The Lingering Effects of Torture

WASHINGTON, July 3, 2009 — -- Like many of the other inmates interrogated at Guantanamo Bay, Adeel's personal nightmare did not end when he returned home.

Today, in his native Pakistan, the sound of approaching footsteps or the sight of someone in a uniform can trigger bad memories and set off a panic attack. The former teacher and father of five now thinks of himself as a suspicious and lonely person.

"I feel like I am in a big prison and still in isolation. I have lost all my life," he told psychologists working for the non-profit Physicians for Human Rights. They diagnosed him as having post-traumatic stress disorder (PTSD) and severe depression.

Newly emerging research on large numbers of torture survivors shows that anecdotal stories like these are common and suggests that "psychological" forms of torture -- often thought to be milder than the direct infliction of physical pain -- can in fact have serious long-term mental health consequences.

Adeel's story is similar to those of other prisoners who may be released this year as President Obama pushes to close the facility. Adeel spent four years in U.S. custody, first at the Bagram Theater Internment Facility in Afghanistan and then at Guantanamo -- and was freed in 2006, never having been charged with a crime.

Adeel said that while in U.S. custody he was sexually humiliated and wrapped in a hood, goggles, earphones and gloves that cut off his senses during a 24-hour flight. His descriptions of what happened match many of the practices that U.S. officials said were used at the prisons. Adeel said he was kept in isolation in a chilled cell, blasted with loud music to prevent him from sleeping, and forced to stand motionless in the hot sun for hours.

"For two months, I couldn't sleep because there was a very strong light. ... If you fell asleep just for a few minutes they played very loud American music, so you could not sleep," the man who now goes by the alias Adeel recalled in a recent report by the Physicians for Human Rights.

Memos sent in 2002 from the U.S. Department of Justice to the CIA, released earlier this year by President Obama, describe these and other interrogation techniques -- such as tossing prisoners against flexible walls and using waterboarding. These techniques, which leave few physical marks, are also used to toughen American troops undergoing Survival, Evasion, Resistance and Escape training.

After consulting with the military officers who run these programs, the CIA concluded "none of these [officers] was aware of any prolonged psychological effect caused by the use of any of the ... techniques either separately or as a course of conduct," according to one of the memos.

Psychologists and neuroscientists, on the other hand, tend to argue that techniques do cause long-term harm. But what can science actually show about the effects of "psychological" torture on civilians like Adeel years after their real-world interrogations?

Linking a specific form of torture directly to long-term psychological problems is very difficult to do because of the ethics of experimenting on humans. Because scientists cannot torture subjects in the laboratory and check for long-term effects, they study real-world survivors of torture, such as refugees from war-torn countries and former prisoners of war, each of whom has experienced a variety of traumatic experiences.

Doctors who work with these victims often rely not on scientific studies but on their own personal observations to assess the long-term impacts of a particular experience.

Harvard psychiatrist Stuart Grassian, who studies prisoners put into solitary confinement, believes from his own personal experience that "people [put into solitary confinement] become loners." Years after being removed from solitary confinement, "they tend to become irritable, hypervigilant, jumpy, fearful and chronically tense." But when asked to testify in a class-action suit against a "supermax" prison that used solitary confinement, he found few scientific studies to support these beliefs.

The Tortured Mind

Research that tried to isolate the impact of solitary confinement on American soldiers kept in Korean P.O.W. camps, for example, was largely inconclusive. Its analysis was complicated by the fact that people put in solitary confinement are usually mistreated in other ways as well.

New research that tries to untangle the horrors suffered by torture survivors recently was presented at the 11th European Conference on Traumatic Stress in Oslo, Norway. Metin Basoglu, a psychiatrist at King's College London, described the statistical techniques he used to single out the mental impacts of "cruel, inhuman, and degrading treatments" that range from threats and isolation to electric shocks and beatings on the feet.

His previous work suggested that the distinction between the harshness of "physical" torture and the mildness of "psychological" torture is a false one. When torture victims from the former Yugoslavia rated the distress caused by different forms of abuse on a scale from zero to four, those techniques that did not involve physical pain were just as distressing, or even slightly more so, than those that directly inflicted pain. "The threat or anticipation of pain may be worse than the pain itself," said Basoglu.

Bosaglu's latest and largest study looked for links between a person's perception of the severity of an experience and the likelihood of later developing PTSD, the most common disorder associated with torture.

By studying hundreds of political dissidents from Turkey and military prisoners of war of the former Yugoslavia -- all of whom were tortured -- Basoglu discovered that deceptively banal mistreatments that may not cause long-term psychological problems when used individually can lead to mental disorders when grouped together or inflicted sequentially.

Painful Combination

Consider a situation in which a prisoner is slapped across the face while wearing a hood with his hands tied behind his back. Alone, none of these abuses -- slapping, hooding, or hand-tying -- can predict whether that person will develop a long-term mental disorder. But when the techniques are grouped together, said Basoglu, their effects multiply and raise the likelihood of developing PTSD. The psychological trauma of being slapped in the face is made much worse by a blindfold and handcuffs, which prevent victims from anticipating and shielding themselves against the blow.

"We find strong correlations between clusters of events and mental health outcomes," said Basoglu.

Other combinations that predicted PTSD included putting people in stressful, helpless positions to maximize the impacts of verbal threats and stripping their clothes off to enhance the humiliation of being sprayed with cold water.

Psychologist Claudia Catani looked for traces of these long-term clinical problems in the brains of torture survivors at the rehabilitation centers of the University of Konstanz in Germany.

Using a technique that detects magnetic fields created by electrical activity in the brain, Catani compared the patterns of brain activity of non-traumatized people to those of people who had experienced torture and people had subsequently developed PTSD. She found distinct differences in the area of the brain that controls attention that suggest torture victims are more sensitive to the sight of a potential threat.

Some psychologists have argued that, when shown a picture of something horrific like a massacre or a violent act, someone with PTSD will have a stronger reaction because the part of the brain that controls attention will become overactive and fixate on the image.

But Catani found the exact opposite to be the case. The brain activity in torture victims responding to the photos shows that they actually pay less attention to a threatening photo, not that they fixate. Her explanation is that PTSD sufferers carry traumatic experiences deep in their emotional memory and consciousnesses, programming them to react more quickly and strongly to threatening scenes.

"[P]ictures with such explicit contents as war and attack scenes are immediately categorized as a threat and do not require sustained visual processing," said Catani.

Taking Control

Basoglu and Catani both agree that the underlying principle that makes torture so traumatic is the individual's loss of control. Comparing torture to other kinds of trauma, torture survivors tend to be just as likely to develop mental disorders as people who have survived similarly uncontrollable events like massive earthquakes or plane crashes.

"Our data on this is unpublished, but it is the first time someone has compared these groups," said Basoglu.

"If you don't do anything about the clinical condition, these long-term effects do not go away," said Catani. But the good news for people trying to rebuild their lives is that various forms of psychotherapy have been shown in clinical trials to help.

"Torture memories are among the most resilient," said Almerindo Ojeda, director of the Center for the Study of Human Rights in the Americas at the University of California, Davis. "Those neurological interconnections must be very robust."

Though the memory of trauma will always remain, said Catani, confronting that memory can help to reduce the symptoms of PTSD.

"These people can go through their entire lives focused on the traumatic experience, feeling like the trauma is timeless and spaceless," said Catani. "You have to reconnect them ... to help the people put the memory in its place in their autobiographies."