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In this article, we focus primarily on torture as an instrument of governmental repression, although much of the material may be applicable to other torture situations e. Rather than to propose a new or specialized model of treatment, we seek to identify common reactions of clinicians who work in this area, regardless of their theoretical orientation or model of intervention, and to explore general issues in responding to torture victims, whose backgrounds, experiences, and needs may be diverse.

Working with victims of torture may evoke certain feelings or responses in the therapist Bustos, ; Danieli, If not recognized and handled carefully and appropriately, these responses may interfere with the provision of useful clinical services. Therapists who have not encountered torture victims and who may find it difficult to imagine the sometimes extreme reactions a clinician can experience may find it useful to remember personal reactions that may have occurred when working with clients who have suffered from rape, battering, incest, therapist-patient sex, elder abuse, or child abuse i.

Space limitations prevent a substantive discussion of responses a clinician may experience when working with torture victims; they are listed, generally in their most extreme form, simply as a reminder to clinicians to be alert to their possible occurrence. Those who do not have demonstrable competence should seek supervision or consultation from a clinician who possesses expertise in this area.

Clinicians may experience an almost phobic reaction to hearing the details of the torture. They may communicate to the patient, subtly or more obviously, that explicit description of the horrors of the experience is off limits. Thus therapists may influence the patient to collude in an implicit treatment plan whose central objective is to protect the therapist from discomfort or distress. On the other hand, clinicians may find themselves intensely curious and eager to press for details.

Syria's Tortured Artists: Torture survivor turns to art as therapy

They may experience an almost voyeuristic obsession with intensely graphic accounts and may pressure the patient not to leave anything out. In such instances, it is the therapist's rather than the patient's needs that are being met. Clinicians may experience similar reactions of phobic avoidance of or obsessive interest in the physical damage and disfigurement that torture can produce.

When the patient is identified as a torture victim, clinicians may incorrectly assume that that label is the almost solely defining characteristic of the individual. Clinicians may forget that they are working with a person who is a torture victim rather than with a classification i. In a similar manner, clinicians may mistakenly assume that all torture victims are invariably similar if not essentially identical to each other. They may attempt to bypass the process of learning about each person as an individual.

Torture is frequently used as a form of political repression that targets not only individuals but also entire groups of people and communities for subjugation and even destruction in some instances, genocide. Many torture victims have been part of a political struggle that has been central to their identity as individuals. Clinicians must avoid letting their political beliefs and allegiances e.

Clinicians whose strong feelings about the politics of the situation might prevent them from rendering helpful, appropriate, and effective services should consider referring the patient elsewhere, just as a homophobic therapist should consider referring a gay or lesbian client to other sources of help. A more subtle though no less important risk can occur when a recently "politicized" therapist, in an attempt to create solidarity with the client and to achieve political goals that are ostensibly those of the client, engages in inappropriate and unhelpful behavior, perhaps by attending only to a political agenda at the expense of the client's individual wants and needs.

Some victims of torture may be fearful that they are still in danger. For example, some may believe that they are pursued and in danger of being abducted or assassinated by those who conducted the previous torture.

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In some instances, such fear may represent a psychological response to the torture e. However, in some instances there may be inadequate information for determining the validity of this fear and in other instances there may be good reason to believe that the individual is still in danger. Many torture victims in the United States do not have immigrant or even refugee status, and live in fear of deportation.

For these victims, the fear of being sent back to the country in which they were tortured is overwhelming.

Treating victims of torture and violence: Theoretical, cross-cultural, and clinical implications

It is crucial not only to address the victim's fear carefully, realistically, and in a way that offers maximum safety and security, but also to recognize any fear that may be experienced by the therapist. Clinicians may feel that they too are in danger because of their work with the victim.

Inappropriate handling of the fear may not only disrupt the therapeutic alliance and the provision of appropriate clinical services to the patient, but in some cases may place both therapist and patient at undue risk for harm. Clinicians working with victims of torture may experience something akin to survivor guilt or a regret and discomfort 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, directly or indirectly, in the torture. Clinicians working in the United States, for example, may be disturbed that Amnesty International's investigation of the detention of two women in the High Security Unit of the Lexington Federal Prison concluded "that the conditions of confinement constituted cruel, inhuman or degrading treatment" and that "the prisoners' prolonged isolation, humiliating strip-searches and additional restrictions had had a detrimental effect on their physical and mental health" Amnesty International, , p.

This unit, which was reported closed in , subjected the two women who were claimed to have been held there "because of their political beliefs" Amnesty International, , p. The feelings such reports may elicit, if not confronted directly, honestly, and nondefensively by the therapist, may distort and undermine the therapist's attempts to be of help to the victim. Clinicians may also need to confront their reactions to specific instances in which fellow health care professionals were instrumental in torturing the clinician's patient.

Health care professionals can facilitate, enable, or support torture through active complicity as well as tacit acceptance. Historical documentation, for example, has shown that the torture and other atrocities carried out under the Nazi regime involved the active participation of numerous mental and physical health care professionals Cocks, ; Gallagher, ; Lifton, ; Muller-Hill, ; Proctor, It is crucial that the psychology profession forthrightly confront the issue of torture, avoid tacit acceptance of or complicity with programs of torture, and acknowledge and fulfill its professional and ethical responsibilities to victims of torture.

The intensity and pervasiveness of the torture experience may be reflected in the subsequent work between therapist and victim. The dyadic therapeutic situation itself may be evocative of certain aspects of the torture experience: for example, two people, one of whom is licensed by or a representative of the state or larger society and the other of whom is vulnerable and in need, meeting privately in a room; the questioning of extremely personal matters, a process often experienced as intrusive; the character of the regular sessions being explicitly subject to privacy; the discrepancy in power; and the intensity of emotion usually evoked by the process.

It is crucial that the therapist monitor and maintain safe, appropriate, and therapeutic boundaries so that the therapeutic relationship does not unconsciously recreate or act out the destructive relationship between torturer and victim. Some clinicians may find themselves overwhelmed by the accounts of torture and by the obvious suffering and continuing effects experienced by the victim. They may experience depression, anxiety, or symptoms associated with posttraumatic stress disorder e.

Clinicians bear an important responsibility to monitor their reactions carefully, to obtain needed support, and to ensure that they are not too distressed to be effective. Clinicians who work with many victims particularly need to take adequate steps to prevent burnout. Diverse therapeutic approaches e. Our purpose in this section is not to review those specific approaches but rather to note important clinical issues significant to virtually all clinicians who attempt to provide professional services to these individuals.

As the examples provided in an earlier section vividly illustrate, victims of torture have been subjected to atrocities inflicted by those who had overwhelming power over them. Nothing that the victim said or did could change this overwhelming and extreme experience. Trust in or reliance on the external authority was violated in an intense and brutal manner.

Gewalt in Gefängnissen/Folter | SpringerLink

This fact is of fundamental importance for those attempting to help victims of torture. No matter how well meaning, well funded, well designed, or eager to help an individual, organization, or facility is, the services offered will be irrelevant if the victim does not trust. Nothing is more important for the professional than addressing this issue of trust. If it is important to engender the victim's trust, it is equally important to be worthy of that trust. In part that means maintaining awareness of the increasing body of published work on this topic.

It also means maintaining awareness of the different ways in which an individual can communicate, directly or indirectly, the possibility that he or she was a victim of torture. Common psychological and somatic symptoms have been listed and discussed in many of the works cited in this article e. They include anxiety, fear, guilt, shame, impaired memory, difficulty concentrating, sleep disturbances, depression, low self-esteem, distorted sense of identity, sexual problems, headaches, gastrointestinal complaints, outbursts of anger, social withdrawal, and problems with intimacy.

Obviously, many of these phenomena have a relatively high base-rate among those who receive clinical services.

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Cultural factors will influence how victims perceive and express the torture experience and its aftermath. For example, cultural factors may influence the degree to which the effects of trauma are experienced as somatic disorders, as a shameful event not to be disclosed to anyone, or as a phenomenon that neither requires nor deserves professional assistance.

Margaret Welch, executive director of the Walter Briehl Human Rights Association, which provides free therapy to torture victims, emphasizes that adjusting to a new culture is one of the major challenges faced by torture victims who are now living in a different country personal communication, July 4, Clinicians must be sensitive not only to the culture that the victims view as their own but also to the degree to which the victims may be encountering alienation, acculturation stress, and prejudice sometimes including threats and actual violence in their current surroundings.

As mentioned in the previous section on common reactions of therapists, the therapeutic structure can recreate certain aspects of the torture situation and relationship. Moreover, the setting itself as well as certain procedures e. An awareness of these potential similarities can enable clinicians to minimize the extraneous points of similarity and the likelihood that the treatment situation itself will elicit flashbacks and other traumatic recreations.

As Primo Levy wrote, "the memory of a trauma suffered or inflicted is itself traumatic because recalling it is painful or at least disturbing" p. The possibility of organically based impairment must be carefully assessed. Thus many professionals have found an interdisciplinary model especially helpful e. Dental services should also be available: Torture may also involve the breaking, pulling, or stimulation of nerves in the teeth Archdiocese of Sao Paulo, ;Bolling, Dental damage may also result from beatings, lack of hygiene, and malnutrition.

The use of standardized instruments for psychological assessment of torture victims must be done with great care. For some victims, the test-taking situation may be too evocative of the torture situation.

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Others may have concerns that they are being used or abused as research subjects or "guinea pigs. Thus, formal assessment instruments should be used only when there is a clear need for them. However, in many instances, assessment using standardized instruments seems potentially helpful and is not contraindicated. In these instances, the instruments must be adequately normed, translated if necessary , and validated for the relevant population as required by American Psychological Association policy.

Moreover, for test-relevant variables, the instrument must be appropriate for the victim's language skills, reading level, cultural and educational background, and so on. The Minnesota Multiphasic Personality Inventories MMPI and MMPI-2 , in their original English versions or in careful translations, have been useful in assessing victims of torture, particularly in cases in which the test results have strengthened psychological testimony to support claims for asylum. It is only in the last decade that studies have begun to formally assess the degree to which torture victims tend to suffer from posttraumatic stress disorder PTSD.

Gewalt in Gefängnissen/Folter

PTSD that occurs as a result of torture may persist for long periods despite treatment Weisaeth, While attending adequately to the important medical, cultural, and psychological needs of the victim, it is important that the clinician not neglect the problems that the victim may be experiencing in coping with fundamental daily tasks. For some victims, there may be pressing needs for food, clothing, shelter, and transportation. For some, even if the resources are present, carrying out simple tasks may be virtually impossible.

One victim did not know how to open a door because he had not been allowed to do so for 13 years; nor was he able to make a dark room light by throwing the light switch Weschler, Another victim reflexively removed her clothes when she was in the presence of other people because this was what she had been forced to do repeatedly Russell, For many victims, cognitive impairment is typical; concentration and memory difficulties interfere with language acquisition and the ability to hold a job or pursue an education. Torture can interrupt and sometimes reverse the progress that individuals make through the stages of psychological development.

At any age or developmental stage, torture and its sequelae disrupt the life plan and force the individual to confront an altered set of choices or possibilities. Personal testimony may be an exceptionally healing experience for many victims of torture see, e. Through description of their experiences, some of the most taboo aspects, such as shame, guilt, self-blame, can be acknowledged, worked through, and reconceptualized.

Presenting testimony can help overcome the isolation and secrecy frequently associated with torture. Stephen Biko, for example, noted that the privacy and secrecy of torture not only intensified the psychological pain and isolation of the prisoner but also made easier i. When testimony is communal in nature, it can help counter the victims' sense of being overwhelmed by a powerful communal force.

Nelson Mandela described as common the "assaults [that were] communal in character, what the prison staff called a 'carry on, ' when they used not just batons but even pick handles" p. The testimony can also function as a denunciation of injustice.

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In the words of Agger and Jensen , "personal pain is transformed into political dignity" p. In recent years, Brazilian citizens engaged in a creative and collective version of testimony by collecting and publishing accounts of torture in their country. The Brazilian generals, whose reign of torture ended in March, , had ordered detailed and comprehensive documents compiled on all court cases and subsequent actions, seemingly unaware that their rule might come to an end or that the documents would ever become public Weschler, When the government changed hands, an elaborate covert plan was implemented to photostat all of these documents and to publish them.

The military's own documents, preserved in the Archive of the Supreme Military Court, demonstrated different types of torture and identified 17, individuals who were brought through this system.