Metin Basoglu's blog on war, torture, and natural disasters

Prevention of torture and rehabilitation of survivors – Review of the UN Committee against Torture Working Document on Article 14: Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment

I have recently received a copy of a paper presented at the 12th European Conference on Traumatic Stress in Vienna in June 2011 by psychologist Nora Sveaas from the Department of Psychology of University of Oslo. Dr. Sveaas is also a member of the UN Committee against Torture (CAT). Her paper (entitled Gross human rights violations and reparation: rehabilitation as form of reparation under international law –challenges and approaches) deals with the important issue of redress for survivors of torture and reviews aspects of the CAT Working Document on Article 14, which has been posted in the CAT website for comments. After a recent meeting in Istanbul with my good friend Dr. Sveaas and a stimulating discussion of various issues raised by the CAT Working Document, I decided to provide my comments in the form of a review article. Although these comments were originally intended solely for the attention of the UN Committee against Torture, I later decided to post this article in my blog in the hope that they will be useful to all mental health and human rights professionals as well as the general public.

I present my comments under several headings: definition of torture and cruel, inhuman, and degrading treatment (CIDT), definition of ‘victim of torture,’ and issues relating to rehabilitation of survivors. As much of the issues raised by the CAT Working Document on Article 14 are reviewed in our previous journal articles as well as in our recent book (Basoglu and Salcioglu, 2011, , A Mental Healthcare Model for Mass Trauma Survivors: Control-Focused Behavioral Treatment of Earthquake, War, and Torture Trauma, Cambridge University Press), I commented on some of these issues by providing excerpts from these sources.

I should also add that my review here is based on research findings from numerous studies with thousands of torture, war, and earthquake survivors over the last 25 years. I refrained from referencing every opinion or research finding in this article to avoid making it difficult to read for the general public. Readers interested in the evidence base for my comments are referred to our book where these issues are covered in much greater detail.

Definition of torture

The UN definition of torture makes a distinction between torture and CIDT. Although this distinction is not clearly specified in international law, the term torture is often used to refer to treatment involving physical pain, whereas CIDT refers to detention procedures involving deprivation of basic needs, exposure to aversive environmental conditions, forced stress positions, hooding or blindfolding, isolation, restriction of movement, forced nudity, threats, humiliating treatment, and other psychological manipulations conducive to anxiety, fear, and helplessness in a person. Such a distinction is not based on scientific evidence as  this issue had not been investigated until recently. In a study (Basoglu et al, 2007) of 279 torture survivors in former Yugoslavia countries we found no difference between immediate and long-term psychological impact of physical torture and CIDT. In a  subsequent study (Basoglu, 2009) of a larger sample of 432 torture survivors from former Yugoslavia countries and Turkey, we found CIDT to be associated with more severe distress and greater likelihood of long-term psychological damage. In this study fear- and helplessness-inducing effects of captivity and CIDT were the major determinants of perceived severity of torture and psychological damage in detainees.

These findings do not support the distinction between torture and CIDT made by the Convention against Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment. Although both types of acts are prohibited by this convention, such a distinction nevertheless reinforces the misconception that CIDT causes less harm and might therefore be permissible under exceptional circumstances. This distinction is open to potential abuse, as the narrow definition of torture proposed by the US government in the early 2000s has demonstrated. The following excerpt from the US Justice Department memorandum (Legal Standards Applicable Under 18 U.S.C. §§ 2340-2340a; dated December 30, 2004) is one of the many examples showing how this distinction is utilized to justify a narrow definition of torture (limiting it to severe physical pain).

“Further, the CAT distinguishes between torture and “other acts of cruel, inhuman or degrading treatment or punishment which do not amount to torture as defined in article 1.” CAT art. 16. The CAT thus treats torture as an “extreme form” of cruel, inhuman, or degrading treatment. See S. Exec. Rep. No. 101-30, at 6, 13; see also J. Herman Burgers & Hans Danelius, The United Nations Convention Against Torture: A Handbook on the Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment 80 (1988) (“CAT Handbook”) (noting that Article 16 implies “that torture is the gravest form of [cruel, inhuman, or degrading] treatment [or] punishment”) (emphasis added); Malcolm D. Evans, Getting to Grips with Torture, 51 Int’l & Comp. L.Q. 365, 369 (2002) (The CAT “formalises a distinction between torture on the one hand and inhuman and degrading treatment on the other by attributing different legal consequences to them.”). (14) The Senate Foreign Relations Committee emphasized this point in its report recommending that the Senate consent to ratification of the CAT. See S. Exec. Rep. No. 101-30, at 13 (“‘Torture’ is thus to be distinguished from lesser forms of cruel, inhuman, or degrading treatment or punishment, which are to be deplored and prevented, but are not so universally and categorically condemned as to warrant the severe legal consequences that the Convention provides in the case of torture. . . . The requirement that torture be an extreme form of cruel and inhuman treatment is expressed in Article 16, which refers to ‘other acts of cruel, inhuman or degrading treatment or punishment which do not amount to torture . . . .'”). See also Cadet, 377 F.3d at 1194 (“The definition in CAT draws a critical distinction between ‘torture’ and ‘other acts of cruel, inhuman, or degrading punishment or treatment.'”).”

Such arguments for a restricted definition of torture in the future can only be prevented by abolishing the distinction between torture and CIDT and adopting a broader definition based on sound theory and evidence. The following excerpt from my 2009 article on this issue might provide useful guidelines in this direction:

“An adequate understanding of how captivity experiences differ from ostensibly similar life events in other settings requires close attention to various contextual processes that enhance their impact. For example, beating while blindfolded and hands tied involves three different stressors. Assuming they have effects X, Y, and Z when administered separately (or in different contexts), the cumulative impact of their concurrent administration is not simply additive (i.e., X + Y+ Z) but multiplicative (i.e., X * Y * Z), because blocking visual or behavioral control greatly magnifies the threat value of beating (Basoglu & Mineka, 1992). Thus, the distress associated with each event is largely determined by the interactional (or contextual) impact of all three events, resulting in strong covariance among their distressing effects…

A sound theoretical framework is essential in understanding the traumatic processes in a captivity setting. In a learning theory formulation of torture (Basoglu & Mineka, 1992) based on experimental models of traumatic stress (Overmier & Seligman, 1967; Seligman, 1975; Seligman & Maier, 1967; see also a recent review by Mineka & Zinbarg, 2006), we had pointed to striking parallels between torture in humans and inescapable shock experiments in animals, both involving a situation where the impact of a stressor is maximized by blocking total control over it. This formulation points to certain contextual characteristics of torture that distinguish it from other stressful events. These include (a) intent; (b) purpose (e.g., to extract information/ confession or as an act of punishment or vengeance); (c) exposures to often multiple, unpredictable, uncontrollable, and potentially traumatic stressors likely to induce intense distress in most people; and (d) deliberate and systematic attempts to remove all forms of control from the person to maximize stressor impact and induce a state of total helplessness. This formulation implies that, when the first two criteria are met, a particular stressor constitutes torture to the extent that it serves to remove control from the person to induce total helplessness.”

The distinction between torture and CIDT might have serious implications in effective implementation of Article 14. In the future governments might well dispute reports of torture using arguments similar to those used by the US government in the early 2000s. It is therefore important to clarify what constitutes torture with recourse to sound theory and scientific evidence.

Definition of ‘victim of torture’

The CAT Working Document on Article 14 defines victim of torture as follows:

“Victims are persons who individually or collectively suffered harm, including physical or mental injury, emotional suffering, economic loss or substantial impairment of their fundamental rights, through acts or omissions that constitute violations of the Convention. A person should be considered a victim regardless whether the perpetrator of the violation is identified, apprehended, prosecuted or convicted. The term ‘victim’ also includes the immediate family or dependants of the victim and persons who have suffered harm in intervening to assist victims in distress or to prevent victimization. The term “survivors” may, in some cases, be preferred by persons who have suffered harm. The Committee uses the legal term “victims” without prejudice to other terms which may be preferable in specific contexts.”

This definition is overly restrictive in including only those who have suffered some form of harm. Abundant evidence shows that there are many people who survive torture without any physical or mental harm or any form of loss. For example, in a 1994 study of tortured political activists in Turkey (Basoglu et al, 1994), we found that only 18% had chronic but moderately severe  Posttraumatic Stress Disorder (PTSD). Some experienced brief and multiple episodes of detention and torture but nevertheless endured no physical or mental harm and went about their lives as before. Such resilience is characteristic of political activists committed to a cause and we have demonstrated that preparedness for torture protects against the traumatic effects of torture Basoglu et al, 1997). Exclusion of such cases might make it difficult for them to seek redress for their ordeal. Take, for example, the case of a person who has been detained and tortured for a few days and then released. If this person has suffered no physical or psychological damage it would be rather difficult for him / her to seek redress. Such people often have greater difficulty convincing courts (or immigration officials if they are seeking asylum in another country) that they have been tortured or that their ill-treatment constitutes torture.

The misconception that ill-treatment is torture only if it has led to prolonged physical or psychological damage has unfortunately been reinforced by human rights activists and torture rehabilitation centers in an effort to draw attention to the seriousness of the problem. While this is justifiable for some cases, it is not in the interest of many torture survivors who survive their ordeal without serious consequences. Such emphasis on pathology has also made it easier for the US government to argue that ill-treatment is torture only if it leads to ‘prolonged mental harm.’ The following excerpt from our article (Basoglu et al, 2007) on definition of torture illustrates the nature of this problem:

“Because the study findings are highly relevant to the current controversy surrounding the definition of torture, it is worth examining what they imply for the definition proposed in the US Justice Department memorandum,4 where it is argued that the definition of a particular act as torture requires proof of “prolonged mental harm” associated with that act. This argument was based on literature evidence showing that the most common psychiatric diagnosis among torture survivors is PTSD and that torture survivors have elevated rates of PTSD.4(p15) Because this document cited a review article28 by the main author of the present study (M.B.) and a group of internationally recognized trauma experts (published in 2001 in a book sponsored by the US  National Institute of Mental Health), it is worth briefly examining herein whether the literature evidence supports the argument concerning “prolonged mental harm.” In the cited review article, the statement about PTSD being the most common diagnosis among torture survivors28(p41) was made in reference to the findings of a controlled study17 that was conducted by our research group. This was based on the finding that torture survivors (political activists) had significantly more lifetime and current PTSD than did controls (33% vs 11% and 18% vs 4%, respectively). Although that study pointed to an association between torture and PTSD, the rates of PTSD in the sample were surprisingly low despite the extremely severe torture experienced by the survivors (a mean of 23 different forms of torture and a mean of 291 exposures to torture), as noted earlier. Thus, although there is evidence that torture leads to PTSD in some cases, many people survive extremely severe torture in relatively good psychological health and never develop PTSD. Conversely, some survivors develop PTSD after ostensibly milder forms of ill treatment or psychological stressors that do not involve physical torture. The fact that 60% of the present study participants without any experience of physical torture developed PTSD at some stage and 45% had current PTSD suggests that such cases are not uncommon. These findings do not support a definition of torture based on evidence of “prolonged mental harm.” Such a definition does not make logical sense given that it would disqualify many severely tortured peoples’ experience as torture simply because they did not develop PTSD.”

Thus, Article 14 needs to avoid this misconception by refraining from associating the need for redress solely with physical or mental harm and explicitly state that every torture survivor is entitled to redress regardless of the physical or mental consequences of torture.

Paragraph 39 of the CAT Working Document (page 6) states that redress should be equally accessible to all persons, regardless of “race, colour, ethnicity, age, religious belief or affiliation, political or other opinion, national or social origin, gender, sexual orientation, transgender identity, mental or other disability, health status, economic or indigenous status, reason for which the person is detained, including persons accused of political offences or terrorist acts, asylum-seekers, refugees or others under international protection, or any other status or adverse distinction.’ It is not clear as to whether the terms “mental or other disability” and “health status” refer to torture-induced or torture-unrelated health problems. This paragraph would benefit from more explicit reference to a survivor’s right to redress regardless of physical, mental, and other consequences of torture.

Rehabilitation of torture survivors

A commendable aspect of the CAT Working Document on Article 14 is its emphasis on rehabilitation of torture survivors.  Such emphasis is particularly important in view of research findings (Basoglu et al, 2005), which suggest that various other forms of redress, such as investigation of human rights violations, punishment of perpetrators, disclosure of the truth, public recognition of the crimes committed, public apology by the State, guarantees of non-repetition, monetary and non-monetary compensation, restitution, and satisfaction, are not likely to facilitate recovery from trauma in the absence of psychological interventions specifically designed to help survivors overcome their trauma-induced distress and fear (Basoglu et al, 2005). Such findings underscore the importance of including rehabilitation among other measures of redress.

The document as it stands, however, suffers from some potential ‘loopholes.’ First and foremost, it overlooks the fact that there are no rehabilitation programs demonstrated to be effective and that available evidence suggests that rehabilitation programs are not useful. We have drawn attention to this problem many times over the years and discussed the reasons for lack of progress in torture rehabilitation field in our recent book. The following section (p. 177) highlights the nature of the problem.

“Work in the torture rehabilitation area was largely pioneered by the International Rehabilitation Council for Torture Victims (IRCT) in Denmark, leading to the establishment of more than 200 torture rehabilitation centers around the world (van Willigen, 2007). In 2003, the European Commission (EC) was financially supporting 48 rehabilitation projects, many of which were part of the IRCT network (van Willigen, 2007). In recent years the EC commissioned several projects to evaluate the work of seven rehabilitation centers in Europe and elsewhere, including Primo Levi in France, the Medical Foundation for the Care of Victims of Torture in the United Kingdom, Centre Medico-Psychosocial pour des Personnes Exiles et pour des Victims de Torture (EXIL) in Belgium, Medical Rehabilitation Centre for Torture Victims in Greece, the Centre for Victims of Torture in Nepal (CVICT), Centro de Atencion Psicosocial in Peru, and the Human Rights Foundation in Turkey. The expert reports (Guillet et al., 2005; van Willigen, 2007; van Willigen et al., 2003) based on these evaluations revealed little convincing evidence with respect to the impact of these centers, either in prevention of torture or rehabilitation of survivors. In their report on four centers in Europe, Guillet et al (2005) concluded that the projects “lack objectively verifiable indicators to monitor the work undertaken . . . there is some reluctance and / or lack of knowledge on how to identify evaluation tools and indicators to measure and assess the impact of the work” (pp. 5) “ . . . the impact on patients is difficult to assess in quantitative terms” (pp. 4) and that “ . . . in most cases the centers have very little impact on primary prevention [of torture]” (pp. 6). The concerns expressed about torture rehabilitation programs in our 1988 editorial (Başoğlu and Marks, 1988) were further supported by recent outcome evaluation studies conducted at the Rehabilitation and Research Centre for Torture Victims in Denmark, which showed that their 9-month-long rehabilitation program was ineffective not only in reducing chronic traumatic stress problems (Carlsson et al., 2005) but also torture-related chronic pain in parts of the body (Olsen, 2006).”

Having noted this problem, let us examine the paragraphs under the Rehabilitation section of Article 14.

Paragraph 10

“The Committee affirms that the provision of means for as full rehabilitation as possible for anyone who has suffered harm as a result of a violation of the Convention “should include medical and psychological care as well as legal and social services.” Rehabilitation, for the purposes of this general comment, refers to the restoration of function or the acquisition of new skills required by the changed circumstances of a victim in the aftermath of torture or ill-treatment. It seeks to enable the maximum possible self-sufficiency and function for the individual concerned, and may involve adjustments to the person’s physical and social environment”.

Stipulating psychological care as a form of redress for torture survivors is a welcome development but this is not sufficient in view of the ineffectiveness of currently available torture rehabilitation programs. The question that inevitably needs to be addressed here is: which rehabilitation program? Currently available treatments for PTSD (most common mental health outcome of torture) are developed in Western countries and have serious theoretical and practical limitations in care of torture survivors (reviewed in detail in our book, pp. 157-159).

Among the currently available trauma treatments, exposure treatment (getting a trauma survivor confront distressing memories / situations until anxiety / distress diminishes) is the most promising intervention for torture survivors. Accordingly, we have developed Control-Focused Behavioral Treatment (CFBT; detailed in Basoglu and Salcioglu, 2011, pp. 79-109), which is a theoretically and practically modified and enhanced version of exposure treatment. Our treatment studies show that it is highly effective in reducing traumatic stress in survivors of mass trauma, including natural disasters, war, and torture. Thus, there are alternatives to non-evidence-based and ineffective treatments commonly used with torture survivors. Nevertheless, such treatment knowledge that accumulated over the last 25 years has not been adequately incorporated into in current torture rehabilitation programs (see Basoglu and Salcioglu 2011, pp. 187-195, for a detailed discussion of the reasons). Thus, Article 14 needs to make specific reference to use of evidence-based treatments and clinically significant recovery demonstrated by appropriate outcome evaluations to ensure that the intended aim of Article 14 is achievable.

Paragraph 11

“The Committee emphasises that the obligation of States to provide the means for “as full rehabilitation as possible” refers to the need to restore and repair the harm suffered by the victim whose life situation, including dignity, health and self-sufficiency may never be fully recovered as a result of the pervasive effect of torture, and does not refer to the available resources of States.”

This paragraph appears to be intended to ensure that the States provide specialized rehabilitation services for torture survivors and not simply refer them to a State hospital where the mental healthcare specialist is most likely to prescribe a useless medication or some form of ineffective psychological care. In view of the problem noted above, how will Article 14 be enforced if a government argues that ‘specialized rehabilitation programs’ are no more useful than regular state hospital care in reducing torture-induced traumatic stress problems? If I were a lawyer acting on behalf of a government, I would certainly raise this issue. This is yet another reason why Article 14 needs to explicitly refer to use of evidence-based treatments with proven effectiveness in torture survivors.

Paragraph 12

“In order to fulfil its obligations to provide a victim of torture or ill-treatment with the means for as full rehabilitation as possible, each State party should ensure that specialised services for the victim or survivor of torture is available at multiple levels. These should include: a procedure for the assessment and evaluation of an individual’s therapeutic and other needs, based on, among others, the Istanbul Protocol; and may include a wide range of measures, such as medical, physical and psychological rehabilitative services; re-integrative and social services; family-oriented assistance and services; vocational training, education etc. A holistic approach to rehabilitation which also takes into consideration the strength and resilience of a victim is of utmost importance. Furthermore, victims and survivors may be at risk of re-traumatisation and have a valid fear of acts which remind them of the torture or ill-treatment they endured. Consequently, should be a high priority placed on the need to create a context of confidence and trust in which assistance can be provided.”

The same considerations above also apply to this paragraph. In addition, the term “full rehabilitation as possible” (also used in Paragraph 11) implies that ‘full recovery’ may not be possible in some cases. Taken together with the statement in Paragraph 11 that “the need to restore and repair the harm suffered by the victim whose life situation, including dignity, health and self-sufficiency may never be fully recovered as a result of the pervasive effect of torture,” the document implicitly acknowledges the difficulties in treating torture survivors. This might be reflecting the commonly held view that torture is a particularly severe form of trauma that poses serious difficulties in treatment. This is a misconceived argument that has often been used to justify the ineffectiveness of current rehabilitation programs. The reader is referred to a debate on this issue that was triggered by my critique of current rehabilitation programs published in 2006 in the British Medical Journal (Basoglu, 2006). We have evidence detailed in Basoglu and Salcioglu, 2011, Chapter 9) to show that traumas of human design, such as torture, are as responsive to treatment as natural disaster trauma, provided that an effective intervention is used. Indeed, emerging evidence from an ongoing study (Salcioglu and Basoglu, unpublished data) of CFBT in war and torture survivors (asylum-seekers in Turkey) shows that effective treatment can reduce traumatic stress reactions (e.g. PTSD and depression) by an average of nearly 80% (minimum 60%). Given that 60% reduction in PTSD / depression corresponds to marked improvement in treatment studies (as assessed by both the patient and the therapist), these findings suggest that near-full recovery is possible in most cases with effective treatment. Thus, a less ‘pessimistic’ outlook on this issue in the document and an acknowledgement of the availability of effective evidence-based treatments is not only likely to circumvent an important loophole in its enforcement but also promote  progress in the field of torture rehabilitation by stipulating use of evidence-based treatments with proven efficacy.

An emphasis on a holistic approach to rehabilitation that takes into consideration a person’s strength and resilience may be deemed justifiable, considering that there are humanitarian reasons for helping survivors with their medical, psychological, social, and legal problems. However, if the ultimate aim of such multi-disciplinary holistic approach is to facilitate recovery from trauma and re-integration of survivors into society, the usefulness of current models of rehabilitation is questionable. Traumatic stress (defined as generalized anxiety, fear, helplessness, PTSD symptoms, and depression) is the core problem that impedes normal life functioning in most torture survivors and no rehabilitation program is capable of achieving meaningful re-integration into society without effective treatment strategies that reduce traumatic stress.  Furthermore, current holistic rehabilitation programs include various anti-therapeutic elements and also pose certain risks for survivors in the way they are currently implemented. The following section from our book (p. 191) details this issue:

“Evidence reviewed throughout this book strongly suggests that helplessness is the mediating process in traumatic stress and that treatment is effective to the extent that it reduces helplessness. In view of the close association between avoidance and helplessness, staff attitudes that perpetuate or reinforce avoidance are tantamount to ‘secondary victimization’ in the sense that they may not only block natural recovery processes but also aggravate traumatic stress problems. In a discussion of potentially therapeutic and antitherapeutic aspects of rehabilitation programs for torture survivors (Başoğlu, 1992a), the first author had noted that an understanding among the rehabilitation staff such as ‘whatever you do, do not remind the survivor of his/her trauma experiences’ is likely to reinforce avoidance behaviors (and hence helplessness responses) in survivors and thus perpetuate their victim role. Such attitudes may also block various therapeutic elements inherent in certain rehabilitation procedures. For example, physiotherapy sessions with torture survivors (e.g. when conducted seminaked in a pool in the presence of authority figures often dressed in white uniform) often trigger memories of the torture and evoke considerable anxiety or even panic. These sessions provide valuable opportunities for exposure to trauma reminders and might be expected to produce some therapeutic effects, even inadvertently when not conducted as part of a concurrent exposure treatment program. Yet, such potentially therapeutic effects of exposure are likely to be neutralized by avoidant and consequently avoidance reinforcing attitudes among rehabilitation staff. There are many other aspects of rehabilitation programs (e.g. interviews with clients, psychological assessments, medical investigations and treatments, social support interventions, etc.) with similar exposure elements, the therapeutic effects of which may be blocked by antiexposure attitudes or the ‘avoidance culture’ that often prevails among the staff. We know from experience with waitlist control groups in treatment studies of PTSD that detailed assessment of psychological status alone, a process that involves elements of imaginal exposure, leads to about 20% improvement in PTSD (Başoğlu et al., 2005; Başoğlu et al., 2007b; Ehlers et al., 2003; Foa et al., 1999; Foa et al., 2005). We also observed that some survivors, when asked questions about avoidance behaviors at initial assessment, recognized their avoidance as a problem and instigated self-exposure and improved during a 6 to 8 weeks waiting period before we had a chance to initiate treatment. The fact that an outcome study (Carlsson et al., 2005) of a 9-month-long torture rehabilitation program failed to demonstrate even limited improvement in tortured refugees might well be due to anti-therapeutic elements of the program. Indeed, evidence (Marks et al., 1988) shows that reinforcement of avoidance behaviors (e.g. by anti-exposure instructions) can even block the therapeutic effects of certain antidepressants in anxiety disorders.

A further related anti-therapeutic aspect of rehabilitation programs concerns the view of torture survivors as ‘victims’ who need unconditional attention and social / emotional support to recover from trauma. The perception of a torture survivor as a fragile being that needs strong support and protection from further adversity and stress is particularly prevalent in western countries. Such an approach in rehabilitation essentially amounts to an overprotective parental role on the part of care providers and deprives the survivors of much needed opportunities to learn effective ways of dealing with their own problems and to regain control over their life. We know from our own experience that many torture survivors, particularly political activists, resent being treated like victims and find the label rather demeaning or even offensive. Unconditional social or emotional support is likely to perpetuate helplessness responses and thus the victim role if the survivor is not encouraged to take an active role in dealing with their psychological and social problems. This may be a particularly serious problem in view of the long duration of some rehabilitation programs, which last nearly a year or more. Such a lengthy process means more exposure to helplessness-reinforcing elements in the rehabilitation program. Survivors need to take an active role in treatment and efforts in this direction need to be rewarded verbally and emotionally and reinforced in every way possible. Any failure to make sufficient effort to overcome problems, on the other hand, needs to be discouraged by withholding verbal rewards. Moreover, treatment needs to be time-limited and conditional on the survivor’s compliance with and progress in treatment (see Chapter 4). This is a simple but highly effective behavioral technique in reducing helplessness. An environment of unconditional support makes such therapeutic techniques impossible to administer…

Most importantly, in view of the antitherapeutic elements inherent in an existing ineffective rehabilitation program, the mere addition of a potentially effective treatment is unlikely to achieve the desired outcomes without a restructuring of the entire program along behavioral lines. This means getting rid of all anti-therapeutic elements in the program, including the cultural milieu that promotes the victim role and avoidance-reinforcing attitudes. Such a radical paradigm shift would require extensive re-training of existing staff involved in all aspects of rehabilitation, including even the receptionist at the front door. In view of the many misconceptions about behavioral treatment and potential resistance to the idea of brief treatments, this is obviously not an easy task.”

In brief, draft Article 14, as it stands, is likely to achieve no more than maintaining the status quo in torture rehabilitation field, unless it acknowledges the problem and makes specific recommendations as to how this problem can be overcome. A noted above, rehabilitation programs could be made effective by restructuring them to have a sharp focus on trauma and introducing
specific behavioral interventions that help survivors gain resilience against traumatic stressors. In the way they are currently implemented they are far from promoting resilience in survivors. On the other hand, we do know from treatment studies that exposure treatments (i.e. encouraging a survivor not to avoid trauma cues or reminders) can achieve this. There is also substantial evidence from work with animals and humans that psychological immunization to traumatic stressors is possible by helping a person confront trauma cues (or reminders) until sense of control over these stressors is achieved.

I should also note that the statement that survivors may be at risk of re-traumatization and have a valid fear of acts that remind them of their torture is counterproductive in discouraging use of exposure-based treatments with torture survivors. Such statements are best avoided, as there is already considerable resistance in the torture rehabilitation field against interventions that involve exposure to trauma memories or reminders to enhance resilience. It might also reinforce already prevalent anti-therapeutic attitudes among care providers mentioned in the above excerpt. Such attitudes have contributed to use of ineffective non-trauma-focused approaches in rehabilitation.

Paragraph 14

“States parties must ensure that effective rehabilitation services and programmes are established in the State and are accessible to all victims. States parties’ legislation should establish concrete mechanisms and programmes for providing rehabilitation to a victim or survivor of torture or ill-treatment. It should also be noted that the obligation in article 14 to provide for the means for as full rehabilitation as possible can be fulfilled through the direct provision of rehabilitative services by the State, or through the funding of private medical, legal and other facilities, including those administered by NGOs. States parties are encouraged to establish methods for assessing the effectiveness of rehabilitation programs and services, including by developing relevant indicators and benchmarks.”

In view of the above considerations, Article 14 needs to refer to the need for research to develop effective treatments for torture survivors. As noted earlier, there are very promising treatments that can be easily tested and incorporated into rehabilitation programs. Lack of attention to the need for research in this field has indeed been the primary factor that accounts for lack of effective rehabilitation programs today.  The following section from our book (p. 193) highlights the importance of this issue.

“Funding organizations have unfortunately played an important role in maintaining the status quo in the field of torture rehabilitation by providing unquestioning support for essentially ineffective rehabilitation programs. The possible reasons for such support are beyond the scope of this chapter but suffice it to say that political considerations have always overridden scientific ones. This has contributed to the problem by not only encouraging a non-evidence-based approach but also discouraging scientific research in the field. Indeed, we pointed to this problem many years ago (Başoğlu, 1993), emphasizing the need for research for progress in torture rehabilitation. The fact that there has not been a single randomized controlled treatment study in this field since it came into existence in the 1970s is not a coincidence. Lack of attention to the need for treatment research in this field…is even reflected in the mandate of international organizations established with the specific aim of helping torture survivors, such as the United Nations Fund for Victims of Torture, which explicitly states that “Priority in allocating grants is given to projects providing direct medical, psychological, social, economic, legal, humanitarian, educational or of their family . . . Activities such as investigations, studies, research, and publication of newsletters or similar activities are ineligible for funding from the Fund” (United Nations Office of the High Commissioner for Human Rights, 2010). This is indeed another curious phenomenon in view of the ineffectiveness of current psychological rehabilitation approaches and the fact that effective treatments can only be developed through scientific research…Moreover, research is the most cost-effective approach to trauma-induced mental health problems in a society, given that the enormous economic costs of social and occupational disability arising from these problems can only be prevented by effective interventions developed through research”.

Research is also essential in establishing methods of outcome evaluation. Currently, there is no consensus among trauma experts on any particular assessment method. This can be largely explained by the lack of recourse to sound theory in understanding mechanisms of traumatic stress and which trauma-induced stress problems need attention in assessment and treatment. This problem often leads to wrong choice of assessment measures as well as wrong choice of treatment. The example provided in the following section from our book (p. 194) highlights the nature of the problem.

“In closing this chapter, it is worth briefly commenting on recent attempts to evaluate the outcome of current rehabilitation programs using the World Health Organization (WHO) International Classification of  Functioning, Disability and Health (ICF)(World Health Organization, 2002), which involves an assessment of physical, mental, and social well-being. Although this is a commendable effort, it is not immediately apparent to us how the ICF section on assessment of mental functions effectively guides the assessor in capturing vital information on functional impairment caused by fear- or distress-induced helplessness / avoidance responses in trauma survivors, unless the assessor is well aware of the mechanisms of traumatic stress reviewed in Part 1 and has sufficient experience in behavioral assessment. Furthermore, outcome measures relating to the most common outcomes of traumatic stress (e.g. PTSD and depression) are critical in assessment of treatment effects, as these outcomes are the most important factors that have a direct impact not only on mental and physical health status but also on life functioning. In addition, physical disability (e.g. loss of a limb) arising from a traumatic event may result in social disability not only because of objective loss of functionality related to a particular organ, but also because of its subjective psychological impact, such as  helplessness responses exacerbated or sustained by the loss and its additional impact as a constant trauma reminder. Treatment outcome evaluation based primarily on a measure of disability in trauma survivors without an adequate understanding of mechanisms of traumatic stress in trauma survivors is likely to lead to loss of important information in assessment and misguided interpretation of the data resulting in unwarranted conclusions.”

The above excerpt is referring to the work of the Rehabilitation Center for Torture Victims in Denmark. The disability measure ICF was used in a study (Carlsson et al, 2010) conducted to evaluate treatment outcome 23 months after the completion of a rehabilitation program. The following excerpt from the article that reported the results is also useful in demonstrating the problem. It is also worth noting that the above section from our book was written before the publication of this article.

“No substantial changes in mental health were observed at the 9-month follow-up, and the minor decrease in some symptoms observed between the 9 and 23 months may reflect regression toward the mean or the natural course of symptoms in this cohort…It is of interest that this study found a statistically significant improvement in mental health, but no statistically significant improvement in quality of life between the 2 follow-ups. It is possible that the quality of life measure used in this study is too broad and imprecise to be sensitive enough to detect minor changes in the symptomatic state of traumatized refugees. Our measure of quality of life primarily reflects the social function and situation of the participants, whereas the treatment is focused on mental symptoms. As a consequence, any minor effect of the treatment is likely to be observed primarily with respect to mental symptoms.”

Alternatives to current rehabilitation models

Multi-disciplinary rehabilitation programs, even when they are effective, are not likely to address the needs of the entire population of torture survivors around the world, as there will always be those who will not have access to these programs for various reasons. An alternative outreach approach is therefore needed to ensure that care is delivered to the great majority of survivors. Our work shows that this challenging task can be achieved by developing brief and effective treatments that can be delivered on a self-administered basis. Using a control-focused behavioral approach, we have demonstrated that a highly
effective psychological intervention can be delivered in a single session or through a self-help manual to large numbers of earthquake survivors (see Basoglu and Salcioglu 2011, pp.125-142, for review of evidence). Our currently ongoing work suggests that this intervention can be delivered to torture survivors in an average of 4 sessions in most survivors. It also suggests that,
at least in a non-negligible proportion of cases, this intervention can be delivered on a self-help basis. Accordingly, we are in the process of preparing self-help tools for war and torture survivors. Although this process is yet at an early stage, our work suggests that cost-effective psychological care of many survivors is possible using an outreach approach largely based on self-help treatments. In our book (pp.143-156) we presented such an outreach treatment delivery model in detail.

It is worth emphasizing once again that the greatest obstacle to a survivor’s meaningful re-integration into society is the debilitating problems of traumatic stress. No rehabilitation program can rehabilitate survivors without removing this obstacle no matter how extensive or intensive multi-disciplinary aid is provided. Traumatic stress problems disrupt a person’s functioning in all life domains, leading to substantial functional impairment. Accordingly, a simple but highly effective psychological intervention that reduces traumatic stress can achieve much more than an entire multi-disciplinary program lacking in this intervention. We know from our treatment work with tortured asylum-seekers in Turkey that once the person overcomes traumatic stress, they can deal with their social, legal, and other problems much more effectively, even when little or no additional external help is available (for 2 case examples of how recovery from traumatic stress generalizes to improved functioning in all life domains, see Basoglu and Salcioglu, 2011, pp. 182-186). They are also better able to utilize social and legal assistance when they are free of traumatic stress problems. Therefore, effective psychological treatment can be a powerful alternative to multi-disciplinary rehabilitation programs, particularly in settings where the latter are not available or accessible. Furthermore, this alternative approach confers the additional advantage of being suitable for wide-scale dissemination in the most cost-effective fashion. It is worth noting in this connection that psychological treatment of survivors using our approach costs less than a few hundred US dollars per case, whereas certain lengthy (9-month-long) multi-disciplinary rehabilitation programs that are known to achieve no therapeutic impact on traumatic stress cost 18,900 USD per case (Basoglu and Salcioglu,
2011, p. 178). Thus, the issue of cost-effectiveness is an additional important consideration that needs to be taken into account in endorsing currently existing rehabilitation models. The rehabilitation section of Article 14 would be easier to enforce if effective rehabilitation can be achieved at lower costs. This can only be achieved, however, through research and this is yet another reason why the issue of research needs a high profile in Article 14.

Summary of recommendations

In brief, the CAT Working Document on Article 14 could be further strengthened by:

  • more attention to scientific evidence concerning definition of torture and ‘victims of torture’ and rehabilitation of torture survivors
  • reference to evidence suggesting that redress measures alone are not likely to facilitate recovery from trauma and that recovery requires psychological interventions specifically designed for this purpose
  • a statement that States are under obligation not only to provide effective rehabilitation for torture survivors but also to demonstrate the usefulness of rehabilitation programs through appropriate outcome evaluation
  • a statement that States (including Western countries that host tortured asylum-seekers and refugees) are required to organize and fund research needed to develop effective rehabilitation programs and appropriate outcome assessment tools
  • a statement that rehabilitation centers and other organizations concerned with care of torture survivors in all countries need to adopt an evidence-based approach in rehabilitation and conduct outcome evaluation to demonstrate the effectiveness of their program
  • a statement that care providers need to undertake research to examine the usefulness of various components of their rehabilitation program, eliminate redundant and anti-therapeutic elements, and develop a briefer and more cost-effective rehabilitation program
  • a statement that States and organizations concerned with care of torture survivors need to conduct research with a view to developing (a) brief and effective psychological interventions that can be delivered by self-help tools as well as therapists and (b) outreach programs through which these interventions can be delivered to survivors in the community who may have no access to rehabilitation programs for various reasons

References

Basoglu M and Salcioglu E (2011) A mental health care model for mass trauma survivors: Control-focused behavioral treatment of earthquake, war, and torture trauma. Cambridge University Press.

Basoglu et al (2007) Torture versus other cruel, inhuman and degrading treatment: Is the distinction real or apparent? Archives of General Psychiatry, 64, 1-9.

Basoglu M (2009) A multivariate contextual analysis of torture and cruel, inhuman, and degrading treatments: Implications for an evidence-based definition of torture. American Journal of Orthopsychiatry, 79,2,135-145.

Basoglu M (2006) Rehabilitation of traumatised refugees and survivors of torture – After almost two decades we still do not use evidence based treatments. British Medical Journal, 333:1230-1231.

Basoglu et al (2005) Psychiatric and cognitive effects of war in former Yugoslavia – Association of lack of redress for trauma and posttraumatic stress reactions. Journal of American Medical Association, 294,580-590.

Basoglu et al (1997) Psychological preparedness for trauma as a protective factor in survivors of torture. Psychological Medicine, 27,1421-1433.

Basoglu et al (1994) A comparison of tortured with matched non-tortured political activists in Turkey. American Journal of Psychiatry, 151,76-81.

Carlsson et al (2010) Late mental health changes in tortured refugees in multidisciplinary treatment. Journal of Nervous and Mental Disease, 198:824-828.

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Book on Mass Trauma

Book on a mental healthcare model for mass trauma survivors

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