Publications
APS Bulletin • Volume 13, Number 2, 2003
Pain as Path
Mark Sullivan, MD PhD, Department Editor
Torture Treatment Programs Provide Holistic Care, Seek Pain Professionals’ Participation
David Gangsei, PhD
Department Editor’s Note: Many APS members feel a special duty to people with persistent pain. Their pain is often part of why we have chosen pain as our life’s work. The intentional infliction of pain that is torture—and its long-term consequences—call us to service. But it also repels us because it is horrific, because it is evil, and because it is overwhelming. We need extra courage to address pain that is intentionally inflicted. Here Dr. Gangesi describes much good work in this area that is already underway. Many of these programs can further benefit from the expertise of APS members.
Many people are aware torture exists in the contemporary world, but most are surprised to learn the practice is so widespread it could be called an epidemic.
An Amnesty International survey conducted between 1997 and 2000 found reports of widespread and persistent torture and ill treatment in more than 70 countries (Amnesty International, 2000). Surveys of refugee populations fleeing civil war and systematic oppression estimate between 5% and 35% of refugees are torture survivors (Gnefke, 1999). An estimated 400,000 survivors of politically motivated torture currently live in the United States. The extent of the problem, and a hopeful response, is revealed by the establishment of more than 30 torture treatment programs in the United States (Quiroga, 2002), and more than 200 programs internationally (Gnefke, 1999).
The development of specialized treatment programs for survivors of politically motivated torture is relatively recent. The work began in Denmark in 1974 with the creation of an Amnesty International medical group, which later evolved into the International Rehabilitation and Research Centre for Torture Victims and the International Rehabilitation Council for Torture Victims (Gnefke, 1999). In the United States, the Program for Torture Victims began as a network of volunteers in Los Angeles in 1980. The first formal center, the Center for Victims of Torture, was established in Minneapolis in 1985. U.S. torture treatment received a major boost with the passage of the Torture Victims Relief Act in 1998, which, for the first time, provided federal funds for programs within the United States. More than 25 organizations now receive federal funding totaling $10 million annually for programs administered by the Office of Refugee Resettlement within the Department of Health and Human Services (Quiroga, 2002).
Torture Defined
The United Nations Convention Against Torture defines torture as “any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining from him or a third person information or a confession, punishing him for an act he or a third person has committed or is suspected of having committed, or intimidating or coercing him or a third person for any reason based on discrimination of any kind, when such pain or suffering is inflicted by or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity” (United Nations Office of the High Commissioner for Human Rights, 1984). Some treatment centers add to the definition acts committed by non-official groups such as rebel armies, paramilitary groups, or death squads the government is unable or unwilling to control. Another primary motive for the use of torture today is the intimidation, demoralization, and paralysis of entire communities. As such, torture has become a primary tool in the suppression of movements for justice and democracy.
Torture methods are numerous and varied. With much overlap among categories, observers commonly refer to four types: physical (beating, electric shock, exposure to extreme conditions); psychological (threat, humiliation, mock execution) sexual (rape, forced nudity) and deprivation (of food, water, sleep, hygiene, for example); or overstimulation (noise, light, crowding). Torture may take place in prisons, police stations, clandestine detention centers, remote outdoor locations, or in victims’ homes.
Who Are Survivors?
Torture survivors are people who have suffered abuses and lived. Survivors often flee the scene of their torture; for some, their search for safety takes them to the United States. They come from Africa, Asia, the Americas, the Middle East, and Europe. They are men, women, and children; young and old; university professors and poor farm workers; journalists and housewives. Some are activists for social, economic, relgious, political and environmental justice. Some are family and friends of activists. Some are victims of discrimination targeting citizens of a specific religion, political group, nationality, ethnicity, gender, or sexual orientation. Some are caught in pervasive assaults on entire communities, arbitrarily tortured to terrorize and immobilize the population.
All major U.S. cities with a significant population of immigrants, refugees, and asylum seekers are home to torture survivors. They come from countries suffering civil war, systematic oppression, and political violence. They often settle in locations where their immigrant countrymen and women have already formed communities, but also often land wherever they can.
Note these recent examples:
- A Congoleswoman, age 26, was detained two months in a clandestine prison and beaten and raped for her opposition to the abuse of non-combatants in the civil war. She became separated from her husband and two daughters while fleeing the country. She came to the United States by a long and circuitous route. She hopes to gain political asylum and to continue to search for her family.
- A 42-year-old Eastern European university professor was imprisoned for 9 months of hard labor for being a lesbian. Never charged with an offense, she was repeatedly raped, beaten, and nearly died of pneumonia before being released. She escaped to the United States with a tourist visa. She is training to work in the clerical field, and is looking for teaching opportunities.
- A 50-year-old Kurdish man was arrested four times, imprisoned, and tortured for opposition to the government of Iraq. He persisted in his political work, but, after the last episode, he broke down and left the country under threat of assassination. He came to the United States with his wife and three children, where his children attend school and he works as a shipping clerk.
Treatment Programs
U.S. torture treatment programs are both independent and collaborative. Some are free standing non-profit organizations, some are embedded within larger non-profits, and some are hospital based. In 2001, more than 30 organizations joined to formally incorporate the National Consortium of Torture Treatment Programs, through which they collaborate in areas of clinical practice, advocacy, policy, training, development, and research. Their common characteristic is a commitment to holistic care to meet their clients’ significant mental, physical, legal, social, and basic survival needs. A multidisciplinary approach encompasses staff, independent contractors, volunteers, and collaboration with other institutions and organizations. Effective service delivery requires attention to the dynamics of trauma, mistrust, social and cultural dislocation, language barriers, and cultural differences. It also demands awareness of the strength, resiliency, and resourcefulness of the survivors, and the ability to focus on empowerment and reclamation of pre-torture identity and values.
Professionals’ Roles
Chronic pain is a prominent stressor for torture survivors. This is not surprising, given the frequency of torture techniques such as beating, suspension, falanga (beating of the feet), and prolonged abnormal positioning. One study of 51 survivors examined an average of 8 1/2 years after being tortured showed 92% reporting musculo-skeletal pain, 37% reporting neurological complaints, and many others with pain related to various internal organ systems (Amris & Prip, 2000a). In addition, the impact of pain on psychological functioning can be severe, including contributions to poor body image, damaged self-esteem, anxiety, depression, and impaired capacity for participation in social and community situations (Arcel, 2002). The skills of physicians, physical and occupational therapists, psychologists, nurses, and others are essential to a range of treatments including education, relaxation, physical exercise and physiotherapy, TENS, hydrotherapy, pharmacology, and life skills (Amris & Prip, 2000b).
APS members are invited to contact the torture treatment program in their area to explore ways they can contribute to the rehabilitation process. Professionals choose to volunteer or contract their services for a variety of reasons—to contribute to the struggle for human rights and social justice, to indulge their interest in cross-cultural or international political issues, or to take the opportunity to treat this form of severe trauma. Whatever their motives, many professionals reported this work to be among the most rewarding of their activities. Click here to find contact information for 30 treatment programs affiliated with the National Consortium. Opportunities for collaboration as a volunteer or contractor vary with each program.
The specialized treatment centers will never be able to reach all torture survivors living in the US. Many survivors present for care at general hospitals, clinics, or private medical offices. They often choose to not volunteer information about their torture experience. One study of ambulatory care patients born outside the United States who sought care at urban medical centers found that 6.6% had a history of torture, but none were so identified by their primary care physicians (Eisenman, Keller, & Kim, 2000). Pain professionals who take the opportunity to educate themselves on this issue and can recognize that torture survivors may be among their patients are taking the first step towards providing appropriate service.
Affiliates of the National Consortium of Torture Treatment Programs
References
Amnesty International. (2000). Torture worldwide: An affront to human dignity. New York: Author.
Amris, K. & Prip, K. (2000a). Physiotherapy for torture victims (I): Chronic pain in torture victims: Possible mechanisms for pain. Torture, 10(3), 73-76.
Amris, K. & Prip, K. (2000b). Physiotherapy for torture victims (II): Treatment of chronic pain. Torture, 10(4), 112-116.
Arcel, L.T. (2002). The tortured body as part of the psychotherapeutic dialogue. Torture, 12(1), 25-28.
Eisenman, D., Keller, A., & Kim, G. (2000). Survivors of torture in a general medical setting: How often have patients been tortured, and how often is it missed? Western Journal of Medicine, 172, 301-304.
Gnefke, I. (1999, May). Torture in the world today—A challenge to all physiotherapists. Keynote lecture presented at the 13th International Congress of the World Confederation of Physical Therapy, Yokohama, Japan.
Quiroga, J. (2002, September). A short history of the torture victims relief act. Presentation to Symposium on the Effects of Torture on Survivors, Their Families and Communities, National Consortium of Torture Treatment Programs, Washington, DC.
United Nations Office of the High Commissioner for Human Rights. (1984). Convention
against torture and other cruel, inhuman or degrading treatment or punishment. Retrieved January 13,
2003, from http://www.unhchr.ch/html/menu3/b/h_cat39.htm.
David Gangsei, PhD, is clinical director of Survivors of Torture, International, San Diego, CA. He can be reached at dgangsei@notorture.org.