Lessons from Abu Ghraib
By Clive Cookson
Financial Times Published: July 1 2004 18:18
The shocking pictures from Abu Ghraib prison in Baghdad have
come as a double blow to the doctors and therapists working
with torture survivors in 170 rehabilitation centres around
the world. On top of their dismay that US forces could treat
prisoners so cruelly, staff have been overwhelmed with
requests for help over the past few weeks, as the images and
descriptions reawaken horrific memories in people who have
been tortured.
"The events at Abu Ghraib have had a profound effect on the
people we care for," says Allen Keller, director of the
Bellevue/New York University Program for Survivors of
Torture. "The pictures have been very disturbing and
retraumatising for many of our patients, who have been
suffering a recurrence of nightmares and other sleeping
problems."
Gill Hinshelwood, senior examining doctor at the Medical
Foundation for the Care of Victims of Torture in London,
reports a similar surge in symptoms. "Some of my Iraqi
clients [who suffered under Saddam Hussein's regime] have
had a resurgence of nightmares; others are coming back with
aches and pains," she says. "Many are obsessed with what is
going on."
Yet staff at rehabilitation centres say some good will come
out of the horror of Abu Ghraib, if it increases awareness
of how to diagnose and treat torture. At present the
medical community pays insufficient attention to what Prof
Keller calls a global public health problem. "Around
400,000 torture survivors have come to live in the US
alone," he says.
Richard Mollica, director of the Harvard Program in Refugee
Trauma, agrees. "Despite routine exposure to the suffering
of victims of human brutality, healthcare professionals tend
to shy away from confronting this reality," he says.
"Clinicians avoid addressing torture- related symptoms of
illness because they are afraid of opening a Pandora's box:
they believe they won't have the tools or time to help
torture survivors once they've elicited their history."
Even the damage caused by physical brutality may be hard for
a general practitioner to spot. For instance, falanga, in
which the soles of the feet are beaten with rods, may leave
no outward sign of damage even though internal damage to
nerves and tendons can make walking excruciatingly painful.
Diagnosing and treating the psychological legacy of torture
is even more difficult. All the attention given by
psychology researchers to post-traumatic stress disorder has
not necessarily helped those working with torture victims.
"This emphasis on PTSD has obscured the reality that the
most common mental illness diagnosed in torture survivors is
depression - often a serious and socially debilitating
condition associated with serious medical consequences,"
says Prof Mollica. The depression caused by torture and
extreme violence can be distinguished from other forms of
depression by the intense and repetitive nightmares that
accompany it.
Dr Hinshelwood says this depression is best described as "a
deep and long-term sense of passivity and pessimism". She
adds: "People - and men in particular - are even more
depressed if their torture includes
mistreatment of prisoners at Abu Ghraib. Although there has
been some debate about whether this amounted to torture,
organisations working with torture victims, such the Medical
Foundation in London, state unequivocally that it did. And
they say that US interrogators have used an unacceptably
harsh sort of coercion - sometimes called "stress and
duress" or "torture lite" - systematically, not only in
Iraq, but also at Guantánamo Bay in Cuba and Bagram air base
in Afghanistan.
In response to the shock of many Americans, who asked why
"seemingly normal" US soldiers could behave so sadistically
in Iraq, the American Psychological Association put the
professional view that "most of us could behave this way
under similar circumstances".
Two famous experiments proved the point more than 30 years
ago. First Stanley Milgram at Yale University showed that
most normal volunteers would follow the instructions of an
authority figure - a scientist in a white coat - and give
other people a series of increasingly powerful electric
shocks, even though they elicited agonising screams.
Then Philip Zimbardo set up a simulated prison at Stanford
University, in which students were randomly selected to play
the roles of prisoners and guards. Prof Zimbardo believes
his experiment has striking similarities with Abu Ghraib: "I
have exact, parallel pictures of naked prisoners with bags
over their heads, who are being
According to the APA, these two classic experiments - and
other psychological studies in the laboratory and in the
field - go a long way to explaining what went wrong at Abu
Ghraib. Any prison is an environment in which the balance of
power is so unequal that normal people can become brutal and
abusive, unless the institution has strong leadership and
transparent oversight to prevent the abuse of power.
Abu Ghraib not only lacked such leadership, but also had
another ingredient for abuse: an ethnic, cultural,
linguistic and religious gulf between guards and prisoners.
Robert Jay Lifton, psychiatry professor at Harvard Medical
School, says people are naturally predisposed to distrust or
even attack others whom they categorise as outsiders.
The Abu Ghraib guards allegedly thought they were following
orders from intelligence officers. However, this sort of
mistreatment is counterproductive even from the narrow
viewpoint of intelligence gathering, says Vince Iacopino,
research director of the Massachusetts-based group
Physicians for Human Rights.
"Unfortunately, some may assume that physical and
psychological coercion techniques serve to 'soften up'
detainees for interrogation," says Dr Iacopino. "In our
experience it is clear that physical and psychological forms
of coercion or ill treatment or torture do not provide
accurate and reliable information. On the contrary, by
inflicting physical and/or emotional pain, perpetrators
reduce their victims to a point that precludes obtaining
reliable 'information' - and victims frequently falsely
confess to whatever they think interrogators want to hear."
Prof Mollica points out that perpetrators can also be
psychologically damaged by their experience and requests to
treat them can put doctors in a difficult position.
"In medicine we have the controversial concept of
'medical neutrality', which holds that the doctor has an
obligation to treat someone regardless of political
situation or the circumstances that made them ill," he
says. "But if a perpetrator of torture comes to you for
therapy, what do you do?"
There are clearly far more victims than perpetrators of
torture - and most are more seriously damaged. But there is
hope, as psychologists around the world gain experience in
helping torture victims to recover their mental health,
first through proper diagnosis and then through a mixture of
therapy and, if appropriate, treatment with antidepressants
or other drugs.
"Twenty years ago there was a widespread impression that
survivors of extreme violence could never really recover
from the experience," says Prof Mollica. "Now we are much
more optimistic."
While many torture victims suffer renewed torment through
the images of Abu Ghraib, their long-term prospects may be
becoming slightly brighter.
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