Publications
APS Bulletin • Volume 13, Number 1, 2003
Pain as Path
Mark Sullivan, MD PhD, Department Editor
Treating Torture Survivors:
Reduce Pain and Isolation
Amanda C de C Williams, PhD
Editor’s note: This column usually focuses on pain as a path to something of spiritual, political, or personal value. Pain can also be used as a path to the destruction of human relationships through the use of torture. Wislawa Szymborska, Nobel Laureate in literature, begins her poem, Tortures, as follows:
Nothing has changed.
The body is susceptible to pain,
it must eat and breathe air and sleep,
it has thin skin and blood right underneath,
an adequate stock of teeth and nails,
its bones are breakable, its joints are stretchable.
In tortures all this is taken into account.
Below, Amanda C de C Williams describes her work in providing for the pain of torture survivors. She extends the dialogue initiated in previous columns written by Jamie Mayerfeld (APS Bulletin, November/December 2001) and Michael Nutkiewicz (APS Bulletin, November/December 2002) about the nature of suffering and its moral value.
Torture takes place in more than one-half of the world’s countries, including many signatories to the UN Convention Against Torture. It is often inflicted to intimidate and oppress minority populations. Members of ethnic, religious, or political groups who are viewed as different than the majority are especially vulnerable. In some countries, torture is mainly used against criminals and suspects or prisoners of war. In other countries, torturers make an effort to not leave their marks on survivors’ bodies. Survivors may be hospitalized until they are judged fit to return to their torturers.
We like to think we can recognize evil and torture, but there are no sure torture signs. To protect ourselves, we may deny what we see. I wrote this article on an airplane as I returned from a meeting on torture. This meeting took place in a country that practices torture and persecutes those who document it and treat survivors. Sometimes the knowledge of what one human does to another feels contaminating, and I long to leave it behind. We want to turn away at the same time we feel compassion. How readily did we dismiss press photographs of hooded kneeling prisoners in Guantanamo Bay?
Survivors Deserve Our Services
In his eloquent piece, Nutkiewicz (2002) set suffering and torture in a social context, and drew us as observers into the same context. Compassion in an abstract sense motivates many who work in health care. But turning that compassion into effort to treat every pain patient at the highest standard is difficult because we flinch at the thought of hearing or believing accounts of the origins of pain in torture. Survivors are often profoundly ashamed of what has been done to them or of what they were forced to do. Torture’s capacity to undermine relationships is augmented by the practice of involving family members, friends, and compatriots in witnessing or inflicting torture. The guilt, shame, and humiliation are pervasive. As the foundation of a therapeutic relationship, believing patients’ accounts of pain is critical when treating torture survivors.
Many survivors seek help from specialist services for torture survivors while in their own country or in exile. These services are often offered outside mainstream health and welfare services. Their funding is uncertain, their resources stretched, and their dependence on volunteers often substantial. Despite their limitations, these services provide a lifeline for survivors. Healthcare and welfare workers may be the only people to whom torture survivors confide. Unfortunately, although pain is common among torture survivors, pain specialists rarely work at these service organizations.
Access to pain specialists in mainstream health care may be blocked by ineligibility or a lack of financial resources. Recognizing these obstacles indicates recognition of the need for adequate pain services. It is puzzling when projects developed for torture survivors often provide mainly or only therapies without proven efficacy for mild pain and distress, let alone for severe and complex problems (Williams, Amris, & Van Der Merwe, in press). It is perplexing that the most desperate people are sometimes treated with extraordinarily lightweight therapeutic techniques, to say nothing of the techniques’ questionable cultural appropriateness.
Survivors: Resilient Yet Fragile
The relationship of the complaint of pain to psychological trauma and ongoing symptoms is complex and barely explored in the research literature. What is clear is that the simple assignment of pain to nonspecific symptoms of post-traumatic stress disorder (PTSD) poses the potential failure to address the pain as a problem in its own right and treat it. The applicability of the PTSD symptom-count model is questionable, having been developed primarily in the context of single traumatic events that did not necessarily involve pain or threaten life. But this is not to suggest there is a universal psychological “post-torture” syndrome. Efforts to identify it have failed repeatedly, and many studies of torture survivors in exile or in their home countries find that neither PTSD, depression, nor chronic anxiety are diagnosable in the majority of those sampled. Symptoms are often reported at a level that does not meet diagnostic criteria.
Even after enduring the dreadful practices that aim to destroy survivors psychologically and physically, survivors do, in fact, rebuild their lives and recover psychological equilibrium. It helps to be heard, to receive offers of support from strangers, and to be treated with respect. These are close to the duties Michael Nutkiewicz describes for humans who observe suffering in fellow humans.
While I respect Jamie Mayerfeld’s viewpoint on suffering as intrinsically evil and entirely endorse his rejection of the romanticisation of pain as suffering, we need to recognize that for some people, the meaning of the pain significantly mitigates their suffering. A fascinating study by Holtz (1998) that compares students and nuns tortured by the Chinese in Tibet with age- and sex-matched students and nuns who had not been tortured but were also in exile sought an explanation for the surprisingly low rate of depression of their Buddhist convictions. Not only did they believe leading good lives (for which they suffered) contributed to improved karma, they believed their suffering could directly benefit others. Some described their experience in terms of a sacrifice they made “for the good of the country.” This and other studies have identified protective effects of spiritual and political convictions that provide a context for persecution.
Generally speaking, survivors’ health and recovery from psychological disturbance is affected by current social conditions (e.g., support or isolation from family and community, housing, racism) and general health care (Basoglu et al., 1994a & b; Hauff & Vaglum, 1995; Holtz 1998; Gorst-Unsworth & Goldenberg, 1998; Mollica et al., 1999). This implies a broad role for clinicians and others seeking to support the survivor’s recovery. On a clinical level, listening, validation, and encouraging testimony can be very important, normalizing symptoms and engendering hope of mitigating them (Eisenman, Keller, & Kim, 2002; Piwowarczyk, Moreno, & Grodin, 2000; Pope & Garcia-Peltoniemi, 1991). While clinicians are right to consider potential difficulties for torture survivors who must be undressed, handled, and scrutinized, this can be overemphasized and undermine quality assessment. Similar concerns are often expressed about the use of electrical equipment for treatment, such as TENS, injections, or other methods that may have been used during torture. Their effectiveness among survivors means they should not be ruled out a priori, however. Careful explanation of the procedures and their effects allows survivor-patients to maintain some control and modulate the pace of treatment.
Beyond their clinical roles, pain specialists can serve as consultants and liaisons and offer education and training to torture survivor projects. They can lobby against torture in other countries via professional organizations such as Physicians for Human Rights USA (Bateman, 2001; Maio, 2001) and remain alert to questionable practices in their own countries. Many people worldwide are fighting against the despair of Szymborska’s words: “Nothing has changed.” Awareness of political dynamics and their social impact in countries in which health professionals see refugees can help to both recognize the effects of torture and challenge the tendency to assign torture survivors the responsibility for their injuries (Nathanson, 2001). Torture should be documented and written about for publication so we can share our scarce, but crucial, understanding with fellow clinicians. Lastly, clinicians who wish to stay effective in the field will address their own needs for support and sharing in their efforts to avoid becoming traumatized and/or burned out (Pope & Garcia-Peltoniemi, 1991).
Acknowledgments
I am most grateful to Drs. Kirstine Amris of IRCT Copenhagen, Kate McGuire of Medicins sans Frontières, and Jannie van der Merwe for discussion of many of the issues addressed here, and for sharing their work experiences in this area.
Editor’s concluding note: If pain is intrinsically evil, the intentional pain that is torture is doubly evil because it destroys relationships as well as bodies. Torture is not new. But neither have we outgrown it. We have adapted it to more purposes and found more ingenious justifications for it. As Szymborska writes,
Tortures are as they were, it’s just the earth that’s grown smaller,
and whatever happens seems right on the other side of the wall.
Amanda Williams alerts us to the special responsibility we have to those who have suffered this intentional infliction of pain. Too often, survivors of torture are denied the best pain management has to offer.
References
Basoglu, M., Paker, M., Paker, O., Özmen, E., Marks, I., Incesu, C., Sahin, D., & Sarimurat, N. (1994a). Psychological effects of torture: A comparison of tortured with nontortured political activists in Turkey. American Journal of Psychiatry, 270, 606-611.
Basoglu, M., Paker, M., Paker, O., Özmen, E., Marks, I., Incesu, C., Sahin, D., & Sarimurat, N. (1994b). Factors related to long-term traumatic stress responses in survivors of torture in Turkey. American Journal of Psychiatry, 272, 357-363.
Bateman, C. (2001). Ongoing human rights abuses. South African Medical Journal, 91, 624-625.
Eisenman, D.P., Keller, A.S., & Kim, G. (2002). Survivors of torture in a general medical setting: How often have patients been tortured, and how often is it missed? Western Journal of Medicine, 182, 301-304.
Gorst-Unsworth, C., & Goldenberg, E. (1998). Psychological sequela of torture and organised violence suffered by refugees from Iraq. British Journal of Psychiatry, 172, 90-94.
Hauff, E., & Vaglum, P. (1995). Organised violence and the stress of exile. British Journal of Psychiatry, 166, 360-367.
Holtz, T.H. (1998). Refugee trauma versus torture trauma: A retrospective controlled cohort study of Tibetan refugees. Journal of Nervous and Mental Disease, 186, 24-34.
Maio, G. (2001). History of medical involvement in torture—then and now. Lancet, 357, 1609-1611.
Mollica, R.F., McInnes, K., Sarajlic, N., Lavelle, J., Sarajlic, I., & Massagli, M.P. (1999). Disability associated with psychiatric comorbidity and health status in Bosnian refugees living in Croatia. Journal of the American Medical Association, 282, 433-439.
Nathanson, V. (2001). Editorial: Doctors and torture. British Medical Journal, 319, 397-398.
Piwowarczyk, L., Moreno, A., & Grodin, M. (2000). Health care of torture survivors. Journal of the American Medical Association, 284, 539-541.
Pope, K.S., & Garcia-Peltoniemi, R.E. (1991). Responding to victims of torture: Clinical issues, professional responsibilities, and useful resources. Professional Psychology Research & Practice, 22, 269-276.
Williams, A. C de C, Amris, K., & Van Der Merwe, J. (in press). Pain in survivors of torture and organised violence. In J.O. Dostrovsky, D.B. Carr, & M. Koltzenburg M. (Eds.), Proceedings of the 10th World Congress on Pain. Seattle: IASP Press.
Amanda C de Ce Williams is senior lecturer at Guy’s, King’s & St. Thomas’ (GKT) School of Medicine and Dentistry in London, and psychologist at St. Thomas Hospital in London.