Responding to Victims of Torture:
Clinical Issues, Professional Responsibilities, and Useful Resources
ABSTRACT: This article presents clinical and related approaches to the treatment of torture victims, examines common reactions of clinicians working in this area, identifies useful resources, and emphasizes the need for clinical interventions to be supplemented by research, practice, and education in order to respond adequately to the prevalence of torture and the plight of its victims. [Full text of this article appears below on this web page.]
PLEASE NOTE: This web site includes the following more recent articles in this area:
- "Psychological Assessment of Torture Survivors: Essential Steps, Avoidable Errors, and Helpful Resources" by Kenneth S. Pope, Ph.D., ABPP, International Journal of Law and Psychiatry.
- "The Code Not Taken: The Path From Guild Ethics to Torture and Our Continuing Choices -- Canadian Psychological Association John C. Service Member of the Year Award Address" by Kenneth S. Pope, Ph.D., ABPP, published in Canadian Psychology / Psychologie canadienne (February, 2016)
- "3 Cognitive Strategies That Deny, Discount, & Dismiss Torture: How Individuals, Groups, Governments, & Cultures Enable Torturers" by Kenneth S. Pope, Ph.D., ABPP, Academic Press.
- Online Resources for Working with Refugees,Victims of Torture, & Asylum-Seekers
- "Are the American Psychological Association's Detainee Interrogation Policies Ethical and Effective? Key Claims, Documents, and Results" by Kenneth S. Pope, Ph.D., ABPP, in Zeitschrift für Psychologie / Journal of Psychology.
Responding to Victims of Torture:
Clinical Issues, Professional Responsibilities, and Useful Resources
Psychologists cannot ethically ignore the prevalence of torture or the plight of torture victims. The United Nations (UN) estimates, on the basis of its studies, that torture is currently and systematically practiced in at least 30 countries (Rodley, 1988); in 1988, Amnesty International (1989) "brought to the attention of the [UN's] Special Rapporteur on Torture cases from 43 countries, including Benin, Burkina Faso, Burma, Chile, China (Tibet), El Salvador, Haiti, Iran, Jordan, Liberia, the Philippines, Somalia, Sri Lanka, Syria and Turkey" (p. 23). It is important to note that these formal reports are only of the worst offenders; torture as an activity condoned by the government may be occurring in as many as 60 additional countries (Amnesty International, 1989).
The nature of torture makes it difficult for us to acknowledge its existence, let alone respond humanely, realistically, and effectively to its victims. Survivors of torture have often experienced a physical pain that is overwhelming and obliterating. As Scarry (1985) noted in her comprehensive review and analysis:
At first occurring only as an appalling but limited internal fact, [pain produced by torture] eventually occupies the entire body and spills out into the realm beyond the body, takes over all that is inside and outside, makes the two obscenely indistinguishable, and systematically destroys anything like language.... Terrifying for its narrowness, it nevertheless exhausts and displaces all else until it seems to become the single broad and omnipresent fact of existence.... Its mastery of the body, for example, is suggested by the failure of many surgical attempts to remove pain pathways because the body quickly, effortlessly, and endlessly generates new pathways. (p. 55)
Torture victims often become prey to a cruelly imposed unpredictability. In Prisoner Without a Name, Cell Without a Number , Timerman (1981) described this lack of a reasonably predictable future: "You never knew whether you were being led to an interrogation, torture, death, or another prison where once again you'd have to discover the pathetic mechanisms of survival" (p. 159-160). Part of the torture may include holding the victim in confined isolation, sometimes for years (Foster, 1987). Torture can also produce lasting mutilations that tax psychological assessment and treatment methods. As President Kaunda of the Republic of Zambia asked, "How do you calculate the value of a lost arm, or a lost leg, cut away ears and a mutilated nose, lips and plugged-out eyes and annihilated eyesight of living people?" (Commonwealth Committee of Foreign Ministers on Southern Africa, 1989 , p. xiii). The horrors associated with torture may make it difficult for the profession of psychology to acknowledge the relatively large number of torture victims now living in the United States (see Amnesty International, 1990) and to respond appropriately to their needs. This difficulty may be reflected in the virtual absence of the topic from the journals and other publications of the American Psychological Association.
In this article, we focus primarily on torture as an instrument of governmental repression, although much of the material may be applicable to other torture situations (e.g., certain instances of child abuse, of spouse or partner abuse, and of rituals associated with devil worship). Rather than to propose a new or specialized model of treatment, we seek to identify common reactions of clinicians who work in this area, regardless of their theoretical orientation or model of intervention, and to explore general issues in responding to torture victims, whose backgrounds, experiences, and needs may be diverse.
Common Reactions of Clinicians
Working with victims of torture may evoke certain feelings or responses in the therapist (Bustos, 1990; Danieli, 1980). If not recognized and handled carefully and appropriately, these responses may interfere with the provision of useful clinical services. Therapists who have not encountered torture victims and who may find it difficult to imagine the sometimes extreme reactions a clinician can experience may find it useful to remember personal reactions that may have occurred when working with clients who have suffered from rape, battering, incest, therapist-patient sex, elder abuse, or child abuse (i.e., instances in which an individual in a more powerful role exploits the trust and vulnerability of another person), although of course the parallels are not exact. Space limitations prevent a substantive discussion of responses a clinician may experience when working with torture victims; they are listed, generally in their most extreme form, simply as a reminder to clinicians to be alert to their possible occurrence.
The intensity of the torture victim's suffering and the urgency of responding to a perhaps bewildering diversity of needs may cause clinicians who encounter a torture victim for the first time to forget that competence in this area of practice, as with other areas of psychological practice, does not come solely by virtue of having a doctorate or a license to practice psychology (Pope & Vasquez, 1998). Those who do not have demonstrable competence should seek supervision or consultation from a clinician who possesses expertise in this area.
Clinicians may experience an almost phobic reaction to hearing the details of the torture. They may communicate to the patient, subtly or more obviously, that explicit description of the horrors of the experience is off limits. Thus therapists may influence the patient to collude in an implicit treatment plan whose central objective is to protect the therapist from discomfort or distress.
On the other hand, clinicians may find themselves intensely curious and eager to press for details. They may experience an almost voyeuristic obsession with intensely graphic accounts and may pressure the patient not to leave anything out. In such instances, it is the therapist's rather than the patient's needs that are being met. Clinicians may experience similar reactions of phobic avoidance of or obsessive interest in the physical damage and disfigurement that torture can produce.
When the patient is identified as a torture victim, clinicians may incorrectly assume that that label is the almost solely defining characteristic of the individual. Clinicians may forget that they are working with a person who is a torture victim rather than with a classification (i.e., "torture victim") that summarizes and subsumes all other human characteristics. In a similar manner, clinicians may mistakenly assume that all torture victims are invariably similar if not essentially identical to each other. They may attempt to bypass the process of learning about each person as an individual.
Torture is frequently used as a form of political repression that targets not only individuals but also entire groups of people and communities for subjugation and even destruction (in some instances, genocide). Many torture victims have been part of a political struggle that has been central to their identity as individuals. Clinicians must avoid letting their political beliefs and allegiances (e.g., the relationship of the clinician's own political values to those of the victim or of those who tortured the victim) interfere with the process of providing appropriate clinical services to the victim. Clinicians whose strong feelings about the politics of the situation might prevent them from rendering helpful, appropriate, and effective services should consider referring the patient elsewhere, just as a homophobic therapist should consider referring a gay or lesbian client to other sources of help. A more subtle though no less important risk can occur when a recently "politicized" therapist, in an attempt to create solidarity with the client and to achieve political goals that are ostensibly those of the client, engages in inappropriate and unhelpful behavior, perhaps by attending only to a political agenda at the expense of the client's individual wants and needs.
Some victims of torture may be fearful that they are still in danger. For example, some may believe that they are pursued and in danger of being abducted or assassinated by those who conducted the previous torture. In some instances, such fear may represent a psychological response to the torture (e.g., difficulty in recognizing that it is over or a part of the cognitive-affective mechanism for processing the trauma). However, in some instances there may be inadequate information for determining the validity of this fear and in other instances there may be good reason to believe that the individual is still in danger. Many torture victims in the United States do not have immigrant or even refugee status, and live in fear of deportation. For these victims, the fear of being sent back to the country in which they were tortured is overwhelming. It is crucial not only to address the victim's fear carefully, realistically, and in a way that offers maximum safety and security, but also to recognize any fear that may be experienced by the therapist. Clinicians may feel that they too are in danger because of their work with the victim. Inappropriate handling of the fear may not only disrupt the therapeutic alliance and the provision of appropriate clinical services to the patient, but in some cases may place both therapist and patient at undue risk for harm.
Clinicians working with victims of torture may experience something akin to survivor guilt or a regret and discomfort at not having previously acknowledged and addressed more actively the practice of torture. These feelings may be intensified when the clinician's government was involved, directly or indirectly, in the torture. Clinicians working in the United States, for example, may be disturbed that Amnesty International's investigation of the detention of two women in the High Security Unit of the Lexington Federal Prison concluded "that the conditions of confinement constituted cruel, inhuman or degrading treatment" and that "the prisoners' prolonged isolation, humiliating strip-searches and additional restrictions had had a detrimental effect on their physical and mental health" (Amnesty International, 1989, p. 152). This unit, which was reported closed in 1988, subjected the two women who were claimed to have been held there "because of their political beliefs" (Amnesty International, 1989, p. 152), to 24-hour observation, 24-hour illumination (i.e., no darkness that might have facilitated sleep), and virtually complete isolation from the outside world, in addition to the frequent strip searches and other measures previously mentioned. The feelings such reports may elicit, if not confronted directly, honestly, and nondefensively by the therapist, may distort and undermine the therapist's attempts to be of help to the victim.
Clinicians may also need to confront their reactions to specific instances in which fellow health care professionals were instrumental in torturing the clinician's patient. Health care professionals can facilitate, enable, or support torture through active complicity as well as tacit acceptance. Historical documentation, for example, has shown that the torture and other atrocities carried out under the Nazi regime involved the active participation of numerous mental and physical health care professionals (Cocks, 1985; Gallagher, 1990; Lifton, 1986; Muller-Hill, 1988; Proctor, 1988). As another example, Weschler (1990) has reviewed the documentation amassed by the International Red Cross and other sources indicating (a) that professional psychologists, drawing on theory and research, can be prominent in the design of comprehensive torture programs that maximize psychological and physical torture, sometimes redesigning university psychology department curricula to provide relevant coursework; (b) that physicians may be present in as many as 70% of torture sessions to ensure that maximum pain is inflicted before the individual loses consciousness and, in certain situations, to ensure that the victim neither dies nor carries physical indicants of torture; and (c) that psychologists can assume the persona of clinician to obtain valuable information from actual and potential victims (e.g., to obtain data for statistical analysis, to determine which methods of torture would be most effective for the individual, to identify flaws in the torture program, to use the victim's later learning of the betrayal of the clinical relationship as an aspect of torture). As a final example, the United Nations General Assembly's (1982) Principles of Medical Ethics [NOTE: Please follow this link to a set of over 40 ethics codes.] emphasized that the UN was "alarmed that not infrequently members of the medical profession or other health personnel are engaged in activities which are difficult to reconcile with medical ethics" (p. 1). It is crucial that the psychology profession forthrightly confront the issue of torture, avoid tacit acceptance of or complicity with programs of torture, and acknowledge and fulfill its professional and ethical responsibilities to victims of torture.
The intensity and pervasiveness of the torture experience may be reflected in the subsequent work between therapist and victim. The dyadic therapeutic situation itself may be evocative of certain aspects of the torture experience: for example, two people, one of whom is licensed by or a representative of the state or larger society and the other of whom is vulnerable and in need, meeting privately in a room; the questioning of extremely personal matters, a process often experienced as intrusive; the character of the regular sessions being explicitly subject to privacy; the discrepancy in power; and the intensity of emotion usually evoked by the process. It is crucial that the therapist monitor and maintain safe, appropriate, and therapeutic boundaries so that the therapeutic relationship does not unconsciously recreate or act out the destructive relationship between torturer and victim.
Some clinicians may find themselves overwhelmed by the accounts of torture and by the obvious suffering and continuing effects experienced by the victim. They may experience depression, anxiety, or symptoms associated with posttraumatic stress disorder (e.g., intrusive thoughts, nightmares, unbidden images). Clinicians bear an important responsibility to monitor their reactions carefully, to obtain needed support, and to ensure that they are not too distressed to be effective. Clinicians who work with many victims particularly need to take adequate steps to prevent burnout.
Issues in Providing Clinical Services to Torture Victims
Diverse therapeutic approaches (e.g., psychodynamic, cognitive, existential) have been described as useful in the treatment of victims of torture (e.g., Allodi, 1980; Butcher, Egli, Shiota, & Ben-Porath, 1988; Garcia-Peltoniemi & Jaranson, 1989; Greening, 1990; Landry, 1989; Ochberg, 1988; Ortmann, Genefke, Jakobsen, & Lunde, 1987; Somnier & Genefke, 1986), although there has been relatively little systematic research (Basoglu & Marks, 1988). Our purpose in this section is not to review those specific approaches but rather to note important clinical issues significant to virtually all clinicians who attempt to provide professional services to these individuals.
As the examples provided in an earlier section vividly illustrate, victims of torture have been subjected to atrocities inflicted by those who had overwhelming power over them. Nothing that the victim said or did could change this overwhelming and extreme experience. Trust in or reliance on the external authority was violated in an intense and brutal manner. This fact is of fundamental importance for those attempting to help victims of torture. No matter how well meaning, well funded, well designed, or eager to help an individual, organization, or facility is, the services offered will be irrelevant if the victim does not trust. Nothing is more important for the professional than addressing this issue of trust.
If it is important to engender the victim's trust, it is equally important to be worthy of that trust. In part that means maintaining awareness of the increasing body of published work on this topic. It also means maintaining awareness of the different ways in which an individual can communicate, directly or indirectly, the possibility that he or she was a victim of torture. Common psychological and somatic symptoms have been listed and discussed in many of the works cited in this article (e.g., Garcia-Peltoniemi, in press; Rasmussen & Lunde, 1980). They include anxiety, fear, guilt, shame, impaired memory, difficulty concentrating, sleep disturbances, depression, low self-esteem, distorted sense of identity, sexual problems, headaches, gastrointestinal complaints, outbursts of anger, social withdrawal, and problems with intimacy. Fahy and his colleagues have described the way in which torture can foster development of anorexia nervosa ( Fahy, Robinson, Russell, & Sheinman, 1988). Obviously, many of these phenomena have a relatively high base-rate among those who receive clinical services. However, particularly when providing services to refugee populations or asylum seekers, professionals should be alert to the possibility that such symptoms may be the result of torture; newcomers to the United States may be more likely to have experienced torture (Cervantes, Salgado de Snyder, & Padilla, 1987; Lee & Lu, 1989).
Cultural factors exert subtle or more obvious influences in all forms of psychotherapy and counseling (Pope & Vasquez, 1998), a phenomenon that may be especially relevant for responding to the needs of torture victims. Cultural factors will influence how victims perceive and express the torture experience and its aftermath. For example, cultural factors may influence the degree to which the effects of trauma are experienced as somatic disorders, as a shameful event not to be disclosed to anyone, or as a phenomenon that neither requires nor deserves professional assistance. Margaret Welch, executive director of the Walter Briehl Human Rights Association, which provides free therapy to torture victims, emphasizes that adjusting to a new culture is one of the major challenges faced by torture victims who are now living in a different country (personal communication, July 4, 1990). Clinicians must be sensitive not only to the culture that the victims view as their own but also to the degree to which the victims may be encountering alienation, acculturation stress, and prejudice (sometimes including threats and actual violence) in their current surroundings. Moreover, agencies may want to consider an active outreach program to address the more general needs of refugee communities of which the torture victim is a member, but from which the victim may be physically, socially, or psychologically separated (Garcia-Peltoniemi, Jaranson, & Teter, 1989).
Evocations of the Torture Situation and Relationship
As mentioned in the previous section on common reactions of therapists, the therapeutic structure can recreate certain aspects of the torture situation and relationship. Moreover, the setting itself as well as certain procedures (e.g., an institutionalized bureaucracy, even spending time in the waiting room) may evoke traumatic memories. An awareness of these potential similarities can enable clinicians to minimize the extraneous points of similarity and the likelihood that the treatment situation itself will elicit flashbacks and other traumatic recreations. As Primo Levy (1988) wrote, "the memory of a trauma suffered or inflicted is itself traumatic because recalling it is painful or at least disturbing" (p. 24).
Medical and Dental Needs
The infliction of torture frequently causes both acute and chronic medical problems that need to be assessed and treated ( Amnesty International, 1984; Cathcart, Berger, & Knazan, 1979; Mollica, Wyshak, & Lavelle, 1987). The possibility of organically based impairment must be carefully assessed. Thus many professionals have found an interdisciplinary model especially helpful (e.g., Garcia-Peltoniemi & Jaranson, 1989; Ortmann et al., 1987). Dental services should also be available: Torture may also involve the breaking, pulling, or stimulation of nerves in the teeth (Archdiocese of Sao Paulo, 1986;Bolling, 1978). Dental damage may also result from beatings, lack of hygiene, and malnutrition.
Use of Assessment Instruments
The use of standardized instruments for psychological assessment of torture victims must be done with great care. For some victims, the test-taking situation may be too evocative of the torture situation. Others may have concerns that they are being used (or abused) as research subjects or "guinea pigs." Still others may experience a formal assessment using standardized instruments as too invasive of their privacy or too alien to their culture. Thus, formal assessment instruments should be used only when there is a clear need for them.
However, in many instances, assessment using standardized instruments seems potentially helpful and is not contraindicated. In these instances, the instruments must be adequately normed, translated (if necessary), and validated for the relevant population as required by American Psychological Association (1985) policy. Moreover, for test-relevant variables, the instrument must be appropriate for the victim's language skills, reading level, cultural and educational background, and so on. Finally, the victim must adequately understand and freely consent to the assessment (Pope & Vasquez, 1998).
The Minnesota Multiphasic Personality Inventories (MMPI and MMPI-2), in their original English versions or in careful translations, have been useful in assessing victims of torture, particularly in cases in which the test results have strengthened psychological testimony to support claims for asylum. Clinicians considering the use of the MMPI-2 (see Pope, Butcher, & Seelen, 2000) may wish to contact the Center for Victims of Torture in Minneapolis, Minnesota, which routinely used translations of the MMPI and more recently has begun using the MMPI-2. The center has found using the MMPI-2 in conjunction with the Symptom Checklist-90 (SCL-90, Derogatis, Lipman, & Covi, 1973), the Beck Depression Inventory (Beck, 1972), and, when indicated, neuropsychological assessment instruments, to be useful for some clients.
Clinicians may also wish to consider appropriate translations of the Hopkins Symptom Checklist-25 (HSCL-25):
[T]he HSCL-25 is a short, nonprovocative instrument that puts words around the patient's feelings. Many refugees (especially the trauma victims) are so overwhelmed by their emotions and/or are so shy and reticent that they are unable to articulate their major psychiatric symptoms to interviewers.... The HSCL-25, however, was able to move beyond "just not feeling right" to specify emotional complaints necessary for diagnosis and treatment. (Mollica, Wyshak, de Marneffe, Khuon, & Lavelle, 1987, p. 499)
Posttraumatic Stress Disorder
It is only in the last decade that studies have begun to formally assess the degree to which torture victims tend to suffer from posttraumatic stress disorder (PTSD). The studies have tended to show that PTSD is quite common, in some cases afflicting as many as 50% of refugees from countries in which torture was prevalent (Mollica, Wyshak, de Marneffe, et al., 1987) and 70% of torture victims (Garcia-Peltoniemi & Jaranson, 1989). Furthermore, PTSD in such refugee populations tends to occur with at least one other major clinical syndrome, generally major affective disorder (Garcia-Peltoniemi & Jaranson, 1989; Kinzie, Fredrickson, & Ben, 1984; Mollica, Wyshak, de Marneffe, et al., 1987). PTSD that occurs as a result of torture may persist for long periods despite treatment (Weisaeth, 1989).
Fundamental Daily Needs
While attending adequately to the important medical, cultural, and psychological needs of the victim, it is important that the clinician not neglect the problems that the victim may be experiencing in coping with fundamental daily tasks. For some victims, there may be pressing needs for food, clothing, shelter, and transportation. For some, even if the resources are present, carrying out simple tasks may be virtually impossible. One victim did not know how to open a door because he had not been allowed to do so for 13 years; nor was he able to make a dark room light by throwing the light switch (Weschler, 1990). Another victim reflexively removed her clothes when she was in the presence of other people because this was what she had been forced to do repeatedly (Russell, 1989). For many victims, cognitive impairment is typical; concentration and memory difficulties interfere with language acquisition and the ability to hold a job or pursue an education.
Torture can interrupt and sometimes reverse the progress that individuals make through the stages of psychological development.
A young man in his early twenties... insisted he was an old man; his "soul had been embittered" by what had been done to him; he had "seen it all" and did not like "any of it." At the same time, this young man continues to act like a much younger person particularly in his interpersonal relationships, insisting on perfection from others and flying into a rage when others do not fulfill his unrealistic expectations. (Garcia-Peltoniemi & Jaranson, 1989 , p. 9)
At any age or developmental stage, torture and its sequelae disrupt the life plan and force the individual to confront an altered set of choices or possibilities.
Personal testimony may be an exceptionally healing experience for many victims of torture (see, e.g., Agger & Jensen, 1990 ; Cienfuegos & Monelli, 1983 ; Weschler, 1990). Through description of their experiences, some of the most taboo aspects, such as shame, guilt, self-blame, can be acknowledged, worked through, and reconceptualized. Presenting testimony can help overcome the isolation and secrecy frequently associated with torture. Stephen Biko, for example, noted that the privacy and secrecy of torture not only intensified the psychological pain and isolation of the prisoner but also made easier (i.e., harder to contradict) subsequent reports by the authorities that the prisoner "slipped off a piece of soap, fell and died" (Biko, 1978 , p. 75). When testimony is communal in nature, it can help counter the victims' sense of being overwhelmed by a powerful communal force. Nelson Mandela (1986) described as common the "assaults [that were] communal in character, what the prison staff called a 'carry on, ' when they used not just batons but even pick handles" (p. 209). The testimony can also function as a denunciation of injustice. In the words of Agger and Jensen (1990), "personal pain is transformed into political dignity" (p. 115).
In recent years, Brazilian citizens engaged in a creative and collective version of testimony by collecting and publishing accounts of torture in their country. The Brazilian generals, whose reign of torture ended in March, 1985, had ordered detailed and comprehensive documents compiled on all court cases and subsequent actions, seemingly unaware that their rule might come to an end or that the documents would ever become public (Weschler, 1990). When the government changed hands, an elaborate covert plan was implemented to photostat all of these documents and to publish them. The American translation of this volume appeared as Torture in Brazil (Archdiocese of Sao Paulo, 1986). The military's own documents, preserved in the Archive of the Supreme Military Court, demonstrated 283 different types of torture and identified 17, 420 individuals who were brought through this system. Weschler (1990) provided an account of the project that collected and published these records as well as the rationale for why the Brazilian generals would document so carefully the program of torture carried out under their auspices:
They were like the Nazis.... They imagined that they were laying the groundwork for a civilization that would last a thousand years-that, far from having to justify themselves for occasional lapses, they would be celebrated by all posterity for the breadth of their achievement. (p. 48)
Clinicians must be aware of not only the profoundly healing power of testimony but also its limits when the testimony is ignored or produces no effect. For example, Jose Morais, vice president of the Rio chapter of Tortura Nunca Mais (Torture Never Again), expressed his frustration at the lack of consequences to his denunciation: "On October 29, I published a denunciation (in a local newspaper) in which I gave the names of people who I know were involved in torture.... I am astounded because no one on the list denies it. Society at large is unresponsive. And what is worse, our friends and allies are indifferent" (Hildula, 1990 , p. A-14).
Accepting the Victim's Reactions
Clinicians may tend to anticipate the victim's reactions to the torture. For example, some therapists may expect a version of the "Stockholm Syndrome, " in which captives tend to identify with and sometimes feel extremely warm feelings for their captors. This phenomenon, however, is virtually never reported among victims of torture (Somnier & Genefke, 1986). On the other hand, therapists may be convinced that the victim will express rage at his or her captors; such rage, however, may be absent, particularly at the beginning of treatment.
Most commonly, the victims were bewildered by the cruelty of their oppressors and deeply ashamed and humiliated-which suggests that the main aim of torture, the humiliation and dehumanization of the victim, had been achieved. (Allodi, 1980, p. 231)
What is crucial is that the clinician listen with care, acceptance, and respect to whatever the victim communicates.
Monitoring the Course of Treatment
Studies have shown that although most populations tend to benefit from psychotherapy and related clinical services, some, such as Cambodian victims of torture, frequently tend to show few benefits (Mollica et al., 1990). Moreover, a careful study of therapy for Cambodian, Hmong/Laotian, and Vietnamese groups showed that although many psychological symptoms improved, most somatic symptoms (especially headaches but also trembling, lack of energy, and heart difficulties) actually became worse (Mollica et al., 1990). Treatment of torture victims is a relatively new field. We must carefully address such issues as the goal of therapy and what constitutes successful outcomes.
Professional psychologists working with victims of torture may find helpful the links to over 100 diverse online resources at http://kspope.com/torvic/torture.php.
Although this article has focused on providing clinical services to victims of torture, such services must be viewed as only one aspect of an adequate response to the prevalence of torture and the plight of its victims. There are at least three areas in which professional psychology must confront its responsibilities in regard to torture and its victims: research, practice, and education.
Researchers can address such questions as What clinical and related interventions are most helpful to victims of torture? Researchers can also help us to understand more fully the phenomenon of torture and our responses to it. Extensive studies, many of them highly controversial, have been conducted of the factors that influence individuals to inflict pain and torture on other individuals (e.g., Gibson, 1990; Kelman & Hamilton, 1989; Milgram, 1974; Zimbardo, 1970). Further research is needed to illuminate the processes by which we deny the reality of the torture that is being conducted in the world today and perhaps, through our silence and inactivity, enable it to continue. Arendt (1964) , for example, noted the subsequent condemnation of "the wave of coordination which passed over the German people in 1933 and...turned the Jews into pariahs" (p. 296), with many later claiming to have been unaware of the atrocities that were occurring. She found partial explanation of the behavior of both those who were actively involved and those who failed to attempt to stop the process in "the strange interdependence of thoughtlessness and evil" (p. 288). The reality of the atrocities became distant and remote, without acknowledgement or reflective thought. According to Arendt, "such remoteness from reality and such thoughtlessness can wreak more havoc than all the evil instincts taken together" (p. 288). More recently, Staub (1989 , 1990) explored the psychology of rescuers and helpers who, under conditions of repression, oppose torturers, resist being placed in the role of torturers, or attempt to help victims. We are in need of research that can help enable us to avoid participating even indirectly or passively as, in Camus's (1986) words, either victims or executioners.
Practitioners must provide appropriate clinical services to victims of torture, many of whom live in and are continuing to arrive in the United States. These clinical services can be improved by drawing on what is learned from research and must take into account the special needs of this population. We cannot assume that traditional models for working with traumatized populations-even those who show striking similarities to (as well as important differences from) torture victims, such as victims of rape, battering, incest, sexual abuse by a therapist, child abuse, and elder abuse-will necessarily work most effectively with those who have been tortured. Nor can we assume, as emphasized previously, that all torture victims are alike or will benefit from the same interventions. Victims may have suffered one or more of the almost infinite number of ways in which the mind, body, and spirit can be tortured, such as beatings, electrical shocks, burning, freezing, cutting, isolation, brainwashing, rape, starvation, humiliation, threats, sleep deprivation, sensory deprivation, and being forced to witness the torture of others, to name but a few. Similarly, victims may survive and attempt to recover using any number of diverse resources and coping strategies.
Consequently, practitioners and researchers will find it less useful to search for the most effective treatment model for torture victims than--to paraphrase what has become one of the most fundamental axioms of psychotherapy research (Paul, 1967; Strupp & Bergin, 1969)--to attempt to find what model works best under what circumstances for what person with what cognitive and related coping styles who has suffered what forms of torture and who has what resources available.
Finally, these issues must be addressed in formal and informal education. Our response to the reality and to the victims of torture must not be absent from our graduate courses, our textbooks, our journals, or our professional meetings. It is a responsibility borne both by individuals and by the profession. In 1948 the United Nations adopted the Universal Declaration of Human Rights . Noting the "barbarous acts which have outraged the conscience of mankind," (p. 1), the declaration urges that
every individual and every organ of society, keeping this Declaration constantly in mind, shall strive by teaching and education to promote respect for these rights and freedoms and by progressive measures...to secure their universal and effective recognition. (p. 2)
[NOTE: Some references have been updated since the publication of the original article.]
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