Torture has severe and long-lasting psychological effects. The document discusses definitions of torture from various organizations and the methods and reasons for torture. It outlines the psychological impacts which can include PTSD, depression, anxiety, and sexual dysfunction. Health professionals are in a position to uphold human rights but some have defended or participated in torture. A proper assessment of torture survivors considers cultural factors and establishes trust, while treatment focuses on regaining dignity and trust. Testimonials and accepting the experience can help healing.

1. Mental Health
and
Torture
Ganesan
Human Rights Counsil
Sri Lanka
15th July 2015

2. 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)

3. Definitions
AI: 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)

4. 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

5. 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

6. 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.

7. “Reasons” for Torture
1) 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”)

8. 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.

9. Psychological Torture
Sleep and food deprivation
Isolation
Threats
Witness torture of others
Unpredictability
Nothing to say or do to make it stop

10. Minor….?
constant taunting;
verbal abuse;
intimidations;
insulting the honour of a family member; cultural humiliation
spitting 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

11. 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)

12. Content
Effects of torture
Mental Health services and torture - reality
Justice and Mental Health
Helping survivors of torture

13. Effects of Torture
‘‘the worst scars are in the mind’’

14. Impact of Torture
Question basic human relationships
Destroy victim’s fundamental assumptions
about
safety of the world,
positive value of self,
meaningful order of creation
Violate autonomy of person
Shatter sense of connection between individual
and community

15. Experience of Torture
Brutality – deliberate, cruel, inhumane treatment from
people in official position of power
Intense fear of harm or death
Subjugation and helplessness
Loss of control over one’s body
Humiliation/degradation
Potential to betray oneself, one’s values
Sense of horror
Utter helplessness, serious injury or the threat of
physical injury or death.

16. 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 relation- ships between
the victims and their communities” (Istanbul Protocol, § 235).

17. 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 deprivation
The 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.

18. 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.

19. Disorders
Depression and anxiety
Post traumatic stress disorder
Dissociation
Somatic problems – headache, pelvic pain, etc.
Organic brain syndromes
Loss of sense of predictability
Disconnection
Problems in adjustment
Alcohol and drug abuse

21. 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.

22. 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.

23. 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”.

24. Content
Effects of torture
Mental Health services and torture - reality
Justice and Mental Health
Helping survivors of torture

25. Health services and torture -
reality

26. Doctors
Do no harm
special position to uphold human rights
leaders of society - Agents of change

28. 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)

30. “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

31. 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.

32. Content
Effects of torture
Mental Health services and torture - reality
Justice and Mental Health
Helping survivors of torture

33. 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.

34. Assessment
Respect 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).

35. Assessment 2
Because 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.

36. 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).

37. Content
Effects of torture
Mental Health services and torture - reality
Justice and Mental Health
Helping survivors of torture

38. 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;

39. • 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

40. 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.

41. Negative Responses
Try 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)

42. Treatment
Trust
Relationship
Cultural factors
Testimonials
Accepting the story, reactions and being very clear
of the unacceptability of torture
Relaxation, physiotherapy

43. 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

44. 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

45. 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 Chauvin
London School of Hygiene and Tropical Medicine
Canadian Public Health Association

46. Thank You