Psychology Of Torture Research Paper

Little is known about the prevalence of torture among various at-risk populations. About 5–35 percent of the world’s 14 million refugee population (0.7–4.9 million refugees) are estimated to have had at least one experience of torture (Baker 1992). These figures do not reflect the current extent of the problem after the recent developments in Eastern Europe, former Yugoslavia, Middle East, and other parts of the world torn by political turmoil, nationalistic movements, and regional wars.

In this research paper, the evidence on the long-term mental health effects of torture will be reviewed. Torture is a sociopolitical phenomenon with wide-ranging physical, psychological, social, economic, and political consequences. Our knowledge on these issues is limited owing to the scarcity of systematic research. This review will focus on the psychological effects of torture as relatively more work has been done in this area. Detailed information on the physical effects of torture can be found elsewhere (Skylv 1992). The reader is also referred two books (Basoglu 1992, Jaranson and Popkin 1998) for more detailed information on other aspects of the problem.

The difficulties in defining torture have been widely recognized. Scientific study of this problem requires a clear definition. The definition adopted for the present review is the one that has been provided by the 1986 United Nations Declaration of Human Rights: ‘any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining from him or a third person information or a confession, punishing him for an act he or a third person has committed or is suspected of having committed, or intimidating or coercing him or a third person, or for any reason based on discrimination of any kind, when such pain of suffering is inflicted by or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity.’

2. Psychological Effects Of Torture

Most studies of torture survivors have methodological limitations that preclude definitive conclusions on the psychological effects of torture. These include insufficient description of the interview procedures, assessment instruments, diagnostic criteria, and medical diagnoses. Few studies have examined the relationship between the symptoms and the diagnosis of post-traumatic stress disorder (PTSD). Most studies used an uncontrolled design and thus did not control for other nontorture, potentially traumatic life events. Furthermore, most of these studies have been carried out on refugees so the additional effects of refugee trauma are not controlled for. In recent years, however, controlled studies have been carried out, attempting to overcome some of the methodological problems of the earlier studies. The evidence will be reviewed in two sections, uncontrolled and controlled studies, with greater emphasis on the latter.

2.1 Uncontrolled Studies

In a review of eight studies by Goldfeld et al. (1988), the most common problems in torture survivors were anxiety, depression, irritability/aggressiveness, emotional lability, social withdrawal, disorientation, memory and concentration impairment, impaired reading ability, lack of energy, insomnia, nightmares, and sexual dysfunction. Another review of the literature (Somnier et al. 1992) involving 46 studies, reported similar findings. Although cerebral atrophy, abnormal sleep patterns, somatization, and traumatic brain injury have also been reported (reviewed in Basoglu 1997), the evidence on these findings is not conclusive.

Some of the evidence comes from studies of former prisoners-of-war (POWs) and concentration-camp survivors. In a review of the literature, Miller (1992) concluded that former POWs continue to have anxiety, depression, and PTSD 40 years postcaptivity and torture during captivity is related to more severe psychological problems in the long term. (Solkoff 1992), in his review of the literature on concentration camp survivors, pointed to various methodological problems which characterize the research from which the ‘survivors’ syndrome’ evolved. The author concluded that the effects of Holocaust-related trauma on survivors and the second generation have not been adequately investigated.

2.2 Controlled Studies

A Danish study (Hougen et al. 1988) compared 14 tortured refugees with 14 nontortured controls. The torture survivors had more psychological symptoms than did the controls. The sample size, however, was too small and matching of controls was not adequate. The measurement of symptoms was not sufficiently detailed. Another controlled study (Petersen and Jacobsen 1985) of Spanish torture survivors found that tortured individuals, relative to controls, had more symptoms of depression, anxiety, emotional lability, sleep disturbance, nightmares, and memory and concentration difficulties. However, the measures were not sufficiently detailed and standardized instruments based on established diagnostic criteria were not used. In addition, the sample size (n 10) was too small for statistical analysis.

A more recent study in Turkey (Basoglu et al. 1994a) used standardized assessment instruments in comparing 55 tortured political activists with 55 nontortured political activists and 55 nontortured, nonactivist controls, matched for age, sex, marital and socio-cultural status. The torture survivors had significantly more lifetime and current PTSD than did the controls (33 percent vs. 11 percent and 18 percent vs. 4 percent, respectively). Secondary impact of captivity torture on family, family history of psychiatric illness, and post-torture psychosocial stressors related to long- term psychological status (Basoglu et al. 1994b). Both torture and subsequent psychosocial stressors contributed to traumatic stress symptoms (Basoglu and Paker 1995). In an attempt to explain the relatively low prevalence of PTSD in this sample, the investigators pointed to the possible protective role of a strong belief system, commitment to a cause, prior knowledge and expectations of torture, and prior immunization to traumatic stress (Basoglu et al. 1994b). The majority of the survivors were highly committed political activists with prior expectations of and psychological preparedness for torture. They also had a negative appraisal of the state and had not maintained beliefs concerning a ‘benevolent state’ before the trauma, another factor that may have protected them against the traumatic effects of torture (Basoglu et al. 1996).

The study by Basoglu et al. (1994a), while pointing to the possible protective role of ‘psychological preparedness for trauma,’ could not test this hypothesis because most study participants were highly committed political activists. A further study (Basoglu et al. 1997) was carried out to compare 34 less psychologically prepared, nonactivist torture survivors with the previous sample of 55 tortured political activists. Compared with the political activists, the nonactivists were relatively less severely tortured but had significantly more PTSD (58 percent vs. 18 percent) and major depression (24 percent vs. 4 percent). These findings supported the role of prior immunization in reducing the effects of traumatic stress, and of unpredictability and uncontrollability of stressors in exacerbating the effect of torture.

Another study (Maercker and Schutzwohl 1997), which investigated the long-term effects of political imprisonment in the former German Democratic Republic, compared 146 former political prisoners with 75 controls matched for age and sex. In comparison with controls, the former political prisoners had significantly higher rates of lifetime (59.6 percent) and current PTSD (30.1 percent), claustrophobia, social phobia, substance abuse, and higher scores on measures of anxiety, depression, general psychopathology, and dissociative symptoms.

A controlled study by Shrestha et al. (1998) involved 526 Bhutanese refugee survivors of torture in Nepal matched with 526 nontortured refugees on age and sex. The study group was selected randomly from the Bhutanese refugee community in the United Nations refugee camps in eastern Nepal. Compared with the control group, the torture survivors had more PTSD symptoms, higher anxiety and depression scores, and more musculoskeletal and respiratory system complaints. The authors concluded that torture may increase the risk of mental health problems among refugees and that PTSD symptoms appear to be part of a universal reaction to torture.

A further study (Mollica et al. 1998) in the USA involved 62 Vietnamese ex-political detainees and 22 controls. Compared with the controls, the ex-political detainees showed significantly higher scores on depression and PTSD symptoms but the prevalence rates of PTSD (77.3 percent vs. 88.2 percent, respectively) and major depression (36.4 percent vs. 56.9 percent, respectively) across the two groups did not reach statistical significance. Severity of torture was the most significant predictor of depression and PTSD symptoms, particularly of arousal symptoms among the latter. The authors suggested that a small sample size may have accounted for the lack of statistically significant differences in the prevalence of psychiatric diagnoses.

A controlled study (Holtz 1998) in India involved 35 tortured refugee Tibetan nuns and lay students and 35 nontortured controls matched for sex, age, lay status, and years in exile. Relative to the controls, the torture survivors had significantly higher scores on measures of anxiety but the two groups did not differ on ratings of depression. Lack of prior knowledge of and psychological preparedness for torture was a significant predictor of post-torture anxiety symptoms. Other predictors included male sex, longer duration of torture, exposure to solitary confinement, feelings of hopelessness in prison, and recent arrival in India. The author suggested that the survivors’ Tibetan Buddhist training as nuns may have contributed to their resilience against the traumatic impact of torture.

In conclusion, there is clear evidence that in some individuals torture has psychological effects independently of other associated stressors such as harassment and persecution by the authorities, unlawful detentions, unfair trials, imprisonment, exposure to mass violence and life-threatening situations, threats of death to self and family, having to go into hiding, loss of employment or educational opportunities, bereavement, uprooting, and refugee status. The distinction between the effects of torture per se and those of other associated stressors is important for medical and legal reasons.

3. Implications Of Current Knowledge For Survivor Care Policies

The research evidence reviewed so far may have important implications for legal and public health policies concerning torture survivors. Immigration, asylum, and refugee care policies need to take into account the fact that a significant proportion of asylum seekers and refugees may have a history of torture and be at risk of disabling psychological problems. Due attention to mental health issues may be as important as providing legal, social, and economic aid for refugees. Research findings (Basoglu and Paker 1995) suggest that social support may not be sufficient for recovery unless it is complemented with effective psychological treatment. Greater funding needs to be allocated for mental health care services for tortured refugees and mental health professionals need to play a more central role in policy making in refugee care.

Given the prevalence of torture in the world and the mental health hazards posed by its chronic and disabling psychological consequences, there is an urgent need for psychological treatments with demonstrated efficacy. Survivor care policies need to place greater emphasis on developing effective treatments through systematic research and on training of mental health workers in treatment techniques.

Finally, there has been relatively little scientific interest in the study of torture and the treatment of its consequences, despite the serious mental health hazards posed by the problem. Much of the available resources for survivor care is often used for social, legal, and economic aid and for various rehabilitation programs, the efficacy of which has not yet been demonstrated. In policy making, research is either given low priority or sometimes even dismissed as unethical. Scientific research with due regard for ethical issues is possible and essential for effective survivor care. Study of torture survivors also has important implications for human rights, theory, assessment, classification, treatment of traumatic stress responses, and legal issues concerning torture survivors.

4. Directions For Future Research

Future research needs to focus on three main issues: psychobiological mechanisms of traumatization, factors related to long-term psychological functioning, and effective treatments for survivors of torture. Given the evidence on the role of psychological preparedness for trauma as a protective factor, further studies are needed to elucidate the behavioral and cognitive components of this construct. A better understanding of resilience factors is needed to develop more effective treatment programs.

More research is needed to clarify cognitive responses to torture and their bearing on long-term outcome. Among these cognitive responses, sense of injustice arising from impunity for perpetrators is of particular importance. Little is known how various forms of compensation and redress relate to survivors’ psychological functioning. Studies of this issue would also be useful in clarifying the psychological effects of ‘truth and reconciliation’ processes, such as in South Africa, both on survivors and on the community. It could also provide insights into how such processes should be conducted to avoid further traumatization and maximize the psychological well-being of survivors and their community.

Further work is needed to examine how various stressors such as torture, uprooting, refugee trauma, and loss of social support relate to psychological problems in survivors of torture. International collaborative studies are needed to develop standardized and validated assessment instruments for refugee and nonrefugee torture survivors.

There is need for greater emphasis on research in developing effective treatments for torture survivors. Controlled treatment trials are needed to identify the most effective treatments and their mechanisms of action. Given the scarce resources available for the care of torture survivors, the efficacy of current rehabilitation models needs to be evaluated and their therapeutic ingredients clarified. For Western countries facing a serious refugee problem, epidemiological studies are needed to investigate the prevalence of past torture and associated psychosocial problems among refugee populations.

Bibliography:

1. Amnesty International 1998 Amnesty International Report, Amnesty International Publications, London
2. Baker R 1992 Psychosocial consequences for tortured refugees seeking asylum and refugee status in Europe. In: Basoglu M (ed.) Torture and Its Consequences: Current Treatment Approaches. Cambridge University Press, Cambridge, UK
3. Basoglu M 1992 Torture and Its Consequences: Current Treatment Approaches. Cambridge University Press, Cambridge, UK
4. Basoglu M 1993 Prevention of torture and care of survivors: an integrated approach. Journal of the American Medical Association 270: 606–11
5. Basoglu M 1997 Torture as a stressful life event: a review of the current status of knowledge. In: Miller T W (ed.) Stressful Life Events. International Universities Press, New York, pp. 45–70
6. Basoglu M, Paker M 1995 Severity of trauma as predictor of long-term psychological status in survivors of torture. Journal of Anxiety Disorders 9: 339–50
7. Basoglu M, Paker M, Paker O, Ozmen E, Marks I M, Incesu C, Sahin D, Sarimurat N 1994 a Psychological effects of torture: a comparison of tortured with nontortured political activists in Turkey. American Journal of Psychiatry 151: 76–81
8. Basoglu M, Paker M, Paker O, Ozmen E, Oahin D 1994 b Factors related to long-term traumatic stress responses in survivors of torture in Turkey. Journal of the American Medical Association 272: 357–63
9. Basoglu M, Paker M, Ozmen E, Tasdemir O, Sahin D, Ceyhanli A, Incesu C, Samimurat N 1996 Appraisal of self, social environment, and state authority as a possible mediator of post-traumatic stress disorder in tortured political activists. Journal of Abnormal Psychology 105(2): 232–6
10. Basoglu M, Mineka S, Paker M, Aker T, Livanou M, Gok S 1997 Psychological preparedness for trauma as a protective factor in survivors of torture. Psychological Medicine 27: 1421–33
11. Goldfeld A E, Mollica R F, Pesavento B H, Faraone S V 1988 The physical and psychological sequelae of torture: symptomatology and diagnosis. Journal of the American Medical Association 259: 2725–9
12. Holtz T H 1998 Refugee versus torture trauma: A retrospective controlled cohort study of Tibetan refugees. Journal of Nervous and Mental Disease 186: 24–34
13. Hougen H P, Kelstrup J, Petersen H D, Rasmussen O V 1988 Sequelae to torture. A controlled study of torture victims living in exile. Forensic Science International 36: 153–60
14. Jaranson J M, Popkin M K 1998 Caring for Victims of Torture. American Psychiatric Press, Washington, DC
15. Maercker A, Schutzwohl M 1997 Long-term effects of political imprisonment: a group comparison study. Social Psychiatry and Psychiatric Epidemiology 32: 435–42
16. Miller T W 1992 Long-term effects of torture in former prisoners of war. In: Basoglu M (ed.) Torture and Its Consequences: Current Treatment Approaches. Cambridge University Press, Cambridge, UK, pp. 107–35
17. Mollica R F, McInnes K, Pham T, Smith Fawzi M C, Murphy E, Lin L 1998 The dose–effect relationship between torture and psychiatric symptoms in Vietnamese ex-political detainees and a comparison group. Journal of Nervous and Mental Disease 186: 543–53
18. Petersen H D, Jacobsen P 1985 Psychical and physical symptoms after torture. A prospective controlled study. Forensic Science International 29: 179–89
19. Shrestha N M, Sharma B, van Ommermen M, Regmi S, Makaju R, Komproe I, Shrestha G B, de Jong J 1998 Impact of torture on refugees displaced within the developing world: symptomatology among Bhutanese refugees in Nepal. Journal of the American Medical Association 280: 443–8
20. Skylv G 1992 The physical sequelae of torture. In: Basoglu M (ed.) Torture and Its Consequences: Current Treatment Approaches. Cambridge University Press, Cambridge, UK, pp. 38–55
21. Solkoff N 1992 The Holocaust: survivors and their children. In: Basoglu M (ed.) Torture and Its Consequences: Current Treatment Approaches. Cambridge University Press, Cambridge, UK, pp. 136–48
22. Somnier F, Vesti P, Kastrup M, Genefke I K 1992 Psycho-social consequences of torture: current knowledge and evidence. In: Basoglu M (ed.) Torture and Its Consequences: Current Treatment Approaches. Cambridge University Press, Cambridge, UK, pp. 56–71