Lessons from Abu Ghraib

Thursday, Jul 01, 2004

The shocking pictures from Abu Ghraib prison in Baghdad have come as a double blow to the doctors and therapists working with torture survivors in 170 rehabilitation centres around the world. On top of their dismay that US forces could treat prisoners so cruelly, staff have been overwhelmed with requests for help over the past few weeks, as the images and descriptions reawaken horrific memories in people who have been tortured.

"The events at Abu Ghraib have had a profound effect on the people we care for," says Allen Keller, director of the Bellevue/New York University Program for Survivors of Torture. "The pictures have been very disturbing and retraumatising for many of our patients, who have been suffering a recurrence of nightmares and other sleeping problems."

Gill Hinshelwood, senior examining doctor at the Medical Foundation for the Care of Victims of Torture in London, reports a similar surge in symptoms. "Some of my Iraqi clients [who suffered under Saddam Hussein's regime] have had a resurgence of nightmares; others are coming back with aches and pains," she says. "Many are obsessed with what is going on."

Yet staff at rehabilitation centres say some good will come out of the horror of Abu Ghraib, if it increases awareness of how to diagnose and treat torture. At present the medical community pays insufficient attention to what Prof Keller calls a global public health problem. "Around 400,000 torture survivors have come to live in the US alone," he says.

Richard Mollica, director of the Harvard Program in Refugee Trauma, agrees. "Despite routine exposure to the suffering of victims of human brutality, healthcare professionals tend to shy away from confronting this reality," he says. "Clinicians avoid addressing torture- related symptoms of illness because they are afraid of opening a Pandora's box: they believe they won't have the tools or time to help torture survivors once they've elicited their history."

Even the damage caused by physical brutality may be hard for a general practitioner to spot. For instance, falanga, in which the soles of the feet are beaten with rods, may leave no outward sign of damage even though internal damage to nerves and tendons can make walking excruciatingly painful.

Diagnosing and treating the psychological legacy of torture is even more difficult. All the attention given by psychology researchers to post-traumatic stress disorder has not necessarily helped those working with torture victims.

"This emphasis on PTSD has obscured the reality that the most common mental illness diagnosed in torture survivors is depression - often a serious and socially debilitating condition associated with serious medical consequences," says Prof Mollica. The depression caused by torture and extreme violence can be distinguished from other forms of depression by the intense and repetitive nightmares that accompany it.

Dr Hinshelwood says this depression is best described as "a deep and long-term sense of passivity and pessimism". She adds: "People - and men in particular - are even more depressed if their torture includes rape or sexual abuse."

Sexual abuse was, of course, a prominent feature of the American mistreatment of prisoners at Abu Ghraib. Although there has been some debate about whether this amounted to torture, organisations working with torture victims, such the Medical Foundation in London, state unequivocally that it did. And they say that US interrogators have used an unacceptably harsh sort of coercion - sometimes called "stress and duress" or "torture lite" - systematically, not only in Iraq, but also at Guantanamo Bay in Cuba and Bagram air base in Afghanistan.

In response to the shock of many Americans, who asked why "seemingly normal" US soldiers could behave so sadistically in Iraq, the American Psychological Association put the professional view that "most of us could behave this way under similar circumstances".

Two famous experiments proved the point more than 30 years ago. First Stanley Milgram at Yale University showed that most normal volunteers would follow the instructions of an authority figure - a scientist in a white coat - and give other people a series of increasingly powerful electric shocks, even though they elicited agonising screams.

Then Philip Zimbardo set up a simulated prison at Stanford University, in which students were randomly selected to play the roles of prisoners and guards. Prof Zimbardo believes his experiment has striking similarities with Abu Ghraib: "I have exact, parallel pictures of naked prisoners with bags over their heads, who are being sexually humiliated by the prison guards, from the 1971 study." d4 According to the APA, these two classic experiments - and other psychological studies in the laboratory and in the field - go a long way to explaining what went wrong at Abu Ghraib. Any prison is an environment in which the balance of power is so unequal that normal people can become brutal and abusive, unless the institution has strong leadership and transparent oversight to prevent the abuse of power.

Abu Ghraib not only lacked such leadership, but also had another ingredient for abuse: an ethnic, cultural, linguistic and religious gulf between guards and prisoners. Robert Jay Lifton, psychiatry professor at Harvard Medical School, says people are naturally predisposed to distrust or even attack others whom they categorise as outsiders.

The Abu Ghraib guards allegedly thought they were following orders from intelligence officers. However, this sort of mistreatment is counterproductive even from the narrow viewpoint of intelligence gathering, says Vince Iacopino, research director of the Massachusetts-based group Physicians for Human Rights.

"Unfortunately, some may assume that physical and psychological coercion techniques serve to 'soften up' detainees for interrogation," says Dr Iacopino. "In our experience it is clear that physical and psychological forms of coercion or ill treatment or torture do not provide accurate and reliable information. On the contrary, by inflicting physical and/or emotional pain, perpetrators reduce their victims to a point that precludes obtaining reliable 'information' - and victims frequently falsely confess to whatever they think interrogators want to hear."

Prof Mollica points out that perpetrators can also be psychologically damaged by their experience and requests to treat them can put doctors in a difficult position.

"In medicine we have the controversial concept of 'medical neutrality', which holds that the doctor has an obligation to treat someone regardless of political situation or the circumstances that made them ill," he says. "But if a perpetrator of torture comes to you for therapy, what do you do?"

There are clearly far more victims than perpetrators of torture - and most are more seriously damaged. But there is hope, as psychologists around the world gain experience in helping torture victims to recover their mental health, first through proper diagnosis and then through a mixture of therapy and, if appropriate, treatment with antidepressants or other drugs.

"Twenty years ago there was a widespread impression that survivors of extreme violence could never really recover from the experience," says Prof Mollica. "Now we are much more optimistic."

While many torture victims suffer renewed torment through the images of Abu Ghraib, their long-term prospects may be becoming slightly brighter.

Clive Cookson