Torture Journal Vol 27 No. 3 2017 by IRCT International Rehabilitation Council for Torture Victims

Jour nal on Rehabilitation of Torture Victims and Prevention of Torture

VOLUME 27, NO 2, 2017, ISSN 1018-8185

2017

TORTURE 3

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 3, 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 torture Editor in Chief Pau Pérez-Sales, MD, PhD Editorial Assistant Nicola Witcombe, MA, LLM Editorial advisory board S. Megan Berthold, PhD, LCSW

Contents Editorial

Pau Pérez-Sales, Editor in Chief

Scientific Articles

Rehabilitation of torture survivors and prevention of torture: Priorities for research through a modified Delphi Study Pau Pérez-Sales, Nicola Witcombe, Diego Alonso-Otero

Commentaries: José Quiroga, Mahmud Sehwail, Carlos Jibaja Zárate,Yakov Gilinskiy, Metin Bakkalcı, Frances Lovemore, Jens Simon Modvig Impact of NET on torture survivors in the MENA region Ane Kirstine Viller Hansen, Nete Sloth Hansen-Nord, Issam Smeir, Lianne Engelkes-Heby, Jens Modvig 49 Tortured Logic: Information and Brutality in Interrogations

Hans Draminsky Petersen, MD

John W. Schiemann

Jim Jaranson, MD, MA, MPH

Commentaries: Lawrence Alison & Emily Alison, Glenn Carle, Hans Draminsky Petersen. Response by the author

Marianne C. Kastrup, MD, PhD

Jens Modvig, MD, PhD

Perspectives

Duarte Nuno Vieira, PhD, MSc, MD

Australian immigration detention and the silencing of practitioners

Önder Özkalipci, MD June C. Pagaduan-Lopez, MD José Quiroga, MD

April Pearman, Stephanie Olinga-Shannon

Statements

WPA Declaration on Participation of Psychiatrists in Interrogation of Detainees

Nora Sveaass, PhD

World Psychiatric Association

Morris V. Tidball-Binz, MD

Commentaries: Stephen Soldz, Steven H. Miles

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: publications@irct.org Subscription http://irct.org/media-and-resources/publications#torture-journal Price: EURO 100 per year. www.irct.org/Library/torture-journal.aspx. The journal is free of charge for health professionals.

Condemnation on any restriction to the European Convention on Human Rights European Network of Rehabilitation Centres for Survivors of Torture 99 Comment: Jacques Hartmann Book review

Remember. Violation of human rights: a medical, psychological and political outlook. By Paz Rojas Pau Pérez-Sales

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News

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.

Victimisation of hunger strikers at Guantánamo Bay

Front page: Mogens Andersen, Denmark Layout by Jordi Calvet Printed in Lithuania by KOPA.

Letters to the Editor

Katie Taylor

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Torture in the Kashmir Valley and Custodial Deaths in India Inamul Haq

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1 EDITORIAL

Call to action: Reinvigorating a global research agenda for the sector Pau Pérez-Sales, MD, PhD, Psych*, Editor in Chief

mean that other topics are not considered relevant and will not have a space in our pages. We hope you find the exercise useful and enlightening. We also have a quite technical and theoretical debate in this issue: Professor John W. Schiemann accepted a challenge from the Journal: summarise and expand on his 2016 book Does torture work? The book applies mathematical models of game theory to an interrogational torture setting. The result is thought-provoking. As are the three comments by Lawrence Alison, researcher from the University of Liverpool, Glenn Carle, former CIA interrogator and Hans Draminsky Petersen, past member of the SPT, and the final reply of Prof Schiemann. These are complemented by a research paper by Ane Kirstine Viller Hansen, Nete Sloth Hansen-Nord, Issam Smeir, Lianne Engelkes-Heby and Jens Modvig on the Impact of Narrative Exposure Therapy (NET) on torture survivors in the Middle East and North Africa region. Amongst other contributions, a much awaited and well-received Statement by the World Psychiatric Association is also included. After two years of consultations of a task group of the Section on Psychological Consequences of Persecution and Torture, the General Assembly of WPA approved in October 2017 the statement ‘Banning the participation of psychiatrists in the

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For the past nine months the Torture Journal has been conducting a Delphi Study on priorities of research in the field, involving the editorial board and more than 50 panellists from all over the world to reach a consensus. The results will surprise many readers, both in relation to the topics that were considered a priority and those that were not. The results are challenging as far as they draw, for the first time, a shared agenda for the sector. We have invited some leading authors in the field to comment on the results. As Jens Modvig, Chair of the United Nations Committee against Torture states in his comment, “these research priorities could form the backbone of an internationally agreed research agenda. For this to happen, stakeholders would have to get together and discuss and adopt a common research agenda, preferably with the presence of donors within the field. I can only encourage stakeholders to take such an initiative—a workshop—to facilitate that research”. All research studies, like this Delphi study, depend somehow on sample and analysis. The results must always be considered in a cautious way. But this is a start. Not only the ten top-ranked priorities, but the more than 170 potential lines of research collected in Annex 1 to the paper. The Torture Journal will launch in the year to come targeted Calls for Papers on those topics considered a priority. This does not

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interrogation of detaineesâ&#x20AC;&#x2122;. This is a landmark and very important declaration in the fight against torture. Though torture is illegal, as stipulated by a number of wellknown conventions and treaties, and thus subjected to international prosecution, psychiatrists have sometimes been involved in situations connected to ill-treatment and torture which are ethically unacceptable on any grounds. The purpose of this position statement is to provide ethical guidelines for practice, in which psychiatrists are explicitly forbidden and must refrain from participating in any procedure linked to the interrogation of a detainee. This statement helps to address accountability for physicians involved. Useful supporting commentaries are provided by Professor Stephen Soldz, member of the Coalition for an Ethical Psychology, and Professor Steven Milles from the University of Minnesota Center for Bioethics. This issue of the Torture Journal demands that time is taken over it. Mathematical models and research data require quiet consideration. Even more so, the call to action suggested by the Delphi Study and the commentators requires further deliberation. Responses, ideas and comments from all readers are most certainly welcome.

EDITORIAL

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Rehabilitation of torture survivors and prevention of torture: Priorities for research through a modified Delphi Study Pau PĂŠrez-Sales, MD, PhD, Psych*, Nicola Witcombe, MA, LLM**, Diego Otero Oyague, LPsy ***

Abstract

*) Editor in Chief, Torture Journal, SiR[a] Centre, GAC Community Action Group and Hospital La Paz, Spain. **) Torture Journal, International Rehabilitation Council for Torture Victims, Copenhagen ***) Independent Consultant, Peru Correspondence to: pauperez@arrakis.es

publication which led the study). Findings: The panellists came up with 174 possible lines of research from which 40 were prioritised. Some more theoretical research lines especially regarding neurobiology, evidence-based treatments or ethical debates were not considered a priority. From individual research lines, the four highest ranking were: long-term outcomes and effects of interventions (including chronicity, factors leading to re-traumatisation and implications for public health); outcomes of the Istanbul Protocol (impact of documentation of torture in the judicial system); trans-generational trauma; and, torture in the context of those disappeared and in extrajudicial killings. While there were not significant differences in priorities by gender, the analysis by geographical area showed important peculiarities suggesting that a single worldwide agenda of research might not be realistic or desirable, and that local and regional priorities must be taken into account. Discussion: Overall, the study shows a dissociation between what we know, what we would like to know and what we research. Most of the research published in medical and psychological journals is around local experiences, epidemiological data, case reports and mixed outcome

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Background: Research is a key element in prevention and in ensuring that survivors of torture have access to appropriate and effective rehabilitation, but it is often neglected as more pressing issues frequently come first. Methods: A modified Delphi study with three rounds of consultation was used to reach a consensus of expert panellists with respect to top research priorities in the interdisciplinary field of torture rehabilitation and prevention. Panellists included professionals (medical, psychologists and psychiatrists, lawyers, social workers and members of organizations of survivors) from 23 countries balanced by gender, geographical area, profession and area of work (country of asylum versus where torture is perpetrated). Aims were to stimulate an interdisciplinary debate, foster research and inform the future publishing priorities of the Torture Journal (the

studies, which were not among experts’ priorities. This points to the fact that existing research can be repetitive and that there is ample scope for other research topics in the future, particularly interdisciplinary research. Conclusion: Whilst it is accepted that global research priorities are unlikely to fully reflect research needs at every level (local/national/regional for example), some important conclusions can be drawn. The anti-torture sector is a fairly young field of academia and is interdisciplinary in nature. A wide scope of research can therefore be usefully undertaken and published for dissemination. It is hoped that the findings of this study may be a useful starting point for consideration and fundraising. Keywords: Torture rehabilitation, torture prevention, Delphi Study, Pau and Diego, interdisciplinary

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Introduction

There is much to do in the struggle against torture and to ensure that survivors have access to appropriate and effective rehabilitation. Research is a key element in this process, although it is often neglected as more pressing issues frequently come first. In a field were urgency is the norm, research is ethically and methodologically complex (Huggins, 2000; Newman, Willard, Sinclair, & Kaloupek, 2001). With survivors knocking on the door every day, research seems a secondary element only for welloff centres. But the truth is that there is an ethical responsibility towards those we serve to work according to well-established practices and we lack data (Amris & Arenas, 2004; Green, Rasmussen, & Rosenfeld, 2010). Torture evolves constantly and the literature of the 1980s and 1990s needs— as in every field - updating. There is a lot of research on the side of perpetrators

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sponsored by governments under civil or military programs (Llanusa-Cestero, 2010; McCoy, 2008; Physicians for Human Rights, 2010) and the field is rapidly evolving. In a recent review, the first author concluded that there was a ten-year delay between technical and conceptual advances (sic) by perpetrators, and the timid answer from academia and human right activists (PérezSales, 2016 pp 165-7). New methods of torture, more sophisticated, more handsoff, appear. Research has been scarce and often repetitive and the future demands more innovative responses, new impulses and ideas (Manicavasagar et al., 2002). In this process, participation of survivors throughout the process of research is essential (Jackson, 2007) The torture movement is a young one with significant challenges. Efficacy of treatment has been challenged on different fronts (Başoğlu, 2006; Jaranson, 2006; Miles, 2009; Patel, Williams, & Kellezi, 2016) and outcome studies can indeed be problematic. From a research point of view, even in very basic studies on efficacy, the generalisability of results is severely undermined by study populations being too heterogeneous and having experienced differing types of torture over differing periods of time and research tools being often too dissimilar (Gurr, R. & Quiroga, 2001; Jaranson & Quiroga, 2011). Finally, and from a practical point of view, funding is difficult to obtain for many reasons, not least the political climate where human rights are not prioritised. A strength and a challenge of the movement is its interdisciplinary nature. This fosters debate and allows torture to be seen from the perspective of the biomedical, forensic, legal, anthropological, social, philosophical etc. However, it is also a challenge. How do we bring these strands together meaningfully?

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The Torture Journal (Journal on Rehabilitation of Torture Victims and Prevention of Torture) is an interdisciplinary, international scientific journal, which seeks to be a forum for the exchange of original research and systematic reviews by professionals concerned with the biomedical, psychological and social interface of torture and the rehabilitation of its survivors. It also seeks to enhance understanding and cooperation in the torture field through diverse approaches. The Torture Journal launched a Delphi Study in order to establish global research priorities with a view to informing the future publishing priorities of the journal and at the same time assisting the wider torture community with a consensus with respect to research priorities (Mikton et al., 2016, Collins et al., 2015). The Delphi Study was intended to be as comprehensive and interdisciplinary as possible by involving experts in the field of prevention and rehabilitation of torture survivors across disciplines, geographical location and gender. Secondary objectives were to stimulate an interdisciplinary debate among different sections of the global movement and to create synergies in future research and publication. Method

Preliminary round: At a meeting of the Editorial Advisory Board in 2016, an initial list of research lines was compiled based on research topics through a brainstorming and discussion exercise. Each expert present1 was asked to think and name three important research gaps with respect to torture in general and with respect to rehabilitation of survivors specifically, without any further instruction or specific suggestion by researchers. The group produced a set of 119 initial recommendations. The topics and grouping were later e-mailed and corrected by the experts participating in this preliminary round. Round 1: In February 2017, a wide sample of 154 experts were identified. The involvement of experts across disciplines, geographical location and gender was deemed a priority. In March 2017, these potential panellists were contacted by email (in English with a

S. Megan Berthold (US), Hans Draminsky Peterson (Denmark), James Jaranson (US), Marianne Kastrup (Denmark), June Pagaduan Lopez (Philippines), José Quiroga (Chile/US) , Nora Sveaass (Norway), Morris Tidball-Binz (Argentina), Onder Özkalıpcı (Turkey), Victor Madrigal (Costa Rica), Leanne Macmillan (UK), Pau Pérez-Sales (Spain)

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The Delphi method is a structured methodology to get a collective expert opinion from a panel of specialists who would rarely or never meet physically due to their geographical location and their differing disciplines (Collins et al., 2011, Mikton et al., 2016). It is a useful technique which results in the opinions of a representative sample of experts converging through consecutive rounds of questioning and/or ranking. After each round, a collective feedback of the group’s decisions is provided to the group. In successive waves, the experts are encouraged to readjust their

earlier answers by taking into account what the group thinks and prioritises. This allows reducing the number of options until a final agreement is made. The mean, median scores or cumulative scores of the final round determine the results. Thus, to make a recommendation for priority lines of research in the anti-torture sector, we developed a Delphi Study to reach a consensus amongst a representative worldwide panel of experts.

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translation in French and Spanish) and asked if they would participate. The initial step was that they were encouraged - but not required - to review, comment on and edit the initial set of 119 research lines that arose from the preliminary round. For easy reviewing of the potential panellists, the authors divided the list into seven thematic areas. The feedback obtained from these panellists was collated to avoid duplication and incorporated into the research lines, which meant modification to some with respect to clarity and an overall increase to 174 research lines (‘comprehensive list of research topics’) and the thematic areas to eight (Annex 1). Email exchange with panellists took place if there was an uncertainty about what they meant. It was not possible to incorporate all the feedback. For example, some panellists queried the use of so many research lines either because they did not have time to respond to them all, or because they were concerned that the ranking would be so similar that they would not give meaningful results. Some pointed to possible interpretative repetition between lines. This was taken into account when considering the initial findings and whether an additional round was necessary (see below). However, the rationale behind this method was to be as inclusive and comprehensive as possible to the participants. Round 2: The finalised research lines were sent out to the 62 experts (40.25% response rate) who had agreed to take part. This included the 11 members of the Editorial Advisory Board and the Editor in Chief. They were asked to rank the priority of each, with respect to importance, from the point of view of necessity and gaps to fill in the next five to ten years (0: No priority; 1: Little priority; 2: Medium relevant;

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3: Maximum priority). Guidelines were given that the priority score was designed to highlight the most important topics of research from the panellist’s point of view. They were asked to try to distribute their ranks and give the maximum score (3) to no more than 10 topics overall. There were running totals of maximum priority scores at the end of each section and at the end, however, some panellists did not keep to this guideline which had an effect when deciding to do a third round. They were also asked to rank feasibility from 0 to 3 (0: Not feasible at this point; 1: Hardly feasible—needs specific conditions such as a highly specialised centre; 2: Feasible for an average research centre/ researcher; 3. Feasible even for a nonresearch centre). Guidelines were given that research is feasible when it is technologically or methodologically possible to carry out the research, including related costs and capacity. A topic of research can be a priority but contemporary science does not yet have a realistic capacity to endorse it or there are too many factors involved to have it meaningfully researched. Panellists received results from previous rounds in an Excel spreadsheet pre-formatted for easy scoring of priorities. The panellists were automatically advised of the number of research lines scored and if there were too many of the total number of high-priority lines selected. The panellists were also asked to provide socio-demographic data, which was subsequently used to analyse the data: Gender; Geographical area of work; Number of years working in the torture field ((0-5, 5-10, 10-15, 15+); Relation to the torture field (Health Professional/ Rehabilitation (e.g. physician, forensic expert, psychiatrist, psychologist, physiotherapist, nurse), or Psychosocial worker (social worker, community worker, facilitator, peer-support

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group, trainer)Â or Legal professional (legal representative, lawyer, documentation and advocacy)); Primary activity (Direct care or Managerial/legal support/advocacy or Academia/research); Research activity (Published an academic paper in a peerreviewed journal related to the field of torture, Authored a book or report related to the field of torture, Have been a principal investigator in a research involving torture survivors, Participated as a member of a research team); and, finally, whether the panellist works in a country of asylum or a refugee-producing country. They were also asked whether they considered they had a conflict of interest, and if so, what, and whether the research lines being in English had prevented them from contributing meaningfully. Thirty-six experts responded initially and a Latin square analysis was carried out based on geographical area and primary activity to identify gaps. In an effort to fill these gaps, follow-up emails were sent to experts as well as to the original 154 experts. Additional efforts to identify new experts were also made. These efforts resulted in five more panellists (see Annex 2 for an overall list of panellists).

Statistical analysis: To build the global ranking (Table 1), raw scores were derived from the simple sum of the priority values assigned by panellists. Analysis by gender, geographical location, professional profile and the profile of survivors attended was carried out using standardised scores. These were obtained by dividing the raw scores by the number of panellists in each category. Besides conceptual analysis of topranked research lines by socio-demographic variables, we looked for significant differences by using non-parametric U-Mann Whitney Test for two samples and Kruskal-Wallis Test for multiple groups. Statistical significance was set at 0.05. While the first gives an overall view of main priorities by sector, the second shows significant differences by line of research.

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Round 3: In this final round, the 62 experts who had originally agreed to take part and the new panellists (n=67) were asked to rank what they considered to be the 10 most important research lines out of a possible 40, and to put them in order of priority (1: least important; 10: most important). In Round 2 feasibility scores did not substantially change priority scores, at least for the top-ranked categories. Thus, for the sake of clarity to panellists, the 40 research lines for Round 3 were derived from the priority score in Round 2. We included those research lines that fell in the top quartile of best ranked answers.

Response rate was high (n=44, 65%). A similar Latin square analysis was undertaken to ensure proper distribution of panellists according to the key independent variables (geographical areas and professional specialities) and individual emails were sent to reinforce participation when significant gaps were detected. Although the intention was to keep seven geographical areas (Asia, Pacific, Europe, Latin America, Middle East and North Africa, Sub-Saharan Africa and North America), the results forced a different grouping to five areas (Asia, Australia-North America, Europe, Latin America and Africa) to allow for meaningful statistical analysis. Some panellists from Brazil and Argentina discussed their responses with colleagues and indeed some explicitly reported that their responses were the result of a group effort. We decided to respect this decision as a legitimate expression of a collectivistic style of work.

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Figure 1: Method: Rounds of consultation of experts

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Qualitative considerations: Some qualitative data was captured during Round 2 and 3 as panellists put extra notes and qualifications in their covering emails and in a â&#x20AC;&#x2DC;Notesâ&#x20AC;&#x2122; section next to the research lines. These comments were taken into account by the authors as far as possible when considering the results. Results

Following the preliminary round and Round 1, all of the 174 research topics that the group of worldwide experts consider worthwhile researching (Annex 2) were grouped into eight thematic blocks and ranked in Round 2. The wording used by panellists was respected wherever possible. The top quartile of priorities went forward to Round 3 to give a more refined picture.

Table 1 shows the resulting top-ranked research lines. Table 2 shows a summary of the three top priority lines disaggregated by key variables: gender, geographical area, professional profile and mail profile of survivors attended. A more extended version can be found in Annex 3. Table 3 details statistical differences by line of research. Discussion

The results of the study are consistent and show a portrait of the priorities for research in a worldwide and representative multidisciplinary sample of professionals of the health, legal and advocacy fields that work with survivors of torture. In this discussion, an overview of responses will be

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Table 1: Priorities for research—overall sample. Priority

Research Line

Score

Long-term outcome—Long-term effects of interventions—Cohort studies with survivors. Reactivation of symptoms. “Chronicity” in torture survivors. Factors leading to re-traumatization/”Chronification” (internal and external factors), Implications for public health.

161

Outcomes of Istanbul Protocol. Impact of documentation of torture in the decisions of the judicial system. Does forensic documentation really impact judges in their decisions? Which elements are considered relevant?

136

Trans-generational trauma. Define criteria. Preventive and therapeutic approaches.

107

104

Strategic use of clinical data for advocacy. Recommendations and guidelines.

101

Examples of national good policies in the application of General Comment #3 on the Right to Rehabilitation. Examples of good national plans for integral care of torture survivors. Examples of negative experiences. Recommendations.

Psychosocial support to survivors during the legal process. Good practice protocols for survivors that act as witnesses in trials.

Survivor participation in setting research priorities and research design. Participatory action research.

Critical review and updated data on psychometric tools widely used in the torture sector

Providing rehabilitation services in dangerous settings (e.g., when under threat from the state; where torture is rampant, etc.).

Minimum standards of good care. What do health professionals and survivors consider a minimum of “good access” to rehabilitation services for torture survivors?

Concept/description/Indicators of psychosocial/community impact of torture.

Psychological impact of impunity. Paths to recovery where impunity prevails.

Tools for quick documentation in police stations, pre-trial detentions and monitoring of prisons.

Use of sexual violence in individual torture for both women and men.

Models of family interventions.

Care for caregivers.

Politics and the tightening of asylum law and policies (including mass deportation, increased detention, possibly harder to pass credible fear interview, discriminatory policies toward refugees and asylum seekers from certain religious or ethnic background

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Fight against impunity as a healing process. Meta-analysis/review on the impact of justice on survivors’ well-being. Protective and risk elements. Do-no-harm principles and recommendations.

Tools for Credibility analysis of the allegations of ill-treatment or torture for supporting survivors’ claims.

Analysis of the relationship between psychological and somatic symptoms in torture survivors. Chronic pain. Chronic somatic complaints.

Intersection between justice and rehabilitation (for the positive or negative).

Impact of judicial interventions on individual well-being. Does access to justice improves quality of life?

Survivors of torture and empowerment.

What “rehabilitation” of torture survivors means. Defining the field.

Dual loyalty. Participation of health professional in torture—Passive support to torture. No documentation of evidence as complicity. Medical role in impunity. Dilemmas and solutions for doctors working under dual loyalty (e.g. the problem of daily attention).

Impact of torture by combined or cumulative impacts.

Ethical standards in documentation of torture.

Relation between different types of torturing environments, impacts on survivors and rehabilitation strategies.

Developmental disruptions, long-term impact of relatives’ torture, Impact of witnessing torture.

Definition. Tools (and validation) for assessing psychological torture.

Definition of torture. Evidence-based distinction between torture and CIDT.

Effective implementation of the International Consensus on Minimum Standards for the Psychosocial Work in Exhumation Processes for the Search for Disappeared persons.

Victims’ priorities regarding types of reparation.

Role of media (TV series, films, apps and video games…) in banalizing torture and increasing indifference (bystanders) /support to it.

Reasons for supporting /tolerating torture. Increasing support (political, legal, corporative and even social) to the use of torture as shown by polls and sociological studies.

Patterns of torture based on political contexts and analysis of conditions where there is a heightened risk of torture?

Beyond torture methods - Definition of Torturing Environments.

Coordination between national Mental Health services (where available) and Torture Rehabilitation services

The increasing role of witnesses in redress and the impact of increasing threats to witnesses.

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analysed first, followed by the specific top lines of research. Opening the lens: global perspectives arising from the study: Overall tendencies

The initial exercise of collective brainstorming provided a set of 174 possible lines of research.

Whilst there was some overlap between lines of research and more than one research idea could be found in an item, this reflects an intention to be true to the wording and responses of the panellists. Despite this, it shows an astonishing richness of ideas. Rather than showing that there is nothing new to research, it shows that there are

Table 2: Comparison by key variables (original research line number-min=0; max=100) Long-term outcome—Long-term effects of interventions (124-31) Trans-generational trauma (22-30) Examples of national good policies in the application of General Comment #3 on the Right to Rehabilitation (86-29)

Male

Long-term outcome—Long-term effects of interventions (124-43) Outcomes of Istanbul Protocol (73-35) Survivor participation in research. Participatory action research. (128-24)

Geographical Distribution Asia

Does access to justice improve quality of life? (132-70) Impact of torture by combined or cumulative impacts (5-53) Psychometric tools (6-50) Outcomes of Istanbul Protocol. Impact of documentation of torture in the decisions of the judicial system (73-43) Tools for Credibility analysis (70-43)

Europe

Long-term outcome—Long-term effects of interventions (124-45) Outcomes of Istanbul Protocol (73-38) Strategic use of clinical data for advocacy (174-27) Survivor participation in setting research priorities and research design (128-23) Examples of national good policies (86-22)

Latin America

Long-term outcome—Long-term effects of interventions (124-61) Torture in the context of those disappeared and in extrajudicial killings (27-60) Trans-generational trauma (22-54) Examples of national good policies (86-50) Psychosocial support to survivors during the legal process (141-34)

África and Middle East

Psychometric tools (56-31) Strategic use of clinical data for advocacy (174-30) Care for caregivers (119-29) Models of family interventions (101-28) Providing rehabilitation services in dangerous settings (83-28)

North America and Pacific

Strategic use of clinical data for advocacy (174-33) Politics and the tightening of asylum law and policies (171-31) Survivor participation in setting research priorities and research design (128-30) Minimum standards of good care in rehabilitation services (88-30) Long-term outcome - Long-term effects of interventions (124-27)

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Gender Female

Primary Activity Direct Care

Trans-generational trauma (22-46) Long-term outcome (124-42) Psychosocial support to survivors during the legal process (141-43) Survivor participation in setting research priorities and research design (128-33) Examples of national good policies (86-30)

Academia/Research

Long-term outcome (124-55) Outcomes of Istanbul Protocol (73-34) Psychometric tools (56-34) Strategic use of clinical data for advocacy (174-26) Survivor participation in setting research priorities and research design (128-26)

Managerial/Legal/ Advocacy

Outcomes of Istanbul Protocol (73-58) Psychosocial support to survivors during the legal process (141-30) Care for caregivers (119-29) Politics and the tightening of asylum law and policies (171-28) Minimums of â&#x20AC;&#x153;good accessâ&#x20AC;? to rehabilitation (88-26)

Profile of survivors National Survivors

1. Outcomes of Istanbul Protocol (73-38) 2. Long-term outcome (124-37) 3. Torture in the context of those disappeared (27-30) 4. Examples of national good policies (86-28) 5. Trans-generational trauma (22-25)

Asylum Seekers

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1. Long-term outcome (124-41) 2. Strategic use of clinical data for advocacy (174-32) 3. Trans-generational trauma (22-29) 4. Psychosocial/community impact of torture (95-28) 5. Models of family interventions (101-23)

more doubts than certainties and much still to do. Reviewing what the panellists suggested as relevant lines of research against the backdrop of the available literature (including the indices of the Torture Journal) as a barometer of what is being researched in the field, most of them are simply not present. In other words, there is a dissociation between what we know, what we would like to know and what we research. Most of the research published in medical and psychological journals is around local experiences, epidemiological data, case reports and mixed outcome studies. There appear to be many more research questions that panellists think have not been answered yet. This points to the fact that existing

research can be repetitive and that there is ample scope for other research topics to be the focus in the future. This does not mean that others are not doing research on some of these topics that scarcely appear in our publications. For instance, in the field of interrogation of detainees there has been much advancement in recent years, but limited to specific research groups of forensic psychologists not specifically linked to the field of torture research. Additionally, it may reflect the fact that some potential researchers/researcherpractitioners are unable to participate due to political, security or resource issues. Part of the gap between what we know and what we want to know could be solved if we were

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Table 3: Statistical differences by line of research according to key socio-demographic variables (original research line number)

Gender Geographical Area

Primary Activity

Profile of survivors

Line of research (code as referenced in Annex 1)

M / Group

Care for Caregivers (119) Sexual violence (13) Torturing environments (4) Relationship between torturing environments and clinical impacts in survivors (6) Sexual violence (13) Torture in forced disappearance (27) Models of family intervention (101) Care for caregivers (119) Impact of judicial interventions on well-being (132) Role of Media (167) Politics and the tightening of asylum law and policies (171) Transgenerational trauma (22) Torture in forced disappearance (27) Psychometric tools (56) Impact of Istanbul Protocol (73) Long-term outcome (124) Victimâ&#x20AC;&#x2122;s priorities regarding types of reparation (146) Strategic use of clinical data for advocacy (174) Developmental disruptions (18) Intersection between justice and rehabilitation (131)

Female 2.19, Male 0.50 Female 1.96, Male 0.65 Africa Africa, Europe

0.03 0.05 0.016 0.012

Africa Latin America Africa Africa Asia, Latin America

0.037 0.016 0.03 0.022 0.043

Asia North America-Pacific

0.003 0.05

Direct Care Direct Care Academia Legal-Advocacy Academia + Direct Care Academia

0.005 0.009 0.020 0.016 0.002 0.049

Academia + LegalAdvocacy Asylum National

0.005

Rapporteurs - were actually discarded in the early rounds. These included research related to gender perspectives (items 10-12, 14); torture in health institutions (items 15-17); coercive versus cognitive interviewing (item 7); torture linked to social cleansing policies (23-24); torture in demonstrations and other non-custodial settings (26-30, 44-47); torture and migration (30-31,34,75, 117,118); solitary confinement and torture in prisons (3942,121); neurobiology of torture (48-49); use of new technologies (50-51); relationship between PTSD, trauma and torture (63-64); early identification of victims and

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able to work in a more interdisciplinary way, integrate knowledge from other fields and were able to read and learn more from connected disciplines and perhaps bridge the gap to useful data sets that never see the light of day and to potential researchers who against their own wishes do not have a voice. Before turning to the priorities, it is of value to review what has not been considered a priority. It is note-worthy that the topics prioritised by the panellists reflect a focus on quite classical topics of interest in the field. New or ground-breaking topics â&#x20AC;&#x201C;including most of those addressed in the last few thematic reports by the UN Special

0.040 0.026

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documentation of torture in massive atrocities (67,74,79); updating, adapting or strengthening the Istanbul Protocol (69, 77,78); medical and pharmacological treatment based on evidence (102,103, 105-110); cultural meaning of torture (111-116); implementation and efficacy of National Prevention Mechanisms (149, 151) or implementation of international databases (173). It is possible to speculate over the reasons behind these notable absences. These topics may of course still be of interest to panellists, but may not be considered a priority for a host of reasons, including that they are aware of research already being undertaken. The anti-torture sector (if our sample is to represent it) encompasses many different contexts, from a field worker who carries out basic psychosocial and counselling activities in a dangerous context, to a therapist from the global north who does expressive therapies with asylum seekers, from a lawyer that does strategic litigation of selected cases, to a neurobiologist that does empirical research on brain tissue damage, from a human rights organization doing country reports to torture survivors who speak out. This being so, it may be that some of the topics were only a priority to a statistically insignificant number of, or at least fewer, panellists, or those interested in those topics were not sufficiently represented in the sample. While recent literature on the neurobiology of torture has been among the most innovative and influential (Elbert et al., 2011; Oâ&#x20AC;&#x2122;Mara, 2016) panellists may see this as unrelated to their everyday concerns. This is the case even when feasibility is not an issue; including feasibility as a measure did not change the limited importance given to this kind of research by our panellists suggesting that it is not a coincidence that neurobiological research is

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only considered a possibility by the fewest of the major research centres. The only (limited) exception pointed out by two panellists is when neurobiology can help in better defining torture, in determining the difference between torture and CIDT, or in documenting torture for legal processes. This may reflect a tendency in the sector to delay in responding to state-of-theart thinking, which is a concern in an environment where a significant proportion of military research spending goes to basic psychological research (Intelligence Science Board, 2006). There is a similar tendency with new technologies on how the brain, human consciousness and human will can be manipulated and controlled and the implications in terms of cognitive liberties and new generations of human rights. This deserves some reflection, at least in research centres where this kind of research is viable. Turning to what has been prioritised, we find the definition of torture versus CIDT (1); specificities of contemporary torture and torturing environments (4,5,6,60); specificities of certain populations -sexual violence, children and transgenerational trauma, extrajudicial killings and forced disappearance (13,18,22,27); documentation of torture (43), and impact on the judicial system (73); definition of rehabilitation and good practices (82,83,86,88,92,124), measures, questionnaires (56,59,70, 76); community indicators (95); empowerment of victims (128, 130); impunity, justice and redress (131,132,138,141,142,146,148); ethical aspects (148, 152); and political and sociological aspects (165, 167, 170, 171). Although the overall picture shows great heterogeneity, in reviewing manually expertsâ&#x20AC;&#x2122; responses one by one, it is possible to discern that what has clearly been prioritised is practice over theory; most panellists have ranked not according to a global idea of the

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priorities of the anti-torture movement, but according to one or more aspects of their direct needs related to their primary activity (see Annex 3 for top priorities by sociodemographic variables). Although there is a strong emphasis on treatment and rehabilitation issues, when this category is scrutinised in more detail, experts show an interest in what “rehabilitation” means, national policies in the application of General Comment #3 of the CAT regarding the duty of the State to provide reparation measures, including full rehabilitation of victims.2 This opens the debate on how this reparation and rehabilitation should be provided and dilemmas on the dual role of the State as perpetrator and provider of help and the role of independent organizations which have been providing legal advice and health services for decades. While this has a clear advocacy side, the importance given by panellists to this line of research may also reflect the critical financial situation of many of these centres and the dangers of being absorbed by the State and eventually closed depending on political priorities and policies. It may also reflect the debate on the minimum standards of

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General Comment #3 of the United Nations Committee against Torture was published in December 2012 and is devoted to the implementation of article 14 of the Convention that says that each State party is required to “ensure in its legal system that the victim of an act of torture obtains redress and has an enforceable right to fair and adequate compensation, including the means for as full rehabilitation as possible”. The Comment also states “that a person should be considered a victim regardless of whether the perpetrator of the violation is identified, apprehended, prosecuted or convicted, and regardless of any familial or other relationship between the perpetrator and the victim.” It establishes the highest possible standard in the duty of the State to repair and specifically, to provide rehabilitation.

rehabilitation and what can be considered good practice at the national level as well as links and coordination with existing mental health services. National policies are, in fact, considered more important than research into working in complex and unstable contexts, particularly by experts from the global north. However, this may also reflect a concern that needs of torture survivors are best met through long-term, structural support. Somewhat surprisingly, the panellists either do not show a great interest in the best therapeutic models or they believe this research has already been done or is being done. The obsession for so-called evidence-based treatments and guidelines of good practice shown by some academia and especially by funders, seems not to be shared by most of the experts. There is only some concern for pain and somatic unexplained symptoms and the interplay of body expressions of distress, and in a better definition and measurement of psychological torture. These are unresolved challenges in current therapeutic models. In response to panellists’ general lack of prioritising shortterm, evidence-based outcome studies, it is tempting to say that most practitioners have the idea that what they do is simply correct because it comes from years of therapeutic experience, but this is of course open to debate; some therapies, which still have insufficient research support in the work with torture survivors (like Narrative Exposure Therapy, Cognitive Behaviour Therapy or Psychological First Aid) (Dieltjens et alt 2014; Patel, Kellezi, & Williams Amanda, 2011) are often adopted uncritically and arguably prematurely considered as evidence-based, possibly reflecting the need to validate practice in front of donors and out of a need to belong to mainstream practices. Using

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trans-theoretical paradigms, most of the models that are the subject of research are in fact manualised variations on the same traditional narrative techniques that therapists have been doing for decades (Perez-Sales, 2017). Some experts might have a more humanistic, existentialist approach and do not consider relevant to their practice to undertake case-control studies of manualised therapies. This being so, common sense solutions represented by quite flexible and patient-tailored modular treatments in which the therapist chooses among different packages according to the survivors needs seem to be one of the most promising options for the future (Bolton et al., 2014; Murray et al., 2014). There is also a strong concern with justice and redress, not only from legal professionals. While there is a wealth of clinical literature and essays linking impunity with damage and re-traumatization and analysing justice as a healing factor (Rojas, 2017), experimental studies demonstrating that this is so, including considering optimal conditions for specific profiles of survivor and their specific needs in this process and how to properly address the relation of justice and well-being, are virtually nonexistent. This is a neglected field of research, perhaps because the importance of the fight against impunity seems so self-evident on the one hand, but concrete data remains difficult to capture, something which our experts stress. Many panellists also show a strong interest in the interplay between the legal and medical world, especially the relationship between documentation of medical and physical consequences, rehabilitation and justice. One topic stands out in the responses: the impact of the documentation of torture (and particularly the Istanbul Protocol) on legal processes, especially from European panellists. This will

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differ within jurisdictions and their diverse evidentiary rules, as well as on the national, regional and international level. Additionally, there are other specific points of concern (132-134): the process of justice in itself (independent of the sentence) as a no-harm and eventually healing process and best practices in working in support of victims during the legal process. Advocacy is also deemed important in the overall picture, especially regarding the use of clinical data for activist purposes. While 60% of the panellists work in Europe, North America and Australia there is scarce interest in research involving refugees and asylum seekers, apart from political advocacy which is a concern for North American panellists, but not for European experts nor for professionals working with internal displacement or migrants in the global south. The so-called European crisis does not appear to have had an influence on priorities for research, at least in this study. This is surprising when this topic represents a vast majority of what most journals (the Torture Journal among them) have been receiving as submissions, giving cause for reflection. One hypothesis for this seemingly surprising fact is that a lot of research done in this area involves replicating very basic epidemiological or general-purpose unspecific outcome studies that often do not give new or insightful results. This can be called opportunistic research and is not intended to answer complex or novel questions. By contrast, the topic of torture in democracy, contemporary torture and the effect of combined and cumulative effects of torture and the definition of torturing environments are deemed important by panellists and considered important priorities. Debates on ethical aspects of torture also attract little attention. This is in contrast with what readers will find in their

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bookstore: approximately seven out of ten books published in the last ten years on torture are related to ethical or philosophical debates on whether torture is justifiable or not under certain conditions. The fine picture: scope of research lines

If, instead of overall tendencies, we consider research lines (Table 1) our panellists clearly point to five main topics for future research:

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(1) The first topic is the consequences of torture as a chronic disease (124). This includes research on factors that lead to re-traumatisation or â&#x20AC;&#x153;chronificationâ&#x20AC;?, and that can make an identity to be built around victimhood. This refers to symptoms that can evolve depending on psychosocial circumstances but that need a long-term overview. Panellists are concerned by what happens with untreated torture survivors over time, factors for relapse and implications in terms of public policies. The experience of long-running treatment centres (like those linked to the PRAIS program in Chile, to name one example) gives support to the idea that, at least for a substantial proportion of survivors, symptoms are latent. (2) The second topic is outcomes of the forensic documentation of torture in general and the Istanbul Protocol in particular (73). A great deal of time in rehabilitation centres is devoted to documenting torture for legal processes, such as, asylum claims, strategic litigation or defending victims from self-indictments under torture (Hass, 1990). This brings with it a host of implicit questions: Are the efforts in, for example, the use of the IP and training of judges/prosecutors/ police influencing individual court decisions and wider judicial practice?

What aspects are genuinely considered by judges and administrators? Does the quality of the evidence provided make a difference? How can we better adapt forensic work to these legal tasks? Our panellists stress the importance of some of these and other inter-related issues, such as, credibility analysis in the allegations of ill-treatment and torture, and the documentation in complex environments, especially police stations and prisons (70,76). (3) A third topic of legitimate concern in many geographical areas is related to second and third generation effects, which is the next top-rated topic of concern for panellists (22). While there have been research studies in survivors of the Holocaust since the 1960s and especially in the 1980s and 1990s (Hass, 1990; Hogman, 1998), this is an emerging topic in Latin America (CINTRAS, EATIP, GTNM/RJ, 2009), Asia (Daley, 2006; Dalgaard & Montgomery, 2015) MENA (Fritzemeyer, 2017) and in African countries (Daud, Skoglund, & Rydelius, 2005) (Baum, 2013). Most of this research involves clinical description, models of family therapy or qualitative unstructured descriptions. The methodological and conceptual challenges of this kind of research are enormous and undoubtedly in an epoch where the links between early attachment and trauma are also at the foreground of research. (4) The panellists consider research on torture linked to forced disappearance a priority (60). Interestingly, no academic journal specifically addresses this topic and it is often not considered as a key topic in symposia on rehabilitation of torture survivors. This unexpected and very important finding must be discussed with a view to potentially widening the

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scope of the Torture Journal to include forced disappearance, extrajudicial executions and working with mass graves, along with research done by groups and organizations working on these topics. (5) Finally, panellists were concerned about the use of databases for research and advocacy (172). When in a globalised world we are aiming to build large databases connecting different sources of data and make them available to researchers, how can this be translated into real change when working with torture survivors? Classical clinical databases gather mainly epidemiological information that provides a picture of what is out there; how many cases, with what profile and shows tendencies. Advocacy demands a different kind of database that might allow researchers to make links with the social and political environment. However, as more variables are included, the more difficult it is for users, who are usually busy clinicians unless there is a body of researchers and funding support. A kind of compromise is needed. Finally, the technical and security challenges of human rightsâ&#x20AC;&#x2122; databases are also a challenge in the sense that whilst data needs to be available for advocacy purposes, it also needs to be adequately protected and anonymised. There is undoubtedly rich opportunity here and the panellists seem to demand more work in this area. Analysis by socio-demographic data By enlarge, the analysis by sociodemographic data showed little meaningful variation, which may have been a result of the size of the sample (See Annex 3 for the top ranked 40 lines by socio-demographic

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data). Nonetheless, it added depth of understanding in some important research lines (such as that with respect to forced disappearances (see below)). Differences between groups: There are slight differences by gender (Annex 3). There is some reordering of top priorities, but this is difficult to interpret and may be due to an unequal distribution of gender by geographical area (more females in Latin America and Europe as compared to MENA and sub-Saharan Africa). Geographical Distribution: In countries where violence is seen as part of the recent past, concerns were related to long-term outcome and rehabilitation policies. There was no clear pattern in North America-Pacific (probably due to the small sample size). Panellists from Europe rank in line with the overall sample. In Latin America, significant differences appeared: greater importance was given to work with the disappeared, with a greater focus on the relationship between impunity, justice and healing, long-term outcomes and transgenerational trauma (especially taking into account the time elapsed since many Latin American dictatorships ended), and psychosocial and community perspectives. In the Middle East and North Africa panellists were more concerned with therapy: working with survivors of sexual violence and working with somatic complaints besides a strong emphasis on legal and forensic working and supporting victims. This was entirely different in sub-Saharan Africa where the priorities were caring for caregivers and family work, probably in relation to working in complex and unstable contexts and the importance of family in the African context. Finally, in the North America there was a concern with advocacy linked to refugees, possibly connected to their day-to-day work at an historical moment of very hard governmental

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policies against migrants and survivors of torture. All these are examples showing that a single worldwide agenda of research might not be realistic or desirable. While there is the need for some universal shared priorities, research must also tackle regional and national local concerns (Table 2). Primary activity: Again, there are more similarities than differences when comparing the top five priorities for professionals who undertake direct care, academia-research and legal and advocacy activities, probably linked to the fact that most of our panellists combine two or more of these activities and, in any case, share the same analysis and plans in multi-professional teams. Profile of survivors: Both professionals working in asylum or with national victims show a similar profile, similar to that of the general sample.

Conclusion

Delphi methodologies are always exploratory and intended to provide guidelines and food for thought. They are an attempt to quantify the shared priorities of a representative sample of experts in a certain field. This study is, to our knowledge, the first done in the field of prevention and rehabilitation of torture. It shows that providing definitive research priorities for an interdisciplinary, heterogeneous and global group is challenging. The current study suggests that there is a dissociation between what we know, what we would like to know and what we research, and that there are important gaps of knowledge. It also shows that, although a uniform set of priorities may not be meaningful for every local or even regional context, there is some consistency. We expect that the results can provide a guiding light for the Torture Journal in the coming years, and we hope that research projects will not only become a reality, but that the research lines set out in this study can inspire academics and professionals in human rights and rehabilitation centres. The Torture Journal, as the interdisciplinary academic journal of reference to the antitorture community, will surely try to foster and publish research along these lines.

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Limitations of the study The study shows a unique perspective of what the anti-torture sector considers priorities for research. The results, as with any Delphi exercise, depend on the selection of panellists. Any effort to make a representative sample depends on the actual responses received. Our study might show a slight overrepresentation of European experts and of professionals doing direct care with survivors. This might have affected the overall results, and is only partially compensated by a detailed analysis by key variables. In Round 2, the number of research lines (174) was overwhelming and may have resulted in a lower response rate than had there been fewer research lines. That said, the number of responses were not significantly different for Round 3, when only the top 40 research lines were used. Using an Excel spreadsheet was perhaps cumbersome compared to using an online survey option. However, it was felt that,

given the high number of research lines and that the hope was to reach panellists who perhaps do not have consistent internet access, that this was the best method. Furthermore, an online survey option may perhaps have increased the response rate. As shown in Annex 2, samples from Round 2 and 3 are mostly the same, but some panellists only responded to one round or the other. The Latin square analyses was used to maintain the balance and representativeness of the sample as far as possible.

Whilst this holds true, it is important to stress that the study may not have reflected the richness of possible and necessary research in its entirety and there remains some very important absences. Most experts had over 15 years of experience of working with torture survivors and their responses were largely based on their professional experience. More theoretical fields may have naturally fallen outside their immediate areas of interest. It is important to reflect on the fact that the field is a rapidly evolving one with new advances and an emphasis on psychological coercion rather than physical pain, which frequently demands flexibility and adaptability from researchers. That being so, the comprehensive list originally compiled can assist in setting future publication priorities for the journal as well as being useful in wider discussions in different contexts, not least in stimulating debate in what are the next steps in building a sector that can respond to the changing and demanding environment in which most of us work. Acknowledgements The authors would like to thank Leanne Macmillan, the former Director of Research Development of the IRCT for her support and insight.

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References Amris, S., & Arenas, J. (2004). Impact assessment in rehabilitation of torture survivors. -- A long-term research strategy based on a global multi-centre study design. Part I: Theoretical considerations. Psyke & Logos, 25, 37–76. Başoğlu, M. (2006). Rehabilitation of traumatised refugees and survivors of torture. BMJ: British Medical Journal, 333(7581), 1230–1231. https:// doi.org/10.1136/bmj.39036.739236.43 Baum, R. (2013). Transgenerational trauma and repetition in the body: The groove of the wound. Body, Movement and Dance in Psychotherapy, 8(1), 34–42. https://doi.org/10.1080/17432979. 2013.748976

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Bolton, P., Bass, J. K., Zangana, G. A. S., Kamal, T., Murray, S. M., Kaysen, D., … Rosenblum, M. (2014). A randomized controlled trial of mental health interventions for survivors of systematic violence in Kurdistan, Northern Iraq. BMC Psychiatry, 14(1), 360. https://doi.org/10.1186/ s12888-014-0360-2 CINTRAS, EATIP, GTNM/RJ, S. (2009). Daño transgeneracional. Consecuencias de la represion politica en el Cono Sur [Trasngenerational harm: Consequences of political repression in the South Cone]. Santiago: LOM Editores. Collins, P.Y., Patel, V., Joesti, S.s., March, D., Indel, T.R., & Darr, A.S. (2011) Grand challenges in global mental health. Nature 475(7354): 27-30 DOI: 10.1038/475027a Daley, T. C. (2006). Mental health issues among second generation cambodian children and communication processes with their parents. Dissertation Abstracts International: Section B: The Sciences and Engineering. Dalgaard, N. T., & Montgomery, E. (2015). Disclosure and silencing: A systematic review of the literature on patterns of trauma communication in refugee families. Transcultural Psychiatry, 52(5), 579–593. https://doi. org/10.1177/1363461514568442 Daud, A., Skoglund, E., & Rydelius, P.-A. (2005). Children in families of torture victims: transgenerational transmission of parents’ traumatic experiences to their children. International Journal of Social Welfare, 14, 23–32. https://doi.org/10.1111/ j.1468-2397.2005.00336.x Dieltjens, T., Moonens, I., Van Praet, K., De Buck, E., & Vandekerckhove, P. (2014). A Systematic Literature Search on Psychological First Aid: Lack of Evidence to Develop Guidelines. PLoS ONE, 9, e114714. https://doi.org/10.1371/journal.pone.0114714 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 Fritzemeyer, K. (2017). “… yes, it’s difficult, because we have to satisfy her heart”— Exploring Transgenerational Effects of Collective Persecution and Genocide in Kurdistan-Iraq. International Journal of Applied Psychoanalytic Studies, 14(1), 7–21. https://doi. org/10.1002/aps.1513 Green, D., Rasmussen, A., & Rosenfeld, B. (2010). Defining Torture : A Review of 40 Years of Health Science Research What Are the Definitions of Torture Used in the Scientific How Is

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mind control, classified behavioral research and the origins of modern medical ethics. In A. Ojeda (Ed.), The trauma of psychological torture. Praeger Publisher. Mikton, C.R., Tanaka, m., Tomlinson, m., Streiner, D.L., Tonmyr, L., Lee, B.X., Fisher, J., Hegadoren, K., Pim, J.E., Sharlenna Wang, S.J., & Macmillan, H.L. (2016) Global research priorities for interpersonal violence prevention: a modified Delphi study Bulletin of the World Health Organization 95:36-48 http://dx.doi. org/10.2471/BLT.16.172965 Miles, S. H. (2009). Profane Research Versus Researching the Profane: Commentary on Başoglu (2009). American Journal of Orthopsychiatry, 79(2), 146–147. https://doi. org/10.1037/a0015680 Murray, L. K., Dorsey, S., Haroz, E., Lee, C., Alsiary, M. M., Haydary, A., … Bolton, P. (2014). A Common Elements Treatment Approach for Adult Mental Health Problems in Low- and Middle-Income Countries. Cognitive and Behavioral Practice, 21(2), 111–123. https://doi. org/10.1016/j.cbpra.2013.06.005 Newman, E., Willard, T., Sinclair, R., & Kaloupek, D. (2001). Empirically supported ethical research practice: the costs and benefits of research from the participants’ view. Accountability In Research, 8(4), 309–329. Retrieved from http://ovidsp.ovid. com/ovidweb.cgi?T=JS&PAGE=reference&D=m ed4&NEWS=N&AN=12481796 O’Mara, S. (2016). Why torture doesn’t work. The neuroscience of interrogation. Harvard University Press. Patel, N., Kellezi, B., & Williams Amanda, C. D. C. (2011). Psychological, social and welfare interventions for psychological health and well-being of torture survivors. Cochrane Database Of Systematic Reviews, 10. https://doi. org/10.1002/14651858.CD009317 Patel, N., Williams, A. C. D. C., & Kellezi, B. (2016). Reviewing outcomes of psychological interventions with torture survivors : Conceptual , methodological and ethical Issues. Torture Journal, 26(1), 2–16. Pérez-Sales, P. (2016). Psychological torture: Definition, evaluation and measurement. Psychological Torture: Definition, Evaluation and Measurement. https:// doi.org/10.4324/9781315616940 Physicians for Human Rights. (2010). Experiments in torture : Evidence of human subject research and experimentation in the “ Enhanced ” Interrogation Program. Washington: Physicians for Human Rights. Schiemann, J. (2016). Does torture work? Oxford University Press.

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Severity of Torture Conceptualized and. Journal of Traumatic Stress, 23(4), 528–531. https://doi. org/10.1002/jts. Gurr, R. & Quiroga, J. (2001). Approaches to torture rehabilitation. Torture, 11(Supplement 1:1-35). Hass, A. (1990). In the shadow of the Holocaust. The second generation. Cambridge University press. Hogman, F. (1998). Trauma and identity through two generations of the Holocaust. Psychoanalytic Review, 85(4), 551–578. Huggins, M. (2000). Reconstructing atrocity: How torturers, murderers, and researchers deconstruct labels and manage secrecy. Human Rights Review. https://doi.org/10.1007/s12142-000-1043-6 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: National Defense Intelligence College Press. Jackson, L. E. (2007). From torture to treatment: A constructivist leadership participative action research approach to curriculum development for paraprofessional training to provide community mental health services in post-Saddam Iraq. Dissertation Abstracts International Section A: Humanities and Social Sciences. Retrieved from http://search.ebscohost.com/login. aspx?direct=true&db=psyh&AN=2007-99001001&site=ehost-live Jaranson, J. M. (2006). Rehabilitation of traumatised refugees and survivors of torture: a reply to Basoglu. BMJ, 333(7581), 1230–1231. https:// doi.org/10.1136/bmj.39036.739236.43 Jaranson, J. M., & Quiroga, J. (2011). Evaluating the services of torture rehabilitation programmes: history and recommendations. Torture : Quarterly Journal on Rehabilitation of Torture Victims and Prevention of Torture, 21(2), 98–140. Llanusa-Cestero, R. (2010). Unethical research and the C.I.A. Inspector General Report of 2004: observations implicit in terms of the common rule. Accountability in Research, 17(2), 96–113. https://doi.org/10.1080/08989621003708493 Manicavasagar, V., Silove, D., Tang, K., Aroche, J., Steel, Z., Chaussivert, M., … Coello, M. (2002). Towards a Researcher-Advocacy Model for Asylum Seekers: A Pilot Study Amongst East Timorese Living in Australia. Transcultural Psychiatry. https://doi. org/10.1177/1363461502039004491 McCoy, A. W. (2008). Legacy of a dark decade: CIA

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Annex I Lines of research from Round 2 in eight categories

Area Sub-group

Research line

(1) CONCEPTS, POPULATIONS AND METHODS Definition 1

Definition of torture. Evidence-based distinction between torture and CIDT. United Nations definition vs others (I,e Amnesty International)

How to define torture in resilient individuals. Survivors that have endured multiple torture events for 15 years or more. Implications for the “suffering” criteria.

How the consideration of new groups of survivors as falling in the definition of torture affects the definition—better definitions for special groups. How these new groups change the social perception of torture.

Contemporary torture 4

Beyond torture methods - Definition of Torturing Environments.

Impact of torture by combined or cumulative impacts.

Relation between different types of torturing environments, impacts on survivors and rehabilitation strategies.

International standards in the interrogation of detainees. Coercive versus cognitive interviewing.

Is torture useful? Is it an effective method in eliciting information from a detainee?. Confirmatory studies in different interrogational settings

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Victim groups, locations, types of torture, specific vulnerabilities risks, impacts and needs Gender Perspectives 10

Methods of torture specific to women and specific impacts. Trafficked women and torture and other forms of torture by non-state actors

Mother separated from their babies for minor infractions as torture.

Torture related to LGBTIQ identity

Use of sexual violence in individual torture for both women and men.

Collective rape in political conflict. Proper evidence collection and documentation.

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Health-Care, Social Services, Geriatric Settings

Torture in psychiatric institutions. Monitoring and prevention.

Torture in health institutions (especially non-medical treatment of drug addicts).

Elderly - Ill-treatment in involuntary admissions of elderly people. Diagnostic challenges in geriatric institutions. Monitoring and prevention.

Children

Developmental disruptions, long-term impact of relatives’ torture, Impact of witnessing torture in the community.

Developmental disruptions - infant torture (a) in country of origin (b) as a refugee.

The effect on caregivers of torture/kidnapping of their children.

Impact on identity and worldviews of torture in adolescents.

Trans-generational trauma. Define criteria. Preventive and therapeutic approaches.

Social cleansing

Homeless people / Marginalized populations / People in social deprived areas (slums/favelas..) subject to torture as part of social cleansing policies.

Torture in the fight against narcotic crime control, human and drug trafficking, youth gangs.

Torture as part of initiation rituals for secret societies in the developing world.

Torture in the context of repression and control of social protests against social inequality and criminalization of protests and demonstrations.

State terrorism

Torture in the context of those disappeared and in extrajudicial killings (torture resulting in death—denial of information to relatives as torture—Evidence-based data for legal claims as torture). Long-term impact of ambiguous loss—Comparing impacts in relatives of detained/disappeared in the short term (e.g. Sri Lanka), middle term (e.g. South Africa, Chile) and long-term (e.g. Spanish mass graves of the Civil War).

Ill treatment and systematic violence by Non-State actors in context of war and civil war by private gangs, human traffickers, rebel or terrorist groups occupying territories.

Torture practices in western democracies as compared to oppressive regimes. Impacts.

Forced displacement / Refugees / Migration

Torture and migration. Torture linked to border control of refugees and in centres of detention of migrants. Comparative study between patterns of torture documented in countries of origin with those documented in countries of destination.

Traumatized refugees—evidence for psychosocial resilience and vulnerability factors (access to labour market, legal situation or having an identity as determinants of health).

Long-term predictors of resilience. Meaning as long-term predictor.

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Political motivation as a protective or risk factor in torture survivors. Resilience and activism - comparing the impact of torture on activist and on partner/family member/non-activist.

Differences between those who fled and those who stayed in the country.

New types of perpetrators 35

The perpetrator in torture that is not part of an interrogation process.

The transition from perpetrator to victim and from victim to perpetrator.

Torture / ill-treatment in daily interactions and in wider contexts including in bureaucracies.

The psychology and social psychology of doing evil.

Places of Detention, Deprivation of Liberty. Specific aspects 39

Torture/Conditions that amount to torture in prisons. Reassessing minimum standards amounting to torture. Academic studies on the adequacy of CPT Standards and recommendations.

Documentation of torture in prisons. Refining methods for National Prevention Mechanisms and other monitoring bodies.

Solitary confinement as torture.

Conditions when punishment amounts to torture.

Places where torture actually happens: epidemiology of torture in short-term (i.e. police stations) versus long-term detention (i.e prison) centres. Should prevention focus more on early phases of judicial processes and less on convicted subject.

Police and social dissent

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Police equipment. Use of teargas/Use of Taser guns

Standards of practice in the use of force by police. Police brutality amounting to torture.

Ill-treatment - Torture in demonstrations and other non-custodial settings. Role of doctors in the documentation of police brutality in demonstrations and barriers to the effective implementation of their role (i.e Bahrein, Turkey).

Examples of good practice, protocols and guidelines in police action.

(2) ASSESSMENT Neurobiology 48

Biological mechanisms underpinning torture—damage.

Neuroscience and torture. New technologies as applied to torture research.

New technologies as applied to interrogation of suspects.

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Biological markers for legal/forensic documentation of torture.

Neuropsychology 52 53

Uses of neuropsychological test in the documentation of torture. Head trauma. Minor brain injury.

Neuroscience and rehabilitation.

Psychometric Tools 54

Transcultural tools to classify torture methods.

Cross-cultural / Transcultural tools to measure the impact of torture using a comprehensive perspective.

Critical review and updated data on psychometric tools widely used in the torture sector (i.e Harvard Trauma Questionnaire).

Neuropsychology/Psychometric tools in documenting deception, malingering or exaggeration in false torture survivors.

Medical Diagnosis 58

New/Updated medical tests for clinical and forensic documentation of ill-treatment and torture.

Community Impacts 59

Concept/description/Indicators of psychosocial/community impact of torture.

(3) MEDICAL ASPECTS Psychological Torture 60

Definition. Tools (and validation) for assessing psychological torture.

Somatic Complaints 61 62

Analysis of the relationship between psychological and somatic symptoms in torture survivors. Chronic pain. Chronic somatic complaints.

Classification 63

Opportunities and limitations of the new DSM-V system/ICD-11 proposals.

Alternatives to PTSD in the conceptualization of the impact of torture.

Emic/Ethnic definitions of illnesses associated to trauma and torture.

Functionality 66

Applicability of Measures of function, disability and heath (like ICF).

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Massive sleep disorder in torture survivors. Actimetry as a cost-efficient alternative to polysomnography in documentation and measure of treatment outcomes

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(4) LEGAL/FORENSIC DOCUMENTATION OF TORTURE Concept 67

Controversies in the proper identification and recognition of victims. Who is to be considered a victim in transitional justice and legal claims?

Capacity 68

Map of forensic capacities globally. Countries where there is installed capacity for medical and psychological documentation of torture.

Istanbul Protocol 69

Balance of the Istanbul Protocol as a research and forensic tool. Strengthening— Improving—Interpretation Guidelines.

Tools for Credibility analysis of the allegations of ill-treatment or torture for supporting survivors’ claims.

Use of IP in other forensic contexts- eg documenting assault, domestic violence, trafficking cases subjected to prostitution or servitude including violence.

“Evidentiary inflation”. Judges applying criminal standards of “beyond reasonable doubt” instead of administrative standards of “reasonable assumption” in asylum claims. Implications and solutions.

Outcomes of IP. Impact of documentation of torture in the decisions of the judicial system. Does forensic documentation really impact judges in their decisions? Which elements are considered relevant?

Good practices when resources or conditions are not optima 74

Specificities of the IP with refugee population. Adapted versions for international protection claims / migrant detention centres.

Documentation of torture in context of collective/massive atrocities

Tools for quick documentation in police stations, pre-trial detentions and monitoring of prisons.

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Documentation in primary care 77 78

Awareness and knowledge of the use of the IP in primary health care settings.

Adaptations of medico-legal documentation (i.e. documentation of injuries in general health care) to IP standards.

Rejection 79

Rejection of asylum claims alleging that historical or past torture does not preclude torture in the future– Scientific study of the “past-does-not-mean-future” argument as a basis for rejection (i.e. following up cases after being returned).

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Post-Mortem Assessment 80

Recent post-mortem findings in cases of death by torture (i.e. acute compartment syndromes after hanging or falanga).

Innovations 81

Use of information and communications technology for safely reporting torture and ill treatment and reaching more vulnerable populations.

(5) TREATMENT - REHABILITATION Definition 82 83

What “rehabilitation” of torture survivors means. Defining the field.

Providing rehabilitation services in dangerous settings (e.g., when under threat from the state; where torture is rampant, etc.).

National Policies 84

Policy process in national settings. National legislation and relevant stakeholders related to prevention, rehabilitation and redress.

Nexus between torture and poor governance. Torture related to corruption.

Reporting on State-sponsored-organised rehabilitation services—Compliance with General Comment #3.

Minimum standards of good care. What do health professionals and survivors consider a minimum of “good access” to rehabilitation services for torture survivors?

Controversies in the right to rehabilitation—(a) The role of the State as direct provider or funder. (b) Public Health System versus Specialized Networks (c) Free Choice between State and Non-State providers of services.

Accessibility—rural / urban inequalities in access to rehabilitation services. Cost-efficient alternatives in contexts where no rehabilitation centres are available.

Best practices in ensuring sustainability of rehabilitation centers. Right to rehabilitation not depending on political debate.

Coordination between national Mental Health services (where available) and Torture Rehabilitation services

International consensual set of indicators to assess outcome of rehabilitation programs. Adaptation to different contexts and conditions.

Clinical and non-clinical indicators of efficacy for multi-sectoral—complex interventions.

Outcome indicators for psychosocial and community based programmes.

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Psychotherapy 96

Basic non-specialized interventions. Psychological and social counselling and Psychological First Aid as applied to torture survivors, especially in low-resource countries or emergency settings.

Psychotherapeutic approaches that work. For whom, for what, and under what conditions?. Implementation of Randomized Controlled Outcome Trials (RCT)

Naturalistic or quasi-naturalistic studies in psychotherapy research: systematic documentation, pre-post clinical trials and quasi-experimental outcome trials based on actual practices.

Beyond specific techniques. Non-specific factors in therapy. Relative contribution to a positive outcome in psychotherapy.

Group Work 100

Models of group work. From mutual support to complex trauma therapeutic groups.

Family therapy 101

Models of family interventions.

Expressive and Body therapies 102

Integrating health and psychological treatment. Pain, somatic expressions of suffering and torture.

103

Physiotherapy interventions based on evidence.

104

Expressive therapies (creative movement therapy, art, music) in the healing process.

Medical treatment -Pharmacotherapy

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105

Knowledge transfer from best evidence. Special considerations for torture survivors.

106

Pharmacotherapy based on evidence.

107

Pharmacotherapy that work to target specific diagnoses or symptoms.

Professionals 108

Cost-effective treatment for non-specialists, especially primary care and community workers.

109

Identification and treatment of survivors by health professionals employed in detention centres.

110

Community torture treatment programs with paraprofessionals/community health works (using CETA or other intervention methodologies).

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Community, Cultural and spiritual issues 111

Beyond individual rehabilitation to community rehabilitation (in situation of collective trauma).

112

Interventions that include cultural meanings or ethnocultural treatments of dealing with the impact of torture (i.e. symbolic healing / symbolic therapies).

113

Spirituality and rehabilitation.

114

Psychosocial / Community healing and recovery practices. Transfer of knowledge from low and middle income countries.

115

Role of interpreters in rehabilitation. Training.

116

Training methods in cultural competence for staff. Cultural humility.

Special Populations 117

Access to Care / Rehabilitation for people on the move

118

Ensuring rehabilitation to tortured asylum seekers denied protection.

119

Care for caregivers.

120

Positive and negative experiences in the work with torture survivors from LGBTI community.

121

Rehabilitation of torture victims in prisons and other places of detention. Determining factors for success of interventions.

122

From Detention to Community: Lessons Learnt in the Provision of Through care for Tortured Detainees, Prisoners, Ex-detainees, Ex-prisoners, and their families. Proactive detection of tortured ex-detainees in the community and provision of help.

Outcome measures 123

Long-term differences between those who receive rehabilitation treatment or not. Is it true that time heals?

125

Going beyond clinical measures to include quality of life, rebuilding a life project, social, daily functioning and community cohesion etc.

126

Guidelines with Best Practices approaches/level of recommendation specific for torture survivors.

Participation of survivors in design and evaluation of programmes. 127 128

Survivor participation in clinical management.

Survivor participation in setting research priorities and research design. Participatory action research.

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129

Survivor-informed outcome measures.

130

Survivors of torture and empowerment.

Justice and Rehabilitation 131

Intersection between justice and rehabilitation (for the positive or negative).

132

Impact of judicial interventions on individual well-being. Does access to justice improves quality of life?

133

Life between trials when in a legal proceeding. Instrumentalization of survivors when engaged in legal proceedings.

134

Impact of reparation versus reparation plus rehabilitation (when the states “repairs” only on material/economic grounds).

135

Rehabilitation and long-term peacebuilding.

136

Sociological impact of Justice (i.e. Argentina & Chile as examples).

137

Retaliation on organizations and human right defenders serving torture survivors.

(6) JUSTICE AND REDRESS Victim’s support

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138

Psychological impact of impunity. Paths to recovery where impunity prevails.

139

Confronting the perpetrator. Encounters between survivors and perpetrators.

140

Traditional cultural practices in the transitional justice process for perpetrators and survivors.

141

Psychosocial support to survivors during the legal process. Good practice protocols for survivors that act as witnesses in trials.

142

Fight against impunity as a healing process. Meta-analysis/review on the impact of justice on survivors’ well-being. Protective and risk elements. Do-no-harm principles and recommendations.

143

The increasing role of witnesses in redress and the impact of increasing threats to witnesses.

Intentionality 144

Intentionality Assessment. Criteria for an objective forensic assessment of intentionality of perpetrators for legal procedures.

Impunity 145

How to avoid impunity (in a broad sense). Sharing anti-impunity strategies that worked.

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Compensation 146 147

Victims’ priorities regarding types of reparation.

Redress and compensation for innocent people in prolonged pre-trial detention in unusual harsh conditions.

Torture & Mass graves 148

Effective implementation of the International Consensus on Minimum Standards for the Psychosocial Work in Exhumation Processes for the Search for Disappeared persons.

No repetition 149

Anti-torture laws and implementation of these.

150

Universal Periodic Review: Lessons Learnt in its Utilisation as a Tool for Promoting Global Compliance and Implementation of National Level Interventions on Torture Prevention and Rehabilitation of Torture Victims.

151

National Prevention Mechanisms. Research on implementation and results.

(7) ETHICS Research 152

Ethical standards in documentation of torture.

153

Standards of dealing with data-protection. Data protection versus statistics on torture and data protection versus reporting on the outcome of projects to donors

154

Ethical standards in research with survivors and perpetrators.

155

Aftercare for researchers. Ethical implications in the use of students in torture research.

156

Transparency and accountability in the use of research funds. Standards of good practice

Professional role 157

158

Dual loyalty in non-health professions.

159

Ethical issues in clinical supervision.

160

Ethical issues with interpreters.

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Survivor’s autonomy 161

162

Survivor experience of documentation process. Challenging avoidance or respecting the survivor’s autonomy - exploring the tension between the needs of the evidentiary process and how much disclosure is enough?

Ethical issues with use of technology and social media.

(8) SOCIOLOGY - POLITICAL ENVIRONMENT - ADVOCACY - PREVENTION Sociology of torture 163

Pre-conceptions—social construction of the concept of “torture”- how people perceive torture. Manipulation of the public opinion about torture; its nature, its impact on victims, families, communities etc.

164

Sociological barriers to rehabilitation of survivors.

165

Reasons for supporting /tolerating torture. Increasing support (political, legal, corporative and even social) to the use of torture as shown by polls and sociological studies.

166

Role of education in human rights (civil and military servants and general population).

167

Role of media (TV series, films, apps and video games…) in banalizing torture and increasing indifference (bystanders) /support to it.

168

Research targeting proposals to legalize certain forms of torture.

History 169

Historical evolution of torture. The transition to becoming more and more psychological.

Political context 170

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171

Patterns of torture based on political contexts and analysis of conditions where there is a heightened risk of torture?

Epidemiology 172 173

Clinical records guidelines. Good practice and recommendations for databases

Reliable data on worldwide and country prevalence applying consensual criteria.

Advocacy 174

Strategic use of clinical data for advocacy. Recommendations and guidelines.

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Annex 2 Panellists by round

Abosede Omowumi Babatunde, Aida Seif El Dawla , Andrea Northwood, Andrew Rasmussen, Amanda Williams, Barbara Conde, Barbara Preitler, Bettina Birmanns, Bhava Poudyal, Carlos Jibaja Zárate, Changho Sohn, Craig Higson-Smith, Daniel Savin, David R Curry, Dina Al Shafie, Edeliza Hernandez, Edvard Hauff, Emmanuel Sarabwe, Eugenia Mpande, Fabiana Rousseaux, Felicitas Treue, Frances Lovemore, Fredrik Saboonchi, Hans Draminsky Petersen, Helena Solà, Jens Simon Modvig, Jeroen Knipscheer, Jessica Carlsson Lohmann, Jorge del Cura Anton , José Quiroga, Juliet Cohen, June Pagaduan Lopez, Kathi Anderson, Kolbassia Haoussou, Leanne Macmillan, Lilla Hardi, Mandira Sharma, Marianne Kastrup, Mechthild Wenk-Ansolhn, Morris Tidball-Binz, Raija-Leena Punamäki, Ramesh Prasad Adhikari, Sebnem Korur Fincanci, Morris Tidball-Binz, Noemí Sosa, Nora Sveaass, Paul Bolton, Pau Pérez-Sales, Sara Fridlund, S. Megan Berthold, Solvig Ekblad, Tania Kolker, Uju Agomoh, Uwe Harlacher, Vera Vital Brasil, Vincent Iacopino, Wilder Tayler.

Note: This Annex does not represent an exhaustive list of the contributors as some panellists expressly did not give permission for their name to be included and permission was not given in some cases due to administrative or technical reasons. Even though names are set out here, some panellists saw their responses as a collective effort from their centres.

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Annex 3 Round 3 items in original order (not by priority) by socio-demographic data. Yellow denotes the top five priorities for each variable.

Item 1

Definition of torture. Evidence-based distinction between torture and CIDT.

Item 2

Beyond torture methods - Definition of Torturing Environments.

Item 3

Impact of torture by combined or cumulative impacts.

Item 4

Relation btw types of torturing environments, impacts on survivors and rehabilitation strategies.

Item 5

Use of sexual violence in individual torture for both women and men.

Item 6

Developmental disruptions, long-term impact of relatives’ torture, Impact of witnessing torture.

Item 7

Trans-generational trauma. Define criteria. Preventive and therapeutic approaches.

Item 8

Torture in the context of those disappeared and in extrajudicial killings

Item 9

Psychometric tools widely used in the torture sector (i.e Harvard Trauma Questionnaire).

Item 10 Concept/description/Indicators of psychosocial/community impact of torture. Item 11 Definition. Tools (and validation) for assessing psychological torture.

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Item 12 Relationship between psychological and somatic symptoms. Chronic pain. Somatic complaints. Item 13 Tools for Credibility analysis for supporting survivors’ claims. Item 14 Outcomes of IP. Impact in the decisions of the judicial system. Item 15 Tools for quick documentation in police stations, pre-trial detentions and monitoring of prisons. Item 16 What “rehabilitation” of torture survivors means. Defining the field. Item 17 Providing rehabilitation services in dangerous settings Item 18 Examples of national good policies for integral care of torture survivors.

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Geographic Area

Gender

Primary activity

Work location

ASIA (n=3)

NA+P (n=7)

LA (n=8)

Africa + MENA (n=10)

Europe (n=17)

M (n=18)

F (n=27)

Direct Care (n=16)

Legal (n=10)

Academia - Research (n=17)

Asylum National (N=16) (N=24)

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Item 19 Minimum standards of good care in rehabilitation services for torture survivors Item 20 Coordination between national Mental Health services and Torture Rehabilitation services Item 21 Models of family interventions. Item 22 Care for caregivers. Item 23 Long-term outcome –Cohort studies. Implications for public policies. Item 24 Survivor participation in research. Participatory action research. Item 25 Survivors of torture and empowerment. Item 26 Intersection between justice and rehabilitation (for the positive or negative). Item 27 Impact of judicial interventions on individual well-being. Item 28 Psychological impact of impunity. Paths to recovery where impunity prevails. Item 29 Psychosocial support to survivors during the legal process. Item 30 Fight against impunity as a healing process. Item 31 The increasing role of witnesses in redress and the impact of increasing threats to witnesses. Item 32 Victims’ priorities regarding types of reparation. Item 33 Effective implementation of Minimum Standards in Exhumation Processes Item 34 Ethical standards in documentation of torture.

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Item 35 Dual loyalty. Participation of health professional in torture – Passive support to torture Item 36 Reasons for social supporting /tolerating torture Item 37 Role of media (TV series, films, apps and video games…) in increasing indifference /support Item 38 Patterns of torture based on political contexts Item 39 Politics and the tightening of asylum law and policies Item 40 Strategic use of clinical data for advocacy. Recommendations and guidelines.

Note: NA = North America; P = Pacific;

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Geographic Area

Gender

Primary activity

Work location

ASIA (n=3)

NA+P (n=7)

LA (n=8)

Africa + MENA (n=10)

Europe (n=17)

M (n=18)

F (n=27)

Direct Care (n=16)

Legal (n=10)

Academia - Research (n=17)

Asylum National (N=16) (N=24)

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Related to Rehabilitation of torture survivors and prevention of torture: Priorities for research through a modified Delphi Study Comment I Torture as a chronic disease

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José Quiroga* The Delphi study presented here shows an apparently surprising first priority line for research in having lifetime data to consider the consequences of torture as a chronic disease. But this is not so surprising if we attended to the following facts: • Torture is a very special and distinctive traumatic experience because of its severe physical and psychological suffering intentionally inflicted by another human being. Torture is also a socio-political trauma that is inflicted with the full force of the state over an individual. The State, instead of protecting the person, destroys him/ her. Both elements are unique and part of what we call extreme traumatization (Bettelheim, 1943)

*) Former Medical Director of Program for Torture Victims (PTV)—USA. Correspondence to: JQuirogaMD@aol.com

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• Additionally, most victims are powerless, and suffer hopelessness, being under the complete and total control of the perpetrator. The life or death of the victims depends arbitrarily on the decisions of others. The victims face impossible dilemmas, having to take impossible decisions that face them with betrayal and long-life shame or guilt. (Castillo, 1989) • The classification of the psychological impact of torture is not well-collected by the standard World Health Organization (WHO) or American Psychiatric Association (APA) diagnosis of PTSD and/or depression. There are essential psychopathological and sociological elements which are not collected (Becker, 1995). We cannot consider the natural history of PTSD as representative of the evolution of the symptoms of surviving torture. As a physician, I have worked with survivors of torture since the military coup in Chile in 1973. In my 40 years of experience, I have learned that torture is a chronic, lifetime process for a significant number of victims who experience persistent anxiety, depression or PTSD symptoms, cognitive impairment, attentional deficits and memory problems. • The symptoms can decrease with time, but reminders of the traumatic situation produce again significant distress and reactivation of symptoms. The traumatic experience of torture is reactivated. • Furthermore, the principal physical complaint in many victims is chronic pain. Permanent scars on the body are visible in 40 -70 % of the victims, and serve to remind them of the traumatic event[s] (Scary, 1997). A small proportion suffer permanent disabilities such as seizure disorder or cognitive

39 D E B AT E

research, with wider samples and more sophisticated tools, and hopefully with comparison groups needs to be promoted in Argentina, Uruguay, and Brazil. • We need also, to better understand the complexity and extreme situation of the torture victim, and to formulate a better approach to treatment, to do qualitative analysis and use, clinical descriptions that go beyond PTSD and are closer to psychopathology, biology and neuroscience of the brain. Torture needs to be recognized as a clinically identifiable disorder. PTSD is not enough to capture its complexity - and needs to be identified, in those affected, as a chronic disorder. Today “torture” is only a legal definition and not considered a mental or medical diagnosis. This is a misconception and a gruesome error. In my view, this situation needs to change and cohort studies with survivors on long-term impact and treatment will cast light on this complex issue. References American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. Arlington. https://doi.org/10.1176/appi. books.9780890425596.744053 Beal, A. L. (1995). Post-traumatic stress disorder in prisoners of war and combat veterans of the Dieppe Raid: A 50-year follow-up. Canadian Journal of Psychiatry, 40(4), 177–184. Becker D. (1995). The deficiency of the concept of Post-Traumatic stress disorder when dealing with victims of human rights violations. In Kleber RJ, Figley CR, Gersons B. (Eds). Beyond Trauma: Cultural and Societal Dynamics. Plenum Press. https://doi.org/10.1016/S02727358(96)00033-5 Bettelheim B. (1943). Individual and mass behavior in extreme situations. Journal of Abnormal Social Psychology. 38:4717-452 Castillo MI, Gómez E, Kovalsky J. (1990). La tortura como experiencia traumática extrema, su expresión en lo psicológico, en lo somático y en

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losses after traumatic brain injuries. In spite of these symptoms, the majority can function in society, but not without mental and or physical pain. • Little information exists in the literature in relation to the magnitude and longterm recovery of torture survivors and their conditions for a full functional life. Clarification of the natural history and evolution of symptoms and factors of protection and vulnerability linked to reactivation are a mandatory area for future research, as suggested by the Delphi study we discuss here. A preliminary study of 28 victims who were tortured between 1973 and 1974 in the Pisagua detention center in Chile using the Istanbul Protocol and the Harvard Trauma Questionnaire (HTQ) showed that more than 40 years after torture 54.5% had pervasive symptoms of depression, 45.5% suffered anxiety, and 16.7% PTSD. The study showed a prevalence of all disorders significantly higher than in the general population of Chile.(Gomez-Varas et al., 2016). This is not surprising. A pioneering study with a sample of 276 Canadian World War II veterans (Beal, 1995) found that that fifty years after the end of the war 43.4% of the veterans presented with symptoms of PTSD (according to DSM III-R) as compared with 29.9 % of non-POW veterans. I have not done a systematic review of the topic, but judging by experience, this is what we would expect in other samples and I would encourage a meta-analysis of available data. • We need to get more cohort studies on long-term consequences of torture. But also a study comparing treated and non-treated groups, to analyse the longterm impact of our therapies. Similar

lo social. In CODEPU Seminario Internacional Tortura Aspectos médicos, psicológicos y sociales, prevención y tratamiento. Ediciones CODEPU Gómez-Varas, A-G, Valdés J, Manzanero, A. (2016). Evolución demorada de trauma psicológico en víctimas de tortura durante la dictadura militar en Chile. Revista de Victimologia 4:105-12.

Comment II A Palestinian view of the results of the Delphi study

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Mahmud Sehwail* The results of the study provide an accurate and comprehensive way that make full sense from a Palestinian point of view. It is mostly true that torture victims really demonstrate a kind of chronicity, and shame has often be considered as a cardinal symptom of it. The remote consequences of torture appear in the form of family and social problems. The aim of torture is not to kill the body but to kill the soul and to spread fear in the person, family and in the whole community. The majority of torture survivors we attend to suffer from multiple traumatic events or re-traumatization. At Treatment and Rehabilitation Center for Victims of Torture (TRC) we use the term Continuing Traumatic Stress disorder (CTSD) which leads to chronicity and makes treatment more difficult. Long-term consequences of trauma can affect the neuroplasticity of the brain and be evidenced by a reduction in the volume of hippocampus and an increase in the activity of the amygdala. It is an important theme how we link chronicity

*) President and Founder of Treatment and Rehabilitation Center for Victims of Torture (TRC), Consultant Psychiatrist. Correspondence to: mahmud.sehwail@trc-pal.org

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with biological markers and find evidences of permanent brain damage. Many resources should be allocated to it to provide signals of the complexity of trauma and its remote sequelae in the context of torture that continues for decades, as in our region. Besides this, it is always important to emphasize research on pragmatic and evidence-based methods of intervention rather than relying on classical lengthy methods of psychotherapy. At TRC we use different models of treatment. Many of our patients express their psychological symptoms in the form of somatic complaints. It is not strange to discover at a certain stage during primary health care that physical complaints are indeed psychosomatic and linked to torture. These are important aspects of research also. Medico-legal documentation, when conducted in a safe environment, is a key part of this process and can be considered as therapeutic as it includes retelling the traumatic story of torture to the therapist who acts as a witness. We at TRC use the Istanbul Protocol and agree that we need more research on it. We would also like to stress the importance given in the study to the care for caregivers. This will provide an armour against burn-out and negative transference. At TRC, we organize occasional open days when the team gathers for free activities to prevent burn-out in addition to regular supervision. However, burn-out is an issue for us that deserves more research. Finally, in the study, it was considered that empowering victims of torture regarding medical, psychiatric and psychosocial rehabilitation should be considered relevant and this matches our experience. This is an important part of the framework of international law to reintegrate victims into the society. However, empowering

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is also about providing vocational rehabilitation and helping the survivor to earn a living and this is not exactly reflected in the study despite our experience in this regard being very positive. We would like to commend this exceptional work that can give important tips on old and new avenues for research.

Comment III Latin American priorities for research in the prevention and rehabilitation of torture Carlos Jibaja Zรกrate*

*) Director of Mental Health Area. Centro de Atenciรณn Psicosocial (CAPS), Peru. Correspondence to: cjibaja@caps.org.pe

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The Delphi methodology used in this outstanding research has allowed a wide group of experts from 23 countries from different regions of the world to reach 40 thematic axes, which have been agreed upon and weighted, generating a list of prioritized topics. There are several aspects that the study presents which I found especially remarkable: the dissociation between what we know, what we would like to know and what is being investigated; the predominance of applied over theoretical research; the notion of establishing regional priorities instead of unifying them on a global scale; the non-prioritization of more contemporary research lines such as those associated with gender perspective, neurobiology, updates to the Istanbul Protocol, the implementation and effectiveness of National Prevention Mechanisms, the use of new technologies among others.

I would like to comment, as a Peruvian, on the priorities for Latin America. These, in my opinion, accurately reflect the areas of interest shown by the centers that serve torture survivors. I feel fully identified. Research on psychosocial treatments for torture survivors that include a community and socio-political view with long-term follow-up and building appropriate indicators for that is clearly a priority. The socio-political and legal context that generates impunity and violence against survivors continues to operate in our countries, and these factors are behind the chronicity and recurrence of the symptoms and the difficulties in coping abilities of the survivor. Enforced disappearances and extrajudicial executions are legally typified in a different Convention (not that against torture), but there are many points in common in regard to the possible torture or death of the victim, as well as abuses and humiliations suffered at the hands of the State. Both are key elements in the rehabilitation of relatives and require emotional elaboration in the overwhelming majority of the cases. This is an under-researched and important topic in Latin America. Likewise, our centers serve family members of third and even fourth generation victims, who apparently have conflicts disconnected from situations of intentional violence experienced by the survivor and the most direct family group (for example, intra-family violence), but when going deeply into the psychotherapy and the living conditions of the relatives, the causal relationships between the problems presented and the experiences of torture seem obvious. The experiences of horror and violence experienced by the survivor or her relatives, by not being emotionally tackled,

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can pass to new generations as traumatic burdens felt in the body, in interpersonal conflicts, as implicit family mandates, etc. We have a wealth of clinical and qualitative observations and a lack of strong research data that can foster rehabilitation programs and demand actions from the State. The panelists have also prioritized the systematic study of national comprehensive care plans for survivors of torture as part of their right to rehabilitation: data on comparative experiences of national rehabilitation plans in countries such as Chile and Uruguay, to mention two examples, are important to learn what has worked and the importance of ecological, sociopolitical and cultural differences. Finally, another priority is the accompaniment of victims during legal proceedings. The victim can be an individual, a couple, a group of people affected within a town, or a high Andean community, etc. who at the beginning of the legal process does not usually have a clear idea of how â&#x20AC;&#x2039;â&#x20AC;&#x2039; long and exhausting the process will be. It is important to systematize experiences on the work of therapeutic agents that serve as a point of support for the survivors as well as the legal team. Identifying areas of research at a regional level, as well as having the possibility of systematically studying them, are tasks that are often postponed due to our sociopolitical and economic contexts in which we urgently need to direct attention to the survivor and the fight against impunity in public instances. This study takes a step in the right direction to contribute to concentrating efforts and resources in the investigation of what we do, what we are interested in investigating and what we need to know more about in the Latin American region. We hope this can be taken into account by fundraisers and donors and help

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in developing this research agenda in the following years to come.

Comment IV Priorities for research â&#x20AC;&#x201C; a view from Russia Yakov Gilinskiy , PhD, Dr of Science (Law), Prof. * It would seem that the whole history of mankind screams against torture. But torture by police and prison staff continues in different countries. This topic, unfortunately, is very actual for Russia in the twenty-first century, where torture is systematically applied (Gilinsky, 2007;2011). We welcome the initiative of Torture Journal. The main advantages of multi-center, multi-country research are its international character and generalization of results, complex, interdisciplinary nature, use of the latest methods in a shared way and, according to the priorities that arise from the Study, focus on practical results in order to reduce torture and provide assistance to people who have survived torture. I find the results of the study reliable due to the efforts to ensure the representativeness of panellists and an open research methodology. The process, through three rounds of consultation, allow for a reliable consensus and an agenda for shared research in the sector. Panellists included professionals (medical, psychologist and psychiatrists, lawyers, social workers and members of organizations of survivors) from 23

*) St. Petersburg, Russia Correspondence to: yakov.gilinsky@gmail.com

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most important questions: how should the courts respond to torture claims during the investigation? As a summary, I think that the study showed the most important problems of torture, assistance to victims of torture, and the results of the study can serve as the beginning of a series of collaborative research studies of these problems. References Gilinskiy Y. (2011). Torture by the Russian Police: An Empirical Study. Police Practice and Research. An International Journal, 12, N2, 163-171. Gilinskiy Y., et al. (2007). Sociology of violence. Arbitrariness of law enforcement bodies by the eyes of people. Nizhny Novgorod: Committee against torture.

Comment V Do we have a holistic perspective of torture-related research? Metin BakkalcÄą, MD* This is an invaluable study conducted with the contribution of many experts. Bringing together the leading professionals in the field and adopting an interdisciplinary approach, I am sure this study will make a significant contribution to the literature on the subject, will strengthen the existing studies, and will open new horizons for all of us. I want to share my first unstructured impressions to the results. I am surprised about the little importance given by the panellists to medical aspects of torture. Unfortunately I had the impression that for the experts, rehabilitation is reduced to its psychological aspects alone. I feel like the lack of a holistic

*) Secretary General, Human Rights Foundation of Turkey (HRFT) Correspondence to: mbakkalci@tihv.org.tr

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countries balanced by gender, geographical area, profession and area of work. As a result of the expert rounds, the results highlight the importance of longterm outcomes and effects of interventions (including chronicity, factors leading to retraumatisation and implications for public health); outcomes of the Istanbul Protocol (impact of documentation of torture in the judicial system); trans-generational trauma; and, torture in the context of those disappeared and in extrajudicial killings. All of them relevant topics in Russia. It is amazing that the research did not find significant differences in priorities by gender. I cannot think of a clear explanation for this. The extent and type of torture varies widely between countries. Therefore, it is not surprising that the analysis by â&#x20AC;&#x153;geographical area showed important peculiarities suggesting that a single worldwide agenda of research might not be realistic or desirable, and that local and regional priorities must also be taken into accountâ&#x20AC;?. All the top priorities seem pertinent and worth researching: the definition of torture; specificities of contemporary torture and torturing environments; specificities of certain populations - sexual violence, children and transgenerational trauma, extrajudicial killings and forced disappearance; documentation of torture, and impact on the judicial system; definition of rehabilitation and good practices, measures, questionnaires; community indicators; empowerment of victims; impunity, justice and redress; ethical aspects; and political and sociological aspects. An important issue is how the state - the perpetrator of torture- provides help for the rehabilitation of victims of torture. An initial step for that is the recognition that torture exists, which is not the reality in some of our countries where it is denied by authorities. Of course, and linked to this, is one of the

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understanding of rehabilitation (especially, the absence of importance given to physical complaints, medical findings, diagnosis, treatment process and reporting and also all social approaches linked to these points) is an important lacuna here. The true understanding of holistic rehabilitation stated in CAT General Comment 3 should include medical and psychological care as well as legal and social services. I am afraid that the way the authors ordered topics in categories might have weakened the reliability of the results by not giving proper emphasis to medical aspects. This is also reflected in the discussion, where again I am surprised by the dominance of the psychological perspective. I am concerned by the fact that the Istanbul Protocol is scarcely mentioned as a research priority and it is considered as a tool for forensic documentation of torture. I prefer to use the term “medical” and avoid “forensic”, as this might lead to the wrong impression that such an evaluation can only be conducted by a certified forensic expert or a government expert. In fact, all the medical professionals in this field should use and respect the Istanbul Protocol as a shared unified tool. We need a wider medical perspective here. I would also like to express some concerns regarding the distinction between the categories “assessment in country of asylum versus where torture was perpetrated” and “whether the panellist works in a country of asylum or a refugeeproducing country”. Both expressions are problematic and ignore that torture is also a practice in these “countries of asylum”, including Europe and the US, bearing in mind, for example, the European Court of Human Rights sentences condemning different European countries for practices considered as amounting to torture.

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Furthermore, the distinction between country of asylum and refugee-producing country is problematic in practice. As a person writing from Turkey, we are providing services to persons predominantly tortured in Turkey and living in Turkey, a country also hosting 3.3 million Syrian refugees. It might be that there are not noticeable differences in priorities because these categories need a conceptual revision. I would like to mention two additional points: the complexity of the idea of “building an identity around victimhood” and in which sense this is produced by the trauma itself, but also by the purely traumafocused approach of medical professionals. I believe that turning “victimhood” into an identity -and sometimes the main identityfor torture survivors who actually have a wide array of experiences alongside the experience of torture, encloses the survivor into a “torture victim”. Importantly, the concept “psychological torture” would need further clarification, as far as it is well-known and mentioned in Istanbul Protocol (Paragraph 145) that the distinction between physical and psychological methods is artificial. This is a major topic, but before proposing research on psychological torture as a priority, some conceptual clarification is needed. From a more general stand I would also suggest the use of the concept “anti-torture movement” (which is also used in the study) instead of the concept of “anti-torture sector”. Finally, I have to state that I am very glad to read in the discussion that “the obsession for so-called evidence-based treatments and guidelines of good practice shown by some academia and especially by funders, seems not to be shared by most of the experts.” In treatment and rehabilitation services, our utmost priority and focus should be improving the physical,

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psychological and social well-being of torture survivors, rather than satisfying funders through numbers. Considering the absolute prohibition of torture, the need for an apology and the right to full redress are the highest priority, and as the authors suggest, our circles should be more sensible to this deep political perspective with an emphasis on human rights’ values. Comment VI Response to Delphi Study: reflections from Zimbabwe Frances Lovemore, MD*

*) Director, Counselling Services Unit, Zimbabwe Correspondence to: franlovemore@gmail.com

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The political terrain of Zimbabwe has created a complex environment for both survivors of torture and their families and for the health and legal professionals providing treatment, rehabilitation and access to reparations and justice, as limiting impunity contributes to prevention of torture. Torture prevalence in Zimbabwe is directly correlated to political threat, the conflation of the state and the ruling liberation party, ZANU PF, which retains political control through intimidation and targeted torture of activist and opposition leaders and members. Many survivors have been targeted and tortured on numerous occasions over decades in close proximity to their abodes. The economic reality of Zimbabwe forces them to return to their homes and live among the perpetrators, who are ever present and reactivated as required by the state/ruling party. The chronicity of the prevalence of torture

combined with the limited health care services and the prevalence of both communicable and non-communicable disease contributes to challenges with regard to holistic rehabilitation and monitoring of impact of interventions with regard to treatment. The other limiting factor with regard to rehabilitation interventions is access to services. The risk to clients’ and their families’ safety seeking treatment and rehabilitation can limit the number of times the client can attend the clinic. Torture is prohibited under Section 53 of the Constitution of Zimbabwe Amendment (No.20) Act 2013, but is not criminalised. Nor has Zimbabwe signed the UN Convention against Torture. Perpetrators are therefore charged with “causing grievous bodily harm” in the criminal justice system, and in the civil litigation system can be found guilty in terms of the constitution and forced to pay compensation. Since 2000, when the Istanbul Protocol was declared the official United Nations guideline to treatment and documentation of torture, the protocol has been used by both the medical and legal responders to torture victims. In this complex landscape, the outcomes of the Delphi study fit strongly with the prevailing conditions in Zimbabwe and indicate that the research work in Zimbabwe can contribute significantly to a global agenda of research with respect to the topics chosen as top priorities. The agreed ten research priorities dovetail neatly with on-going work with survivors and can be calibrated to suit a broader range of research capabilities in small centres participating in research projects. The data available in Zimbabwe is rich and detailed. It is of utmost importance to carry out an empirical analysis of the strategic use of data for advocacy. This can have a direct positive impact in outcomes

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for torture survivors. The clinical records of survivors provide a comprehensive record of progress and challenges faced in the provision of services and their impact in an unstable environment. Also, as the study suggests, doing research on the use of the Istanbul Protocol that could contribute to a comparative analysis of the effectiveness of forensic medico-legal records. Also the impact of psychosocial support during legal processes, mentioned in the study, has been observed to be effective in Zimbabwe, and a research project is in fact underway in our Unit to evaluate the impact of the support. We also give utmost importance to another point stressed by panellists: empowering survivors. Survivors have assisted in developing their rehabilitation programs at our Unit, and the next logical step is to also involve them in setting research priorities within the Zimbabwe context. Finally I must mention the first-ranked topic: Cohesive studies on the long term impact of torture on communities and society and the imperative to provide comprehensive access to rehabilitation as defined by General Comment #3 on a longterm perspective. Research on this important topic could provide the body of evidence required to ensure that the adequate provision of services to survivors and their communities, including reparation, remain or become a key priority of governments and donor agencies and that freedom from torture remains a benchmark in the human rights evaluation of countries. With the research priorities now defined by this seminal study, I see possibilities to utilise well-established program work to contribute to multi-centre collaborative research for relatively little cost, and for centres to be able to accept a research component into their daily work and

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contribute to multi-centre studies and advocacy activities. The high cost of certain types of research such as neuro-biological research is inappropriate in many centres, as ours, where resources are extremely limited and the survivorsâ&#x20AC;&#x2122; needs are wide-ranging and complex, and likely to be long-term. The Delphi study highlights that applied research to practical problems is possible in all centres, but particularly in low resource centres. Comment VII Reflections on priorities and the way forward Jens Simon Modvig* The Delphi study presented above provides very interesting results in terms of research priorities within the torture field, ie prevention of torture and rehabilitation of torture victims. Among the four top priorities, two have to do with the impact of interventions: (i) the long-term impact of rehab interventions in terms of preventing chronicity and re-traumatization, and (ii) the impact of doing medico-legal documentation of torture. The third highlighted area (although the second in priority) deals with the impact of torture across generations, ie the transgenerational impact of torture and the fourth relates to further research on forced disappearance as torture. An important question in this connection is: What makes experts give priority to a particular research area? Immediately, one would assume that priorities are knowledgebased, that is, proposed research priorities

*) Director of Health Department, Chief Medical Officer in DIGNITY â&#x20AC;&#x201C; Danish Institute Against Torture. Chair, UN Committee against Torture Correspondence: JMO@dignityinstitute.dk

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actually leads to convictions of perpetrators or redress to victims. While we have recently seen evidence that a preventive approach to fighting torture is in fact effective, it remains to be demonstrated that fighting impunity is an effective strategy to fight torture. We all believe that a well-prepared court case—in this case including good Istanbul Protocol compliant documentation—has better chances of winning than a case of alleged torture with no corroborating medical evidence. However, it remains to be seen how much better the chances of winning the case, and this is highly relevant knowledge for all involved with litigation of cases of torture. A particularly relevant question is which parts of the Istanbul Protocol examination makes a difference in the court’s decisions. Research might contribute to this knowledge. A situation of increasing interest is prosecution of cases of alleged torture with no physical marks. Such cases pose challenges to the persons documenting the cases in order to provide corroborating medical/mental health evidence. The fourth most prioritized topic is research into torture in the context of enforced disappearances and extra-judicial killings. This field is highly important but very difficult to research. Nobody with knowledge about torture would doubt that many or most cases of enforced disappearances also include torture, and that the same applies to extrajudicial killings. Especially, if we look at the fundamental legal safeguards on arrest (the right to legal counsel, the right to call upon a medical doctor and the right to inform relatives about the arrest)—rights which are considered the most important measures to prevent torture. The absence of these rights is characteristic of incommunicado detention which may lead to enforced disappearances. However, there is silence

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represent the knowledge that we do not have but would like to have. This could be based on a basic scientific approach, ie, we lack knowledge to understand the field better. However, another possibility is offering itself: Knowledge and arguments are needed in the practical (or operational) work against torture. This could be in advocacy work or in direct interactions with agents like courts, prosecutors, prison authorities or other Criminal Justice Authorities. The main prioritized topic—longterm impact of interventions—serves as guidance to the rehabilitation movement. It will provide knowledge as to which interventions are effective, and which factors and interventions prevent chronicity. Such knowledge will sustain the right to rehabilitation and strengthen the arguments that all States parties to the UN Convention against Torture must establish rehabilitation services which are available, accessible, and appropriate. The better the knowledge of how to provide long-term effective interventions is founded, the better are the arguments for the State to actually establish such interventions. From a public health point of view, it would be highly relevant to document the long-term health economic benefits of early interventions and counteract the development of chronically incapacitated victims with heavy symptomatology and limited or no ability to contribute to societal development. It has to be added that rehabilitation services in states which recently perpetrated torture, are most often not considered appropriate by victims, and other solutions have to be found. The impact of using the Istanbul Protocol in the fight against torture is the second most prioritized research topic. The reason behind that may be that we need more evidence to the extent that a solid medico-legal documentation of torture cases

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surrounding these cases, and getting reliable information of the true course of events, including the use of torture, is demanding. In particular, the impact of enforced disappearances on the relatives should be highlighted as an indirect way of inducing severe pain and suffering of relatives. Such research would most likely have to start as case-based researchâ&#x20AC;&#x201D;presenting single cases of enforced disappearances or extrajudicial killings, where the component of torture had been revealed based on testimonies or autopsy findings. While such case stories exist, there is no systematic research to build a consistent relationship between these phenomena. At the policy and prevention level, such research efforts should be supported by the UN Committee against Torture, the Committee for Enforced Disappearances and the Working Group for Arbitrary Detention. In conclusion, the Delphi study seems for the first time to have pinpointed highly relevant research priorities within the scientific and practical work against torture. These research priorities could form the backbone of an internationally agreed research agenda. For this to happen, stakeholders would have to get together and discuss and adopt a common research agenda, preferably with the presence of donors within the field. I can only encourage stakeholders to take such an initiativeâ&#x20AC;&#x201D;a workshopâ&#x20AC;&#x201D;to facilitate that research within the torture field pulls in the same direction. In this context, key players such as the Torture Journal, IRCT, the Committee against Torture, research organizations like DIGNITY and CVT, and universities involved with torture-related research now have the initiative.

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Impact of Narrative Exposure Therapy on torture survivors in the MENA region Ane Kirstine Viller Hansen MSc.*, Nete Sloth Hansen-Nord MSc*, Issam Smeir EdD*, Lianne Engelkes-Heby BSc*, Jens Modvig MD, PhD* Contributors who collected data for this research: Malek Lakhoua1, Anissa Bouaske1, Linda Dridi1, Ameera Abdul Kareem Marran Marie2, Mohammed Azeez Raheem3, Chro Qadir3, Hani Mostafa4, Raghda Sleit4, Hussein Alsalem5, Mohammad Qatawneh5, Areej Sumreen5, Sana Hamzeh6, Marie Abdel Ahad6, Rahil Bahij6, Nancy Jabbour 6, Fatima Alqaadi7, Manar Arar8, Raya Farsakh8, Sanaa Mohammad9

••

*) DIGNITY - Danish Institute Against Torture, Denmark Correspondence to: nsh@dignityinstitute.dk 1) Tunisian Institute of Rehabilitation of Torture Survivors (Nebras), Tunisia 2) Bahjat Al-Fuad rehabilitation centre for torture victims, Iraq

Abstract

Introduction: Narrative Exposure Therapy (NET) is a brief cognitive-behavioural intervention for individuals with posttraumatic stress disorder (PTSD) which has mostly been used to treat traumatised asylum seekers and refugees in highincome settings. Evidence is scarce on the effectiveness of NET with torture survivors, especially in the Middle East and North African (MENA) region where health systems are unable to meet the increasing needs of mental health disorders caused by war and displacement. Methods: During the period 2013 to 2016 DIGNITY - Danish Institute Against Torture, in collaboration with partners, implemented a capacity-building training programme on NET among 44 Arabic health professionals from highly specialised torture rehabilitation centers in Jordan, Palestine, Egypt, Lebanon,

) Wchan Organisation for Victims of Human Rights Violations, Iraq 4) Al Nadeem Centre for Torture Victims, Egypt 5) Nour al Hussein Foundation - Institute for Family Health, Jordan 6) Restart Center for Rehabilitation of Victims of Violence and Torture, Lebanon 7) Al Fanar Rehabilitation Center for Victims of Violence and Torture, Sudan 8) Treatment and Rehabilitation Center for Victims of Torture (TRC), Palestine 9) Syrian Bright Future, Syria

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Key points of interest: Narrative Exposure Therapy treatment of survivors of torture and war living in unsafe and difficult environments in the Middle East and North Africa region was associated with a reduction in symptoms of post-traumatic stress disorder, anxiety and depression, pain perceptions and levels of disability, and improvements in self-reported health. This research suggests a positive influence of minimizing language barriers between therapist and client, and staying in a familiar cultural context while receiving Narrative Exposure Therapy. This research suggests that trauma treatment should not be delayed until refugees or asylum seekers resettle to live in a stable and permanent environment.

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Iraq, Tunisia, Libya, Sudan and Syria. A multi-centre study was carried out across all centres comprising of the collection of client data on socio-demographic variables, torture exposure, and psychosomatic health indicators. Clinical assessment of mental health symptoms among torture survivors was performed by the NET therapists pre- and post NET therapy and at four months’ follow-up, and means were compared. Results: Our findings show a statistically significant reduction in average psychological symptom load for PTSD (from 3.20 to 1.80), anxiety (2.78 - 1.61) and depression (2.75 - 1.96) with the largest effect on PTSD symptoms, and a larger effect for women than men. The results indicate improvements in selfreported health (3.85—2.82) and physical disabilities (2.90—1.76), as well as reduction in pain perceptions after therapy (4.44 -3.44). The duration of treatment was three months on average with a span from one to eight months. Discussion: This study provides new evidence suggesting a strong positive effect of NET in an Arab cultural setting which remains under-represented in the NET evidence base. However, some important limitations of the study preclude drawing firm conclusions, namely the lack of a control group, a high number of dropouts in follow up data and a potential risk of information bias. Contexts familiar to the torture survivor and shared cultural norms and language between the client and the therapist might positively affect the effect of NET on PTSD symptoms. This capacity-building training programme established a community of Arab trauma mental health experts in the MENA-region, and their implementation of NET was associated in time with a reduction of the mental health symptom load of survivors of torture and war.

SCIENTIFIC ARTICLE

Keywords: Torture, Middle East and North Africa, Narrative Exposure Therapy, rehabilitation, PTSD Introduction

The burden of disease caused by armed conflict and violence is rising (Robjant & Fazel, 2010). In 2011, when the Arab spring was initiated, people of the Middle East and North Africa (MENA) region were attempting to end corruption, increase political participation, rebel against oppression, and bring greater economic opportunities to their homelands. However, the Arab Spring led to the displacement of millions of refugees and asylum seekers as the region was consumed by civil wars, and widespread human right violations, including torture, increased. Alongside this rise, the mode of armed conflict and violence changed, affecting health-related outcomes and approaches. Torture survivors and refugees experience complex trauma, including sustained exposure to repeated or multiple traumatic incidents, often of an interpersonal nature, occurring in circumstances where escape is impossible (Mørkved, 2014). Refugees are vulnerable to developing mental health disorders including post-traumatic stress disorder (PTSD) (Gwozdziewycz & Mehl-Madrona, 2013). Asylum-seekers, who often have experienced the same pre-displacement stressors as refugees, are even more vulnerable to PTSD due to their insecure residential status (Schauer, Neuner, & Elbert, 2005; Crumlish & O´Rourke, 2010). Miller and Rasmussen (2010) state that daily stressors influence the relationship between armed conflict and mental health, emphasizing the role of daily stressors on mental health among people exposed to war. These daily stressors include language barriers, cultural differences,

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cognitive behaviour therapy (TFCBT), and testimonial therapy (TT) (Robjant & Fazel 2010). During NET the patient is encouraged to create a narrative of the entire lifespan from birth to the present with a special focus on reporting all traumatic experiences. In this way, the patient narrates all stressful life events in chronological order (Schauer et al., 2005), which makes NET suitable for persons exposed to multiple traumatic events (Hensel-Dittmann et al., 2011). During the treatment sessions, the patient and the therapist collaborate on constructing a detailed narration of the patientâ&#x20AC;&#x2122;s biography. The aim of the therapy is to create a chronological structure of the fragmented memories of the traumatic events. The narration should include the sensory, emotional and cognitive experiences of the patient. The patientâ&#x20AC;&#x2122;s testimony is written down by the therapist after the end of each session. In the last session, the patient and the therapist sign the written testimony. The testimony can later serve as an eye-witness report documenting human rights violations. NET is a standardised approach and can be delivered in a relatively small number of sessions. Each session lasts between 60-120 minutes and is preferably organised with one or more sessions per week with a maximum of 14 days between each session (Robjant & Fazel, 2010). Many refugees migrate frequently due to lack of employment or fear of deportation by authorities in refugee-hosting countries. Therefore, a brief treatment model minimises therapy having to end prematurely. It is argued that NET is applicable in many cultures, since it is based on an oral narrative tradition which is a common element in many cultures (Schauer et al., 2005) including many of those represented in the MENA region. Oral cultures utilise a form of

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instability, low social status, low employment rates, poor living conditions and lack of social support which might be related to having refugee status in new countries (Budosan, Aziz, Benner, & Abras, 2016). To successfully treat PTSD, the psychological and biological processes which form the basis for the condition must be addressed. Efforts have been made to explain the three main symptoms of PTSD; re-experiencing of intrusive memories, active avoidance, and hyper-arousal. The patients are often unable to reconstruct the traumatic event in a coherent and chronological manner. This fragmented memory lacks contextual information, hence causing a sense of constant threat as the traumatic event is indistinguishable from the present context. Furthermore, the re-experiencing of intrusive memories occurs due to the way memories of traumatic events are activated by one or more internal or external cues (Brewin & Holmes, 2003; Robjant & Fazel, 2010). Narrative Exposure Therapy (NET) is a manualised short-term cognitive-behavioural intervention targeting survivors of conflict and organised violence. NET was developed to treat clinical issues specifically observed in refugees who experienced repeated traumatisation. To meet the needs of this target group NET is delivered as a shortterm standardised therapy in emergency settings where there is scarce access to human and monetary resources (Schauer et al., 2005). This is essential since there is a documented shortage of mental health professionals in the MENA region. Global health observatory data shows that Jordan in 2014 possessed 0.51 psychiatrists and 0.27 psychologists per 100,000 residents (WHO, 2014). NET builds on components from other therapeutic approaches such as prolonged exposure therapy, trauma focused

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communication in which knowledge, art, ideas and cultural norms are received, preserved, and transmitted orally from one generation to another mainly through stories or narration (Zaharna, 1995). Additionally, it is imperative for the listener to play an active role in communication. They must construct meaning from what they have heard, as the meaning is not always blatantly apparent. It is well-documented that cultural sensitivity has a positive impact on treatment outcomes (Whaley & Davis, 2007), which makes NET an applicable therapeutic modality in the MENA region. NET remains one of the best supported psychosocial interventions to effectively decrease PTSD symptoms, documented in seven randomized controlled trials (RCTs) among adults (Adenauer, et al., 2011; Hijazi et al., 2014; Morath et al., 2014; Neuner, Schauer, Klaschik, Karunakara, & Elbert, 2004; Neuner et al., 2008; Neuner et al., 2010; Stenmark, Catani, Neuner, Elbert & Holen, 2013). The results of the RCTs show that NET was effective in decreasing PTSD and depression symptoms relative to inactive controls among refugees and asylum seekers displaced in high-income countries (Nosé et al., 2017). Four of these studies included torture survivors among the clients treated of which two were from the Middle East (Adenauer et al., 2011; Hijazi et al., 2014). This study investigates the effect of NET on PTSD, anxiety and depression symptoms, as well as on disability, self-rated health and pain among torture survivors in the MENA region using a pre-post design. Methods The intervention: Based on the extent of the problem of torture survivors and traumatised refugees in the MENA region in combination with limited rehabilitation services available for this target group,

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DIGNITY, in collaboration with MENA partners, decided to work to enhance torture survivors’ and traumatised refugees’ access to effective rehabilitation and justice in the MENA region through a Regional Rehabilitation project (2012-2017). The project developed a “NET capacity-building training model” which involved training and supervision of mental health professionals from rehabilitation centres in the MENA region. The aim was to empower local mental health professionals to become trainers and supervisors of NET so that they could disseminate their knowledge to colleagues and institutions in the region. The NET capacity-building training model allowed trainees to advance through three stages: practitioner, supervisor, and trainer. In the first stage, ‘practitioner’ trainees received a five-day training course on trauma theories, screening, diagnosis, and treatment utilising the NET approach. Trainees were then asked to treat three clinical cases using NET with online clinical supervision through Skype by NET experts. Trainees who successfully treated three cases using NET under supervision, and who showed interest in becoming supervisors, could advance to the second stage. In the second stage supervisor trainees were required to attend another five-day clinical supervision course based on the Discrimination Model of Supervision (Bernard & Goodyear, 2009). In this model, the clinical supervisors play three roles throughout the supervision process: teacher, counselor and consultant. The Discrimination Model also highlights three areas of focus for building skills: intervention, conceptualisation and personalisation issues. Interventions examine how technical aspects of the therapeutic process are handled. Conceptualisation examines how trainees formulate case from theory, and finally personalisation issues

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Data collection: Selection criteria for receiving treatment was exposure to war trauma and/or torture and being above the age of

15 years, which at the same represented inclusion criteria for participation in the study. Clients who dropped out during the course of the treatment were excluded from the statistical analyses. A contextualised structured questionnaire to monitor the effect of NET was designed. The questionnaire consisted of various variables assessing socio-demographic background information, traumatic head injury, family support, torture history, self-rated health and pain. The questionnaire also comprised the Arabic version of the validated scales Harvard Trauma questionnaire (HTQ 1-16) (Shoeb, Weinstein & Mollica, 2007) measuring PTSD, Hopkins symptoms checklist (HSCL-25) (Mahfoud et al., 2013) for anxiety and depression and WHO Disability Assessment Schedule 12 items (WHODAS 2.0) assessing disability and functioning, using official Arabic versions. These questions in HTQ 1-16 provide a score derived from the first 16 items of the test which relate directly to the symptoms of PTSD as listed in the Diagnostic and Statistical Manual of Mental Disorders, (4th Edition Revised (DSM-IVR)) with a cut-off value at 2.5 (average scores equal to or higher than 2.5 are considered indicative of PTSD) (Mollica et al., 1992). Symptoms of anxiety and depression were assessed by the HSCL-25 with a cutoff value at 1.75 for depression and anxiety. We constructed dichotomous variables for the scores of PTSD, anxiety and depression. Self-rated health was examined with the single-item measure: “In general, would you say that your health is excellent, very good, good, fair, or poor?” on a five-point scale where 1 equals excellent and 5 equals poor). Self-rated health was included in the monitoring of NET, because it has been established as a strong predictor of mortality and morbidity (Idler & Benyamini, 1997;

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focus on helping them to be aware of their own issues and how those impact their ability to counsel their clients effectively. Following completion of the course, trainees were matched with colleagues from subsequent groups of trainees and became their respective supervisors. The match was based on geographical location and, where necessary, the supervision sessions were conducted through Skype. Finally, those who completed five to seven clinical cases under supervision were trained to become supervisors. The third stage of becoming a trainer required attendance at a five-day Training of Trainers (ToT) course. All trainings were offered in Arabic by Arabic-speaking trainers and based on an Arabic ToT manual and a monitoring and evaluation manual. Trainees were educated in presenting and using the training materials. For the first time, training materials on NET were developed in Arabic, which ensured accessibility of training materials and quality of future trainings. The NET capacity-building training model contributed to the execution of NET therapy in each home country of the trained therapists. Under this project 44 psychologists and psychiatrists from Jordan, Palestine, Egypt, Lebanon, Iraq, Tunisia, Libya, Sudan and Syria were trained and supervised in NET, out of which 16 went on to become trainers of NET in their native countries. All mental health professionals collected clinical data on their NET clients. Because of the ToT approach the mental health professionals were not trained simultaneously and therefore only 19 distributed their data to the authors for analysis, documentation and publication.

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Schnittker & Bacak, 2014). The single item question “How much pain have you had during the last 4 weeks?” was used to assess pain on a 6-point scale where 0 reflected ‘none’ and 6 equalled ‘very severe pain’. Health and disability were assessed using the 12-item WHO Disability Assessment Schedule (WHODAS 2.0). The WHODAS 2.0 assesses the level of functioning in six domains in life: cognition (understanding and communicating); mobility; self-care; getting along with others; life activities; and participation in society. For each item, respondents rate the degree to which they have experienced difficulty in that area of functioning over the past 30 days on a 5-point scale (1 = None; 5 = Extreme or Cannot Do). The WHODAS 2.0 provides an overall disability scale, where a higher score indicates greater disability. There are no widely agreed clinical cut-offs for the scale (Konecky B et al., 2014). However, normative data is defined in the WHODAS manual (WHO, 2010). The normal distribution is based on a multi-country Survey Study on Health and Responsiveness (WHO, 2000-2001) carried out in 61 countries worldwide. In this survey, it was intended to produce comparable population estimates across cultures and groups, all samples were selected from nationally representative sampling frames (Üstün TB et al. 2003). Exposure to torture was examined with a dichotomised variable saying, “Have you ever been exposed to torture?” The trainees were trained in identifying victims of torture from the definition set out in the United Nations Convention Against Torture and Cruel, Inhuman or Degrading Treatment. Furthermore, the clients were referred by UN organisations working with refugees or through local medical institutions. The clients’ symptoms of PTSD, anxiety and depression were assessed before

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therapy and at the final therapy session, as well as levels of pain, disability and selfrated health. Follow-up was intended to be conducted after four months and consisted of variables measuring symptoms of PTSD, anxiety and depression. A qualitative data component was developed to record the clients’ perception of the course of treatment: “How has the treatment affected you in terms of how you feel, what you are able to do and how you think of all aspects of your life, e.g. your health and well-being, social relations and integration within the larger social system?”. The qualitative data was collected by the therapists and written as notes by the therapists in a text box in the questionnaire. Before receiving therapy, the clients were informed about the purpose of the data collection and that the study protects anonymity. Informed consent was given orally by clients to the therapists and registered in writing by the therapists. Clients were informed that they had the right to withdraw from the therapy at any time for any reason. Ethical approval was obtained from an internal ethical committee which follows the ethical guidelines of the European Research Council (ERC). The rehabilitation centres managed all data in compliance with protocols for the protection of human subjects in their respective countries, where they existed. Statistical analyses: Health status (symptoms of PTSD, anxiety and depression, selfreported health, pain and disability) was compared before and after therapy. Comparisons of the mean score for PTSD, anxiety, depression, pain and disability were performed using paired-samples t-test. The assumption of homogeneity of variances was tested using Levene’s test. Self-rated health was tested by Pearsons χ2-test. The level of disability was plotted into a diagram

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before and after therapy and compared to the distribution score in a normal population defined in the WHODAS manual (WHO, 2010). Furthermore, the mean score was calculated pre- and post-therapy and compared to percentiles for the said normal population. The effect of the therapy was further evaluated by comparisons of the qualitative data and the quantitative data. All analyses were conducted with a two-sided level of significance (p<0.05) and calculated in SPSS 19.0. Results

Table 1 shows the distribution of socioeconomic baseline data regarding 110 torture survivors and traumatised refugees who received NET. The proportion of men was higher than women, and the majority were in the age range 36-45 years. The level of education was almost equally distributed, with most people having completed primary school. The majority of clients were Syrian, Iraqi, Sudanese and Tunisian. Most cases

from Syria were treated in Lebanon, where the number of refugees exceeded 1 million in 2017 (UNHCR, 2017). The Rehabilitation Centre in Tunisia, on the other hand, dealt with torture victims from Tunisia only. Half of the study population was married and lived in households with two to five members. The unemployment rate was relatively high (46.4%), while 18.2% had a full-time job. On average, clients in this study received eight individual NET sessions and the duration of treatment was three months on average with a span from one to eight months. Despite clientsâ&#x20AC;&#x2122; difficulties in remembering when the torture happened, it was possible to obtain data on the time of the most recent torture event for 38 respondents. Most were tortured between 2011 and 2016 (18 respondents), followed by 12 in the 1990s and 7 in the 2000s and a single person in the 1980s.

Figure 1: Torture methods exposed to (%)

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Table 1: Description of the population Middle east (n=110) (%)

58 (52.7 %)

Divorced

6 (5.5 %)

Widow(er)

3 (2.7 %) 10 (9.1%)

Gender

Missing

Male

63 (57.3 %)

Employment*

Female

38 (34.5 %)

None

51 (46.4 %)

Missing

9 (8.2 %)

Full-time

20 (18.2 %)

Age categories

Self-employed

14 (12.7 %)

15-17

6 (6.6 %)

Part-time

9 (8.2 %)

18-25

5 (5.5 %)

Unpaid housework

4 (3.6 %)

26-35

16 (14.5 %)

Missing

12 (10.9 %)

36-45

27 (24.5 %)

Household members

46-55

18 (16.4 %)

0-3

38 (41.3 %)

56+

10 (9.1 %)

4-7

27 (42.3 %)

Missing

28 (25.5 %)

8-11

15 (13.6 %)

Missing

18 (16.4 %)

Education Level

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Married

None

3 (2.7 %)

Primary school

33 (30 %)

Secondary school

24 (21.8 %)

Vocational education

14 (12.7 %)

Higher education

24 (21.8 %)

Missing

12 (11 %)

Nationality

Syrian

37 (33.6%)

Iraqi

15 (13.6 %)

Sudanese

12 (10.9 %)

Tunisian

25 (22.7 %)

Libyan

4 (3.6 %)

Jordanian

1 (1 %)

Palestinian

10 (9.1 %)

Egyptian

1 (1 %)

Other

2 (1.8 %)

Missing

3 ( 2.7%)

Marital status Single

33 (30 %)

during the last month.

Within this sample, 74.5% were directly exposed to torture, whereas 13.6% were traumatised refugees who fled from war. In 11.8% of the cases, the torture exposure was missing. Methods of torture for this study are shown in Figure 1. Threats, humiliations, beatings and deprivation were the most frequent types of torture. Direct exposure to beatings of the head can cause loss of consciousness and in severe cases, traumatic brain injury. Further descriptive analysis showed that torture survivors and traumatised refugees were at high risk of brain injury since 54.5% (n=60) of this sample was exposed to beatings to the head. Among these, 36.4% (n=40) experienced loss of consciousness. For those exposed to beating to the head, the frequency of beatings was between one and four times. It was important to assess the risk of traumatic brain injury because

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don’t know. They tied me and started to investigate me, beating me and insulting me—then raped me.” The core analysis of this article examined the effect of NET as changes in psychological symptoms of PTSD, anxiety and depression pre- and post-therapy. Table 2 shows the mean values, number and percentages of clients with a symptom load above the cut-off point for PTSD (≥2.5), anxiety and depression (≥1.75) pre- and post-treatment. A significant reduction in average psychological symptom load for

it could limit the benefits from treatment. Relatively more women than men were exposed to sexual torture (26.8%) and women (57.7%). Pearsons χ2-test showed statistically significant difference (p=0.007). Sexual torture was often part of other types of torture: “My family house was attacked. They wanted to take my brother by force—I interferred and shouted, swore at them and attacked them to stop them from taking him. So, they arrested me with him. They covered my head and took me to a house that I

Table 2: Pre- and post-assessments of mental health symptoms PTSD (n=72)

Anxiety (n=71)

Depression (n=67)

Mean pre

3.2

2.78

2.75

Above cut-off pre

91 (82.7 %)

96 (87.3 %)

88 (80 %)

Mean post

1.80

1.61

1.96

Above cut-off post

5 (4,5 %)

24 (21,8 %)

60 (54.5 %)

Mean difference

1.4 *

1.17 *

0.79 *

FOLLOW-UP

n=12

n=11

Mean follow-up

1.58

1.61

1.72

Above cut-off

Mean pre

3.26

2.69

2.68

Mean post

1,96

1.58

2.18

Mean difference

1.3 *

1.11 *

0.5 (p=0.16)

Mean pre

3.15

2.98

2.88

Mean post

1.65

1.7

Mean difference

1.5 *

1.28 *

1.18 *

PRE

POST

Gender comparison Male

* p<0.000

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Female

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Table 3: Pre- and post-assessment of pyhsical health symptoms Pre

Post

p-value

Pain (n=61)

4.44

3.44

0.000

Disability (n=57)

2.90

1.76

0.000

PTSD, anxiety and depression was detected. The largest decrease was obtained for PTSD with a decrease of 1.4. The tendency of reduced PTSD and anxiety symptomatology remained the same when adjusting for gender. Gender comparisons revealed higher symptom reductions for females than males. Apart from depressive symptoms for males, all mean differences were highly statistically significant (p<0.000). The dropout rate was 23% since 25 persons had completed the pre-tests, without completion of post-tests. Only full completions of pre-and post-tests were included in the analysis.

In this study, self-rated health was rated significantly (p=0.004) better at the final assessment compared to the first assessment. Before therapy, the mean score was high; 3.85 indicating a poor self-rated health. After therapy, the score declined to 2.82. We detected a positive shift in all five categories of self-rated health. In the pre-assessment, most cases were distributed in the categories good, fair and poor, whereas in the final assessment, they have shifted to the better categories, including excellent which had not been used in the pre-assessment. At four monthsâ&#x20AC;&#x2122; follow-up, data was only obtained from 11 to 12 individuals. The

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Figure 2:WHO Disability Assessment Schedule (SUM score 1-60)

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dreams and nightmares are less, especially those connected to the shocking events. There is still a percentage of anxiety and depression due to reasons of ‘no income’ and ‘worries about the future of my children’ and then I am also scared that my husband will leave my children and run away from his duties and expenses.” The decreased prevalence of nightmares was substantiated by an analysis of a single item in the HTQ, asking about recurrence of nightmares. Our results show that nightmares on average decreased significantly from 3.03 to 1.44 (p=0,005) on a score from 1-4. Discussion

NET improves psychosomatic health in the MENA region: Our findings show a strong statistically significant reduction in symptoms of PTSD, anxiety and depression amongst survivors of torture who received NET in the MENA region in the period 2013-2016. NET had its greatest impact on PTSD symptoms and its lowest on depression symptoms. This result is not surprising since NET targets PTSD and not depression. So even though we know that the symptoms are interlinked, we did not expect a high impact on depression. One theory of explanation is that traumatised individuals who come from and live in shame-based societies such as those in the MENA region (Fessler, 2004) may be impacted by their upbringing and culture where one’s inability to fulfill obligations and live up to others’ expectations is considered to be monumental. Specifically, it is possible that trauma victims who are experiencing a low level of functioning and unable to perform their social roles might see themselves as being in an inferior position, and subsequently adopt non-assertive submissive and submissive defensive behaviors. These

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results showed maintained lower levels of PTSD, anxiety and depression, and despite the small sample size, the results were maintained as significant (p=0.000). The level of pain decreased significantly (p=0.000) with a mean score at 4.44 before NET to 3.44 after NET. The level of disability improved significantly after the last session of therapy. On a scale from 1-5, the mean score was 2.90 before therapy, whereas it decreased to 1.76 (p=0,000) after therapy. However, comparing the sum-scores in our study to the distribution norms set in the multi-country Survey Study by Üstün TB et al. 2003, both pre- and post-therapy measurements showed extraordinarily higher levels of disability (Figure 2), indicating that torture survivors and traumatised refugees experienced severe functional challenges in their daily lives in addition to mental health problems. The effect of NET reduced the symptoms of disability, but our sample is still half of the normal distribution. In terms of clients’ self-reported experiences of attending NET, the qualitative evaluations showed torture survivors and traumatised refugees felt their relations with others and communication had improved, as exemplified here: “The therapy made me a social person. My self-confidence is better, I learned to speak about what is hurting me to the specialist. I feel more relaxed—I was afraid of people after what happened to me but thank God I am dealing with everyone in a better way and I am not scared anymore.” Our study participants expressed better integration into society, e.g., as increased participation; felt they could have a role in their lives; experienced less fear; and, finally, showed improved sleeping with fewer nightmares: “When speaking about memories and hurting events the psychological effect is less,

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behaviours and emotions have been linked to depression (Gilbert, 2016). This study assesses the effect of NET on anxiety. Likewise, this study is the first to present somatic effects of NET, showing improvements in self-reported health as well as a reduction in pain perceptions and levels of disabilities after treatment. This points to a positive association between psychological and somatic health outcomes related to NET. Furthermore, our findings show a larger effect for women than men. This supports previous literature that women benefit more from trauma therapy than men (Békés, Beaulieu-Prévost, Guay, Belleville, & Marchand, 2016). In the present study, it is possible that men found the NET requirement to relive the traumatic experience and express feelings and associated physiological responses as more challenging. The exposure element of NET may be particularly difficult for men in male-dominated societies such as in the MENA region. So far, the effects of NET on PTSD and depression in torture survivors have mainly been evaluated in high-income settings. This research evaluates the effect of NET on PTSD and depression in torture victims who continue to live in unsafe and difficult environments facing legal, employment, and financial challenges in their current middle- or low income countries. Some faced threats of deportation back to their home country on a regular basis, and some were still at risk of being tortured. This research rejects the assumption that trauma treatment should be delayed until refugees or asylum seekers resettle to live in a stable and permanent environment (Norredam, Mygind, & Krasnik, 2006). Instead, the current findings coincide with previous studies suggesting treatment need not be delayed (Stenmark et al., 2013).

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Do daily stressors affect the effect of NET on mental health? Our research indicates that daily stressors affect the effect of NET on PTSD symptoms, supporting previous evidence (Miller and Rasmussen, 2010). Other important factors besides the NET treatment model may explain why our participants from the MENA region experienced more significantly reduced PTSD symptoms than those from highincome countries. One might be the context surrounding the client while receiving therapy, which in our study population was familiar cultural norm settings. Another aspect might be whether the therapist shares the same cultural background as well as language with the client, since socio-cultural knowledge and cultural competency of the therapist are crucial in the collaboration with the client (Hassan et al., 2016). In the case of our study population the NET therapists had extensive cultural competencies, for some due to shared nationality between therapist and client, and no interpreters were necessary in the therapeutic sessions. Finally, the client’s social status and feeling of identity may play an important role in the effect of therapy, which is often related to asylum or refugee status. In our study population about 50% were employed, where, in contrast, the employment rate may be much lower among refugees living in camps. Hassan et al. (2016) suggests that improved living conditions and livelihoods may improve the mental health of refugees and internally displaced persons even more than psychological and psychiatric interventions. Strengths and limitations: Despite some important limitations, this study represents new evidence on the effect of NET among torture survivors in the MENA region. Limitations include that it was carried

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different place without giving prior notice to the therapists. Despite the intention of collecting follow-up data after four months, the response rate was very low (12 clients) since many clients were refugees and had migrated after four months. The data is thus insufficient to estimate the long-term effects of NET. Finally, there was a large amount of missing data, which can cause biased estimates and decreased statistical power, as well as weakened generalisability. In the core analysis of this study, we only included cases where clients had completed full pre-and post- scales for PTSD, anxiety and depression. As all findings were highly significant, it seems likely that the results could be generalised to a larger sample with high compliance to the treatment. However, the missing data may have underor overestimated the detected larger effect of NET among women. Strengths include that the multicentre approach enabled us to test the applicability of NET on a large number of NET cases across the MENA region since many therapists from different countries performed this therapy in their respective country contexts. The significant results dispersed over a large group of therapists also strengthened the reliability of the results. The application of mixed methods with openended answering options in connection to the quantitative measures increased the validity of the research. Furthermore, all therapists received monitoring and evaluation training prior to using the tool, increasing both validity and reliability. Implications for practice: Our results can inform decisions in clinical practice and in policy-making, suggesting a positive influence of familiar contexts and cultural norm settings surrounding clients while

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out without a control group, which made it impossible to rule out spontaneous improvement, or improvement due to other treatments, medication, and/or because of environmental, psychosocial and community changes. This is particularly the case as the measures used were mostly related to symptoms and not to other aspects related to the deep experience of survivors. This is something that could be clarified with further studies including a control group (for instance through having similar measures with waiting lists of participants). The risk of information bias should be considered as the therapist collected data prior to, and after therapy, which can cause an overestimation of the effect of the therapy. On the other hand, it is likely that self-reported psychological symptoms were underestimated because of stigmatisation of mental health challenges in the Middle East. That said, reliability of the reported outcomes was strengthened since reporting a positive progress of their therapy outcomes was potentially against their self-interest; a significant proportion of treated clients had applied for refugee status and severe mental health symptoms can be seen as having an advantage over others in terms of being granted refugee status. This study had a relatively high dropout rate, but this should be seen in light of the difficult contexts the clients lived in. Most clients lived illegally in their hosting countries; Jordan, Lebanon and Egypt. They faced daily threats of immediate deportation by authorities, or physical harassment or abuse by local nationals. Two main reasons for dropout of treatment were that some felt the need to move their housing location when they felt threatened. Secondly male clients, who had to work illegally to support their families suddenly moved once they found a new job in a

receiving NET, as well as highlighting the importance of the therapist having a high level of cultural competency, and competency in the same language as the client with no need to use interpreters during sessions. In conclusion, this educational project managed to fill a gap in the mental health arena in the MENA region by establishing a community of Arab mental health specialists within trauma counselling in the region with promising results that strongly suggest that short-term NET therapy can significantly reduce the mental health symptom load of survivors of war and torture. Acknowledgements We would like to thank all the health professionals of the participating rehabilitation centres in the MENA region for their support and collaboration in the data collection process. Importantly, we are also grateful to the NET clients for the invaluable information provided for this study.

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References Adenauer, H., Catani, C., Aichinger, H., Keil, J., Ruf, M., & Neuner, F. (2011). Narrative Exposure Therapy for PTSD increases top-down processing of aversive stimuli - evidence from a randomized controlled treatment trial. BMC Neuroscience, 12, 127. Békés, V., Beaulieu-Prévost, D., Guay, S., Belleville, G., & Marchand, A. (2016). Women with PTSD benefit more from psychotherapy than men. Psychol Trauma, 8, 720-727. Bernard, J. M., & Goodyear, R. K. (2009). Fundamentals of clinical supervision (4th ed.). Needham Heights, MA: Allyn & Bacon. Brewin, C. R., & Holmes, E. A. (2003). Psychological theories of posttraumatic stress disorder. CLIN PSYCHOL REV, 23, 339 - 376. Budosan, B., Aziz, S., Benner, M. T., & Abras, B. (2016). Perceived needs and daily stressors in an urban refugee setting: Humanitarian Emergency Settings Percieved Needs Scale of Syrian refugees in Kilis, Turkey. Intervention 1-12.

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Crumlish, N., & O’Rourke, K. (2010). A systematic review of treatments for post-traumatic stress disorder among refugees and asylum-seekers. J Nerv Ment Dis., 198, 237-51. doi: 10.1097/ NMD.0b013e3181d61258. Fessler, D. (2004). Shame in Two Cultures: Implications for Evolutionary Approaches. Journal of Cognition and Culture 4.2 Gilbert, P. (2016). Depression: The Evolution of Powerlessness. Rouledge: NY. Gwozdziewycz, N., & Mehl-Madrona, L. (2013). Meta-Analysis of the Use of Narrative Exposure Therapy for the Effects of Trauma Among Refugee Populations. The Permanente Journal 17. Doi: http://dx.doi.org/10.7812/TPP/12-058. Hassan, G., Ventevogel, P., Jefee-Bahloul, H., & Barkil-Oteo, A. (2016). Mental health and psychosocial wellbeing of Syrians affected by armed conflict. Epidemiology and Psychiatric Sciences, 25, 129-141. Hensel-Dittmann, D., Schauer, M., Ruf, M., Catani, C., Odenwald, M., Elbert, T., & Neuner, F. (2011). Treatment of Traumatized Victims of War and Torture: A Randomized Controlled Comparison of Narrative Exposure Therapy and Stress Inoculation Training. Psychotherapy and Psychosomatics, 80, 345-352. Hijazi, A. M., Lumley, M. A., Ziadni, M. S., Haddad, L., Rapport, L.J., & Arnetz, B.B. (2014). Brief narrative exposure therapy for posttraumatic stress in Iraqi refugees: a preliminary randomized clinical trial. J Trauma Stress, 27, 314-22. doi: 10.1002/jts.21922. Idler, E. L. & Benyamini, Y. (1997). Self-Rated Health and Mortality: A Review of Twenty-Seven Community Studies. Journal of Health and Social Behavior, 38, 21-37. Konecky B, Meyer EC, Marx BP, et al (2014). Using the WHODAS 2.0 to assess functional disability associated with DSM-5 mental disorders. American Journal of Psychiatry 171, 818-820. Mahfoud, Z., Kobeissi, L., Peters, T. J., Araya, R., Ghantous, Z., & Khoury, B. (2013). The Arabic Validation of the Hopkins Symptoms Checklist-25 against MINI in a Disadvantaged Suburb of Beirut, Lebanon. International Journal of Educational and Psychological Assessment, 13, 17-33. Miller, E. K., Rasmussen, A. (2010). War Exposure, Daily Stressors, and Mental Health in Conflict and Post-Conflict Settings: Bridging the Divide between trauma-focused and psychosocial frameworks. Social Science and Medicine, 70, 7-16. Mollica, R.F., Caspi-Yavin, Y., Bollini, P., Truong, T., Tor, S., Lavelle, J. (1992). The Harvard Trauma Questionnaire. Validating a cross-cultural

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Schaal, S., Elbert, T., & Neuner, F. (2009). Narrative exposure therapy versus interpersonal psychotherapy. A pilot randomized controlled trial with Rwandan genocide orphans. Psychotherapy and Psychosomatics, 78, 298–306. Schauer, M., Neuner, F., & Elbert, T. (2005). Narrative Exposure Therapy - a short term intervention for traumatic stress disorders after war, terror or torture. Cambridge, MA: Hogrefe & Huber. Schnittker, J., & Bacak, V. (2014). The Increasing Predictive Validity of Self-Rated Health. PLoS ONE 9. https://doi.org/10.1371/journal. pone.0084933. Shoeb, M., Weinstein, H., & Mollica, R. (2007). The Harvard Trauma Questionnaire: Adapting a Cross-Cultural Instrument for Measuring Torture, Trauma and Posttraumatic Stress Disorder in Iraqi Refugees. International Journal of Social Psychiatry. Stenmark, H., Catani, C., Neuner, F., Elbert, T., & Holen, A. (2013). Treating PTSD in refugees and asylum seekers within the general health care system. A randomized controlled multicenter study. Behav. Res. Ther., 1, 641-7. UNHCR (2017). Populations. Retrieved from URL: http://reporting.unhcr.org/population. Üstün TB et al. (2003). WHO multi-country survey study on health and responsiveness 2000-2001. In: Health systems performance assessment: debates, methods and empiricism. Geneva, World Health Organization, 2003, 761–796. WHO (2010) Measuring Health and Disability: Manual for WHO Disability Assessment Schedule (WHODAS 2.0)/ Üstün, T B., Kostanjsek, N., Chatterji, S., & Rehm, J. (Eds) Whaley, A. L., & Davis, K. E. (2007). Cultural Competence and Evidence-Based Practice in Mental Health Services: A Complementary Perspective. American Psychologist, 62, 563-574. doi: 10.1037/0003-066X.62.6.563. WHO (2014). Global Health Observatory data repository. Retrieved from URL: http://apps.who. int/gho/data/node.main.MHHR?lang=en. Zaharna, R. (1995). Bridging Cultural Differences: American Public Relations Practices & Arab Communication Patterns. Public Relations Review, 21, 241-255.

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instrument for measuring torture, trauma, and posttraumatic stress disorder in Indochinese refugees. J Nerv Ment Dis. 180, 111-6. Morath, J., Gola, H., Sommershof, A.., Hamuni, G., Kolassa, S., Catani, C., Adenauer, H., Ruf-Leuschner, M., Schauer, M., Elbert, T., & Groettrup, M. (2014). The effect of trauma-focused therapy on the altered T cell distribution in individuals with PTSD: Evidence from a randomized controlled trial. Journal of Psychiatric Research 54: 1-10. doi: 10.1016/j. jpsychires.2014.03.016. Mørkved, N., Hartmann, K., Aarsheim, L. M., Holen, D., Milde, A. M., Bomyea, J., & Thorp, S. R. (2014). A Comparison of Narrative Exposure Therapy and Prolonged Exposure Therapy for PTSD. Clinical Psychology Review, 34, 453-467. doi: 10.1016/j.cpr.2014.06.005. Neuner, F., Kurreck, S., Ruf, M., Odenwald, M., Elbert, T., & Schauer, M. (2010). Can AsylumSeekers with Posttraumatic Stress Disorder Be Successfully Treated? A Randomized Controlled Pilot Study. Cognitive Behaviour Therapy, 39, 81-91. Neuner, F., Onyut, P.L., Ertl, V., Odenwald, M., Schauer, E., & Elbert T. (2008). Treatment of posttraumatic stress disorder by trained lay counselors in an African refugee settlement: a randomized controlled trial. J Consult Clin Psychol 76,686-94. doi: http://dx.doi.org/10.1037/0022006X.76.4.686. 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. J Consult Clin Psychol 72,579-87. doi: http://dx.doi. org/10.1037/0022006X.72.4.579 2. Norredam, M., Mygind, A., Krasnik, A. (2006). Access to health care for asylum seekers in the European Union - a comparative study of country policies. Eur J Public Health, 16, 285-289. doi: https://doi.org/10.1093/eurpub/cki191. Nosè, M., Ballette, F., Bighelli, I., Turrini, G., Purgato, M., Tol, W., Priebe, P., & Barbui, C. (2017). Psychosocial interventions for posttraumatic stress disorder in refugees and asylum seekers resettled in high-income countries: Systematic review and meta-analysis. PLoS ONE, 12, e0171030. doi: 10.1371/journal. pone.0171030. Robjant, K., & Fazel, M. (2010). The Emerging Evidence for Narrative Exposure Therapy. Clinical Psychology Review, 30, 1030-39.

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Tortured Logic: Information and brutality in interrogations John W. Schiemann PhD*

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Key points of interest: • Employs mathematical game theory to assess the pragmatic argument for interrogational torture, with the intuition behind the math presented here. • Multiple real world uncertainties facing both interrogators and detainees mean that information from torture will be unreliable. • These same uncertainties cause torture to exceed limits and controls imposed by torturers themselves, leading to slippery slopes of torture frequency and brutality. • A rigorous logical examination supports historical, social scientific, psychological, and neurobiological evidence refuting the pragmatic argument for interrogational torture. Abstract

Background: Pragmatic arguments for interrogational torture rest on the twin assumptions that torture generates reliable information and that torture can be controlled and limited. Methods: I

*) Department of Social Sciences & History, Fairleigh Dickinson University, Madison, New Jersey. Correspondence to: jws@fdu.edu

assess the claims of torture proponents by providing the intuition behind a game theoretic model of interrogational torture. Tracing out the logic of different combinations of possible interrogators and detainee types results in eight outcomes that can be compared to three claims made by torture proponents: that information will be predictably reliable, that the frequency of torture will be minimized, including no torture of innocents, and that the severity of torture can likewise be limited and controlled. Findings: Of the eight outcomes generated by the model, only two result in full information, but an innocent is tortured in both and in one the detainee providing information is tortured after having no more information to give. Moreover, these outcomes are only possible for an extremely restricted and empirically unlikely combination of circumstances. With respect to torture frequency, detainees are tortured in seven of the eight outcomes, including innocent detainees. The incentives facing interrogators also compel them to ratchet up their brutality in an effort to compel information. Discussion: The outcomes of a model of interrogational torture based on the proponent ideal violate the three conditions individually necessary to support that ideal: (1) information from torture is unpredictable and unreliable, with no information and false information far more

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likely than good information; (2) torture will be used more frequently—including against innocents—than control and limits permit; (3) torture will be more brutal than controls and limits allow. Conclusion: The only thing reliably effective about interrogational torture is its ability to generate slippery slopes of frequency and brutality, violating the basic premises of the pragmatic argument for interrogational torture. Keywords: interrogation, torture, game theory Introduction

See also O’Mara (2011, 2009), Elbert et al. (2011), Elbert et al. (2006), and Maercker & Forstmeier (2011). For an accessible introduction to game theory see Gibbons (1992). My analysis applies strictly to interrogational torture, where the goal is to compel information, but to ease the exposition I sometimes use “torture” alone. For another recent application of game theory to the effectiveness of interrogational torture, see Baliga and Ely (2016). As a result, the presentation here is necessarily incomplete and imprecise in places. For the formal mathematical argument, including a description of the model and proofs of equilibria and propositions, see Schiemann (2016). I also address there in detail the understandable concern about using a rational model to account for the effectiveness aspect of interrogational torture, something I unfortunately lack the space to do here.

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A recent international survey showed that over one in three respondents support torture to obtain intelligence in some circumstances (International Committee of the Red Cross (ICRC) 2016, 10). This is a decline from two-thirds saying no in 1999 to 48% in 2016 (ICRC 2016, 10). This change in public opinion is complemented and supported by an analogous shift to a pragmatic approach assessing costs and benefits in public policy discussions, legal thinking, and philosophy. Even the current President of the United States openly advocated interrogational torture “worse than waterboarding” partly because “it works” (Johnson 2016). Although many understandably continue to attack interrogational torture on legal and rights-based grounds, others from philosophy, history, and public policy have challenged the pragmatic argument on its own terms (Johnson & Schmidt 2016, pp 132, 122; Rejali, 2007, esp. chaps. 21-22; Rumney, 2014). One of the most damning challenges to the proponent argument is one familiar to readers of this journal: the powerful neurological and physiological evidence that torture is not only unlikely to facilitate the recall of episodic memories, but may very well cause the destruction of such

memories via tissue loss in relevant brain regions (O’Mara, 2015).1 I complement these arguments by approaching interrogational torture in a new way: examining the logic of interrogational torture using game theory, a branch of applied mathematics that models strategic interaction between two or more people.2 In the limited space here I provide the intuition behind the formal argument.3 I argue that tracing out the proponents’ own logic of torture shows that torture is ineffective yet inevitably results in brutality that both outweighs any information gained and exceeds proponents’ own limits and controls. In other words, the outcomes of an analytical model of interrogational torture constructed according to the proponent’s own conception, with limits on torture, fail to match up to the claimed outcomes of the proponent normative model: what they say should happen when torture is introduced into interrogations. The paper proceeds as follows. In section one I identify some necessary conditions

and the proponent’s ideal outcome - four criteria of success - that interrogational torture is supposed to satisfy on the proponent account. This is the normative model. Having delineated in normative terms how interrogational torture should work on the proponent view, I first build an informal model of interrogational torture in section two. This is the analytical model. Informed by proponent ideas about limits and controls on torture, this model identifies the important elements in the strategic dynamic between a torturer and a detainee. The remainder of section two follows the proponent logic of torture to its conclusions, showing how different outcomes (e.g. a detainee provides information but is tortured anyway) emerge from the initial conditions. Section three confronts the normative model’s pragmatic criteria of success sketched in section one with these outcomes of the analytical model. This comparison demonstrates that interrogational torture fails to satisfy the necessary conditions identified by proponents themselves.

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The Proponents’ Normative Model

Whatever the influence of utilitarian philosophers, it is legal scholars who have elaborated the most concrete proposals for institutionalizing torture in such a way that it maximizes information while simultaneously limiting abuses. They boil down to three individually necessary conditions an interrogational torture program must meet: Condition 1. Information Reliability. Interrogational torture is successful if and only if detainees give up (nearly) all their information so that the ratio of clear and valuable information to all other information (non-valuable, false and misleading, and no information) is high.

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Condition 2. Torture Frequency. Interrogational torture is successful if and only if torture is not employed too frequently, that is, the total frequency of torture is low, torture is not used on cooperative detainees after they have provided all their information, and not on innocent detainees tortured for telling the truth.4 Condition 3. Torture Severity. Interrogational torture succeeds only if torture is not employed too severely, that is, not much beyond the minimum degree necessary to compel valuable information.5 Put together, this is the ideal outcome claimed by proponents of interrogational torture: Torture Justification Outcome. Torture in interrogations is justified on the proponent view if and only if torture is not used against cooperating detainees who have provided all their information, nor against innocent detainees, nor exceeds the minimum frequency and severity necessary, to elicit valuable information, and (the threat of) torture generates all, or nearly all, the valuable information possessed by knowledgeable detainees. These are the necessary conditions to be satisfied by the proponents’ normative model. We now sketch a game theoretic, analytical model reflecting the implicit logic of torture proponents.

Here and hereafter, all phrasing about “innocents,” “necessary” and “unnecessary torture,” and “minimum” torture is meant to capture the proponent point of view, not the author’s. Exactly what constitutes the “minimum” is unclear even for torture proponents, but a gross violation of any reasonable notion of minimum is sufficient to refute the pragmatic model.

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Methods and Findings

To keep them distinct, I use the pronoun “he” for the detainee and “she” for the interrogator.

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Methods: An Analytical Model of Interrogational Torture To think about torture from the proponent’s perspective, imagine a detainee facing an interrogator willing to torture, but preferring not to do so.6 The detainee, of course, prefers not to be tortured, but some detainees (cooperatives) are willing to provide information if threatened with (more) torture whereas some detainees (resistants) continue to resist, refusing to provide information (or providing false information) even when threatened with torture and actually tortured. An innocent detainee resembles the cooperative type insofar as he is willing to lie and tell the interrogator what she wants to hear to in order avoid torture. Of course neither a cooperative nor an innocent detainee would want to cooperate with an interrogator and be tortured anyway. Note that an innocent detainee can please the interrogator only if the interrogator asks a leading rather than objective question. An innocent detainee cannot provide an answer to the question “what is the address of the safe house?” but can say “yes” to the question “the safe house is at 10 Maple Lane, isn’t it?” Of course, a detainee who actually knows something might confirm the leading question of 10 Maple Lane when he knows it is actually at 25 Elm Street. Thus the value of “cooperating” under leading questioning is entirely dependent upon the accuracy of the original question and so cannot—by definition—provide any new information. Despite numerous attempts throughout the

history of torture to prevent them, leading questions are used all the time and so we will include this possibility in our model. Although proponents of interrogational torture always assume the detainee is a terrorist, rather than a suspected terrorist, the history of torture past and present is replete with examples of innocents swept up and tortured even when efforts are made to prevent this. Rejali’s extensive analysis of torture by the French during the Battle of Algiers found that the most charitable ratio of the numbers of innocent who were arrested for every actual insurgent was a staggering 15 to one (Rejali 2007, p 483). Former U.S. Army general Janis Karpinski, commander of Abu Ghraib during the height of the abuses there, later estimated that “about 90 percent” of the detainees brought in for interrogation as terrorists were “innocent of terrorism or any related activity” (Karpinski 2005). Many of the detainees held by the United States at its military prison at Guantánamo Bay, Cuba were innocents sold to the US military for bounties in Afghanistan (Denbeaux et al., 2006, pp 15, 21). Thus, of the original 780 detainees, 730 have been transferred and 41 remain in custody because they are believed threats (New York Times, 2017). More than one in five of the known 119 detainees in the CIA’s interrogational torture program were innocent (United States Senate 2014, pp 19, 42). Although in practice few interrogators are likely to place much weight on this probability, we want to assume our theoretical interrogators at least consider the possibility in order to give proponents the benefit of the doubt. Thus, we assume that if an interrogator really does think a detainee were innocent, she would refuse to torture. What else might you be uncertain about as an interrogator? Suppose you have asked some objective questions and

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received good information in return. And then your detainee says he knows nothing more. Do you threaten (more) torture? In principle you would assume there must be some questions to which a detainee would have no answer; no detainee knows literally everything. If, however, you think he is holding back, you are committed to torturing more. What will the detainee be uncertain about? Any cooperative or innocent detainee will have at least one major concern: that talking really will stop the torture (remember that the resistant type never talks or provides only false information). How likely is it that someone who has been kidnapped, thrown into a cell and tortured or threatened with torture will believe the interrogator that she will not torture if she is told what she wants to hear? It would be difficult for an interrogator to convince someone that she is not sadistic and only wants information. It is important to note that in order to give the proponents the benefit of the doubt, we will assume that the interrogator is not sadistic but instead pragmatic when we analyze the outcomes. We must, however, include the sadistic type of interrogator in the model because a real-life detainee would think it is at least possible that the interrogator is sadistic and not pragmatic and this could affect his behavior. There is another problematic source of uncertainty that is not shared by both the detainee and the interrogator. While a cooperative detainee will assume that if he does provide good information it will be recognized as such—what is the point of torture otherwise?—this does not always happen. Sometimes interrogators do not understand that the information is valuable. It may contradict other (bad) intelligence in which they have confidence or it may seem implausible. Whatever the reason, the

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interrogator may think the detainee is lying and so continue to torture—presumably to the surprise of the cooperative detainee. Thus we have a detainee sitting across from an interrogator. The detainee could have information and be cooperative or resistant, or he could not have information and be innocent. The interrogator, who could be pragmatic or sadistic in the mind of the detainee, will have some estimation of the relative likelihood of each detainee type going in. Since, according to the logic of torture, it is always the threat of (more) torture in the future which is supposed to compel truth telling in the present, the detainee either provides valuable information or does not, and then the interrogator either tortures or does not. The detainee’s decision to provide information depends on the value of the information (or the desire not to tell a lie if innocent), the anticipated costs of torture, and his belief about whether or not the interrogator is pragmatic or sadistic. Not providing valuable information might mean providing throw away, nonvaluable information, providing misleading information, or no information at all—literally staying silent. If valuable information is provided, the interrogator might be uncertain about how valuable it is and will definitely be uncertain about whether the detainee has any more information he is not divulging. Using, in part, the detainee’s behavior to update her beliefs about these uncertainties, the (pragmatic) interrogator will decide whether or not to torture. As spare as this sketch may seem, this model captures some of the most critical dimensions of the proponent model of interrogational torture. Findings: Outcomes of the Analytical Model To analyze interrogational torture, we systematically explore each combination of detainee and interrogator choices and beliefs

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Table 1: Interrogational Torture Objective Questioning

Leading Questioning

Complete valuable information, surprise torture

Ambiguous information, selective torture

Incomplete valuable information, surprise torture

False confirmation, selective torture

Complete valuable information, selective torture Incomplete valuable information, selective torture No information, torture No information, no torture

her all the information he has or whether she believes he is still holding back. If she believes he has given up everything, then she does not torture (remember, she’s pragmatic not sadistic). If she believes instead that he has not divulged all he knows and he is holding back information, she tortures him. In this case, the detainee will be surprised, since he believed the interrogator would believe he had divulged everything and so expected he would not be tortured. Note that this surprise is only from the perspective of the detainee and is based purely on what he thought the interrogator would think and do; it is not based on having necessarily actually given all his information. He could be surprised at the interrogator’s response even though he was withholding information because he thought he had successfully deceived the interrogator. So there are really two outcomes here: one in which a detainee withholding some more information is unexpectedly tortured and one in which he really did give up all his information and is unexpectedly tortured, again with “unexpected” referring to the detainee’s perspective: Incomplete valuable information, surprise torture and Complete valuable information, surprise torture, respectively. The same two possibilities are also true when the detainee provides information and the interrogator does not torture because she really does believe that the

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and trace out what each type of interrogator and each type of detainee would do in that circumstance. Doing so results in eight outcomes, summarized in Table 1 in terms of both information and torture. Two occur under leading questioning only (Ambiguous information, selective torture and False confirmation, selective torture) and two occur under objective questioning only (Incomplete valuable information, surprise torture and Complete valuable information, surprise torture). The remaining four outcomes occur under both objective and leading questioning (Incomplete valuable information, selective torture; Complete valuable information, selective torture; No information, torture; No information, no torture). To see how these outcomes are derived, suppose, for example, that a cooperative detainee faces a pragmatic interrogator and that the detainee is convinced that the interrogator really is pragmatic and so will not torture if he gives up information. The interrogator asks some objective questions and the detainee responds truthfully, providing all the valuable information he has because of the threat of (more) torture. The interrogator, for her part, is convinced that the detainee is cooperative, i.e. has information and gives it up under the threat of (more) torture. The only remaining question is whether she believes that the detainee has given

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detainee has given up all his information. It might be the case that she is correct and there really was no withholding (Complete valuable information, selective torture) or it might be the case that she is wrong and the detainee got away with it, convincing the interrogator that he had given up everything he knew when in fact he had not (Incomplete valuable information, selective torture). In abbreviated form the four outcomes here are: (1) gave up everything, no torture, (2) withheld information, no torture, (3) gave up everything, torture, and (4) withheld information, torture. It is worthwhile pointing out that only the first outcome has the potential to support the proponent point of view (more on why only “potentially” below). In the remaining outcomes, either information remains hidden or the detainee was tortured “unnecessarily” even on the proponent view. In order to get the four outcomes above, the detainee had to believe the interrogator was pragmatic, not sadistic and the interrogator had to believe that the detainee was cooperative and not innocent. The difference between the two selective torture and the two surprise torture outcomes was driven by whether the interrogator believed the detainee had given up everything (and so did not torture the cooperative detainee) or whether she believed the detainee was withholding information (and so tortured the cooperative detainee). Thus far we have identified four outcomes of the model. Changing other beliefs results in other outcomes. Working through the different possible combinations of questioning type as well as beliefs about possible detainee innocence, interrogator type, and full disclosure results in the following possible additional outcomes: Ambiguous information, selective torture; False

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confirmation, selective torture; No information, torture; and No information, no torture. The first two of these additional outcomes occur under leading questioning only. In both outcomes the interrogator has asked a leading question and received the answer she wanted to hear. To return to our earliers example, we imagine she asked “the safe house is at 10 Maple Lane, isn’t it?” and the detainee said “Yes.” In the Ambiguous information outcome the interrogator is unsure whether the detainee is truly innocent or is cooperative and really does have information because all she heard was “Yes” to the leading question. Either detainee type might have replied “yes.” Either way, she is satisfied because she got the answer she wanted to hear from her leading question and so does not torture (though she would torture if displeased with the answer, hence the “selective torture”). The “ambiguous” in the name of this outcome captures the uncertainty about the nature of the detainee (i.e. innocent or cooperative). In the False Confirmation outcome, the interrogator actually knows the detainee is truly innocent, but just does not care because she is again happy with the false confirmation or confession she received and so does not torture him. If, however, the detainee refused to say what the interrogator wanted to hear, she would torture him. This outcome, in other words, corresponds to the vast majority of torture cases, cases in which suspected criminals are tortured for confessions rather than terrorists tortured for intelligence. The two no information outcomes occur under both leading and objective questioning. In the No information, torture outcome, neither an innocent nor a cooperative detainee believes the interrogator’s promise not to torture if the detainee cooperates and so both

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types refuse to cooperate (the resistant type never provides information).7 For her part, the interrogator believes the likelihood the detainee has information (i.e. is not innocent) is high enough for her to torture in an attempt to compel the information from what she believes is a detainee attempting to hide information. In the No information, no torture outcome, the interrogator thinks the chance that the detainee is innocent is high enough that she decides not to torture, despite not receiving any valuable information. Discussion

In the case of the innocent detainee, of course, he cannot cooperate if the questions are objective and “cooperating” under leading questioning means falsely confirming what the interrogator wants to hear.

The torture of innocents is inevitable Our first four outcomes above (Complete valuable information, surprise torture, Incomplete valuable information, surprise torture, Complete valuable information, selective torture, and Incomplete valuable information, selective torture) might seem to provide support for proponents, since at least some valuable information is provided in each outcome. Before considering information, notice first, however, that that both outcomes require the interrogator to be willing to torture an innocent detainee. The interrogator must be willing to torture any detainee who fails to provide information— including an innocent detainee—in order to credibly threaten a cooperative detainee into

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Before turning to how these outcomes compare to the necessary conditions of the normative model in section one above, it is important to note two caveats and limitations that come immediately to mind. First, I do not claim that the model sketched here captures everything about torture. Many, many aspects of torture are better captured—to the extent they can be captured at all—by victim testimonies like Gestapo torture and Holocaust survivor Jean Amèry, by paintings such as those by Khmer Rouge torture survivor Vann Nath, or by Wisława Szymborska’s ``Tortures’’ and other poetry, just to name a few (Amèry, 1980; Szymborska 1998, pp 202-203). Second, I do not even claim that the model captures everything about the effectiveness of interrogational torture for information. For example, while some victims may provide information as the result of a rational decision and expectation torture will stop, I

recognize that others may do so from a loss of control and what might be a baseless hope the torture will stop. Even here, however, the model can serve an “as-if” function, capturing victim and torturer behavior in the same way that physics models billiard balls even if players fail to make the calculations in their head. Either interpretation permits us to interrogate the logic of those who argue torture works. Thus, how do the outcomes of the analytical model compare to proponents’ claims that torture is used only against knowledgeable detainees who refuse to provide information and that once it is used, (the threat of) torture generates all, or nearly all, the valuable information possessed by those knowledgeable detainees? How do the outcomes compare to their claims that torture can be limited and regulated so that it will not be used against cooperating detainees who have provided all their information, nor against innocent detainees, nor exceed the minimum frequency and severity ‘necessary’ to elicit information from knowledgeable detainees?

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revealing information. Unless an interrogator actually tortures after failing to receive valuable information, according to the proponents’ own rationale, no cooperative detainee will reveal that information. In other words, the only way to get any valuable information (just how much we examine shortly) is to violate the necessary condition prohibiting the torture of innocents. This also, however, rules out the Torture Justification Outcome, which claims it is possible to get valuable information without torturing innocents. It is not. The only way to even make it possible to get any valuable information is to torture innocents; refusing to torture innocents means no valuable information. This necessary and inescapable truth explains why the history of torture is littered with the blood and pain of innocents. Information unreliability Although we have already found one normative condition and the torture justification outcome to have been violated, return to the four outcomes in which valuable information is provided by a cooperative detainee: Complete valuable information, surprise torture, Incomplete valuable information, surprise torture, Complete valuable information, selective torture, and Incomplete valuable information, selective torture. There are two problems for information reliability here. First, even if we count all four outcomes, then a maximum of exactly one-half of all possible outcomes result in valuable information. It is highly unlikely you would call a surgical procedure, an airplane, or your car reliable if it worked as often as a coin flip came up heads. Second, the problem is actually worse because the incomplete disclosure versions of the two outcomes mean a detainee got away with precisely that which torture was supposed to prevent: information hiding.

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Thus, we are left with two of the eight outcomes, complete valuable information, surprise torture and complete valuable information, selective torture, and so the ratio drops to one in four - unreliable indeed. It is possible to assess the reliability of information and later the extent of torture more visually. As we saw above, the outcomes depend on three crucial beliefs: the detainee’s information revelation threshold (the point at which the cooperative detainee is willing to divulge information because he believes he won’t be tortured [more] if he does so), the interrogator’s belief about whether the detainee is hiding more information or not (information hiding threshold), and the interrogator’s belief about whether a detainee who provides no information is innocent or not (innocent detainee recognition threshold). Since these are all beliefs, or probabilities, each can be arrayed on an axis from zero to one. Combining them creates a three dimensional cube, as in Figure 1. Since the cube captures the full range of all three beliefs, all of the eight outcomes inhabit this space. The entire cube represents the universe of what can happen in the model. Any particular subset of that space defined by different combinations of being above or below the thresholds marked with dotted lines is an outcome or set of outcomes. The greater the volume taken up by an outcome, the more likely it is because it is supported by a greater range of beliefs. This allows us to compare the relative space taken up by different outcomes to the total possible space and so an outcome’s relative likelihood. In particular, we will examine how much of this space is taken up by the two outcomes with complete valuable information to see how likely they are. Later we will examine how much of this space is taken up by torture to see how likely it is.

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Figure 1: Maximum extent of valuable information and torture torture outcome in green lies to the right of this plane because the interrogator believes the detainee has given up all his information and so does not torture him. Note, however, that in this outcome the interrogator would torture an innocent detainee for not providing information because, although the detainee is truly innocent, the interrogator falsely believes he is not and she is committed to torturing a detainee who fails to reveal information. This is the reason for the “selective” in the name of the outcome. If the interrogator does not believe the detainee has revealed everything (i.e. for values on the horizontal axis to the left of the solid triangle) she tortures. The detainee, however, thinks that the interrogator believes he has divulged everything and so she will not torture him. This difference in

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The region highlighted in yellow represents the Complete valuable information, surprise torture outcome and the region in green encloses the Complete valuable information, selective torture outcome, both under objective questioning. Both lie above the detainee’s information revelation threshold on the left vertical axis (which is why he provides information) and below the interrogator’s innocent detainee recognition threshold marked by the solid triangle on the right diagonal axis (the interrogator believes that if she fails to get information it’s because the detainee is lying, not because he’s innocent). The line separating the two outcomes marked by the solid triangle on the horizontal axis is the interrogator’s information hiding threshold. The Complete valuable information, selective

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beliefs is represented as the region along the horizontal axis between the empty and solid triangles. If so, then he will provide information and then be surprised when she tortures him afterward, generating the Complete valuable information, surprise torture outcome captured by the region in yellow. Including the surprise torture outcome is generous to proponents since torturing a detainee after providing full information violates the normative model’s prohibition on torturing detainees ‘unnecessarily’ and so counts against the proponent model. Thus an interpretation more consistent with proponents’ own promises to limit and control torture would slice off the yellow region represented by the surprise torture outcome, leaving only the green region, which itself violates the prohibition on torturing innocents. Even though both outcomes violate the proponent model’s restrictions on unnecessary torture, what can we say about the relative size of the regions with valuable information in yellow and green? If they took up the entire cube that would mean torture was very reliable because you would get valuable information for a wide range of beliefs on all three axes; high, low, and everything in between. Conversely consider the other (absurd) extreme and imagine the outcomes collapsed to a single point or dot in the cube because valuable information only occurred for three specific values on each of the three axes, say .34, .67 and .41. This would obviously reduce the reliability of torture quite a lot. It turns out that the proponent’s own logic provides some constraints on how large this area can be. First, consider the interrogator’s information hiding threshold marked by the solid triangle along the horizontal axis. In assuming that interrogators prefer not to torture if they can get the information they

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want, we build in costs to them of using torture. This is why it is possible that they would choose not to torture if they thought a detainee was innocent or they thought they had received all of a cooperative detainee’s information: they would bear the cost of torture with no compensating information benefit. If, as is the case in real life, these costs are very low, however, this pushes that threshold to the right so that it is past one-half. After all, an interrogator won’t worry too much about continuing to torture a cooperative detainee past the point he has provided everything he knows if her costs of using torture are low. This means, though, that the green region shrinks to the right, making it smaller and so the outcome less likely. Now consider the interrogator’s innocent detainee recognition threshold marked by the solid triangle along the diagonal axis on the lower right. Imagine for a moment you are the interrogator. Which would you think was the most likely of the three theoretically possible types of detainees—knowledgeable and cooperative, knowledgeable and resistant, or innocent? How probable is it for you that the naked, hooded, shivering, semi-starved man shackled to the ceiling in front of you is completely innocent? You will not think this is very likely. You might consider it somewhat more probable that a detainee is knowledgeable but resistant—at least so far. You are not getting anything out of him but you have confidence that your techniques will work eventually. The upshot here is that you will think the most likely type of detainee shackled in front of you will break under your torture (i.e. is cooperative) and it is far less likely that he has information but can never be broken (resistant), and finally even less likely that he is completely innocent. That, however, pushes the threshold under one-half and it

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likely to give up more valuable information than less valuable information and, consistent with the (empirically flawed) assumptions behind using torture in the first place, more pain is expected to elicit more information than less pain.8 Unlike the other two thresholds, since this one is determined by the simple ratio of information value to pain, there is no general constraint on its location. To be generous to proponents, Figure 1 pushes the threshold all the way down near zero in order to maximize the size of the yellow and green valuable information regions. Even so, however, it is clear that valuable information takes up a relatively small proportion of the total space, making it an unlikely and so unreliable outcome from torture. Moreover, the simple ratio of information value to torture means that in order for the information revelation threshold to be so far down (making the yellow and green regions larger and so those outcomes more likely), either the value of the information must be very low or, if the the information value is high, then the torture must be exceedingly brutal to compensate and still make the detainee reveal it. Finally, it is important to consider what the much larger, non-shaded area to the rear of the cube signifies: (1) truthful, accurate, but non-valuable information, (2) false and misleading information, and (3) no information whatsoever, all from a cooperative detainee who has valuable information. The latter two are particularly problematic for the pragmatic argument for

Flawed because, in fact, more pain may very well reduce the value of any information provided (O’Mara, 2015, pp 48, 106-107, 115-132; Pérez-Sales, 2016, pp 187-188, 222, 267-271). I thank Pau Pérez-Sales for enjoining me to clarify this point.

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gets closer to zero (to the front of the cube) as the probability of a resistant detainee gets closer to zero. Once again this has the effect of shrinking the green and yellow regions with valuable information by squeezing them toward the front of the cube from the back. Putting these two thresholds together tells us something about information reliability before even considering the last threshold on the vertical axis. Squeezed to the front, right corner, the green Complete valuable information, selective torture outcome cannot occupy even a quarter of the total volume of the cube. In other words, you can expect to get valuable information without ‘unnecessarily’ torturing a cooperative detainee fewer than one out of four times you use torture (and only if you are willing to torture an innocent detainee). An additional willingness to violate the prohibition against unnecessary torture and torture detainees beyond the point they have any more information (i.e. including the Complete valuable information, surprise torture outcome in the yellow region) pushes the total volume with valuable information to the left, but only a little, just under one-half on the horizontal axis, a marginal increase in reliability. Finally, take a look at the last threshold, the cooperative detainee’s information revelation threshold on the left vertical axis. For values above this threshold, the detainee reveals information (that is why the yellow and green regions are bounded on the bottom by this threshold). For values below it, the cooperative detainee refuses to reveal information because he thinks he will be tortured anyway. Consistent with the logic of torture, the detainee’s threshold for revealing information is the ratio of the value of his information to the pain of the torture. Once pain becomes the method of interrogation and all else being equal, a detainee is less

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torture. Proponents rarely factor in the costs of misleading information, of time, money, and resources diverted from actual to nonexistent threats or sources of information. Nor is the absence of information to be dismissed as merely neutral, as neither benefit nor cost. Torturing someone who provides no information also costs time and resources in addition to being ultimately ‘unnecessary’ (since it resulted in no information). Moreover, this is precisely what is not supposed to happen once torture is introduced into interrogations; torture is the method that is supposed to ‘break’ resistant detainees, to compel information they would otherwise not release. Slippery slope 1: Torture will be frequent Proponents of interrogational torture claim that the information will be valuable while ‘necessary’ torture is kept to a minimum. The total frequency of torture will be low, cooperative detainees will not be tortured long after they have provided all their information, nor innocent detainees tortured for telling the truth. We have already seen that the first part about information is false, as is the claim about innocents and cooperative detainees. What about the total frequency of torture? Once again, we can assess this claim in two ways, by looking at the proportion of outcomes in which there is ‘unnecessary’ torture as well as the likelihood of torture represented by the cube in Figure 1. Of the eight possible outcomes, there is torture of one or more types of detainees in seven of them. We have already seen that even when valuable information is provided by cooperative detainees, innocent detainees are tortured. In the surprise torture outcome a cooperative detainee is tortured after providing information, as is an innocent for telling the truth. In the False confirmation,

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selective torture outcome, the cooperative detainee is tortured for refusing to confirm a leading question. And resistant detainees are tortured in all seven for refusing to provide valuable information. From this perspective, then, torture will be frequent, not infrequent. Turning to the second, visual, perspective, notice the red-hatched region in Figure 1. This region, in front of the interrogator’s innocent detainee recognition threshold marked by the empty triangle on the lower right diagonal axis, represents ‘unjustified torture’ in one form or another: the torture of a cooperative detainee after providing information, the torture of an innocent detainee for telling the truth, or both. The complementary clear volume to the rear of the open arrow on the lower right represents the No information, no torture outcome in which no detainee is tortured. Assuming that the costs to the interrogator and the state of using torture are low, as seems reasonable, this hatched volume is just under half of the entire cube, meaning that even when torture is introduced as a supposed last resort, it will be used about half of the time under the assumption most generous to proponents— hardly limited torture. Moreover, this depends on the generous assumption that interrogators are willing to forgo torture if they think a detainee is innocent when they do not get valuable information from them (to the rear of the empty arrow on the lower right axis). Less generously but more realistically, if we think that in most cases an interrogator is likely to interpret a failure to elicit valuable information as a sign of resistance, rather than innocence, then the entire space in front of the empty arrow, where all the remaining seven outcomes are located, is taken up by torture. Either way, it seems clear, torture will be far more frequent than its proponents imagine and claim in their justification of the practice.

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from the logic of interrogational torture commit an interrogator to increasing pain, to driving down that threshold in the hope of making it more likely a detainee will talk. In other words, here too there is a slippery slope, violating proponent limits on torture’s brutality. Conclusion

There is a basic contradiction between the unavoidable premise behind the ageold logic of torture—more torture means more information—on the one hand, and the claims of those who defend a program rooted in this very same logic—torture can be minimized yet information maximized on the other hand. We have seen that neither is true. The only thing reliably effective about interrogational torture is its ability to generate slippery slopes of frequency and brutality, to escape the limits and controls imposed on it. Torture is maximized yet information is minimal. These results emerge from the proponents’ own model for how torture is supposed to work, including limits on the torture ‘necessary’ to elicit information. By tracing out the different possible combinations of detainees and uncertainties associated with interrogational torture, it is possible to generate the wide range of outcomes that we observe in the real world. This systematic approach also helps demonstrate why the tendency to justify interrogational torture as a one-off event with reference to the ticking bomb scenario, whether by utilitarian philosophers or politicians, is unhelpful. When states sanction torture, it becomes institutionalized, it becomes a system and bureaucracy of torture. A rigorous examination of interrogational torture in even a simple model complements other approaches by demonstrating how interrogational torture twists logic as well as bodies.

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Slippery slope 2: Torture will be brutal In addition to claiming that the frequency of torture across detainees can be minimized and controlled, proponents also argue that the severity or brutality or intensity of torture visited upon any one detainee can likewise be minimized and controlled to roughly that ‘necessary’ to elicit information. This, however, conflicts with the proponents’ own basic pain–information logic. Recalling that the cooperative detainee’s decision to reveal information is based on the ratio of the value of the information to the costs of the torture, consider the incentives for the interrogator. She cannot control the value of the information possessed by the detainee and she cannot know the effects of any particular torture (some detainees can withstand cramped confinement longer than others). All she can control is the severity or degree of torture she inflicts on a particular detainee. Once torture becomes the method of interrogation, her only hope of increasing the likelihood of getting information is to increase the degree of pain, to torture more. Once again it may be easier to see this visually by returning to Figure 1. Grabbing the solid arrow on the vertical left axis and driving it down is the graphical equivalent of what was just said about the incentive facing the interrogators. Driving down the threshold means increasing the ratio of pain to information in an effort to push him over his threshold; that is the only tool she has left once she starts torturing. The point is that, even discounting the very real and significant effects (1) of a sincere motivation to ‘get the bad guys,’ (2) of an organizational culturing pushing interrogators to ‘do what it takes,’ (3) of pressure from higher-ups, and (4) of psychological biases, the incentives alone

Acknowledgments I am grateful to Carol Rounds, Robert Houle, Pau Pérez-Sales, and two anonymous reviewers for their comments on earlier versions of this paper. Remaining errors are, of course, my own.

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References Améry, J. (2009). At the Mind’s Limits: Contemplations by a Survivor on Auschwitz and its Realities. (T. Rosenfeld, S. & Rosenfeld, S.P., trans.). Bloomington, IN: Indiana University Press. 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 Denbeaux, M., Denbeaux, J., Gratz, D., Gregorek, J., Darby, M., Edwards, S., Hartman, S., Mann, D., & Skinner, H. (2006). “Report On Guantanamo Detainees: A Profile of 517 Detainees through Analysis of Department of Defense Data.” Seton Hall University School of Law. Elbert, T., Rockstroh, B., Kolassa, IT., Schauer, M., & Neuner, F. (2006). “The influence of organized violence and terror on brain and mind: A coconstructive perspective”. In Lifespan development and the brain: The perspective of bio-cultural coconstructivism (Baltes, P. B., Reuter-Lorenz, P. A., & Rösler, F., eds). Cambridge: Cambridge University Press pp. 326–375. https://doi. org/10.1017/CBO9780511499722 Elbert, T., Schauer, M., Ruf, M., Weierstall, R., Neuner, F., Rockstroh, B., Junghofer, M. (2011). Zeitschrift Für Psychologie, 219(3), 167–174. Gibbons, R. (1992). Game Theory for Applied Economists. Comparative and General Pharmacology (Vol. 34). http://doi.org/10.1017/ CBO9780511791307.017 ICRC. (2016). People on War: Perspectives from 16 Countries. International Committee of the Red Cross. Geneva, Swizterland. Johnson, D. A., Mora, A., & Schmidt, A. (2016). The strategic costs of torture: How “enhanced interrogation” Hurt America. Foreign Affairs. 95(5):121-132 Johnson, J. (2016). Trump says torture works, backs waterboarding and much worse. Washington Post. February 17 Karpinski, J. (2005). Interview, Janis Karpinski, “Frontline: The Torture Question”. pbs.org. October 18, 2005. Retrieved from: http://www. pbs.org/wgbh/pages/frontline/torture/interviews/ karpinski.html.

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Maercker, A., & Forstmeier, S. (2011). Torture and atrocity sequelae in methodologically sophisticated studies. Zeitschrift Für Psychologie / Journal of Psychology, 219(3), 182–183. http://doi. org/10.1027/2151-2604/a000066 New York Times, The. (2017). “The Guantánamo Docket.” Retrieved from: https://www. nytimes.com/interactive/projects/guantanamo/ detainees?mcubz=1. O’Mara, S. (2009). Torturing the brain. On the folk psychology and folk neurobiology motivating “enhanced and coercive interrogation techniques.” Trends in Cognitive Sciences, 13(12), 497–500. http://doi.org/10.1016/j. tics.2009.09.001 O’Mara, S. (2011). On the imposition of torture, an extreme stressor state, to extract information from memory: A baleful consequence of folk cognitive neurobiology. Zeitschrift Für Psychologie / Journal of Psychology, 219(3), 159–166. http://doi. org/10.1027/2151-2604/a000063 O’Mara, S. (2015). Why Torture Doesn’t Work: The Neuroscience of Interrogation. Cambridge, MA: Harvard University Press. Pérez-Sales, P. (2016). Psychological Torture: Definition, Evaluation, and Measurement. Philadelphia: Taylor & Francis Group. doi. 10.1097/ WTF.0000000000000152 Rejali, D.M. (2007). Torture and Democracy. Princeton, NJ: Princeton University Press. Rumney, P.N.S. (2014). Torturing terrorists: Exploring the limits of law, human rights and academic freedom. London: Routledge. Schiemann, J.W. (2016). Does Torture Work? New York: Oxford University Press. Szymborska, W. (1998). Poems new and collected, 1957– 1997. (Stanislaw Baranczak and Clare Cavanagh, trans.) New York: Harcourt Brace & Co. United States Senate. (2014). Select Committee on Intelligence Study of the Central Intelligence Agency’s Detention and Interrogation Program, Findings and Conclusions, Executive Summary. Washington D.C.: United States Senate. Approved December 13, 2012, Updated for Release April 3, 2014, Declassification Revisions December 3, 2014. Retrieved from: http://www.intelligence.senate. gov/study2014/sscistudy1.pdf.

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Related to ‘Tortured logic: Information and brutality in interrogation’ by John W. Schiemann. (pages 64 to 78) Comment I Old sins cast long shadows: Further reflections on the power of rapport over retributive Interrogation. Laurence Alison*, Emily Alison*

*) Critical and Major Incident Psychology, Psychological Sciences, University of Liverpool. Correspondence to: L.J.Alison@liverpool.ac.uk

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Schiemann’s article is a refreshing and welcome take on the arguments for and against torture. The notion of using a dendritic set of outcome options based on inputs that relate to reliability, sadism, limits and control is a useful way to approach the problem. His argument that, taking all these features into account results in the logical outcome that it should never be used is a compelling one. However, we do think, nuanced though that argument is, other things need to be taken into account. For too long the scientific debate has been polarised into one of moral outrage at even contemplating ‘harsh’ methods without providing an alternative solution. More recently, evidence has been found for ‘rapport based’ methods that supply a viable, ethical strategy (Alison and Alison, 2017). To be clear, our view is that, on moral grounds, it is repugnant and should never

be contemplated. However, as scientists, we also need to consider the scientific merits of any proposed ‘method’ for extracting information. There is a moral argument and then there is a scientific argument and too often the two have been conflated. So, Schiemann’s logical, decision tree analysis is very welcome. However, there are some additional points we would wish to make. The Mitchell and Jessen post 9/11 enhanced interrogation techniques are an important one to consider (Mitchell and Harlow, 2016). For example, with regards to Mitchell and Jessen’s ‘methods’ they claim that they did not extract information from Khalid Sheik Mohammed during the waterboarding sessions but rather after them, when he was asked to consider giving information to avoid such an experience happening again. Indeed, Mitchell claimed to be a strong proponent of rapport based methods, though he regularly uses dismissive terms such as ‘tea and sympathy’ to describe them. His argument was that inducing learned helplessness could encourage a detainee to cooperate and it was after inducing this state, through the enhanced interrogation techniques that the detainee would then be more amenable to the ‘rapport’ based methods. Thus, the argument was not that torture worked ‘in the moment that it was being used’ but that, effectively, it ‘softened’ the detainee up in order to presumably become more ‘susceptible’ to the rapport based methods. In order to really understand the efficacy of torture techniques, we do need to engage with and thoroughly consider the arguments put forward by torture proponents. In considering whether there are scientific arguments that support torture, it does not mean we lose the ability to see the immoral reasons why torture should not be used. Instead, we need to fully consider

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the counter arguments that might be put forward by torture proponents. These include the following (not exhaustive) list: • If it doesn’t work, why do we find ourselves repeatedly using it? • Torture is not expected to work at the time of doing it, but rather to soften the detainee up to make him/ her more amenable to rapport based methods • As a general rule, we should not torture but there may be some occasions (e.g. ticking time-bomb argument), in some desperate situations and with certain types of detainee where it might be necessary. The first question is an interesting one. Alison and Alison (2017) and Carlsmith and Sood (2009) have argued that one motivation is surely retribution with no real ambition to seek information at all. This notion emerged as long ago in the 16th century to justify the trial and execution of men, women and even children for witchcraft. In many cases, the principle purpose was to rid communities of problematic individuals (Gaskill, 2005). In essence then the end goal is not information but publically condoned retribution. One cannot help think that during times of national crisis a key motivating force is to exact revenge. Sternberg (2003) has carefully considered the role of hate as a specifically directed emotion that begins with (i) generation of hatred and disgust at the target group, (ii) anger and a sense of ‘them and us’ (iii) contempt and, finally (iv) punishment for those that do not support the in group. In such cases torture does ‘work’ to extract reliable intelligence or informationit works to enact retribution on those who have wronged. The interrogators become the vehicle through which we make that retributive act. The second statement argues that the torture itself didn’t work other than to show that these phases can be stopped and to then

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offer an ‘out’ to a ‘softened’ up detainee. We think this argument, although marginally more nuanced than the over simplified model that some of the anti-torture camp have caricatured it as, still fails to hold any logic. The argument seems to be that what an interrogator offers the detainee is the following, ‘this doesn’t have to happen again—have a think about whether you want to tell us about X and if you do, you then won’t have to be subjected to this again’. Thus, the notion is of torture + threat + contemplation period = consideration that it may be best to talk. This avoidance of aversive stimuli in exchange for information is, in our view also highly problematic. First, and as per Schiemann’s very sensible train of thought, what guarantees does the detainee have that it will indeed stop if information is forthcoming? Second, why not lie about the information in order to avoid giving up key information? Third, even if the detainee tells the truth will s/he be believed and if not will the torture resume? Fourth, even if the detainee tells the truth, what happens if more information or more details are required? In such an instance, do we go back to the pattern of torture + threat + contemplation? These detailed other decision paths need to be considered and, indeed, we are in the process of doing so (Surmon Bohr, Alison and Alison, In Preparation, 2018). However, our analysis always results in the same outcome—namely a zero-sum game in which no one wins, since neither the detainee, nor the torturer can know in advance and for certain what each other’s’ next move will be. The final statement suggests a greater degree of reserve in the use of torture. Namely, it intimates that it should only ever be used as a final resort when the stakes are high and all else has failed. Tempting though that may be (especially in desperate times), it offers only a short term solution (at best)

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to an organisation and country’s reputation, a transgressive act from which the interrogator may never recover and terrible psychological and physical consequences for the detainee. The adage of ‘old sins cast long shadows’ is especially relevant to the history of torture and so, whilst we accede to the notion that through rapport you cannot always make things better, with torture, you most certainly can make things worse. References Alison, L. & Alison, E. (2017). Revenge Versus Rapport: Interrogation, Terrorism, and Torture. American Psychologist, 72(3) 266-277. DOI 10.1037/amp0000064. Alison, L., Alison, E., Noone, G., Elntib, S., & Christiansen, P. (2013). Why Tough Tactics Fail and Rapport Gets Results: Observing Rapport-Based Interpersonal Techniques (ORBIT) TO Generate Useful Information from Terrorists. Psychology, Public Policy and Law, 19, 411-431. DOI 10.1177/0093854815604179 Cobain, I. (2013). Cruel Britannia: A Secret History of Torture. Portobello Books. Carlsmith, K. & Sood, A. (2009). The Fine Line Between Interrogation and Retribution. Journal of Experimental Social Psychology, 45, 191-196. DOI 10.1016/j.jesp.2008.08.025 Gaskill, M. (2005). Witchfinder: A Seventeenth-Century English Tragedy. London, United Kingdom: John Murray. Mitchell, J. E. & Harlow, B. (2016). Enhanced Interrogation: Inside the Minds and Motives of the Islamic Terrorists Trying to Destroy America. Penguin Random House.

Comment II Glenn L. Carle* For nearly twenty years now, I have spoken of my involvement in the “Enhanced Interrogation Techniques” (EIT) Program,

*) former National Intelligence Officer for Transnational Threats, career CIA officer and interrogator of a High Value Detainee

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and even then, one where the reliability of each piece of ‘life saving intelligence’ is unknown. In Cobain’s (2013) very eloquent book ‘Cruel Brittania’—an extensive coverage of the history of the use of torture by the British, he does allude to the notion that some (and note the word ‘some’) information may have been extracted through torture (though the book is strongly anti torture in its general tenor). For example, he notes some information did come from detainees in the second world war London Cage, the five techniques used in the Mau Mau uprising as well as in the Troubles in Northern Ireland in the 1970s. However, there are two separate, but critically important counter arguments that still question the argument of ‘sometimes and only in extreme circumstances’. The first is a very simple one: where is the evidence? Although several books, authors and interrogators indicate their torture based methods worked, our request remains, ‘show me’. We have been fortunate enough to observe countless hours of field interrogations and all we have ever seen is rapport working. Even mild sarcasm has a deleterious effect (Alison, Alison, Noone, Elntib and Christiansen (2013). We are quite prepared to adjust our rapport based model if we can be furnished with a sample of audio or video clips showing enhanced interrogations working but the data from those that espouse and defend those methods has never been forthcoming. It may be hard for us to submit to evidence to the effect of torture on moral grounds but if we see it working we will say it works. No one has been in a position to say this so on those basic most fundamental principles of ‘convince me by showing me’ - there is nothing. The second point relates to what we call the ‘long interrogation game’. There are countless examples of the consequences of torture as a recruiting tool for extremists, a massive blow

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trying to show the American public how the United States unnecessarily betrayed its values, deluded and lied to itself about what it did, and changed its culture and institutions for the worse. Atavistic demons of torture possessed us and made us a cruder society, and a spurious ticking time bomb scenario seduced us to betray our values. John Schiemann’s Tortured Logic: Information and brutality in interrogations coolly and rationally demonstrates to us how the EIT program is founded on faulty assumptions, and how the arguments of its proponents themselves demonstrate that the program’s premises guarantee that torture become frequent and progressively brutal, once accepted as a “useful” tool of interrogation. Schiemann shows this through a game theory analysis of possible behaviors by detainees and interrogators. Game theory was far from our minds when I was interrogating my detainee, and yet Schiemann’s analysis of the motives and calculated actions of detainee and interrogator, acting within a framework calling for torture in various circumstances of cooperation or resistance by a detainee, brought the tragic pressures my colleagues and I dealt with painfully back to life. Schiemann accurately captures the nearly irresistible dynamic that leads to torture once “EIT”s have been accepted as a legitimate technique, and he dispatches the falsehoods used to assert that torture can extract useful information and yet be limited in extent once begun. It does not, and it cannot. I note with tragic irony that, literally, Schiemann engages in cooler, more, and deeper analysis of the rationales, costs, and benefits (sic) of “enhanced interrogation”— torture—than occurred in the entire CIA throughout the Enhanced Interrogation Program. This devastating point also emerges in the historically important,

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and utterly accurate, Senate Intelligence Committee Report on Torture. My one surprise in reading the Senate Report was to discover how widely-shared was opposition to the premises and practices of the EIT program among those of us involved in it, as was the conclusion that EITs were ineffective, illegal, counter-productive, and mindless. Schiemann’s conclusions do not surprise me, as they mirror those I reached as I struggled with how to conduct an honorable, legal, effective interrogation. His analysis, however, surprises by so easily tearing down the Potemkin Village rationale of those defending the need for and utility of torture. But Schiemann brings reason to an argument of faith; the cerebral cortex and reason are so often powerless confronted with the amygdala and atavism. His logical proofs will not change the minds of torture’s defenders. It should, however, shift the trajectory of the debate going forward for those who will respond to tomorrow’s existential moments. Schiemann examines eight possible outcomes in the dynamic between interrogator and detainee in an “EIT” program. The outcomes range from the detainee providing completely valuable information without torture, or from it; to providing incomplete but valuable information without torture, or from it; to ambiguous information, falsely confirmed information, no information… Each of the eight outcomes is a function of whether torture was used extensively, selectively, or not at all. The conclusions of the analysis are simple and, in my experience, spot on. When torture is part of an interrogation doctrine: 1) The torture of innocents is inevitable 2) The information provided is unreliable 3) Torture will be frequent and increase to universal use, despite the claims of the

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EIT program’s proponents that it would only be used when necessary 4) Torture will be progressively brutal

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The game theory analysis of whether to torture, what to do in the event of one response by the detainee or another, however, is more thoughtful than was the practice in fact. Detainees were assumed to be “guilty”—to have critical information— because they were detained. Therefore, EITs would be used as a matter of course. Otherwise, the detainee would not have been brought into the detainee, EIT program. Guilt and innocence were not part of any interrogation equation. Further, I often struggled against the explicit “guidance” that the lack of an answer by the detainee on a given question “proved” that he was withholding information, and that, therefore, I had to increase “pressure” on the detainee so that he would provide the information he was withholding. My retort that the detainee’s lack of answers to specific questions, in my assessment, often (not always) indicated that the detainee did not know the answers, and was responding truthfully, was taken as proof that I had “fallen in love” with my detainee; I should focus, instead, on forcing the detainee to provide the information his lack of answer proved he was withholding. My further protestations that this response was stupid and irrational (something like “asserting that his professed lack of knowledge proves he is withholding information does not, ipso facto, prove that the detainee knows the information and is withholding it. I assess that he answered truthfully…”) simply tarred me as an apostate. I have pointed out elsewhere that the typical response of clergy to such jarring doctrinal challenge is to burn the apostate, not reexamine the doctrine.

This recurring argument with the EIT program’s masters raises a key dynamic that Schiemann’s game theory analysis, and his assessments, underemphasize. It can only be so, since Schiemann is rational and analytical (and his assessments accurate.) Kafka was far more important to the genesis and running of the EIT program than was any analysis of whether EITs—torture— made any sense. In The Trial Kafka captures the dynamic that obtained in the EIT program: “No,” said the priest. “It is not necessary to accept everything as true, one must only accept it as necessary.” CIA’s— the US Government’s—EIT program and, indeed, much of the US Government’s “War on Terror,” was atavistic and visceral, not a rational response to a terrorist threat, or to how to conduct a successful interrogation. The reasoning among many was that the nation was under threat, the institution had decided to engage in EITs, the government stated that EITs were not torture, so therefore they were not torture. Assessing varied outcomes of interrogation, under various assumptions by detainee and interrogator—this was far beyond any prepared approach, or subsequent analysis, of whether to engage in EITs or whether they worked. The program was the program, detainees had information because they were detainees, and therefore one would use EITs on them. As I was literally told once when I was trying to place a specific terrorist group’s actions in a regional context: “Sociology is great, Glenn. But this is not a graduate school seminar. Just find me the f---ing terrorists.” There was another defining component to the EIT program: The rightly infamous “one percent doctrine.” The one percent doctrine, evinced by Vice President Cheney, in the context of counter-terrorism operations and interrogations, held that

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the US must act as though the individual were guilty, even if there were only a “one percent” chance that an individual was what we apprehended might be the case. I saw, I heard, this doctrine invoked as our operative guidance over and over, sometimes sincerely, sometimes as what I took to be a thin rationalization to exculpate one party or another. Given this, it was certain that any detainee considered an HVT, or a threat (which, by definition, a detainee was) would be subjected to EITs. Careful assessments of game theory possibilities were beyond the reality we all lived. A detainee was part of the one percent, surely, and surely would be subject to EITs. Schiemann rightly debunks the assertions of the EIT program’s proponents: That torture gives reliable information and that torture can be controlled. He does not note, however, two important and telling points: First, the only “proponents” of the EIT program are the Bush administration and CIA officials involved in the program’s conception and management and, second, all supposed defenses of the program’s efficacy and success have been made ex post facto. These views were not strongly advocated at the time, but have been made since to justify a program that clearly violates numerous American and international laws—whatever the ratiocinations of the political hacks who drafted the infamous “torture memo” which provided legal cover for the program (“We’re okay. We’re covered” I was told at the time, when I asked, among other things, “But what about the Geneva Conventions?”…) Proponents repeatedly cite the mantra of the “twenty” terrorist operations that information obtained from EITs enabled the CIA and FBI to stop. But, without going into classified information, it has been shown that these twenty terrorist operations (sic) either were stopped without EIT-

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provided information; or more frequently were vastly overblown in how they were presented to policymakers (it should be noted that both senior CIA officers and senior Bush administration officials were frequently sold, frankly, a false, although often sincerely held, narrative by the counter-terrorism bureaucracy of the CIA. But that is a separate, albeit critical, story.) To my knowledge, none of the twenty terrorist operations stopped by the CIA and FBI had anything to do with information provided by EITs, and I was in as good a position as most anyone to know what we knew, and how we knew it. As I repeated and repeated during my years working on the “War on Terror”: “The closer one looks, the less one sees.” And, the closer one looks at EIT-produced information, the more one sees that Schiemann’s assessment gets it right: torture provides bad information, to which I add: torture also perverts the US as a nation, replacing law and reasoned action in the national defense, with an atavistic series of assumptions and actions, which harm us more than protect us. Game theory can seem bloodless to those studying international relations. Perhaps. But, in this instance, at least, it has exposed the fraud of the defenses made of EITs—of torture. If we take Schiemann’s insights to heart, we can undo some of the harm the EIT program—we—have donre to ourselves. Comment III Hans Draminsky Petersen, MD.* I should start with the admission that I have little or no knowledge of game theory and

*) ex-member and vice-chair of the UN Subcommittee on Prevention of Torture (SPT)

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threshold the detainee is believed to not retain information and consequently torture should not be used. This, however, is not the case since the green segment to the right of the threshold (Figure 1) includes innocent detainees who cannot give information and therefore are tortured. I find this in conflict with the concept of a threshold. In the text it is explained that the rear segment in the figure includes cooperative detainees who give no information whatsoever. I cannot understand how such a detainee can be classified as cooperative. These issues therefore put me in doubt of whether I have understood the model correctly. Conceptual reservations: It is assumed that the victim is in a constant dialogue with him or herself assessing all the time how far s/he will continue without giving all the information s/he has, while realising that the price for not giving the required information will lead to continued torture and while assuming that giving information - the whole or parts of it - will mean an end to torture. (S/he may well be disappointed to see that torture continues after having given the information, cf. below and the paper.) However, this bargaining with him or herself in a rational manner does not quite fit my understanding about how this kind of torture works. In particular, for the innocent X who happened to be detained, perhaps because another innocent Y under torture was forced to denounce others and happened to mention X’s name. For the innocent X, and probably for the majority of torture victims according to the author’s quoted literature, logic and bargaining are not relevant issues. Contrary to the picture portrayed here, I believe that most often in intelligence interrogation the strategy is twofold: (1) to make the (guilty) victim give up values; and,

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this may well be the reason why I find some elements of John W. Schiemann’s article Tortured logic: Information and brutality in interrogation illogical. However, since it can be assumed that most readers of the Torture Journal lack knowledge about game theory, my observations and response to the article may be relevant. The model described in the paper only deals with torture scenarios where the objective is to obtain key intelligence information and not with the vast majority of torture cases where obtaining confessions from criminal suspects is the objective although that problematic is mentioned briefly and put into the context of the model. The model works with the three dimensions of a cube (Figure 1). Each of the three axes have thresholds: the detainee’s threshold for revealing information; the interrogator’s threshold for believing that the detainee is hiding information; and the interrogator’s threshold for believing that the detainee is innocent. Together these three thresholds demarcate sections of the cube, which are described as outcomes of interrogations; obtaining from the detainee all or part of the desired information as replies to leading or open-ended questions in conjunction with torture, leading to more torture or to the end of torture. The author explains that by moving the thresholds and thereby changing the sizes of the segments, the likelihood of obtaining reliable information without having to use torture unnecessarily can be estimated. Some reservations as to the logic of the model: One of the dimensions in the figure deals with the interrogator’s belief that the detainee is hiding information. A threshold for the interrogator is indicated; to the left the detainee is believed to retain information, which consequently calls for torture. I infer that to the right of the

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(2) to reduce his/her discernment by way of applying a battery of psychological and physical torture methods simultaneously and successively (well aware that from the outset all innocent people cannot be selected out and hence, some will have to be tortured). The Inter-American Convention to Prevent and Punish Torture states, inter alia, in its definition of torture that: “Torture shall also be understood to be the use of methods upon a person intended to obliterate the personality of the victim or to diminish his physical or mental capacities, even if they do not cause physical pain or mental anguish.” Obliteration of the personality surely means that the person loses their integrity, gives up their values and “betrays” their political ideals, their friends and fellows in the organisation that they belongs to. I don’t see this as a matter of the victim bargaining with himself, but as a break-down. Diminishing the mental capacity means the loss of discernment and not knowing exactly what is happening and what s/he is doing or saying, which is far from what in other contexts would be regarded as rational reasoning. Logic in the normal sense does not apply for the victim. The aim of torture is that the victim looses all control at both levels. In the author’s model it is assumed that the interrogator’s questions can be divided into two categories: leading questions to which the only possible answers are “yes” or “no” and “objective”/open-ended questions. The two types are kept as separate from each other in the model. It is further assumed that innocent detainees, i.e. those who have no information, cannot answer objective questions. I believe that the interrogation is different; the detainee is bombarded with both types of questions simultaneously making the distinction illusory. Moreover, unfortunately the innocent detainee can

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in fact answer objective questions, e.g. give names of real persons who - falsely - are claimed to be implied in the crime under investigation, which reflects the break-down of the detainee, cf. above. But naturally, the innocent cannot provide useful intelligence information. The conclusions of the study are clear. Some valid points are made about the dynamics of intelligence torture which are worth remembering; they are in accordance with common sense and with what we know and what is reported /quoted by the author: If torture is used to obtain “necessary information”, e.g. to prevent terrorist acts or to fight organised crime, it has to be accepted that some persons with no affiliation to the criminals and having no relevant information are tortured since the interrogator can not know in advance which role and information the individual suspect has. Likewise, the interrogator cannot know exactly when in the process of interrogation and torture the victim has given all the relevant information he has; hence, it is very likely that the interrogator continues the torture after having obtained all of the detainee’s information. Moreover, at that point the interrogator may very well increase the intensity of torture because of the logic of torture: information will be obtained by way of torture, hence, if (additional) information is not obtained more torture must be applied. Furthermore, the interrogator is faced with the difficulty of assessing the validity of the information obtained, having to sort out the valid from the fabricated, misleading and useless. Accepting torture under certain circumstances will lead down a slippery slope and imply that a lot of innocent people will be tortured. Frequency and brutality of torture cannot be kept under control.

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The well-known arguments against torture suffice: Torture is a crime under international law. It is very harmful to the victims, to democracy and to the torturers. But it is reassuring that the model, just like the analysis of the ticking bomb scenario, comes out with results that fit to our common arguments. Response by the authors John W. Schiemann PhD* I appreciate the careful reading of my paper by all three commenters. I recognize that my paper is unusual for the Torture Journal in both argument and method. As a result, I am all the more grateful that practitioners from very different fields took the time to work through my paper. All three make good points and I welcome the opportunity to respond, even if only very briefly. All the reviewers agree—and I with them—that torture is morally repugnant, illegal and should be prevented irrespective of efficacy. Thus, while we might all agree with Hans Petersen that “[t]he well-known arguments against torture” should “suffice,” we also know that unfortunately they have not. Hence my attempt to, following the Alisons, “fully consider the counter arguments … put forward by torture proponents” and confront them directly using their own logic. Of course, this approach is not without its own problems and limitations, and I respond to the three sets of comments in turn.

*) Department of Social Sciences & History, Fairleigh Dickinson University, Madison, New Jersey. Correspondence to: jws@fdu.edu

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All of this goes against the arguments and assumptions of proponents of torture that reliable information can be obtained by way of torturing without having to torture innocent persons and without exceeding controlled limits, i.e. torture will not be more brutal than strictly necessary and will end when the information is obtained. Schiemann’s model has many similarities with the “ticking bomb scenario” where the preconditions, however, are extremely simplistic: (1) we know that a big terrorist attack will take place; (2) we have detained a person and we know that he is one of the perpetrators; (3) we know that he has the one piece of information necessary to prevent the attack; (4) we know that he will only give us the information if we torture him; and, (5) once having obtained the information we will be able to recognise it as the key we need to prevent the attack and torture will stop. The model described here is much more realistic: The torturer does not know whether the detainee is innocent or has the information required to prevent the crime; the torturer will not know if obtained information is the key to the resolution of the problem. When comparing the analysis of the ticking bomb scenario with this scenario based on game theory, the only consideration that was new to me was that it is likely that the detainee will be tortured even harder after having given all the information he has because the torturer is not able to immediately realise that he has got all of the victim’s information. However, a somewhat similar reasoning exists in the ticking bomb scenario where it is inferred that the victims who have no information to give are likely to suffer most torture. Hence, I am not quite convinced that the application of game theory in the torture scenario has provided substantial new information.

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Response to the Alisons. The three questions raised by the Alisons are often asked and so good ones to raise here. I don’t disagree with their answers, but would add some further considerations to the first two. With respect to why torture continues to be used despite its ineffectiveness, there is an additional explanation beyond retribution: what I called in my book the dangerous seduction of intuition. We have all felt pain and so we can all imagine being subjected to it and deciding to give up information to avoid (more of) it. The trouble is that intuition sometimes leads us astray and there is both observational and experimental evidence that people are able to withstand more pain than they anticipate ex ante. As to the argument that torture is only supposed to “soften up” detainees so that rapport will elicit information later, the points made by the Alisons’ are more or less those I make in my article and my book and so I agree. What I would point out in addition is that the Mitchell/Jessen program was pure theory. The Senate torture report makes it very clear that the torture as actually practiced differed little from its historical predecessors, with information sought at the time of torturing. Finally, the Alisons are, in my mind, spot on with their two counterarguments to the ticking bomb justification. Response to Carle. One dimension not captured by the model, Carle points out, is the Kafkaesque nature of the decision to use torture in the first place and the subsequent bureaucratic inertia to continue using it. Moreover, I, like Carle, noted that the Senate report revealed how much resistance to the program there was within the CIA and how many sincere but perhaps originally reluctant believers had been hoodwinked by others within the

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CIA. Together they constitute a critical, but untold story deserving of further research. It remains, however, very gratifying that the empirical experience of a real interrogator supports the more abstract model in multiple dimensions, from the strategic dynamic between detainee and interrogator to the the assumption by headquarters that a failure to provide information means the detainee is hiding information. My model gave the proponents every benefit of the doubt; Carle’s testimony shows that gift is far too generous and so the worst outcomes are all the more likely. Response to Petersen. I believe there may be some misunderstanding of the model and its purpose insofar as the torture of an innocent does not conflict with the concept of a threshold because there are different thresholds for cooperative and innocent detainees in objective questioning. I hasten to acknowledge, however, that the responsibility for any such misunderstanding rests with me and my failure to clearly explain the model. I appreciate the two conceptual points about the reality of torture conflicting with the model’s portrayal of the victim’s running inner dialogue as well as the distinction between objective and leading questioning. Even so I believe there are both broader and narrow caveats relevant here. First and more broadly, it is important to bear in mind both the purpose and nature of a model. Models simplify reality in order to identify and explicate important mechanisms or processes. Just as a wind-tunnel model of an airplane does not account for distasteful food, but attempts to model accurately flight behaviour, my model fails to capture every reality about interrogational torture in order to assess the proponents’ argument on its

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own terms. Proponents believe that a torture victim will eventually “decide” to give up information under threat of more pain and misery and so the model reflects that; it is not meant, nor does it claim, to be an accurate phenomenological representation of what it means to be tortured. Second and more narrowly, my reading of accounts and memoirs of torture and the realistic but variegated outcomes of my model together suggest that the model’s simplifications are reasonable. Some torture victims actually do seem to go through something resembling that inner dialogue. The distinction between objective and leading questioning is not illusory— otherwise there would not have been rules and regulations on leading questions littered throughout the history of torture. Nor is it unhelpful insofar as the distinction helps bring out how easy it is to get bad information from leading questions and how innocents will be tortured under objective questioning. Indeed, Glenn Carle’s response makes clear that the assumptions of the model, however spare, are reasonable and accurate and tracing out their consequences is valuable even if it fails to capture everything about interrogational torture, let alone torture generally.

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Torture was gradually excised from Continental European judicial systems from the sixteenth to the eighteenth centuries as a result of both arguments about human rights from Enlightenment philosophes as well as doubts about torture’s efficacy and necessity within a changing system of legal proof. Today, combining these efforts in rigorous arguments against torture’s efficacy may be the best way to push torture back into the dark recesses of history—where it belongs.

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Australian immigration detention and the silencing of practitioners

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April Pearman, B.PSYCH, BA*, Stephanie Olinga-Shannon, BAPS/BA (Hons),*

In recent years, the Australian Government has framed the arrival of asylum seekers by boat as a national security risk and the policy of stopping ‘unauthorised maritime arrivals’ has been used extensively by various political parties in their election campaign platforms (Phillips, 2017). Media coverage has reinforced this framing with the portrayal of asylum seekers arriving by boat as economic migrants and threats to Australian society and security (Blood, 2011; Bleiker et al, 2013). The Australian Border Force Act 2015 (the Act) merged the immigration and customs department and introduced weapons and uniforms for some employees. Importantly, the Act also introduced secrecy provisions that are further eroding the humanitarian response to asylum seekers. Whilst the restrictions with respect to health professionals have now been lifted, the attempt to effectively gag workers who witness conditions in places of detention still begs the question: why the lack of transparency? Under the ‘secrecy provisions’ of the Act, ‘entrusted persons’ (any persons employed by the Department of Immigration and Border Protection (DIBP) or subcontracting to the department) who disclose ‘protected information’ (any information obtained in *) Association for Services to Torture and Trauma Survivors (ASeTTS), Perth, Australia.

their capacity as an ‘entrusted person’) can face criminal conviction and a maximum of two years imprisonment (Australian Border Force Act, 2015). The law applies to immigration detention centres both on the Australian mainland (known as onshore immigration detention centres) and those centres in Papua New Guinea, Nauru and on Christmas Island that house asylum seekers who were attempting to reach the Australian mainland by boat (known as offshore immigration detention centres). Under the Act, entrusted persons are able to report any incidents to the DIBP officials and it is assumed that this will be sufficient in fulfilling any ethical or professional reporting obligations. Health professionals, including ASeTTS’ counselling staff, were included in this category from 1 July 2015 until September 2016, at which point the government quietly changed the law to avoid further detrimental publicity. However, it remains in force for teachers, social workers not working as counsellors, and other professionals working in immigration detention centres. Prior to the introduction of the Act, all staff working in detention centres were able to advocate for the needs of their clients inside detention centres, to DIBP officials, as well as more widely. Clearly, this is necessary to avoid potential abuse of individuals and human rights violations

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Impact on health professionals everyday work and research

Immigration detention has always been a very challenging work environment for practitioners. Ethical and boundary dilemmas are a constant feature of this working context. To witness daily the plight

of asylum seekers is devastating, with the average period of time for people held in immigration detention centres currently 440 days (DIBP, 2017b). For practitioners, to assist detainees in regards to their traumatic pasts, whilst being acutely aware of their current life challenges, including a highly triggering environment, which is counterproductive for trauma recovery can feel like the provision of a sub-standard service. This is not unlike the practice of doctors in wars patching up troops to send them back out to battle. Counsellors can have feelings of guilt when leaving the centre each day, in full knowledge that their clients do not currently share the same human right. The Act added another layer on top of these existing dynamics, making work in immigration detention even more complex, as it criminalised actions that were previously viewed as appropriate professional behaviour. The Act left health practitioners in a double-bind. In Australia, as elsewhere, psychologists and counsellors register with professional associations that monitor their professional conduct. Registered psychologists adhere to the Australian Psychological Society (APS) Codes of Ethics and must, for example, report to the relevant authorities criminal activity or the abuse of minors (Australian Psychosocial Society, 2007). If they do not, they can face professional investigation with consequent de-registering from their professional body or face a criminal conviction with a maximum two years’ imprisonment. However, under the Act, psychologists were unable to report to anybody other than the DIBP. If a psychologist reported, for example, abuse to the police, they could therefore have faced two years' improsonment and a criminal conviction under the Act. A criminal conviction can also have ramifications for future employment, travel and residency in

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(witnessed or reported), as well as to allow for mandatory reporting issues or whistle-blower situations. Assaults and deaths of asylum seekers in immigration detention centres are known to have occurred (Australian Human Rights Commission 2014, Procter et al 2013). Crucially, practitioners and others have been able to provide important information to the Australian public about the living conditions, treatment of asylum seekers and incidents of violence in immigration detention centres as well as to the Australian Senate, United Nations and Human Rights Commission inquiries and the media, amongst others. This is of particular importance as immigration detention centres in Australia are often located in extremely remote areas with limited public access and as the Australian Government releases limited information about the centres beyond a monthly statistical report detailing the number of detainees, their basic demographic information and the duration of their detention in these centres (see DIBP, 2017a). Information provided by practitioners is therefore not only important with respect to the individual protection of asylum seekers, but also for accountability and the improvement of public policy. With information restricted beyond the walls of the detention centres, harmful events can be covered up: there is a significant risk created by the ‘blind spots’ in transparency and accountability created in the name of ‘border control’.

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Australia and overseas. Under Austrialian law, a conviction of one year’s imprisonment or more may result in deportation for practitioners who are not Australian citizens, even if they hold permanent Australian residency, and potential loss of registration. The potential penalty imposed under the Act can therefore prevent practitioners from speaking publicly about the situation or treatment of asylum seekers in immigration detention centres. The Act also impacted the effectiveness of advocacy and research carried out by health professionals. ASeTTS and other rehabilitation centres draw on staff ’s experiences inside immigration detention centres for submissions into public inquiries, such as, the Australian Human Rights Commission’s 2014 National Enquiry into Children in Immigration Detention and various consultations on asylum seeker wellbeing. Whilst ASeTTS could and did continue to support asylum seekers rights publicly, it was no longer possible to draw on practitioner experiences inside immigration detention for advocacy work whilst the Act was in place. The Act functioned as a ‘gag order’ for service providers, advocates and researchers. It was unclear whether data collated in immigration detention could be shared with research partners and ultimately in publicly available research. Large datasets of mental health assessments collected inside immigration detention centres are rare but necessary to inform evidence-based public policy decisions relating to asylum seekers (Killedar and Harris, 2017). For ASeTTS, publishing such research is of course intended to inform and influence public policy and is integral to broader systemic advocacy for the needs and rights of clients. As it was a new law, there is no legal precedent, so for

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the first time, practitioners, organisations and university researchers had to consider the legal implications of making information public. This had a direct impact on slowing down research projects and information dissemination plans. Furthermore, the law targeted individuals so there was combined personal and organisational risks associated with operating in a manner that was considered ethical prior to the introduction of this new legal framework. Reaction to the Act

The introduction of the Border Force Act was met by a significant public outcry from relevant professional associations and their members such as the APS, Australian Association of Social Workers (AASW) and the Australian Medical Association (AMA). These groups protested against the law and engaged in various forms of opposition via public statements, public protest, and in some instances, doctors refusing to release patients from hospitals back to immigration detention centres (Dudley, 2016). The AMA led the legal fight against the Border Force Act in the High Court of Australia. A few days before the case was to be heard, the Australian Government decided to legally settle with the AMA, and exempt ‘health professionals’ rather than have the case heard in the High Court, which would have exposed the design process of the law (Hall, 2016). The Border Force Act was deliberately quietly amended to exempt ‘health professionals’ with minimal communications regarding the amendment and provoked limited media attention. This episode, although thankfully shortlived for health professionals, made us and other practitioners question the boundaries of whether ethical services can continue to be delivered under such circumstances. More importantly perhaps, it underlines the

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importance of being able to speak publicly about what is seen or heard in immigration detention. Although the exemption granted to health practitioners occurred in September 2016, the issue remains for practitioners who are not exempt, such as social workers. That such a law was possible in a liberal democracy such as Australia exemplifies the erosion of ethics in immigration and sets a dangerous precedent for other countries (Jakubowicz, 2016). The Border Force Act was passed with support from the opposition, Australia’s other major party the Australian Labour Party (ALP) (known as bi-partisan support). This signals that, even if a different government takes power, the Act is unlikely to change. The law is a further example of the ‘race to the bottom’ for other democratic countries at a time when there are more people seeking asylum globally than ever before (UNHCR, 2017). What is perhaps even more disturbing, the Act echoes the same degradation of human rights and practice of silencing as the regimes from which refugees are escaping. References

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Australian Human Rights Commission. (2014). The Forgotten Children. The National Enquiry to Children in Immigration Detention. Sydney. Australian Psychological Society. (2007). Code of Ethics. Melbourne, Victoria. Bleiker, R., Campbell, D., Hutchison, E. & Nicholson, X. (2013). The visual dehumanisation of refugees. Australian Journal of Political Science, 48(4) 398–416. Department of Immigration and Border Protection (DIBP). (2017a). Immigration Detention Statistics. Retrieved from https://www.border.gov.au/about/ reports-publications/research-statistics/statistics/ live-in-australia/immigration-detention Department of Immigration and Border Protection (DIBP). (2017b). Immigration Detention and Community Statistics Summaries: 30 September 2017. Retrieved from https://www.border.gov.au/ ReportsandPublications/Documents/statistics/ Immigration-detention-statistics-30-september-2017.pdf

Dudley, M. (2016). Helping professionals and Border Force secrecy: Effective asylumseeker healthcare requires independence from callous policies. Australasian Psychiatry, 24(1), 15–18. https://doi. org/10.1177/1039856215623354 Hall B. (2016). ‘A huge win for doctors’: Turnbull government backs down on gag laws for doctors on Nauru and Manus. The Sydney Morning Herald. Sydney. Jakubowicz, A., (2016) European leaders taking cues from Australia on asylum seeker policies. The Conversation. 7 November. Killedar, A., & Harris, P. (2017). Australia’s refugee policies and their health impact: a review of the evidence and recommendations for the Australian Government. Australian and New Zealand Journal of Public Health, 41(4), 335–337. https://doi. org/10.1111/1753-6405.12663 Blood, R. (2011). “Any one of these boat people could be a terrorist for all we know!” Media representations and public perceptions of “boat people” arrivals in Australia. Journalism, 12(5), 607– 626. https://doi.org/10.1177/1464884911408219 Phillips J. (2017). A comparison of Coalition and Labor government asylum policies in Australia since 2001. In: Library P (ed) Research Paper Series 2016-17. Canberra: Parliament of Australia, Department of Parliamentary Services. Procter, N.G., De Leo, D. & Newman, L. (2013). Suicide and self-harm prevention for people in immigration detention. Medical Journal of Australia, 199 (11) 730-732. https://doi.org/10.5694/ mja13.10804 UN High Commissioner for Refugees (UNHCR) (2017). Global Trends: Forced Displacement in 2016.

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World Psychiatric Association Declaration on Participation of Psychiatrists in Interrogation of Detainees

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Statement banning the participation of psychiatrists in interrogation procedures

1. The Madrid Declaration establishes the Ethical Standards for Psychiatric Practice.1 Article 2 of the section on Specific Situations says: “Psychiatrists should not take part in any process of mental or physical torture, even when authorities attempt to force their involvement in such acts”. 2. The World Psychiatric Association reiterates its position that psychiatrists should not participate in, or otherwise assist or facilitate, the commission of torture2 of any person under any circumstance. Psychiatrists who become aware that torture has occurred, is occurring, or being planned, must report it promptly to a person or persons in a position to take corrective action. 3. Every person in military or civilian detention is entitled to appropriate medical care. Denial of adequate health care to a detainee may be considered as ill-treatment or torture. 4. Psychiatrists working in detention facilities under any kind of contract, either private or public, are physicians who adhere to the Hippocratic Oath “to practice for the good of their patients and never to do harm“. Therefore, they should not participate or assist in any way, whether directly

or indirectly, overtly or covertly, in the interrogation of any person deprived of liberty3 on behalf of military, civilian security agencies or law enforcement authorities nor participate in any other professional intervention that would be considered coercive in that context. 5. “Interrogation” refers to the attempt to elicit from a person deprived of liberty information that is not intended for the therapeutic benefit of the person. This includes, but is not limited to obtaining information for the purposes of incriminating the detainee, identifying or incriminating other persons. It refers to a deliberate attempt to elicit information from a person deprived of liberty for the purposes of incriminating the detainee, identifying or incriminating other persons, or otherwise obtaining information that might be of value to those who control the detainee. It also includes the creation of environments that might undermine the self or the identity of the detainee, or favour a breaking of his autonomy, selfdetermination or will, including but not limited to, humiliation, debasement or punishment. It does not include interviews or other interactions with a person deprived of

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Berlin. 10 October 2017

Approved by the General Assembly of the World Psychiatric Association in Madrid, Spain, on August 25, 1996, and enhanced by the WPA General Assemblies in Hamburg, Germany on August 8, 1999, in Yokohama, Japan, on August 26, 2002, and in Cairo, Egypt, on September 12, 2005. 2 Torture is defined in this document according to the 1984 United Nations Convention Against Torture as ‘Any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining from him or a third person information or a confession, punishing him for an act he or a third person has committed or is suspected of having committed, or intimidating or coercing him or a third person, or for any reason based on discrimination of any kind, when such pain or suffering is inflicted by or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity.’ It also adheres to the World Medical Association Declaration of Tokyo that includes participation of doctors in similar acts by Non-State actors. For the present statement, cruel, inhuman and degrading treatment and punishment comprises acts that fulfil the criteria of torture although purpose or intentionality cannot be clearly established. Regarding people under any form of detention or imprisonment, it includes the provisions of A/RES/43/173 Body of Principles for the Protection of All Persons under Any Form of Detention or Imprisonment, Principle Six: ‘The term “cruel, inhuman or degrading treatment or punishment” should be interpreted so as to extend the widest possible protection against abuses, whether physical or mental, including the holding of a detained or imprisoned person in conditions which deprive him, temporarily or permanently, of the use of any of his natural senses, such as sight or hearing, or of his awareness of place and the passing of time.’ 3 ‘Detainee’ should be defined as any person confined or controlled by any agency or person acting in an official capacity or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity.

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liberty that have been appropriately authorized by a court or by counsel for the detainee or a medical interview that is conducted as part of a therapeutic or forensic process under demand or proper informed consent of the person deprived of liberty. 6. Requesting, releasing or causing transfer of medical records or clinical data or allowing access to clinical files for interrogation purposes would be a serious breach of the code of conduct and a violation of professional ethics. 7. No psychiatrist should participate in the interrogation of persons held in custody by military or civilian investigative or law enforcement authorities. Participation includes intervention in the environment where the prisoner is held, advising on ways to confuse or debilitate the person to act against his or her will, doing psychological or medical examinations to certify the health of prisoners or detainees for interrogation, being present in the interrogation room, suggesting strategies, asking or suggesting questions, or advising authorities on the use of specific techniques of interrogation with particular detainees. 8. Psychiatrists may provide training to military or civilian investigative or law enforcement personnel on the adequate care to persons, recognizing and responding to persons with mental illnesses, on the possible adverse medical and psychological effects of techniques and conditions of interrogation, and on other areas within their professional expertise that will not harm the physical or psychological health or well-being of the person.

Related to the World Psychiatric Association Declaration on Participation of Psychiatrists in Interrogation of Detainees Comment I Principles determine practice

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Stephen Soldz* The WPA Declaration on Participation of Psychiatrists in Interrogation of Detainees constitutes a landmark development for the profession of psychiatry as well as other health professions. It codifies the most advanced thinking that has resulted from many years of interaction between national security and law enforcement priorities and the fundamental ethical foundations of the health professions. This declaration is important in carrying the discussion beyond the realm of “torture” to that of interrogation more broadly. In the discussion of the proper roles for psychiatrists and other health professionals, two issues have become entangled. One issue is the involvement of psychiatrists in torture or other prisoner or detainee abuse.

*) Director, Social Justice and Human Rights Program, Boston Graduate School of Psychoanalysis and Edmond J. Safra Center for Ethics, Harvard University Correspondence to: ssoldz@bgsp.edu

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Most, but unfortunately not all, contributors to this discussion believe that psychiatrists should not participate in torture because no one should participate in torture. This is a matter of law. Questions are then sometimes raised as to what are the boundaries of the “torture or ill-treatment” that are to be banned. Is it only detainee treatment that reaches the legal threshold for torture? Or does it include all treatment of detainees that could reasonably be construed as “coercive?” This is the question that most prior policies have addressed. A second issue concerns the appropriate boundaries between national security or law enforcement activities and those of psychiatrists. What, if any, activities in this domain, such as consultation on interrogations, are not appropriate for psychiatrists, even if involvement in those activities is appropriate for intelligence or law enforcement personnel? This question is not a legal one, but one of essential professional boundaries that can only be answered by appeal to a profession’s telos, and to its foundational ethical principles. It is to this latter question that the Declaration gives a clear answer when it comes to involvement in interrogations, be they to do with national security or law enforcement. It establishes a bright line: any direct involvement in interrogations of any kind is an inappropriate activity for psychiatrists. In establishing this line, the Declaration implicitly relies upon the telos of medicine as grounded in improving the health and well-being of the individuals and groups who are the target of any psychiatric intervention. It is implicitly based upon a deep respect for the two most foundational ethical principles for medicine, as well as for all other health professions, namely nonmaleficence—“do no harm”—and respect for the autonomy of individuals,

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from which the requirement for informed consent derives. This Declaration recognizes that interrogation, even ethically acceptable interrogation when conducted by appropriate personnel, violates the autonomy of the individual and can easily violate nonmaleficence. Therefore, it is not an appropriate activity for psychiatrists. A decade ago, a 20-year veteran U.S. Army interrogator put the matter clearly to me: “We veteran interrogators are not interested in the line between torture and non-torture because we should never go near that line. If we go near it, it means we’ve already lost control of the situation. However, I would never say my profession doesn’t cause harm. Your profession, however, is based on a different ethic. As a society, we need your profession. We can’t risk entangling it with mine.” The Declaration clearly and succinctly embodies this understanding. We can only hope that it will be widely adopted and that all the other health professions will adopt similar policies. Comment II The WPA Declaration on Psychiatry and Interrogation: Why now? Steven H. Miles, MD*

*) Professor Emeritus of Medicine and Bioethic, Maas Family Foundation Chair in Bioethics, University of Minnesota and Board Member, Center for Victims of Torture, Minneapolis Minnesota Correspondence to: Miles001@umn.edu

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The World Psychiatric Association’s Section on Psychological Consequences of Torture and Persecution issued a noteworthy “Declaration on Participation of

Psychiatrists in Interrogation of Detainees", which was formally approved by the WPA in October 2017 (p 94-95). The Declaration is clear and self-explanatory. The rationale for this expansion of the World Psychiatric Association’s Declaration of Madrid merits explanation and context. Torturing regimes are increasingly inclined to use psychological torture. This is not because it improves the interrogation. There is no evidence to support such a contention. Psychological torture is as effective as physical torture in breaking prisoners down and disabling their subsequent participation in civil society. However, it does so without leaving somatic scars, torn ligaments, mutilated appendages, resolving bone fractures or subcutaneous calcifications (caused by electrical burns) that can serve as evidence in trials or news media. In short, psychological torture’s ‘benefit’ is shielding regimes from human rights prosecutions. Psychiatric torture is widely practiced. All torture entails degradation, humility, engendering fear and hopelessness, suffering at watching others or loved ones being tortured. Psychiatrists have little to add to the brutality of ordinary guards, police, and soldiers. Psychiatric expertise adds drugs that induce dystonia, nausea, or disorientation, confinement in psychiatric facilities, and cultural knowledge to degrade (e.g., feeding pork to Islamic prisoners). It also plies a pseudoscientific veneer to interrogation plans that makes unsupportable predictions about the efficacy of varying the nature and intensity abuse. This pseudoscience gives professional solace to psychiatristtorturers who practice a shopworn craft that has been shown to lack merit. Such practitioners have been employed throughout the Communist nations, in

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Britain, Brazil, and most notably recently by the United States in its war on terror. The Declaration clarifies the Madrid Declaration in three ways. It rejects the idea that a regime may exempt interrogational psychiatrists from a primary therapeutic obligation to the well-being of prisoners. This was the premise of US policy for engaging psychologists for torture during the war on terror. It was the objective of the American Psychological Association “PENS report” that was commissioned by and for the US military. The latest Declaration bars transmitting medical records to interrogation officials as happened in the US, Soviet Union and United Kingdom practices during the war on terror, the cold war, and the ‘troubles’ in Northern Ireland respectively. It also requires reporting torture in a manner akin to the World Medical Association’s 2007 Resolution on the responsibility of physicians in the documentation and denunciation of acts of torture or cruel or inhuman or degrading treatment (Declaration of Copenhagen). The platform of health professional standards and international law is adequate. It is now time for societies like the World Medical Association and World Psychiatric Association to move to address accountability for physician torturers. Professional societies and human rights organizations must create and promote procedure manuals and casebooks to assist criminal courts and licensing boards to process cases against health professionals who are complicit with torture. They must create a registry of the nearly one hundred cases where physicians have been accountable for torture to correct the misconception that prosecution or professional sanctions are impossible. They must consider the reports of the United Nations Special Rapporteur on Torture in

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deciding whether member nations’ medical communities are in sufficient compliance with international ethics that are designed to divorce physicians from torturers.

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The European Network condemns any restriction to the European Convention on Human Rights

The European Network of Rehabilitation Centres for Survivors of Torture was founded in 2003 and is a professional network of doctors, psychologists, psychotherapists, social workers and lawyers from over 100 organisations and rehabilitation centres in Europe that provide specialist rehabilitation to survivors of torture and other human rights violations, either asylum seekers and refugees in host countries or victims of past or current regimes.*

The European Network condemns any restriction to the European Convention on Human Rights

*) This statement was submitted for publication by committee members Elise Bittenbinder, Nimisha Patel and Camelia Doru on behalf of the European Network of Rehabilitation Centres for Survivors or Torture. Correspondence to: cameliadoru@icarfoundation.ro

On 15 November 2017, Denmark took the chairmanship of the Committee of Ministers of the Council of Europe. The European Network welcomes Denmark’s stated aim that “The Council of Europe must continue to combat torture … the Danish chairmanship will … make sure that the fight against torture is strengthened.” However, Denmark has also announced plans to continue the programme of reform of the European Court of Human Rights. The European Network is concerned at reports that the Danish Minister for

For additional background see http://refugees.dk/ en/news/2017/may/danish-chairmanship-of-thecouncil-of-europe-to-weaken-human-rights/

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The European Network of Rehabilitation Centres for Survivors of Torture (‘the European Network’) welcomes Denmark’s determination to combat torture, but criticises any proposal to restrict the European Court of Human Rights in its ability to interpret the European Convention on Human Rights and Fundamental Freedoms (‘the Convention’) in respect of family reunion, as suggested by the Danish Minister for Immigration and Integration. Proposals to limit such rights to citizens of the 47 countries which

make up the Council of Europe, and to withdraw them from citizens of other countries, will severely restrict refugees’ opportunities for family reunification.1

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Immigration and Integration, Inger Støjberg, has suggested that these plans would lead to the restriction of the right to family reunification, while it would no longer be a right for refugees—and thus for victims of torture among them—under Article 8 of the Convention. The European Network strongly opposes any measure that will result in denying any refugee the possibility of living together with their family. Evidence clearly demonstrates that victims of trauma and torture depend on their family for sustained rehabilitation and integration in the recipient country. State signatories to the UN Convention Against Torture (UNCAT), which includes the 47 member states of the Council of Europe, are required by article 14 of that Convention to “ensure in its legal system that the victim of an act of torture obtains redress and has an enforceable right to fair and adequate compensation, including the means for as full rehabilitation as possible.”

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General Comment No. 3 of the Committee against Torture on the implementation of article 14 by States parties makes clear that the term “victim” also includes affected immediate family or dependants of the victim. The European Network considers that the absence of immediate family and/or dependents has real and direct implications for and is detrimental to the successful recovery—both physical and psychological—for traumatised asylum seekers and torture survivors. The risk of developing additional severe and enduring health problems is very high for those without their family and relatives particularly since the absence of family

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also weakens the torture survivor’s social networks which further impedes their sustained recovery. The European Network therefore strongly disagrees with any proposals to restrict refugees’ access to family re-unification as this is likely to have devastating and irreversible health consequences to those torture survivors affected.

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Exploring the connections between the Danish Chairmanship of the Council of Europe, torture survivors, and rehabilitation centres Jacques Hartmann*

1. Why does Denmark want reform?

Immigration has long been a dominant theme in Danish politics. In the late 1990s, the Danish People’s Party (DPP) began to denounce immigration, multiculturalism and Islam as alien to Danish society and values. Since 2001, the DPP has supported various minority coalition governments and gained extensive influence on Denmark’s immigration policy, which is now one of the most restrictive in Europe. Critique of the Convention system is not new in Denmark, where much debate has focused on Article 8,2 which includes a right to respect for family life. This right is especially controversial when it affects immigration policy, such as family re-unification or the deportation of foreign criminals. In May 2016, the Danish Supreme Court delivered a judgment which reignited the debate, by preventing the deportation of a notorious convicted criminal and Croatian national, Gimi Levakovic. Despite Levakovic’s egregious criminal record, the Danish Supreme Court found that his deportation would constitute a disproportionate interference with his right to respect for family life. The decision started a maelstrom.3 Public outrage was fuelled by the fact that Levakovic was a household name, after

P. Alston, The Populist Challenge to Human Rights, Journal of Human Rights Practice (2017) 1–15. Article 8(1) sets out,’Everyone has the right to respect for his private and family life, his home and his correspondence.’ The debate in Denmark is in many ways reminiscent of the debate in the UK in the early 2000s. See C. Geart, On Fantasy Island (OUP, 2016).

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As the statement by the European Network of Rehabilitation Centres for Survivors of Torture details, in November 2017 Denmark took over the rotating chairmanship of the Council of Europe. The Council — an international organisation aiming to uphold human rights, democracy, and the rule of law in Europe — was established in 1949. Today, it has 47 members states, including all members of the EU. It works by agreeing international legal standards in a wide range of areas, but is best known for the adoption of the European Convention on Human Rights. Denmark is a founding member of the Council and a founding party of the Convention and has traditionally been a strong supporter of human rights. Yet initially the Danish Government’s chief priority during the six-month long chairmanship was reform of the Convention system. Whilst the cut and thrust of politics means there is now less focus on reform, there remains a strong anti-human rights sentiment in Denmark, reflecting a

populist challenge that has engulfed not just Denmark but the entire world.1

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he had appeared on a 2015 Danish TV documentary. Politicians across the political spectrum have since called for reform of the Convention system. The current minority centre-right coalition, consisting of three parties and supported by the DPP, works on the basis of a political agreement adopted in November 2016, which expresses the need to ‘critically review’ the European Court of Human Rights’ dynamic interpretation.

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2. Is there a need for further reform?

The Convention system has already been reformed. From 2010–2015 four high-level conferences were convened to identify means to guarantee the long-term effectiveness of the Convention system.4 This led to the adoption of two amendment protocols. Protocol 15 which, among other things, will introduce a reference to the ‘principle of subsidiarity’, according to which the primary responsibility for implementing and enforcing the Convention lies with national authorities; and Protocol 16 which will allow the highest domestic courts to request advisory opinions from the the European Court of Human Rights. So far, however, neither of the two protocols have recieved ratifications to enter into force. Denmark, moreover, has no intention of ratifying Protocol 16. Despite this lack of progress, a comprehensive two-year expert review of the reform process highlighted positive results and concluded in 2015 that there was no need for ‘major reform’.5

4 5

Interlaken (2010), Izmir (2011), Brighton (2012) and Brussels (2015). The longer-term future of the system of the European Convention on Human Rights, Report of the Steering Committee for Human Rights (11 December 2015) 11.

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3. What reforms are envisaged by Denmark?

The objective of the Danish chairmanship remains somewhat unclear. This is partly due to the fact that many Danish politicians seem to be in a competition to express the most discontent with the current human rights system, which means that it is not always easy to distinguish hyperbole from policy statements. The chairmanship, however, focuses on five themes, including ‘Combating torture’ and the ambiguous theme, the ‘European human rights system in a future Europe’.6 The first theme will lead the Danish chairmanship to focus on the fight against torture, which will include a seminar in March 2018. The seminar will focus on combating torture in the early stages of police custody and pre-trial detention. The second theme included a high-level expert conference, which took place from 22-24 November 2017. In a subsequent conference report, the Danish Government writes that previous reforms of the Convetion system have brought ‘notable progress’, such as strengthening the principle of subsidiarity, improving the efficiency of the European Court of Human Rights and addressing the need for more effective implementation of its judgments.7 Despite the progress, the report states that the ‘Danish Chairmanship wishes to ensure that the measures already adopted are effectively

‘Europe in a time of unrest and upheaval—strong values and a future-proof Council of Europe’, The Danish Chairmanship of the Committee of Ministers of the Council of Europe (November 2017 to May 2018). Available at: <www.coe.int/ en/web/chairmanship>. Conference report High-Level Expert Conference 2019 and Beyond: Taking Stock and Moving Forward from the Interlaken Process. Available at: <www.ft.dk/samling/20171/almdel/REU/ bilag/118/1838949/index.htm>

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implemented, including through the entering into force of Protocol 15’.8 A further priority is ‘enhanced dialogue’ between member states and the Court. 3.1 Enhanced Dialogue The Danish Minister of Justice has stated that criticism of the Convention system in countries like Denmark to a large degree stem from feelings of detachment. He said: ‘Populations and decision-makers feel they are not being involved and listened to’.9 In Denmark, critique has, in addition to the deportation of foreign criminals, focused on the European Court of Human Rights’ dynamic interpretation. Dynamic interpretation means that standards in the Convention are not static, but rather interpreted in light of social changes by the Court. In this regard, it has been criticised for interpreting rights into the Convention that the drafters never intended to include. Despite not being contrary to international law, the Minister of Justice has explained that the Government will use its chairmanship to focus on the European Court of Human Rights’ dynamic interpretation, which he thinks has gone too far.10 The aim of the enhanced dialogue is to establish better means to influence the Court.11 It is not, however, clear how this could be done without also undermining its impartiality. Dialogue is important.

Conference report (n 7) 3. Ibid., 4. 10 Overrasket justitsminister vil tage dommer på ordet og blande sig i kontroversielle sager, Politiken (28 August 2017). 11 See comments made by the Danish Prime Minister at a press conference on 3 November 2017. Availble at <www.regeringen.dk/nyheder/danmark-overtager-formandsskabet-for-europaraadets-ministerkomit%C3%A9/>.

4. What will be the outcome of the Danish Chairmanship?

It has been and remains difficult to predict the outcome of the Danish chairmanship. Much of the early Danish debate focused on reforming the Convention system. Later, focus shifted to the Court’s dynamic interpretation. More recently, however, the Government seems to have changed tack. Whereas blame was initially placed squarely with the European Court of Human Rights, the Danish Prime Minster has since acknowledged that Danish courts might have wrongly applied human rights precedents.16 This shift of blame seems to have lowered expectations of the chairmanship and the

Dean Spielmann, “Whither Judicial Dialogue?”, Sir Thomas More Lecture, Lincoln’s

Inn (12 October 2015). 13

Conference report (n 7) 5. By comparison, in 2016 Denmark intervened in 34 EU cases before the European Court of Justice. 15 This possibility will not be open to the Danish Supreme Court unless Denmark ratifies protocol 16. 16 See press conference (n 11). 14

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The former President of the Court, Dean Spielmann, described judicial dialogue as the ‘golden key’ to a desirable future for the protection of human rights in Europe.12 Yet, dialogue already exists. As noted by the current President, Guido Raimondi, one of the most salient features of the reform process, which started in 2010, has been an intensification of the dialogue with national courts.13 States can also influence the Court’s interpretation by intervening in ongoing cases. Yet, Denmark has only done so once.14 A futher possibility for influencing the Convention system is envisaged in Protocol 16, which, when it enters into force, will allow for advisory opinions.15

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Danish Government now seems to be focused on a stocktaking exercise that will result in the adoption of a political declaration in April 2018. But whilst the Convention system and Article 8 appears to be safeâ&#x20AC;&#x201D;at least for the time beingâ&#x20AC;&#x201D;there seems little prospect of an end to the populist agenda, which is spurred on by a significant political segment in Denmark that continues to want and demand reform to the Convention.

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105 BOOK REVIEW

Recordar. Violación de derechos humanos: una mirada médica, psicológica y política,1 by Paz Rojas. Published by LOM Ediciones, Santiago de Chile, 2017 (ISBN: 9789560009982) Pau Pérez-Sales, MD, PhD, Psych**, Editor in Chief

Remember. Violation of human rights: a medical, psychological and political outlook. **) SiR[a] Centre, GAC Community Action Group and Hospital La Paz, Spain. Correspondence to: pauperez@arrakis.es

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The text, published with the help of the University of Oslo, is a compilation of lectures and essays by Dr. Paz Rojas, a Chilean doctor, an international expert in the fight against torture, who at 85 years’ old, is still actively collaborating as Vice President of the Comite de Defensa de los Derechos del Pueblo [Committee in Defense of the Rights of People] (CODEPU). It will soon be 40 years since that November in 1980 when CODEPU was founded. The organization subsequently spread across the country and had working teams in some of the main Chilean cities, providing legal and psychosocial assistance to victims of torture. CODEPU is still integrated into many platforms of contemporary struggles for human rights. Paz Rojas was a friend of the family of President Salvador Allende and experienced firsthand the military coup and the years that

followed. She was arrested by the Chilean intelligence (DINA) in 1974 and had to go into exile until 1980, working in those years as a therapist for Chilean exiles in France. Her most well-known text, Torture and Resistance in Chile, was born from that experience and it was originally published in French. Her model of understanding work with torture survivors is based on the consideration of the therapeutic task as an integral part of the whole political struggle. From Paris, Paz Rojas gathered the testimony of exiles who arrived as therapy, but also with the aim of not only teaching others to resist torture in case they were detained, but in order to politically denounce torture in international institutions. In 1988, the plebiscite that ended the military dictatorship would take place. The reader should not expect from this book an academic or a research text. It is a collection of short essays (mostly between two and five pages) written as reflections from practice. They reflect on a series of universal themes: • society split by the dictatorship and the way in which fear generates attitudes of submission and acceptance of the status quo without criticism; the alienation of the victim by society and the resulting double victimisation as someone who represents a danger; the silent majority in front of the militant minority in a society that Paz Rojas does not hesitate to qualify as sick and pathogenic. Psychological War understood as the propaganda raised to create affinity with the repressor and distance with the dissident. The omnipresent silence in which people know but remain silent in a combination of fear with guilt and hostility. • the difficulties of putting into words traumatic experiences, the dilemma between telling or not, between silence to avoid pain and dissociative reactions

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(labelled at that time as Acute Exogenous Reactions), criticism of the concept of post-traumatic stress and the impossibility that it includes the breakdown of trust in the human being, the violation of dignity, the clash with cruelty and the breakdown of human bonds, the isolation, the shame and the pain that remain indelibly, and above all the persecutory image of the torturer that is linked to the deep experience of the torture survivor. Particularly shocking is the case described on pages 151 and following on the manner in which torturers of the Air War Academy were acquitted of very serious crimes for which there was evidence and witnesses because the Chilean Legal Medical Service concludes in their expert reports that at the present time (years after torture) there were no signs of full post-traumatic stress disorder in some of the claimants and therefore torture could not be proven. • criticism of a relevant part of transitional justice initiatives carried out in Chile. Her disenchanted vision of the Commission of Truth and Reconciliation (Rettig report) for its forgetfulness of the victims of torture, her rejection of the Mesa de Diálogo with the military and her critical view of the mandate, composition and results of the Truth Commission on Political Prison and Torture (Valech Commission). Her main criticism to all these processes is that they are strategies that do not recognise the suffering of victims with names and surnames but rather outline and dilute them, and that they serve as a guarantee for impunity by not collecting the names of the perpetrators or generating processes of justice. • the perpetrator as someone dehumanised, accustomed to cruelty, that obeys without questioning and

BOOK REVIEW

who is offered power and covered by an umbrella of impunity. • impunity as a pathological element that deepens the wounds of torture by denying it, creating the impression that what the victim experienced is not real and did not happen, that society does not recognise it and that individual dignity is sacrificed in the name of a supposed collective benefit. Impunity, in the opinion of Paz Rojas, generates clinical syndromes of equal or greater severity than torture itself: anomie, impotence, frustration, alienation, loss of sense of belonging to a sick society that prefers to deny and not face the past. As part of it, the experience of Pinochet’s detention in Chile and the battle surrounding his extradition to Spain and the expert assessments that were made to try to prove whether or not he could face justice. The book in short is a set of small experiential texts that dot a whole life trajectory dedicated to militancy from clinical practice, illustrating many phenomena that have somehow transmuted over time but in essence, have not changed. As Nora Sveaass indicates in the prologue, her struggle against impunity in the 80s -and her insistence on the right and need to care after torture- have been important for the general understanding of these issues -both amongst groups of health professionals - but also in the legal sphere - in relation to accountability and justice. For those of us who have lived through at least part of the time recounted, Paz Rojas’ book is crossed with intense emotions. Those that convey the honesty of a life dedicated to the struggle for human rights.

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Victimisation of hunger strikers at Guantánamo Bay Katie Taylor, MA*

*) 1

Reprieve, London To find out more visit www.reprieve.org.uk/topic/ guantanamo-bay/

nutrition for the detainees, evidence gathered by Reprieve has shown that in practice, force feeding is part of a brutal regime designed to punish the hunger strikers. Prisoners have been routinely subjected to ‘forced cell extractions’ or FCEs, during which they are stormed in their cells by guards clad in riot gear, beaten, and then dragged to the feeding chair. The tubes used to force feed prisoners are regularly used at the wrong size, causing agonising pain as they were inserted into the stomach through the nose. In 2014, the UN Committee Against Torture warned the Obama Administration that the force feeding of prisoners on hunger strike, even without such additional abuse, constituted “ill-treatment in violation of the Convention [Against Torture].” Khalid Qasim is a Yemeni national who has been held without charge or trial since 2002. He told Reprieve that his requests to see a doctor, and to have his vital signs checked, had been repeatedly refused since September. He is no longer allowed to take vitamins. He has repeatedly collapsed in recent weeks, and feels weak and dizzy. His joints are beginning to ache. He says he is terrified that he could die, or suffer permanent organ damage. This is why Reprieve is calling on the Trump administration to allow the prisoners urgent independent medical attention—and to listen to their protest. Ultimately, the prisoners must be

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In recent weeks, Reprieve1 has gathered reports from those we assist in detention in Guantánamo Bay. They show that under the Trump Administration, the authorities at the prison have begun cracking down harder than ever on those who are hunger striking. Medical assistance is being used as a tool of coercion, with prisoners on hunger strike being denied essential checks on their blood and vital signs. Force feeding—once carried out with brutal regularity—is now undertaken at the point where prisoners are near collapse, meaning that hunger strikers face a real risk of permanent injury. At least 780 detainees have been held at Guantanamo since the prison there opened in 2002. Today, 41 detainees remain at the prison, in conditions of indefinite detention which compound their existing trauma. Several of these men have undertaken a hunger strike, as their only means of peacefully protesting their detention without charge or trial. Guantanamo detainees have been hunger-striking at the prison for years; and for many years, the authorities has been force feeding the prisoners. While the prison authorities have claimed that this is a necessary medical measure, designed to ensure basic

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given fair trials, or released, and the prison closed for good. Prisoners who are not hunger striking, such as Saifullah Paracha, have also been victimised. Saifullah—a grandfather from Pakistan who has never been charged—recently told his lawyer at Reprieve that he had just been ‘FCEed’ for the first time. He said: “It felt like when we were brought in to Gitmo. Not since the beginning days of Guantanamo has it been like this. It’s a hell.” He described the abuse as “collective punishment”, handed down “because of the hunger strike.”2 In the last issue of the Torture Journal, I and a former colleague at Reprieve, Polly Rossdale, wrote in these pages about the torture suffered by prisoners at Guantánamo Bay, and the sequelae of that torture. Our article highlighted the fact that the majority of men held in Guantanamo were indefinitely detained without charge or trial, and were subjected to rendition, torture and other cruel, inhuman and degrading treatment. For those released, the consequences of that torture has a daily impact on their ability to rebuild their lives.

http://www.newsweek.com/guantanamo-baysoldest-prisoner-not-beginning-has-it-beenhell-710587

NEWS

109 LETTERS TO THE EDITOR

Torture in the Kashmir Valley and Custodial Deaths in India Inamul Haq*

Dear Editor,

*) PhD candidate under the supervision of Dr Beryl Anand, Assistant Professor, Centre for Gandhian Thought and Peace Studies, Central University of Gujarat

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I would like to draw your readersâ&#x20AC;&#x2122; attention to the fact that custodial violence and death is a dark reality in India, where the poor, the deprived classes, women and political activists are the worst victims of police brutality in India (Prakash and Chaudhary, 2015). It has even been reported that women, religious minorities, the poor and vulnerable sections of society are specifically targeted (National Project on Preventing Torture in India, 2008). Since the unrest that started with the insurgency in the Kashmir Valley in the 1990â&#x20AC;&#x2122;s, the Indian state has systematically used force and coercion with a view to making citizens compliant in the region. Normal Kashmiri people are arrested by police and security forces in order to identify suspected militants. Arrest can occur on the basis of suspicion rather than evidence leading to abuse by police. Thousands have disappeared, not only in Kashmir, but also in Jammu. In 2011 for example, the State Human Rights Commission (SHRC) of Jammu and Kashmir found 2730 bodies dumped in unmarked graves in 38 sites in North Kashmir. Among them, 574 were identified as the bodies of local Kashmiris

(Human Rights Watch, 2012). Police, security forces and intelligence agencies use torture in the form of assault, physical abuse, custodial deaths, rape, threats, psychological humiliation and deprivation of food, water, sleep and medical attention. Torture in custody is now considered an inevitable part of any police investigation as it is widely practised throughout India (Seth, 2010). Authorities consider torture to be an interrogational tool for investigation and perceive that there is nothing wrong in punishing a victim in custody. The rate of deaths in custody is also high (Lokaneeta, 2011). The Indian National Human Rights Commission (NHRC) records that from 2001-2010, 14,236 individuals died in custody (1,504 in police custody and 12,732 in judicial custody), which is an average of 4.3 deaths per day. Most of the deaths occurring are the direct result of torture in custody. All cases of death in police and prison custody are not documented because the National Human Rights Commission does not have jurisdiction over armed forces (section 19, Human Rights Protection Act (NHRC, 2011)). These deaths occur either due to negligence by authorities with respect to hygiene levels of food and deprivation of medical assistance, or by unlawful, prolonged detention and torture. The Asian Centre for Human Rights (2011) has consistently underlined that about 99.99% of deaths in police custody can be ascribed to torture and generally occur within

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forty-eight hours of the victims being taken into custody. Torture and other human rights abuses like arbitrary detention and disappearances are particularly common in Jammu and Kashmir and North-Eastern states and extra-judicial killings and death in custody are said to be increasing in the Kashmir Valley (Haneef, 2015). The Indian Penal Code which stipulates that arrestees must be brought before a magistrate within 24 hours is not upheld in the region and security forces have virtual immunity from prosecution. Yet, it is a paradox that torture continues to exist in India (Seth, 2010). India is a liberal democracy with clear national constitutional and statutory provisions against torture that are purportedly being developed and monitored by a strong and independent judiciary. The Supreme Court of India condemns torture and has outlined best practices for police and other state actors. However, state legislatures have not responded by codifying these national provisions and practices into law. This inaction has led to torture and ill-treatment not being challenged and a culture of impunity (NPTTI, 2008). India does not allow any international organizations like Amnesty International and Human Rights Watch or domestic human rights organizations, like the National Human Rights Commission, to document cases of torture and other abuses in the Jammu and Kashmir and northeastern states like Manipur (Amnesty International, 2016/17). In Kashmir valley, the laws, like the Armed Forces Special Power Act 1990, have not only suspended the powers of the judiciary and accountability within the everyday legal system, but also provide extensive legal protection to the armed forces (Duschinski, 2010). In the Kashmir Valley, torture is practiced as a means of extracting information or a confession, or for punishing

LETTERS TO THE EDITOR

persons who are believed to be supporters of militants (OFMI, 2012). Methods used are brutal which physically and psychologically impair the victims and can mean they face health problems throughout life. Many victims become militant (Kashmir Coalition Civil Society, 2009). The concept of modern policing is still a mirage in India, where police are expected to function as a tool for social control rather than to serve the society. The increasing incidence of torture and deaths in custody has assumed such alarming proportions that it is undermining the rule of law and the administration of criminal justice system.

References Amnesty International. (2016/17). Amnesty International Annual Report. London: Amnesty International Ltd Asian Centre for Human Rights. (2011). Torture in India 2011. New Delhi: Asian Centre for Human Rights. Duschinski, H. (2010). Reproducing regimes of impunity: Fake encounters and the informalization of everyday violence in Kashmir valley. Cultural Studies, 24(1), 110â&#x20AC;&#x201C;132. https://doi. org/10.1080/09502380903221117 Haneef, K. M. (2015). Impunity to Military Personal in Kashmir Valley, a Heart Touching Debate Since 1989. International Research Journal of Social Sciences, 4(7), 54â&#x20AC;&#x201C;58. World Report. (2012). USA: Human Rights Watch. Organization For Minorities in India. (2011). Torture commons by police officers in India. India: Organization For Minorities in India. Lokaneeta, J. (2011). Transnational torture: law, violence and state power in the United States and India. New York: New York University Press. National Project on Preventing Torture in India. (2008). Torture and Impunity in India. Tamil Naidu: Peoples Watch. Jammu and Kashmir Coalition Civil Society. (n.d.) Peace and Processes of Violence: An observation on situation in Jammu and Kashmir from 2002 to 2009. Srinagar: Jammu and Kashmir Coalition Civil Society. Prakash, A. & Chaudhary, A. (2015). Custodial torture: a naked violation of human rights. International Journal of Legal & Social Studies. 2(2), 42-58. Seth, R. (2010). Custodial torture and its remedies. Retrieved from http://www.legalservicesindia.com/ article/article/custodial-torture-297-1.html.

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Rehabilitation of torture survivors and prevention of torture: Priorities for research through a modified Delphi Study Pau Pérez-Sales, Nicola Witcombe, Diego Alonso-Otero

Statements: Position statement on banning the participation of psychiatrists in the interrogation of detainees, and Condemnation on any restriction to the European Convention on Human Rights

Impact of NET on torture survivors in the MENA region Ane Kirstine Viller Hansen, Nete Sloth HansenNord, Issam Smeir, Lianne Engelkes-Heby, Jens Modvig

Book review: Remember. Violation of human rights: a medical, psychological and political outlook. By Paz Rojas Pau Pérez-Sales

Tortured Logic: Information and Brutality in Interrogations John W. Schiemann

News: Victimisation of hunger strikers at Guantánamo Bay Katie Taylor

Australian immigration detention and the silencing of practitioners April Pearman, Stephanie Olinga-Shannon

Letter to the editor: Torture in the Kashmir Valley and Custodial Deaths in India Inamul Haq

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The Torture Journal is a scientific journal that provides an interdisciplinary forum for the exchange of original research and systematic reviews by professionals concerned with the biomedical, psychological and social interface of torture and the rehabilitation of its survivors. It is fully Open Access online, but donations are encouraged to ensure the journal can reach those who need it (www.irct. org). Expressions of interest in the submission of manuscripts or involvement as a peer reviewer are always welcome.

The Torture Journal is published by the International Rehabilitation Council for Torture Victims which is an independent, international organisation that promotes and supports the rehabilitation of torture victims and the prevention of torture through its 150 member centres around the world. The objective of the organisation is to support and promote the provision of specialised treatment and rehabilitation services for victims of torture.

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