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Torture Victim, Survivor, Citizen Suzana Kulovic, M.D.
The subject of this paper is presentation of new group of patients in medicine -torture victims/survivors, and certain implications their treatment has on medical ethics and the social responsibility of physicians. The focus is on some aspects of politically motivated torture.
In the title of the paper words are put in certain order which is implying the process of overcoming passive state of "victim" of torture, to the possibilities of "survivor" of torture, who can, by various kinds of therapeutic procedures done by helper (physician for instance) he rehabilitated to the active position of citizen.
For the first two stages of the described process, torture and the surviving of torture, quotation marks are put round words "torture" and "survivor", which are highlighting the object language expression.
Psychological commentary upon the mental imaginary of particular words for the concept, rehabilitation to the position of citizen, is being emphasised by labelling such aim of the outcome of the rehabilitation process as
highly contextually symbolised, not formal only.
This defines the role of the helper, which is a classical role of helper for the torture victim/survivor, but for the level of citizen's functioning of the previously mentioned, active citizen's appearance of helper regarding the context of victimisation and rehabilitation is needed; i. e. if, for instance physician, wants to rehabilitate torture victim/survivor
to the level of active citizen, she/he has to be a citizen herself/himself, apart from being a therapist. This is a ecessary, it is a demand for successful rehabilitation, but it is often avoided by helpers and their networks, because it puts them in a position of citizens activism of political kind when they should questioned powerful decision making instances.
The term "torture victim" is not originally medical, psychiatric or psychological. As a word it means only that a person- a victim was submitted to torture. As a notion "torture victim" became of medical concern at the end of sixties and at the beginning of seventies. That was the first time in the history of medicine that the very powerful group of social establishment, medical professionals, were faced with the consequences of the effects of some structures of the establishment, or with the effects of by establishment structures delegated individuals-torturers, on misfortunate individuals-torture victims.
Until the mentioned time medicine was taking care of the consequences of torture at individuals, without obligation to comment the external ehiology precisely of such consequences. Medicine had no obligation to act towards
diminishing or eradication of the causes of torture which are certain socio-political situations; nevertheless medical model in every other case was actively directed toward the cause of the illness or a disease if the either was diabetes or diarrhoea for instance. Medical professionals were not obligated to spot the cause of the torture in a sense of fixing the responsibility at certain external objects/ society structures that caused the consequences of torture by performing it or permitting it. Therefore, medical professionals did not take their share of social responsibility for the ill conditions of their patients-torture victims that they treated. The avoidance of the social responsibility in this case meant violation of medical ethics (Geneva version of Hippocratic Oath from 1948).
Holocaust survivors were rehabilitated, with the medical participation, of course, but the Holocaust itself was defined in a broader context of responsibility.
Medical examination of the new group of patients, torture victims, resulted in evidence and knowledge which could not be denied and which demanded different approach form classical medical healing model. This meant an
outreach of medicine into social field in political way, which differs a lot from usual appearance of medicine in socium as it was during vaccination against epidemic diseases, for instance. This was and still is a new situation, and new ethical demand form medical profession. Such social outreach was not included in classical medical concepts of prevention defined in public health or in strategies of social psychiatry.
The awareness of the health consequences of the, mainly politically motivated, torture on victim's health demand social and political action.The time of "court physicians", when it was enough to name for health "bad agent" has passed. For more then thirty years now we are witnessing the shaping of new medical ethics in respect to the human rights, and politics. So medical machinery became important part of global human rights machinery, which determined new perspective and new dangers for medicine as a profession. Medical power, the power of modern shamans, the archetypes of the masters of life and death in collective unconscious, combined with political power, requires legal and ethical redefinition of some boundaries of medicine and its ethics.
The term "torture victim" is in a way misguiding. When we are dealing with victims of torture, we are dealing with people whose bodies and souls are damaged by torture, but who have survived torture. Moreover, the victims
themselves prefer the term "survivor". That is known fact for all those who work with victims of any kind that those people do not like the term "victim". This shows that victims are aware of the disadvantages of the victim's position. We should make a distinction between the uneasiness with the term "victim" on a part of victim/survivor and the insisting on that term from the instances which usually try to use victimised people for their political goals, which do not have to be wrong or bad.
Why victims, who usually have no psychodynamic education, according to the literature and as I have learned from my experience as a helper, feel so uneasy with the term "victim"?
Victim is not a moral category as a word. The word itself does not show or prove that victim is good or bad, right or wrong in respect to the event of victimisation. Victim as a notion describes person submitted to brutal, violent and inhumane actions of the torturer-who was stronger by the position. During the time of torture, in dialectics of victim and torturer, torturer is the almighty one, the one who has the whole power of the universe at that time and who is exercising it upon the helpless victim. Throughout the time of torture, torturer has on disposal the life, the
senses, and every other aspect of victim's exi stence, as if he, the torturer, was the God's chosen one. If not life, the torturer certainly takes away a dignity and self-respect of the victim and, therefore dehumanises the victim. That is way it is not surprising that victims do not like the word victim once they come out of the torture as
alive-survivors. This is illustrating the awarene ss of the affected individuals of their main problems- feelings of helplessness and feeling of dehumanisation.
In literature term "victim" is used when the torture as a method is described, or when it is being legally defined as a phenomenon in our society. When we are talking about healing and rehabilitation we are more likely to use term "survivor". To achieve the extent of rehabilitation of torture survivor when she/he can act as a citizen, we ought to achieve the certain social level of recovery and integration of the survivor in the society. Such stage of social reintegration of survivor in the society requires civic action of helpers in society in a sense of clarification of
their attitude towards the social situati on that made torture possible either by direct public condemnation of the situation or by the intervention at decision makers instances which are officially responsible for the situation.
That puts additional tasks on the helpers in rehabilitation process. Firstly it implies the clear and visible attitude of a helper towards the circumstances (the state regime usually) which made torture possible.
Only description of methods of torture and assessments of healing and rehabilitation methods are not enough. It is unavoidable for the helper to have a knowledge about the social conditions in which torture happened, and
in which rehabilitation takes place. This includes political criticism of decision-makers. That criticism is necessary in order to define and remove obstacles to the processes of rehabilitation in the environment where survivor will live. Moral neutrality is impossible regarding therapy and reintegration of rehabilitated survivors in the society. Objective criticism, not projectivity, of the society instances (national and international) which should have prevented torture is unavoidable in completing the recovery process of a particular victim. As previously
mentioned impossibility of moral neutrality of therapists while they are dealing with torture victim/survivors, it would be essentially amoral to stay publicly and politically neutral regarding the causes of torture.
Legal Definition of Torture
According to of UN the documents, the Convention against Torture and Other, Cruel, Inhuman or Degrading Treatment or Punishment, which was adopted on December 10, 1884 by the General Assembly of the United
Nations, which entered into force on June 26, 1987, torture victim is a individual submitted to 'torture' which is:
1. For the purposes of this Convention, the term "torture" means any act by which severe pain or suffering, weather 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, or 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. It does not include pain or suffering arising only from, inherent in or incidental to lawful sanctions.
2. This article is without prejudice to any international instrument or national legislation, which does or may contain provisions of wider application.
According to the annual at 1960s report from Amnesty International, torture takes place in more then a third of the countries of the world. To this disastrous official proportion that is describing the expansion of torture,
which oppressive governments are using today, we might add the well-known fact that torture takes place "unofficially", often. This additional estimated proportion, together with the general dilatation of torture as a
way of interaction of opposed sides in which one is stronger by position, is illustrating certain major discontents of our civilisation, as Freud would say. Today in 5 of 6 countries torture is being used; this includes Europe.
The Purpose and the Consequences of Torture throughout History The purpose of torture is to destroy the individual, to break down the personality. This way anxiety and terror is spread to the rest of society. When the victim can be described as living dead, then the goal of torture has been achieved.
Most of the methods which torturers use today have been used throughout history. They are physical and psychological. Torture as a process starts by a violent and brutal arrest in the home continues with softening -up
phase which includes unsystematic threats and physical attacks which are, together with always present humiliation, supposed to exhaust a victim physically and psychologically. The physical torture takes place
(systematic beating, sexual, torture, electric torture, suffocation torture, burning, suspension, pharmacological torture, mutilations, and dental torture). Simultaneously, psychological torture takes place including deprivation and exhaustion, threats about torture, disablement, execution and threats against the family members or friends, witnessing the torture of others and humiliation. This all together leaves physical, psychological and psychosomatic consequences at the victims of torture.
But I would like to emphasise one difference between torture in ancient and pre-modern societies and one that takes place in modern and our post-modern time. The important difference is not only in the technical means of
torture (the use of electricity for example), but in the fact that today torturers a more likely to leave the torture victim alive then their ancient colleagues. This is showing the different social aim of tortures today. Their interest is political control and power gained by arousal of terror in the society by torturing a victim, which does not interest them as a person at all. Ancient tortures by torturing individuals who were personally representing the unacceptable and for their power threatening ideas also kept their power, but punishing, as the aim was present.
In classical Greece and Rome, during the Middle Ages, and until the mid-18th century, the judiciary had used torture for dual purposes of extraction confessions from the accused, and as a part of the penalty for
extraordinary crimes. Well described, regarding the reasons, purpose and techniques, is the torture of the Holy Inquisition at the end of 15th century. Gradually the use of torture diminished, so that during the 18th century it was said, that torture was almost non existent in Europe .However, wars, revolutions and executions continued, as we all know, and the violence continued. Therefore, this statement is to be taken with a distance.
My comment, as a psychiatrist who is not a historian but who has some contact with social sciences, is that torture, as we defined it, is a method of choice in those times of history when open conflict is not predominant expression of violent part of human nature, and when one party can not exterminate another one, "just like that" (that happened in history), without being sanctioned by some relevant instance; example is the pressure, political and economic sanctions, of international community on the governments who use torture upon certain group of citizens. By torture those governments achieve almost the same result as if they exterminated the target group, even better one, which is bizarre statement, but near to the real sad state of affairs in today's world.
Anyway we can say that during the W.W.II and after it, torture came into fashion again, in the most literal meaning of the word. It was impossible not to recognise Holocaust survivors as damaged with unforeseeable torture.
The Holocaust is a gross example of torture on the highest scale imaginable. The conceptualisation of medical science, psychiatry and psychology was rather ambivalent in a sense of scientific causality of the observed consequences, although public prevailing humanistic approach was undivided in an assessment that Holocaust was the result of the radical evil. Hannah Arendt described that evil as "evil so deep that it owerfowls any conventional category of sin and defeats attempts to fix responsibility or to imagine a suitable punishment". Herman Kahn's question "Will survivors envy the dead" haunts our time, and expresses the sincere and deep consternation and fear. The shocking experience of Holocaust was followed with world's promise that we will develop the nternational instruments and mechanisms to prevent mass murders, mass torture, genocide and Holocaust in future. We developed the instruments, international bodies that are incarnating declarations, conventions, and statements, but there are certain obstacles in the implementation of agreements that should protect human life, human rights and human dignity. Somehow people incline to repeat old patterns, and they forget easy and
forgive hard, if they forgive at all.
Moreover, this upside-down situation of the twentieth century is complicated with the global integration and numerous local disputes, that altogether appears as a paradoxical splitting of opposed processes, and
fragmented picture which we call World today.
Throughout history it was recognised that various types of events affect the psychological well being of humans. Therefore, Hippocrates wrote about this, and in 1649 Decartes described the psychological impact of trauma
that outlasted the trauma period. Nineteenth century psychiatry, exemplified by Charcot and Janet, also accepted that severe trauma had long-term psychological effect on human beings. In 1889 Oppenheim proposed the concept of traumatic neurosis. During and after the W.W.I many groups reported observations under various headings such as 'war neurosis', 'shell shock', and 'battle fatigue', which emphasised the long-term impact
of external traumatic events on the human mind.
After Freud it became accepted that childhood trauma experienced during certain vulnerable periods can effect person's life permanently. For the subject of this paper, from very fruitful Freud's work I would highlight the theses that childhood trauma is being internalised within the metapsychological structures, causing the internal and external conflicts if repeated in future life. Introjection of traumatic event when person is helpless by position is the main point. Despite the work of Freud and others dominant doctrine during most of the 20th century has been that
psychological events do not cause psychiatric diseases. This doctrine was rooted in classical German medical psychiatry and this point of view included the effect of the extreme psychological trauma of the concentration camps during the W.W.II. It was proposed that if survivors from the concentration camps had symptoms, they were likely to have had problems in their personality structure steaming from trauma during childhood. As a consequence of this attitude no compensation was paid to survivors immediately after the war.
Gradually it became clear that the concentration camp survivors did indeed
have long-term psychological sequelae. Comprehensive work of Yeal Danieli was the indispensable part of various efforts of many concerned about the Holocaust. Robert Jay Lifton initiated by his famous book the discussion of role of physicians in politically motivated torture, its individual consequences and social roots.
Furthermore, no early trauma could be demonstrated in the majority of torture survivors, and above-mentioned dominant doctrine could no longer be upheld. Moreover, it began to be questioned whether psychological trauma
itself could induce such changes without the concomitant effect of the poor physical conditions found in the camps-for example hunger. That was the time when a new group of patients become the matter of medical,
psychiatric, psychologists' and humanitarian concern-group which become psychologically and physically ill due to the impact of external extreme happenings. In the late 1960s Amnesty International managed to focus public
attention on the existence of the torture in the world.
Extensive investigations using the most up-to date medical technology revealed numerous dysfunction, psychological and physical at torture victims, and various studies showed that childhood trauma to the
personality of the victim is not a prere quisite. Consequently concentration camp experience could no longer be reduced to one or multiple factors causing symptoms at the fragile individual.
This was the very important conclusion for the development of the medical and humanistic movement engaged in rehabilitation of victims of torture and violence because it was finally proved that there is no scientific reason
to blame the victim. This new social perception of the victimisation, enabled more appropriate approach to the problem of torture victims/survivors and victims of violence by recognising the significance of the external cause, and by introducing the necessity of external (socio-political) actions upon such causes, apart from individual or group rehabilitation in narrow meaning of the word.
Social Dimension of Victimisation and Rehabilitation of Torture
Victims/Survivors
Certain violations of the social compact are too terrible to utter aloud: this is the meaning of the world unspeakable which is often mentioned in literature about Holocaust, torture victims/survivors and victims of violence today.
Such unspeakable violations are happening daily, media are full of horrifying news from all over the globalised Globe, and on infinite number of professional meetings of various professions the horror is being described and counted in firm numbers which call to some kind of action. But somehow it seems that it is in human nature to assume that someone else is going to initiate the action. After 10 years of my personal participation in numerous meetings on the topic of victims of politically motivated violence and torture I must say that I am shocked with the capacity of my colleagues for mere perseveration and verbigeration, and for the production of statements,
recommendations, papers and books which are circulating in only our close circles, and which are never presented appropriately to the public. I could not avoid association that all that benevolent humanistic machinery
is a self-fulfilling prophecy. It is hard to avoid the question why are we reporting, particularly politically motivated torture, at our humanitarian meetings and our medical meetings if we do not do nothing about the cause. Apart from Amnesty International, London, IRCT, Copenhagen and Physicians for Human Rights, Boston other professional helpers who are witnessing torture and human rights violations are rather shy. They are hard to be seen and hard to be heard advocating the rights of people not to be tortured (except on meetings).
It is even harder to see them or to hear them criticising the instances that are responsible for torture and human rights violations in the country of origin of the (medic al) professionals. This is firstly concerning the reporting of the torture and human rights violations from the newly independent states, formed on the territory of former Yugoslavia. It is typical that, for instance, Croatian professionals report Croatian atrocities accusing the Serbian authorities or minority, and usually pardoning eventual mistakes from the side of Croatian authorities. This
patriotic reporting in scientific journals and on meetings become a custom in the region. Maybe other professional helpers can get by with such "scientific" reporting, but medical professionals can not, regardless of their racial, ethnic or gender characteristic or origin. The reason is that the code of ethics of medical professionals/helpers is more precise and, therefore, less "negotiable" and harder to "adapt" for the daily political purposes. The impotence of helpers to influence disastrous events is especially hard to understand when it comes to medical profession. Physicians can be described in many ways, but the attribute of impotence or powerlessness would not fit into the description of either physicians or their organisations. Physicians are very powerful figures in every society in western culture, and other cultures, too. Their associations, GO and NGO are also very powerful. It is really puzzling how can it be that the whole powerful medical world can not make a unique statement, f. i. concerning the recent disputes on the territory of former Yugoslavia, and say that patriotic behavior of physicians has a limit which is defined my medical ethics. Therefore, if a physician wants to stay the part of international
medical family she/he should respect the medical code of ethics, regardless of the dictate of national political top. She/he can, of course, chose patriotism in a sense of understanding that casualties of "them" are not that tragic or important as "our" casualties. Then she/he should not be a part of medical family any more. She /he can belong only to the ethnic group for which she/he is expressing such unconditional love, which is surpassing the demands of our civilised world and professional ethics, as a citizen which we call nationalistic chauvinist. On the other hand, medical associations, like World Medical Association (WMA) and World Psychiatric Association (WPA) could show that they have more demanding code of ethics for their members then Hague Tribunal (ICTY).
This is one of the most discouraging parts of the whole enterprise described in this paper. Medical professionals or psychiatrists, are not meant to make the world perfect, to arrange it, or to control the social happenings. But as the incarnation of moral demands and ethical codes of the profession they represent on the highest level WMA and WPA could at least make a statement which would mark some behaviour of their members as unacceptable for the medical profession. Such symbolic condemnation of gross human rights violation, done and supported by certain medical professionals who misuse their power in their society, should be sanctioned from WMA and WPA publicly. My proposal is that WMA and WPA should sanction unethical behavior of their members by the cancellation of membership of the national association if the particular national association does not cancel the membership of its troubled member. This symbolic punishment on behalf of powerful part of International Community, which WMA and WPA are, is not going to stop the wars, or violence, or torture, but it is necessary to be done in order to preserve sense of morality in the profession and to prove that, mentioned honourable instances have a reason to exist apart from spending money on themselves. WMA and WPA are not meant
only to develop the scientific level and exchange of scientific data within the profession. They are the moral authorities of the profession, and part of their mandate is to preserve ethical code of the profession
when it is violated; this includes the political misuse of medicine and psychiatry in doing and in scientific reporting.
One thing I have noticed, which I think is important for this matter, is that we are not communicating with our colleagues (professional national associations) whose countries are involved in heavy human rights violations, asking them-demanding to define themselves towards the happening. The protests go to politicians in a certain region who are usually insensitive for moral judgements, ethics, questions of human rights, the rights of minorities and similar notions which are the obstacles in their way of obtaining power. I agree that AI, IRCT, PHR and
other significant international organisations should continue to protest against the governments which are responsible for the atrocities. But this avoidance of questioning the position and attitude and role of the
professionals (in this case medical) in the whole mess is proving my sense that physicians are in every society the untouchable instance which is assumed as moral-without questioning. That is of course a wrong assumption.
Atrocities however refused to be buried. Torture survivors come to us as patients or we meet them in our social group.
They can not be avoided. Conspiracy of silence, as the expression of a need for denial, from the side of individual and from social side, is blocking the healing process and it is enabling the transgenerational transmission of traumatic events to the next generation.
The horror will come out in some way. It can be expressed as health damage of torture victim/survivor, which is usually general reduction of hers/his personal abilities. Individual or group physical and psychological rehabilitation is never completed if the contextual meaning is not given to the traumatic event. Folk wisdom is filled with ghosts who refuse to rest in their graves until their stories are told in a way that makes sense.
Remembering and telling the truth about terrible events are prerequisites both for the restoration of the social order and for the healing of individual victim/survivor. Torture victims/survivors tell their stories in contradictory and fragmented manner, regarding the content and emotions, which often undermines their credibility. When truth is finally recognised, when the story is told and accepted by those who listen (medical personnel, care takers, officials), survivors can begin their recovery. All traumatic syndromes (health damage caused by extreme external events) have some basic features in common, so the rehabilitation and recovery processes also follow a common pathway. The fundamental stages are establishing safety, healing process, which includes reconstructing the
trauma story, and restoring the connection between survivors and the community.
Man made traumas have some common features, which are not seen at the victims of natural disasters. This is especially important for torture victims/survivors. Victims of natural disaster accept it psychologically as the "acts of God" as well as those who bear witness (therapists for instance). Shame and survivors guilt are not leading psychological features of the losses which might be extensive. Witnesses, (society) sympathise readily with such
victims, and actions aimed to diminish the harm of the event are somehow in the compliance with the real effort of the helping side. Recovery is giving encouraging results, and co-operation of all sides is so smooth.
When the traumatic events are of human design, as they are in wars, genocide and torture, there is their devastating effect on a " good matrix" which spares nobody involved. "Good matrix" is corresponding with Ego
ideal, the introjects of good individual and collective believes and memories. Erasing "good matrix" is complicating the psychological situation of a victim/survivor and those who are trying to help her/him.
The dialectics of victim/perpetrator is a complex psychological problem that requires thorough and detailed explanation and it should be, and usually is included in separate chapters on healing and rehabilitation
processes. The matter is that helpers or witnesses of the man made trauma are caught in the conflict between victim and perpetrator. It is morally impossible to stay neutral in this conflict. The bystander is forced to take sides. This is relevant for psychotherapy and for the social perception of the large group.
Supportive attitude helpers have in therapy of survivors. In order to help survivors to become citizens helpers should "take the side of torture survivor" by confronting the instances, which perform, torture and delegate
torturers with their professional knowledge and power. The best position among helpers, regarding the possibilities of successful legal confrontation of the "tortures asylums-authoritarian regimes and oligarchic groups, have medical profession. Unfortunately, we are witnessing that medical profession is not confronting
"tortures asylums". Moreover, there are several examples in last two years that medical profession gave the asylum to the torturers and that it has obstructed justice, under political pressure of the powerful instances, by
the means of false findings with the excuse of false humanism.
These amoral incidents are very dangerous for the medical profession, which is facing many other new challenges of high-tech medicine and bioethics. The role of medicine in global politics and justice is apparent. Medical
profession should serve to people, not to the powerful instances of the establishment, and it should be aware that it is one of the most powerful parts of the establishment with proportional social responsibility.