Psychological torture: Characteristics and impact on mental health

Abstract

Torture has been illegal in most of Europe and the United States for over a century but persisted in other parts of the world. The changing geopolitical landscape has led to its resurgence in recent years. The public rejection of traditional forms of torture that rely on the infliction of physical pain has paradoxically increased the reliance on psychological methods of torture. This critical commentary aims to define and characterize psychological torture (PT) while exploring practical, legal, ethical and therapeutic implications relevant to clinicians and policymakers. Psychological torture comes in a range of forms. It is being increasingly justified and adopted by legitimate authorities in the name of national security. The emphasis on the avoidance of physical pain leads to the assumption that PT does not produce the levels of suffering and harm that are associated with physically violent forms of torture. This same assumption has allowed for the implication of mental health professionals in theorizing and providing legitimacy for the actions of perpetrators. Psychological torture is still poorly defined with limited understanding of its long-term psychiatric impact on those who are subjected to it. The role of mental health professionals in preventing or addressing psychological torture remains ambiguous and needs to be reinforced.

Keywords

Torture psychological torture trauma post-traumatic stress disorder human rights

Introduction

The practice of torture has been illegal in most of Europe and the United States since the 19th century. Until then, torture had been carried out openly, legally and often condoned socially. In the 20th century it became associated with totalitarian regimes and paramilitary groups. Yet, the major contemporary shift in perspective on torture concerns western nation states and their law enforcement agencies.

The study of torture faces the primary challenge of agreeing on a suitable definition. The most pessimistic scholars have gone as far as declaring that a ‘true’ definition of torture is elusive (Kenny, 2010), arguing instead for a better characterization of what constitutes acts of torture (Brecher, 2007). The United Nation’s convention against torture and other cruel, inhuman or degrading treatment or punishment define 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, 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’ (Garcia, 2010, p. 1; UN, 2005). This legal definition has several pitfalls. Firstly, it relies on terms such as the ‘severity of suffering’ and the ‘motivations of the perpetrator’ that are grossly subject to interpretation (Perez-Sales, 2017, p. 3). Secondly, the perpetrator is defined specifically as a representative of the state apparatus at a time where similar acts have been carried out by individuals or groups outside this sphere. Kenny who documented the torture techniques used by Irish Republican Army (IRA) in the course of its long confrontation with the British state proposes the alternative definition of ‘the systematic and deliberate infliction of severe pain or suffering on a person over whom the actor has physical control, in order to induce a behavioural response from that person’ (2010, p. 136).

The political context of the war on terror has led to a relative normalization of acts of torture. oday, state sponsored torture occurs mostly outside of accountable legal structures, conducted by ‘security agents’ in unofficial ‘black’ sites (Einolf, 2007). The ‘upgrade’ of interrogation techniques by the US military and its allies is the practical facet of a broader philosophical re-evaluation of what constitutes torture, how it impacts individuals and how it fits with liberal values. In this context by liberalism we mean a social system that attempts to prioritize the dignity of human beings and respect for their choices. A situation that is in principle incompatible with torture (Luban, 2007).

Characteristics of psychological torture

Torture is considered to include a physical and psychological component because the mind and the body are thought to be inseparable (Perez-Sales, 2017, p. 7). Imposing extreme conditions on bodily functions will inevitably disrupt the mind. Sleep deprivation, starvation or accumulation of white noise are all techniques that rely on this principle. The difficulty in separating the physical from the psychological deterred some authorities from delineating a clear boundary between the two forms of torture. An additional challenge is that most sustained effects of physical torture are also primarily psychological (Reyes, 2007).

According to Perez-Sales psychological torture (PT) is a term of exclusion where a set of practices are used ‘to inflict pain or suffering without resorting to direct physical violence’ (Center for the Study of Human Rights in the Americas (CSHRA), 2005). On the one hand, PT can refer to torture techniques that do not aim to hurt the body or leave physical marks. These have included death threats, extensive solitary confinement, forced to witness torture of others, deprivation of sensory stimuli, sexual humiliation or exploitation of already established psychological vulnerabilities such as phobias (Hooberman et al., 2007). On the other hand, it can designate the psychological objectives of all forms of torture, ‘to break down the detainee psychologically’ (Kramer, 2010, p. 1) or to ‘to disrupt profoundly the senses or the personality’ (Garcia, 2010, p. 5). The organization Physicians for Human Rights attempted to define PT as ‘severe mental pain or suffering caused by the threat of or actual administration of procedures calculated to disrupt profoundly the senses or personality’ (Allen, 2007). Severity is purely subjective and depends on parameters such as age, gender, health or religious beliefs (Gray & Zielinski, 2006). The set of legal memoranda known as ‘Torture Memos’ propose another definition of psychological suffering which is the infliction of ‘severe mental pain or prolonged mental harm for substantial duration lasting months or even years’ (Cole, 2009, p. 153). This implies that the process must be substantial, leave no physical scar, break down the detainee psychologically and disrupt the sense of identity (CSHRA, 2005; Perez-Sales 2017; Reyes, 2007; UNHCR, 2005). This definition disqualifies intensive yet short-lived traumatic abuse despite it being associated with long term psychiatric pathology. Finally, Reyes (2007) denotes that several aspects must be taken into consideration in defining PT including what was done to the person, the overall situation and the individuals’ vulnerabilities. The conditions of incarceration can by themselves function as elements of psychological torture. Extreme overcrowding, extreme temperatures, extreme lighting conditions, sensory deprivation are also examples of such techniques that require very little logistics and skills. Deprivation from the most basic facilities for sleep and hygiene can also be a source of distress, especially when maintained over a long period of time coupled with uncertainty over one’s fate. An abnormal environment is defined as ‘one to which we are not optimally adapted but can accommodate through the development of coping strategies’ (Leach, 2016, p. 12). It encompasses intense stimuli (light, sound, smell) that can disrupt an individual’s psychological integrity or personality. Polar explorers, deep sea divers or astronauts expose themselves by choice whilst prisoners and victims of psychological torture are forcibly placed in such environments. The involuntary aspect of exposure and the resulting loss of control is key to understanding the dramatic level of distress it may generate (Leach, 2016). More intimate knowledge of individual vulnerabilities can lead to their exploitation.

Techniques that fall under psychological torture

Psychological torture methods can be standardized or designed based on individual profiling of the subject. The most popularized techniques include sleep deprivation, solitary confinement, fear and humiliation, use of threats and phobias, forced nudity, sexual and cultural humiliation (Borchelt & Pross, 2005). The primary purpose of these was not the extraction of information directly, but subjugation by bringing about ‘a loss of self-continuity and self-sameness; a loss of coherent and cohesive sense of self; feelings of narcissistic injury and a fragmentation of the ego and identity processes’ (Wilson, 1989).

Prolonged isolation took place in Abu Ghraib prison in Iraq where detainees were held for 23 hours a day in a small concrete cell with no exposure to daylight. Short-term isolation was found to cause an inability to concentrate, disorientation in space and time and loss of motor coordination. Sleep deprivation was used as an interrogation tactic in Afghanistan, Iraq and Guantanamo. One reported method for keeping detainees awake involved shackling the detainee in a standing or seated position with his hands attached to the ceiling by a long chain and his feet to the floor (O’Mara, 2015, p. 153). The maximum permissible length of sleep deprivation was 180 hours, after which detainees were allowed to sleep for eight uninterrupted hours (Cole, 2009, p. 167). Sleep deprivation was found to facilitate interrogations (O’Mara, 2015, p. 154); however other studies revealed that it was associated with false and inaccurate memories of past events because it damages memory, and logical reasoning (Frenda et al., 2014, 2016). Nobel laureats Solzhenitsyn and Sternberg, reflecting on their Soviet internment in his 1975 ‘Gulag Archipelago’ wrote that ‘a person deprived of sleep acts half-unconsciously or altogether unconsciously so that his testimony cannot be held against him’ (p. 112).

Forced nudity, sexual humiliation and violation of cultural and religious beliefs were used systematically (Borchelt & Pross, 2005; Vorbrüggen & Baer, 2007). Female interrogators at Guantanamo, having acquired knowledge on the Muslim faith, were known to rub lotion on prisoners’ arms during Ramadan, a month when physical contact with a woman is particularly prohibited. Detainees were forced to look at pornographic pictures and videos while being subjected to degrading comments over their sexuality. According to the Center for Victims of Torture (CVT) in Minnesota, sexual humiliation aims to create a power difference between prisoner and interrogator, by stripping the victim out of his identity, inducing shame and establishing constant physical and sexual assaults (Agger, 1989). Forced nudity defies the most basic right of privacy and reinforces the control of the interrogator over the victim’s body and mind. In several contexts, US personnel were known to deliberately impose sexual violations on Arab Muslim male inmates with the intention of leaving them feeling mentally degraded and wounded in their masculinity (Punamaki, 1988).

Psychological torture and ‘Torture Lite’

The signing of treaties and conventions (e.g. U.N. Convention Against Torture), the establishment of watchdog institutions (e.g. European Committee for the Prevention of Torture, U.S. State Department Human Rights Bureau), and increased media scrutiny have not succeeded at eradicating the use of torture. Paradoxically, the scrutiny of international regulators and human rights organizations have led to an increase in the use of ‘stealth technology’ in torture (Rejali, 1994).

As an alternative to the term of psychological torture, ‘torture lite’ is the politically correct nomenclature when referring to techniques that do not leave physical evidence. Forced standing, sleep deprivation, personal humiliation, and isolation are all part of its arsenal (Cunniffe, 2011). This ‘clean torture’ is favoured by liberal democratic governments who argue for its legitimate use in circumstances that involve intelligence gathering or fighting terrorism (UNHCR, 2005). The moral distinction between physical and psychological torture methods is based in part on the belief that a proportional correlation exists between the degree of physical harm inflicted on a victim and the level of suffering. This misconception is implicitly encouraged by some authorities with the dual aim of appeasing the public’s natural rejection of state violence and protecting it from the sense of communal ‘moral distress’ typically experienced by perpetrators or facilitators of ethically questionable behaviour. The motivation behind these efforts to avoid physical violence is driven by concern for the wellbeing of the perpetrator rather than the victim. They are also driven by the need for a level of efficiency and discretion that were no longer afforded by traditional torture methods (Wolfendale, 2009). One main advantage of psychological torture from the torturer’s perspective, is that it leaves no tangible evidence of it ever taking place. The absence of physical scars, injuries or bruises makes it harder for the victim to prove his case in judicial settings where he only has his testimony of traumatic memories and psychological suffering to share. Victims of psychological torture who develop long term mental health issues face a second obstacle: the general public suspicion and the stigma faced by individuals with mental disorders. These hurdles are likely to reduce the likelihood of acts of psychological torture being reported, especially when are not paired with physical pain-inducing torture.

The psychiatric consequences of psychological torture

Psychological Torture often leaves the victim with serious health consequences (Borchelt & Pross, 2005). Short and long-term effects include memory impairment, somatic complaints such as headaches, avoidance, nightmares, severe depression, feelings of humiliation and post-traumatic stress disorder. Some detainees in Guantanamo reported incoherent speech, disorientation, paranoia and delusions.

The association between exposure to torture and the prevalence of psychiatric disorders has been studied using the learning theory model (Gray & Zielinski, 2006). This model suggests that torture will have more impact if (1) it incorporates frequent exposure to unexpected or uncontrollable stressors and (2) if it includes lack of control over the aversive stimuli leading to the helplessness state. As a result, the traumatic impact of torture will be proportional to the unpredictability of the techniques used, and the feeling of helplessness experienced by the victim (Başoğlu et al., 2007). These same parameters were found to be associated with poor long-term psychological functioning (Gray & Zielinski, 2006). Several studies have explored the association between the different types of torture and mental health symptoms. Findings revealed that the frequency of psychological and physical torture or the combination of both increased symptoms of PTSD, but the extent of that association is difficult to establish (Punamäki et al., 2010). In a study conducted on asylum seekers in Australia, the rate of PTSD was 36.8% and included those who were exposed to traumatic events such as torture (Basoglu et al., 2001). Anxiety and depression are frequent comorbidities as well. Controlled studies in refugees show a greater risk of developing a mental health disorder in those subjected to torture (De Jong et al., 2001). In a cohort of Somali refugees, the risk was six times higher (Jaranson et al., 2004). Two reviews and meta-analysis of post-war studies concluded that torture and cumulative trauma were strong predictors of PTSD (Johnson & Thompson, 2008).

Interestingly, questions remain on the extent to which torture was responsible for psychiatric morbidity when other experiential confounders are accounted for. In a study on Iraqi refugees living in the United States, Kira et al. (2006) found that torture was not a significant predictor of PTSD after controlling for other life events. The latter finding was consistent with that of Hollifield et al. (2011) on Kurdish refugees in Colorado revealing that torture itself was not an independent predictor of PTSD. Post settlement stressors like poor socioeconomic status and the absence of social support were found to be important contributing risk factors (Abu Suhaiban et al., 2019). Additionally, resulting chronic injuries also mediated the relationship between torture and PTSD among survivors (Rasmussen et al., 2007). Physical injuries and the presence of a disability may act as a constant reminder and a permanent symbol of the trauma (Choi et al., 2017). Studies conducted on South Korean torture survivors revealed a high prevalence rate of psychological disorders including 33.3% for PTSD and 41.6% for major depressive disorders (Choi et al., 2012). A study examining the relationship between types of torture (physical, psychological, deprivation of basic needs and sexual) and long-term development of PTSD symptoms revealed that physical torture in itself did not predict long term post-traumatic symptoms. However, psychological torture and deprivation of basic needs explained PTSD symptoms in torture survivors (Gorman, 2001). This evidence replicates findings that psychological torture carries an equal, sometimes stronger association with PTSD than physical torture (Basoglu et al., 2001).

Wolfendale argues for the severity of an act of torture not to be measured by physical scars but by the suffering it caused, and how it left the individual feeling ‘isolated, overwhelmed, terrorized and humiliated’ (Wolfendale, 2009, p. 50). Başoğlu et al. (2007) conducted a study to compare long-term effects of isolation and forced standing with the effects of physically violent techniques in 279 torture survivors from Sarajevo, Serbia and Rijeka. Results revealed that ‘torture lite’ did not differ from physical torture in terms of the level of mental suffering it caused. The latter was consistent Conroy’s assessment of who fourteen Irish men who were subjected to sleep deprivation, forced standing and noise bombardment by British forces and were found to display severe traumatic sequalae (Conroy, 2001). These techniques were also noted to induce a state of psychosis in some subjects and were implicated in the death of inmates. An Afghani prisoner froze to death after being left in a room naked with no blankets, and another died after being beaten and asked to stand in a stress position (Wolfendale, 2009). In the absence of validated information on what individuals have been subjected to and on the consequences on their wellbeing this debate is unlikely to be resolved in the near future.

The Istanbul Protocol was established to standardize the assessment and documentation of the impact of torture on victims (UN, 2004). It includes neuropsychological tests were found to clearly distinguish between damages resulting from organic brain injury and those linked to psychological trauma (Mollica, 2011). Testing can also determine the impact of torture on attention, memory, learning capacities, psychomotor functions and abstract reasoning (Perez-Sales, 2017). However, the potential use of neuropsychology for assessment and monitoring of torture aftermath requires further exploration.

The involvement of mental health professionals in psychological torture

Effective design and implementation of advanced psychological torture techniques require an understanding of neuropsychological processes, psychopathology and human resilience. It is on that premise that mental health professionals have often been asked to contribute to law enforcement efforts or counter-terrorism through profiling of suspects and also in breaking them psychologically. Stanley Milgram emphasized the benefits of this brand of psychological research, arguing that ‘if we have sufficient knowledge of the psychology of obedience, then this will allow us to resist malign authority’ (De Vos, 2011, p. 292). Milgram envisaged an ambiguous role for psychologists, as part of the ‘clean-up crew’ tasked with alleviating the consequences of torture. De Vos (2011) was more categorical in his proposition for ‘getting the psychologists that are working for the detainers out and bringing psychologists who are working for the detainees in’ (p. 294). In his view and that of the coalition or ethical psychology, psychologists had to choose a side, exclusively that of the victim.

It is known that healthcare personnel, including psychologists, have historically been involved and collaborated in torture (Suedfeld, 1990). After the attacks of 9/11, the Bush administration formally authorized the ‘enhanced interrogation’ of detainees suspected of links to the attackers and the global Islamist terror network. The unprecedented security threat became an opportunity for applying interrogation techniques sophisticated over decades by the Central Intelligence Agency (CIA) (McCoy, 2007; Olson et al., 2008; Soldz, 2011). The Debility, Dependency, Dread (DDD) paradigm is a set of techniques that aim to systematically undermine the individual’s sense of self. Low-tech methods include sleep deprivation, isolation, sensory distortion, sexual and cultural humiliation and self-inflicted pain (stress positions). The subjected victim to unpredictable combinations of these techniques is left feeling hopeless, helpless and completely dependent on the whims of the torturer. Evidence is mounting on the role played by psychologists in planning, supervising and conducting interrogations sessions where these techniques were used extensively. Others were contracted to train CIA interrogators in their use (Benjamin, 2007; Mayer, 2007).

The most documented contemporary example remains the role of mental health professionals at Bagram Airbase, Camp Guantanamo and the Abu Ghraib prison in the wake of the US wars in Afghanistan and Iraq. Dedicated Behavioural Science Consultation Teams (BSCTs) formed by the US military had the duty to closely monitor interrogations and advise on how to safely and effectively ‘break’ a detainee (McCoy, 2007). Psychologists were tasked with devising effective strategies to induce temporary disorientation and paranoia in human subjects. Their recommendations could be as simple as frequent cell reassignment, mixing sane inmates with disturbed, dysregulate or aggressive individuals and turning prisoners into informants to create a climate of constant mistrust and self-doubt. Personal intimate information and clinical records highlighting psychological weaknesses, sensitivities or even phobias were also brought out during interrogation sessions. More concerning, psychologists were suspected of collecting scientific data and conducting behavioural research on detainees without their consent in violation of the Nuremberg Code and Geneva Convention.

Ethical dilemmas and institutional response

While such identification with the perpetrator may be deemed shocking to most mental health practitioners, Olson et al. (2008) suggest similarities in the psychological processes at play in the Stanley Milgram ‘Obedience to Authority’ experiment and the Abu Ghraib abuse sessions. The enforcers of torture may have been influenced by the status of the psychologists that infers credibility, authority but also goodwill. What is more concerning is that the latter acted as if their clinical or scientific standing coupled with their physical absence from the torture scene sanctioned their role in causing human suffering.

The involvement of health professionals, including psychologists in abusive interrogations led the American Psychological Association (APA) (2005) to form a Presidential Task Force on Psychological Ethics and National Security (PENS). Its initial position came in an ambivalent statement. Psychologists were deemed to ‘have a valuable and ethical role to assist in gathering information that can be used in our Nation’s and other nation’s defence’ (p. 2). Nonetheless such a role should entail delicate balance of ethical considerations, where psychologists must ensure to maintain a safe and ethical environment for participants (APA, 2005). In theory, psychologists were limited to the role of ensuring interrogations by third parties were ethical, legal, and effective. In practice, much was left to the subjective good sense of the psychologist. Although later the APA acknowledged the situation as a ‘stain on our collective integrity’ (Kaslow & McDaniel, 2015) critics believe that this backtrack was too little too late and deserved a more radical reflection within the organization (Pope, 2018); The American Psychiatric Association (2006) was more categorical from the onset regarding the involvement of psychiatrists in interrogations of so-called terror suspects at Guantanamo in ‘alleged violations of professional medical ethics’. It thus prohibited the participation of psychiatrists in intelligence-lead interrogations in a statement released in May 2006: ‘No psychiatrist should participate directly in the interrogation of person[s] held in custody by military or civilian investigative or law enforcement authorities, whether in the United States or elsewhere’ (Halpern et al., 2008, p. 8). Similarly, the American Medical Association (2014) stated, ‘Physicians must oppose and must not participate in torture for any reason’.

Recommendations for addressing psychological torture

Several professional organizations have issued statements asking their members not to ‘participate in, or otherwise assist or facilitate, the commission of torture of any person’ (APA, 2006, p. 1). In addition, these associations encourage members who become aware of torture practices to report them, such as one reports physical abuse. This should be preferably with the victim’s consent but may be justified regardless. Knowing that this position may sometimes expose health professionals to harassment or coercion, the World Medical Association called through the Declaration of Hamburg professional national associations and the international community to support and protect ‘in the face of threats or reprisals resulting from a refusal to condone the use of torture or other forms of cruel, inhuman or degrading treatment’ (WMA, 2007, p. 1).

When providing medical or mental health services to detainees in prisons, military facilities or detention centres, the absolute primary obligation of the clinician should be the wellbeing of the detainees. This should be enshrined in contractual agreement at both institutional and individual levels. Disclosure of information on mental health should remain privileged and not be disclosed to the interrogator directly or indirectly, unless in the best interest of the detainee. More generally, mental health professionals should be educated in the principles, consequences and treatment of the trauma arising from psychological torture. This awareness should be maintained through continuing professional development in health, human rights and legal framework regulating their involvement.

Health providers are often caught in a difficult situation between their duty to their patients and their obligations to the state (World Medical Association (WMA), 1975). Advocacy efforts are critical to either change the laws that allow these practices or to deter less scrupulous professionals from participating. One prime example is the relative success of advocacy campaigns done by physicians’ group in Egypt against FGM, and in Turkey against virginity exams (Amon, 2010).

Conclusion

The use of psychological torture is illegal under the Geneva Convention laws (Borchelt & Pross, 2005). Despite the prohibition of torture in international law, the practice persists (Gilligan & Nesbitt, 2009). The increased reliance on psychological techniques to extract information from prisoners is driven by the attempts of authorities in liberal democracies to balance efficiency with social acceptability and legal boundaries. Many survivors experience a range of psychological symptoms that are not always accounted for through standard assessments. The mental health professions have an important role in identifying, preventing and addressing psychological torture.

Footnotes

Authors’ note

The authors alone are responsible for the content and writing of the article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Joseph El-Khoury

Andres Barkil-Oteo

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