This article was downloaded by: [RMIT University] On: 12 March 2015, At: 02:03 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Medicine and War Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/fmcs19
Medical, psychological and social aspects of torture: Prevention and treatment Danitza Jadresic MRC Psych
a
a
Visiting Psychiatrist, Medical Foundation for the Care of Victims of Torture , 96–98 Grafton Road, London, NWS 3EJ Published online: 22 Oct 2007.
To cite this article: Danitza Jadresic MRC Psych (1990) Medical, psychological and social aspects of torture: Prevention and treatment, Medicine and War, 6:3, 197-203, DOI: 10.1080/07488009008408932 To link to this article: http://dx.doi.org/10.1080/07488009008408932
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form
Downloaded by [RMIT University] at 02:03 12 March 2015
to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
CONFERENCE REPORT
Medical, Psychological and Social Aspects of Torture: Prevention and Treatment DANITZA JADRESIC MRC Psych
Visiting Psychiatrist, Medical Foundation for the Care of Victims of Torture, 96-98 Grafton Road, London NWS 3EJ
Downloaded by [RMIT University] at 02:03 12 March 2015
KEYWORDS
State terror
Torture
Introduction The Conference on Medical, Psychological and Social Aspects of Torture took place in Santiago on 14-18 November 1989 during the run-up to the first presidential elections held in Chile since the military coup which deposed Allende's government in September 1973. Included amongst its objectives were: (a) the provision of a forum where Chilean professionals who have worked with victims of torture could meet and exchange ideas with members of related international organizations, and (b) the public denunciation of the use of torture in Chile. Throughout the Conference, a meeting of professional, therapeutic and political ideas was particularly important. The Conference was not without its risks; one of the organizers revealed that she had received three threatening phone calls in the preceding week and that many professionals had been afraid to attend. Conference organization The Conference was organized jointly by the Geneva based World Organization against Torture, and the Santiago based Mental Health Team of the Committee for the Defence of People's Rights (CODEPU), Santiago, Chile. It was co-sponsored by the Social Aid Foundation of Christian Churches (FASIC), the Foundation for the Protection of Children Damaged by Emergency States (PIDEE), and by the Centre for Research and Treatment of Stress (CINTRAS). Inauguration The opening ceremony was based on the presentation of CODEPU's first book, Person, State, Power. Studies on Mental Health. Chile 1973-1989, which is a collection of essays and published articles, currently only available in Spanish. While introducing the book, Dr Castillo Velazco stressed that an important part of such studies of victims of torture has to be preventative, in other MEDICINE AND WAR, VOL.6,197-203 (1990)
198
D.JADRESIC
words, 'how to ensure that torture should never happen again'. Other speakers emphasized the need to develop an increased awareness of ethics, not only in the medical profession but also in society as a whole. A political role for the health professional was clearly and convincingly supported in most of the later presentations and discussions.
Downloaded by [RMIT University] at 02:03 12 March 2015
Definition and objectives of torture
The Conference commenced with an analysis by Dr A. Estrada (CODEPU) of the definition, aims and techniques of torture. The statistics on torture vary according to the definition employed. The United Nations' Declaration Against Torture (1975)* defines torture as any serious physical or mental suffering deliberately inflicted by, or at the instigation of, a public official on another person in order to obtain information or a confession from that person or a third party, to punish that person for proven or suspected actions, or to intimidate others. This definition excludes the suffering caused by legitimate imprisonment if it is within the bounds of the UN's Minimal Rules for the treatment of prisoners (CODEPU, 1989). Controversial points in the UN Declaration are, for example, its suggestion that torture constitutes only a quantitatively worse form of 'cruel, inhuman or degrading treatment', and the exclusion of more subtle means of torture, such as hidden behavioural conditioning or endless repetition of monotonous auditory or visual stimuli. There is pressure at present in international law circles to change the definition of torture. This would embrace a broader concept of organized state violence when it has the same aims as torture. The mental suffering or anguish produced in the population as a result of the illegitimate actions of the State must also be considered. These include, for example, the psychological and political effects on family and friends, and on society as a whole, of the abduction of individuals and their sudden disappearance without trace.
Agents and techniques of torture
The agents of torture Torture, even if narrowly defined, is a crime against humanity (A. Dominguez, sociologist, Chilean Commission of Human Rights). Innumerable cases of torture were reported to Amnesty International and other human rights organizations since the beginning of the Chilean dictatorship. Apologists for the military Government may have tried to write these off as mere excesses in the hands of a few exalted individuals, but the highly organized nature of
*Reprinted in Ethical Codes and Declarations Relevant to the Health Professions, 2nd edition, 1985, Amnesty International, 1 Easton Street, London WC1X 8DJ.
Downloaded by [RMIT University] at 02:03 12 March 2015
TORTURE: PREVENTION AND TREATMENT
199
the process leaves no doubt that in Chile torture was a deliberate policy on the part of the military dictatorship. It was planned to induce the maximum degree of fear and subjugation in the population. This framework for the phenomenon of torture is important, not only in the political analysis of torture but also in the assessment of psychopathology in the agents of torture. It has become obvious from the statements of ex-torturers in Greece and more recently in Chile that the torturer is not necessarily a psychopath with sadistic drives, but that many are people with obedient and submissive personalities who learn to torture under the influence of alienating military training methods (Dr E. Perez, CODEPU). A recurrent theme during the Conference concerned the future of the torturer. With the advent of a parliamentary democracy, the military's proposals for amnesty and the popular demands for justice have become a burning controversy. Whatever the outcome, there will be a need to rehabilitate torturers back into the ways of a humanitarian society. Therapists will be called upon to develop an empathic and non-punitive therapeutic alliance with the torturers as potential clients. Techniques of torture Reference was made to the large number of physical, sexual and psychological torture techniques which were used in Chile throughout the 16 years of the dictatorship. These were refined over the years and seem at times to have been selected according to the type of prisoner involved. The aim was to achieve the maximum results with the least physical evidence. Dr Sohrens gave an account of his experience and that of Dr F. Bustamante in dealing since 1974 with genito-urinary trauma. They often elicited a history of severe degrees of pain from the application of electricity to the urethra, sometimes to the point of causing loss of consciousness; haematomas and swelling of the scrotum and haematuria often occurred for a short period after the experience of the torture, but were never present at the time of the medical consultation. They were not surprised at an absence of genito-urinary signs of torture in their patients, although sometimes finding evidence of physical torture in other parts of the body. Medical interventions such as electrocoagulation, which leave greater initial lesions in the urethral meatus, often disappear without trace after a short time. Traumatic sports injuries to the genitals are also known not to leave long-lasting visible signs in the great majority of cases. Prolonged solitary confinement has been one of the most widely used forms of torture in Chile since 1986. It is considered to be a highly effective torture technique as, again, it leaves no visible sequelae, and yet may have serious long-term psychological effects. It is thus 'cleaner' and has little international recognition as a form of torture. Elisa Neumann (clinical psychologist) cited Thomas Myers' work on sensory deprivation with American volunteers, and compared it with the experience of FASIC in dealing with 32 victims of solitary confinement in Chile. Chilean testimonies
Downloaded by [RMIT University] at 02:03 12 March 2015
200
D.JADRESIC
describe small and dirty prison cells which severely restrict body movement; uniform colours and light; silence broken only by occasional distant noises; and a restricted daily routine related to eating and going to the toilet. Myers' volunteers experienced mounting anxiety with disturbance of sleep and appetite, and temporo-spatial disorientation, after the first few days of the experiment. These progressed to proprioceptive hallucinations, feelings of derealization, serious difficulties with concentration and attention, and impaired judgement after the first week. It is clear that the enormous uncertainty generated by the conditions of imprisonment, together with the expectancy of the political prisoner about the possibility of physical torture or death, greatly exacerbate the anguish of solitary confinement. Deprived of a normal social framework of reference, the subject loses his/her sense of identity and can easily be manipulated in the interrogation into informing upon others or making a 'confession'. Solitary confinement may lead to long-lasting psychological damage which can be extremely difficult to treat subsequently. It is common for political prisoners held in this way to develop feelings of guilt, diminished self-esteem, and paranoid ideas. They may be left with impaired concentration and memory, chronic sleep disturbance, anxiety, depression, phobias, and other symptoms. The well-known and respected lawyer and human rights activist, Rene Garcia Villegas, gave a moving personal account of his experience of solitary confinement in 1974. He had never talked about it before, and it was clear that his testimony was a harrowing experience for him despite his matter-of-fact tone and his composed demeanour. He related how his sense of social justice and freedom were reaffirmed by his ordeal and how he had launched into writing an 800-page treatise on the subject of human rights in the months subsequent to his release. Medical and psychiatric effects of torture
Another moving moment in the Conference came when a tape-recording was heard which had been smuggled out of the local public prison with a message of solidarity and hope from political detainee, Dr Pedro Marin. This doctor has co-ordinated a study of the physical and psychological morbidity of the political prisoners in the prison where he is detained. This has been possible because of the medical, psychosocial and psychotherapeutic care which has been given to political prisoners by various human rights organizations over the years, often under poor conditions and with inadequate material resources. Dr Marin's study was based on a questionnaire and medical record survey of 194 political prisoners between January 1987 and October 1989. Morbidity was related to the violent events during arrest and torture, to solitary confinements, and to the poor living conditions in prison. The most commonly observed clinical conditions were as follows:
TORTURE: PREVENTION AND TREATMENT
201
Downloaded by [RMIT University] at 02:03 12 March 2015
gastroenteritis tension headaches respiratory infections post-traumatic arthralgia dermatological conditions anxiety or depressive disorders sleep disturbance peptic ulcers injuries, including cranial injury, sometimes followed by posttraumatic epilepsy. Loss of privacy and individual choice are inherent in the treatment of political prisoners. This has caused additional anguish in women who have given birth while in prison: women detainees have related how they have resisted attempts by prison staff to make arrangements for unnecessary Caesarean sections to 'get it over with'. This is another example of the loss of control over their bodies to which political prisoners may be subjected (CODEPU: Person, State, Power). Dr R. Erazo (FASIC) drew attention to the widespread acceptance of the concept of post-traumatic stress disorder (PTSD) in the European and North American literature on the effects of torture. He contrasted this to the almost total absence of this diagnostic term in Chile and in many countries in which there are on-going repressive regimes. In these latter circumstances, it is not only the intrusive memories of torture that paralyse the individual but also the well-founded fear that it may happen again, and the threatening reality that s/he lives in from day to day. It might be more appropriate in these countries to talk about a 'continuing traumatic stress disorder', in which both therapist and patient are affected by the political environment they live in. Diagnostic categories to help evaluate prognosis and treatment lose their fine distinctions in this situation, in which political factors might predominate. I. Agger (clinical psychologist, Oasis, Denmark) added that the danger of medicalizing the experience is that it leaves the subject feeling more helpless and isolated from the collective experience of trauma. Furthermore, the concept of PTSD in therapeutic work with political exiles must not draw attention away from the enormous stresses of adapting to a new culture and a new country. There was a consensus of opinion, however, that the concept of PTSD was useful in communication between professionals and to describe the symptoms of a 'healthy person's reactions to a sick situation'. Dr J. Barudy (Collectif Latin-Atnericain de Travail Psycho-social — Exil, Belgium) used a family systems approach to analyse the role of Latin American machismo in the effects of torture and exile on family life. He pointed out that the successful outcome of the process of adaptation lay somewhere between the two extremes of a ghetto existence and a complete integration with loss of original political and cultural identity.
Downloaded by [RMIT University] at 02:03 12 March 2015
202
D.JADRESIC
The effects on families in Chile have been observed to vary to some extent according to the nature of the political repression suffered by them. Common to all, however, are the high prevalence of emotional and behavioural difficulties in children, both at home and at school. These are particularly common in adolescence. A frequent problem in the spouses of the disappeared ('desaparecidos') has been a denial of both its significance and the obvious psychopathology it engenders, and the difficulty of working through a bereavement process. Families of the executed have sometimes lived in terror for years, in an almost housebound existence, fearful of everyone. The evaluation of psychopathology is, as always, made difficult by the fact that in many cases the bereaved have actually been followed and watched by agents of the repression. In the families of political prisoners the social effects are mainly related to social stigmatization towards the spouse and his/her family, and the problems of economic survival and social isolation. Public denial of the repressive situation, and the psychological warfare transmitted through the media, result in a state of confusion and guilt in affected family members which is very difficult to unravel in a therapeutic encounter. Political and therapeutic factors in the use of testimony
A political understanding of the trauma of torture and/or exile is essential to establish trust in the therapist/patient relationship. It also gives significance to the patient's symptoms and allows the development of resources for coping from the patient's own political identity. Within this framework for the therapist/patient relationship came the use of testimony as a therapeutic and political exercise. It was first developed in Chile in the underground work of the 1970s when testimonies were collected to provide evidence of the human rights violations of the military dictatorship. It soon became apparent that testimony was a cathartic experience for ex-prisoners, which allowed them to re-establish their connection with reality. Dr Soren Jenssen (Oasis, Denmark) gave an excellent account of the practical aspects of testimony as a therapy in exile. He highlighted the preparatory work with and psychological support of interpreters, the importance of maintaining eye contact with the client even as the interpreter is translating, and the use of auxiliary tools during testimony, for example, tape-recordings, drawings, and roleplay. Different forms of psychosocial interventions were described by a number of therapists from different organizations; these included individual, family, marital and group work, with techniques of psychodynamic, behavioural, or systemic therapy, some forms of non-verbal therapy and social work.
TORTURE: PREVENTION AND TREATMENT
203
Downloaded by [RMIT University] at 02:03 12 March 2015
Conclusion It is not surprising that about one-third of the Conference was devoted to a political understanding of the phenomenon of torture. This reflects the different approach that health workers have taken in countries where torture is systematically used by the government, as opposed to the rather clinical approach that is used in Europe. It would be impossible for a health worker in Chile dealing with a victim of torture to ignore the political significance of the condition s/he is called upon to treat. In a country where the legal system has turned a blind eye to the practice of torture, the role of the medical and allied professions in bearing historical witness to this practice assumed a vital significance in the country's political process. This role is inextricably linked to the therapeutic value of testimony. The interaction between therapist and client in this context is all the more poignant for the client as it validates his or her experience in the eyes of the external world; this is undoubtedly a major factor in its therapeutic value. An opposition candidate won the country's presidential elections in the month following the Conference. There will, however, be no changes in the judicial system in the near future and it has been said that torture will effectively continue to be denied in public. It is most likely that human rights organizations in Chile will continue to receive referrals for therapeutic work with victims of torture in the coming years. Some of the people they are treating now have only recently dared to approach them after years of living with the disturbing psychological sequelae of organized violence. It is to be hoped that the work of this Conference will have been useful not only in improving the quality of our work with victims of torture, but also in increasing public awareness of this abhorrent form of violence. (Accepted 20 April 1990)
Medicine and War Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/fmcs19
Medical, psychological and social aspects of torture: Prevention and treatment Danitza Jadresic MRC Psych
a
a
Visiting Psychiatrist, Medical Foundation for the Care of Victims of Torture , 96–98 Grafton Road, London, NWS 3EJ Published online: 22 Oct 2007.
To cite this article: Danitza Jadresic MRC Psych (1990) Medical, psychological and social aspects of torture: Prevention and treatment, Medicine and War, 6:3, 197-203, DOI: 10.1080/07488009008408932 To link to this article: http://dx.doi.org/10.1080/07488009008408932
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form
Downloaded by [RMIT University] at 02:03 12 March 2015
to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
CONFERENCE REPORT
Medical, Psychological and Social Aspects of Torture: Prevention and Treatment DANITZA JADRESIC MRC Psych
Visiting Psychiatrist, Medical Foundation for the Care of Victims of Torture, 96-98 Grafton Road, London NWS 3EJ
Downloaded by [RMIT University] at 02:03 12 March 2015
KEYWORDS
State terror
Torture
Introduction The Conference on Medical, Psychological and Social Aspects of Torture took place in Santiago on 14-18 November 1989 during the run-up to the first presidential elections held in Chile since the military coup which deposed Allende's government in September 1973. Included amongst its objectives were: (a) the provision of a forum where Chilean professionals who have worked with victims of torture could meet and exchange ideas with members of related international organizations, and (b) the public denunciation of the use of torture in Chile. Throughout the Conference, a meeting of professional, therapeutic and political ideas was particularly important. The Conference was not without its risks; one of the organizers revealed that she had received three threatening phone calls in the preceding week and that many professionals had been afraid to attend. Conference organization The Conference was organized jointly by the Geneva based World Organization against Torture, and the Santiago based Mental Health Team of the Committee for the Defence of People's Rights (CODEPU), Santiago, Chile. It was co-sponsored by the Social Aid Foundation of Christian Churches (FASIC), the Foundation for the Protection of Children Damaged by Emergency States (PIDEE), and by the Centre for Research and Treatment of Stress (CINTRAS). Inauguration The opening ceremony was based on the presentation of CODEPU's first book, Person, State, Power. Studies on Mental Health. Chile 1973-1989, which is a collection of essays and published articles, currently only available in Spanish. While introducing the book, Dr Castillo Velazco stressed that an important part of such studies of victims of torture has to be preventative, in other MEDICINE AND WAR, VOL.6,197-203 (1990)
198
D.JADRESIC
words, 'how to ensure that torture should never happen again'. Other speakers emphasized the need to develop an increased awareness of ethics, not only in the medical profession but also in society as a whole. A political role for the health professional was clearly and convincingly supported in most of the later presentations and discussions.
Downloaded by [RMIT University] at 02:03 12 March 2015
Definition and objectives of torture
The Conference commenced with an analysis by Dr A. Estrada (CODEPU) of the definition, aims and techniques of torture. The statistics on torture vary according to the definition employed. The United Nations' Declaration Against Torture (1975)* defines torture as any serious physical or mental suffering deliberately inflicted by, or at the instigation of, a public official on another person in order to obtain information or a confession from that person or a third party, to punish that person for proven or suspected actions, or to intimidate others. This definition excludes the suffering caused by legitimate imprisonment if it is within the bounds of the UN's Minimal Rules for the treatment of prisoners (CODEPU, 1989). Controversial points in the UN Declaration are, for example, its suggestion that torture constitutes only a quantitatively worse form of 'cruel, inhuman or degrading treatment', and the exclusion of more subtle means of torture, such as hidden behavioural conditioning or endless repetition of monotonous auditory or visual stimuli. There is pressure at present in international law circles to change the definition of torture. This would embrace a broader concept of organized state violence when it has the same aims as torture. The mental suffering or anguish produced in the population as a result of the illegitimate actions of the State must also be considered. These include, for example, the psychological and political effects on family and friends, and on society as a whole, of the abduction of individuals and their sudden disappearance without trace.
Agents and techniques of torture
The agents of torture Torture, even if narrowly defined, is a crime against humanity (A. Dominguez, sociologist, Chilean Commission of Human Rights). Innumerable cases of torture were reported to Amnesty International and other human rights organizations since the beginning of the Chilean dictatorship. Apologists for the military Government may have tried to write these off as mere excesses in the hands of a few exalted individuals, but the highly organized nature of
*Reprinted in Ethical Codes and Declarations Relevant to the Health Professions, 2nd edition, 1985, Amnesty International, 1 Easton Street, London WC1X 8DJ.
Downloaded by [RMIT University] at 02:03 12 March 2015
TORTURE: PREVENTION AND TREATMENT
199
the process leaves no doubt that in Chile torture was a deliberate policy on the part of the military dictatorship. It was planned to induce the maximum degree of fear and subjugation in the population. This framework for the phenomenon of torture is important, not only in the political analysis of torture but also in the assessment of psychopathology in the agents of torture. It has become obvious from the statements of ex-torturers in Greece and more recently in Chile that the torturer is not necessarily a psychopath with sadistic drives, but that many are people with obedient and submissive personalities who learn to torture under the influence of alienating military training methods (Dr E. Perez, CODEPU). A recurrent theme during the Conference concerned the future of the torturer. With the advent of a parliamentary democracy, the military's proposals for amnesty and the popular demands for justice have become a burning controversy. Whatever the outcome, there will be a need to rehabilitate torturers back into the ways of a humanitarian society. Therapists will be called upon to develop an empathic and non-punitive therapeutic alliance with the torturers as potential clients. Techniques of torture Reference was made to the large number of physical, sexual and psychological torture techniques which were used in Chile throughout the 16 years of the dictatorship. These were refined over the years and seem at times to have been selected according to the type of prisoner involved. The aim was to achieve the maximum results with the least physical evidence. Dr Sohrens gave an account of his experience and that of Dr F. Bustamante in dealing since 1974 with genito-urinary trauma. They often elicited a history of severe degrees of pain from the application of electricity to the urethra, sometimes to the point of causing loss of consciousness; haematomas and swelling of the scrotum and haematuria often occurred for a short period after the experience of the torture, but were never present at the time of the medical consultation. They were not surprised at an absence of genito-urinary signs of torture in their patients, although sometimes finding evidence of physical torture in other parts of the body. Medical interventions such as electrocoagulation, which leave greater initial lesions in the urethral meatus, often disappear without trace after a short time. Traumatic sports injuries to the genitals are also known not to leave long-lasting visible signs in the great majority of cases. Prolonged solitary confinement has been one of the most widely used forms of torture in Chile since 1986. It is considered to be a highly effective torture technique as, again, it leaves no visible sequelae, and yet may have serious long-term psychological effects. It is thus 'cleaner' and has little international recognition as a form of torture. Elisa Neumann (clinical psychologist) cited Thomas Myers' work on sensory deprivation with American volunteers, and compared it with the experience of FASIC in dealing with 32 victims of solitary confinement in Chile. Chilean testimonies
Downloaded by [RMIT University] at 02:03 12 March 2015
200
D.JADRESIC
describe small and dirty prison cells which severely restrict body movement; uniform colours and light; silence broken only by occasional distant noises; and a restricted daily routine related to eating and going to the toilet. Myers' volunteers experienced mounting anxiety with disturbance of sleep and appetite, and temporo-spatial disorientation, after the first few days of the experiment. These progressed to proprioceptive hallucinations, feelings of derealization, serious difficulties with concentration and attention, and impaired judgement after the first week. It is clear that the enormous uncertainty generated by the conditions of imprisonment, together with the expectancy of the political prisoner about the possibility of physical torture or death, greatly exacerbate the anguish of solitary confinement. Deprived of a normal social framework of reference, the subject loses his/her sense of identity and can easily be manipulated in the interrogation into informing upon others or making a 'confession'. Solitary confinement may lead to long-lasting psychological damage which can be extremely difficult to treat subsequently. It is common for political prisoners held in this way to develop feelings of guilt, diminished self-esteem, and paranoid ideas. They may be left with impaired concentration and memory, chronic sleep disturbance, anxiety, depression, phobias, and other symptoms. The well-known and respected lawyer and human rights activist, Rene Garcia Villegas, gave a moving personal account of his experience of solitary confinement in 1974. He had never talked about it before, and it was clear that his testimony was a harrowing experience for him despite his matter-of-fact tone and his composed demeanour. He related how his sense of social justice and freedom were reaffirmed by his ordeal and how he had launched into writing an 800-page treatise on the subject of human rights in the months subsequent to his release. Medical and psychiatric effects of torture
Another moving moment in the Conference came when a tape-recording was heard which had been smuggled out of the local public prison with a message of solidarity and hope from political detainee, Dr Pedro Marin. This doctor has co-ordinated a study of the physical and psychological morbidity of the political prisoners in the prison where he is detained. This has been possible because of the medical, psychosocial and psychotherapeutic care which has been given to political prisoners by various human rights organizations over the years, often under poor conditions and with inadequate material resources. Dr Marin's study was based on a questionnaire and medical record survey of 194 political prisoners between January 1987 and October 1989. Morbidity was related to the violent events during arrest and torture, to solitary confinements, and to the poor living conditions in prison. The most commonly observed clinical conditions were as follows:
TORTURE: PREVENTION AND TREATMENT
201
Downloaded by [RMIT University] at 02:03 12 March 2015
gastroenteritis tension headaches respiratory infections post-traumatic arthralgia dermatological conditions anxiety or depressive disorders sleep disturbance peptic ulcers injuries, including cranial injury, sometimes followed by posttraumatic epilepsy. Loss of privacy and individual choice are inherent in the treatment of political prisoners. This has caused additional anguish in women who have given birth while in prison: women detainees have related how they have resisted attempts by prison staff to make arrangements for unnecessary Caesarean sections to 'get it over with'. This is another example of the loss of control over their bodies to which political prisoners may be subjected (CODEPU: Person, State, Power). Dr R. Erazo (FASIC) drew attention to the widespread acceptance of the concept of post-traumatic stress disorder (PTSD) in the European and North American literature on the effects of torture. He contrasted this to the almost total absence of this diagnostic term in Chile and in many countries in which there are on-going repressive regimes. In these latter circumstances, it is not only the intrusive memories of torture that paralyse the individual but also the well-founded fear that it may happen again, and the threatening reality that s/he lives in from day to day. It might be more appropriate in these countries to talk about a 'continuing traumatic stress disorder', in which both therapist and patient are affected by the political environment they live in. Diagnostic categories to help evaluate prognosis and treatment lose their fine distinctions in this situation, in which political factors might predominate. I. Agger (clinical psychologist, Oasis, Denmark) added that the danger of medicalizing the experience is that it leaves the subject feeling more helpless and isolated from the collective experience of trauma. Furthermore, the concept of PTSD in therapeutic work with political exiles must not draw attention away from the enormous stresses of adapting to a new culture and a new country. There was a consensus of opinion, however, that the concept of PTSD was useful in communication between professionals and to describe the symptoms of a 'healthy person's reactions to a sick situation'. Dr J. Barudy (Collectif Latin-Atnericain de Travail Psycho-social — Exil, Belgium) used a family systems approach to analyse the role of Latin American machismo in the effects of torture and exile on family life. He pointed out that the successful outcome of the process of adaptation lay somewhere between the two extremes of a ghetto existence and a complete integration with loss of original political and cultural identity.
Downloaded by [RMIT University] at 02:03 12 March 2015
202
D.JADRESIC
The effects on families in Chile have been observed to vary to some extent according to the nature of the political repression suffered by them. Common to all, however, are the high prevalence of emotional and behavioural difficulties in children, both at home and at school. These are particularly common in adolescence. A frequent problem in the spouses of the disappeared ('desaparecidos') has been a denial of both its significance and the obvious psychopathology it engenders, and the difficulty of working through a bereavement process. Families of the executed have sometimes lived in terror for years, in an almost housebound existence, fearful of everyone. The evaluation of psychopathology is, as always, made difficult by the fact that in many cases the bereaved have actually been followed and watched by agents of the repression. In the families of political prisoners the social effects are mainly related to social stigmatization towards the spouse and his/her family, and the problems of economic survival and social isolation. Public denial of the repressive situation, and the psychological warfare transmitted through the media, result in a state of confusion and guilt in affected family members which is very difficult to unravel in a therapeutic encounter. Political and therapeutic factors in the use of testimony
A political understanding of the trauma of torture and/or exile is essential to establish trust in the therapist/patient relationship. It also gives significance to the patient's symptoms and allows the development of resources for coping from the patient's own political identity. Within this framework for the therapist/patient relationship came the use of testimony as a therapeutic and political exercise. It was first developed in Chile in the underground work of the 1970s when testimonies were collected to provide evidence of the human rights violations of the military dictatorship. It soon became apparent that testimony was a cathartic experience for ex-prisoners, which allowed them to re-establish their connection with reality. Dr Soren Jenssen (Oasis, Denmark) gave an excellent account of the practical aspects of testimony as a therapy in exile. He highlighted the preparatory work with and psychological support of interpreters, the importance of maintaining eye contact with the client even as the interpreter is translating, and the use of auxiliary tools during testimony, for example, tape-recordings, drawings, and roleplay. Different forms of psychosocial interventions were described by a number of therapists from different organizations; these included individual, family, marital and group work, with techniques of psychodynamic, behavioural, or systemic therapy, some forms of non-verbal therapy and social work.
TORTURE: PREVENTION AND TREATMENT
203
Downloaded by [RMIT University] at 02:03 12 March 2015
Conclusion It is not surprising that about one-third of the Conference was devoted to a political understanding of the phenomenon of torture. This reflects the different approach that health workers have taken in countries where torture is systematically used by the government, as opposed to the rather clinical approach that is used in Europe. It would be impossible for a health worker in Chile dealing with a victim of torture to ignore the political significance of the condition s/he is called upon to treat. In a country where the legal system has turned a blind eye to the practice of torture, the role of the medical and allied professions in bearing historical witness to this practice assumed a vital significance in the country's political process. This role is inextricably linked to the therapeutic value of testimony. The interaction between therapist and client in this context is all the more poignant for the client as it validates his or her experience in the eyes of the external world; this is undoubtedly a major factor in its therapeutic value. An opposition candidate won the country's presidential elections in the month following the Conference. There will, however, be no changes in the judicial system in the near future and it has been said that torture will effectively continue to be denied in public. It is most likely that human rights organizations in Chile will continue to receive referrals for therapeutic work with victims of torture in the coming years. Some of the people they are treating now have only recently dared to approach them after years of living with the disturbing psychological sequelae of organized violence. It is to be hoped that the work of this Conference will have been useful not only in improving the quality of our work with victims of torture, but also in increasing public awareness of this abhorrent form of violence. (Accepted 20 April 1990)
