Torture Journal Vol 27 No. 2 2017 by IRCT International Rehabilitation Council for Torture Victims

Jour nal on Rehabilitation of Torture Victims and Prevention of Torture

TORTURE â&#x20AC;&#x201C; VOLUME 27, NO 2, 2017 VOLUME 27, NO 2, 2017, ISBN 1018-8185

2017

TORTURE 2

TORTURE Journal on Rehabilitation of Torture Victims and Prevention of Torture Published by the International Rehabilitation Council for Torture Victims (IRCT), Copenhagen, Denmark. TORTURE is indexed and included in MEDLINE. Citations from the articles indexed, the indexing terms and the English abstracts printed in the journal will be included in the databases Volume 27, No 2, 2017 ISBN 1018-8185 The Journal has been published since 1991 as Torture – Quarterly Journal on Rehabilitation of Torture Victims and Prevention of Torture, and was relaunched as Torture from 2004, as an international scientific core field journal on t orture Editor in Chief Pau Pérez-Sales, MD, PhD Guest Editor – (jointly edited the special section: In the name of the war on terror) Michelle Farrell, BA, LLM, PhD Editorial Assistant Nicola Witcombe, MA, LLM Editorial advisory board S. Megan Berthold, PhD, LCSW Hans Draminsky Petersen, MD Jim Jaranson, MD, MA, MPH Marianne C. Kastrup, MD, PhD Jens Modvig, MD, PhD Duarte Nuno Vieira, PhD, MSc, MD Önder Özkalipci, MD June C. Pagaduan-Lopez, MD José Quiroga, MD Nora Sveaass, PhD

Contents Editorial

Pau Pérez-Sales, Editor in Chief

Scientific Articles

Can disability predict treatment outcome among traumatized refugees? Sabrina Friis Jørgensen, Mikkel A. Auning-Hansen, Ask Elklit 12 Detainees' perception of the doctors and the medical institution in Spanish police stations: An impediment in the fight against torture and ill-treatment Hans Draminsky Petersen, Benito Morentin 27 Special Section: In the name of the war on terror

An account of ‘Life after Guantánamo’: a rehabilitation project for former Guantánamo detainees across continents Polly Rossdale, Katie Taylor 47 Obstacles to torture rehabilitation at Guantanamo James Connell, Alka Pradhan, Margaux Lander

The United States Supreme Court Case Ziglar v. Abbasi and the severe psychological and physiological harms of solitary confinement Eric Ordway, Jessica Djilani, Alexandria Swette 79 Perspectives

Torture without physical pain: Inside cell 24 of the special wing for political prisoners-Evin prison (Iran) Hasti Irani 88 Solitary confinement, Section 350 Evin prison in Tehran S. M. Khodaei 96

Morris V. Tidball-Binz, MD Language editing Monica Lambton, MA, BA Correspondence to IRCT Vesterbrogade 149, building 4, 3rd floor, 1620 Copenhagen V, Denmark Telephone: +45 44 40 18 30 Email: irct@irct.org Subscription www.irct.org Price: EURO 50 or DKK 375 per year. www.irct.org/Library/torture-journal.aspx. The journal is free of charge for health professionals. The views expressed herein are those of the authors and can therefore in no way be taken to reflect the official opinion of the IRCT. Front page: Mogens Andersen, Denmark Printed in Denmark by Scanprint a/s, Horsens, Jylland

Obituary

Professor Bent Sørensen Henrik Marcussen, MD, DMSc

103

Book review

Combating Torture and other Ill-Treatment: A Manual for Action By Amnesty International Pau Pérez-Sales 107 Letters to the Editor

Literature reviews are not all the same Amanda C de C Williams 109 Public perception does not accurately reflect resources available to Survivors of Torture in the United States Alison Burke 111

1 EDITORIAL

Drawing the fine line between interrogation and torture: towards a Universal Protocol on Investigative Interviewing Pau PĂŠrez-Sales, MD, PhD, Psych*, Editor in Chief

*) SiR[a] Centre, GAC Community Action Group and Hospital La Paz, Spain. Correspondence to: pauperez@arrakis.es

tional perception of what amounts to torture. This is probably linked to the low level of recognition that psychological torture continues to have. Besides, the Istanbul Protocol does not include interrogation as part of torture within a defined category (United Nations High Commissioner for Human Rights, 2004) What is ethical and admissible in obtaining information from a detainee? The distinction between interviewing (asking the suspect for her version of the offence) and interrogation (accusatorial strategies designed to elicit a confession, which is the only acceptable end of the encounter) is an important one. While interrogations sometimes follow procedures and regulations, there remains a lack of transparency in many countries, and coercive interrogation is still the norm for many detainees that are deemed a menace. Coercive interrogation Coercion happens when someone is deprived of his will and forced to act against himself. Coercion is a relational variable subjected to cultural and historical oscillations (Moston & Fisher, 2008). Any interrogation that coerces the detainee and deprives him or her of his freewill potentially enters into the realms of ill-treatment or torture. Police manuals reflect the belief that interrogation and torture are entirely separate spheres. However, an

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Interrogation is an essential component of a comprehensive view of torture and deserves special reflection. In interrogational torture, physical and psychological techniques serve the purpose of creating the physical, cognitive and emotional exhaustion in the detainee considered necessary for the successful questioning of a potential source of information. Interrogation can, at the same time, be conducted in a way that deepens the effect of torturing methods and environments when the interview is carried out in a way that fosters cognitive and emotional exhaustion, leading to breakdown (PĂŠrez-Sales, 2016). Interrogations follow procedures and regulations, but in most countries there is a lack of transparency and information. Academia has only recently begun to do systematic research on interrogation and interviewing techniques (Walsh, Oxburgh, Redlich, & Myklebust, 2017; Intelligence Science Board, 2006; Meissner, 2012; Rassin & IsraĂŤls, 2014) to prove effects beyond personal opinions. Coercive interrogation is often noteworthy by its absence in the debate on torture and perhaps this is because it can be tricky to address; it does not fit squarely in the tradi-

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interrogation could be considered torture according to the UN Convention against Torture if it induces severe psychological suffering or pain for a stated purpose, namely, giving information or self-incrimination. That being so, states have a duty to ensure that effective measures are taken to prevent interrogation amounting to torture and ill-treatment. This would include, for example, adequate investigation into particularly wrongful convictions and the role ill-treatment or torture has played during the interrogation, eventually making it possible for interrogators to be held accountable. Coercion is linked to interview strategies which employ manipulative dialogue, deception, false evidence and trickery, maximisation of responsibility or charges, false minimisation of responsibility or false promises of leniency (Table 1). The fact is that in most countries these are seen not only as acceptable, but as complex and valued skills to be acquired in the training process of an investigator (Forrest & Woody, 2010; Inbau, Reid, Buckley, Jayne, & Jayne., 2013; Kostelnik & Reppucci, 2009). As Inbau (2013 p. xii) puts it: “psychological tactics and techniques that may involve trickery and deceit; they are not only helpful but frequently indispensable in order to secure incriminating information from the guilty or to obtain investigative leads from otherwise uncooperative witnesses or informants”. Research shows that accusatorial methods obtain slightly more confessions than information-gathering methods, but the information is much less reliable and it is associated with an unacceptable increase in false confessions. This leads to erroneous convictions because, once the person has made a self-incriminating statement, it will almost invariably be accepted as unquestionable proof by judges and juries in spite of eventual allegations of torturei (Forrest & Woody, 2010).

EDITORIAL

Table 1: Main methods used in coercive interrogation I n coercive interrogation, the interrogator: • Only accepts the possibility that the detainee is guilty and refuses to accept anything that goes against this hypothesis. This has been decided in the fact-finding and pre-interview phase. The interrogator does not want to listen to what the detainee has to say, only to lead him or her to recognise his or her responsibility. • Tells the detainee that there is ‘absolute certainty’ that the detainee committed the alleged offence and that there is sufficient incriminating evidence (or confessions by witnesses or other detainees). If necessary, the interrogator lies. • Does not allow the person to make any denial and cuts off interventions that do not go in the desired direction. The detainee is only allowed to say things which are in line with the desired direction. • Exhaustion, argumentation, emotional manipulation or any other tactics deemed necessary are employed. • Uses different ‘acting’ approaches (friendly/ unfriendly, among others), in theatrical strategies to manipulate the detainee’s will. • Exploits personal information and detection of potential feelings of shame and guilt related to the detainee’s social network or to personal mattears. • Presents an alternative question in which both options are incriminating following hours of interrogation and when the person is extremely tired, confused and wants to end interrogation at any price.

One of the biggest achievements in the fight against illtreatment of detainees is when the UK following the introduction of the Police and Criminal Evidence Act 1984 (PACE), required the audio-taping of all police interviews with suspects, a measure later adopted in Norway and other countries. In practical terms, this means that courts are able to apply the exclusionary rule and dismiss evidence when they take the view, by considering the tape, that the interrogation was coercive, and thus inadmissible.

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skilled approach to interviewing terrorists in an operational field setting. This was confirmed for a subsequent analysis of 181 police interrogations with international (Al-Qaeda and Al-Qaeda-inspired) paramilitary, and right-wing terrorists. The study showed that adopting an adaptive rapport-based interrogation style in which suspects are treated with respect, dignity, and integrity is the most effective approach for reducing suspects’ use of passive, verbal, and no-comment counterinterrogation tactics (Alison et al., 2014). A retrospective study with 100 convicted offenders showed a strong correlation between cooperation and confessions and a humanitarian interviewing score (Snook, Brooks, & Bull, 2015). Granhag, Kleinman, & Oleszkiewicz (2016) have empirically tested the efficacy of the so–called Scharff method (an empathetic method following the name of a friendly and successful German Luftwaffe interrogator) when compared to a direct accusatorial approach. The results seem to be consistent also in collectivistic societies like Japan (Wachi, Watanabe, Yokota, Otsuka, & Lamb, 2016). In summary, there is a wealth of recent experimental research, some of it naturalistic studies in real field situations that show that empathetic and respectful interviewing is not only more ethically acceptable, but more efficient than coercive interrogation. From the interrogator’s point of view

Goodman-Delahunty, Martschuk, & Dhami (2014) propose classifying interrogation methods in legalistic, physical, cognitive and social strategies that can be either coercive or non-coercive (Table 2). They performed a retrospective study with 64 interrogators and 30 “high-value” detainees from five countries describing specific interrogator-detainee interactions according to the above categories. The accusatorial approach

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State of the art: the evidence against coercive interrogation Over and above the ethical issues surrounding coercive interrogation, there is an increasing body of evidence supporting the use of Investigative Interviewing. Different experimental paradigms in social psychology using students or volunteers have shown that an information-gathering approach yields more relevant information than an accusatorial approach and leads to more diagnostic impressions by third party observers (see for instance Evans et al., 2013). Positive (praise) and negative (deprecation) emotional approaches to interrogation are more efficient than a direct, accusatorial approach (Evans et al., 2014). Also, a series of complex observational studies using a dynamic-interactive approach and content analysis of videorecorded interactions has shown that suspect cooperation was positively influenced by rapport and relationship building techniques, though it was negatively impacted by direct presentation of alleged evidence and confrontation/competition. Moreover, the dynamic, negative effects of confrontation/competition approaches lasted for up to 15 minutes compromising all of the interview that followed (Kelly, Miller, & Redlich, 2016). Importantly, in a specific study analysing 418 video interviews with 58 convicted terrorists, Alison, Alison, Noone, Elntib, & Christiansen (2013) with a multidimensional measure of strategies, interactions and outcomes, present a structural equation model revealing that motivational interviewing was positively associated with adaptive interpersonal behaviour from the suspect’s side, which, in turn, increased interview results, and exactly the opposite for even minimal expression of maladaptive interpersonal interrogator behaviour. The study provides a unique validated analysis of the benefits of a rapport-based, interpersonally

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Table 2: Classification of strategies in coercive and non-coercive interrogation Strategy

Coercive

Non-coercive practices

Legalistic

Accusatorial, guilt-presumptive, maximization, minimization

Information gathering, open-ended questions, avoid pre-judgment

Physical

Isolation, restraints, extreme temperatures, assault

Refreshments, soft furnishing, breaks

Cognitive

Confront with evidence, deceive about evidence, surprise

Present evidence for confirmation, explanations, transparent process

Social

Intimidation, threats, hostility

Rapport, reciprocity, friendliness, respect, consideration

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Source: Goodman-Delahunty, Martschuk, & Dhami (2014)

was positively correlated with physically coercive strategies and negatively with forms of social persuasion. Detainees were more likely to disclose meaningful information in response to social strategies and earlier in the interview when rapport-building techniques were used. They were less likely to cooperate when confronted with evidence. Disclosures were also more reliable and complete in response to non-coercive strategies, especially rapportbuilding and procedural justice elements of respect and voice. Physical coercion, intimidation and deception were reasons cited for providing false information both by interrogators and detainees. Similar results were obtained in a survey commissioned by the task force that led to the creation of the High-Value Detainee Interrogation Group (HIG) by Obama’s administration (Russano, Narchet, Kleinman, & Meissner, 2014) with 42 highly experienced military and intelligence interrogators. The conclusions are quite in line with the well-known qualitative study with a focus group of veteran interrogators by Arrigo and Wagner (2007). In fact, the US Senate Intelligence Committee Report on CIA’s detention and interrogation program (CIA, 2014) concluded that “the CIA’s use of its enhanced interrogation techniques was not an effective means of acquiring intelligence or gaining cooperation from detainees” (p. 3).

Why, then, if there is such overwhelming evidence that investigative interviewing yields better results at less emotional and political costs, is coercive interrogation in most countries the norm? Damian Corsetti, a former interrogator at Bagram (Afghanistan) and Abu Ghraib (Iraq) in his memoires (Pardo, 2014) explains that inappropriate and coercive interrogations are the result of lack of training, group pressure and imitation of others in the use of physical and psychological violence, pressure from headquarters for daily reports with fast positive results linked to personal characteristics of the interrogator (a sense of heroism, a sense of omnipotence and power, perception of immunity and full legal coverage if needed, among others) (Pérez-Sales, 2016). While Corsetti’s justifications represent an extreme environment for interrogators and not the usual law-enforcement environments, it gives an insight into lower-level practice and can help us to understand why coercive interrogations are still widespread. As veteran interrogators recognise, when the interrogator is under pressure with a detainee considered of high value, investigative interviewing demands more effort and control. Different naturalistic and experimental research models have shown what can be called the high confidence/low accuracy combination. Interrogators can rely on their perceived

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of US residents found that the desire for harsh interrogation is largely isomorphic with the desire to punish, and that both effects are mediated by the perceived moral status of the target, but not the perceived effectiveness of the interrogation (Carlsmith & Sood, 2009). So, are we seeking information or revenge? The stress of interrogation

Interrogation is a stressful experience in itself. The subject usually feels high levels of anxiety and fear because of the conditions of detention (even if they are not harsh conditions), isolation (including being alone with one’s thoughts), lack of control and uncertainty about what will happen next, how long the situation will last and the potential consequences. This can clearly impair the subject’s ability to remember, to think clearly and logically, and to make proper decisions. Thus, the experience of interrogation is not a neutral encounter between two people, even under normal conditions. Claiming innocence is also not easy. Neurophysiological experimental studies have shown in innocent subjects the significantly higher physiological costs of defending their innocence as compared to groups of guilty and innocent people that choose to “confess” (Guyll et al., 2013). Exhaustion encourages the detainee to believe in promises of leniency and minimisation or maximisation tactics and the false idea that the justice system will in the end recognise innocence and not take into account the false confession. Madon,Yang, Smalarz, Guyll, & Scherr (2013) have shown in a series of experimental studies how the length of the interview (even the expectation of length) results in short-sighted decisions to confess, irrespective of whether the subject is innocent. Davis and Leo (2012) have developed a model that links basic routine elements of a law-enforcement interrogations to confessions called the IBRD (Interrogation-Related

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unique capacity to distinguish when a detainee can provide useful information (Costanzo & Gerrity, 2009). If they are confident but wrong in their judgment that a suspect is lying, they are likely to turn to coercion and ill-treatment as a means of forcing a suspect to tell the “truth.” A review of studies has recently shown that police officers trained in the use of coercive interrogation (and thus assuming that a suspect is guilty as a departing point for the interrogation) tend to assume there is more deception and lies where there are none. Stressful and high-working memory conditions exacerbate misattribution errors in interpreting suspects’ non-verbal and verbal behaviour (Kleider-Offutt, Clevinger, & Bond, 2016). In coercive interrogation, the fact is that it is impossible to distinguish true from false information. It is almost impossible to know when to stop interrogation and decide that silence is due to lack of information and not resistance to cooperate and thus, to escalate to ever more coercive tactics ending in torture. The importance of regulation in this area is also emphasised by the public’s apparent willingness to accept behaviour which is contrary to human rights. There appears to be a widespread assumption that detainees are by virtue of their status guilty and thereby deserve what they get, which is likely to be reinforced by popular culture and media (Flynn & Salek, 2012; Gronke et al., 2010; Homant, Witkowski, & Howell, 2008; Miller, 2011; Thomas, 2011). To cite one particular study, after the Madrid train bombings in March 2004, 66% of US-citizens supported not allowing suspects to sleep, 57% hooding for long periods of time and 38% withholding food and water (Washington Post, 2004). All of these are considered key elements in inducing a false confession (Davis & Leo, 2012). Choosing a hard interrogation style seems more an issue of retribution that efficiency. An experimental study conducted with a broad national sample

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Regulatory Decline) which proposes that a person’s self-regulation capacities must remain intact in order to confront stressful situations. In their experimental model there are three situations in particular (emotional overload, sleep deprivation and glucose deficiency linked to food and water restrictions) that undermine the capacity to self-regulate, making the person more vulnerable to pressure during interrogation. Coercive interrogation (most frequently, hours of exhaustive questioning with interrogators shifting roles, taking turns and using emotional and cognitive manipulation tactics) leads the person to either reveal pieces of information (which may be true but are most likely to be fabricated) in an attempt to stop the situation, or confess to whatever is demanded of him or her. Even if some of the information is true, the weakness causes the detainee’s memory to be partial and unreliable, merging what might be true with what has been suggested or fabricated, causing inaccurate information. O’Mara has, among many contemporary neuroscientists (Elbert et al., 2011; Jacobs, 2008; Putnam, 2013; van Bergen, Jelicic, & Merckelbach, 2008), accurately summarised how stress, pain, sleep deprivation, starving, drowning or manipulating temperature affects the brain and affects memory and executive functions (O’Mara, 2011, 2016). There are some experimental paradigms linking the use of pain in interrogations to disclosure of information. Houck & Conway (2015) developed a model in which participants played a game that was designed to be a proxy of an interrogation scenario. As part of the game, participants were instructed to keep specific information hidden from an opponent while their hand was submerged in varying temperatures of ice water (a cold pressor test that causes pain). Further, their opponent verbally pressured them to reveal the information. Analyses revealed that participants were

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more likely to reveal false information when exposed to the cold pressor test, and this effect became more pronounced as manipulated water temperatures became colder (from 10 degrees to 5 degrees to 1 degree). John Schiemann (2012; 2016) has applied mathematical models linked to game theory to see which combinations of interactions between interrogator and detainee produce more effective results. He showed that what he calls the Bush model of interrogation can hardly be justifiable in terms of efficacy. It necessarily results in increasingly frequent and brutal torture, including innocents, but fails to reliably yield valuable information. In game theory, the interrogator that follows coercive techniques is not the winner. Baliga and Ely (2016) have also recently developed a dynamic model of interrogational torture in which they include the political and credibility costs of torture showing that coercive interrogation is only cost-efficient in very limited and unrealistic circumstances. Universal Protocol on Investigative Interviewing.

Juan Méndez, during his time as United Nations (UN) Special Rapporteur on Torture called on States to develop a universal protocol on investigative interviewing (UN Doc. A/71/298) to limit the capacity of law enforcement officials to engage in torture, mistreatment, and the use of coercive methods during interviews. According to preliminary data, only 25 countries around the world have regulations that promote investigative interviewing practices (Table 3). As discussed above, there is overwhelming and increasing evidence from social experimental psychology, reports from experienced interrogators, neurobiology and forensic science and game theory that shows coercive interviewing is ineffective.

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Additionally there is an increasing body of knowledge on successful interviewing addressing topics related to linguistics (question types, timing of questions etc), rapport building (especially on types of empathic behaviours to suspects and outcomes), different models of disclosure of evidences and others (Bull, 2014; Oxburgh, Myklebust, Grant, & Milne, 2015)

This is knowledge that lacks diffusion to counter-balance the folk knowledge of media and film surrounding coercive interrogation as a useful tool to save lives (Flynn & Salek, 2012; Van Veeren, 2009). National legislation and international law must move one step ahead of the demands of society and act according to ethically sound principles and scientific evidence. A set of standards for

Table 3: Key elements in Special Rapport proposal on Universal Protocol for Investigative Interviewing (Mendez, 2016) Elements of a universal protocol for interviews A. Alternative model of investigative interviewing 1. Legal framework against coercive questioning and techniques

• Detailed guidance on the purpose and parameters of a human rights-compliant interviewing model • Prohibition of any form of coercion during the questioning of suspects, to interviews of witnesses, victims and other persons in the criminal justice system • Irrespective of the international or non-international character of the conflict and of the status of the person questioned

2. Guiding principles of investigative interviewing

• Interviewing model based on the principle of presumption of innocence • Physical environment and conditions during questioning must be adequate, humane and free from intimidation • Interviewers must seek to obtain accurate and reliable information in the

B. Set of standards and procedural safeguards

• Information on rights • Right of access to counsel • Right to remain silent • Additional safeguards for vulnerable persons • Recording • Medical examination

C. Accountability and remedies

• Complaint mechanisms, investigations and sanctions • Exclusion of evidence

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pursuit of truth; gather all available evidence pertinent to a case before beginning interviews; prepare and plan interviews based on that evidence; maintain a professional, fair and respectful attitude during questioning; establish and maintain a rapport with the interviewee; allow the interviewee to give his or her free and uninterrupted account of the events; use open-ended questions and active listening; scrutinize the interviewee’s account and analyse the information obtained against previously available information or evidence. • Training and change in culture and mindset

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proper interrogation of detainees and witnesses is vital. Recent strategic meetings in Geneva (27 January 2017) and New York (9 June 2017) outlined three different parts: a set of guidelines on investigative interviewing methods, a set of procedural safeguards accompanying interviews (i.e. legal assistance, systematic recording) and a section with guidance for monitoring and implementation (see Table 3). Key to this debate is the concept of torturing environments (Pérez-Sales, 2016). The line between interrogation and torture should be based on the selection of ethically acceptable techniques, but it would be naïve to think that torture can be avoided by using only certain methods. There is no point in distinguishing between interrogation and torture based on the use of certain allowed techniques without considering the context. Some, if not all, of the techniques used in the Enhanced Interrogation program (which has been found to constitute torture) appear on the most recent taxonomy of interrogation techniques (Kelly et al., 2016; Kelly, Miller, Redlich, & Kleinman, 2013; Kelly, Redlich, & Miller, 2015). As the testimonies of survivors demonstrate, the most benign interrogation procedure can destroy a person when he or she has been subjected to a ‘softening’ period, or when used in a cumulative or sequential way, or in a context of exhaustion and confusion. The presence or absence of torture is defined not by technique, but by the context and the way in which techniques are applied (Pérez-Sales, 2016). Interrogation techniques can amount to torture and should be integrated into a general schema on how torture works. The fact that this is one of the more neglected aspects in research on psychological torture makes it all the more

See the online proceedings at http://events.irct.org/

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important and the beginning of the work to develop a Universal Protocol on Investigative Interviewing is welcomed. This issue

In this issue, in addition to the usual scientific articles, we have two sections focused on particular topics. In the first, the focus is on the right to rehabilitation of torture survivors who have been or remain at Guantánamo Bay detention centre, a topic that grew out of presentations given at the 10th International Scientific Symposium organised by IRCT that was held in Mexico City in December 2016ii. Polly Rossdale and Katie Taylor present a review of Reprieve’s Life after Guantánamo Project that provided worldwide assistance to ex-detainees. The second paper, by James Connell, Alka Pradhan and Margaux Lander, addresses the complex issues involved in tackling the right to rehabilitation for detainees still at Guantanamo. It explores important legal and medical aspects of the right to rehabilitation in this context. Despite not being technically on US soil, these detainees have been exposed to torture by the US authorities and are thus entitled, according to the UN Convention against Torture and General Comment 3, to rehabilitation. The section is complemented by a third paper concerning ill-treatment actually on US soil by Eric Ordway, Jessica Djilani and Alexandria Swette, which describes the Ziglar vs Abassi case, and the Amicus Brief that was submitted in support of it. Filed in 2002, Abbasi arose out of the mass detentions of immigrants following the September 11 terrorist attacks. Indiscriminately labelled and treated as terrorist suspects and confined for months under extremely harsh conditions and subjected to physical violence, most of them were released months later without any formal charge, and suffering from severe physical and

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References Alison, L., Alison, E., Noone, G., Elntib, S., Waring, S., & Christiansen, P. (2014). The efficacy of rapport-based techniques for minimizing counter-interrogation tactics amongst a field sample of terrorists. Psychology, Public Policy, and Law, 20(4), 421–430. https://doi.org/10.1037/ law0000021 Alison, L. J., Alison, E., Noone, G., Elntib, S., & Christiansen, P. (2013). Why tough tactics fail and rapport gets results: Observing RapportBased Interpersonal Techniques (ORBIT) to generate useful information from terrorists. Psychology, Public Policy, and Law, 19(4), 411– 431. https://doi.org/10.1037/a0034564 Arrigo, J. M., & Wagner, R. V. (2007). Psychologists and military interrogators rethink the psychology of torture. Peace and Conflict: Journal of Peace Psychology, 13(4), 393–398. https://doi. org/10.1080/10781910701665550 Baliga, S., & Ely, J. C. (2016). Torture and the commitment problem. Review of Economic Studies, 83(4), 1406–1439. https://doi.org/10.1093/ restud/rdv057 Bull, R. (2014). Investigative Interviewing. New York: Springer. Carlsmith, K. M., & Sood, A. M. (2009). The fine line between interrogation and retribution. Journal of Experimental Social Psychology, 45(1), 191–196. https://doi.org/10.1016/j. jesp.2008.08.025 Committee Study of the CIA’s detention and interrogation Programm. (2014). Senate Intelligence Committee Report on Intelligence. New York: Melville House Publishing. Costanzo, M. a., & Gerrity, E. (2009). The Effects and Effectiveness of Using Torture as an Interrogation Device: Using Research to Inform the Policy Debate. Social Issues and Policy Review, 3(1), 179–210. https://doi.org/10.1111/j.17512409.2009.01014.x Davis, D., & Leo, R. (2012). Acute suggestibility in police interrogation: self-regulation failure as a primary mechanism of vulnerability. In A. M. Ridley, F. Gabert, & D. La Rooy (Eds.), Suggestibility in legal contexts (pp. 171–195). John Wiley & Sons. Elbert, T., Schauer, M., Ruf, M., Weierstall, R., Neuner, F., Rockstroh, B., & Junghöfer, M. (2011). The Tortured Brain. Zeitschrift Für Psychologie, 219(3), 167–174. https://doi.org/10.1027/21512604/a000064 Evans, J. R., Houston, K. A., Meissner, C. A., Ross, A. B., Labianca, J. R., Woestehoff, S. A., & Kleinman, S. M. (2014). An empirical evaluation of intelligence-gathering interrogation tech-

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mental health consequences. The Amicus Brief filed by a group of prominent medics, scholars and human right defenders is focused on the ill-effects of solitary confinement. This final paper in the section therefore serves as a reminder that, in addition to the higher profile cases of Guantanamo and the so-called Extraordinary Rendition detention centres, there are also incidents of torture and ill-treatment on US soil. The second focus can be found in the Perspectives Section of the Journal and is devoted to Iran. Two survivors of torture share their experience. Hasti Irani (a pseudonym) explains in a compelling way the impacts of solitary confinement. The second paper, based on information gathered whilst in detention with no small risk to the author, collects information from 16 in-mates to offer experiences on methods, impacts and coping with solitary confinement. Finally, we are glad to also include two regular scientific articles. Sabrina Friis Jørgensen, Mikkel A. Auning-Hansen and Ask Elklit present data on the lack of relationship between disability and clinical symptoms in torture survivors under rehabilitation. Hans Draminsky Petersen and Benito Morentín analyse ethical elements in the medical documentation of torture through the subjective experience of a sample of Basque torture survivors. We sincerely hope that readers will find the variety articles in this issue fascinating.

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niques from the united states army field manual. Applied Cognitive Psychology, 28(6), 867–875. https://doi.org/10.1002/acp.3065 Evans, J. R., Meissner, C. A., Ross, A. B., Houston, K. A., Russano, M. B., & Horgan, A. J. (2013). Obtaining guilty knowledge in human intelligence interrogations: Comparing accusatorial and information-gathering approaches with a novel experimental paradigm. Journal of Applied Research in Memory and Cognition, 2(2), 83–88. https://doi.org/10.1016/j. jarmac.2013.03.002 Flynn, M., & Salek, F. (2012). Screening Torture: Media representations. Cambridge, UK: Cambridge University Press. Forrest, K. D., & Woody, W. D. (2010). Police Deception during Interrogation and Its Surprising Influence on Jurors ’ Perceptions of Confession Evidence. The Jury Expert, 22(6), 9–23. Goodman-Delahunty, J., Martschuk, N., & Dhami, M. K. (2014). Interviewing high value detainees: Securing cooperation and disclosures. Applied Cognitive Psychology, 28(6), 883–897. https://doi.org/10.1002/acp.3087 Granhag, P. A., Kleinman, S. M., & Oleszkiewicz, S. (2016). The Scharff Technique: On How to Effectively Elicit Intelligence from Human Sources. International Journal of Intelligence and CounterIntelligence, 29(1), 132–150. https://doi.org/10.1080/08850607.2015.1083 341 Guyll, M., Madon, S., Yang, Y., Lannin, D. G., Scherr, K., & Greathouse, S. (2013). Innocence and resisting confession during interrogation: effects on physiologic activity. Law and Human Behavior, 37(5), 366–75. https://doi.org/10.1037/ lhb0000044 Houck, S. C., & Conway, L. G. (2015). Ethically Investigating Torture Efficacy: A New Methodology to Test the Influence of Physical Pain on Decision-Making Processes in Experimental Interrogation Scenarios. Journal of Applied Security Research, 10(4), 510–524. https://doi.org/ 10.1080/19361610.2015.1069636 Inbau, F. E., Reid, J. E., Buckley, J. P., Jayne, B. C., & Jayne., B. C. (2013). Criminal interrogation and confessions. Washington DC: Johns and Bartlett Learning. Intelligence Science Board. (2006). Educing Information Interrogation : Science and Art. (D. L. S. Robert Destro, Robert Fein, Pauletta Otis , John Wahlquist, Robert Coulam, Randy Borum , Gary Hazlett, Kristin E. Heckman and Mark D. Happel, Steven M. Kleinman, Ariel Neuman and Daniel Salinas-Serrano, Ed.). Washington DC:

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National Defense Intelligence College Press. Jacobs, U. (2008). Documenting the neurobiology of psychological torture: conceptual and neuropsychological observations. In A. E. Ojeda (Ed.), The trauma of psychological torture (pp. 163–173). London: Praege. John, S. (2016). Does torture work? Oxford University Press. Kelly, C. E., Miller, J. C., & Redlich, A. D. (2016). The dynamic nature of interrogation. Law and Human Behavior, 40(3), 295–309. https://doi. org/10.1037/lhb0000172 Kelly, C. E., Miller, J. C., Redlich, A. D., & Kleinman, S. M. (2013). A taxonomy of interrogation methods. Psychology, Public Policy, and Law, 19(2), 165–178. https://doi.org/10.1037/ a0030310 Kelly, C. E., Redlich, A. D., & Miller, J. C. (2015). Examining the meso-level domains of the interrogation taxonomy. Psychology, Public Policy, and Law, 21(2), 179–191. https://doi. org/10.1037/law0000034 Kleider-Offutt, H. M., Clevinger, A. M., & Bond, A. D. (2016). Working Memory and Cognitive Load in the Legal System: Influences on Police Shooting Decisions, Interrogation and Jury Decisions. Journal of Applied Research in Memory and Cognition, 5(4), 426–433. https:// doi.org/10.1016/j.jarmac.2016.04.008 Kostelnik, J. O., & Reppucci, N. D. (2009). Reid training and sensitivity to developmental maturity in interrogation: results from a national survey of police. Behavioral Sciences & the Law, 27(3), 361–79. https://doi.org/10.1002/bsl.871 Madon, S., Yang, Y., Smalarz, L., Guyll, M., & Scherr, K. C. (2013). How factors present during the immediate interrogation situation produce short-sighted confession decisions. Law and Human Behavior, 37(1), 60–74. https://doi. org/10.1037/lhb0000011 Meissner, C. (2012). Interview and Interrogation Methods and Their Effects on Investigative Outcomes. Campbell Systematic Reviews (Vol. 13). https://doi.org/10.4073/csr.2012.13 Mendez, J. (2016). Juan Mendez - Special Rapport on Non-Coercive Interrogation. A /71/298. Moston, S., & Fisher, M. (2008). Perceptions of Coercion in the Questioning of Criminal Suspects. Journal of Investigative Psychology and Offender Profiling, 4, 85–95. https://doi. org/10.1002/jip O’Mara, S. (2011). On the Imposition of Torture, an Extreme Stressor State, to Extract Information From Memory. Zeitschrift Für Psychologie. https://doi.org/10.1027/2151-2604/a000063

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neuroscience of interrogation. Harvard University Press. Oxburgh, G., Myklebust, T., Grant, T., & Milne, R. (2015). Communication in Investigative and Legal Contexts: Integrated Approaches from Forensic Psychology, Linguistics and Law Enforcement (Wiley Series in Psychology of Crime, Policing and Law) 1st Edition by. Wiley. Pardo, P. (2014). El Monstruo. Memorias de un interrogador (The Monster. Memories of an interrogator). Madrid, España: Libros del KO. Pérez-Sales, P. (2016). Psychological torture: Definition, evaluation and measurement. Psychological Torture: Definition, Evaluation and Measurement. https://doi.org/10.4324/9781315616940 Pérez-Sales, P. (2016). Psychological Torture: definition, evaluation and measurement. LondonNew York: Routledge. Putnam, F. W. (2013). The role of abusive States of being in interrogation. Journal of Trauma & Dissociation : The Official Journal of the International Society for the Study of Dissociation (ISSD), 14(2), 147–58. https://doi.org/10.1080/ 15299732.2013.724344 Rassin, E., & Israëls, H. (2014). False Confessions in the Lab : A Review. Erasmus Law Review, (December), 2–7. Russano, M. B., Narchet, F. M., Kleinman, S. M., & Meissner, C. A. (2014). Structured interviews of experienced HUMINT interrogators. Applied Cognitive Psychology, 28(6), 847–859. https:// doi.org/10.1002/acp.3069 Schiemann, J. W. (2012). Interrogational Torture: Or How Good Guys Get Bad Information with Ugly Methods. Political Research Quarterly. https://doi.org/10.1177/1065912911430670 Snook, B., Brooks, D., & Bull, R. (2015). A Lesson on Interrogations From Detainees: Predicting Self-Reported Confessions and Cooperation. Criminal Justice and Behavior, 42(12), 1243–1260. https://doi. org/10.1177/0093854815604179 United Nations High Commissioner for Human Rights. (2004). Istanbul Protocol. Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. (PROFESSION). Geneva. Van Bergen, S., Jelicic, M., & Merckelbach, H. (2008). Interrogation techniques and memory distrust. Psychology, Crime & Law, 14(5), 425–434. https://doi. org/10.1080/10683160701822533 Van Veeren, E. (2009). Interrogating 24 : Mak-

ing Sense of US Counter-terrorism in the Global War on Terrorism. New Political Science, 31(3), 361–384. https://doi. org/10.1080/07393140903105991 Wachi, T., Watanabe, K., Yokota, K., Otsuka, Y., & Lamb, M. (2016). Japanese Interrogation techniques from prisoners’ perspectives. Criminal Justice and Behavior, 43(5), 617–634. https:// doi.org/10.1177/0093854815608667 Walsh, D., & Bull, R. (2015). Interviewing suspects: examining the association between skills, questioning, evidence disclosure, and interview outcomes. Psychology, Crime & Law, 21(7), 661–680. https://doi.org/10.1080/10683 16X.2015.1028544 Walsh, D., Oxburgh, G., Redlich, A., & Myklebust, T. (2017). International Developments and practices in investigative Interviewing and Interrogation. Vol I and II. Routledge Books. Washington Post. (2004). Bush and Iraq. Washington Post– ABC News Poll. Retrieved from http:// www.washingtonpost.com/wp-srv/politics/polls/ trend_052304_q27_31.html

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Can disability predict treatment outcome among traumatized refugees? Sabrina Friis Jørgensen, Cand.psych.*, Mikkel A. Auning-Hansen, Cand.psych,* Prof. Ask Elklit**

Key issues

• Although the overall level of disability exhibited by traumatized refugees is high and deeply affects their everyday life, it is not a predictor of symptoms of PTSD, anxiety or depression following treatment. • The ability to 'get along' was a significant predictor of PTSD following treatment. • A focus on the participants’ social relationships is important when planning and providing mental health interventions.

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Abstract

The aim of the present study was to examine the influence of disability on changes in symptoms of PTSD, anxiety, and depression among treatment-seeking traumatized refugees. Eighty-one refugees participated in different rehabilitation programs. PTSD symptomatology was assessed by the HTQ-IV and symptoms of depression and anxiety were assessed by the HSCL-25. Disability was assessed by the WHODAS 2.0 before treatment. Following treatment, no

*) Rehabilitation Center for Torture Survivors – Jutland (RCT-Jutland), Denmark **) National Centre for Psychotraumatology, Institute of Psychology, University of Southern Denmark, Odense, Denmark Correspondence to: sfjoergensen@rct-jylland.dk

statistically significant changes in PTSD, depression, and anxiety symptom scores were observed. Disability in the domain ‘getting along’ was a significant predictor of PTSD scores following treatment, when controlling for baseline scores. Neither total disability nor individual disability domains predicted any other symptom changes. Living with one’s partner did, however, seem to be a consistent and significant predictor of treatment outcome. The results are discussed in terms of clinical implications and future research needs. Keywords: refugees, disability, PTSD, depression, anxiety, torture survivors Introduction

Many refugees have experienced physical and psychological traumas before or during their flight (Kirmayer, et al., 2011). In the post-migration phase, refugees often meet substantial challenges (ACPMH, 2007; Murray, Davidson, & Schweitzer, 2010). Adverse experiences such as discrimination and acculturation difficulties are common, requiring higher levels of functioning than many refugees have (ACPMH, 2007; Davidson, Murray & Schweitzer, 2008; Slobodin & de Jong, 2015; Sachs, 2011). By virtue of their traumatic and adverse experiences, refugees have an elevated risk of developing physical, social, and psychological

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problems (Davidson et al., 2008; Kirmayer, et al., 2011; Nickerson, Bryant, Silove & Steel, 2011). Three reviews have examined the efficacy of rehabilitation programs and treatment outcomes (McFarlane & Kaplan, 2012; Palic & Elklit, 2011; Slobodin & de Jong, 2015). The reviews found modest reductions in psychopathological symptoms among refugees. Underlying predictors of treatment outcome remains unknown. There is therefore clearly a need for additional studies examining predictors of treatment outcome in refugee samples to inform rehabilitation programs.

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Disability Studies have indicated that a lack of treatment effect among traumatized refugees could be due to high levels of symptom severity, disability, and chronicity exhibited by the refugees seeking treatment (Nickerson et al., 2011). Further, other findings have suggested that a diagnosis alone is a poor predictor of treatment outcome (Lund, SĂ¸rensen, Christensen, & Ă&#x2DC;lholm, 2008; WHO, 2002 & 2010). Whilst disability has been postulated as a better predictor of treatment outcome than a diagnosis and that high levels of disability may affect treatment efficacy, the influence on treatment outcome among traumatized refugees has yet to be examined. Previous studies have examined the relationship between psychiatric disorders and disability in a unidirectional fashion by conceptualizing disability as the result of symptoms (Rodriguez, Bruce, Pagano & Keller, 2005). It has been suggested that psychiatric disorders and disability influence and reinforce one another. Ormel et al. (1994) hypothesized that psychiatric distress could lead to poor psychosocial functioning, which subsequently leads to poorer prognosis or new disease onset. Prospective studies

have offered support for a distress-disability cycle hypothesis, by demonstrating that poor psychosocial functioning during remission of anxiety and depression predicted later recurrences (Rodriguez et al., 2005; Solomon et al., 2004). That said, it has not been fully tested if disability can predict treatment outcome in a refugee sample, as tests have only extended to the first link in the distress-disability cycle. On the other hand, several studies have provided evidence that psychiatric disorders are associated with disability among refugees (Buhmann, 2014; Mollica et al., 2001; Momartin, Silove, Manicavasagar, & Steel, 2004; Sachs, 2011; Steel, Silove, Chey, Bauman, Phan and Phan, 2005; Thapa, Van Ommeren, Sharma, de Jong and Hauff, 2003; Vojvoda, Weine, McGlashan, Becker, & Southwick, 2008). It is therefore possible that disability might influence the maintenance and severity of PTSD, anxiety, and depression among refugees, and thereby treatment outcome. Disability is defined as a dysfunction in one or more of the functioning levels (impairments, activity limitations, and participation restrictions) of the International Classification of Functioning (ICF). The ICF can be classified as a bio-psychosocial model, as it takes into account biological, individual, and social perspectives of health, and defines functioning through three levels of human functioning: all body functions, activities, and participation (WHO, 2002). The concept of disability is etiologically neutral, which is useful when assessing disability among refugees experiencing multiple co-occurring physical and psychological conditions (WHO, 2002). An etiologically neutral disability construct makes it possible to examine disability as an independent predictor of changes in symptom levels following treatment.

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Predictors of mental health and treatment outcome There is a general consensus of the impact of pre-migratory experiences on mental health. Several studies have reported a cumulative effect of trauma, where the number of traumatic experiences predicted the severity of psychopathological symptoms (Davidson et al., 2008; Murray et al., 2010). The type of traumatic experiences has also been found to influence symptoms (Davidson et al., 2008; Kirmayer et al., 2011; Steel, Chey, Silove, Marnane, Bryant & van Ommeren, 2009). However, evidence of the influence of various post-migratory variables on mental health has been inconsistent. These inconsistencies might reflect that the level of distress caused by post-migratory problems depend on several factors, such as, the similarity between the culture of origin and culture of settlement, social support, acceptance by the new nation etc (Buhmann, 2014; Davidson et al., 2008; Kirmayer et al., 2011; Murray et al., 2010; Slobodin and de Jong, 2015). It is therefore likely that results vary across sociocultural contexts. Postmigratory problems also interact with individual characteristics making the salience of various post-migratory problems difficult to evaluate (Davidson et al., 2008; Tempany, 2009). Current daily functioning can be an indicator of the ability to meet the challenges in the post-migration phase, and may represent a more objective indicator of salience for the individual (Sachs, 2011). Studies examining disability as a predictor of treatment outcome might be more easily generalizable across sociocultural contexts. Study Aims The aim of the present study was to examine the influence of disability on changes in symptoms of PTSD, anxiety, and depression among traumatized refugees, when controlling for factors that previous research found

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to be associated with these psychopathological symptoms. It was hypothesized that disability was a predictor of changes in mental health symptoms among refugees participating in rehabilitation programs. Methods

Participants and Design The participants were participating in a rehabilitation program in Denmark, having been referred by their general practitioner. The admission criteria for treatment included legal residence, meeting the ICD-10 criteria for PTSD (WHO, 1992), and having experienced a traumatic event in a country outside Denmark. The exclusion criteria included recurring psychotic episodes, substance abuse, and severe needs in terms of stabilization efforts. Patients who had demonstrated at least one baseline measure of symptoms of PTSD, anxiety or depression, and at least one post-treatment measure of the same symptoms, were included in the sample (N = 83) (HTQ IV and the HSCL25). Two patients were removed from the analysis as more than 20% of the items on the scales measuring PTSD, anxiety, depression, and disability were missing. The number of patients varied in the different analyses as a result of missing data. For example, some of the socio-demographic information was not collected for all patients, and some patients did not answer both questionnaires. Procedure Participants were allocated to different multidisciplinary rehabilitation programs based on the evaluation of their bio-psychosocial resource profile and needs by trained clinicians. They received a mean of 26 treatment sessions over a period of three to six months. The treatment consisted of consultations with psychologists, physiother-

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apists, and social workers. Some participants were also examined by an orthopedic consultant and/or a psychiatrist. The study was conducted in accordance with the Helsinki Declaration and was approved by the Danish Data Protection Agency. Written informed consent was obtained from all participants. Socio-demographic information was collected during a structured clinical interview prior to obtaining the baseline measurements. Self-report questionnaires were answered pre- and post-treatment. The questionnaires had previously been translated and back-translated into the participants’ native languages. If necessary, translation was provided by trained interpreters during assessment and treatment. Measures The socio-demographic information is presented below in Table 2 under Results, and an overview of the treatment variables is presented in Table 3. The remaining data, which came from self-report measures is listed below.

The Hopkins Symptom Check List-25 (HSCL-25): The HSCL-25 was used to assess symptoms of depression and anxiety

The Brief Pain Inventory – short form (BPISF): The BPI-SF consists of two subscales and a total score of pain (Cleeland, 2009; Cleeland & Ryan, 1994). The BPI-SF consists of four items measuring pain severity at its “worst,” “least,” “on the average,” and “now”. Furthermore, seven items measure how much the pain has interfered with seven daily activities. The items were scored on numeric rating scales. For pain intensity, 0 indicated no pain and 10 indicated the worst pain imaginable. For pain interference, 0 indicated no interference and 10 referred to complete interference. The BPI-SF has been demonstrated to have solid psychometric properties across different cultures and clinical conditions (Cleeland, 2009; Cleeland & Ryan, 1994; Dworkin et al., 2008). The reliability estimate in the current sample was high with a Cronbach alpha coefficient of .94. The World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0): The WHODAS 2.0 is a 36 items-scale which assesses disability across six domains: cognition, mobility, self-care, getting along, life activities, and participation. In accordance with the guidelines offered by the

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Harvard Trauma Questionnaire-Revised, part IV (HTQ-IV): The HTQ-IV includes 16 items covering PTSD symptoms as described in DSM-IV (Mollica, McDonald, Massagli & Silove, 2004). Items were scored on a 4-point Likert scale. The cut-off score of ≤ 2.5 was used in accordance with similar studies on refugee populations (Buhmann, 2014; Palic & Elkit, 2009; Raghavan, Rasmussen, Rosenfeld, & Keller, 2013). The reliability estimates in the current study were high with a Cronbach alpha coefficient of .90 at baseline and .96 post-treatment.

(Mollica et al., 2004). The HSCL-25 consists of 10 items measuring symptoms of anxiety and 15 items measuring symptoms of depression. Items were scored on a 4-point Likert scale. A cut-off score of ≤ 1.75 was suggested by the authors and has since been validated in other studies (Lavik, Laake, Hauff, Solberg, 1999; Mollica, Wyshak, de Marneffe, Khuon, & Lavelle, 1987; Smith Fawzi, Murphy, Pham, Lin, Poole, & Mollica, 1997). In the current study, the reliability estimates of the HSCL-25 were high at baseline and post-treatment, with Cronbach alpha values of .91 and .96, respectively.

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WHO, only 32 items are used if a patient is not currently working or going to school (WHO, 2010). The items were scored on a 5-point Likert scale. In accordance with the WHO’s recommendations, domain scores and summary scores were calculated using item-response-theory (IRT) based scoring. Using the IRT-based scoring, the scores were converted into a metric, ranging from 0 (no disability) to 100 (full disability) (WHO, 2010). The WHODAS 2.0 demonstrated

good reliability and validity, and a factor structure that has proved consistent across cultures and patient populations (Federici, Meloni, & Presti, 2009; WHO, 2010). The WHODAS 2.0 defines disability according to the ICF (WHO, 2010). Examples of items in the WHODAS 2.0 can be seen in Table 1. The reliability of WHODAS 2.0 (32 items) in the current sample was high with a Cronbach alpha coefficient of .94.

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Table 1: Examples of items in the WHODAS 2.0 (32 items) Domain 1: Cognition (contains 6 items)

• In the past 30 days, how much difficulty did you have in: »» ➢Item 1: Concentrating on doing something for ten minutes? »» ➢Item 3: Analysing and finding solutions to problems in day-to-day life? »» ➢Item 5: Generally understanding what people say

Domain 2: Mobility (contains 5 items)

• In the past 30 days, how much difficulty did you have in: »» ➢Item 1: Standing for long periods such as 30 minutes? »» ➢Item 3: Moving around inside your home?

Domain 3: Self-care (contains 4 items)

• In the past 30 days, how much difficulty did you have in: »» ➢Item 1: Washing your whole body? »» ➢Item 3: Eating?

Domain 4: Getting along (contains 5 items)

• In the past 30 days, how much difficulty did you have in: »» ➢Item 1: Dealing with people you do not know? »» ➢Item 3: Getting along with people who are close to you?

Domain 5: Life activities (contains 4 items)

• Because of your health condition, in the past 30 days, how much difficulty did you have in: »» ➢Item 1: Taking care of your household responsibilities? »» ➢Item 3: Getting all the household work done that you needed to do?

Domain 6: Participation (contains 8 items)

• In the past 30 days: »» ➢Item 1: How much of a problem did you have joining in community activities (for example, festivities, religious or other activities) in the same way anyone else can? »» ➢Item 3: How much of a problem did you have living with dignity because of the attitudes and actions of others? »» ➢Item 5: How much have you been emotionally affected by your health condition?

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included the following predictors: baseline HTQ-IV PTSD scores, WHODAS domain ‘getting along’, age, living with one’s partner, and being single. The post-treatment HSCL-25 depression model included baseline HSCL-25 depression scores, living with one’s partner, and BPI interference scores. Finally, the post treatment HSCL-25 anxiety model included baseline HSCL-25 anxiety scores, orthopedic consultation, living with one’s partner, being single, BPI severity, and BPI interference. Results

The current sample spanned 18 nationalities, including a majority from Bosnia (30%), Afghanistan (12%), and Syria (11%), respectively. Nearly 52% of the sample was female with a mean age of 44.20 years. The majority of the sample was married (72.8%). The mean number of years living in Denmark was 15. An overview of treatment sessions is presented in Table 3. 32% participants participated in at least one treatment session with the psychiatrist, and 56 received psycho-pharmacological medicine. There were more participants receiving psychopharmacological medicine than consultations with the psychiatrist. These numbers reflect that some participants were treated with psycho-pharmacological medicine by their general practitioner or a psychiatrist elsewhere. Table 4 displays mean scores for pain and disability measures. 99% of the participants reported having experienced pain within the last 24 hours. 65 participants answered 32 WHODAS items, but only 25 participants answered all 36 items on the WHODAS 2.0. Therefore, only the 32 items were included in the analyses.

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Statistical Analysis Statistical analyses were conducted using IBM SPSS Statistic 22. Missing value analyses were performed and Little’s MCAR test showed that data missing from the self-report measures was missing completely at random. The expectation maximization technique was used to impute missing values for cases missing less than 20% values. Shapiro-Wilk test was used to assess for normal distribution, and the level of significance was set to .05. Changes in the HTQ-IV scores and the HSCL-25 scores from baseline to post-treatment were evaluated with paired-samples t-test for continuous parametric variables, and Wilcoxon signed-rank test for non-parametric variables. If the assumptions of the Wilcoxon signed-rank tests were violated, exact sign tests were used. Cohen’s d was calculated to evaluate the effect sizes of changes in symptoms of PTSD, anxiety, and depression. McNemar's tests were used to determine significant differences in the proportion of participants scoring above cut-off for PTSD, anxiety, and depression at baseline and post treatment. A zero-order correlation matrix was generated to determine whether there was an association between disability scores and post-treatment symptom scores. Thereafter, significant predictors of treatment outcome (p < .05) were identified in regression models adjusting for the corresponding baseline score. Potential predictors included socio-demographic variables (Table 2), treatment variables (Table 3), pain severity and pain interference (Table 4), baseline HSCL-25 and HTQ-IV scores (Table 5), and WHODAS 2.0 scores (Table 4). Significant predictors were subsequently included in multiple regression analyses. The post treatment HTQ-IV PTSD model

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Table 2: Overview of socio-demographic variables (N = 81) (N = 81)

n/m

(SD) %

Range

Age

44.20

(9.5)

23-62

Male

48.1 %

Female

51.9 %

Mean years in Denmark

15.1

(7.5)

1-31

Danish citizenship [n=81]

28.4 %

Need for interpreter [n=81]

64.2 %

Mean years in school in country of origin

10.3

(3.6)

0-17

Education in country of origin [n=57]

64.9 %

Parents [n=65]

61.5 %

Partner/spouse [n=60]

3.3 %

Siblings [n=68]

77.9 %

Children u18 years [n=56]

5.4 %

Children 18+ years [n=57]

8.8 %

Married

72.8 %

Single

11.1 %

Divorced/ Separated

13.6 %

Widowed

2.5 %

Salary

16 %

Social Security benefit

50.6 %

Jobseeker's allowance

3.7 %

Disability pension

6.2 %

Sickness benefits

21 %

Other

Family in country of origin:

Marital status:

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Income:

2.5 %

Worked in DK [n=66]

77.3 %

Worked in country of origin [n=59]

79.7 %

Family members outside primary family [n=70]

62 %

Friends with other ethnicity than Danish [n=70]

70 %

Danish friends [n=60]

66.7 %

Living with partner [n=61]

85.2 %

Social network:

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Table 3: Overview of treatment variables (N = 81)

n/m

(SD) %

Range

Individual treatment sessions

25.6

(11.3)

4-51

Psychotherapy sessions

9.9

(4.3)

0-30

Social work sessions

7.8

(5.2)

0-28

Physiotherapy sessions

7.7

(4.8)

0-20

Consultation with the orthopedic consultant

66.7 %

Consultation with the psychiatrist

43.2 %

1 type of psycho-pharmacological medicine during treatment

69.1 %

> 1 type of psychopharmacological medicine during treatment

40.7 %

Table 4: Descriptive statistics for pain and disability (WHODAS 2.0: N = 65)

Disabilitya

(SD)

Range

BPI-SF total

7.1

(2.1)

.36-9,8

BPI-SF Pain severity

6.6

(2.2)

0-10

BPI-SF Pain interference

7.4

(2.3)

0-10

WHODAS Total disability

65.1

(20)

16.9-95.3

100

WHODAS Cognition

68.5

(22.7)

0-100

98.5

WHODAS Mobility

63.6

(26.7)

0-100

96.9

WHODAS Self-care

(26.5)

0-90

92.3

WHODAS Getting along

66.3

(30.2)

0-100

96.9

WHODAS Life activities

71.8

(29.1)

0-100

96.9

WHODAS Participation

67.6

(20.8)

13.7-100

100

(BPI-SF: N = 77)

Note: aSummary score or domain score above 0. WHODAS = World Health Organization Disability Assessment Schedule 2.0 BPI-SF = the Brief Pain Inventory â&#x20AC;&#x201C; short form T O RT U RE Vo lu m e 2 7 , Nu m be r 2 , 2 0 17

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Table 5: Changes in symptoms of anxiety, depression, and PTSD (HSCL-25: N = 75) (HTQ-IV: N = 69) HSCL-25 Total

Baseline M 7.1

(SD) (.54)

Post treatment Range 1.40-

M 2.97

(SD)

Range

(.66)

1.20-

.11

3.87 HSCL-25 Anxiety

6.6

(.59)

1.60-4

Diff. score (SD) (.59)

3.82 2.98

(.72)

1-4

Range -1.1

.49a

.21

.20a

.16

.38a

.16

.47a

.13

-2.2 .14

(.67)

-1.1 -2.1

HSCL-25 Depression

7.4

HTQ-IV PTSD

65.1

(.56)

1.27-

2.97

(.66)

3.87 (.49)

1.56-

1.27-

.10

(.61)

3.90 3.05

(.65)

1.25-4

– 2.3 .09

(.65)

3.88 HTQ- IV Reexperiencing

68.5

HTQ-IV Avoidance

63.6

HTQ-IV Arousal

(2.58)

6-16

-1.1 -1.63 -2.44

12.78

(2.93)

5.84-

.37

(3.12)

-7 -10

.70b

.19

.77

(4.67)

-1 -15

.18c

.08

-9 -14

.70b

92.3

16 46

(3.77) (2.76)

9-27 9-20

20.05 16.02

(4.44) (3.62)

9-28 5-20

.26

(3.98)

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Note: aWilcoxon signed-rank test; bSign test; cPaired-samples t-test., HTQ-IV = Harvard Trauma QuestionnaireRevised, part IV, HSCL-25 = The Hopkins Symptom Check List-25

Changes in Symptom Scores An overview of the HSCL-25 scores, HTQ-IV scores, differential scores, p-values and Cohen’s d are presented in Table 5. 74 out of 75 participants (98.7 %) scored above the cut-off score of ≤ 1.75 on the anxiety and depression subscales at baseline. Post-treatment, 5 (6.7%) participants scored below cut-off for depression and 7 (9.3%) for anxiety. Using exact McNemar's tests, this decrease in participants scoring clinically significant symptoms was not statistically significant. Effect sizes were small for all the changes in symptom scores (d = .16 - .21). At baseline, 60 out of 69 participants (87 %) scored above the cut-off score of ≤ 2.5 for PTSD which decreased to 56 (81 %) post-treatment. An exact McNemar's test revealed that this decrease was not statistically significant (p = .42). Effect sizes were small for all the changes in the HTQ-IV subscale scores (d = .08 - .19). Predictors of Change A zero-order correlation matrix is presented in

Table 6. The results of the multiple regression analyses for each outcome are presented in Table 7. The multiple regression model predicting post-treatment PTSD scores was statistically significant [F(5, 36) = 9.18, p < .001, adj. R2 = .50] with ‘living with one’s partner’ and the WHODAS 2.0 domain ‘getting along’ significantly adding to the prediction. In the preliminary regression analyses, having parents, a partner, or children under the age of 18 in the country of origin were also identified as significant predictors of post treatment PTSD scores. However, in the PTSD regression model, variables regarding family in the country of origin were excluded, as there was no data available about these variables for 16 to 25 participants. The multiple regression model predicting post-treatment depression was also significant [F(3, 50) = 17.48, p < .001, adj. R2 = .48]. Baseline anxiety scores and living with one’s partner proving to be significant predictors. The regression model predicting posttreatment anxiety was also statistically significant [F(6, 46) = 7.54, p < .001, adj. R2

21 SCIENTIFIC ARTICLE

= .43] with baseline anxiety scores and living with one’s partner adding significantly to the prediction. Being married was also a significant predictor in the preliminary regression analyses, however, it was dropped from the anxiety regression model, as its correlation with the variable ‘being single’ was an issue concerning multicollinearity. Discussion

The findings indicated that participants overall exhibited high levels of disability at baseline. Comparing the disability scores with population norms provided by the WHO(2010), the mean disability score was above the 90th population percentile. Other studies also reported high levels of disability among refugees compared to the general population and psychiatric in-patients (Palic,

Kappel, Nielsen, Carlsson, & Bech, 2014; Steel et al., 2005). The number of participants reporting pain in the current sample was also very high (99%), yet similar to other studies of traumatized refugees in clinical settings (Buhmann, 2014). Findings indicated that baseline PTSD, depression, and anxiety scores were high and consistent with other studies of traumatized refugees in clinical settings (Buhmann, 2014; Palic & Elkit, 2009; Carlsson, Olsen, Mortensen, & Kastrup, 2006; Carlson, Mortensen, & Kastrup, 2005). Although the HSCL-25 scores and the HTQ-IV scores improved following treatment, the level of change was non-significant. Previous studies have reported similar non-significant reductions in overall levels of PTSD, anxiety, and depression (Birck, 2001; Carlsson et al., 2005; Mollica, Wyshak,

Table 6: Zero-order correlation matrix between disability scores and pre- and post-symptom scores Post Post

Baseline

treatment

HSCL-25

HSCL-

depres-

25depres-

25anxiety

sion

(N = 63)

Baseline HSCL-25 anxiety (N = 63)

WHODAS Total disability

.733**

.409**

.600**

.302*

.640**

.464**

WHODAS Cognition

.580**

.259*

.470**

.171

.483**

.332**

WHODAS Mobility

.662**

.384**

.451**

.220

.521**

.381**

WHODAS Self-care

.422**

.170

.429**

.099

.393**

.215

WHODAS Getting along

.629**

.465**

.520**

.345**

.570**

.481**

WHODAS Life activities

.591**

.348**

.441**

.250*

.417**

.266*

WHODAS Participation

.617**

.337**

.500**

.300**

.569**

.433

HTQ IV PTSD

* p < .05; ** p < .005

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(N = 59)

Post treatment HTQ IV PTSD (N = 59)

Baseline

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Table 7: Summary of multiple regression analyses examining post treatment HSCL-25 scores and HTQ-IV scores Variable

SEB

Dependent variable: Post treatment HSCL-25 anxiety scores (N = 53)

Adj. R2 .43

BPI-SF total

.40

.12

.40**

BPI-SF Pain severity

.04

.15

.03

BPI-SF Pain interference

.43

.20

.28*

WHODAS Total disability

.03

.04

WHODAS Cognition

.41

.79

.18

WHODAS Mobility

-.23

.26

-.12

Dependent variable: Post treatment HSCL-25 depression scores (N = 54)

.48

Baseline HSCL-25 depression

.60

.13

.54**

Living with partner

.52

.16

.32**

BPI interference

.06

.03

.21

Dependent variable: Post treatment HTQ-IV PTSD scores (N = 42)

.50

Baseline HTQ-IV PTSD

.26

.16

.26

WHODAS ‘getting along’

.01

.003

.39*

Age

.01

.11

Living with partner

.62

.30

.40*

Being single

.05

.37

.03

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Note:* p < .05; ** p < .01

Lavelle, Truong, Tor, & Yang, 1990), while others found statistically significant symptom reductions following multidisciplinary treatment (Brune, Haasen, Krausz, Yagdiran, Bustos, & Eisenman, 2002; Carlsson et al., 2005; Raghavan et al., 2013). There may be several reasons for these non-significant findings. First, the participants had been living in Denmark for a mean of 15 years, indicating that their traumatic experiences occurred many years ago. It was therefore plausible that trauma-related distress may have been present for several years and possibly chronic in nature. Similar studies have also reported long-lasting distress levels

that seemed to be chronic (Birck, 2001; Carlsson et al., 2005; Palic & Elkit, 2009). Second, it has been suggested that participants admitted to specialized treatment centers comprise some of the most severely affected refugees (Carlsson et al., 2005; Nickerson et al., 2011), and prolonged absence of treatment possibly had a negative effect on distress levels over time (Nickerson et al., 2011). In the present study, no single treatment-related variables predicted treatment outcome, indicating that traumatized refugees represent a group of participants which is somewhat resistant to treatment. Importantly, however, other studies

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have argued treatment effect is not typically evident until six months after the end of treatment (Lund et al., 2008). It may therefore be too soon to draw any conclusions regarding the efficacy of the rehabilitation programs in treating PTSD, anxiety, and depression. The RCT-Jutland is currently preparing a nine-month follow-up study. Further analyses of follow-up data might reveal whether there is any long-lasting or a delayed treatment effect.

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Predictors of treatment outcome Overall, few predictors of treatment outcome were found which might have been the result of methodological issues. Nevertheless, it was hypothesized that disability would be a statistically significant predictor of changes in symptoms of PTSD, anxiety, and depression following treatment. Disability in the domain of ‘getting along’ was a statistically significant predictor for post-treatment PTSD scores. In fact, higher levels of disability within the domain of ‘getting along’ predicted higher PTSD scores following treatment. ‘Living with one’s partner’ was also a significant predictor with respect to PTSD and was associated with higher symptom scores following treatment. In similar studies, social support has conversely often been found to be a protective factor for the development and maintenance of psychopathological symptoms among refugees (Davidson et al., 2008; Kirmayer et al., 2011). On the other hand, stressors in family life have been found to negatively impact symptom severity and treatment effect of PTSD (Lund et al., 2008). Anger, marital conflicts, and domestic violence are common problems among refugees suffering from PTSD, often making PTSD symptoms more sever (ACPMH, 2007; Hinton, Rasmussen, Nou, Pollack, & Mary-Jo, 2009; Nilsson, Brown, Russell, & Khamphakdy-Brown, 2008). In this study,

’living with one’s partner’ also predicted higher post-treatment anxiety and depression scores. As 96 percent of the participants experienced disability in the domain of ‘getting along’, it is perhaps not surprising that ‘living with one’s partner’ was associated with poorer treatment outcome. Neither total disability nor individual disability domains predicted any other symptom changes. There are several possible explanations for this finding. Firstly, disability might not be a predictor of treatment outcome as hypothesized. It has been suggested that it is necessary for refugees to address trauma-related symptoms before being able to manage other psychosocial stressors (Nickerson et al., 2011). According to this argument, disability can be seen as a consequence of trauma-related symptoms and, in order to reduce disability, the trauma-related symptoms would have to be treated first (Nickerson et al., 2011). Secondly, whilst disability has been postulated as a better predictor of treatment outcome than a diagnosis among other populations, there are, however, some substantial differences in disability exhibited by refugees and other treatment-seeking populations. These differences include the severity of disability and magnitude of change in disability scores following treatment (Buhmann, 2014; Palic et al., 2014; Steel et al., 2005; Tempany, 2009). Even though the results indicated that disability was not a predictor of treatment outcome, the methodological issues suggest that caution should be used in drawing any definitive conclusions. For example, the small sample size may increase the risk of type II errors and complicate generalization. The sample was also quite homogeneous regarding the level of mental health symptoms, which could also lead to type II errors.

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Implications The level of disability exhibited by the participants was very high and affected several life domains, suggesting that disability should still be a focus of rehabilitation. Generally, the results suggested that the participants faced multiple co-occurring and complex problems, indicating a need for multidisciplinary treatment. However, if the aim of treatment is solely to reduce symptoms of PTSD, anxiety, and depression, it is questionable whether participants should be allocated to different treatment programs based on their level of functioning, rather than the severity of psychopathological symptoms. It is recommended that future studies examining disability among refugees should also include culture-sensitive measures of disability to gain an insight into the disability experienced by the individual and to see whether a culture-sensitive measure of disability might predict treatment outcome. The finding that disability in the domain of ‘getting along’ predicted less improvement in symptoms of PTSD, and that ‘living with one’s partner’ predicted less overall symptom improvement indicates that a focus on the participants’ social relationships is important when planning and providing mental health interventions. Interventions would benefit from including the family of the patient, especially the partner, if the patient wishes to do so. Limitations The present study has important limitations. Firstly, participants were allocated to different treatment programs, but considered as one sample. Despite this heterogeneity, all were traumatized, participating in treatment at the same treatment center, and receiving treatment based on the rehabilitation perspective. Secondly, the study design was not randomized nor controlled, which means that

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causal conclusions regarding the relationship between predictor variables and treatment outcome must be drawn with caution. However, the study was naturalistic and exploited clinical data and as such it has high external generalizability. Thirdly, self-report questionnaires were used. When using self-report questionnaires, the risk of reporting bias increases. Steel et al. (2009) found a higher prevalence of mental disorders when using self-report questionnaires. Nevertheless, the rates of symptoms of PTSD, depression, and anxiety in the present study were similar to other comparable studies (Buhmann, 2014; Palic & Elkit, 2009). Finally, change in psychopathological symptoms is not necessarily a fully encapsulating outcome, as they do not embrace rehabilitation in its wider, holistic sense (Johansen, Rahbek, Møller, & Jensen, 2004). It is possible that the inclusion of other outcome measures would have contributed to a better understanding of the impact of disability. Conclusion

The refugees referred to treatment at the RCT-Jutland exhibited high levels of pain, disability, and symptoms of PTSD, anxiety, and depression, indicating a crucial need for treatment in this particular population. Following treatment, no statistically significant changes in symptom scores were observed. With respect to PTSD, disability in the domain of ‘getting along’ was a significant predictor of post-treatment scores. Other regression analyses found that neither global disability scores nor the disability domains predicted other treatment outcomes. Generally, few variables seemed to predict treatment outcome, which could be due to methodological limitations. ‘Living with one’s partner’ did however seem to be a consistent and significant predictor of treatment outcome, which indicates the importance of

25 SCIENTIFIC ARTICLE

including the family of the patient in treatment, whenever possible. References

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Australian Centre For Posttraumatic Mental Health (ACPMH) (2007). Australian Guideline for the treatment of Adults with Acute Stress Disorder and Posttraumatic Stress Disorder. Melbourne: ACPMH. Birck A. (2001). Torture victims after psychotherapy — a two year follow-up. Torture, 11(2), 55−58. Brune, M, Haasen, C, Krausz, M, Yagdiran, O, Bustos, E, Eisenman, D. (2002). Belief systems as coping factors for traumatized refugees: a pilot study. European Psychiatry. 17: 451-58. Buhmann, CB. (2014). Traumatized refugees: Morbidity, treatment and predictors of outcome. Danish Medical Journal, 61(8): B4871. Carlsson, JM, Mortensen, EL, Kastrup, M. (2005). A Follow-Up Study of Mental Health and Health-Related Quality of Life in Tortured Refugees in Multidisciplinary Treatment. The Journal of Nervous and Mental Disease, 19 (10): 651–57. Carlsson, JM, Olsen, JM, Mortensen, EL, Kastrup, M. (2006). Mental Health and Health-Related Quality of Life A 10-Year Follow-Up of Tortured Refugees. The Journal of Nervous and Mental Disease, 194 (10): 725–31. Cleeland, CS. (2009). The Brief Pain Inventory User Guide. Retrieved from https://www.mdanderson.org/education-and-research/departmentsprograms-and-labs/departments-and-divisions/ symptom-research/symptom-assessment-tools/ brief-pain-inventory-users-guide.html . Cleeland, CS, Ryan, KM. (1994). Pain assessment: Global use of the brief pain inventory. Annals of the Academy of Medicine, Singapore, 23 (2): 129–38. Davidson, GR, Murray, KE, Schweitzer, R. (2008). Review of refugee mental health and wellbeing: Australian perspectives. Australian Psychologist, 43 (3), 160-74. Dworkin, RH, Turk, DC, Wyrwich, KW, Beaton D, Cleeland, CS, Farrar, JT et al. (2008). Interpreting the Clinical Importance of Treatment Outcomes in Chronic Pain Clinical Trials: IMMPACT Recommendations. The Journal of Pain, 9 (2): 105-21. Federici, S, Meloni, F, Presti, AL. (2009). International Literature Review on WHODAS II (World Health Organization Disability Assessment Schedule II). Life Span and Disability, 12 (1): 83-110.

Hinton D, Rasmussen A, Nou L, Pollack M, MaryJo G. (2009). Anger, PTSD, and the Nuclear Family: A Study of Cambodian Refugees. Social Science & Medicine, 69 (9): 1387-94. Johansen, JS, Rahbek, J, Møller, K, Jensen, L. (2004). Hvidbog om rehabiliteringsbegrebet. Århus: MarselisborgCentret. Kirmayer, LJ, Narasiah, L, Munoz, M, Rashid, M, Ryder, AG, Guzder, J et al. (2011). Canadian Guidelines for Immigrant Health: Common mental health problems in immigrants and refugees: general approach in primary care. Canadian Medical Association Journal, 183 (12): 959-67. Lavik, NJ, Laake, P, Hauff, E, Solberg, Ø. (1999). The use of self-reports in psychiatric studies of traumatized refugees: Validation and analysis of HSCL-25. Nordic Journal of Psychiatry, 53 (1): 17-20. Lund M, Sørensen JH, Christensen JB, Ølholm A. (2008). MTV om behandling og rehabilitering af PTSD - herunder traumatiserede flygtninge. Vejle: La Cour Offset. McFarlane CA, Kaplan I. (2012). Evidence-based psychological interventions for adult survivors of torture and trauma: A 30-year review. Transcultural Psychiatry, 49 (3–4): 539–67. Mollica, RF, McDonald, LS, Massagli, MP, Silove DM. (2004). Measuring trauma, measuring torture: instructions and guidance on the utilization of the Harvard Program in Refugee Trauma’s Versions of the Hopkins Symptom Checklist-25 (HSCL-25) and the Harvard Trauma Questionnaire (HTQ). Cambridge, MA: Harvard Program in Refugee Trauma. Mollica, RF, Sarajlic, N, Chernoff, M, Lavelle, J, Vukovic, IS, Massagli, MP. (2001). Longitudinal study of psychiatric symptoms, disability, mortality, and emigration among Bosnian refugees. JAMA, 286 (5): 546−54. Mollica, RF, Wyshak, G, Lavelle, J, Truong, T, Tor, S, Yang, T. (1990). Assessing symptom change in Southeast Asian refugee survivors of mass violence and torture. The American Journal of Psychiatry, 147 (1): 83−88. Mollica, RF, Wyshak, G, de Marneffe, D, Khuon, F, Lavelle, J. (1987). Indochinese versions of the Hopkins Symptom Checklist-25: a screening instrument for the psychiatric care of refugees. The American Journal of Psychiatry, 144 (4): 497-500. Momartin, S, Silove, D, Manicavasagar, V, Steel, Z. (2004). Comorbidity of PTSD and depression: associations with trauma exposure, symptom severity and functional impairment in Bosnian

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refugees resettled in Australia. Journal of Affective Disorders, 80: 231–38. Murray, KE, Davidson, GR, Schweitzer, RD. (2010). Review of Refugee Mental Health Interventions Following Resettlement: Best Practices and Recommendations. American Journal of Orthopsychiatry, 80 (4): 576–85. Nickerson, A, Bryant, RA, Silove, D, Steel, Z. (2011). A critical review of psychological treatments of posttraumatic stress disorder in refugees. Clinical Psychology Review, 31: 399–417. Nilsson, JE, Brown, C, Russell, EB, KhamphakdyBrown, S. (2008). Acculturation, Partner Violence, and Psychological Distress in Refugee Women From Somalia. Journal of Interpersonal Violence, 23 (111): 1654-63. Ormel, J, VonKorff, M, Ustun, TB, Pini, S, Korten, A, Oldehinkle, T. (1994). Common Mental disorders and disability across cultures: Results from WHO Collaborative Study of Psychological Problems in General Health Care. JAMA, 272: 1741-48. Palic, S, Elklit, A. (2009). An explorative outcome study of CBT-based multidisciplinary treatment in a diverse group of refugees from a Danish treatment centre for rehabilitation of traumatized refugees. Torture, 19 (3): 248-70. Palic, S, Elklit, A. (2011). Psychosocial treatment of posttraumatic stress disorder in adult refugees: a systematic review of prospective treatment outcome studies and a critique. Journal of Affective Disorders, 131 (1-3): 8-23. Palic, S, Kappel, LM, Nielsen MS, Carlsson, J, Bech, P. (2014). Comparison of psychiatric disability on the health of nation outcome scales (HoNOS) in resettled traumatized refugee outparticipants and Danish inparticipants. BMC Psychiatry, 14: 330-40. Raghavan, S, Rasmussen, A, Rosenfeld, B, Keller, AS. (2013). Correlates of symptom reduction in treatment-seeking survivors of torture. Psychological Trauma: Theory, Research, Practice, and Policy, 5 (4): 377–83. Rodriguez, BF, Bruce, SE, Pagano, ME, Keller, MB. (2005). Relationships among psychosocial functioning, diagnostic comorbidity, and the recurrence of generalized anxiety disorder, panic disorder, and major depression. Journal of Anxiety disorders, 19: 752-66. Sachs, E. (2011). Assessing the Impact of Psychological Distress on the Daily Functioning of Refugees: Creating a High-Risk Symptom Profile for Disability among Nonwestern Trauma Survivors. New York: UMI Dissertation Publishing. Slobodin, O, de Jong, JTVM. (2015). Mental health interventions for traumatized asylum seekers

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and refugees: What do we know about their efficacy? International Journal of Social Psychiatry, 61 (1): 17–26. Smith Fawzi MC, Murphy E, Pham T, Lin L, Poole C, Mollica RF. (1997). The validity of screening for post-traumatic stress disorder and major depression among Vietnamese former political prisoners. Acta Psychiatrica Scandinavica, 95 (2): 87-93. Solomon DA, Leon AC, Endicott J, Mueller TI, Coryell W, Shea T, Keller MB. (2004). Psychosocial impairment and recurrence of major depression. Comprehensive Psychiatry, 45 (6): 423-30. Steel, Z, Chey, T, Silove, D, Marnane, C, Bryant, RA, van Ommeren, M. (2009). Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: A systematic review and meta-analysis. Journal of the American Medical Academy, 302 (5): 537–49. Steel, Z, Silove, D, Chey, T, Bauman, A, Phan, T, Phan, T. (2005) Mental disorders, disability and health service use amongst Vietnamese refugees and the host Australian population. Acta Psychiatrica Scandinavica, 111: 300–309. Tempany, M. (2009). What Research tells us about the Mental Health and Psychosocial Wellbeing of Sudanese Refugees: A Literature Review. Transcultural Psychiatry, 46 (2): 300–315. Thapa, SB, Van Ommeren, M, Sharma, B, de Jong, JTVM, Hauff, E. (2003) Psychiatric disability among tortured Bhutanese refugees in Nepal. American Journal of Psychiatry, 160: 2032-37. Vojvoda, D, Weine, SM, McGlashan, T, Becker DF, Southwick, SM. (2008) Posttraumatic stress disorder symptoms in Bosnian refugees 3 1/2 years after resettlement. Journal of Rehabilitation Research & Development, 45 (3): 421-26. World Health Organization (WHO) (2010). Measuring Health and Disability: Manual for WHO Disability Assessment Schedule (WHODAS 2.0). Malta: World Health Organization (WHO). World Health Organization (WHO) (2002). Towards a Common Language for Functioning, Disability and Health: ICF. Geneva: World Health Organization. World Health Organization (WHO) (1992). The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Description and Diagnostic Guidelines. Geneva: World Health Organization.

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Detainees' perception of the doctors and the medical institution in Spanish police stations: An impediment in the fight against torture and ill-treatment Hans Draminsky Petersen, MD*, Benito Morentin, MD, PhD**

Key messages

Abstract

Background: As part of a program by the Basque Government (Spain) and the University of the Basque Country, persons who have alleged exposure to torture and ill-treatment have been examined by psychol-

*) Consultant to the Istanbul Protocol Project in the Basque Country (IPP-BC) Working Group **) Section of Forensic Pathology, Basque Institute of Legal Medicine, Spain. University of the Basque Country Correspondence to: hdp@dadlnet.dk

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• Doctors’ professional performance in Spanish police stations as perceived by most detainees was grossly insufficient. • In general, doctors did not manage to establish an atmosphere of confidence. They were often perceived not to be neutral or independent, and even as cooperating with the police. • Expressed threats of reprisals for telling the doctors about ill-treatment seems to have been commonplace. • Although there has been some improvement after 1991, in comparison to before, the medical institution in police stations still fails to constitute a means to prevent torture and ill-treatment. • The medical examination of detainees and its implementation in some police stations in Spain that deal with incommunicado detentions should be reorganised. The Spanish National Preventative Mechanism has an important role in this process and ensuring that necessary changes are implemented.

ogists and psychiatrists according to the Istanbul Protocol (IP). Medical examinations of detainees with the aim, inter alia, to document abuses is fundamental for torture prevention. The IP prescribes how this should be done to ensure data collection and prevent reprisals for having reported ill-treatment to the doctor. Objectives: The objectives were to assess detainees' perception of the medical examinations which they underwent at different types of Spanish police institution and to compare practice between institutions; and, to compare information from the period 1969-1991 with that from 1992-2014. Methods: All information about medical examinations of incommunicado detainees from 202 extensive IP reports was analysed according to a 19-item tool developed for the purpose dealing with the doctors' professional performance, the confidence of the detainees in the doctors, reprisals and procedural safeguards (Annex 1). All information was classified as acceptable, unacceptable /insufficient or totally unacceptable. Findings: Very often the detainees perceived the doctors' professional

performance as insufficient or totally unacceptable and the doctors did not instil their confidence. Threats of police reprisals and failure to observe procedural safeguards were often reported. There were no differences in the comparison between institutions. When comparing the two study periods an improvement was found over time. However, 64% of the scores came out as totally unacceptable or insufficient for the most recent period indicating that the medical institution in police stations where the detentions had taken place failed to constitute a preventive means against torture and ill-treatment. Limitations: Only 57% of the 202 reports assessed contained relevant information; data was retrieved retrospectively; the interviews were done years after detention without a particular focus on medical examinations. Keywords: Spain, torture, ill-treatment, medical examinations, Istanbul Protocol, detainees' perception, quality, forensic doctors

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Introduction

The European Committee for the Prevention of Torture (CPT) has on many occasions visited Spanish police stations and has repeatedly concluded that they found credible and consistent allegations of ill-treatment (European Committee for the Prevention of Torture, various). In 2004 the United Nations' (UN) Special Rapporteur on Torture stated that in Spain "torture is more than sporadic and incidental" (UN report of the Special Rapporteur, 2004). Likewise, civil society organisations have collected information on torture and ill-treatment in Spanish police stations, e.g. Amnesty International, 1980; Morentin, Callado, & Idoyaga, 2008; and, Perez-Sales, Morentin, Barrenetxea, & Navarro-Lashayas, 2016. An official report of the Basque

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Government estimates that there has been 5500 public allegations of torture and ill-treatment in the Basque Country in the period between 1960 and 2013 (Basque Government, 2013). Generally, an incentive to carry out torture and ill-treatment exists if the ensuing confession of a crime carries heavy weight in the verdict of the court, which is the case in Spain. On the other hand, Spain has ratified the UN Convention against Torture that obliges states to criminalise torture. Moreover, detainees are regularly examined during the period of detention by forensic doctors, who have to write medical reports about the results of the examinations. Hence, when torture and ill-treatment is applied, police officers are normally careful not to use methods that leave physical marks. In line with this, the vast majority of Basque persons who allege torture and ill-treatment describe that they have been completely isolated and exposed to a large number of physical and psychological methods simultaneously or successively - the torturing environment - during most of the first days and nights of detention until confession (PĂŠrez-Sales, Navarro-Lashayas, Plaza, Morentin, & Salinas, 2016). Methods often reported consist, inter alia, of: aggressive, lengthy and repeated interrogations and being confronted with false evidence and testimonies obtained through torture and ill-treatment of other persons or with manipulated statements from the detainee; hooding and other procedures with the aim of confusing and disorientating the detainee about the date and time and the proceedings of the detention; humiliations, including nudity during interrogations; constant threats of harm to the body and rape against oneself or family members; forced witnessing of torture or listening to screams and noises resembling a torture scenario; repeated use

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tion in police stations, seen from the detainees' perspective, has not been done before. The objective of the present article is to analyse quantitatively the detainees' perception of their medical examination in police custody based on the information contained in the 202 IP reports taken from the second investigation of IPP-BC Working Group. In the current study, institutions where detainees were medically examined were classified as follows: (a) local police stations (LPS) where the individual doctor cannot be expected to have a great deal of experience in performing such examinations; (b) the Central Police Station in Madrid (CPSM) where many examinations are done by a few doctors; (c) the special anti-terrorist tribunal (the Audiencia Nacional (AN)), to which detainees are transferred before appearing in court and where they are not interrogated or physically abused. The aim was to assess whether the detainees' perception of the medical examination depended on the institution where the examinations took place. Moreover, an additional objective was to assess whether there had been improvements over time in the way medical examinations are conducted as perceived by the persons examined, taking into consideration that the CPT experts have made recommendations on the issue to the Spanish Government since its first visit in 1991. Hence, data from 1969-1991 was compared with that from 1992-2014. In this article, medical institution denotes all aspects of medical services: relevant laws and regulations, the organisation in the Ministry of Interior and the Ministry of Health, the chain of command from the ministries to the places of detention, the implementation of laws and regulations including supervision and oversight. It also includes the doctors and their training and compliance with the

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of blunt violence particularly against the head and testicles; total sleep deprivation and other physiological deprivation; forced lengthy maintained standing or awkward body positions; physical exercise until exhaustion; asphyxiation procedures with a plastic bag or with water. The Istanbul Protocol (IP) is a UN document (United Nations, 2004). It sets standards for the examination, investigation and reporting of allegations of torture and ill-treatment. The IP prescribes that, when interviewing a person who claims to have been tortured, several procedural safeguards should be taken into account. This is in order to ensure privacy during the examination and confidentiality of information, to ensure the collection of all relevant information and safeguard against pressure and threats from the police to discourage detainees from reporting ill-treatment. The IP stresses the importance of the doctor obtaining the confidence of the examinee. The Istanbul Protocol Project in the Basque Country (IPP-BC) Working Group was created several years ago. In its first study 45 persons who had alleged torture were examined and the main conclusion was that allegations were credible (Argituz et al., 2014; Istanbul Protocol Project in the Basque Country Working Group, 2016; Navarro-Lashayas et al., 2016; PĂŠrez-Sales et al., 2016a; PĂŠrez-Sales et al, 2016b). Recently, the IPP-BC Working Group has done a second investigation (requested by the Basque Government) using the IP in 202 cases of allegations of torture (see Material and methods section below). The results are being analysed. In the first study of the IPP-BC Working Group, a qualitative analysis of the detainees perception of the medical examination was carried out (Morentin, 2014). However, a quantitative analysis of the medical examina-

regulations, the facilities where examinations take place, safeguards for medical confidentiality and the integrity of detainees in relation to their medical examinations.

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Material and methods

Participants: The Basque Government, in collaboration with the IVAC (the Basque Institute of Criminology of the University of the Basque Country), has undertaken research on torture and ill-treatment committed by security bodies in the period 1960-2013 as part of the Peace and Coexistence Plan ('Plan de Paz y Convivencia'). IVAC has established a register of Basque people who have alleged torture and ill-treatment while held under incommunicado detention in the application of antiterrorist legislation. The report - published by the Institute in 2016 - compiled a total of approximately 3,000 allegations of torture and ill-treatment. From this compilation the IVAC, IPP-BC Working Group randomly selected 202 persons to be examined in accordance with the IP as to credibility of allegations and medical and psychological consequences of torture. The Spanish anti-terrorism legislation (paras 509, 520bis, 527) allows for incommunicado police detention for five days, which can be extended to a total of 13 days (Spanish Criminal Procedure Code). Incommunicado detainees may be held and interrogated in LPS (local police station) for a while and later transferred to CPSM (central police station) for further interrogation or to AN (anti-terrorist tribunal). They may also be transferred directly to the CPSM for interrogation. From CPSM, detainees are transferred to AN. In all types of institution detainees should regularly be examined by forensic doctors, who write a report on each examination.

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Instruments and procedure of the IP evaluation: The IPP-BC Working Group is composed of about 40 professionals, mostly from the field of mental health, affiliated to different health and human rights associations. Each case was initially evaluated by one psychiatrist or clinical psychologist who - after obtaining informed consent - conducted extensive clinical interviews following a semi-structured format based on the IP. The interviews were recorded on tape or video and transcribed. The interviews included a battery of psychological tests. The initial report was reviewed by and discussed with one or more colleagues from the group. Additional evidence, e.g, relevant reports from forensic doctors or other doctors, if available, was analysed by forensic doctors and physicians of the IPP-BC Working Group. A final IP report included demographic and criminological data, extensive testimonies of torture and ill-treatment, coding of torture methods according to the IP, physical and psychological symptoms in relation to torture, psychological and physical findings, results of psychometric tests, psychiatric diagnoses following the International Classification of Diseases (ICD) 10th version, physical sequelae, and an assessment of the level of credibility. Information from the IP reports; availability and assessment: The 202 extensive testimonies of the IP reports were read and all the information about medical examinations during detention in police stations was analysed. In the interviews with the ex-detainees, there had been no specific focus on the medical examination. As a consequence, relevant data for this study was incomplete and only existed in 116 reports. An IP report could contain data on medical examinations done in different institutions during the same

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detention or during different detentions if the person had been arrested more than once. Information from one detention could also cover several medical encounters in one or more institutions. In order to structure this information for the purpose of this study, a tool was developed containing 19 items (mostly based on IP recommendations) organised in four groups. Issues included in the analysis and criteria for scoring appear in Annex 1. Six items were identified describing the detainee's perception of the doctor's professional conduct; five items related to the detainees' confidence in the doctor(s) and the medical institution; two items on reprisals by the police in relation to the medical examinations; and six items related to procedural safeguards. Scoring of the items was done on the following basis: totally unacceptable (judged by the authors or expressed by the examinee), 3 points; partially unacceptable or insufficient, 2 points; and, acceptable, 1 point. Statistical analysis: The Ď&#x2021;2 test was used to compare the scoring of groups of items and the total scores from the different categories of institutions (LPS, CPSM and AN) and the two study periods (before and after 1991). All analyses were carried out using the SPSS (Statistical Package for Social Sciences) program. The chosen level of significance was p<0.05.

Results

Information on the medical examinations during incommunicado detention existed in 116 (87 men and 29 women) of the 202 IP reports. The median age of the persons at the time of detention was 25 years (range 17-66). The medical examinations took place during detentions in the period 1969 -2014 (Table 1). In six cases there was information from two detentions. In 39 IP reports there was information about medical examinations from two or three institutions. Information came from CPSM (n=66), LPS (n= 64), AN (n=17), hospitals (n=10), and prisons (n=4). The circumstances around examinations done in hospitals (the objective being merely therapeutic) were quite different from those taking place in police custody. As an example, nine of the ten who were examined in a hospital said that police officers were present during the examination, two said that they were handcuffed and one said that officers tried to change the decision of the doctor. Four examinations were done in prisons, of

Table 1: Number of detentions in relation to periods of five years. Note: six persons had been detained several times. Period of detention

1969 - 1974

1975 - 1979

Number of detentions

1980 - 1984

1985 - 1989

1990 - 1994

1995 - 1999

2000 - 2004

2005 - 2009

2010 - 2014

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Ethical issues: The data generated is currently kept on paper and in digital format, which

has been approved by the Basque Agency for Data Protection (AVPD). All documentation is kept confidentially in the premises of the University of the Basque Country (UPV/ EHU). The research has been reviewed and approved by the Commission for Ethics in Research and Teaching of the UPV/EHU. Informed consent from all participants has been obtained.

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which ill-treatment was reported by three and two said that this was ignored by the doctors. The reading of all available information gave rise to 678 assessments/scorings of statements from the detainees about medical examinations: 277 (41%) were considered

totally unacceptable, 202 (30%) insufficient / unacceptable and 199 (29%) as acceptable. The scorings are shown in Table 2 and Figures 1 and 2. Table 3 gives some details about the authors' observations.

Table 2: Number of observations and scorings by item and groups of items. ('totally unacceptable', 3 points; 'partially unacceptable or insufficient', 2 points; and 'acceptable', 1 point).

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Number of observations

Levels of scoring

ITEMS (grouped)

1 point

2 point

3 point

Items 1-6. Doctors' professional performance

227

95 (42%)

51 (22%)

81 (36%)

1: Doctor's response to requests concerning health

2: Doctor's response to allegations of ill-treatment

3: Doctor's response to question about 17 the time

4: The doctor enquired about ill-treatment

5: The doctor performed a physical examination

6: Duration of the medical encounter

Items 7-11. Detainees' confidence in the doctor

221

41 (19%)

62 (28%)

118 (53%)

7: Detainee's confidence in the doctor

8: Detainee's perception of the doctor's affiliation to the police

9: Detainee's perception of the doctor's cooperation with the police

10: Detainee's motivation to see the doctor

11: Detainee alleged ill-treatment to the doctor

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Items 12-13. Reprisals

4 (20%)

16 (80%

12: Threats of reprisals for reporting ill-treatment to the doctor

13: Reprisals for having told about ill-treatment

Items 14-19. Procedural safeguards

210

63 (30%)

85 (40%)

62 (30%)

14: The doctor introduced him-/ herself as a doctor

15: The doctor's general attitude

16: Information about the objective of the examination

17: Police presence during the medical examination

18: Place of examination

19: Manner in which detainee was taken to the doctor

Items 1-19

678

199 (29%)

202 (30%)

277 (41%)

Figure 1: Scorings - total and for the four groups of items - related to three kinds of institutions: CPSM (Central Police Station in Madrid); AN (Audiencia Nacional); LPS (Local Police Stations).

Item 7-11

Item 12-13

Item 14-19

Item 1-19

The black segment of each bar represents the cases evaluated as acceptable (1 point): the white segment those considered as partially unacceptable or insufficient (2 points): and the grey segment those considered as totally unacceptable (3 points).

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Item 1-6

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Figure 2: Scorings for the two study periods (until 1991 and from 1992), given by group of items and total.

Item 1-6

Item 7-11

Item 12-13

Item 14-19

Item 1-19

Table 3: Some observations about individual items retrieved from the 116 (57%) reports with available relevant information. Item

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Nยบ

Issue

Observations

The doctor's response to health needs

Such response was insufficient or non-existent in 27/44 (61%) of cases where from the existing information it was judged that something or more could have been done considering the circumstances, e.g. providing sanitary pads for women with menstruation or analgesics to persons with a headache.

The doctor's response to allegations of torture

Only 12/30 (40%) of the detainees were confident that the doctor entered all allegations of ill-treatment into the record. One doctor interrupted the detainee narrating ill-treatment by saying that such information should be given to the judge and not to the doctor.

The doctor's Two persons said that the doctor refused to inform them about the reply to detainee's time and date with reference to instructions from the police. In three question about cases the doctor did not reply, but let the person look at a watch. time and date

The doctor enquired about ill-treatment

In only 24/56 (43%) of the cases does it appear that the doctor enquired explicitly about ill-treatment. In the remaining cases the doctor only did so in an ambiguous manner or not at all.

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A physical examination was done

In only 28/72 (39%) of the cases the doctors reportedly performed a full physical examination.

Duration of the medical encounter

There was only scarce information about the thoroughness / duration of the medical encounters. A few ex-detainees said that the examination was done in a few minutes.

Detainee's confidence in the doctor

Total lack of confidence in the doctor was expressed in 61 cases (86%).

Detainee's perception of the doctor's affiliation to the police

One person said that he was taken to an office where a person introduced himself as a doctor. The detainee said that he had been ill-treated. The person then revealed that he was a guardia civil and warned the detainee against reporting ill-treatment next time he saw a doctor. Another reported that he identified the doctor as one of those who later took part in interrogations. 25 expressed that they saw the doctor as just another police officer.

Detainee's perception of the doctor's cooperation with the police

Six ex-detainees were convinced that the doctor cooperated with the police as judged by the presence of a walky-talky switched on on the doctor's table or by the fact that officers knew the information that the detainee had given to the doctor. One person said that he heard the voice of the doctor while being subjected to suffocation. Eleven ex-detainees thought that the doctor cooperated with the police due to e.g. they observed cordial relations between the doctor and the officers, or by the fact that the doctor spoke remarkably loudly with an open door during the interview. In two cases the doctor examined the detainees several times a day and paid particular attention to the colour of their nails, which made the detainees think that the doctor was informed about the suffocation procedures that they had undergone. One said that the doctor was present in the torture room when the detainee was resuscitated after having undergone suffocation in water. In one case - not included above - the doctor refused to believe that allegations of torture were true, but later the doctor was present during interrogations that were then remarkably little harsh (sic.).

The detainee's motivation to see the doctor

A few declared that the only good reason for seeing the doctor was to have a break from torture or to be informed about the time and date.

The detainee alleged ill-treatment to the doctor

46 persons (47%) did not tell the doctor anything about the torture they had undergone because of fear of reprisals and 18% only informed the doctor on some occasions. Only 35% reported consistently the ill-treatment they had been subjected to.

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Threats of reprisals for reporting ill-treatment to the doctor

18 persons said that they, before the encounter with the doctor, had been threatened with reprisals if they reported ill-treatment to the doctor. The police officers in some cases mentioned that they would be informed about the content of the interview with the doctor.

Reprisals for having reported ill-treatment to the doctor

Only one person said that he was further ill-treated with reference to the fact that he had told the doctor about ill-treatment. In another case the ex-detainee said that he was beaten immediately after the medical examination just outside the doctor's office and that the doctor did not appear in the corridor although he could not have missed the sounds. In one case the police interrupted the medical examination and took the detainee to interrogation and ill-treatment.

Did the doctor introduce him- / herself as a doctor

In 35/39 (90%) of the cases the doctors did not introduce themselves in a correct manner showing an ID-card. One doctor refused to show his ID-card on the detainee's demand, which lead the detainee to refuse to cooperate to an examination. Another person said that his eyes were covered during the examination impeding him from seeing the doctor.

General attitude of the doctor

In only 13/52 (25%) it appeared that the doctor's attitude was empathetic and /or interested.

The detainee received information about objective of the examination

This issue was included since its importance is stressed in the Istanbul Protocol. We did not find anything in the reports indicating that such information was given to any detainee.

Presence of officers during the medical examination

In 11 cases it was stated that the police were present during the examination and in another 21 cases officers stood within hearing distance with the door open to the doctor's office. In 14 (30%) of cases the examinations were reportedly done in private.

Place of examination

Most often medical examinations reportedly took place in on office; in a few cases in a cell or in places where there was no privacy at all.

Manner in which detainee was taken to the doctor

Detainees were taken to the examination by officers who participated in interrogations, and 12 stated that they were hooded or forced to bend head and body forward on the way to the doctor's office.

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Comparisons between institutions and periods of time: There were 313 scorings from CPSM, 52 from AN and 313 from LPS. Concerning comparison of institutions, there were no statistically significant differences either in the scorings of all items together or in the comparison of groups of items (Figure 1). There were a total of 222 scorings in the first study period and 456 in the second

(Figure 2). The scorings of all items together, the doctors’ performance (items 1-6) and procedural safeguards (items 14-19) were significantly lower for the second period (Table 4). Due to the low number of observations concerning reprisals this group was excluded from separate statistical calculations.

Table 4: Group of items with statistically significant differences concerning the two study periods (χ2 test).

Group of items

Issue

First period.

Second period.

Levels of scoring

1 point

2 points

3 points

1 point

2 points

3 points

Statistical values p

χ2 value

1-6

Doctors' professional performance

17 (26%)

15 (23%)

34 (51%)

78 (48%)

36 (22%)

47 (29%)

0.002

12.2

14-19

Procedural safeguards

12 (17%)

28 (39%)

32 (44%)

51 (37%)

57 (41%)

30 (22%)

0.001

14.8

1-19

All

37 (17%)

64 (29%)

121 (55%)

162 (36%)

138 (30%)

156 (34%)

<0.001

33.2

Scorings were: acceptable, 1 point; partially unacceptable or insufficient, 2 points; and totally unacceptable, 3 points.

Discussion

preventing such abuses. Access to a medical examination while detained has been shown to be an important predictor for occurrence of torture and ill-treatment (Carver & Handley, 2016). It requires that the medical examination is structured adequately and carried out accordingly, reflected in items 1-6 (Annex 1). Other necessary requirements for such an examination to be effective in the fight against torture and ill-treatment are that the detainees trust /have confidence in the doctor, that the doctor is independent and neutral and is perceived as such and that the detainee can engage with the doctor without fear of or the risk of reprisals, reflected in

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The right to a medical examination for all detainees is enshrined in resolutions of the United Nations (1998; 2015). The medical examination in places of detention has the objective of protecting the detainee's health, which includes safeguarding against ill-treatment. A detainee should have the possibility to relate ill-treatment to an independent doctor, who should be trained to assess such allegations with respect to consistency between allegations of ill-treatment, ensuing symptoms and the results of a physical examination and a psychological assessment. Documentation of torture and ill-treatment is paramount in fighting impunity and

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items 7-11. Trust is an essential component of eliciting an accurate account of abuse. Earning the trust of someone who has experienced torture or other forms of abuse requires active listening, meticulous communication, courtesy and genuine empathy and honesty. Physicians must have the capacity to create a climate of trust in which disclosure of crucial, but perhaps very painful or shameful, facts can be discussed (United Nations, 2004). Reprisals and threats of reprisals are reflected in items 12-13. The IP prescribes a number of procedural safeguards related to the medical examination reflected in items 14-19. The doctor should introduce introduce him/ herself as a matter of accountability and establish an appropriate atmosphere during the examination. Privacy and confidentiality must exist, the place of examination must be appropriate and the transfer from the cell or interrogation room must not be intimidating. The high number of scores that came out as unacceptable or insufficient (71%) from all types of institution and in both periods of time clearly indicate that there were serious shortcomings in all aspects concerning the medical examination as perceived by the detainees. There were no differences when comparing institutions. When comparing the two study periods an improvement was found over time related to the doctorsâ&#x20AC;&#x2122; professional performance and procedural safeguards. However, the fact that 64% of the scores came out as unacceptable or insufficient for the most recent period clearly shows that the improvements were highly insufficient. Hence, it may be inferred that the recommendations of the CPT have had only limited impact on the way medical examinations of incommunicado detainees are done in police stations according to the statements of detainees. This finding was also

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reflected in previous studies of forensic medical documents issued in the same categories of places of detention in Spain (Petersen, Morentin, Callado, Meana, & Idoyaga, 2002; Morentin, Petersen, Callado, Idoyaga, & Meana, 2008). It is also in line with statements of the CPT (CPT 2011). The low quality of the medical examinations carried out in Spanish detention centres has been documented by different fora. For example, in 1991 and 1998 by the CPT, the European Council's Commissioner for Human rights (MuiĹžnieks, 2013), the Ombudsman of the Basque Country (2011), by the European Court of Human Rights, (such as, Beortegui Martinez v Spain (no. 36286/14), 31 May 2016), by Amnesty International (2009), and in quantitative analyses of 743 medical documents issued in police stations (Morentin et al., 2008; Petersen et al., 2002). The present results show that, in general, the incommunicado detainees who have been medically examined in police stations share this opinion about the quality of the medical examinations. There was consistency between observations concerning the four groups of issues: At the outset of a medical examination the doctor should, inter alia, introduce himself (group 4, procedural safeguards), which has been one of the recommendations made by the CPT to the Spanish government CPT (1994). This item scored insufficient or unacceptable in 19/23 cases (83%) in the last study period which means that, in the vast majority of cases, the doctors did not show their ID card to the detainees. Detainees may well see this as if the doctors dissociate themselves from their responsibilities and from the examinees; it is unlikely to establish an environment of confidence (group 2, confidence). 61 detainees expressed that they had no confidence in the doctors, 25 expressed that

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watches, which should be seen against the background of the apparently widespread practice of police agents staying within hearing distance of the encounter between the doctor and the detainee. Although the number of cases is small, it gives a clear indication that the police on some occasions have involved doctors in creating a torturing environment, which, inter alia, consists of causing total confusion and disorientation without any markers for the detainee to orientate himself/herself in the proceedings of the interrogations. In line with this, the observations of some detainees that private information given to the doctor had become known to the police indicate that such information could be used by torturers to find personal weaknesses of detainees. This would mean that doctors on some occasions collaborated in a complex torturing environment by not observing professional confidentiality, either by performing examinations without privacy, or by providing officers with confidential information. Whether or not the doctors accurately recorded the narrated information it remains the impression of the detainees. However, the fact that the detainees did not have any access to the content of the medical reports underlines their complete lack of all control. If the detainee during his detention had insight into the medical documents it would probably encourage the doctors to document accurately the narrated ill-treatment and symptoms and observed findings, and it would probably diminish the detainee's mistrust in the medical institution. This is also contrary to the CPT's recommendation that results of medical examinations be made available to the detainee and his lawyer (2003). It is also noteworthy that many ex-detainees perceived the doctors as not being proactive in their collection of information on

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they saw the doctor as just another police agent, 17 thought that the doctors somehow cooperated with the police and 64 refrained totally or partially from telling the doctor about the ill-treatment they had been exposed to (group 2, confidence). It is possible to surmise that the lack of confidence is linked to the doctors’ general attitude (group 4, procedural safeguards) towards the detainee, e.g. often described as uninterested, cold or hostile, and it is related to police threats of reprisals (group 3, reprisals). The environment of pressure was observed and commented upon by the CPT (June 1994, p.15): “Given the pressure that can be brought to bear on a detained person, forensic doctors should not necessarily accept the face value statements by such persons to the effect that they are being treated well”. The doctors’ perceived cooperation with the police (group 2, confidence) fits the description that the medical examinations were often performed with officers within hearing distance (group 4, procedural safeguards). In addition, it was perceived that there was insufficient record keeping of allegations of ill-treatment and a lack of relevant and feasible response to detainees' request for medical treatment (group 1, professional conduct). In consonance with this, the CPT has also, from its first visit in 1991, repeatedly recommended to the Spanish government that all medical examinations should be conducted out of hearing and preferably out of sight of police or Civil Guard officers. This issue scored insufficient or unacceptable in 23/34 cases (68%) in the last study period. 17 detainees asked the doctor to inform them of the time. In two cases the doctors replied that the police had forbidden them to give such information. In three cases the doctors did not reply, but showed their

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ill-treatment; 32/56 (57%) of the interviewees expressed that the doctor only implicitly or did not enquire about ill-treatment at all, thereby contributing to an impression that doctors often preferred not to report ill-treatment, i.e. supporting the police. Threats of reprisals apparently works; 18 persons said that they had been threatened not to say anything about ill-treatment; in 64 statements (n=98) it appeared that the detainees refrained totally or partially from telling the doctors about ill-treatment out of fear of reprisals. Many detainees reported that they were taken to the doctor's office by officers who participated in the interrogations. This provided an opportunity to threaten reprisals if the detainee told the doctor about the ill-treatment at a crucial moment for the detainee to establish a relationship of trust with the doctor. In line with this, many ex-detainees reported that the way in which they were taken to the doctor was threatening and humiliating, being hooded or forced to bend their head and body forward. It is remarkable that only one person said that he was punished for having told the doctor about ill-treatment. A possible explanation is that the torturing environment is so systematic and effective that reprisals are useless for the police; however, threats are relevant since the aim is to prevent information about ill-treatment appearing in the medical documents. Absence of such information in the medical record will be contrasted with allegations of ill-treatment that later on may be reported in court. If allegations of ill-treatment and physical lesions are absent in the medical document, all allegations will most likely be considered invalid by the court (CPT 2007). For some of the important aspects of the medical examinations, e.g. how the doctors enquired about ill-treatment and how they

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responded to such allegations, the statements from the ex-detainees varied significantly. This most likely reflects the lack of clear guidelines for doctors concerning their role as protectors of the detainees' rights to health and to freedom from torture and ill-treatment. This is in line with what has been concluded on the basis of analyses of 743 medical documents concerning examinations carried out in the same police stations (Petersen et al., 2002; Morentin et al., 2008). Statistical calculations on scores of individual items were not carried out for various reasons: (a) for many of the items, the number of observations was small, which - together with what is mentioned under limitations below â&#x20AC;&#x201C; would make interpretation problematic; (b) the items are interrelated within and between groups and should not be seen as individual problems; (c) eventual statistical differences may draw attention to details and away from the overall problem that the medical service in the institutions concerned should be reorganised (for a further discussion, please see the conclusion). The 202 IP reports which make up the source of the information analysed here represent testimonies that were assessed by evaluating psychologists and physicians to be consistent and credible. Moreover, there appears to be no incentive for the ex-detainees to exaggerate or fabricate information about their experiences concerning medical examination during detention. Limitations

The information available cannot be assumed to give a complete picture of all details of the examined persons' perception of the doctors' performance and the medical institutions in police detention; the data used here is incomplete and was retrieved retrospectively from interviews where there had been no detailed systematic questioning on the

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between subgroups of information. Conclusions

The doctors professional performance as perceived by most detainees was grossly insufficient. In general, the doctors did not manage to establish an atmosphere of confidence. The doctors were often perceived as not neutral and not independent and sometimes even cooperating with the police. The detainees very often feared reprisals for telling the doctor about ill-treatment. Expressed threats of reprisals for telling the doctors about ill-treatment seems to have been commonplace Basic procedural safeguards were not observed by the doctors in the majority of the cases. The reported conduct of police agents is a serious problem and doctors share some of the responsibility for this by e.g. accepting to carry out medical interviews and examinations with police agents present outside an open door within hearing distance. All of these issues constitutes serious impediments for making the medical examination in police stations an effective safeguard against torture and ill-treatment. The problem in some police stations in Spain seems to be so systematic when dealing with incommunicado detainees that the structure of the medical examination and its implementation should be reorganised, regularly supervised by independent experts and monitored or studied in a focused and systematic manner. The medical institution responsible for the health of the detainees, including protection against torture and ill-treatment, in police stations must be independent and seen as such by the detainees. The doctors working there should have clear instructions about their role and conduct and the content

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medical examinations in police stations. The data does however represent precise transcriptions of the ex-detainees' statements given to interviewing psychologists. With respect to most of the interviews, many years have elapsed from the period of detention to the interview and the detainees' impressions may have been somewhat modified in the course of the years. On the other hand, torture and ill-treatment are extreme experiences and in general victims can relate many elements in great detail. Many of the reported details from the medical examinations, such as, whether the doctor introduced him-/herself, whether fear prevented the detainee from reporting torture and the conduct of the police, are very concrete and it can be supposed that they would have been remembered well. That being so, the overall content of the ex-detainees' accounts represents a fair picture of the (subjective) perception of 116 persons with respect to the manner in which the medical examinations in police stations are carried out in cases where the incommunicado detainee is suspected of having committed crimes related to activities that fell under the anti-terrorist legislation. In 86 (43%) of the IP reports there was no information on medical examinations. It may reflect that no medical examination took place or that experiences from the encounter were perceived as insignificant compared to the experiences of torture and ill-treatment. Importantly, the lack of information may also reflect that the examinees were not very critical of the medical institution, thereby distorting the results. Scores expressed as a percentage should therefore not be regarded as precise measures of prevalence. Notwithstanding these limitations, the data allows some conclusions to be drawn given the large amount of information that was retrieved and the consistency found

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of a medical examination; the format for the examinations should include questions about physical as well as psychological ill-treatment and somatic and psychological symptoms, together with a full physical examination, a psychological assessment and a conclusion as to consistency between alleged ill-treatment, ensuing symptoms and objective findings. The record keeping should be meticulous. The detainees should have a genuine opportunity to complain about ill-treatment and to be heard in court. One of the necessary prerequisites is that the detainees are informed and receive the relevant documentation. A beginning could be to give them immediate access to all medical documents made during their detention and to provide them with copies of all medical documents when they leave the police station. Although there has been some improvements from the first to the second study period, our results clearly indicate that the medical institution in police stations still fails to constitute a preventive means against torture and ill-treatment, which we also have found previously by other means (Petersen et al., 2002; Morentin et al., 2008) and which has also been indicated by the CPT (CPT 2011). These results can be considered together with the fact that many crucial issues dealt with by the CPT in their recommendations to the Spanish government appeared to have been ignored e.g. the doctor's obligation to introduce him/herself and to conduct the examination out of hearing distance of police officers and that the detainee and his/her lawyer should be provided with the results of the medical examination (CPT 2011). This leads to the inference that the CPT has only had limited effect on the preventive function of medical examinations in police stations. The responsibility for this lies with the Spanish government.

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The Spanish National Preventive Mechanism (NPM) under the Optional Protocol to the UN Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment came into operation in 2010 with a mandate in many ways similar to that of the CPT. Given the study periods of the present project, a discussion of the possible impact of the visits to police stations by the NPM is not meaningful. However, the existing knowledge about the practices as to incommunicado detention - particularly those exercised under the anti-terrorist legislation - should be sufficient for the responsible ministries to rethink the structure and function of existing safeguards against ill-treatment in places of detention. The Spanish NPM has an important role in this process and ensuring that necessary changes are implemented. Acknowledgements

Health organizations participating in the Istanbul Protocol Project in the Basque Country (IPP-BC) Working Group were Ekimen Elkartea, Asociación para el Estudio de Problemáticas Sociales, Jaiki-Hadi, Prebentzio eta Asistentziarako Elkartea, OME-AEN, Osasun Mentalaren Elkartea/ Asociación de Salud Mental y Psiquiatría Comunitaria, ARGITUZ, Asociación pro derechos humanos, Grupo de Acción Comunitaria (GAC), and Centro de Recursos en Salud Mental y Derechos Humanos. Professionals of the IPP-BC Working Group included Ainara Iraizoz, Ana Gil, Ana Isabel Ruiz de Alegría, Brais Pereira , Eider Zuaitz, Haizea de la Llosa, Iñaki Markez, Iñigo Ibarzabal, Ion Ibañez de Opakua, Itziar Caballero, Itziar Gandarias, Ixone Legorburu, Joana Miren Ruiz, Jone Ortuondo Aresti, Josefina García de Eulate, Julene Zuazua Álvarez, Leire Celaya, Lorena Leiro, Maddi López, Maitane

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Ibernia, María Beloki, Marian Mendiola, Maribi Armendariz, Maritxu Jimenez., Mayi Sarasketa, Miguel Ángel Navarro, Myriam Ruiz, Nagore López de Luzuriaga, Norma Ormaetxea, Oihana Andueza, Olatz Barrenetxea, Pau Pérez Sales, Teresa Velasco Plaza, Urko Zalbidea, Uxoa Larramendi and Yolanda Resano. We are also grateful to Dr. Rasmus Goll at the Department of Gastroenterology, the University Hospital of Northern Norway in Tromsø, for advice on statistical issues.

References

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Amnesty International. (1980). Report of an Amnesty International mission to Spain 3-28 October 1979. London: Amnesty International Publications. Amnesty International. (2009). Spain: Out of the shadows - time to end the incommunicado detention. London: Amnesty International Publications. Argituz, AEN, Ekimen Elkartea, GAC, Jaiki-Hadi, OME, OSALDE, Departamento de Psicología Social (UPV/EHU). (2014). Incommunicado detention and torture. Assessments using the Istanbul protocol. Bilbao: Ekimen Ed. and Irredentos Libro. Basque Government, Presidency. (2013)Informe-base de vulneraciones de derechos humanos en el caso vasco 1960 -2013. Vitoria-Gasteis 2013; June 2013. [Database on human rights violation in the Basque Country]Retrieved from http:estaticos. elmundo.es/documentos/2013/06/14informe_ base_es.pdf Basque Institute of Criminology of the University of the Basque Country. (2016). Instituto Vasco de Criminología. Proyecto de investigación de la tortura en Euskadi entre 1960-2010: Informe preliminar sobre diseño y primeros pasos del estudio sobre la tortura. [Project to investigate torture in the Basque Country 1960 -2010. Preliminary report on design and first steps of the study on torture] Donosti. Retrieved from http://www.eitb.eus/multimedia/ documentos/2016/06/27/1987310/Memoria%20 Proyecto%20tortura%202016.pdf Carver R, Handley L (2016). Does torture prevention work? Liverpool: Liverpool University Press 2016. European Committee for the Prevention of Torture (CPT). Reports from visits to Spain: 1-12 April 1991; 10-22 April 1994; 10-14 June 1994; 22 November - 4 December 1998; 22-26 July 2001; 22 July - 1 August 2003; 12-19 December 2005; 19 September – 1 October 2007; 31 May - 13 June 2011. Retrieved from http://www.cpt.coe.int/ Istanbul Protocol Project in the Basque Country Working Group. (2016). Incommunicado detention and torture in Spain, Part I: The Istanbul Protocol Project in the Basque Country. Torture 26(3): 3-7. Morentin B. (2014). In Incommunicado detention and torture. Assessments using the Istanbul protocol. Bilbao: Ekimen Ed. and Irredentos Libros 2014. Morentin B, Callado LF, Idoyaga I. (2008). A followup study of allegations of ill-treatment /torture from incommunicado detainees in Spain. Torture 18(2): 87-98.

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Morentin B, Petersen HD, Callado LF, Idoyaga I, Meana JJ (2008). A follow-up investigation on the quality of medical documents from examinations of Basque incommunicado detainees. The role of the medical doctors and the national and international authorities in the prevention of illtreatment and torture. Forensic Science International 182:57-65. Muižnieks N (2013). Report of the Commissioner for Human Rights of the Council of Europe following his visit to Spain from 3 to 7 June 2013, para. 134. CommDH(2013)18. Strasbourg. Navarro-Lashayas MA, Pérez-Sales P, Lopes-Neyra G, Martínez MA, Morentin B. Incommunicado detention and torture in Spain, Part IV: Psychological and psychiatric consequences of ill-treatment and torture: trauma and human worldviews. Torture 2016; 26: 34-45. Péres-Sales P, Morentin B, Barrenetxea O, NavarroLashayas MA. (2016a). Incommunicado detention and torture in Spain, Part II: Enhanced credibility assessment based on the Istanbul Protocol. Torture 2016(3); 26: 8-20. Pérez-Sales P, Navarro-Lashayas MA, Plaza A, Morentin B, Salinas OB. (2016b). Incommunicado detention and torture in Spain, Part III: "Five days is enough": the concept of torturing environment. Torture 26(3): 21-33. Petersen HD, Morentin B, Callado LF, Meana JJ, Idoyaga I (2002). Assessment of the quality of medical documents issued in central police stations in Madrid, Spain: The doctor's role in the prevention of ill-treatment. J Forensic Sci 47(2):293-298. The Basque Ombudsman /Ararteko. Estudio sobre el sistema de garantías en el ambito de la detención incomunicada y propuestas de mejora. VitoriaGasteiz 2011. http://www.ararteko.net/RecursosWeb/DOCUMENTOS/1/5_2093_3.pdf United Nations report of the Special Rapporteur on the question of torture: Visit to Spain. 6. February 2004. E/CN.4/2004/56/Add.2. United Nations. (1988) Body of Principles for the Protection of All Persons under Any Form of Detention and Imprisonment. A/RES/43/173. Retrieved from http://www.un.org/documents/ga/ res/43/a43r173.htm United Nations. (2004). Manual on the effective investigation and documentation of torture and other cruel, inhuman or degrading treatment or punishment. United Nations; New York and Geneva. http://www.ohchr.org/Documents/Publications/training8Rev1en.pdf

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United Nations. (2015). Standard Minimum Rules for the Treatment of Prisoners (the Nelson Mandela Rules). 70/175. Retrieved from https://www. unodc.org/documents/justice-and-prison-reform/ GA-RESOLUTION/E_ebook.pdf

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Annex 1 Tool to assess detainee's perception of the medical examination

<Issue

Score>

Acceptable 1 point

Insufficient 2 points

Unacceptable 3 points

Items related to doctor's professional conduct (1-6) 1

The doctor's response to an obvious health need

Appropriate (given the circumstances)

Insufficient

Absent or irrelevant

The doctor's response to allegations of torture

All allegations were recorded

Something was entered into the record

Absent or irrelevant

The doctor's reply The doctor gave the to detainee's question information about hour and date

The doctor did not reply, but let the detainee look at his watch

The doctor refused to answer referring to order from the police

The doctor enquired The doctor asked about ill-treatment specifi-cally about ill-treatment

The doctor did so in an ambiguous manner

The doctor did not ask at all

A physical examination was done

A full examination was done, or an invitation to do so was given

Some parts of the No initiative to body were examined, perform a physical examination

Duration of the medical encounter

30 minutes or more

15-30 minutes

A few minutes

Items related to detainees' confidence (items 7 -11) Detainee's confidence in the doctor

Directly or indirectly Confidence expressed conficoncerning some dence aspects

Expressed lack of confidence

Detainee's perception of the doctor's affiliation to the police

The detainee thought that the doctor could be a police officer

The detainee observed that the doctor acted as a police officer

Detainee's perception of the doctor's cooperation with the police

The detainee thought - without substantiation - that the doctor collaborated

The detainee's observations substantiated that the doctor collaborated

The doctor treated information confidentially and was not present during interrogations

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The detainee's The record could be motivation to see the useful or medical doctor treatment could be given

The examination No motivation at all was a break in ill-treatment or an opportunity to be informed about time

The detainee alleged Reported all ill-treatment to the ill-treatment in spite doctor of risk of reprisals

Reported something at some occasions

Did not report at all out of fear for reprisals

Ambiguous message that could be threatening

Direct threats

Items on reprisals (items 12 -13) 12

Threats of reprisals for reporting ill-treatment to the doctor

Reprisals for having reported ill-treatment to the doctor

Punishment for having reported ill-treatment

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Items related procedural safeguards (items 14 -19) 14

Did the doctor introduce him- / herself as a doctor

ID card was shown

Orally without showing an identity card

General attitude of the doctor towards the detainee

Interested or empathic

Distant or lacking interest

Cold or hostile

The detainee received information about objective of the examination

Information included the aim of documenting (ill-) treatment

Some information, but not about documenting (ill-) treatment

No information at all

Presence of officers during the medical examination

Officers within hearing distance, e.g. with open door to doctor's office

Officers present during the medical examination

Place of examination The doctors office

The cell

Public place without privacy

Manner in which detainee was taken to the doctor

Guided by officers Taken by the officers Taken while hooded who did not take who interrogated or forcibly bent part in interrogations forward

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An Account of ‘Life after Guantánamo’: a rehabilitation project for former Guantánamo detainees across continents Polly Rossdale, MA Cantab, E.MA, Katie Taylor, MA

Key points of interest:

• Reprieve’s Life after Guantánamo (LAG) project suggests the value of a Multidisciplinary Approach in rehabilitation of torture survivors. • Undertaking advocacy at the same time as rehabilitation made the project more effective and legitimate amongst both users and other political actors. • LAG guidelines address pre-planning for resettlement, setting up a resettlement team, dealing with the media and mitigating stigma, immediate issues upon an individual’s arrival in the new host country and longer term integration planning. • A security resettlement framework, rather than a humanitarian one, impedes rehabilitation. • Former Guantánamo detainees found peer support important for their recovery.

This paper describes a project established in 2009 by the human rights charity, Reprieve, to coordinate rehabilitation for men who have been released from long-term detention at the US military base of Guantánamo Bay. The majority of the men referred to the project were deemed unable to return to their home country because of the risk they faced of torture or other persecution and were therefore resettled in a third country.

Thanks are extended to Michelle Farrell, BA, LLM, PhD, our guest legal editor, who together with the Editor in Chief jointly edited the in the name of the war on terror section.

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Abstract

This paper also refers to Tunisian former Guantánamo detainees with whom Reprieve worked, who had initially been resettled in a third country but then following the Jasmine Revolution and the fall of the Ben Ali regime, were able to return to their home country. Reprieve then provided assistance to them and their families under the Life after Guantánamo in Tunisia project. This paper briefly outlines the abuse and nature of psychological control at Guantánamo and, based on the first-hand experiences of the Project Coordinator and Caseworker, offers non-clinical observations of the apparent consequences of this control on the former detainees who were referred to the project. The Life after Guantánamo project facilitated social, medical, psychological, legal and financial assistance in partnership with local service providers and through liaison with host governments and intergovernmental organisations, such as the International Organisation for Migration (IOM), United Nations High Commissioner for Refugees (UNHCR) and the International Committee of the Red Cross (ICRC). The paper recounts the type of assistance provided, highlights some of the challenges faced and, based on learnings made over the project’s eight year duration, makes recom-

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mendations, for future work with former Guantánamo detainees and others who have been detained and subject to torture and inhuman and degrading treatment in the ‘War on Terror’. Keywords: Guantánamo, torture rehabilitation, War on Terror, psychological torture, indefinite detention, torturing environment Background

Since 2002, some 780 men have been held at the US military prison at Guantánamo Bay (as at June 17th 2017) (The New York Times, 2017). According to the 2014 report of the Senate Intelligence Committee Study on CIA detention and interrogation program, men held at Guantánamo Bay have been subjected to rendition, torture or other cruel, inhuman and degrading treatment or punishment and indefinite detention, the majority without charge or trial. A 2006 study by Seton Hall Law School of 517 of the detainees indicated

that 86% of the men were ‘bounty’ prisoners, captured by Pakistani authorities or the Northern Alliance and handed over to the United States for a significant sum of money. Flyers distributed by the U.S. promised “wealth and power beyond your dreams” for those handed over. Only four have, so far, received final convictions by a military commission (US Court of Military Commission – Guantánamo, n.d., Denbeaux and Denbeaux, 2006). An estimated 741 men have reportedly been transferred to 59 countries. However, this number is an estimate because of prisoners who were hidden in CIA-run black sites and because the destination country is not known in 10 cases (The Miami Herald, 25 October 2016, New York Times, n.d.). Of these, 142 men were transferred to third countries under Obama’s administration (2009-2016) because of instability in their home country or because they were deemed to face a risk of torture or persecution.

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Table 1: Geographical location of resettlement of detainees Third Countries which Accepted Former Guantánamo Detainees under the Obama Administration

Number of Former Guantánamo Detainees Resettled

Albania

Belgium

Bermuda

Bosnia and Herzegovina

Bulgaria

Cape Verde

El Salvador

Estonia

France

Georgia

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Germany

Ghana

Hungary

Ireland

Italy

Kazakhstan

Latvia

Montenegro

Oman

Palau

Portugal

Qatar

Saudi Arabia

Senegal

Serbia

Slovakia

Spain

Switzerland

UAE

Uruguay

Total

142

The nature of the Guantรกnamo regime has been written about fairly widely and will therefore only be briefly outlined here in order to provide a context for what follows.

What is considerably less well-known and understood is its effects and the efforts that have been made to assist released men in their recovery. Conditions and Abuse

LAG is unable to provide information on the men it worked with in each country as this would mean breaching confidentiality due to the small number resettled in each country to there being so few numbers.

Guantรกnamo is a regime of isolation and near total control. Despite the fact that the prison is arguably under the greatest public spotlight

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Source: Reprieve, based on internal documents and the New York Times Guantรกnamo Docket, n.d.i

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in the world, information about the regime and conditions has been achieved through dogged and pioneering litigation and human rights activism. For example, it was only after the landmark case of Rasul v Bush in 2004 that defence lawyers, including Reprieve’s founder Clive Stafford Smith, gained access to the prison (Rasul v. Bush 542 U.S. 466 (2004)). Detainees at Guantánamo initially had no contact whatsoever with the outside world. On arrival in Guantánamo, they had no idea where they were. According to Reprieve clients, they often guessed based on the weather – some thought Brazil, others Qatar. Each step towards greater transparency was hard won as a set of legal and administrative practices was specifically designed to keep things hidden (BBC, 2014). Reprieve lawyers and the staff of the Life after Guantánamo project observed that these practices designed to ensure opacity had significant psychological consequences for the detainees.

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Psychological Control

As highlighted in the US Senate Select Committee on Intelligence’s report on CIA torture, published in redacted form in December 2014, interrogation techniques developed for the U.S.’ ‘War on Terror’ detention relied heavily on systematised psychological torture (Senate Intelligence Committee Study on CIA Detention and Interrogation Program, Findings and Conclusions no. 13, 2014). Interrogation at Guantánamo is based on a military Cold War era programme aimed at training forces in survival and resistance following capture by an enemy: SERE (survival, evade, resist, escape). With the explicit objective of breaking the personality, SERE was reverse engineered so as to extract information rather than support withholding information (Ibid). The psychologists

contracted had no experience in interrogation nor relevant cultural or linguistic knowledge. They developed interrogation techniques based on the theory of ‘learned helplessness’. According to the Senate Committee Report, in this context this theory referred to the belief that a detainee would become passive and depressed and thereby cooperative in interrogation if subjected to uncontrollable or adverse events (Senate Select Committee on Intelligence: Committee Study of the Central Intelligence Agency's Detention and Interrogation Program, 2014). Practices sought to destroy the sense of self and the relationship to others; in the words of former CIA Director Michael Hayden, for the detainee to “get over his own personality and put himself in a spirit of cooperation.” (Senate Select Committee on Intelligence: Committee Study of the Central Intelligence Agency's Detention and Interrogation Program, 2014 p.486). Health professionals – the very people from whom the men have to seek help – were complicit in or perpetuated this psychological control (The PLoS Medicine Editors, 2011; Borchelt and Fine, Physicians for Human Rights, 2005). Independent reports and Reprieve clients describe how the provision of healthcare was conditional on “cooperation.” (Bloche & Marks, 2005). Psychologists have participated in interrogations. Detainees have been subjected to non-consensual treatment, including the prescription of drugs without being informed of the medication prescribed (Denbeaux, Camoni, Beroth, Chrisner, Loyer, Stout, & Taylor, 2011). Guantánamo operates a particular system of indefinite detention. Very few of the men detained there have ever been charged with any crime or tried. It took two and a half years from the first ‘War on Terror’ use of the prison for the Supreme Court to clarify that U.S. courts had jurisdiction to consider challenges brought by Guantánamo detain-

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ii iii

Reprieve client files.. www.reprieve.org.uk

Life after Guantánamo

Reprieve is an international Human Rights NGO founded in 1999 by Clive Stafford Smith who was one of the first lawyers to gain access to prisoners at the military base, with a view to defending their rights.iii Reprieve’s lawyers have represented upwards of 80 men detained in Guantánamo. Based on these crucial lawyer-client relationships and, in response to President Obama’s Executive Order days after taking office (Executive Order 13492, 22 January 2009), that he would close the prison, Reprieve established ‘Life after Guantánamo' (LAG) in 2009 to facilitate access to medical, psychological, social and legal support for former detainees who had been released to third countries. In addition, from 2012, LAG also ran a project in Tunisia, providing direct services to former detainees and their families for the first time. The tasks of the LAG project are multifarious but consist primarily of advocacy, coordination and pastoral care. Men were either referred to the project by their lawyers or, as LAG’s reputation grew, by other former detainees or as self-referrals. Wherever political contexts permitted, staff visited former detainees on or soon after arrival in their new host country to work directly with them, with host governments and international and local NGOs and, where necessary, to identify specialist service providers. Such visits were subsequently supplemented by regular skype and phone contact with the former detainee, their family members, government officials and others responsible for their care. From 2009 until 2013, the first author was Project Coordinator of Reprieve’s Life after Guantánamo project. She then continued her oversight of the project as Deputy Director of the Abuses in Counter Terrorism team. She has a background

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ees regarding the legality of their detention (Rasul et al. v Bush, President of the United States, 2004 No. 03-334). However, even if they were cleared for release in the administrative process created to review their detention, they still could, and many did, remain detained. Being cleared for release, when they had not been charged with a crime, is the closest most of the detainees have got to being ‘declared’ in some fashion innocent. Detainees and former detainees have made it clear that this ‘indefinite detention without trial’ generates terrible uncertainty, deep mistrust and hopelessness.ii More generally the prison system is run on the basis of punishments and incentives (United Nations Economic and Social Council, 2006). Basic necessities, soap and toilet paper, even water, are ‘comfort items’, given or removed when someone is deemed compliant or not. Men who inform on others are rewarded with anything from hamburgers to pornography (The Guardian, 2013). Punishments include long periods of solitary confinement and force-feeding for hungerstrikers (American Civil Liberties Union Appeal for Justice et al., 2013). Exposure to strobe lights, noise torture, sensory deprivation and sleep disturbance have also been used (Lewis, 2004), as well prolonged isolation, sexual and cultural humiliation (Borchelt & Fine, Physicians for Human Rights, 2005). Enhanced interrogation techniques included these and other practices such as stress positions, temperature manipulation, beatings, waterboarding and threats of harm (Physicians for Human Rights, 2007, 2008).

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working with refugees and victims of torture and she left Reprieve in 2015. The second author joined Reprieve as Life after Guantánamo Caseworker in 2010. Prior to joining Reprieve she worked in the Middle East, specialising in children’s rights. She is now a Deputy Director and has coordinated the Life after Guantánamo project since 2014. The two authors had daily contact with former Guantánamo detainees, conducted dozens of country visits, identified potential partner organisations, developed support plans and advocated on the men’s behalf to governments and other stakeholders.

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Responding to Needs

The Life after Guantánamo project followed two different approaches: in Tunisia, LAG established a local multidisciplinary team to provide direct services to former detainees, their families and the families of men still detained in Guantánamo, whereas, in other countries, LAG sought to coordinate and facilitate access to care and services, rather than offer direct provision of the needed social, medical, psychological and legal services. In 2012 LAG piloted the unique project in Tunisia, setting up the first multidisciplinary torture rehabilitation services after the revolution, and establishing a local team to provide direct psychological, medical, social and legal support. Tunisia was selected for this pilot project for several reasons: the presence of a strong human rights community who had previously worked in semi clandestine conditions under the Ben Ali regime and were now keen to bring human rights actions and discourse into government. Reprieve had had several Tunisian clients in Guantánamo and had established relationships with Tunisian human rights defenders, as well as their clients’ families. Reprieve encountered an interest and desire for such a project from all these actors. From

2012 33 people received assistance through the Life after Guantánamo Tunisia project. Both inside and outside of Tunisia, former detainees were referred to the project by their U.S. habeas counsel. As the project evolved, former detainees began to refer other former detainees and we also began to receive self-referrals. Once referred to the project, the LAG team would work with the former detainees to assess their rehabilitation goals and the obstacles that the project could meaningfully address in order to reach their goals. Family reunification was often key to former detainees’ stated goals, and so LAG treated the family unit as integral to rehabilitation. Therefore, particularly in the Tunisian project, key family members themselves became beneficiaries of the project and engaged with the LAG team on goal-setting to address their status as victims of secondary-trauma. Once a beneficiary’s goals were established through conversations with the LAG team, and the obstacles to those goals identified, the LAG team would work to identify needed services to address these obstacles whether they were social, legal or medical. This is where the work in Tunisia differed; whereas elsewhere, Reprieve would identify, sensitise and coordinate local services, in Tunisia several factors made the provision of direct services viable and valuable. There was a dearth of available existing specialist rehabilitation services in Tunisia but professionals were keen to offer support to this group of men, recognising that they were victims of injustice and torture. Moreover, these professionals were able to provide culturally appropriate assistance in the men’s native language. This meant that the best solution there was to recruit and train a multidisciplinary team including a doctor, psychiatrist and social workers who could directly provide medical,

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ent second opinions on medical examination results; the provision of direct medical and psychiatric care to beneficiaries in Tunisia through the three-year project there. LAG conducted legal interventions in 27 cases (37%). For many of the men resettled in third countries, their legal status was either unclear or the rights that accrued to that status were undefined or there was no obvious legal pathway to regularisation of their status. The majority of legal interventions therefore involved identifying or working with a local lawyer to regularise immigration status. In a handful of cases LAG took witness statements and instructed other counsel in relation to tort claims over governments’ complicity in the U.S.’ detention programme and the resulting rendition and torture. Twelve clients were re-imprisoned after release from Guantánamo, either in immigration detention as a result of being resettled without a clear legal status, or as a result of governments re-detaining men on the basis of discredited allegations which followed them from Guantánamo. LAG assisted in efforts to secure the release of seven of these men, working with local counsel and conducting media advocacy. It should be noted that the absence of an intervention does not indicate an absence of need. In some cases, LAG staff were aware of needs which could not be met by the project because staff were not permitted to visit the country or because those needs fell outside the remit of the project. Challenges: Impact of detention, organisational and political

Observations on the impact of Guantánamo detention: At the beginning of the project in 2009, one former Guantánamo detainee asked: “What do you even do? What is this Life after Guantánamo Project? If you call it

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psychological and social care. The level of contact depended upon the wishes of the beneficiary and his/her specific circumstances. Regular follow up meant that LAG could facilitate new services in response to a beneficiary’s evolving rehabilitation needs. There was no formal exit of the project; rather, beneficiaries would reach a stage where they felt that LAG’s support was no longer needed. In relation to LAG’s work beyond Tunisia, in third countries, the support and assistance for former detainees involved a complex web of actors, which complicates the possible assessment of impact. The discussion below is based on a review of LAG’s case files of 73 former detainees and family members from August 2009 – June 2015 in 21 countries and describes only the type of assistance LAG offered. The types of assistance offered were based on the goals established by the beneficiaries in discussion with the LAG team and what was practical and within the remit of the project. Across all of LAG’s work, the majority of interventions were social: LAG provided social assistance in 62 cases (85%). Social care included liaison with host governments, NGOs and private landlords to deal with housing issues, to facilitate access to financial support, language learning, vocational training, other job-seeking support and general integration and country orientation. This work included advocating with the host countries’ governments to provide a consistent and suitable stipend for resettled men and sourcing external funding for needed educational programmes and vocational training. In 50% of cases (37) LAG offered healthcare-related assistance - facilitating physical or psychological care. Health-related interventions included sourcing funding and arranging for medico-legal evaluations and for emergency surgery; obtaining independ-

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that, you have to give life.” This man was expressing the sense that the Guantánamo regime destroys the feeling of being alive. Any rehabilitation project needs to be aware of and address the depth and longevity of this experience. Furthermore, the men’s expressed feeling of the utter destruction of their lives in the wake of Guantánamo detention demonstrates the urgent need for a dedicated and holistic rehabilitation programme tailored to their unique experiences and circumstances. Guantánamo detainees have been exposed to prolonged periods of traumatic events from their initial capture and extraordinary rendition onwards. Over the course of the eight years of the LAG project’s existence so far, the authors have observed certain patterns of behaviour on release and resettlement which would fit within a range of Post Traumatic Stress Disorder symptoms such as persistent insomnia, memory loss, inability to concentrate, disturbances in executive functions. These and other symptoms that include confusion, anger and the inability to trust are well known sequelae of torture (Turner and Gorst, 1993). In Guantánamo mistrust and paranoia have also arisen as a result of specific circumstances: sensory deprivation, isolation, inhumane treatment, humiliation and attacks to identity, the indefinite nature of the detention, administrative and legal practices that exert psychological control, a profound sense of personal injustice, opacity and deception. A lack of confidence is especially noteworthy. According to Reprieve clients, interrogators often pretended to be a doctor or the Red Cross (ICRC) or a detainee’s defence lawyer. All lawyers have to be U.S. citizens in order to obtain the security clearance required to work in Guantánamo but Reprieve clients reported that when they first met an American who introduced themselves as

their lawyer, it was hard to trust that they were indeed who they said they were. Some also reported being put on a plane and told they are going home, only to be returned to their cell or moved to another part of the camp. Paranoia and mistrust after many years of experiencing such practices are logical responses to illogical events. The authors observed a tendency on release for former detainees participating in the project to see the world outside of Guantánamo as structured like Guantánamo and to behave and act accordingly. To many of these men, the outside world may not feel metaphorically like Guantánamo but as though it really is Guantánamo. A former detainee may not feel the difference between walking freely down an elegant Central European street and sitting in a steel cell in Camp V. “I am in a big Guantánamo,” said one.iv Acts of refusal become the main coping mechanism – often making use of the body, the only thing over which the men had some control during their incarceration. Hence, hunger strikes to protest indefinite detention without charge, when outside become hunger strikes to protest an amorphous, ill-defined sense of injustice, articulated as a fitting protest for a meagre stipend or a perceived failure on the part of a caregiver (Reuters, 2010; The Miami Herald, 1 September 2016). Former detainees who for years have largely only been able to articulate their needs through demands made to military guards, for toilet paper or improved food for example, came to expect that relationships in the outside world would operate on a similar demand-response basis. For example LAG project staff observed that some former detainees would focus on seeking to improve

iv Reprieve client file.

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absence of any apology, acknowledgement or legal redress, an overwhelming sense of non-specific injustice permeates everything. When the service provider is not distinguished from the original perpetrator there is a barrier to assistance.vii Thus, one of LAG’s vital functions is to sensitise service providers to these particular perceptions and work with both them and the former detainees to build a relationship of trust so that the assistance provided was both appropriate to the former detainees’ needs and offered in a way that the men are able to benefit from it. The enormity of the injustice is also sometimes mirrored by a concomitant personal grandiosity. Grandiosity in a psychological sense is usually defined in terms of an inflated sense of self-importance, an exaggerated belief in one’s power or uniqueness. Whilst the authors have noted in multiple cases examples of apparently grandiose behaviours, they are not aware of any instances where a psychiatric diagnosis has been made that takes account of this type of symptomatology. Rather, over time and experience, LAG staff came to see this behaviour as a natural sequela of previous impotence when in Guantánamo incongruously coupled with their role on the international political stage simply by virtue of being Guantánamo detainees. The result of this for the former detainees and for the LAG project was a further layer of unrealistic expectations of what post-release life should be like. This poses challenges both for the

Reprieve client file.

vi vii

Reprieve client files.

This could be seen as part of the tendency towards overgeneralization amongst trauma victims and negative assumptions. See ‘Schema Change Perspectives on Post Traumatic Growth’, R. Janoff Bulman in Handbook of Posttraumatic Growth: Research and Practice, eds. Lawrence Calhoun and Richard Tedeschi. p.86. 2006. New York.

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the minutiae of daily living conditions rather than securing a suitably protective legal status. Similarly, the authors observed that one aspect of this institutionalisation was how the punishment and incentive regime continued to play out, outside of Guantánamo. Thus for instance, men may perceive an electrical power cut or poor internet reception as a personal affront — a targeted unjust punishment which must be remedied immediately—rather than an everyday annoyance experienced by many. Injustice and broken promises in Guantánamo become a perceived schema of unfairness and broken promises in the outside world. One former detainee described the impact of this particular form of institutionalisation very poignantly: “I thought actually before I was released ‘I can cope with this, no problem, I’ve survived Guantánamo, I can survive normal life.’ Actually I found normal life at that stage was harder than Guantánamo. I could deal with, I learned how to deal with GTMO. I can deal with the officers, I can deal with the guards, I can deal with the six or seven people who come into my cell and have a fight with me, but actually I could not deal with [normal] people.”v The result is that for some the ‘normal world’ feels impossible and their response is: “I’m going back to Gtmo where I just eat and sleep and wait for the end of my life”. “My future is black. I won’t live longer than 10 years”.vi There is the challenge of re-learning to distinguish the different roles of those with whom they interact. Guantánamo’s world was small, myopic even: interactions were limited to the guards and (depending on the security level) to other prisoners, occasionally to a military doctor or a psychologist, rarely to a lawyer or a delegate of the ICRC. On release there may be a tendency to see and treat everyone as part of a small, intimate world. In the

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project, in terms of managing expectations, and for the men themselves in both psychological and practical terms. The U.S. authorities repeated that the men who were detained in Guantánamo are the “worst of the worst”, so bad that the old rules don’t apply to them and new ones must be found. The men have been singled out and fashioned with a grandiose narrative around them by others: former Secretary of Defence Donald Rumsfeld told us that these men were “among the most dangerous, best trained, vicious killers on the face of the earth.” (The New York Times, 2002). Then, after release, the Guantánamo regime, which has been omnipotent in the daily lives of the prisoners, continues symbolically in terms of global power and high-level intervention. In order to be released they are not subject to the ordinary rule of law; a court order on its own will not guarantee release, but the signature of the U.S. Secretary of Defence is required and they are subject to the whims of Congress, to diplomatic negotiations and political deals conducted with foreign governments by a Special Envoy within the State Department.viii It does not seem surprising if some of this external political narrative is absorbed internally, possibly as a psychological defence, albeit in complex and indirect ways. A further response to omnipotent control is to ‘split’. This defence mechanism involves dividing helpers into good and bad, communicating different messages to each and setting some up to fail. This challenge to service providers and caregivers requires very tight communication and coordination in response. Lastly, self-referential thoughts, feelings and perceptions can sometimes lead to paranoia amongst former detainees. As with the sense of injustice, what the men experience once out of Guantánamo is grounded in reality as the suspicion and mistrust is

based reasonably on past experience. Former detainees have been surveilled, monitored and harassed and even re-imprisoned after release. Some are constantly shadowed. Security services have approached even those that a former detainee may have casually spoken to, advising them to avoid “retired terrorists” and they have reportedly told landlords to evict former detainees. On the other hand, this everyday reality can tip over into paranoia. The huge difficulty for these often surveilled men therefore is in making an accurate judgement of their environment: when is a landlord evicting them because they simply no longer want them as a tenant and when is it because he has been told to do so by the security services? At LAG, we are reminded often of the saying, just because you’re paranoid doesn’t mean they are not after you. Organisational challenges: Many former detainees were sent to States that have little tradition of welcoming refugees, and little or no welfare infrastructure. Some have only a very small and isolated Muslim community. The majority of governments - whatever the nature of the regime - have opted to place the resettlement programme in the hands of the security services, rather than officials from the Ministry of Immigration, Social Affairs or Health or NGOs with experience working with refugees or torture survivors. Framing former Guantánamo detainees as potential security threats rather than as torture victims seeking refuge has the effect

viii

For a brief summary of the efforts to close Guantánamo and the legislative and political obstacles see ‘With final detainee transfer, Obama’s Guantánamo policy takes its last breath’, Missy Ryan and Julie Tate, Washington Post. 28 Dec 2016.

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of replicating many of the abuses of their detention including perpetuating arbitrary systems of control and demonization. There are common and identifiable patterns across resettlements, such as the reliance on a security rather than humanitarian framework described above. However, men imprisoned in Guantánamo have been released to fifty-nine different countries and each resettlement context is different and poses new challenges. Any overarching, international rehabilitation project needs to be agile and open to respond to these new settings appropriately. Political challenges: In the case of Guantánamo, the notoriety of the name is doubleedged. The media and political attention paid to these cases offers a platform on which to re-examine the narrative of the ‘War on Terror’. This has value in itself and can foster an atmosphere conducive to rehabilitation where the individual’s voice and story is truly heard. On the other hand, the media is ready to exaggerate any perceived failure. For instance, the failure of a former detainee to hold down a job within a year of release has been the subject of criticism in the national press. As outlined above, excessive attention can feed grandiose behaviours and facilitates the kind of transactional demand-and-response relationships that were nurtured so corrosively in the prison.

Over the last eight years LAG staff have observed certain consistent findings and developed recommendations that may be usefully applied across various country contexts. The Value of a Multidisciplinary Approach: Since the effects of torture are multiple, many torture rehabilitation programmes around the world are multidisciplinary

Peer support and the value of ‘Brotherhood’: It is important to note that this project supported only a small percentage of detainees ever released from Guantánamo and that the vast majority of former Guantánamo detainees deal with life and try to recover without any professional support whatsoever. Many former Guantánamo detainees relied primarily on each other as their primary source of support, indeed, they are the only people who really know what the experience was like. Until very recently all recovery from the ordeal of Guantánamo detention took place

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Findings

(Jaranson & Quiroga, 2011). The LAG team shared the view that a multidisciplinary approach was imperative to support former Guantánamo detainees’ rehabilitation needs: progress made in one aspect of a beneficiary’s life could be rendered meaningless by a crisis in another aspect. For instance, social goals, such as language-learning, were often undermined by an insecure legal status which prevented former detainees from imagining a safe future in their host countries. This sense of insecurity, combined with a difficulty in focusing characteristic of survivors of torture makes tasks such as new language acquisition much more challenging. There is also a practical aspect: former detainees would question the value of learning a new language such as Hungarian, Georgian or Kazakh, if they did not know how long they would be permitted to reside in the country. In a context where there is no legal remedy or redress, such as Guantánamo, the importance of broadly conceived reparations is even greater for moral, strategic and for therapeutic reasons. In the absence of compensation or formal redress, the provision of rehabilitation support can itself be reframed as an aspect of reparation.

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in the context of many of the men’s friends, their ‘brothers’, still being detained. Naturally, after release, many were preoccupied by the fate of those they had left behind. In this regard, the Life after Guantánamo project had an advantage: knowing that the project and legal colleagues at Reprieve are assisting their ‘brothers’ still in prison was important to trust-building and a sense that notwithstanding the personal battles they were facing, others are enduring worse. Reprieve’s dual role of representing men in Guantánamo and offering rehabilitation upon release therefore meant that firstly, prior knowledge of Reprieve and its staff made the men more open to receiving assistance from LAG and secondly, because of the ongoing legal assistance provided to their detained ‘brothers’, increased the benefit former detainees saw in the rehabilitation.

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The value of advocacy in a rehabilitation project: Reprieve’s advocacy can complement rehabilitation coordination and adds value by helping to challenge the narrative that all Guantánamo detainees are guilty of crimes of terrorism: a fallacy that perpetuates stigma and inhibits recovery.ix In 2012 and early 2013 in Tunisia, LAG engaged in advocacy with the new Tunisian government urging it to bring their citizens home. This dialogue also facilitated other discussions between LAG and government officials about the

Similarly, it has been suggested that public awareness of trauma impacts the outcomes of PTSD, with greater awareness reducing the stigma. (Purtle, Lynn, & Malik, 2016) x

Due to the sensitivity around Guantánamo releases LAG often worked bilaterally. These guidelines were shared with individual governments that expressed an interest in learning from past experiences of releases.

rehabilitation of those who were already home. Beneficiaries told staff that the programme’s dual role in supporting their rehabilitation and advocating for the release of those still detained in Guantánamo was important to them. Best Practice Guidelinesx: The Life after Guantánamo project developed Best Practice Guidelines for governments that had agreed to resettle men released from the US military prison at Guantánamo Bay. The guidelines address pre-planning for the resettlement, setting up the resettlement team, dealing with the media and mitigating stigma, immediate issues upon an individual’s arrival in the new host country and longer term integration planning. These guidelines were based on principles LAG had sought to put in place that would facilitate recovery by being diametrically opposed to the Guantánamo regime. After years of indefinite detention and arbitrary rules and punishments, the guidelines recommend clarity, flexibility and transparency as key principles in resettlements. This applies to all aspects of the resettlement from the amount of financial support, to the legal status, freedom of movement, family reunification, to the duration of support. Trained by a clinical psychologist and trauma specialist LAG developed collaborative goal-setting as a useful tool because any assistance designed without the men’s input is likely to be perceived as an imposition and rejected; long term integration planning should be developed in partnership. Final remarks and recommendations

The effectiveness of LAG’s approach to rehabilitation has received recognition. Guantánamo’s Periodic Review Board, the administrative body established by President Obama, which determined whether detainees

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the fact of survival. Acknowledgements

Acknowledgement should be given to Dr Brock Chisholm, a co-founder of Trauma Treatment International, who trained the LAG Tunisia team on topics that included mental health difficulties of SERE survivors, assessment tools, treatment planning and goal setting. The authors would particularly like to thank the members of the Life after Guantánamo Tunisia team, Rim ben Ismail, Dr Zeineb Abroug, Dr Elias Ben Daoud and Sana Rebhi. In particular, we pay tribute to the compassion and dedication of Drs. Abroug and Ben Daoud who have both since passed away.

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can be cleared for release, cited support from Reprieve’s 'Life after Guantánamo' project as a positive factor supporting a decision to clear a detainee for release. Reprieve’s LAG project seeks local and international partnerships and cooperation and is guided by the articulated goals and needs of the former detainees. In one sense however, LAG staff are not, or at least not always, “on the front line”. Former detainees also sometimes receive crucial assistance from doctors, psychologists, psychiatrists and social workers in their new host country. These professionals may work for the government, for NGOs, IGOs or independently in private practice. Several experts from IRCT member centres have provided medical and psychological support. One suggestion to take LAG’s findings forward would be to establish a network through which these professionals could provide more systematised support, exchange experiences, evaluate treatments and develop further recommendations and best practice. In Guantánamo ‘due process’ was sacrificed at the altar of a politics of fear. After years of being built up as “the worst of the worst” during detention, there follows on release the flurry and the unbearable weight of expectations of what freedom might mean. The men are faced with the difficulty of what freedom actually is. Often the tools they have to cope with this are institutionalized ones, incentivised and transactional. The guiding principles for rehabilitation and reintegration for these men have to be based on undoing the psychological internalization of the regime. Hence the value of clarity, transparency, flexibility and beneficiary goal-setting. Recovery from the trauma of Guantánamo can build on the sole positive aspects of the detention experience: the importance of a sense of ‘good’ brotherhood and ultimately the strength inherent in

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References American Civil Liberties Union Appeal for Justice et al (2013). ‘Joint letter to Chuck Hagel on the force-feeding of hunger-striking prisoners at Guantánamo Bay. Retrieved from https://www. hrw.org/news/2013/05/13/joint-letter-chuckhagel-force-feeding-hunger-striking-prisonersguantanamo-bay. American Psychologist Association. (2015). Diagnostic and Statistical Manual of Mental Disorders (DSM–5) (5th Edition). BBC (2014). Guantanamo Bay: Force feedings that test US secrecy. 10 Oct 2014. Retrieved from http://www.bbc.co.uk/news/magazine-29556641. Borchelt, G., Fine, J. (2005) Break them Down: Systematic Use of Psychological Torture by U.S. Forces. Physicians for Human Rights. Retrieved from https://s3.amazonaws.com/PHR_Reports/ break-them-down.pdf. Bulman R.J. (2006). Schema Change Perspectives on Post Traumatic Growth. In Calhoun, L. and Tedeschi, R. (Eds.), Handbook of Posttraumatic Growth: Research and Practice. New York. Denbeaux, M., Denbeaux, J. (2006). Law Report on Guantanamo Detainees. A Profile of 517 Detainees through Analysis of Department of Defense Data. Retrieved from http://law.shu. edu/publications/guantanamoReports/guantanamo_report_final_2_08_06.pdf. Denbeaux, M., Camoni, S., Beroth, B., Chrisner, M., Loyer, C., Stout, K., Taylor, P. (19 May 2011) Drug Abuse. An exploration of the government’s use of mefloquine at Guantanamo. Seton Hall Law School. Retrieved from http://law. shu.edu/ProgramsCenters/PublicIntGovServ/ policyresearch/upload/drug-abuse-explorationgovernment-use-mefloquine-gunatanamo.pdf. Executive Order 13492. (2009). Review and Disposition of Individuals Detained at the Guantánamo Bay Naval Base and Closure of Detention Facilities. Retrieved from https://www.gpo.gov/fdsys/ pkg/FR-2009-01-27/pdf/E9-1893.pdf. Gregg Bloche, M., and Marks, J.H (2005) Doctors and Interrogators at Guantanamo Bay. N Engl J Med 2005; 353:6-8 July 7, 2005 DOI: 10.1056/NEJMp058145. Retrieved from http://www.nejm.org/doi/full/10.1056/ NEJMp058145#t=article. Guardian, The (2013). ‘CIA turned Guantánamo Bay inmates into double agents, ex-officials claim. 26 Nov 2013. Iacopino, V. & Xenakis, S.N. (2011). Neglect of Med ical Evidence of Torture in Guantánamo Bay: A Case Series. PLoS Medicine. https://doi. org/10.1371/journal.pmed.1001027

Jaranson, J., and Quiroga, J. (2011). Evaluating the services of torture rehabilitation programmes: history recommendations. Torture Vol 21(2). Lewis, N.A., (2004). Red Cross Finds Detainee Abuse in Guantánamo. The New York Times 30 Nov 2004. Retrieved from http://www.nytimes. com/2004/11/30/politics/red-cross-finds-detaineeabuse-in-guantanamo.html on 28 Feb 2017. Mehta, C. and Dougherty, S. (December 2015). Truth Matters: Accountability for CIA Psychological Torture. Physicians for Human Rights. Retrieved from https://s3.amazonaws.com/ PHR_Reports/truth-matters.pdf. Miami Herald, The (1 September 2016) ‘Friend says ex-Guantánamo detainee weak from hunger strike’. Retrieved from http://www.miamiherald. com/news/nation-world/world/americas/guantanamo/article99337517.html. Miami Herald, The (25 October 2016). By the Numbers, Retrieved from http://www.miamiherald. com/news/nation-world/world/americas/guantanamo/article2163210.html. New York Times, The (n.d.) Guantanamo Docket, Retrieved from https://www.nytimes.com/interactive/projects/guantanamo/transfer-countries. Physicians for Human Rights & Human Rights First (August 2007) Leave no Marks. Enhanced Interrogation Techniques and the Risk of Criminality. Retrieved at https://s3.amazonaws.com/ PHR_Reports/leave-no-marks.pdf. Physicians for Human Rights (2008) Broken Laws, Broken Lives. Medical Evidence of Torture by US Personnel and its Impact. Retrieved at https://s3.amazonaws.com/PHR_Reports/BrokenLaws_14.pdf. Purtle, J., Lynn, K., and Malik, M. (2016) Calculating The Toll Of Trauma” in the headlines: Portrayals of posttraumatic stress disorder in the New York Times (1980–2015). American Journal of Orthopsychiatry, Vol 86(6), 2016, 632-638. Rasul et al. v. Bush, President of the United States et al. (2004) No. 03-334. http://caselaw.findlaw. com/us-supreme-court/542/466.html. Rasul v. Bush 542 U.S. 466 (2004). Retrieved from https://supreme.justia.com/cases/federal/ us/542/466/. Reuters, ‘Guantanamo detainees in Slovakia enter hunger strike’ (24 June 2010) Retrieved from http://uk.reuters.com/article/idUKLDE65N220. Ryan, M., and Tate, J. (2016) With final detainee transfer, Obama’s Guantanamo policy takes its last breath. The Washington Post 28 Dec 2016. Retrieved from https://www.washingtonpost. com/world/national-security/with-final-detainee-

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transfer-obamas-guantanamo-policy-takes-itslast-breath/2016/12/28/dfdf8cb2-cd0f-11e6a747-d03044780a02_story.html?utm_term=. b03165e57d49 on 28 Feb 2017. Seelye, K. (2002) A nation challenged: captives; Detainees Are Not P.O.W.'s, Cheney and Rumsfeld Declare. The New York Times 28 Jan 2002. Retrieved from http://www.nytimes. com/2002/01/28/world/a-nation-challengedcaptives-detainees-are-not-pow-s-cheney-andrumsfeld-declare.html on 28 Feb 2017. Senate Intelligence Committee Study on CIA Detention and Interrogation Program (2014). Retrieved from https://www.feinstein.senate.gov/ public/index.cfm/senate-intelligence-committeestudy-on-cia-detention-and-interrogationprogram. Senate Select Committee on Intelligence: Committee Study of the Central Intelligence Agency's Detention and Interrogation Program (2014). Retrieved from https://www.feinstein.senate.gov/ public/_cache/files/7/c/7c85429a-ec38-4bb5968f-289799bf6d0e/D87288C34A6D9FF736F9459ABCF83210.sscistudy1.pdf Turner, S., and Gorst, C., (1993) The Psychological Sequelae of Torture. In: International Handbook of Traumatic Stress Syndromes. Wilson, J.P. and Raphael, B. (Eds.). New York: Plenum Press. Retrieved from https://www.freedomfromtorture.org/sites/default/files/documents/ Turner%26Gorst-Unsworth-PsychologicalSequelaeOfTorture%20.pdf. United Nations Economic and Social Council (2006). Situation of detainees at Guantanamo Bay: Joint Report of Special Procedures of the UN Commission on Human Rights, 15 Feb 2006. Retrieved from http://dag.un.org/bitstream/ handle/11176/259174/E_CN.4_2006_120-EN. pdf?sequence=3&isAllowed=y US Court of Military Commission â&#x20AC;&#x201C; Guantanamo (n.d.). Retrieved from http://www.mc.mil. T O RT U RE Vo lu m e 2 7 , Nu m be r 2 , 2 0 17

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Obstacles to torture rehabilitation at Guantánamo Bay James Connell JD*, Alka Pradhan JD, LLM*, Margaux Lander BA*

Key inssues:

• The United States has a legal duty to provide rehabilitation to the current detainees under international law. • The conditions under which detainees are held make it impossible to physically or mentally rehabilitate them, or even to provide them with basic medical assistance. • Innovative ways must be found to try to assist with rehabilitation when the prospect of being set free remains elusive.

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Abstract

This article sets out the legal duty of the United States of America to provide victims of torture and cruel, inhumane and degrading treatment (CIDT) the right to full rehabilitation under international law, including those still detained at the facility at Guantánamo Bay. After an examination of some of the torture methods used on these detainees, while they were in the custody of the CIA and arguably afterwards, it goes on to indicate the current obstacles to rehabilitation, including on-going incarceration, lack of impunity, classification of medical documents and limited access to non-military staff. Limited options for possible psychological assistance towards the right to rehabilitation are considered.

*United States Department of Defense, Military Commissions Defense Organization. This article has been redacted by the United States military authorities before being published.

Keywords: Torture, International Law; prisoners, Cruel, Inhuman, or Degrading Treatment, detention, security, rehabilitation, survivors, Guantánamo. Introduction

In the early 2000’s, the United States adopted a policy of using torture and other cruel, inhuman, and degrading treatment (CIDT) against Muslim men considered to be terror suspects. The techniques were initially authorized for use by the Central Intelligence Agency, and later “bled” into detention operations conducted by the Department of Defense (DoD) in Afghanistan, Iraq, and Guantánamo (Constitution Project, 2013). Although President George W. Bush never acknowledged that the techniques used during brutal CIA interrogations constituted torture or CIDT, President Obama finally admitted in 2014 that, “We tortured some folks.” That same year, a declassified, redacted Executive Summary of a Congressional investigation documented some of the shocking details of the CIA’s “Rendition, Detention, and Interrogation” program (SSCI, 2014). The techniques certainly did not “hide in a vault at the CIA” (Biswas & Zalloua, 2011, p.27). Human beings tortured other human beings - yet under the guise of national security, the torturers have enjoyed impunity. One of them (Dr. James Mitchell, one of the psychologists who developed the CIA program) is currently promoting a memoir about his work with the CIA, and elaborates on his view of the characters and motivations

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The group of experts whose mandate is to interpret the treaty, receive and respond to periodic reports by state parties, and receive individual communications regarding potential violations by state parties. ii

One of the many legal controversies at the United States Military Commissions at Guantánamo Bay is the enforceability of the Convention Against Torture. One military commission has ruled that although the United States is bound by the Convention Against Torture, tortured individuals cannot enforce its provisions (United States Military Commission 2013).

right to torture rehabilitation has been interpreted as “a universal duty to provide [victims] with health care and reintegrative services, without considerations as to whether formal complaints or court decisions have been made, to who was responsible for the torture or where it happened” (Sveass, 2013). Recalling that the United States acknowledged the application of the CAT to the territory under its control at Guantánamo Bay in 2014, although the government insists that it does not create rights of action for Guantánamo detainees. (United States v. KSM, AE200II 2013). Nevertheless, the application of the CAT at Guantánamo legally means that regardless of “belligerent” or “clearance” status, every torture victim at Guantánamo must be given access to holistic rehabilitation by the government. That has not been the case. This article will summarize some of the obstacles to treatment of Guantánamo prisoners suffering from the effects of their torture and CIDT, and offer suggestions for amelioration of these obstacles. This article will not address the issue of treatment of those men who have been released or resettled from Guantánamo, who face overwhelming but distinct challenges. Background: The torture techniques

Beginning in 2002, the United States government actively sanctioned “enhanced interrogation techniques” for use on terror suspects, which included techniques long-recognized by international law to constitute torture or CIDT. In order to authorize the use of such techniques on terror suspects, members of the Bush administration issued legal memoranda disqualifying the application of 18 U.S.C. paras 2340-2340A, the United States anti-torture statute. In August 2002, then-Assistant Attorney General Jay Bybee

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of the detainees whom he tortured. Meanwhile, many of the survivors remain imprisoned at Guantánamo Bay and unable to speak freely about their suffering. The continuing effects of torture on these men, and their lack of access to medical treatment, are the subjects of this article. The United States has signed and ratified the UN Convention Against Torture (“CAT”) which mandates treatment for all survivors of torture, including those at Guantánamo Bay (Chlopak, 2002). Article 14 of the CAT explicitly requires that every state party ensures that torture victims have “enforceable rights” to compensation, which includes “the means for as full rehabilitation as possible.” The Committee against Torturei has explained that the obligation of States parties 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 (Convention against Torture, 2012, General Comment No. 3).ii Such rehabilitation “should be holistic and include medical and psychological care as well as legal and social services” (CAT 2012, General Comment No. 3). The CAT therefore recognizes an enforceable right of all torture survivors to receive rehabilitation, and a legal duty of the state to provide such rehabilitation. Importantly, the free-standing

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stated in a memo to White House Counsel Alberto Gonzales that “for an act to constitute torture as defined in Section 2340, it must inflict pain that is difficult to endure. Physical pain amounting to torture must be equivalent in intensity to the pain accompanying serious physical injury, such as organ failure, impairment of bodily function, or even death.” (Bybee, 2002). Notwithstanding the comparison of “physical pain” to medical death, Mr. Bybee continued his analysis with a second memo enumerating the techniques to be used as “1. attention grasp, 2. walling, 3. facial hold, 4. facial slap (insult slap), 5. cramped confinement, 6. wall standing, 7. stress positions, 8. sleep deprivation, 9. insects placed in a confinement box, and 10. the waterboard.” (Bybee, 2002). All of these techniques were approved by Bybee as consistent with the U.S. anti-torture statute. The torture of detainees was not merely sadism; the explicit goal was to achieve “learned helplessness” of the prisoners. “The goal of interrogation is to create a state of learned helplessness and dependence conducive to the collection of intelligence in a predictable, reliable, and sustainable manner” (CIA, 2004, p.2). Mitchell has described it as involving classical and avoidance conditioning (Mitchell, 2016). Two memos issued in 2005 by Steven Bradbury, former Acting Assistant AttorneyGeneral, re-evaluate the CIA’s interrogation

techniques. In the first memo, Bradbury slightly modified Bybee’s assessment of the legal standard, stating that techniques violating the anti-torture statute must cause “severe physical or mental pain and suffering,” but dropping the “organ failure” level of severity in the definition. (Bradbury, 2005a). Bradbury’s first memo, entitled “Application of 18 U.S.C. §§ 2340-2340A to Certain Techniques That May Be Used in the Interrogation of a High Value Al Qaeda Detainee,” enumerates a slightly different list of techniques, however – giving rise to questions regarding how the techniques changed in the intervening years: 1. Dietary manipulationiii, 2. Nudityiv, 3. Attention grasp, 4. Walling, 5. Facial hold, 6. Facial slap (insult slap), 7. Abdominal slap, 8. Cramped confinement, 9. Wall standingv, 10. Stress positions, 11. Water dousingvi, and 12. Sleep deprivation.vii The last two techniques were particularly damaging: the redacted Executive Summary of the SSCI Report states that “[t]he waterboarding technique . . . was physically harmful, inducing convulsions and vomitings . . . Internal CIA records describe the waterboarding of Khalid Sheikh Mohammad as a ‘series of near-drownings,’” which would seem to place them legally within “organ failure” level of physical disruption (SSCI, 2014, p. 3). The second Bradbury memo is entitled “Application of 18 U.S.C. §§ 2340-2340A

vi iii

Bradbury memo 1: 900 kcal/day plus 10 kcal/kg/day, multiplied by 1.2 for a sedentary detainee. iv

Used to cause “psychological discomfort,” with ambient temperature to be kept at 68 degrees Fahrenheit and “no sexual abuse or threats of sexual abuse permitted.” As we now know, this stricture was not followed. v

Standing 4-5 feet away from a wall with arms outstretched to the wall, without permission to move hands or feet. There is no maximum time period guidance given for use of this technique.

20 minutes duration of pouring allowed if water was 41 degrees Fahrenheit; 40 minutes with water temperature of 50 degrees; or 60 minutes with water temperature of 59 degrees. vii

Maximum duration allowed was 180 hours before detainee had to be allowed to sleep “without interruption for at least eight hours.” According to the SSCI Redacted Executive Summary, “CIA interrogators subsequently reported subjecting Adnan al-Libi to sleep deprivation sessions of 46.5 hours, 24 hours, and 48 hours, with a combined three hours of sleep between sessions.” (p.134).

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penetrated using “the largest Ewal [sic] tube” CIA officials had, for the sole purpose of demonstrating the “interrogator’s ‘total control’” over the tortured men, in accordance with the “learned helplessness” model designed by Mitchell and his colleague Bruce Jessen (SSCI, 2014, pp. 100, 82). During anal penetration of detainees, CIA officials would sometimes insert pureed food items, including “hummus, pasta with sauce, nuts, and raisins” (SSCI, 2014, p. 100). The CIA also used loud music or white noise, constant light, and shaving as extralegal techniques. The SSCI recounts how despite the CIA’s assurances that shaving was only conducted upon intake and was not punitive, “Detainees were routinely shaved, sometimes as an aid to interrogation; detainees who were participating at an acceptable level were permitted to grow their hair and beards” (SSCI, 2014, p. 429). The CIA also “use[d] music at decibels exceeding the representations to [the Department of Justice],” and “numerous detainees were subjected to the extended use of white noise” (SSCI, 2014, p. 429). Again, this clearly violated the prohibition detailed in Bradbury’s memo on “severe mental pain or suffering.” The United States government claims that use of torture techniques ended when the CIA detainees arrived at Guantánamo Bay in September 2006. However, this claim discounts the separate allegations of torture and CIDT during at least the first five years of military detention at Guantánamo (2002-2007), and also ignores the allegations by some former CIA detainees that use of torture techniques has continued at Camp 7, where they are held. These allegations are detailed below. It also ignores that under the CAT, failure to provide torture rehabilitation constitutes a continuing treaty violation that must be addressed.

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[the United States anti-torture statute] to the Combined Use of Certain Techniques in the Interrogation of High Value CIA Detainees” (Bradbury Memo to Rizzo on Combined Use, 2005). This memo reflects reality at the CIA black sites, more than any of the previous memos, in that it contemplates (and provides legal authorization) for use of the above techniques in combination, which is how the CIA had applied them from the beginning of detention in 2002. As the SSCI said in the redacted Executive Summary of its report on CIA rendition: "Beginning with the CIA's first detainee, Abu Zubaydah, and continuing with numerous others, the CIA applied its enhanced interrogation techniques with significant repetition for days or weeks at a time. Interrogation techniques such as slaps and ‘wallings’ (slamming detainees against a wall) were used in combination, frequently concurrent with sleep deprivation and nudity. Records do not support CIA representations that the CIA initially used an ‘open, non-threatening approach,’ or that interrogations began with the ‘least coercive technique possible’ and escalated to more coercive techniques only as necessary (SSCI, 2014, p. 3)." To demonstrate the combined use of torture techniques, the SSCI describes CIA sleep deprivation as “keeping detainees awake for up to 180 hours, usually standing or in stress positions, at times with their hands shackled above their heads. At least five CIA detainees experienced disturbing hallucinations during prolonged sleep deprivation, and, in at least two of those cases, the CIA nonetheless continued the sleep deprivation” (SSCI, 2014, p. 3). We also know that multiple techniques were used that had not been “legally authorized” by the U.S. Department of Justice. Multiple detainees were anally

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Current conditions of the tortured at Guantánamo

Despite an effort to reduce the prison population at the close of the Obama Administration, 41 prisoners remained at Guantánamo on January 20, 2017. These prisoners include some of the most well-known of the men to experience U.S. interrogation methods: Abd al Rahim al Nashiri, Abu Zubaydah, Khalid Shaikh Mohammad, and Mohammad al Qahtani. They also include the authors’ client, Ammar al Baluchi. As al Baluchi has described, “Years later I still have trigger responses to sound and scents among other things. The intense feelings of the torture flood in and are often unexpected when they come. The threats and fear continue to plague me daily making it difficult to not remember the torture that I still endure” (Amnesty International, 2017, p.19). Although all of the Guantánamo prisoners are Muslim, they are otherwise culturally diverse. The 41 prisoners come from 13 countries (Rosenberg, 2017). Many are Arabs, but many are not. Many speak Arabic as their first language, but many do not. Many have post-secondary education, but many do not. This diversity of backgrounds has resulted in wide variations in the presentation of trauma and impact on mental health (Sayed 2003). In 2016, New York Times reporters conducted the most comprehensive review of the mental health consequences of the U.S. government’s interrogation methods to date. The New York Times concluded that, “After enduring agonizing treatment in secret C.I.A. prisons or coercive practices at the military detention camp at Guantánamo Bay, Cuba, dozens of detainees developed persistent mental health problems . . . .” (Apuzzo, Fink, & Risen 2016). It found that, “At least half of the 39 people who went through the C.I.A.’s ‘enhanced interrogation’

program, which included depriving them of sleep, dousing them with ice water, slamming them into walls and locking them in coffinlike boxes, have since shown psychiatric problems.” (Apuzzo, Fink & Risen 2016). Although reviews of detainee medical records are severely limited by many of the factors discussed in this article, one record review in 2011 found that each of the nine reviewed “detainees continues to experience severe, long-term and debilitating psychological symptoms that are likely to persist for many years, and possibly a lifetime” (Iacopino & Xenakis, 2011, p.4). Declassified portions of a classified psychological assessment of al Nashiri show that he shows long-term effects of his torture, including continuing nightmares, a phobia of water, and other signs of post-traumatic stress (Savage, 2017). Other detainees, including al Baluchi, have complained of similar, or worse, sequelae (Amnesty International, 2017, p. 19). Obstacles to rehabilitation at Guantánamo

Some of the obstacles to torture rehabilitation at Guantánamo are the same/similar to those faced by treatment seekers and providers the world over. For example, “[d] escribing the physically and psychologically painful experiences of being tortured can itself be an exceptionally painful and overwhelming process” (Pope, 2012, p.421). The brain organizes itself around “a presumed permanent need for defense,” (Elbert et al., 2011, p.167), and torture survivors often simply cannot recall the details care providers and attorneys want to know. Guantánamo does, however, present a number of rare or even unique challenges to the torture survivors imprisoned there:

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the victims is compromised by the daily reminder of their own powerlessness in the face of the continuing power of their tormentors. The psychological consequences of impunity exacerbate the damage” (Fields, 2008, p. 154). Although these concerns are real, there are still two reasons to consider the viability of any torture treatment that might be possible. First, the U.S. legal position that it has the right to incarcerate the Guantánamo prisoners under the law of war does not relieve the United States of the duty, or the prisoners of the right, of torture rehabilitation under international law. Second, the issue of incarcerated torture survivors is not unique to Guantánamo. “There is not a good methodology to calculate the magnitude of the problem of torture worldwide, but the numbers of torture survivors should be several million” (Quiroga & Jaranson, 2005, p. 70). The United Nations Special Rapporteur on Torture visit prisons around the world and are mandated to submit urgent appeals regarding the torture of prisoners or lack of medical treatment for tortured prisoners. Therefore, although Guantánamo may be a unique prison setting, methods of verifiably ending torture and effectively treating torture survivors within prison conditions must be developed. Isolation Guantánamo prisoners are currently divided into two groups for detention purposes. Approximately 15 so-called “High Value Detainees” are generally detained in Camp 7, which a reviewing admiral in 2009 said was “effectively” a “supermax facility” (Walsh, 2009). The remaining approximately 26 prisoners are in Camp 6 [other camps], which the reviewing admiral described as “designed by U.S. standards for maximum security detention” (Walsh, 2009). An officer at Guantánamo has testified that it is not

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Threatening environment The first and most obvious obstacle to torture rehabilitation at Guantánamo is that the torture survivors are also prisoners, as the United States continues to incarcerate the men, ostensibly under the law of war. Eight men are charged and face proceedings in a military commission; two others have been convicted but not yet sentenced; and another is serving a sentence while his case is on appeal. The other thirty men do not face charges. This dual role of detainee/prisoner and torture survivor is a result of the policy decision to use torture on terror suspects. “Torture is also justified by the crimes and identities of the terrorists—they are the ‘worst of the worst. . . .’ But while the bodies of prisoners may be subject to violence for the extraction of information, they [must now also be] objects of care” for the government, which is inherently contradictory. (Biswas & Zalloua, 2011,103). Some suggest that torture rehabilitation is impossible in this prison environment. For example, prominent torture rehabilitation center Freedom from Torture has proposed, “the environmental context in which rehabilitative services are offered must be safe and stable” (PRI, 2013). Guantánamo fails both the objective and subjective components of these criteria, given that prisoners and their medical care remain in the complete control of the Department of Defense. Indeed, most of the factors mentioned in this article could be viewed as demonstrating the unsafe environment and instability of Guantánamo as a context for torture treatment. Others may suggest that torture treatment at Guantánamo would be counterproductive. “If the government does not change and/or if, as happened in Chile and Argentina, those committing these acts receive immunity from prosecution, any modicum of rehabilitation for

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possible to earn a transfer from Camp 7 to Camp 6 [another camp] through good behavior (United States v. KSM, AE448 2016, p.6). Two declassified sources have demonstrated at least some involvement of the CIA in Camp 7 beyond the prisoners’ transfer from black sites in 2006. First, the SSCI wrote, “After the 14 CIA detainees arrived at the U.S. military base at Guantánamo Bay, they were housed in a separate building from other U.S. military detainees and remained under the operational control of the CIA” (SSCI, 2014, p.160). Second, the CIA in 2016 declassified a highly redacted Memorandum of Agreement between the CIA and Department of Defense regarding Camp 7 (Memorandum of Agreement, 2006). Among other things, this “sets out the duties and responsibilities of DoD and CIA concerning DoD’s detention of certain individuals designated by the President to be transferred to the control of the Secretary of Defense, who were captured in the War on Terrorism and who have conducted and/or have engaged in planning for, terrorist acts against US persons or interests” (Memorandum of Agreement, 2006). Given that the very existence of Camp 7 was classified until 2008 very few details about it exist publicly (Rosenberg, 2008). One of the authors (James Connell) is among the few who have been inside Camp 7, pursuant to a military commission order, but classification restrictions prevent discussion of details. Two prisoners, however, have testified about their perception that torturous conditions mimicking the CIA black sites continue in Camp 7. Ramzi bin al Shibh is a 45-year-old Yemeni man accused of participation in the planning of the 9/11 attacks (National Commission on Terrorist Attacks, 2004). Bin al Shibh has consistently accused U.S. authorities of subjecting him to “sounds and

vibrations” in his cell at Camp 7 that prevented him from sleeping and affected his health. In Mitchell’s 2016 book, he discussed using vibration on bin al Shibh (allegedly by a piece of heavy machinery) at the black sites (Mitchell, 2016). Nevertheless, Guantánamo authorities have denied bin al Shibh’s claim, and in 2013 prosecutors used bin al Shibh’s allegation to seek evaluation of his mental state (Ramstack, 2013). The evaluators could not reach a conclusion given the information available to them, which at the time did not include Mitchell’s book, but would have included bin al Shibh’s CIA medical records, which are in the government’s possession and may have included reference to the vibration technique at the black sites (Serrano, 2014). In February 2016, bin al Shibh testified before the military commission about what he deemed systematic and intentional “noise and vibrations” inside Camp 7. During his testimony, he said that when he protested about the sounds, a U.S. Navy psychiatrist drugged him. He described being drugged: “[T]he worst time in my life was at that moment when they gave me injection, more worse than black site. Black site was abuse, was physical abuse, was torture. But this one, the injection without any reasons, that was the worst thing I have ever went through” (Transcript, Testimony of Ramzi bin al Shibh, 2016, p.11142). Later, in 2016, another prisoner known as Hassan Guleed also testified about the conditions of confinement at Camp 7. He said, “we have mental torturing [torture] here at Camp 7 . . .the noises are different, sometimes hammering, high-pitched noises, chemical smell… for six years” (Transcript, Testimony of Hassan Guleed Dourad, 2016, p.12180). Another element that Guleed revealed was the 2009 opening of the so-called “beanholes” – the slots in each detainee’s door through which prison meals

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are passed (2016, p.12176). Guleed stated that prior to 2009, Camp 7 prisoners could not open or communicate with one another through the beanholes. Prisoners are currently allowed to open their beanholes.

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Untrained legal teams This strict isolation means that generally the only people, other than prison staff, who have regular access to Guantánamo prisoners are each prisoner’s legal team, if the prisoner has one. Legal teams are provided by the Department of Defense’s Military Commissions Defense Organization, for those detainees in active trial proceedings at Guantánamo. The core members of the legal teams are attorneys, paralegals, investigators, intelligence analysts, and linguists. No legal team is allocated an independent psychologist for their client, although some teams have succeeded in obtaining funding for nonGuantánamo -based security-cleared psychologists to meet occasionally with their clients. The legal teams themselves are not professionally trained in psychological issues, and are required to focus on litigation rather than treatment. In many ways, the legal teams are woefully unprepared to work with survivors of torture. Many of the 41 prisoners remaining at Guantánamo – those not in active military commission proceedings - simply do not have a legal team. The United States government supports some representation: various Federal Public Defender offices, as well as non-governmental organizations like Reprieve, the Center for Constitutional Rights, the American Civil Liberties Union, pro bono lawyers and law firms representing prisoners seeking writs of habeas corpus in federal court, or other administrative or judicial relief. These legal teams have varying mandates and levels of resources. The identities of these legal teams can

present severe challenges to building a trusting relationship. As Sveaass notes, the following factors are of crucial importance: “The level of confidence that the person has with respect to receiving rehabilitation services offered by the authorities, the question as to whether the person still lives in the state where violence has been committed and whether the necessary steps have been taken with regard to complaints, assessments and documentation” (Sveass 2013). Those who work with survivors of torture must build on a foundation of trust, respect, believability, and sensitivity, recognizing the political context of torture (Engstrom & Okamura, 2004). Not only are Guantánamo prisoners still in the custody of the state that tortured them, without serious legal remedy for their acknowledged torture – but the Military Commission Defense Organization is primarily composed of U.S. military personnel. Many of its civilian and contract employees have military or intelligence backgrounds similar to those of officials who initially tortured the prisoners at the black sites or at Guantánamo. All lawyers at Guantánamo must be able to obtain security clearances, which means that they must be U.S. citizens. Prisoners often suspect the loyalty or motives of their appointed legal teams. Some prisoners, lacking trust in the American legal system and their American lawyers, have declined representation altogether. Beyond their identities, the military commission legal teams are by definition focused on legal matters, and lack psychological resources or training. Although the standard of practice in capital cases within the United States requires at least one team member qualified to screen for psychological issues, military commission funding authorities have been slow to support psychiatric or psychological expert services. Some military

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commission legal teams include a consultant psychologist or psychiatrist, but these experts must generally focus on evaluation rather than treatment. A predominantly Western approach to medical treatment As briefly mentioned, in order to be allowed contact with a Camp 7 prisoner (those prisoners tortured by the CIA at the black sites) a person generally must have a security clearance at the Top Secret/Secure Compartmented Information/Special Access Program level. Guantánamo authorities only allow contact with Camp 6 prisoners to people with Secret level clearances. These security restrictions mean that every person who has contact with Guantánamo prisoners is necessarily American. American medical, psychological, and legal professionals, however well-meaning, do not align with the physical and mental illness conceptualizations of all of the culturally and ethnically diverse prisoners at Guantánamo (Sayed, 2003). “Culture has a major influence on how we understand, express, and resolve mental distress and medical symptoms” (Quiroga & Jaranson, 2005, p. 41). For example, devout Muslims may discuss some of their symptoms in terms of the effects of Jinn or in distinction from the effects of Jinn.viii It is widely accepted amongst Muslims that Jinn are real creatures that are capable of causing physical and mental harm, such as possession (Khalifa & Hardie, 2005). Many Muslims also believe that Jinn can enter the human body and cause mental illness. Symptoms of Jinn possession could be forgetfulness, lack of energy and morbid fears (Khalifa, Hardie, Latif, Jamil, & Walker, 2011). American professionals, particularly the detention authorities at Guantánamo, have been quick to dismiss these complaints because they are

expressed in an unfamiliar cultural vocabulary. In 2014, hunger striker Abu Wa’el Dhiab challenged what he deemed to be inhumane force-feeding procedures at Guantánamo, and was ordered to undergo physical and psychological evaluations by independent (non-Guantánamo-affiliated) doctors. Dhiab had numerous problems with his legs and back, including broken ribs from being forcibly extracted from his cell, that required the use of a wheelchair during his 13 years at Guantánamo.ix While the U.S. government said derisively that Dhiab suffered only “from self-described ‘genies’ in his legs,” (despite giving him morphine for his pain), in fact his psychological report stated that: "There is no evidence of hallucinations, delusions, or illusions. He refers to cultural traditions of ‘spirits or jins’ that can influence health and state of mind. His descriptions are appropriate to his culture and his physical complaints. Cognitive processes are intact (Xenakis Expert Report, 2014)" Many other prisoners do not wish to discuss their symptoms because they do not think they will be believed – or worse, they believe that they will be drugged into silence as Bin al Shibh has been. The New York Times interviewed one Guantánamo doctor who recalled prescribing “powerful anti-psychotics” after prisoners complained of being “plagued by jinns,” even as she wondered, “Are we doing the right thing?” (Fink 2016).

viii

Jinn are described in Islamic writings as created beings, that can see us but cannot be seen by humans. The origins of Jinn can be traced back to the Qur’an, originating before mankind from “smokeless flame of fire.” Jinn are said to inhabit dark places such as graveyards and caves and are known for tempting or seducing mankind to stray from Allah (Khalifa & Hardie, 2005) ix

http://www.courthousenews.com/genies-cited-in-oncesecret-briefon-wheelchair-ban-at-Guantánamo /.

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Cultural humility is critical, and service providers need to acknowledge the “baggage they bring of their own cultures—their own ethnic backgrounds along with the culture of medicine—to the patient’s bedside, and that these may not necessarily be superior” (Fadiman, 2012). In a limited capacity, there may be opportunities for Guantánamo prisoners to speak with linguists who share their language and even occasionally their cultural heritage. However, these linguists are not trained mental health providers and may not know the essential terminology or concepts needed to discuss symptoms and issues in a sensitive manner (Pope, 2012). Most importantly, their mandate is legal, rather than medical, and they are simply unequipped and unable to provide any kind of rehabilitation.

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Classification of medical information and treatment One obstacle unusual to Guantánamo is the use of security classification to limit the transfer of medical information. The CIA high-value detainee program was “extraordinarily compartmentalized in order to maximize secrecy” (Khalili, 2013, p. 151), and much about the program remains classified, including the locations of the black sites and the personnel involved in the commission of torture. As a result, U.S. authorities have applied numerous classification regimes at Guantánamo, making the transfer of information to, from, and about prisoners very difficult. A complex regime governs information transfer at Guantánamo, with different rules for prisoners in various statuses. Former CIA prisoners have no access to telephone or ordinary mail, except to contact their families through the International Committee of the Red Cross. Other prisoners (Camp 6) have the ability to arrange occasional

telephone calls with their attorneys and family members, albeit with a member of a Privilege Review Team on the line with them to end communications if any information presumed either classified or inappropriate is conveyed. Most prisoners’ legal communications fall under protective orders issued by the District Court in D.C. and Joint Task Force-Guantánamo Bay, which provide that all of their communications are presumed classified until declassified by a Privilege Review Team (Eisenberg, 2009). Until recently, the prisoners charged with offenses in a military commission were governed by a separate set of orders, which were generally less restrictive. Those military commission orders treated prisoner communications as unclassified unless they concern specific torture-related categories (primarily location and personnel information). The categories did not include torture techniques a prisoner experienced or their symptoms – meaning that prisoner communications about their torture and enduring injuries were generally unclassified. The orders allow the attorneys limited authority to handle unclassified information without supervision, and provided a mechanism for the attorneys to obtain classification review in case of doubt. It was therefore possible for attorneys to share those torture details with treatment providers who could correspond with some Guantánamo prisoners through their attorneys or even offer remedies - as two of the authors have previously done. Such correspondence would necessarily be slow and limited by classification concerns, but could and did take place. In June 2017, however, the chief military commission judge, James Pohl, ruled that even unclassified legal mail from the former CIA prisoners could no longer be shared with members of the public, including potential outside caregivers, such as inde-

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pendent organizations who routinely provide care for the imprisoned. Therefore, even that limited avenue of treatment for Guantánamo prisoners continuing to deteriorate from the

effects of their torture may now be closed. The following statement from Mr. al Baluchi is an example of torture description that may be useful for rehabilitation provid-

ers. This statement had previously been cleared for public release. New statements may not now be shared with the public:

tion from their American jailers face an uphill struggle with poorly-trained personnel and classification barriers.

Medical infrastructure Medical care of the prisoners is, in many ways, irreversibly damaged through destruction of the provider-patient relationship by doctors’ roles in the CIA torture. The prisoners who still seek rehabilita-

Psychologists in torture program It is important to understand that the goal of CIA torture and CIDT was not short-term information, but rather long-term compliance. The CIA view was that, “Effective interrogation is based on the concept of using

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damage to the survivors (SSCI, 2014). Cultural norms mean that acknowledging sexual victimization from same- or oppositesex interrogators is especially difficult for Muslims imprisoned at Guantánamo (Pope, 2012). “Implicit in these scenarios is the idea that sexual torture is a source of particular humiliation and un-manning for Muslims and that sexual freedoms are a particular treasure of the West” (Bhattacharyya, 2008, 13). Among other symptoms, survivors of sexual trauma report deep feelings of shame and guilt (Oosterhoff et al., 2004, 71). Only a particularly sensitive and trusted professional can properly elicit and evaluate the sexual trauma of some of the Guantánamo prisoners. Medical care at Guantánamo Joint Task Force-Guantánamo Bay, which runs the prisons, includes abundant medical and psychological staff, but does not include professionals specializing in torture rehabilitation. Assessing and treating torture survivors is a highly specialized field requiring particularized competence (Pope, 2012). According to a number of reports, medical and psychological personnel do not ask their patients at Guantánamo what happened to them during interrogation. Captain Albert J. Shimkus, USN (retired), commanded the Guantánamo hospital, told The New York Times that his medical staff “was dealing with the consequences of the interrogations without knowing what was going on.” (Apuzzo, Fink, & Risen, 2016). In one of the rare studies of Guantánamo prisoner medical records, Iacopino & Xenakis reviewed the medical records of nine prisoners and compared them with other evidence of the prisoners’ abuse. They observed that, “The medical doctors and mental health personnel who treated the detainees at GTMO failed to inquire and/or

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both physical and psychological pressures in a comprehensive, systematic, and cumulative manner to influence [prisoner] behavior, to overcome a detainee’s resistance posture” (CIA, 2004, p. 1). “Refined through years of practice, the agency’s psychological paradigm came to rely on a mix of sensory overload and sensory deprivation for a system attack on all human stimuli via seemingly banal procedures—manipulation of heat and cold, light and dark, noise and silence, isolation and the intense interrogation” (McCoy, 2012, 53). The CIA thus specifically intended to alter the long-term psychological make-up of their prisoners. One participating psychologist has made clear the participation of medical doctors and psychologists in the CIA program (Mitchell, 2016). The Guantánamo Behavioral Science Consulting Teams also included psychologists. Given the participation of psychologists in the original abuse, the process of torture assessment outside the context of a trusting relationship itself evokes echoes of the torture (Pope, 2012). “Some of the acute neurobiological responses to trauma may facilitate the encoding of traumatic memories. The memories of traumatic experiences remain indelible for many decades and are easily reawakened by all sorts of stimuli and stressors” (Charney, 1993). Evidence suggests that interrogators used techniques of sexual, religious and moral humiliation to break down the prisoners. Many of the techniques deliberately degraded the Islamic faith, for example, violating explicit taboos relating to women, pornography and homosexuality. “Torturers targeted degradation of subject: sexual violations and humiliations . . . [and] desecration of religious objects and rituals” (Bufacchi & Arrigo, 2006, p. 356). In particular, interrogators used anal penetration as a tool of control, sometimes causing long-term

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document causes of the physical injuries and psychological symptoms they observed” (Iacopino & Xenakis, 2011, p. 4). Another reason a therapeutic relationship between military psychologists and Guantánamo prisoners is virtually impossible is the lack of respect for a prisoner’s right to medical privacy. A prior policy required medical practitioners to provide medical information to the military and CIA on request (Bloche & Marks 2005). Prosecutors at Guantánamo claim the right to inspect prisoners’ medical records, and have done so on many occasions. Furthermore, prison authorities deny the prisoners access to their medical records on the basis that the medical records are classified. Even attorneys for the prisoners cannot access full versions of the medical records. The United States government has created a situation where the legal authorities seeking the execution (in some cases) of the prisoners can access their full medical files, but the putative patients and their defense teams cannot. It should be noted that this engenders numerous legal issues beyond failure to provide access to rehabilitation. Other limitations on an effective and appropriate doctor-patient relationship include frequent rotations of staff, limited access to historical and personal information/ background. As active-duty military, the medical providers at Guantánamo serve limited rotations, both as part of ordinary military practice and, probably, as an anti-elicitation measure. These providers do not have access to any medical records from before September 2006. In fact, the authors have actually seen unclassified medical records describing 6 September 2006 (the date of transfer from black sites) as the patient’s birthday. Options for torture rehabilitation?

Given the massive obstacles to even basic

medical treatment at Guantánamo, the possibilities for meaningful torture rehabilitation are miniscule. However, small opportunities to alleviate the ongoing torture effects may exist. Under current law, these possibilities for treatment would have to take place outside the United States and take into account the security structure of Guantánamo imprisonment. Treatment within the United States is impossible at this time. Current U.S. law prohibits the transfer of Guantánamo prisoners to the United States, even for medical treatment. This law could change, but would require a change in political currents. The holistic treatment approach used by many treatment centers is also not possible at Guantánamo. Many people involved in rehabilitation of torture victims advocate holistic approaches which seek to restore the individual’s functioning in the context of family and community (Kira 2002). This approach is precluded by the restrictive environment at Guantánamo, which permits only specific group classes in Camp 6, [the camps], no classes in Camp 7, and only rare communication with family, largely via letters. One possible approach might be narrative exposure therapy (NET). NET is based on Testimony Method (Cienfuegos & Monelli, 1983), which was developed specifically within a human rights framework to treat traumatized survivors of the Pinochet regime in Chile. NET procedure is two-fold; it places “focus on the habituation of emotional responding to reminders of the traumatic event experienced and the construction of a detailed narrative of the event and its consequences” (Neuner, Schauer, Klaschik, Karunakara, & Elbert, , 2004, p. 580). Given the extraordinary efforts of the United States to silence the Guantánamo prisoners, telling their stories may have particular power, although the ability to

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Conclusion

By adopting a policy of torture followed by imprisonment, the United States has created a terrible conundrum for itself. It has a legal, moral, and ethical responsibility to provide access to rehabilitation for torture survivors, but is instead imprisoning them indefinitely and subjecting them to conditions and restrictions which make such rehabilitation

almost impossible. The United States has constructed a security regime which prevents its military medical care providers from effectively treating prisoners seeking rehabilitation, and bars almost all other qualified professionals from offering and providing such rehabilitation service to those prisoners. Rehabilitation for survivors of torture and CIDT at Guantánamo will require rethinking traditional models of treatment to work around the United States’ current regulation and policies – or humanitarian transfer of detainees to countries that will provide such treatment.

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share torture details through legal mail may now be curtailed, as mentioned above. Mahmadou Ould Slahi wrote his Guantánamo Diary through short declassified statements over a period of years, to express his experiences at Guantánamo and elsewhere. Ammar al Baluchi has had a number of statements regarding his experiences declassified, allowing him to tell parts of his story, albeit in a fragmented way (Amnesty International, 2017). Abu Zubaydah, through his attorney, has discussed his interest in describing part of his experience through courtroom testimony, although his most recent effort to testify did not succeed (Rosenberg, 2017). Some possibility may also exist for treatment by correspondence, if the rule regarding detainee statements was once again changed such that they were subject to “public” release after declassification. Although many treatment modalities require a personal connection between therapist and patient, it might be possible to provide treatment through guided self-help. For example, control-focused behavioral treatment is designed for implementation outside traditional therapy channels, and might present a possible vehicle for treatment (Başoğlu & Mineka 1992; Başoğlu & Şalcioğlu 2011). The correspondence involved in treatment would necessarily be slow, but could be carried out under the existing security structure at Guantánamo.

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9/11 commission report: Final report of the National Commission on Terrorist Attacks upon the United States. New York:W.W. Norton. Neuner, F., Schauer, M., Klaschik, C., Karunakara, U., & Elbert, T. (2004). A comparison of narrative exposure therapy, supportive counseling, and psychoeducation for treating posttraumatic stress disorder in an African refugee settlement. Journal of consulting and clinical psychology, 72(4), 579. Oosterhoff, P., Zwanikken, P., & Ketting, E. (2004). Sexual torture of men in Croatia and other conflict situations: an open secret. Reproductive health matters, 12(23), 68-77. Penal Reform International (2013, July). Rehabilitation support for survivors of torture: A case study: Freedom from Torture Rehabilitation Model. Retrieved from https://www.penalreform.org/resource/case-study-freedom-torturerehabilitation-model/ Pope, K.S. (2012). Psychological assessment of torture survivors: Essential steps, avoidable errors, and helpful resources. International Journal of Law and Psychiatry 35, 418-426. Rosenberg, C. (2016, October 25). Guantánamo by the Numbers. The Miami Herald. Retrieved from http://www.miamiherald.com/news/ nation-world/world/americas/Guantánamo /article2163210.html Rosenberg, C. (2008, February 7). Platinum captives held at off-limits Gitmo camp. The Miami Herald. Retrieved from http://www.miamiherald. com/news/nation-world/world/americas/Guantánamo /article1932471.html Rosenberg, C. (2016, February 24). Alleged 9/11 plotter testifies: Guantánamo noises, vibrations are real, they drugged me for protesting. The Miami Herald. Retrieved from http://www.miamiherald.com/news/nation-world/world/americas/Guantánamo /article62287467.html Rosenberg, C. (2017, May 18). Abu Zubaydah chooses not to testify at Guantánamo war court. Retrieved from http://www.miamiherald.com/ news/nation-world/world/americas/Guantánamo /article151445502.html Quiroga, J., & Jaranson, J. M. (2005). Politically-motivated torture and its survivors. Torture, 15, 2-3. Ramstack, T. (2013, December 19). Judge orders sanity evaluation for accused 9/11 conspirator. Reuters. Retrieved from http://www.reuters. com/article/us-usa-Guantánamo -idUSBRE9BI0WV20131219 Savage, C. (2017, March 17). C.I.A. Torture Left Scars on Guantánamo Prisoner’s Psyche for Years. The New York Times. Retrieved from

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Journal of the Royal Society of Medicine, 98(8), 351-353. Khalifa, N., Hardie, T., Latif, S., Jamil, I., & Walker, D. M. (2011). Beliefs about Jinn, black magic and the evil eye among Muslims: age, gender and first language influences. International Journal of Culture and Mental Health, 4(1), 68-77. Khalili, L. (2012). Time in the Shadows: confinement in counterinsurgencies. Stanford University Press. Kira, I.A. (2002). Torture Assessment and Treatment: The Wraparound Approach. Traumatology, 8, 61-90. Klasfeld, A. (2014, June 19). ‘Genies’ Cited In OnceSecret Brief on Wheelchair Ban at Guantanamo. Courthouse News. Retrieved from https://www. courthousenews.com/genies-cited-in-oncesecret-briefon-wheelchair-ban-at-guantanamo/ McCarthy, T. (2016, February 7). Donald Trump: I'd bring back 'a hell of a lot worse than waterboarding.' The Guardian. Retrieved from https://www.theguardian.com/us-news/2016/ feb/06/donald-trump-waterboarding-republicandebate-torture McCoy, A. W. (2012). Torture and impunity: The US doctrine of coercive interrogation. University of Wisconsin Pres. McColl, H., Higson-Smith, C., Gjerding, S., Omar, M. H., Rahman, B. A., Hamed, M., & LowShang, C. (2010). Rehabilitation of torture survivors in five countries: common themes and challenges. International journal of mental health systems, 4(1), 16. Mckenna Longacre, M. M., Silver-Highfield, E., Lama, P., & Grodin, M. A. (2012). Complementary and alternative medicine in the treatment of refugees and survivors of torture: a review and proposal for action. Torture, 22(1), 38-57. Memorandum of Agreement Between the Department of Defense (DOD) and the Central Intelligence Agency (CIA) Concerning the Detention by DOD Of Certain Terrorists at a Facility at Guantánamo Bay Naval Station (2006), FOIA Released 6541712 (2016), Retrieved from CIA Reading Room, https://www.cia.gov/library/readingroom/document/6541712 Mitchell, J. (2016). Enhanced Interrogation. Crown Forum, USA. Mollica, R. F., & Caspi-Yavin, Y. (1991). Measuring torture and torture-related symptoms. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 3(4), 581. Montgomery, E., & Patel, N. (2011). Torture rehabilitation: Reflections on treatment outcome studies. Torture, 21(2), 141-5. National Commission on Terrorist Attacks. (2004). The

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https://www.nytimes.com/2017/03/17/us/politics/ Guantánamo -bay-abd-al-rahim-al-nashiri.html Sayed, M.A. (2003). Conceptualization of mental illness within Arab cultures: Meeting challenges in cross-cultural settings. Social Behavior and Personality: an international journal, 31(4), 333-341. Scarry, E. (1985). The body in pain: The making and unmaking of the world. Oxford University Press, USA. Senate Select Committee on Intelligence (“SSCI”). (2014, December 9). Executive Summary of the Committee Study of the Central Intelligence Agency’s Rendition, Detention, and Interrogation Program. Retrieved from https://www. feinstein.senate.gov/public/index.cfm/senateintelligence-committee-study-on-cia-detentionand-interrogation-program. Serrano, R. A. (2014, December 10). Senate report on CIA torture could aid terrorism suspects in court. Los Angeles Times. Retrieved from http://www.latimes.com/world/middleeast/la-fgtorture-gitmo-20141211-story.html Sveaass, N. (2013, May 8). Gross human rights violations and reparation under international law: approaching rehabilitation as a form of reparation. European Journal of Psychotraumatology, 4, 10.3402/ejpt.v4i0.17191. Retrieved from http:// doi.org/10.3402/ejpt.v4i0.17191. United States District Court of the District of Columbia, Petitioner’s Notice of Filing of Expert Report of Stephen N. Xenakis, M.D., L.L.C. (2014, September 15). Retrieved from www.miamiherald.com/news/nation-world/world/americas/ Guantánamo /article2524292.ece/binary/The%20 retired%20Army%20psychiatrist%27s%20report%20to%20the%20court. United States Military Commission, Guantánamo Bay. (2013, February 16). AE200II Order to Defense Motion to Dismiss Because Amended Protective Order #1 Violates the Convention Against Torture. Retrieved from http://www. mc.mil/Portals/0/pdfs/KSM2/KSM%20II%20 (AE200II).pdf United States Military Commission, Guantánamo Bay. (2016, February 24). United States v. Khalid Shaikh Mohammad, et al., Testimony of Ramzi bin al Shibh. Retrieved from http://www. mc.mil/Portals/0/pdfs/KSM2/KSM%20II%20 (TRANS24Feb2016-AM1).pdf. United States Military Commission, Guantánamo Bay. (2016, June 2). United States v. Khalid Shaikh Mohammad, et al., Testimony of Guleed Hassan Dourad. Retrieved from http://www.mc.mil/Portals/0/pdfs/KSM2/ KSM%20II%20(TRANS2June2016-AM1).pdf. United States Military Commission, Guantánamo

Bay. (2016, September 7). AE448 Mr. al Baluchi’s Motion to Remove “High Value Detainee” Designation. United States Military Commission, Guantánamo Bay. (2013, February 16). AE200II Order to Defense Motion to Dismiss Because Amended Protective Order #1 Violates the Convention Against Torture. Walsh, P.M., VADM. (2009, February 23). Guantánamo Bay Investigation Report. C-SPAN. Arlington, VA: Pentagon Briefing Room. Retrieved from https://www.c-span.org/video/?284246-1/ Guantánamo -bay-investigation-report

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The United States Supreme Court case Ziglar v. Abbasi and the severe psychological and physiological harms of solitary confinement Eric Ordway, Esq.*i, Jessica Djilani, Esq.**, Alexandria Swette, Esq.**

Introduction Key points of interest:

In the aftermath of the September 11, 2001 terrorist attacks, a group of Middle Eastern, North African, and South Asian men was arrested for immigration violations, held as “terrorism suspects,” and detained in federal prison for months. Each of these men was, or was believed to be, Muslim or Arab. These men (the “Detainees”) alleged that they were detained solely on the basis of their religion or race, and that there was no individualized basis to suspect them of terrorism. They further alleged that, during their detention, they were abused physically and verbally and subjected to inhumane conditions, including solitary confinement. After several months, the Detainees were cleared of any connection to terrorism and deported. The Detainees allege that they suffered severe psychological and physiological harms as a result of the conditions of their detention and that they continue to suffer the effects of this trauma today.

*) Partner, International Arbitration and Trade practice group, Weil, Gotshal & Manges LLP. **) Associates, Securities Litigation practice group, Weil, Gotshal & Manges LLP. i

All three contributors are also co-authors of the legal submission that is the subject of this article. Correspondence to: eric.ordway@weil.com

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• A group of men were arrested for immigration violations and held as “terrorism suspects” after the September 11, 2011 attacks. • In a 2016 United States Supreme Court case, a group of medical, scientific, and health-related professionals filed an amicus brief, in support of the men. • The amicus brief discussed the overwhelming medical and scientific research, spanning decades and countries, which demonstrates that prolonged solitary confinement causes severe psychological and physiological trauma and damage. • It also highlighted that international legal standards and the laws of other countries have condemned the use of solitary confinement for over fifteen days as cruel and inhumane treatment, and, in some cases, torture. • This comprehensive summary of the numerous studies on solitary confinement is a model for others seeking to challenge the future use of this practice.

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In 2002, the Center for Constitutional Rightsi filed a federal lawsuit in New York on behalf of a group of these Detainees seeking money damages from United States government officials to remedy the constitutional violations against them. The case languished for a number of years until 2015, when the Court of Appeals for the Second Circuit ruled that the high-level officials named as defendants could be sued for damages for their roles in the religious profiling, detention, and abuse of the Detainees. In 2016, the government sought permission to appeal this decision to the Supreme Court of the United States. The Supreme Court heard oral argument on the case in January 2017 and rendered its decision in June 2017. In support of the Detainees and their claims against the high-level officials, several interested groups submitted briefs to the Supreme Court as amicus curiae, or “friends of the court.” Amicus curiae briefs are written by a person or group who is not a party to a lawsuit but has a strong interest in the action, can provide a unique perspective on the subject matter at issue, and seeks to influence the court’s decision. One of these briefs, the Brief of Medical And Other Scientific And Health-Related Professionals As Amici Curiae (the “Solitary Confinement Brief ” or “Brief ”) focused on a particular aspect of the abusive conditions of the Detainees’ imprisonment: the use of solitary

https://ccrjustice.org/

Available at: https://ccrjustice.org/sites/default/files/ attach/2016/12/Medical_and_Other_Scientific_and_ Health-Related_Professionals_Amicus.pdf. Several other organizations and groups also filed amicus curiae briefs with the Supreme Court on behalf of the Detainees including, among others, the American Civil Liberties Union, the American Association for Justice, and a group of former correctional officers. iii

Additional information about the case, including a case timeline, is available at https://ccrjustice.org/ziglar-v-abbasi.

confinement. The Brief was submitted on behalf of a group of medical, scientific, and health-related professionals who have extensive experience studying the psychological and physiological effects of solitary confinement and who are committed to limiting the application of the practice (Brief Of Medical And Other Scientific And Health-Related Professionals As Amici Curiae In Support Of Respondents And Affirmance, Ziglar v. Abbasi, No. 151358(Dec. 22, 2016)).ii The Brief considered the issue of solitary confinement from a global perspective and demonstrated that the overwhelming medical and scientific consensus, spanning decades and countries, is that prolonged solitary confinement causes severe psychological and physiological trauma and damage. The Brief also highlighted that, in recognition of the severe pain and suffering inflicted by prolonged solitary confinement, international legal institutions have condemned its use for over fifteen days as cruel and inhuman treatment and, in some cases, as torture. The Brief thus urged the Supreme Court to permit the Detainees to pursue their constitutional claims against the government officials and to seek damages against them for the harms the Detainees endured while imprisoned. This article discusses the facts giving rise to the case and the scientific evidence on solitary confinement submitted in the Solitary Confinement Brief. Keywords: Solitary Confinement, Detention, Immigration, Prisoner rights, Torture, Cruel and inhumane treatment, Racial profiling, Amicus, Psychological harm, US law, Constitutional law Procedural Background of Ziglar v. Abbasiiii

Ziglar v. Abbasi involves the claims of eight

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action,” so-named after the 1971 case of Bivens v. Six Unknown Named Agents of Federal Bureau of Narcotics, in which the Supreme Court of the United States held that lawsuits for money damages may be brought against federal officers for certain constitutional violations.iv The Detainees brought several claims in this action: (1) a claim challenging the conditions of their confinement under the due process clause of the United States Constitution (the “Constitution”);v (2) a claim alleging that Defendants subjected Plaintiffs to the challenged conditions because of their actual, or perceived, race, religion, ethnicity, and/or national origin, and thereby violated the equal protection clause of the Constitution;vi (3) a claim arising under the free exercise clause of the Constitution;vii (4) and (5) two claims generally alleging interference with counsel; (6) a claim under the Fourth and Fifth Amendments of the Constitution alleging unreasonable and punitive strip searches;viii and, (7) a claim for conspiracy to interfere with civil rights under the United States Code. In May 2016, the Government Officials petitioned the Supreme Court to overturn the Second Circuit’s decision that the Detainees were permitted to bring these claims. After the Supreme Court agreed to hear the case, briefs for the Detainees,

Prior to Bivens, the United States legislation had not provided a damages remedy to individuals whose constitutional rights had been violated by agents of the federal government. A Bivens remedy is available in cases involving constitutional violations unless Congress has expressly curtailed that right of recovery or “special factors counselling hesitation” exist. v

The due process clause of the Constitution protects persons from intrusions by the government into a their life, liberty or property, without due process of law.

The equal protection clause of the Constitution ensures that all people are protected equally under the law. vii

The free exercise clause of the Constitution prohibits the government from interfering with a person’s exercise of his or her religion. viii

The Fourth Amendment of the Constitution protects people against unreasonable searches and seizures of property and arbitrary arrests by the government.

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men, Ibrahim Turkmen, Akhil Sachdeva, Ahmer Iqbal Abbasi, Anser Mehmood, Benamar Benatta, Ahmed Khalifa, Saeed Hammouda, and Purna Bajracharya. These men are of Middle Eastern, North African, or South Asian origin; six of them are Muslim, one is Hindu, and one is Buddhist (Memorandum Opinion at 6, Turkmen v. Hasty, No. 13-981 (2d Cir. Jun. 17, 2015 )). At the time they were arrested, these Detainees were “out-of-status” aliens, i.e., persons who had either (1) entered the United States illegally or (2) entered the United States legally but fell “out of status” by violating the rules or guidelines for their non-immigrant status (often by overstaying their visas) in the United States and were legally deportable (Ibid, p. 4). The Detainees brought claims against high-level Bush administration officials, including John Ashcroft (the former Attorney General), Robert Mueller (the former Director of the FBI), James Ziglar (the former Commissioner of the Immigration and Naturalization Services), Dennis Hasty (the former warden of Metropolitan Detention Center in Brooklyn, New York (the “MDC”)), Michael Zenk (another former warden of the MDC), and James Sherman (former MDC Associate Warden for Custody) (together, the “Government Officials”), for their roles in the post-9/11 profiling and abuse of the Detainees. The Detainees’ claims were brought as a “Bivens

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including the amicus curiae briefs, were filed. The case was argued before the Supreme Court on January 18, 2017. On June 19, 2017, the Supreme Court, in a 4-to-2 decision, held that the claims against all of the Government Officials (except for those against Warden Hasty of the MDC)ix were insufficient as a matter of law, and prohibited the Detainees from seeking damages for their harms. Ziglar v. Abbasi, No. 15-1358, 137 S. Ct. 1843 (2017).x In dismissing the Detainees’ claims, the Court applied a “special factors” analysis and concluded that a Bivens-type of damages remedy could not be extended to the Detainees’ claims. Specifically, the Court reasoned that permitting the Detainees’ claims for damages to go forward in this context would permit courts to inquire into issues of national security and interfere with the sensitive functions of the Executive Branch of the United States government, which had set the policy adopted by the Government Officials in the wake of the September 11th attacks. Accordingly, the Court determined that Congress – not the Supreme Court – should decide whether these type of claims should be allowed (Ibid, p. 1860-63). In a powerful dissent, Justice Breyer, joined by Justice Ginsburg, argued that a Bivens action could not be extinguished even though the Detainees’ claims concerned the actions of high-level Government Officials

The Supreme Court remanded the Detainees’ claim for prisoner abuse against Warden Hasty to the lower court for additional analysis, finding that the Detainees’ prisoner abuse allegations against Mr. Hasty state a plausible ground to find a constitutional violation if a Bivens-type damages remedy is found to be proper under the “special factors” analysis. x

The Supreme Court’s opinion can be found at https:// ccrjustice.org/sites/default/files/ attach/2017/06/2017-06-19_ZiglarvAbbasi_ SCOTUSdecision.pdf.

and a detention policy that occurred after a serious attack on the United States. The dissenting opinion stressed the seriousness of the Detainees’ claims and the importance of the role that courts must play in checking abuses of executive power. Comparing the majority’s decision to other regrettable episodes in America’s history, Justice Breyer wrote that “[i]n wartime as well as in peacetime, it is important, in a civilized society, that the judicial branch of the Nation’s government stand ready to afford a remedy for the most flagrant and patently unjustified unconstitutional abuses of official power” (Ibid, p. 1873). Harms Suffered By the Detainees

In their Complaint, the Detainees alleged that, while incarcerated at the MDC, they were subjected to physical and psychological abuse and held in brutal conditions, including placement in solitary confinement in the Administrative Maximum Special Housing Unit (“ADMAX SHU”). As described in the Complaint, “[e]ach Detainee was confined to a ‘tiny cell[]’ for ‘at least 23 hours a day,’ alone or with one other detainee, for months on end.” (Brief, p. 5). “The cells were completely ‘bare’; no property, not ‘even toilet paper’ or ‘other personal hygiene items,’ were kept in the cells (Ibid.). ” “‘[B]right lights were kept on in the cells . . . 24 hours a day,’ causing sleep deprivation” (Ibid) and the Detainees could not even manufacture darkness by covering their faces (Ibid, p. 23). Because prison rules forbade detainees to cover their heads while lying in bed at night, they had no escape from the constant light (Ibid). In addition, “the cells were ‘very cold at night.” (Ibid, p. 5.) The Detainees alleged that, for the first month, they “were ‘denied all recreation’ outside their cells and subjected to a ‘communications blackout’ forbidding ‘any social

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Benmar Benatta “‘snapped’ and began banging his head against the bars of his cell.”(Brief, p. 23). He was so distraught over his “inexplicable, prolonged, and arbitrary confinement” that he twice attempted to injure – or possibly kill – himself by repeatedly banging his head into the walls and bars of his cell. (Complaint, paras. 179-82). On another occasion, he used a plastic spoon to cut himself (Ibid, para. 206). According to the Complaint, the effects of solitary confinement continue to plague the Detainees to this day, long after their release. The Complaint alleges that “[s]everal have trouble with concentrating, communicating, trusting others, sleeping, studying, and finding work and some have lost their homes, businesses, or jobs.” (Brief, pp. 18-19). The Detainees now “face numerous long-term and potentially permanent mental health issues, including post-traumatic stress disorder, depression, anger, isolation, fear of travel, difficulties handling open areas or light, and an inability to enjoy life.” (Brief, p. 19). The Solitary Confinement Brief

The Brief addressed the scientific evidence regarding the psychological and physiological consequences of solitary confinement. The term “solitary confinement,” as used in the international medical and legal literature and throughout the Brief, refers to “the confinement of prisoners for 22 hours or more a day without meaningful human contact.” (Brief, p. 2 citing the Nelson Mandela Rules, 2015, Rule 44). Nineteen prominent medical and other scientific and health-related professionals from all over the world (the “Amici”) sponsored the Brief in support of the Detainees, including a member of the United Nations Subcommittee for the Prevention of Torture, experts from the World Health Organization and World Psychiatric Associa-

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or legal visits or telephone calls.’” (Ibid). Then, “[e]ven after the bans were lifted, the [D]etainees were deterred from recreation by the extreme cold in the outdoor recreation ‘cages,’ subjected to grossly humiliating mandatory strip-searches, suffered abuse in transport, and were routinely denied the weekly legal calls and monthly social calls technically permitted.” (Ibid.). Indeed, four of the Detainees were not permitted a single social visit throughout their imprisonment in the ADMAX SHU (Ibid). In addition, the Muslim Detainees alleged that they were “denied access to the Koran, religiously appropriate food, and the means to maintain their daily prayer requirements.” (Ibid, p. 31). They also alleged that they were “punished for praying . . . one received an incident report for refusing to stand up for count during prayer, while others were unable to obtain razors or hygienic supplies (which guards purposely passed out during prayer times).” (Ibid). As alleged in the Complaint, the conditions of the Detainees’ restrictive and isolated confinement caused them to suffer significant psychological and physiological trauma. For example, the Detainees suffered severe sleep deprivation as a result of the constant light and cold temperatures. The Complaint alleged that one Detainee, Saeed Hammouda, would restlessly pace in his small cell to induce fatigue. (Fourth Amended Complaint, Turkmen v. Ashcroft, No. 02 CV 2307 (SMG) (E.D.N.Y. Sept. 13, 2010) (the “Complaint”), para. 223). Another Detainee, Purna Raj Bajracharya, who was kept in an ADMAX SHU cell completely alone for two months, “we[pt] constantly” during his confinement, thought he was “going crazy,” reported suicidal thoughts, and “scream[ed] to guards that he was going to die.” (Ibid, para. 241). The Complaint further alleged that, “after a bout of sleepless nights”,

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tion, pre-eminent psychologists and psychiatrists, prison health services experts, neuroscientists, physicians and medical professors. The Amici have extensive experience studying the psychological and physiological effects of solitary confinement and other punitive conditions of incarceration. The Amici advanced two principal points: First, the overwhelming medical and scientific consensus, spanning decades and countries, demonstrates that prolonged solitary confinement causes severe psychological and physiological damage. Second, international legal standards and the laws of other countries prohibit the imposition of solitary confinement under the circumstances of the Detainees’ case. The Psychological and Physiological Effects of Solitary Confinement Psychological Harms of Solitary Confinement: A critical observation of the Brief was that extensive research conducted in prison systems throughout the United States and in many other countries is “remarkably consistent” in finding that prolonged solitary confinement inflicts “deleterious psychological effects.” (Brief, pp. 8-9 citing Bennion, 2015). In fact, “[n]early every scientific inquiry into the effects of solitary confinement over the past 150 years has concluded that subjecting an individual to more than 10 days of involuntary segregation results in a distinct set of emotional, cognitive, social, and physical pathologies.” (Brief, p. 9 citing Appelbaum, 2015). Decades of case studies, articles, and personal accounts from the United States and around the world show that solitary confinement produces a “strikingly consistent” set of “psychiatric symptoms” in prisoners (Brief, p. 12 citing Appelbaum, 2015). These harms include anxiety, panic, withdrawal, hypersensitivity, ruminations,

cognitive dysfunction, hallucinations, loss of control, irritability, aggression, rage, paranoia, depression, a sense of impending emotional breakdown, self-mutilation, and suicidal ideation and behavior (Brief, p. 12 citing Haney, 2003).“‘Even those without a prior history of mental illness’ are at serious risk of developing these precise symptoms.” (Brief, p. 12 citing Appelbaum, 2015). Medical studies have documented the troublingly high rate of psychological disturbances among isolated inmates. For example, “Dr. Grassian’s 1983 study of isolated inmates at Walpole, Massachusetts, provides one striking record of the prevalence of psychopathology in solitary confinement” (Brief, p. 14 citing Grassian, 1983). In the study, “[h]alf of the interviewed inmates suffered from ‘difficulties with thinking, concentration, and memory’—with a quarter reporting ‘acute confusional states;’” “‘[t]wo-thirds exhibited ‘hyperresponsivity to external stimuli;’” and “[h]alf had experienced ‘hallucinations,’ such as ‘hearing voices,’ and ‘perceptual distortions,’ like seeing ‘[t]he cell walls start wavering.’” (Brief, p. 14 citing Grassian, 1983). In addition, “[t] wo-thirds suffered from ‘massive free-floating anxiety,’ while nearly half experienced obsessive thoughts like ‘primitive aggressive fantasies’ and 'persecutory fears.’” (Brief, p. 14 citing Grassian, 1983). Other studies concluded that “[t]he psychological trauma inflicted by solitary confinement results in extraordinarily high rates of self-harm” in prisoners – a rate much higher than that of inmates held in the general population (Brief, p. 16 citing CANY, 2004). For example, a 2014 study of New York City jails reported that while “only 7.3% of admissions included any solitary confinement, 53.3% of acts of self-harm and 45.0% of acts of potentially fatal self-harm occurred within this group.”(Brief, p. 16

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Physiological Harms of Solitary Confinement: The Brief also demonstrated that the deleterious health effects of solitary confinement are not only psychological but physiological as well. Indeed, experts have found numerous corresponding physiological consequences among inmates subjected to solitary confinement. The litany of negative health effects associated with even a short

period of solitary confinement has been noted in health studies from around the world and includes insomnia, headaches, lethargy, dizziness, heart palpitations, appetite loss, weight loss, severe digestive problems, diaphoresis (i.e., profuse sweating), back pain, joint pain, deteriorated vision, shaking, chills, and aggravation of preexisting medical problems (Brief, p. 20 citing Fujio, 2013). A number of medical studies also have documented the highly prevalent physiological symptoms among inmates held in solitary confinement. For example, “Dr. Haney’s 1993 Pelican Bay study revealed that more than 80% [of prisoners in solitary confinement] suffered from headaches, lethargy, and troubled sleep,” and “[o]ver 50% experienced loss of appetite, dizziness, nightmares, heart palpitations, and perspiring hands.” (Brief, pp. 21-22 citing Haney, 2003). In addition to the immediately apparent effects of solitary confinement on the human body, studies strongly suggest that solitary confinement can fundamentally alter the structure of the human brain in profound and permanent ways (Brief, p. 26). For example, “Dr. Huda Akil, a neuroscientist and specialist in the effects of emotions and stress on brain structure and function, reports that each key characteristic of solitary confinement—lack of physical activity, meaningful interaction with others and the natural world, and visual stimulation—‘is by itself sufficient to change the brain . . . dramatically, depending on whether it lasts briefly or is extended,’ even just for days.” (Brief, p. 25 citing Allen, 2014). As is the case with psychological harms, “[t]his neurological damage, and other physiological harms inflicted by solitary confinement can be long-lasting, even permanent. Several studies conclude that the decline in brain activity that occurs in solitary confinement,

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citing Kaba, 2014). The analysis in this study “of 244,699 incarcerations revealed that exposure to solitary confinement increased the odds of experiencing self-harm by 6.89 times and potentially fatal self-harm by 6.27 times.”(Ibid). Even after release from prolonged solitary confinement, studies indicate that inmates “may continue to suffer psychological damage ‘severe enough to cause near permanent mental and emotional damage.’” (Brief, p. 17 citing Vasiliades, 2005). The lasting mental health implications of “prolonged isolation include the inability to initiate or control behavior or interact with other people, loss of one’s sense of self and control over emotions, and withdrawal into a fantasy world.” (Brief, p. 18 citing Haney). Because prolonged solitary confinement transforms inmates’ personalities, they subsequently grapple with an altered self-image, as well as overwhelming feelings of inadequacy, “invalidating stigmas, relived abuse, uncontrollable paranoia or anxiety, self-imposed seclusion, [and] difficulties with sexual intimacy.” (Brief p. 18 citing Martel, 1999). The Amici concluded that the Detainees claim to have experienced many of the same psychological disturbances as those recorded in the medical and scientific research and that the medical and scientific research supports the claim that the Detainees’ post-incarceration suffering resulted from their prolonged solitary confinement.

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as confirmed by EEGs, can be irreversible if isolation is prolonged,” as it was in this case (Brief, p. 26 citing Shalev, 2008). Based on these studies, the Amici thus concluded that in addition to the immediately apparent physiological harms that the Detainees suffered during solitary confinement, the Detainees endured physiological effects that may be long-lasting or even permanent (Ibid). Solitary confinement under international law: Finally, the Amici argued that under international standards, the use of solitary confinement on the Detainees was impermissible because it was (i) based on religion or race; (ii) based on the pretext of immigration violations; and (iii) used as a measure of first, not last, resort. The Amici further argued that, even if the use of solitary confinement had been justified in this case, the indefinite, prolonged duration and extreme conditions imposed violated international laws. International legal standards recognize that solitary confinement qualifies as torture, as well as cruel and inhuman treatment of prisoners. Under international laws, “torture” and “cruel and inhuman treatment” both refer to “the infliction of ‘severe physical or mental pain or suffering.’” (Brief, p. 28 citing ICRC, n.d.). Torture, additionally, is inflicted for “a specific purpose,” like “obtaining . . . information or a confession” or “any reason based on discrimination of any kind.” (Ibid). Based on these standards, the Amici concluded that both of these purposes motivated the imposition of solitary confinement in this case and, therefore, amounted to torture and cruel and inhuman treatment. Conclusion

The Detainees in this case alleged that, after the September 11th attacks, they were held for months as “terrorism suspects” in solitary

confinement in federal prison solely on the basis of their religion or race. After they were cleared and deported from the United States, the Detainees brought several claims against various high-ranking Government Officials for damages as a result of the harms they suffered. In 2016, after the Court of Appeals for the Second Circuit ruled that the Government Officials could be sued for damages, the Government Officials appealed to the Supreme Court of the United States. The Supreme Court reversed the decision of the Court of Appeals, ruling that the Detainees’ claims were insufficient as a matter of law and that the Detainees were prohibited from seeking damages for the harms they suffered. While this landmark case ultimately denied the Detainees’ claims, it exposed widespread use of solitary confinement in the United States, as well as the punishment that many illegal aliens and others suffered in the immediate aftermath of the September 11th terrorist attacks. The case also provided an opportunity to the Detainees and others to challenge the regular use of solitary confinement and other conduct in United States prisons that amounts to torture under international standards. Given this opportunity, the Amici, a group of prominent professionals from around the globe, submitted the Brief in order to detail the established, well-documented, and exhaustive medical and other scientific and health-related research that virtually unanimously concludes that prolonged solitary confinement inflicts profound psychological and physiological on inmates. The Brief demonstrated to the Supreme Court Justices and others that the Detainees in this case were subjected to treatment that experts condemn as tantamount to torture. The Brief further demonstrated that the imposition of solitary confinement on the

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Detainees violated international legal standards and norms. And, until the practice of solitary confinement is outlawed, the Brief serves as a model for others who, in the future, again seek to challenge the use of solitary confinement in the courts.

References

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Allen, K. (2014). Researchers Study Effects of Prolonged Isolation Among Prisoners, The Toronto Star (Feb. 14, 2014). Retrieved from https:// www.thestar.com/news/world/2014/02/14/ researchers_study_effects_of_prolonged_isolation_among_prisoners.html Appelbaum, K. (2015). Am. Psychiatry Should Join the Call to Abolish Solitary Confinement, 43 J. Am. Acad. Psychiatry & L. 406, 410. Bennion, E. (2015). Banning the Bing: Why Extreme Solitary Confinement is Cruel & Far Too Usual Punishment, 90 Ind. L. J. 741, 756. Bivens v. Six Unknown Named Agents of Federal Bureau of Narcotics, 403 U.S. 388 (1971). Brief Of Medical And Other Scientific And HealthRelated Professionals As Amici Curiae In Support Of Respondents And Affirmance, Ziglar v. Abbasi, No. 15-1358 (Dec. 22, 2016). Retrieved from https://ccrjustice.org/sites/default/ files/attach/2016/12/Medical_and_Other_Scientific_and_Health-Related_Professionals_Amicus.pdf (“the Brief ” or “the Solitary Confinement Brief ”). CANY (2004). Mental Health in the House of Corrections: A Study of Mental Health Care in New York State Prisons, pp. 58-59. Center for Constitutional Rights (2017). Ziglar v. Abbasi (formerly Turkmen v. Ashcroft). Retrieved from https://ccrjustice.org/ziglar-v-abbasi. Fujio, C. et al., (2013). Physicians for Human Rights, Buried Alive: Solitary Confinement in the U.S. Detention System, pp. 1-2. Grassian, S. (1983). Psychopathological Effects of Solitary Confinement, 140 Am. J. Psychiatry 1450, 1453. Haney, C. (2003). Mental Health Issues in Long Term Solitary and “Supermax” Confinement, 49 Crime & Delinq. 124, 130-31. International Committee of the Red Cross (ICRC) (n.d.). Customary IHL - Rule 90, Torture & Cruel, Inhuman or Degrading Treatment. Retrieved from https://ihldatabases.icrc.org/ customary-ihl/eng/docs/v1_rul_rule90. Kaba F. et al. (2014). Solitary Confinement & Risk

of Self-Harm Among Jail Inmates, 104 Am. J. of Pub. Health 442, 442. Martel, J. (1999). Solitude & Cold Storage: Women’s Journeys of Endurance in Segregation, Elizabeth Fry Soc’y of Edmonton, 87. Shalev, S. (2008). A Sourcebook on Solitary Confinement, Mannheim Centre for Criminology, London School of Economics and Political Science, 20. Memorandum Opinion, Turkmen v. Hasty, No. 13-981 (2d Cir. June 17, 2015). Retrieved from https:// ccrjustice.org/sites/default/files/attach/2015/06/ Turkmen%20v.%20Ashcroft%20Second%20 Circuit%20Ruling%206-17-15.pdf Fourth Amended Complaint, Turkmen v. Ashcroft, No. 02 CV 2307 (SMG) (E.D.N.Y. Sept. 13, 2010) (the “Complaint”). United Nations General Assembly (2015) Res. 70/175, Rule 44. Retrieved from http://www. un.org/en/ga/search/view_doc.asp?symbol=A/ RES/70/175 (“the Nelson Mandela Rules”) Vasiliades, E. (2005). Solitary Confinement & Int’l Human Rights; Why the U.S. Prison System Fails Global Standards, 21 Am. U. Int’l L Rev. 71, 76-77. Ziglar v. Abbasi, No. 15-1358, 137 S. Ct. 1843 (2017).

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Torture without physical pain: Inside cell 24 of the special wing for political prisoners-Evin prison (Iran)

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Hasti Iranii

I come from Iran, an immense country of more than 77 million inhabitants, the cradle of Persian civilization, and one of the richest and most ancient cultural traditions of humankind, with deep values of respect and tolerance. 38 years ago there was an Islamic revolution that turned Iran into a country that has Islam as an official religion and in which laws must conform to Sharia or Islamic law. I belong to the Christian minority, officially recognised in the Iranian constitution, but only for those born in an ethnically Christian family. People who, like me, were born into an Islamic family and converted to Christianity, are considered apostates and guilty of a serious crime under Sharia. In the last year alone about 200 people who have been accused of apostasy have been imprisoned and many have been tortured. That was the reason I was detained. We Christians are no threat to the national security of Iran. We are not going against the State. But we are treated as such. We, although citizens of Iran, are under Criminal Law, the Enemy. Each city in Iran has at least one prison. The largest, Evin prison, in Tehran, is a huge i

Hasti Irani is a pseudonym due to security and family reasons. She is presently in exile. ii

Section 209 of the Evin prison is an unofficial and secret detention centre in Tehran, Iran, that operates under the administration of VAJA, the Islamic Republic of Iran's Ministry of Intelligence. It contains 90 solitary confinement cells. Correspondence to: publications@irct.org

set of buildings that houses 12,000 prisoners. Section 2 A and 209ii houses the Special Prisoners, political detainees, usually amounting to more than two hundred persons. After interrogation and torture many of them are transferred to Section 350, where political prisoners are under conditions of extreme psychological torture. And this is only Tehran. Every city has its prisons, although there is little news about them. Life in Iran feels like being in a large prison that houses many smaller detention centres within it. In Iran, students, journalists, lawyers, film directors ... are imprisoned for opinion crimes. There are no legal guarantees. Courts are religious courts. The wings for political prisoners in Evin Prison are not like the others. They were once designed with international assessment to create an environment best suited to psychological torture. I would like to share my experience as a person who was arrested and tortured in the wing for political detainees at Evin Prison. Rebuilding this story has taken years. Rebuilding the story began five years ago when an Istanbul Protocol assessment was filled in. It hardly managed to record even a part of my experience. It was simply not my time to talk. The first damage of psychological torture is that it is not possible to speak of it. It's too deep and too painful. Difficult to explain and difficult to understand. Being able to write this text today is part of my path and a

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up and down, as if you are for sale. She wants you to sit on your feet and open your legs as far as possible. Repeat this several times … You have no power. Only obey. When this was finished, I found myself in a very small, filthy and cold cell that had white walls. I had been thrown into solitary confinement. The guard flung three blankets into the cell and blurted, 'One is for a mattress, one on you and use one as a pillow'. I was jolted with the slamming of the cell door. I looked around me and at the blankets that were, like me, tossed into the cell. The cement floor was covered with a thin, filthy carpet, too abhorrent to step on. There was a small sink to wash hands and face with foul-smelling water. The air in the cell reeked with a stench from the drain. I soon found out that if I was thirsty, that’s where I could drink. The steel door of the cell had a 12cm hatch on it that had three steel bars so tight that when the hatch was opened from the outside, you couldn’t even get a thin hand through them. There was no door handle from inside on the steel door. After you heard its rusty sound of closing, it would stay un-openable except externally, shutting out completely any contact with the world outside. It was a tiny cell that if measured with the breadth of my hand was only 14 hands by 11 hands, with its concrete walls piercing your soul with their thickness. I stared at the old crumpled blankets piled on the floor. It was very demeaning. I threw them aside and sat down on the hard floor. But the hardness under me was nothing compared with the mental torture provoked in me. From that moment at the start, I came to feel the extreme meaning of humiliation. The slightest symbol is part of the process. Even with the type of clothes they give you, they humiliate you. My trousers were so long and big that one could

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personal process with my therapist that allows me to finally look at my torturers' faces and defy them. I was arrested at home and taken by three guards plus a driver, to Evin prison in the north of Tehran. I was dizzy with question: Why? Where? What for?! In the heavy traffic, I thought, “No one realises that in the car beside them they are taking someone to the destroying chambers to tumble her life for ever, and alter her outlook on life.” Dazed and baffled I arrived at the prison where one of my captors yelled at me to keep my head down and shoved a filthy blindfold to my chest to put on. As if coming out of a blackout I realised this is not a dream and that I was about to see shocking things. Walking blindfolded for the first time, the distance to the cells was extremely difficult. I took my steps in total blackness expecting to hit something or fall into a gully! With every step in this vacuum there was this feeling of an imminent plunge down a ravine. I just walked in darkness. Behind the blindfold, in this unknown space, I had a strange feeling for which I had no portrayal. ‘Turn, left!’ ‘now turn right!’… and then I was handed over to another guard, behind whose sound of steps I now walked. He stopped somewhere and rang a bell for a new guard. He handed me over and said, ’It’s yours!’ Again, I followed the sound of the footsteps. Somewhere she stopped and ordered me to go in. But where, I couldn’t see. She asked me to take my blindfold off now because I had to undress. I found myself in a strange, tiny room - more like a cupboard. I didn’t want to undress before her gaping eyes. I argued to no avail. She said, ‘Do what I tell you!’ Another one arrived but just stood by the door looking, as there was no room for her inside. There was no escape… How loathsome when someone probes your body

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fit into it like a sack. The blouse was so large that it reached to my knees and my hands were hidden in its sleeves. The slippers were so large that my feet were lost in them, taking away control over my steps. And then, there was the chador, veil and the blindfold. This set makes up all your belongings, plus other things that are too shameful to mention… For several days and nights, I just froze on that carpet, completely awake, gaping at the cell door. My eyes were blurred from the glaring white. The walls seemed to close in on me and I could sense the pressure on my bones. Loneliness and total silence. It was only the sound of the guards’ footsteps that told me life went on outside of this grave – even when you are unaware and dead in this tight and unbelievable cell. An existence in a tiny space where there is no one to listen to you and no one to say a word to you, to remind you that you are alive. The cell door would only open at food or toilet times and this was a big relief, to get some air in to the cell. Everything is arranged in such a way to tell you that you are nothing and worthless, a piece of trash – a designation I kept hearing during the interrogations. Everything was cleverly and carefully designed for tormenting. All of a sudden, they lock you in a suspended state, in absolute unknowing. Just solitary isolation as blank as the walls, making you want to scream. I was beginning to lose my mind not knowing what to do. All memories of all sizes from my childhood kept passing before me like a non-stop movie. Some were bitter and some were sweet ones. The trouble is that, in such a repulsive atmosphere, the sweet ones dissolve in a blink but the bitterness of the bad memories linger on. So, you keep talking to yourself non-stop. You ask the question and you answer it. You condemn yourself and you defend yourself, or, in your mind, you hang yourself. Only your tongue is moving and you wish someone

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would open the cell door and say something, even if it was to swear. You either hear yourself or hear the deadly silence. Even when you are quiet and not speaking, it is your thoughts in that terminal silence and utter isolation from the outside world that controls your body, mind and spirit. Such loneliness that confronts you with yourself, demolishes you and impinges upon your soul in such an adverse way that can never be erased. You can only try to come to a compromise with it. I spent several months in a solitary cell, absolutely cut-off from outside world. I was jailed in winter. In the heat of the summer, the temperature inside the cell matched the sun itself but we had to be in the same winter clothes, to smoulder and melt in that oven with constant drips of sweat. My attention seemed so scrunched up in a sack and my mind so pressed that I wasn’t able to dissect my thoughts or empty the sack. I couldn’t get release from my thoughts being munched up and tossed about and confused. I wished there was a sound to bring me back to myself. The deadening loneliness and silence, together with the unbroken glare of the florescent lamps drill into you that it is always day. Despite the tricks I used to keep track of days and numbers, I would suddenly lose sense of time and space and float in a hazy perplexity. Every time the cell door would open and a stretched hand with a bowl of food would appear, the sense of a wild animal in a cage would take hold of me. And when they slammed the door shut, all sorts of apprehensions would blight me. In the isolation of the cell, everything that has happened in your life, whether old and forgotten or new, mob you and badger you. You try to lie down but you get weary, you lean on the wall and try to sit but you

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like. A tormenting feeling that I had even forgotten my identity. I wanted to pull out of my throat all my insides and crush them under my feet. A perplexing and horrific feeing impossible to explain. Time is your enemy and you become your own foe as your mind forces you to confront yourself and wrestle with yourself. This is exactly the outcome they want. How can time be spent in the cell of solitude and silence? Your thoughts bounce off the walls and each becomes a bullet ricocheting back to you. They hit you in such vulnerable parts that you freeze silent and stock-still. In the mornings when the guard came to open the door of the cell to let me out to use the toilet, with a degrading look on her face, she would tightly hold her nose with her scarf so that she wouldnâ&#x20AC;&#x2122;t throw up, because of the stench of the cell. Just with her head, she would point to me to get out. As for me, I had been saturated with that foul smell in the cell, for I had to breathe in the smell of the filthy drain all the time. Although, I confess that bearing the smell of the drain that filled the cell had become far easier than the deadly, maddening isolation. If I were to tell you of just a day in the cell, moment by moment, I am sure even you would get bored. Every day was a copy of the previous day, but worse. All it was, repeating of words upon words, sometimes without thought, just uttering unconsciously as if you want to convince yourself that you are still in the world of the living! I must confess that, what this loneliness, humiliation and self-struggle did to me in this solitary cell has been engraved on my spirit and is too deep to be removed. Whatever they do to you is with the aim of humiliating and degrading you in order to defeat and crush you, take your self-confidence from you and make from you something other than who you are, so that you are

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get fed up. You fall asleep, but how much can one sleep? You get up and march where you stand, 1000, 2000 to 5000, until you sit down again to start from zero once more, but time keeps stretching, without end. How can you keep time with an imaginary clock without the arms? Every moment begets a thousand feet and every foot a thousand branches, like a monstrous giant centipede walking all over your soul to crush it. You long to be able to talk with someone, even for a few moments, and for your ears to hear a voice in this deadly silence. You only see the prison guards who appear and disappear like robots, opening the cell door to hand in a plate of food, or take you to the toilets or shower without an exchange of a single word. Here is a forgotten place outside of this planet. Iâ&#x20AC;&#x2122;m not even allowed to knock on the wall. I am losing it all in this utter isolation. I had become a stranger to myself. There were so many little things in life outside that I used to pass by indifferently, that had now become deeply desirable for me. I wished I had a watch to count the passing of the time, perhaps the seconds would become shorter! I wished I had a mirror to remember myself. Food came with a disposable plate and spoon. I would hide one spoon for each day and when there was seven, I would hide one spoon under my mattress to count a week. But one day, I was looking under my mattress and in amazement said, why have I collected such a lot of spoons?! I thought I was going mad. The forgetfulness that had come to me due to the loneliness of the cell gave me an odd sense. As though I was thrashing about in a swamp of unknown, filling up my lungs with stinking water. Time was passing dead slow and every moment stretched into a century. After a while you forget everything. No matter how I tried with my brain, I could not even remember what my appearance used to be

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not be able to locate your true self. Time doesn’t move. Everyday seems a hundred days and more. Your yearnings melt bit by bit into the terrain of your dreams and you age as the silence of your cell tethers you with the realms of death. I craved an ache to occupy me so that the assault of the termites of my thoughts wouldn’t devour my brain. During the nights, in the fixed silence, when you wouldn’t even hear a footstep, I would hear sounds of screaming, and I would cringe with fear. Here, no one has a name. I, as a prisoner, am just a number. The interrogator is known by a pseudo name and even the prison guards have bogus names. You only know them by their faces. The prison guard calls me: 'You have cross-examination (interrogation), quick! Get ready!' But, then I have to stand blind-folded and facing the wall for hours waiting the interrogation and no one has taken any notice of me! Interrogation sessions involved times of standing blindfolded, facing the wall for hours until your knees start shaking and my back pain seared across my body. I would continually tell myself to persevere, don’t show weakness that would make them gleeful, be strong! However, when you are strong, you get more hurt. Because, while you don’t want to show yourself weak but tough, you get drained from within. Right when there is no more strength to walk, they shout at you to come. So, with a bizarre wobble and stiff legs, I follow the guard. Now I am sitting on a chair facing the wall. Perhaps for the show that he is about to perform on me, he allows me to lift my blindfold slightly to frighten me. Endless questions in circles. Nonsense questions. All the same process of humiliation and denigration. The interrogator resumes his questioning with dirty words. But words weren’t enough and now he had made himself comfortable between my legs

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and I can see from underneath my blindfold how he wants to devour me with his filthy looks. While he is describing an imaginary sexual relationship between me and a friend of my father, his face becomes red hot, his eyes blood red and I feel the heat of his breath on me. My heart is about to stop. My mouth is severely dry and I don't know what he will do next. Every time, in every session, he wanted me to affirm how I enjoyed the way he illustrated this abhorrent imaginary sexual relationship! My body on the chair had frozen and I could feel my icy frame. The pen had jammed in my fingers and was motionless on a dot on the paper. There was no escape, not even a move on the chair. He would then ridicule me and, with his grimy grin tell me: ‘I will continue this until you answer’. When the assistant prosecutor couldn’t get the answer he was looking for from me, he yelled at me: 'Get lost out of the room!' I kept spinning around myself, not finding the door. When they threw me back into my cell, the reverberation of his shouts kept ringing in my head. Like a little child, I longed for my mother’s arms to hide my head in her bosom and to be embraced so that I could get away from the maddening scream of this man. In this solitary cell, his screaming brought back to my mind one of my childhood’s worst nightmares vividly, a traumatic experience I had almost forgotten that suddenly came back. But now there was no escape. There were walls everywhere. I was shaking and my teeth were clattering. I couldn’t tell where I was. I believed I was buried alive. I sank my head under the blanket. Then out again, but the walls and silence were staring at me. I wanted him to hit me, so that, when I returned to that stinking cell, I could agonize with pain, rather than for those degrading

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want. They want you to face only the onslaught of your futile and bewildering thoughts mixed with degradation in that deadening loneliness and muteness of the cell. They want you to lose time and space, forget your identity and, in distress and delusion be ready to face the interrogator again and again. They place you in this hell of delusive thoughts so that you can destroy yourself. You are troubled even with the thought of suicide, wanting to be free from such a blight of torment. But there isn’t anything to show how to release yourself of this regurgitation of mind. You wish someone would open the cell door and say, ‘we have come to take you to be hanged’. I wished they would finish it all before I became a total lunatic and before my delusions would destroy my mind any further. I do not recognize myself. I am losing my identity. In this stifling silence, I only hear myself talking and talking, but what I long for is another voice that can liberate me from this state suspended between illusions and reality. Then, at times, the interrogators resort to rape to degrade you completely and destroy you by pushing you to the limit. It is when a prisoner has no means of blocking this act and the woman is lead like a sheep to the slaughter, defenceless, that she is forced to give in to such violation. And, later, in the cold space of loneliness, this act keeps getting repeated, and repeated. You scream, you crunch your teeth, you bury your head in the filthy blanket and shout to get this sewage out of your awareness. But it’s futile. Even if you doze off out of sheer exhaustion, nightmares, more vivid, will come. Loneliness and loneliness again. The white jail cell of your loneliness. Floating in a weightless confusion. The air in the cell was suffocating and unbearable, as if the walls themselves were grabbing my essence from inside to devour. The ceiling was pressing on

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thoughts they had imputed on me to return to my head in the silence and loneliness of that cell. Physical pain would be, odd it might seem, a relief. So, I said, “Hit me, why don’t you hit me?” With a sneering look and a mocking smile the interrogator said: “We don’t do that here” – even remembering his grin by saying that tormented me in the cell. The most painful part is when people ask you, 'Did they also beat you in prison?' and when the answer is negative, they say oh, it's so good that they didn’t harm you!!! But how can I tell them that my soul has received such a beating that it is full of injuries, stitches and deep infections, albeit unseen… but people believe only what they can see. Physical punishments are minor compared to what they systematically do to your spirit, a slap in the face, a kick or a punch. The real torture begins after the interrogation, when you are alone in the cell, when there is you and the four walls, as if in a steel vault with an intense light in your eyes. On your own, everything that they did to you rushes back. Curiously, this film is being shown whichever way you turn your face. You close your eyes, but you can see the pictures and hear the echoes. The cell walls devour me. I put on my blindfold. You don’t want to see anything and, those obscene words that drag you to the bottom of shame and humiliation and singe your ears, churn all your emotions. You hate yourself. As if someone is crumpling your heart. You hear its beats slowing down and flatlining. In my vexation, I bang my head several times to the concrete wall of the cell. When you are tortured physically, you have pain to indulge in and bear. It doesn’t give you time to wallow in your useless thoughts and you learn to live with your pain somehow. They recede after some time and their traces gradually disappear and one returns to normal. But that’s not what they

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my face, as if to smother me. There was a barrage of thoughts of all shapes coming at my brain from every direction and bombarding my spirit. It was like a hundred arms had projected out of the walls to crush my bones. I couldn’t tell where I was or what was going on. Total loneliness. I seemed to be toiling, hemmed in by walls in this stifling hush. The white lights on the ceiling of the cell never went out, so the walls shone more brightly than they actually were, causing my eyes to twitch and go blank. To turn off the lamps, I would fold my Islamic scarf into a ball and throw it up to them, but to no effect. I had known these types of lamps in the market where the sellers wanted to shine light on their fruit to make it look bigger or more colourful to fool the buyers. I had got brown spots spread all over my hands and neck. Maybe on my face also, and I would get more tense as I didn’t have a mirror to see. Maybe it was from those bright lights, the filthy blankets or the grimy carpet, or maybe they were just in my imagination! One day when, after I had been persecuted to the maximum, I returned to the cell and I banged my head to the wall in ultimate frustration. The next-door cell thought I was knocking to her, so she answered me with two knocks! In all my brokenness, a faint smile came to my lips out of this little knock. I guessed that someone else in that cell was sharing her loneliness with me. They sometimes commit rape with what they do. And they sometimes commit rape with the things they say to you, searing images that will never leave a prisoner’s mind. That’s humiliation. During the day in the presence of other people, maybe these thoughts become a bit hazy, but when alone at night, the screen rolls open and the pictures start flashing, dragging you to the enduring loneliness of the confinement. The utter seclusion and images are so penetrative

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that, like in hardened cement, they can never be removed from your soul. This tiny cell of being alone, drowns you in such deep delusions that the whole spirit screams out of acute pain. A silent scream that no one hears or feels. Then you are left with voices churning inside you, as if thousands of lunatics are chanting. They come and say, you’ll be released tomorrow. So, in that prolonged night, you make it to the morning with a thousand hopes. But there follows many nights that feel 100-years long. Nights and days pass but no one comes to open your cell door and that hope in anticipation that you believed in eventually comes to destroy you. Even in this, every little detail has been so planned, in order to trap you in trite thoughts and illusions, to distant you and remove you from the real world and what you used to be. This way, you won’t be able to find yourself in that multitude of facts and phantoms. Gradually and bit by bit, you begin to forget the faces of your dear ones. When I saw myself in the mirror of the isolation room where I had been hospitalized, I could not recognize the woman in the mirror who was staring at me. Prison is a lawless city, full of insults, debasement, delusions and a thousand other unspeakable things. Then, when you get suddenly thrown out over those high walls, you become suspended in nowhere. You no longer belong to the prison nor are you of the outside world. You are hung between the two spaces. Insomnia follows me since torture. After years, no full remedy for that until now. The images and impressions that become your nightmares and give you insomnia are tangible, permeate the whole of your mind. In fact, they become part of your being. You are left with the new you whom only you know, and it is a hidden torment because

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others don’t understand you. You have left parts of your personality and character behind those bars and have come out with an altered mentality and disposition. Your values have changed and so has your world. Now, even in a room with twenty people, you feel alone and in exile. Just the fact that they don’t understand you is loneliness. These are the wounds of the soul sealed into your being. Especially at night, sometimes you go back to the cell. The humiliation comes back and you can’t stop condemning yourself and your interrogators, you don’t stop talking, not even for a moment, unless you fall asleep. It is enough for a scent, a familiar face, the surroundings of a room or something said, to hurl you back to the dark atmosphere of the persecuting cell. My soul is filled with impressions that even the passage of time will not be able to fade. These are the scars of torture, the scars of psychological torture.

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Solitary confinement, Section 350, Evin prison in Tehran

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S. M. Khodaei I was born in 1985 in Tehran, Iran. I started my political and human rights activism at university by founding a secular student association and publishing student magazines. Because of this, the university disciplinary committee did not allow me to study for two semesters. I was arrested by intelligence officials in 2008 and spent 38 days in solitary confinement in Evin prison (Tehran). That was the first time I was faced with psychological torture. During the repression after the presidential election in 2009, I was arrested for a second time. It was by the Revolutionary Guards (â&#x20AC;&#x2DC;Sepah-e- Pasdaranâ&#x20AC;&#x2122;) and this time I spent about nine months in solitary confinement. This time marked me in many senses. Finally, because of those two incidents, I was convicted by the Revolutionary Court and sentenced to prison. After about six years in Section 350, Evin Prison, I was freed in 2014. Solitary confinement is in fact not allowed under state or religious law in Iran. Article 38 of the constitution of Iran explicitly states that, "Any kind of torture to extort confession or acquiring information is forbidden. Compulsion of individuals to testify, confess or give a forced oath are not allowed. Such evidence, confession or oath, is lacking credibility."i However, we still i

Similar statements can be found in Article 9 of the 2004 Act for Respecting Legitimate Freedoms and Protection of Civil Rights, Article 129 of the Code of Criminal Procedure Act of 1999 and 578 and 579 of the Islamic Penal Code, adopted section 1996. Additionally, the Court of Administrative Justice in judicial precedent No. 435/2004 explicitly prohibits defendants and convicts being housed in solitary confinement. Correspondence to: publications@irct.org

witness the widespread use of these methods in Iran, particularly associated to unofficial detention centers. This also goes against international law and the Mandela rules regarding minimum conditions of detention, which consider that any isolation that lasts for more than 15 days can by itself be considered torture (Mendez, 2015; Penal Reform International, 2002). In recent years, with an increasing number of political prisoners and prisoners of conscience in Iran (in particular after the elections that took place in 2009), the discussions about the type of treatment prisoners are exposed to, including solitary confinement is the subject of public debate. Readers can have access to memories of political prisoners, such as Iranian prisoners, Eza`t Shahi, Bozorg Alavi, Safar Ghahramanian, Taghi Shahram, Vida Hajebi and the European writers Miguel Benasayag and Arthur Koestler. Many people will have in mind the traditional methods of torture in their minds, where physical pain and suffering is used. They may find it difficult to understand psychological torture in general and the suffering of solitary confinement, in part as they are not visible. Both types of scars, physical and psychological, can be traced many years later. In his seminal review, Shalev (2008) pointed out that long-term psychological damage is mainly due to social isolation. Reduced environmental stimuli, and loss of control in daily needs. The absence of external stimuli leads to the brain stimulating itself, through dreams and hallucinations (Grassian, 1983). White torture can lead to permanent

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impairments in brain activity including damage to the brain tissue (O'Mara, 2009). Human Rights Watch and others have reported to the US Senate Judiciary Committee that a large number of people who remained in solitary confinement are mentally ill, even though they did not have a history of mental illness, and that there are more suicides in solitary confinement (Human Rights Watch, 2009; United Nations Special Rapporteur, 2007; Grassian, 2014). It is not the purpose of this paper to review the existing medical and psychiatric literature on solitary confinement. It would be simply impossible. Big book sellers, including Amazon, do not serve Iran. We do not have access to medical databases and only partial access to Internet providers. This paper wants to add to the existing literature on solitary confinement by describing the experience and impacts in a sample of 16 Iranian survivors. Talking with others who have experienced solitary confinement

Conditions of detention

The physical space and facilities of solitary confinement vary, but there were some key elements that configure the experience of detainees (in brackets is the number of the interviewee): • Size of room and bathroom: "The first few days, my cell was relatively large, so that in the morning I could walk around it, in a corner of the cell, the bathroom was separated by a wall, but then I was transferred to a tiny cell that was about 2 feet by 4 feet without a wash basin and toilet. Each time I wanted to go to the toilet, I should drop out paper for this purpose from under the door until the guards realized..." • No human interaction: "Loneliness too bothered me, I wanted to talk to someone. I talked to the officer who was in charge of food distribution, about receiving more or less food until eventually he was forced to speak. Sometimes I would tell a lie that I needed the toilet which would force a prison officer to talk to me, at least, one sentence, but talking was very hard and sometimes they did not answer my questions”. • Social isolation: "I was 42 days in solitary confinement. During this period, only two

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Method During the period 2013 and 2014, and while I had been transferred from solitary confinement to the communal ward, I spoke with 16 male prisoners who had also been in Ward 350 of Evin Prison and had also experienced solitary confinement during the preceding five years. I talked to them following a brief semi-structured interview and tried to systematize information in as far as my own conditions of access to pen and paper and security concerns with the materials obtained allowed. These conditions were not optimal but the information during these talks was straight and honest among co-detainees. Thus, the data lacks the accuracy of an academic study, but gives unique insights as it has been done and written, in many senses, by prisoners within the prison. The period of time that they had been in

solitary confinement was 7.2 months on average. They were all young men (average age 38.6, maximum 54, minimum 22) detained for political and non-political reasons. Half of them had had a previous experience of solitary confinement. We define solitary confinement in Iran, at least among the people whom I interviewed and in my own experience, as being held in complete isolation with only contact with guards and sometimes interrogators for long periods of time, or being permanently held in a cell with less than one hour of access to a yard while being blindfolded.

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or three times for less than five minutes was I able to talk with my family. After I was transferred to the general ward, I realized that I was lucky that I had that possibility because others - even over a period of months had no contact with their family." • Cultural isolation:“The first two-three months, not even religious books were in my cell. It was very bad. In the yard or in the trash outside the cell, I looked for a piece of paper so I could sneak away with myself. It was the fourth month after repeatedly insisting, I got once a newspaper and in the last month I was allowed to go to the cell where there was a television." • Lack of intimacy: “Once in a cell, behind the sink, I found a pack of matches and turned one of them to for entertainment (sic). After a few minutes the guards rushed into my cells and asked how did I get matches?...then I realized that in the cells, there must be a camera … and, after searching, I found a small camera somewhere near the ceiling." • Sensory overload - Troubling sounds: The detainees reported highly disturbing sounds: voices and screaming in the hallway, the sound of the religious Ashura mourning ceremonies, and the sound of the air conditioner. “We had to hear the religious ceremonies that were broadcasted from the speakers.” • Sensory overload - light: The guards, at night, turn off cell lamps and only one lamp was lit as a night light”. “For twenty-four hours a day, lamps were lit in my cell in a way that, to sleep at night, I have to put my head under a blanket or sleep blindfolded.” • Sensory deprivation - Blindfold: All prisoners on arrival at the detention center were blindfolded. The blindfold was also used during interrogations and in the yard. It was sometimes even used in the cell. "After entering the prison, they gave me a

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piece of fabric that was used as a blindfold. I felt very bad, could not see anything. Everywhere I went, someone took my arm firmly, dragging and leading me. Later, I learned I could do up my blindfold enough to see the front of my foot. After many times of nearly falling over and hitting the ground, the guard allowed me to use the blindfold only in the yard and, when I went into the bathroom, I did not have to be blindfolded inside the cell." • Natural light: “During the nearly three years that I was in solitary confinement I was moved to a different cell several times. The worst was that the cells had no windows facing out and there was no natural light into the cell.” This was not a general experience and it was used as a special way of punishment. "There was a fairly large window near the ceiling of my cell covered with lattice steel. Sunlight came into my cell. Sometimes I heard the sound of doves and threw grains of rice through the window. Trying to give them food, was a kind of entertainment for me." • System of rewards: Food quality and buying things were conditioned and only possible with the authorization of the interrogation team. “I was detained in several detention centers. In some, under harsh conditions, the food quality was so bad that it was not edible, but, at the last place of detention, with softer conditions, food quality was much better -even for lunch roast chicken was served with yogurt.” • Breaking identity: Detainees had to wear prison clothes. Some prisoners said that they were deprived of having a shave or hair cut for a long time even when explicitly asking so. For others, without apparent logic, it was the opposite and prison officials at specified times, cut completely their hair and shaved their faces. “Usually once a month shaving was carried out, even

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after I was transferred from solitary confinement to the multiplayer cell ... " • Yard: “We were usually imprisoned during the hours of the day, but we could leave the cell and walk in the yard or corridor area in certain circumstances, the ability to do so and the frequency and duration would be subject to permission from the [chief] interrogator.” “Every day, half an hour in the morning and in the evening, we were forced to walk in the yard with several people together in a straight line, back and forth. We were not able to see each other as they did not allow removal of the blindfold at all." "For about 10 days, we did not leave the cell except for interrogation and bath, and then every day, for 10 minutes I went into the yard. In some cases, after some days of regular walking, prisoners were suddenly faced with restrictions without any logic”. In summary, the main elements that configured life in solitary confinement were the size of the cell, sensory deprivation (solitary confinement in the cell, blindfolded in the yard), sensory overload, deprivation of social contact, lack of intimacy, attacks to identity and individuality and a system of rewards and punishment with no clear rules.

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Impacts Solitary confinement deprives your senses, but most than anything banns colors. Because of blindfolds and because of the monotonous tones of what surrounds you. Colors are at the heart of emotions and feelings. Quoting Koestler: “”When this morning, for the first time I looked out of the window and saw a green field landscape filled with flowers and trees, it was all a dream. The main issue is that the trees and flowers have color. Only after that, you notice the monotony of black and white and its impact” (Koestler, 2006 pp 238-9).

When asked about their mental state, most prisoners (11/16) said that they suffered some kind of severe emotional breakdown, labelled in their own words as depression, anxiety or permanent irritability. Symptoms varied: “My sleep time increased sharply, I eat anxiously, I feel that my confidence was very low, there was no energy in my body and I still feel very tired during most of the day."; "I had little appetite, couldn’t eat, my sleep time was much reduced, I was always tired and I think this was due to a special feeling of helplessness: you cannot do anything. You do not have any control and thus you lose confidence and without even being aware, you give up.”; “As more days passed, there was more tension and anxiety and my nerves were failing. To try to relax, I punched a wall."; “Especially in the first one or two months, I had difficulty in sleeping, nightmares; I saw I was falling from height when I was asleep. At the time my sleep was disturbed and I had insomnia." Also a majority (9/16) complained of cognitive symptoms, and especially long-term amnesia, lack of concentration and inability to think. “I could not concentrate since the first day of the confinement and this lasted all the time since”. “Just after few days it was like everything was erased. I had a kind of amnesia. I could not remember my home phone number and still, after that time, my amnesia for essential things remain. I can’t remember names and numbers”. Most of them (8/16) expressed aggressive feelings of which only a minority (3/16) ever had had at least once before. "I do not remember that I was so nervous and with rage before solitary confinement but I had unsurmountable feelings several times during that period." Half of the detainees (7/16) recognized openly having planned or tried to commit suicide during their time in solitary confine-

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ment. "At the end of the first month, I tried to kill myself using a plastic spoon that came with the meal to cut my veins, I tried to commit suicide. The psychological suffering was not at all tolerable. But it didn’t work, the plastic spoon could not deeply cut my vessels and finally broke." Additionally, some people (3/16) referred to having hallucinationsii. "After 30 days, one night I was sitting in the cell, I heard behind me the sound of my mother's praying. I turned around, but there was nothing."; "After four months, I began to see a luminous thing in my cell. I got up several times at night thinking that there was a form, a kind of special case, to find nothing." Table 2 summarizes the results. Symptoms are self-declared and do not follow a clinical interview. They are the expression of distress in the own words of my co-detainees, with the positive aspects and the limitations that this means.

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thrown in a corner as a mattress. Knee pain was more pronounced in the last days of captivity." Damage to the kidneys, eyesight, pain in the back, severe dizziness and rapid tooth erosion were also mentioned by survivors. “My teeth were severely eroded during that time.” For most of them (11/16) there were also physical problems that they previously had that had got worse in solitary confinement. This included reduced eyesight, more intense stuttering, knee pain, neck pain, hypertension, diabetes, prostate, colon colitis, kidney stones and heart disease disorders among prisoners were also mentioned. “I used to wear glasses but it was forbidden during solitary confinement, I could not use my glasses. After 4 months I was transferred to the general ward and got my glasses, I noticed that my eyes were weaker and had lost vision." I think that lack of access to toilets was one of the reasons which worsened my prostate disease”.

Table 1: Frequency of Symptoms reported.

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Self-declared symptoms Emotional breakdown (“Depression” “Anxiety”…)

78%

Cognitive Symptoms (“Amnesia”, “Lack of concentration” “Inability to think”)

64%

Aggressive feelings

57%

Suicide ideation / attempts

50%

Hallucinations

21%

Physical state during solitary confinement

Everybody (16/16) said that they had physical problems that had arisen during solitary confinement. Among these, deterioration of joints, especially in the feet, and knee pain. “I had to sit or sleep on the floor for days and nights. I had a lot of pain in my legs and knees. The floor was just a flat carpet and we used only a blanket that was

“During the period of solitary confinement, my stuttering got so much worse that the interrogation lasted several hours longer than usual”.

I had an experience myself when one night I began to see besides me a well-known killer in Iran who had been arrested at that time. I felt that he stared me for hours and hours. I thought the interrogators had sent him to stay in my cell to put pressure on me. After many days, I realized that it was only an hallucination.

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Coping with solitary confinement

After all the conversations, we reflected on how each one tried to face confinement. It was a general qualitative observation that two elements were especially relevant: a political or religious belief and previous experience of solitary confinement. Both things did not change things dramatically, but made it slightly easier to deal with. Both were elements that helped us to cope. Politically or religiously motivated persons had somewhat less emotional impacts or could find meaning and calm them, even with harsher conditions. Also having previous experience helped people to assume routines and orient themselves. Although no statistical data support both assertions, in our conversations in prison both were shared thoughts of all of us.

security risks of all of the fellow co-detainees who shared their views and experiences, will help to give insight in the situation of Iran and in the impacts of solitary confinement as an inhuman condition that must be abolished by international law.

Conclusions

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Although all kinds of torture are forbidden in Iran, in practice, solitary confinement is used as a way of obtaining confessions by police forces and intelligence officials routinely, for political and non-political prisoners. In addition, because of the lack of inspections, the countryâ&#x20AC;&#x2122;s hidden detention centers and prisons are beyond the control of monitoring systems and judges. As a result, there is no registration either of the detention nor how was it carried. Victims cannot prove what had happen to them and the conditions in solitary confinement in court. This was also my case once freed, after six years in prison. International organizations recommend and international law prescribes systematic monitoring and inspection of detention centers, prisons and all places where people are deprived of their liberty. This needs to be effectively implemented in Iran. Solitary confinement is torture. Its destroys the soul and the body. We hope that this study, done in very difficult conditions and assuming many

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References Anson, V. (2009). White torture. In an interview with Blaze Hoseinpour on the site Rooz Online. Retrieved from http://www.roozonline.com/ persian/news/newsitem/archive/2009/agust/18/ article/0112e980714.html Arasteh, Modabber, Sharifi Saqez, & Bayan. (2008). "The prevalence of psychiatric disorders in the Central Prison of Sanandaj", Journal of Fundamentals of Mental Health, No. 4, pp 316-311. Arrigo, B., Leslie Bullock, J. (2008). “The Psychological Effect of solitary confinement on Prisoners in super max units”, International Journal of Offender Therapy and Comparative Criminology, 52. 6, 622-40. Atkinson, R.L., et al (1987). Atkinson & Hilgard's Introduction to Psychology (Second Edition). Translator: Baraheni, Mn et al., Tehran: Roushd Print XXI. Koestler, A. (2006). Interview with Death (Witness Spain), Translator: Deyhimi, N; Deyhimi, Xerxes. Tehran: Ney Publishing, Second Edition. Grassian, S. (1983). Am J Psychiatry. 1983 Nov; 140(11):1450-4. Grassian, S. (2006). Psychiatric effects of solitary confinement. Journal of Law and Policy, 22(617), 325–383. Human Rights Watch (2009). Mental Illness, Human Rights and us prisons. Retrieved from https:// www.hrw.org/news/2009/09/22/mental-illnesshuman-rights-and-us-prisons International Organization for Penal Reform, The. (2002). In prison practice: the application of international regulations in the prison. Tehran: Rah-e Tarbiat. Palahang, H. et al (2002), Journal of Psychiatry and Clinical Psychology, Volume 8, Number 13, pp 64-57. Hakimyoun, I. (2007), Iranian intelligence and security agencies until the end of Reza Shah, Tehran: Institute for Iranian Contemporary Historical Studies. Mazaheri, M., et al (2011), "The prevalence of personality disorders among female prisoners of Zahedan prison", Journal of Research in Medical Sciences, Vol. 13, pp. 55-52 Mendez., J. UN Special Reporteur Statement on Solitary Confinement, 44570 § (2011). New York. Mendez., J., & Mendez, J. (2013). Thematic ReportStandard Minimum Rules for the Treatment of Prisoners needs updating (Vol. 42285). Washington: United Nations. National service frame work for mental health (2004). Samaritans Information Resource Pack, 2004, Retrieved from: www.mentalhealth.org.uk O’Mara, S. (2009). Torturing the brain: on the folk

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psychology and folk neurobiology motivating 'enhanced and coercive interrogation techniques'. Trends cogn sciences, Vol.13, Issue:12. pp 497-500. Pérez-Sales P. (2016). Psychological torture. Definition, evaluation and measurement. Routledge Books. Shalev, S. (2008). A sourcebook on solitary confinement. London: Mannheim Centre for Criminology. London School of Economics and Political Science. Shams, A. (2007), General Science prison. Tehran: Rah-e Tarbiat Shariat, SV et al. (2006), "The prevalence of psychiatric disorders in male prisoners of Qasr prison in Tehran", the Faculty of Tehran University of Medical Sciences, Volume 63, Number 3, pp 36-25 United Nations Economic and Social Council (2015). United Nations Standard Minimum Rules for the Treatment of Prisoners (the Mandela Rules). Retrieved from: http://www. unodc.org/documents/commissions/CCPCJ/ CCPCJ_Sessions/CCPCJ_24/resolutions/L6/ ECN152015_L6_e_V1503048.pdf

103 OBITUARY

Professor Bent Sørensen Henrik Marcussen, MD, DMSc

“Bent was a pioneer in the torture rehabilitation movement and his word and actions, through discrete, did so much change – far more than most people could conceive.” Sara Hamze, IRCT, Lebanon (citation from “Words of condolence from the IRCT family”)

Chief of Staff, Department of Plastic Surgery and Burns Unit

When Bent finally finished his studies and became a surgeon of gastro-intestinal diseases, the relevant department at Kommunehospitalet, the illustrious old hospital in Copenhagen, had broadened its scope to include other types of medical issues

Danish medical schools

At the same time, Bent was elected to be a member of faculty at the medical school in Copenhagen after advocating for the creation of and implementation of medical schools. As Vice Dean and later Dean, he became a

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Bent Sørensen was born in 1924 in Fredericia on the east coast of Jutland in Denmark as the middle of three sons. His father was a Post Master and his mother a teacher. In 1942, his medical studies started in Århus and were partially undertaken during the German occupation. Bent’s practical training as a surgeon began immediately after his final medical exams in 1949. In 1961, with the title of Doctor of Medical Science under his belt and with solid surgical experience, he was ready to further his learning by gaining international experience. In the conflict that raged as a result of the Congo’s independence movement against the Belgian’s colonial rule, Bent got together with a handful of colleagues to take part in a Red Cross humanitarian expedition to the Congo to provide medical aid.

including burns. Bent had experience from the department of plastic surgery that focused on treating cleft lips and palates. However, from 1965, he ended up having overall responsibility for burns as well. This circumstance can now of course be seen as setting a path to much of his later work. The Department of Plastic Surgery and Burns Unit was, from then on, the prominent treatment centre in Denmark for serious burns, which specifically involved treating patients’ pain. In this regard, something so simple as water and more water became the key public message; thoughtfulness and simplicity often reap positive results, particularly when combined with researchbased achievements such as skin grafts, intensive antibacterial therapy and isolation of patients against the persistent infections often associated with these sort of injuries. Knowledge that is now obvious was visionary thinking at that point in time. Bent’s department moved to the newly opened hospital where a combination of modern buildings and thinking received international attention. This led to a great deal of travel in connection with educational programmes and teaching, and Bent became known by Danes as the burns expert who every year could be heard on the TV and radio warning against frivolous use of fireworks.

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member of the leading department at Copenhagen University which was able to influence medical education and training. From 1973 to 1981, Bent was also a European member of the medical research in the EF, as it was called then. He was proud to see through the adoption of entry requirements and the theoretical and clinical training of both specialist doctors and general practitioners in the five years he was chairman. Throughout this work, it was Bent’s firm belief that doctors should have a calling to work for the benefit of society and their fellow human beings, a topic which he later took up with respect to torture and human rights. This was exemplified at that time by Bent, as chairman, receiving the pledge that newly educated students took when they became fully-fledged doctors. Bent was already equipped for the work that would follow, namely, the many years that he worked against torture and for human rights. RCT

All this work came rather suddenly to an end when, in 1984, Bent accepted an offer from the Danish Medical Association (Den danske lægeorening (DADL)) to be chairman on the executive committee for the Rehabilitation Centre for Torture Victims, the RCT (now called DIGNITYi). A short time before, in 1981, the RCT had been founded and was being run by Inge Genefke. The Chairman of DADL asked Bent to become chairman of the RCT’s executive committee. A managerial and medical heavyweight was needed because of economic problems and differences of opinion on newly-utilised research methods. Bent had enjoyed a great deal of respect as Dean at the University and, through his i

www.dignityinstitute.org/home/

www.irct.org

OBITUARY

leadership of the Department of Plastic Surgery and Burns Unit, he had the experience that enabled him to create the necessary calm in order to deal with the funding which the then Ministry of Education suggested they would give to the relatively newly founded RCT in order to expand. Bent as chairman was complemented by medical and legal representatives and, happily, the much-needed funds became a reality and thereafter a fixed commitment in the Danish finance law for some time to come. The work at the RCT started at this point to focus on how to treat those who had experienced torture and the necessary knowledge on torture’s consequences, together with the potential to individualised treatment. Whereas the ability to treat physical injuries could be helped with the assistance of physiotherapy etc, psychological injuries proved to be more invasive. Assistance to help survivors get over torture developed, particularly with the introduction of social rehabilitation whilst recognizing the complicated position of being a refugee with language issues. At that time, the people who sought and obtained treatment were physically ruined and extremely badly affected psychologically. They were chiefly from Latin American countries, particularly Chile and Argentina. The new knowledge about torture’s horrors gave a ghastly insight that could take hold of one and Bent became a tireless fighter for justice and providing assistance for this extremely vulnerable group. IRCT, CAT and CPT

Meetings, training and, to an increasing degree, maintaining international connections, led to the founding of the RCT’s international structure, the IRCT.ii It was an organization that would generate numerous future and many-facetted tasks to do with torture for both Bent and others. Additionally,

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it led to Bent’s membership of the United Nations Committee against Torture (CAT) and, later, of the European Committee for the Prevention of Torture (CPT). Before his membership, these committees were made up of lawyers. He was able, as a doctor, to provide renewal and inspiration to the work. He became a travelling ambassador in the work against torture and not least in the coverage and control of the prisons that should be investigated in the 40 member states of the committee. In this capacity, Bent talked to prisoners, guards, inspected conditions, carried out reports and held governments to account in their duty to prevent and fight against torture. In addition, Bent was frequently sought after to give presentations and courses in many (often international) contexts, and these functions were often carried out in tandem with his wife Inge Genefke, founder of the RCT. Both have been honoured with numerous Danish and international prizes and honours. Bent was particularly happy that they both separately received the Danish Medical Association’s Barfred Pedersen’s prize of honour. Bent’s later years

Bent’s character

The memory of Bent Sørensen as a generous humanist, human rights activist and doctor will live for a long time to come. He was not just an immense intellect, with great medical skills and knowledge, he also had charm, empathy and vigour. Above all, he had an ability to get things done that was extraordinary. Unlike the heavy subjects that employed him during his multi-facted work life, Bent had a harmonious life with many reasons to be happy. He was cheerful, sociable and charming – a brilliant host and a natural centre at a gathering. In spite of significant handicaps, such as a heart valve operation and the amputation of one leg, he was physically active up until a few months ago and even went swimming outside in the depths of winter. He was well-versed in music and literature and readily recited the odd citation. At the commemoration on 14th August at the Danish Medical Association in Copenhagen, many people attended, including earlier work colleagues, friends and torture survivors who had been treated under his care. Those who could not be there physically also made their presence felt; the IRCT presented a book which included many deeply felt words, memories and thanks from 76 members of the IRCT family. Many people had been personally touched by their relationship with Bent and wished to give him a final farewell.

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http://www.atsf.dk

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Bent in his later years was chairman for the advisory committee for the Parker Institute at Frederiksberg Hospital in Copenhagen, founded by Alan and Jette Parker’s OAK Foundation. Donations, not least from the Parker family out of respect for Bent and Inge’s work, made the foundation of the Anti-Torture Support Foundation possible.iii The foundation supports urgent work in the fight against torture and was a fund that Bent - until now - has taken an active role in. As a ‘pensioner’, Bent was often called in as an expert witness on cases concerning torture and was, together with 25 other concerned Danes, active in the legal charges against the Danish Prime Minister in 2003,

arguing that the attacks in Iraq were against the constitution. In his articles ‘The Supreme Court carried out a state coup’ and ‘The wall of silence’, he argued in an in-depth and subtle way that, in going to war in Iraq, the government was not only trying to circumvent the Danish constitution, but also failing to uphold the treaties of the United Nations.

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Anti-torture Support Foundation (ATSF) 2002-2017. Administrative work – international: Commission of the European Communities in 1973 in order to survey the Directives concerning the free movement of doctors. Member of this committee from its start in 1976-83.

PROFESSOR BENT SØRENSEN, MD., DMSc. 8.3.1924-30.7.2017 Married physician Kirsten Ammentorp (1949-1989) Married Inge Genefke 1991, MD, DMSc. h.c. mult., founder of RCT (1982) and IRCT (1985).

Education: MD: 1949 DMSc.: 1958 Top Positions within the Danish Medical Health System: Chief of Staff, Department of Plastic Surgery and Burns Unit, University of Copenhagen, 1965-90. Administrative work – national: Member of the board of the Medical Faculty of the University of Copenhagen, Vice-dean, 1972-73, & Dean, 1974-75. Vice-Chairman and Chairman of the Advisory Board on Health Education to the Minister of Education (FLUSU), 1975-81. Member and manager of the board of the

Rehabilitation and torture work: Chairman of the Board, RCT from 1984 to 1990. Member of the IRCT Council, 1990-1995. Member of United Nations Committee against Torture (CAT), 1988 - 1990. Vice-Chairman of the Committee, re-elected 1998, Rapporteur to the Committee until 2000. Member of the European Council Committee for the Prevention of Torture (CPT), September 1989-1997, Vice-President of the Committee, 1989-1995. Senior Medical Adviser to the IRCT for many years. National and International Teaching: Training Courses on Torture and Medical Ethics. Raoul Wallenberg Institute and Danish Institute for Human Rights: Lectures. Report writing: Adviser to the governments of Zambia, Kenya and Nepal on report writing to the UN Committee against Torture. Honours: 12 Honorary memberships - national, European and other international. Order: Knight of the Dannebrog, 1978, of the First Grade, 1990.

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Combating Torture and other Ill-Treatment. A Manual for Action. London. 2016 By Amnesty International Pau PĂŠrez-Sales

international debate as to whether the distinction between torture and cruel, inhuman or degrading treatment (CIDT) should be based on the criterion of severity of suffering or the criterion of purpose of the alleged perpetrator. Amnesty sets out its position by proposing an even broader interpretation. CIDT should be all those conditions that meet the five criteria of the UN definition of torture except one, whatever it may be. However, Amnesty International opposes the idea that Prolonged Death Row should be considered CIDT (p 105) because there cannot be an "appropriate" length of time a prisoner can be held before execution. Arguing that situations of Prolonged Death Row amount to CIDT would in effect be arguing that executions should be carried out sooner. The book is especially (if not only) oriented towards lawyers who will find in it an inexhaustible source of jurisprudence, soft-law and useful pointers. This strength is precisely its main weakness. The text lacks the most basic medical or psychosocial perspective and cites in a marginal way aspects related to the proper detection, support and rehabilitation of victims. It reduces the fight against torture to the field of the legal and thereby impoverishes it. In a text of this magnitude, with more than 300 dense pages, there is scarcely any mention of the Istanbul Protocol or the elements of forensic documentation, beyond some

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The new edition of Amnesty International's anti-torture manual appeared last year in a discreet way. So discreet that, being an international reference text, very few people seem to know about it. This is probably partly due to the contemporary trend to only publish texts and reports in an electronic format. In an environment of electronic saturation, documents can be ephemeral and the benefit of these kinds of general - purpose manuals are diluted. But, be sure, the Amnesty International handbook is a manual to have on the shelf, to consult and underline. Structured in seven chapters, it reviews respectively the historical evolution of international legal mechanisms in the fight against torture (chapter one), international treaties and definitions (chapter 2), safeguards in detention conditions with special emphasis on vulnerable groups and conditions of detention (chapter 4), international obligations on prevention and the role of different professionals (chapter 5), legal elements of truth, justice and reparation for victims of torture (chapter 6) and guidelines for international campaigns for individual cases or countries (chapter 7). The text deserves to be read in full for two reasons: (a) the review of the topics is exhaustive and all readers even the most trained in the subject will find elements they did not know; and, (b) the text sets out the position of Amnesty International on some controversial issues. For example, in the

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references for jurists. This is more surprising when Amnesty International has always had strong medical and psychosocial components in their daily work that are not reflected here. Additionally, the richness of the text, an inexhaustible source of ideas, would be enhanced by a thematic index in the end that would help the reader to easily find references to specific aspects or sentences. All in all, this is a very detailed text that is not meant to be pedagogical and simplify the comprehension of information, but rather to be exhaustive and comprehensive and must certainly be among the list of essential books of certainly any lawyer working with victims of torture.

BOOK REVIEW

109 LETTERS TO THE EDITOR

Literature reviews are not all the same Amanda C de C Williamsi

Dear Editor,

PhD, CPsychol; Reader in Clinical Health Psychology, University College London; Research Consultant, International Centre for Health & Human Rights; and, Consultant Clinical Psychologist, University College London NHS Foundation Trust

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I was very interested in the discussion in the Editorial of the first 2017 issue of Torture Journal which referred to two similar literature reviews with opposite conclusions (Weiss et al., 2016; Patel, Williams, & Kellezi, 2016; Patel, Kellezi, & Williams, 2014) and would like to clarify and elaborate some of the differences, which I think are of relevance to the conclusions. There are two approaches to review. Narrative review selects according to explicit or implicit criteria from studies found by systematic or idiosyncratic search, then proceeds by taking the results of the included studies at face value. This holds even when the included trials are underpowered or uninterpretable, or their results are impossible to differentiate from effects that are not specific to the therapeutic method (anything from the passage of time to interest and concern from the research team). Narrative review authors look for simple majorities across their trial set to report on outcome, disregarding the strong bias in publication towards studies that show positive effects rather than no effects of therapy, the suppression of negative studies where authors or funders had an interest in propagating the (usually drug) treatment, and the tendency of underpowered trials to

show treatment benefit. Narrative reviews frequently disagree, even when their constituent studies overlap very substantially, and because this led to long delays in instituting effective, even life-saving, treatments in medicine, systematic review was developed to provide a cumulative summary of all studies that met reasonable criteria for scientific rigour, and to use a shared and accountable method that enabled widespread sharing of data, updating, and further research within review topics (4). Systematic review and meta-analysis selects by explicit criteria from systematic search, usually only RCTs which it combines in meta-analysis for maximum power, and quantifying the size of effects of treatment, the confidence we can have in those effects, and the likelihood that the findings could be easily overturned by, for instance, discovering unpublished negative trials. The evident advantage over narrative reviews, and the consensus on conclusions that followed the use of transparent and accountable methods, led to the establishment of the worldwide Cochrane Collaboration. Further, among systematic reviews and meta-analyses, Cochrane reviews are the most reliable and least subject to error (Chalmers I, Altman DG, 1995). Weiss et al. (2016) used systematic search and explicit criteria, which considerably strengthens their narrative review, but did not restrict their review to RCTs which, whatever their limitations, at least provide interpretable results by having a comparable untreated or differently treated group. Such a

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comparison group is very important, since nonspecific or placebo effects are a helpful component of any treatment or apparent treatment. Patients who feel that someone is listening to them, asking sensible questions, discussing possible treatments and outcomes, and even expending resources on their account, may well become more hopeful, less anxious, and evaluate their symptoms and problems differently. These effects can be seen as an asset rather than a nuisance, and a reminder to us to do all we can to strengthen those processes of listening, empathy, engagement, and shared agenda with the patient. But because at least some of those processes happen in control arms of trials, it does seem important to identify whether technique-based treatment offers more, which is why it is so hard to interpret uncontrolled studies. This is not to suggest that randomised group studies are the only way forward: we underuse single case studies where people are their own control. So while the Weiss et al. (2016) review provides very valuable data on types of treatment, on targets of treatment, and on evaluation methods in a wide range of included studies, it is not equipped to provide an overall estimate of effectiveness of those treatments, unlike the Cochrane review (2014) and our summary of it for Torture Journal (2016). Thus the apparent contradiction is easily resolved by taking from each review what it provides using appropriate methodology. References Chalmers I, Altman DG (eds). Systematic reviews. London, BMJ Publishing Group, 1995 Page MJ, Shamseer L, Altman DG, Tetzlaff J, Sampson M, Tricco AC, Catalรก-Lรณpez F, Li L, Reid EK, Sarkis-Onofre R, Moher D. Epidemiology and reporting characteristics of systematic reviews of biomedical research: a crosssectional study. PLoS Med 13(5): e1002028. doi:10.1371/journal.pmed.1002028.

LETTERS TO THE EDITOR

Patel N, Williams ACdeC, Kellezi B. Reviewing outcomes of psychological interventions with torture survivors : conceptual, methodological and ethical issues. Torture J 2016;26(1):2-16. Patel N, Kellezi B, Williams ACDC. Psychological, social and welfare interventions for psychological health and well-being of torture survivors. Cochrane Database Syst Rev 2014, Issue 11. Art. No.: CD009317. DOI: 10.1002/14651858. CD009317.pub2. Weiss WM, Ugueto AM, Mahmooth Z, Murray LK, Hall BJ, Nadison M, et al. Mental health interventions and priorities for research for adult survivors of torture and systematic violence: a review of the literature. Torture 2016;26(1):17-45.

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Public perception does not accurately reflect resources available to survivors of torture in the United States Alison L. Burke, MSW

Dear Editor,

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There is a great deal of misinformation regarding resources available to and obstacles faced by survivors of torture (SOTs) in the United States. A key reason for this is the fact that much of the dialogue centers on the perceived burden of immigration. This rhetoric does not accurately communicate the resources available to refugees and asylum seekers in the US. Since public opinion has, historically, played an influential role in shaping immigration law, creating more effective public policy requires discourse to be rooted in fact. SOTs generally arrive in the US as asylum seekers or refugees. When refugees arrive, they are granted work authorization and are eligible to receive benefits, such as refugee cash assistance (RCA) and refugee medical assistance (RMA). These benefits end after the refugee has been in the US for 8 months; any additional benefits vary by state (Office of Refugee Resettlement [ORR], 2016; ORR, 2012). In 2016, the US spent .01% of the national budget on refugee entrant assistance. (Administration for Children and Families [ACF], 2016, p.15; Congressional Budget Office, 2017). Additionally, many refugees arrive in the US with debt since they are required to repay their travel expenses (US Committee for Refugees and Immigrants [USRI], 2017). Asylum seekers face more imposing barriers on arrival. They are ineligible for

refugee benefits, federal public benefits, and many community resources until they have been granted asylum. In addition, they must wait 150 days after filing for asylum to apply forwork authorization (US Citizenship and Immigration Services [USCIS], 2017). Following this, asylum seekers are subjected to a lengthy, and often retraumatizing, legal system. The first step in this process is the asylum interview, which is generally scheduled two years from the filing date. If the case is referred to court, it is often scheduled 3 â&#x20AC;&#x201C; 5 years from the date of referral (American Immigration Council, 2016). The current backlog of asylum cases creates inconsistent wait times affected by court location and chance (Taxin, 2016). The Survivors of Torture Program provides rehabilitation services with an annual budget of approximately $10.5 million. Unfortunately, some SOTs are unable to access these services due to distance (ORR, 2017). Significant studies have shown that asylum seekers and refugees do not have a negative social and economic impact. In 2016, the National Academies of Sciences, Engineering, and Medicine released a report that studied immigration trends in the US over the last 20 years. Their assessment found little evidence that immigration affects the employment rates of native-born workers. When employment was negatively impacted, it affected recent immigrants the most. First generation immigrants proved

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costly on state and local levels. However, second generation immigrants had a substantially positive financial impact on government; paying more in taxes than their parents or when compared to the general population (The National Academies of Sciences, Engineering, and Medicine, 2016). The CATO institute also found that immigrants access public benefits less frequently than the native population (Ku & Bruen, 2013). Furthermore, a Danish study found that the average wage increased in communities where refugees had been resettled (Foged, Mette, & Giovanni Peri. 2016). These studies highlight the economic and social benefits refugees offer their new homes, a fact that is often overlooked in current discourse. History has shown us that public perception influences policy. The US has instituted policies to restrict immigration since the 1800’s, beginning with the Page Act (1875) and the Chinese Exclusion Act (1882). At that time, many Americans disapproved of immigrants’ religion and cultural practices, and viewed them as economic competitors. As a result of popular opinion and rhetoric, immigration policy allowed for, and even enforced, preference for and discrimination against certain nationalities (Johnson, 1998, p. 1120 ff.). As the civil rights movement reshaped opinion and rhetoric, Congress passed the Immigration and Nationality Act (1965) to address the inherent discrimination in the immigration system. Although it retained some limitations, the law also allowed for a more diverse immigration system by eliminating the national origins quota system, and barring racial considerations from directly influencing decisions about immigration visas (Johnson, 1998, p. 1133). Currently, public opinion is shifting again.

LETTERS TO THE EDITOR

Current attitudes and opinions

In general, Americans overestimate rates of immigration and its cost while underestimating immigrants’ value and contributions to the US. Research has shown that Americans’ attitudes towards immigration are more reflective of the individual's demographics than the actual state of immigration in the US (Murray, et al., 2013). Individuals’ opinions of immigrants are also influenced by the immigrants’ income, race, social standing, educational level, and legal status (Hainmueller, et al., 2015). These attitudes are seemingly mirrored by media coverage and political rhetoric. One survey found that a majority of Americans believe that “immigrants to the US are making American society better in the long run.” However, the same survey found that the majority of respondents also believe that immigrants in the US are making crime and the economy worse (Pew Research Center, 2015). In a recent Ipsos survey, 49% of Americans worried about immigration’s impact on jobs and 60% were concerned about immigration placing pressure on public services (Duffy, B. et al., 2016). In February of this year, a draft of President Trump’s executive order on immigrants was leaked. While the executive order was never enacted, it created fear that consequences for using public benefits could be introduced after asylees and refugees had already enrolled in the programs (Fix & Capps, 2017). Additionally, the proposed RAISE Act could greatly affect SOTs. In its current form, the bill would lower the number of refugees allowed into the US to 50,000. It would also make it more difficult, if not impossible, for refugees and asylees to be reunited with their family members (BBC News, 2017). Impact of political rhetoric

Since his campaign, President Trump has portrayed immigrants as less deserving and

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be seen and will not be fully known until hate crime, healthcare, and social service information for 2017 is compiled and released. Words and beliefs are powerful, particularly when ruled by hate and bigotry. More research into how public opinion and rhetoric affect SOTs is needed at this time. It is important to understand how the current dialogue and public opinion impacts the treatment and reception of SOTs by their communities. Additionally, more steps need to be taken to ensure the public has an accurate understanding of the amount spent on helping asylum seekers, asylees, and refugees in relation to the economic benefits. It is my view that now is the time to further research these issues and have an informed debate. People can be controlled by fear and hate but, in my experience, they can also be influenced to show empathy when injustice is explained and exposed. References Administration for Children and Families. (2016). Fiscal Year 2017: Justification of Estimates for Appropriation Committees. Retrieved from https://www.acf.hhs.gov/sites/default/files/olab/ final_cj_2017_print.pdf American Immigration Council. (2016, August 22). FACT SHEET: Asylum in the United States. Retrieved from https://www.americanimmigrationcouncil.org/research/asylum- unitedstates Brader, T. et al. (2008, October). What Triggers Public Opposition to Immigration? Anxiety, Group Cues, and Immigration Threat. American Journal of Political Science, 52, 959-978. BBC News. (2017, August 3). US immigration proposals: Whatâ&#x20AC;&#x2122;s in the Raise Act? Retrieved from http://www.bbc.com/news/world-us-canada-40814625 Congressional Budget Office. (2017, February 8). The Federal Budget in 2016: An Infographic. Retrieved from https://www.cbo.gov/publication/52408 Dewey, C. (2017, March 16). Immigrants are going hungry so Trump wonâ&#x20AC;&#x2122;t deport them. The Washington Post. Retrieved from https:// www.washingtonpost.com/news/wonk/wp/

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less valuable than the native-born population. He has even falsely claimed that veterans are treated worse than undocumented immigrants (Jacabson & Valverde, 2016). Statements like this risk generating resentment of local immigrant populations. These are not just words -- they have changed the way organizations and people behave. Immigration and Customs Enforcement (ICE) is no longer exempting any class of individuals from removal proceedings and their arrests have climbed 40% (ICE, 2017). In one case, ICE arrested a man outside of a church that had been set up as a temporary homeless shelter in winter months (Hernandez, Lowery, & Hauslohner, 2017). In addition the number of hate groups and hate crimes in the US has been increasing since 2015 including a spike following the election (Southern Poverty Law Center [SPLC], 2017). A survey of 10,000 teachers around the country showed heightened anxiety in marginalized students, and an increase of verbal harassment, slurs, and other forms of bigotry (SPLC, 2016). Immigrants, including survivors of torture, from across the country are reacting to the changing climate. For example, there are accounts from all over the US that food assistance enrollment by eligible immigrants has decreased (Dewey, 2016). In Los Angeles, there have been reports that immigrants have been too afraid of deportation to report sexual assault. Reports of sexual assault by Latinos have dropped 10% from the same time last year (Queally, 2017). There are even reports that people are avoiding medical care for fear of deportation (Swetlitz, 2017). In my work as a clinical case manager at a survivors of torture program, I have heard multiple clients express fear of deportation, even though they are in the US legally. The full extent of the fear caused by recent statements has yet to

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2017/03/16/immigrants-are-now-cancelingtheir-food-stamps-for-fear-that-trump-willdeport-them/?utm_term=.97fea143c4e7 Duffy, B. et al. (2016, July). Global Views on Immigration and the Refugee Crisis. Ipsos MORI. Retrieved from https://www.ipsos-mori.com/ Assets/Docs/Polls/ipsos-global-advisor-immigration-and-refugees-2016-charts.pdf Fix, M., & Capps, R. (2017, February). Leaked Draft of Possible Trump Executive Order on Public Benefits Would Spell Chilling Effects for Legal Immigrants. Migration Policy Institute. Retrieved from http://www.migrationpolicy.org/ news/leaked-draft-possible-trump-executiveorder-public-benefits-would-spell-chillingeffects-legal Foged, M. & Giovanni P. (2016). Immigrants’ Effect on Native Workers: New Analysis on Longitudinal Data.” American Economic Journal: Applied Economics. 8, 2, 1-34. Hainmueller, J. et al. (2015, July). The Hidden American Immigration Consensus: a Conjoint Analysis of Attitudes Toward Immigrants. American Journal of Political Science, 59,3, 529-548. Hernandez, H.R, Lowery, W., & Hauslohner, A. (2017, Feb 16). Federal immigration raids net many without criminal records, sowing fear. The Washington Post. Jacobson, L. (2016, Sept 9). Donald Trump’s False Claim Veterans Treated Worse than Illegal Immigrants. Politifact. Retrieved from http://www. politifact.com/truth-o-meter/statements/2016/ sep/09/donald-trump/trump-says-veteranstreated-worse-illegal-immigran/ Johnson, K.R. (1998). The Immigration Laws, and Domestic Race Relations; a “Magic Mirror” into the Heart of Darkness, The Indiana Law Journal. 73, 4, 1111-1160. Ku, L., & Bruen, B. (2013, March 4). Poor Immigrants Use Public Benefits at a Lower Rate than Poor Native-Born Citizens. Cato Institute Economic Development Bulletin, 17. Retrieved from https://www.cato.org/publications/economic-development-bulletin/poor-immigrantsuse-public-benefits-lower-rate-poor Murray, K., et al.(2013). Attitudes Towards Unauthorized Immigrants and Refugees. Cultural Diversity and Ethnic Minority Psychology, 19, 3, 332-341. The National Academies of Science, Engineering, and Medicine. (2016, September 21). Immigration’s long-term Impacts on Overall Waged and Employment of Native-born US Workers. Retrieved from http://www8.nationalacademies. org/onpinews/newsitem.aspx? RecordID=23550

LETTERS TO THE EDITOR

Office of Refugee Resettlement. (2016). About Cash & Medical Assistance. Retrieved from https:// www.acf.hhs.gov/orr/programs/cma/about Office of Refugee Resettlement. (2012, July 12). Asylee Eligibility for Assistance and Services. Retrieved from https://www.acf.hhs.gov/orr/ resource/asylee-eligibility-for-assistance-andservices Office of Refugee Resettlement. (2017). Survivors of Torture Program. Retrieved from https://www. acf.hhs.gov/orr/programs/survivors-of-torture Pew Research Center Hispanic Trends (2015, September 28). US Public has Mixed Views of Immigrants and Immigration., Pew Research Center. Retrieved from http://www.pewhispanic. org/2015/09/28/modern-immigration-wavebrings-59-million-to-u-s-driving-populationgrowth-and-change-through-2065/ Southern Poverty Law Center. (2017, February 15). Hate groups increase for second consecutive year as Trump electrifies radical right. Retrieved from https://www.splcenter.org/ news/2017/02/15/hate-groups-increase-secondconsecutive-year-trump-electrifies-radical-right Southern Poverty Law Center. (2016, November 28). The Trump Effect: The Impact of The 2016 Presidential Election on Our Nation’s Schools. Retrieved from https://www.splcenter. org/20161128/trump-effect-impact-2016-presidential-election-our-nations-schools Swetlitz, I. (2017, February 24). Immigrants, fearing Trump’s deportation policies, avoid doctor visits. STAT News. Retrieved from https://www. statnews.com/2017/02/24/immigrants-doctorsmedical-care/ Queally, J. (2017, March 21). Latinos are reporting fewer sexual assaults amid a climate of fear in immigrant communities, LAPD says. LA Times. Retrieved from http://www.latimes. com/local/ lanow/la-me-ln-immigrant-crime-reportingdrops-20170321-story.html Taxin, Amy. (2016, June 2). Children’s asylum approvals vary by US region. The Associated Press. Retrieved from https://apnews.com/ b140ad95d4a646e9aff67b8c80708e57/ap-exclusive-childrens-asylum-approvals-vary-us-region US Immigration and Customs Enforcement. (2017). Feature: 100 Days of ICE. Retrieved from https://www.ice.gov/features/100-days US Citizenship and Immigration Services. (2017). Asylum. Retrieved from https://www.uscis.gov/ humanitarian/refugees-asylum/asylum US Committee for Refugees and Immigrants. (2017). Travel Loan Services. Retrieved from http:// www.uscripayments.org/

Call for Papers: Forced Migration and Torture: challenges and solutions in rehabilitation and prevention Background There has been increased pressure on public health systems and rehabilitation centers that work with torture survivors and traumatized forced migrants over the last few years, in Europe as well as globally. Massive population displacement over a short time challenges existing services and can threaten holistic rehabilitation treatment. Estimates vary, but it seems likely that as many as 25% of forced migrants are survivors of torture, either in their country of origin, during transit, or in the country where they seek refuge. This pressure has stimulated not only a wealth of new data, but also innovative ways to deal with the situation on the ground. The Torture Journal would like to gather lessons learnt not only from Europe, but also from other parts of the world where migrant torture survivors need attention: Are we dealing adequately with our duty towards torture survivors who are forced migrants? What characterizes the treatment and rehabilitation of migrant torture survivors in recent crises compared to previous ones? Has it changed rehabilitation practices and, if so, it what way? What lessons can be learnt for both the clinical and non-clinical rehabilitation of these vulnerable populations going forward in Europe as well as globally? Objective To gather and disseminate useful experiences developed in order to detect and assist migrant torture survivors; to inspire practitioners to apply such examples in their own practice; and, to allow reflection between contexts, both within Europe and globally. Call for papers Torture Journal encourages authors to submit papers with a rehabilitation orientation, particularly those that are interdisciplinary. We welcome papers on: (a) the definition of torture or torturing environments in migrant/refugee populations; (b) particular victim groups, locations, types of

torture, specific vulnerabilities, with respect to risks, impacts and needs with a specific focus; (c) specific aspects related to places of detention or deprivation of liberty; (d) psychometric tools specifically for working with migrant/refugee torture survivors; (e) medical diagnosis, forensic assessment and appropriate referral mechanisms of torture survivors, and the significance that documentation of torture has regarding obtaining asylum / residence permit, i.e. legal implications; (f) psychosocial and community impacts and interventions; (g) recommended practice for when resources or conditions are not optimal; (h) national policies with respect to the right to rehabilitation; (i) therapies regarding psychotherapy and group therapy; (j) the impact in host societies and studies on sociological views of tortured migrants; (k) cultural and gender specific issues in situations of torture survivors in places of detention and/or refugee situations. Submission guidelines For general submission guidelines, please see the website (http://irct.org/research-development/ torture-journal). Papers will be selected on their relevance to the field, applicability, methodological rigour, and level of innovation. Deadline for submissions: 31st December 2017.

FOR MORE INFORMATION

Contact Pau PĂŠrez-Sales, the Editor in Chief (pauperez@arrakis.es) Nicola Witcombe, Editorial Assistant (naw@irct.com)

Can disability predict treatment outcome among traumatized refugees? Sabrina Friis Jørgensen, Mikkel A. AuningHansen, Ask Elklit Detainees' perception of the doctors and the medical institution in Spanish police stations: An impediment in the fight against torture and ill-treatment Hans Draminsky Petersen, Benito Morentin An account of ‘Life after Guantánamo’: a rehabilitation project for former Guantánamo detainees across continents Polly Rossdale, Katie Taylor

The United States Supreme Court Case Ziglar v. Abbasi and the severe psychological and physiological harms of solitary confinement Eric Ordway, Jessica Djilani, Alexandria Swette Torture without physical pain: Inside cell 24 of the special wing for political prisoners-Evin prison (Iran) Hasti Irani Solitary confinement, Section 350 Evin prison in Tehran S. M. Khodaei

Obstacles to torture rehabilitation at Guantánamo James Connell, Alka Pradhan, Margaux Lander

Online subscription Please sign up to receive an email notification as soon as a new issue is available online at www.irct.org/torture.journal rather than opting for a hard copy.

The IRCT is an independent, international health professional organisation that promotes and supports the rehabilitation of torture victims and the prevention of torture through nearly 200 rehabilitation centres and programmes around the world. The objective of the organisation is to promote the provision of specialised treatment and rehabilitation services for victims of torture and to contribute to the prevention of torture globally. To further these goals, the IRCT seeks on an international basis:

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to develop and maintain an advocacy programme that accumulates, processes and disseminates information about torture as

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well as the consequences and the rehabilitation of torture to establish international funding for re habilitation services and programmes for the prevention of torture to promote the education and training of relevant professionals in the medical as well as social, legal and ethical aspects of torture to encourage the establishment and maintenance of rehabilitation services to establish and expand institutional relations in the international effort to abolish the practice of torture, and to support all other activities that may contribute to the prevention of torture

ISBN 1018-8185