorities that the prisoner "slipped off a piece of soap, fell and died"

Stephen Biko

The Healing Process Involves

Relearning to trust Regaining self and personal dignity Having the chance to talk about what

happened Learning about the symptoms of trauma Grieving the losses- physical, psychological or community Accepting and adapting to disabilities

Future

Following conflicts, opportunities to rethink and redesign health systems may be present. Reaching agreement about the values underlying the system, including the extent to which equity will be promoted, is crucial.

A B Zwi, S Fustukian, J ChauvinLondon School of Hygiene and Tropical Medicine

Canadian Public Health Association

Thank You

torutre and mental health

Health & Medicine