Torture was a sanctioned part of many legal proceedings in much of Europe from the mid-fourteenth century to the end of the eighteenth century, including being used by the Inquisition in heresy cases (Skoll, 2008). By the early twenty-first century torture had generally become publically unacceptable while flourishing in secret (Amnesty International, 2014; Nowak, 2012). Article 1 of the UNCAT, adopted in 1984, defines torture as follows:

… ‘torture’ means 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 does not include pain or suffering arising only from, inherent in or incidental to lawful sanctions. (UN General Assembly, 1984, Article 1.1)

This UNCAT definition is the most commonly used definition for torture worldwide. The US definition of torture adopted in the Torture Victims Relief Act (18 U.S.C. 2340(1) 1998) is more narrow than that of UNCAT, despite the fact that the United States is a signatory to the UNCAT:

‘torture’ means an act committed by a person acting under the color of law specifically intended to inflict severe physical or mental pain or suffering (other than pain or suffering incidental to lawful sanctions) upon another person within his custody or lawful control. (18 U.S.C. 2340(1) 1998)

The way the United States defines what constitutes severe physical or mental pain has been contentious (Basoglu, Livanou, & Crnobaric, 2007). The US definition of torture and its use of torture have faced intense criticism within the United States and abroad, including by some high ranking US military and other officials; leading torture treatment clinicians, researchers, attorneys, and human rights groups; and the UN Committee Against Torture (Amnesty International, 2006; Basoglu et al., 2007; Davis, 2012; Luban & Shue, 2012). A key concern relates to the United States’ efforts to distinguish psychological from physical torture, thus weakening legal protections against the former.

While some are targeted for torture due to their political beliefs and/or activities in opposition to those in power, others are tortured due to their nationality, race, religious beliefs or practices (including being agnostic or atheist), and/or membership in a social group (e.g., lesbian, gay, bisexual, transgender, queer/questioning (LGBTQ)). Others may be tortured due to mistaken identity (e.g., for their imputed political or religious identity or activities, no matter if in error). These individuals may happen to live near an area with heavy rebel activity and the government forces assume (incorrectly) that they are aligned with or supporting the rebels. Some of those who manage to survive torture flee their homelands seeking safety.

In the United States, prisoners are particularly vulnerable to torture and cruel, inhuman or degrading treatment or punishment (CIDT). Prisoners most targeted for sexual violence by officials and other prisoners are: youth in juvenile and adult facilities; transgender and gay detainees or those perceived to be gender variant or gay; immigration detainees; and first-time, nonviolent offenders (Stop Prisoner Rape, 2006). Practices such as excessive strip searches, solitary confinement, the shackling of women prisoners during childbirth, and interrogation methods used by some guards are notable violations (ACLU, 2012; Human Rights Watch/ACLU, 2012). Persons in psychiatric hospitals, nursing homes, and children in congregate care are similarly at risk for chemical restraint when it is not medically appropriate or necessary (Kisken, 2013; Penturf, 2013). It is hard to determine the prevalence of torture and CIDT when those victimized are kept largely hidden from public view with poor access and oversight.

Amnesty International estimates that 112 countries worldwide engaged in the practice of torture of their citizens in 2012 (Amnesty International, 2013). Roughly two-thirds of all governments worldwide sanction torture (Engstrom & Okomura, 2004), including the United States, despite the universal condemnation of the practice of torture (Hajjar, 2012). The United Nations Special Rapporteur on torture and other cruel, inhuman, or degrading treatment or punishment has stated that at least half the countries in the world are engaging in torture or mistreatment at any moment (Méndez & Wentworth, 2011). Reports of torture in Syria are making headlines at the time of this writing, a glaring example of the limitations of existing international efforts to prevent and prohibit torture. Many instances of torture, however, occur outside of the limelight. Conservative estimates are that between 10 and 30 % (300,000–900,000) of the 3 million refugees who came to the United States since 1975 from many countries were torture survivors (Modvig & Jaranson, 2004), and that the percentage among asylum seekers is likely greater (Burnett & Peel, 2001). At the same time, it is difficult to estimate the numbers of individuals from other populations in the United States who have been tortured and subjected to CIDT. These would include children and adults that are kept in solitary confinement and vulnerable persons chemically restrained in the United States in order to subdue and control them more easily.

Chris, a 27-year-old American man was convicted of aggravated murder and sentenced to death. In the supermax⁴ prison where he has been held for the past five years, Chris is confined to his small cell with a solid steel door 23 hours per day. Even during the several hours of exercise time he is allowed per week, he has minimal contact with other humans, limited to guards shackling and handcuffing him and taking him to a cage where he exercises alone. He has been beaten and raped by several of the guards. Strip searches are routine whenever he goes in or out of his cell to the infirmary or to meet with his lawyer. Chris became psychotic during his first year in the supermax, with frightening visual hallucinations of tigers and other wild animals in his cell. He continues to talk to himself and believes that Jesus and Satan are spying on him through the electronic surveillance equipment in his cell. He has tried to kill himself twice at the supermax.

The US government often points to torture and other human rights violations committed by state actors outside of the United States while failing to examine its own actions through a human rights lens. The contradiction is glaring. The United States ratified the International Covenant on Civil and Political Rights (ICCPR) in 1992 and the UNCAT in 1994 and thus has obligations to adhere to the commitments it made not to torture or inflict CIDT or punishment. Notably, however, at the time of this writing the United States has not signed or ratified the 2002 Optional Protocol to the CAT (OPCAT, a treaty that supplements the 1984 CAT) and therefore, is not subject to international inspection of conditions of detention such as the prison where Chris is held. The United States provides asylum to individuals who fled from other countries after being tortured by their governments (recognizing torture as a severe form of persecution) and yet engages in torture itself. Such double standards related to human rights and not engaging fully with the international dialogue related to human rights law have been identified as hallmarks of exceptionalism related to human rights (Ignatieff, 2005). The United States has failed to sign or ratify some major human rights documents and has not fulfilled its duties and obligations in regards to some of the human rights treaties it has ratified. Hertel and Libal (2011) warn of the dangers associated with engaging in such US exceptionalism.

The United States’ use of solitary confinement with minors (Grassian, 2006; Human Rights Watch/American Civil Liberties Union, 2012) and the torture of enemy combatants and suspected terrorists (Hajjar, 2012; Mayer, 2009) are striking examples of the US Government’s violation of human rights through torture (UN Committee Against Torture, 2006). The former chief prosecutor for the military commissions at Guantanamo Bay, Cuba, Retired Air Force Col. Morris Davis, publically condemned the US use of torture in an op-ed in the Los Angeles Times, stressing that torture is always illegal (Davis, 2012). The UNCAT, ratified by the United States, prohibits torture unconditionally, such that “No exceptional circumstances whatsoever, whether a state of war or a threat of war, internal political instability or any other public emergency, may be invoked as a justification of torture” (UN General Assembly, 1984, Article 1). Many organizations (and some legislators) have also denounced the United States’ involvement in torture, including the National Association of Social Workers, the National Religious Campaign Against Torture, the National Consortium of Torture Treatment Programs and its member centers, Human Rights First, and Amnesty International, calling for such things as accountability, the release of the Senate Intelligence Committee’s report on torture and for a federal truth commission to investigate the use of torture by the United States post-9/11 (Gosztola, 2014; Keller & Granski, 2013; Leahy, 2009; NASW, 2006). The United Nations’ Special Rapporteur on Torture and Committee on Torture have repeatedly condemned the US criminal justice system for use of such measures as lengthy solitary confinement and capital punishment (Gilligan & Lee, 2013; Interim Report of the Special Rapporteur, 2011; Méndez, 2012). Solitary confinement, ostensibly employed for the protection of minors held in adult facilities, and long-term segregation in supermax prisons can lead to psychosis and other severe psychiatric harm in a relatively short time and has been identified as a type of torture (Grassian, 2006; HRW/ACLU, 2012).

The UN Human Rights Committee (2014) expressed a number of concerns about the human rights record of the United States regarding torture in its Concluding Observations on the Fourth Periodic Report of the United States of America. Among these were: the United States continues to maintain that the ICCPR does not apply to individuals under its jurisdiction who are being held outside its territory; the limited legal reach of the ICCPR and lack of its full implementation at local levels in the United States; the conditions of detention, including the use of solitary confinement; the extensive use of nonconsensual psychiatric treatment; the extremely limited number of individuals held accountable for past acts of torture, CIDT, and enhanced interrogation; and the absence of comprehensive legislation in the United States criminalizing torture in all its forms, including mental forms of torture.

It is important for clinical social workers to understand the range of possible impacts of torture on individuals as this information can be used to guide clinical assessment and intervention. As in the case of Bataar described at the outset of this chapter, torture often leaves one feeling demoralized, dehumanized, and humiliated on top of struggling with other common physical, psychological, social, and spiritual sequelae (Kinzie et al., 2008; Ortiz, 2001). A meta-analysis of epidemiological studies of torture survivors and refugees in the United States and their home countries found high rates of mental health problems (Steel et al., 2009). Similarly high rates of mental health problems were found in a systematic review of studies of refugees resettled in Western countries (Fazel, Wheeler, & Danesh, 2005). The most common psychiatric conditions diagnosed in refugees are depression, posttraumatic stress disorder (PTSD), comorbid PTSD and depression, psychotic disorders, and anxiety conditions such as phobias and panic (Kinzie, Jaranson, & Kroupin, 2007; Marshall, Schell, Elliot, Berthold, & Chun, 2005; Steel et al., 2009). Often, neither depression nor PTSD captures the range of distress. Complex presentations may include shame, mistrust, conversion, somatic symptoms, unexplained pain, feeling of permanent damage, dissociation, sexual problems, self-blame, guilt, and/or low self-esteem (Quiroga & Jaranson, 2005). Some survivors may also engage in tension reduction behaviors (e.g., substance use, self-injurious behaviors, other forms of externalizing anxiety reduction strategies; Briere & Scott, 2012). These same clinical conditions and symptoms are commonly found in US born individuals who are tortured and/or subjected to CIDT or punishment as well (Grassian, 2006; HRW/ACLU, 2012). Torture survivors may experience a chronic fluctuating course of posttraumatic symptoms, with periods of exacerbations typically triggered by things that remind them of their torture and periods of remission (Kinzie, 2011). Some torture survivors may benefit from long-term treatment (Boehnlein & Kinzie, 2011; Dube, Felitti, Dong, Giles, & Anda, 2003; Kinzie, 2001, 2011; Marshall et al., 2005).

A growing body of epidemiologic research has found an association between exposure to trauma, mental and adverse physical health outcomes, and premature death in veteran, torture, refugee and other populations (Boscarino, 2004; Coughlin, 2012; Schnurr & Green, 2004; Wagner et al., 2013). Trauma exposure and PTSD have been found to be associated with various health conditions such as cardiovascular disease, musculoskeletal conditions, diabetes, gastrointestinal disease, chronic fatigue syndrome, fibromyalgia, and other health conditions. Particularly robust is the evidence linking exposure to psychological trauma and cardiovascular disease across a variety of populations and stressors (Boscarino, 2004).

Torture often affects survivors’ capacity to trust others and form interpersonal bonds, retain a sense of identity, maintain faith in a system of justice, and sustain a sense of existential meaning and hope (Briere & Scott, 2012; Costanzo, Gerrity, & Lykes, 2007; Ortiz, 2001). Torture among refugees and incarcerated youth and adults in the United States is associated with high rates of suicidality (Grassian, 2006; Human Rights Watch/American Civil Liberties Union, 2012), especially when PTSD is present (Ferrada-Noli, Asberg, Ormstad, Lundin, & Sundbom, 1998). Detention of torture survivors who are seeking asylum has been found to be detrimental for their physical and mental health and to put them at risk for suicide (Keller et al., 2003; PHR and Bellevue/NYU, 2003; Silove, Steel, & Mollica, 2001). This is consistent with the experience of torture treatment specialists who also find that the risk of suicide for survivors seeking asylum is high around asylum hearings when they fear that they may be deported.

Asylum law is complex and the stakes of not succeeding in obtaining asylum or another form of legal relief are high. Survivors often live in fear of the dangers associated with being deported back to the country where they were tortured and are typically still seen as a threat to the powers that be. Some torture survivors have been blacklisted and fear that they would be picked up by the authorities at the airport when they first arrive back in their homeland, detained again, and tortured. Many were threatened with death or subjected to mock execution as part of their previous torture and often fear that the authorities would murder them if they returned home.

The asylum process is typically a very retraumatizing and stressful experience, with survivors being required to write and testify in tremendous details about experiences that they have been desperately trying to forget and avoid, including sexual torture and other experiences that are considered deeply stigmatizing and shameful in their culture (Berthold & Gray, 2011; Gangsei & Deutsch, 2007; Herlihy & Turner, 2009). Survivors may experience the legal system as their adversary rather than advocate (Martinez & Fabri, 1992).

Most specialists (and survivors themselves) agree that safety is the most essential ingredient necessary in order for a torture survivor to recover and flourish (Fabri, 2001; Gangsei & Deutsch, 2007; Ortiz, 2001). Obtaining asylum can be an important step toward gaining increased safety. Even in exile, however, one cannot be assured of a safe and trauma-free life. Survivors of torture have been trafficked, subjected to community violence, been diagnosed with cancer and other serious health problems, and experienced other traumas after fleeing their homelands seeking safety. There have been documented reports of perpetrators of torture and other human rights violations from other countries living in the United States and other countries where survivors have fled.⁵

The impact of state-sponsored torture typically affects not only the torture survivor himself or herself, but also his or her family members and community (Berthold, 2013b; Ortiz, 2001). Increased marital and/or intergenerational conflict, compromised family or parental functioning, reduced tolerance for the expression of emotional distress, and increased pressure on children to be successful are all possible in the aftermath of torture (Center for Victims of Torture, 2005). Family members, friends, and associates have told many survivors who fled to the United States that their perpetrators have continued to look for them after they left their country. Quite a few of the survivors treated by torture treatment specialists have had loved ones back home (including their children, spouses, siblings, elderly parents, other relatives, and associates) harmed by the authorities who were looking for them. This harm included being interrogated about the whereabouts of the torture survivor who fled and/or threatened, tortured, disappeared,⁶ murdered, or forced into hiding. One of the common aims of state-sponsored torture is to instill fear in society and silence the opposition (Berthold, 2013b; Quiroga & Jaranson, 2005). Social withdrawal and increased distrust in authority figures and others is common. Some survivors and their loved ones may no longer know if they can trust their friends and associates. Indeed, the survivor may have been apprehended by his or her torturers as a result of someone close to them revealing his or her identity and/or whereabouts under the duress of torture. Social networks, typically a keen source of practical, social, and emotional support, may constrict in the aftermath of torture.

Not all survivors of torture suffer from PTSD or other mental health conditions. Some are highly resilient, possessing significant strengths (Guskovict, 2012; Moio, 2008). Often conceptualized as a defense mechanism, resilience enables individuals to effectively adapt and thrive when faced with adversity or trauma (Bonanno, 2004; Masten & Obradovic, 2008). Some research indicates that the most prevalent outcome of potentially traumatic events (PTEs) may not be psychopathology, but rather resilience and a stable trajectory of healthy functioning (Bonanno, Westphal, & Mancini, 2011). Research with torture survivors has identified a number of factors that appear to be protective or mitigate the harmful impact of their torture, including: the presence of strong support (Basoglu et al., 1994b; Moio, 2008), spirituality (Holtz, 1998), firm commitment to a cause (Basoglu et al., 1997), and advance preparation for one’s torture (Basoglu, Paker, Ozmen, Tasdemir, & Sahin, 1994a). A survivor may be highly resilient and functional in some areas of their lives, while still struggling with symptoms of psychological distress and/or challenges functioning in other areas. Being a survivor of torture or other human rights violations does not define who a person is. It is only one part of his or her life experience.

Clinical social workers in the United States may more routinely come across torture in populations other than asylum seekers (unless they work with a specialty torture treatment program). For example, they may encounter torture and CIDT or punishment in the context of their work in prisons or detention centers (e.g., solitary confinement, the shackling of women prisoners during childbirth; Human Rights Watch/American Civil Liberties Union, 2006, 2012; Lewis, 2012), corporeal punishment of youth in schools (Murphy & Vagins, 2012), and indiscriminate use of chemical restraint in psychiatric or nursing home facilities as well as in child residential, foster care, and juvenile justice facilities (Kisken, 2013; Penturf, 2013). Although some of these practices are frequently not framed or perceived by the United States as torture, they are by others. Whether one calls such treatment CIDT or torture, both are condemned and prohibited by the CAT that the United States has ratified and is obligated to uphold.

The act of torture strips a person of their rights, including the right to self-determine what happens to their physical and psychological integrity. This underscores why a rights-based approach that supports the survivor’s self-determination and ability to reclaim their role as protagonist in their own life (Barbera, 2014) is so essential to their healing process. A rights-based approach to clinical practice with torture survivors is structured to be disparate in all ways to what they experienced during torture to support the reclaiming of their humanity and agency (Fabri, 2001; Ortiz, 2001). Torturers often utilize torture methods that are designed to destroy the victim’s sense of humanity and worth. For Bataar, the young Mongolian man from the case example at the beginning of this chapter, it was vital that his social worker treated him with respect and upheld his fundamental dignity and humanity. While these practice behaviors are essential for professional and ethical social work practice with any person, tortured or not, they are particularly crucial when the nature of the trauma violated the most basic concepts of what it means to be human. These are important ingredients in an overall approach to counteract the dehumanizing treatment survivors experienced at the hands of their torturer(s).

As mentioned in Chapter 1, it is particularly important not to rush through the process of obtaining a torture survivor’s signed consent for services (or signing of other documents) given that the act of signing a document as part of their torture is a fairly common experience for many survivors (e.g., Bataar, in the opening vignette, was forced to sign a document denouncing his identity as a gay man). Some survivors are forced under the duress of torture to sign a false confession or a blank piece of paper before their torturers will release them, and are told that the authorities will fill in his or her alleged “crimes” later. This was the case for “John” (a pseudonym), locked for months in a so-called “safe house,” sodomized and beaten by multiple soldiers each day, accused of being a dissident.

As part of the trauma, those subjected to torture are often told by the perpetrator(s) that, if they survive, nobody will believe them (Gangsei & Deutsch, 2007), that there is no point in telling anyone, and that, if they do, they (or their loved ones or associates) will be tortured or killed. These threats, along with the common posttraumatic stress response of avoidance of things that remind the survivor of the trauma, contribute to many survivors not feeling safe or able to tell their social worker or others about their torture. Survivors and their family members frequently live with shame and fear of further persecution, feelings that also reinforce their remaining silent about the torture. It can be impossible to find the words to express or explain one’s traumatic experiences (Dalenberg, 2000) in any language. They may worry that, even if they did reveal their experience of torture, the clinician would not believe or truly understand what happened or will think less of them (given the intense shame and stigma associated with many of the methods of torture; Fabri, 2001). Indeed, it can be hard or frightening for a clinician to know what humans are capable of doing to one another and confront evil (Northwood, 2003; the impact of this work on clinical social workers will be discussed in detail in Chapter 5 of this book).

Given this reality and the negative impact of human-perpetrated torture on relationships, social workers providing clinical services to torture survivors must attend deeply to building a safe and trusting therapeutic relationship. In the absence of a trusting relationship, the process of healing may be negatively affected (Fabri, 2001; Kanninen, Salo, & Punamaki, 2000). Employing strong basic clinical skills (e.g., active listening, validating that what the person went through was real, and demonstrating trustworthiness over time) can be valuable mechanisms of healing. Demonstrating one’s commitment to upholding the survivor’s right to confidentiality, a foreign concept for some, by checking with the survivor each time and gaining their consent before communicating with others involved in their case to coordinate services reinforces that one is trustworthy and responsive. A survivor recently told his social worker, after being granted asylum after 6 years of court appearances and multiple bouts of suicidal ideation, that regaining faith in humans again through his relationship with the social worker helped him the most in his recovery. “You cared about me and didn’t give up. Nobody has ever done that before. You stuck with me over all these years,” the survivor explained, adding, “You remained hopeful when I was hopeless. That helped me to keep going” (Anonymous survivor, personal communication, March 4, 2014).

Ortiz (2001), an American Ursuline nun abducted and tortured in 1989 by members of the US backed Guatemalan military for her work with indigenous peoples, describes what it feels like to be a survivor of torture and to receive services from a clinician, emphasizing what is and what is not helpful. While noting that suicide is a very real concern for some survivors of torture, Ortiz describes how frightening and retraumatizing forced hospitalization can be (recreating the feeling of detention during one’s torture). She recommends that it be avoided when possible. Ortiz (2001) provides insight that for some torture survivors, “suicide would be granting our perpetrators the satisfaction of knowing that they were successful in destroying us completely. Instead, for us, survival is our ultimate act of defiance” (p. 21). She urges practitioners to focus more heavily on the resilience found in survivors, honor their cultural beliefs and approaches to healing, recognize transitional survival strategies (rather than just labeling them as pathological), be nonjudgmental, and give survivors control over their own decisions and their path toward recovery.

Ortiz urges clinicians to be cautious not to misdiagnose, something more likely if the clinician does not understand the experience of torture or take adequate time to create a therapeutic environment conducive to the survivor feeling safe to reveal details of his or her experiences. Ortiz (2001) recounts the experience of a woman misdiagnosed with an eating disorder that explained that her problem with eating was not a control issue as the psychiatrist posited. Her problem with eating was because she would start to choke when she tried to swallow food, flooded with memories of being raped and forced to swallow the semen (and sometimes urine) of her torturers. Another survivor, labeled as depressed, acknowledges that of course his heart was very sad after witnessing his neighbors murdering each other and being forced to flee and leave loved ones behind. For this survivor, and many others, deep sadness was normal and to be expected, rather than a sickness or mental illness. Misdiagnosis can lead to inappropriate treatment and further abuses and deprivation of rights, leaving the survivor to feel labeled, dehumanized, and inferior, much like the way they were treated by their torturers.

Two models of treatment, Narrative Exposure Therapy (NET) and the Self-Trauma Model (STM), will be briefly discussed as examples of being consonant with a rights-based practice and appropriate for work with torture survivors and other survivors of human rights violations. NET was developed for the short-term treatment of individuals who are experiencing PTSD as a result of massive violations of their human rights (Schauer, Neuner, & Elbert, 2005). It draws on Trauma-Focused Cognitive Behavioral Therapy (TF-CBT; Cohen, Mannarino, & Deblinger, 2006) and Testimony Therapy developed to treat Chilean torture survivors (Cienfuegos & Monelli, 1983). Among the many strengths of this therapeutic approach from a human rights perspective, is that NET does not medicalize the problem of posttraumatic stress or stigmatize the individual who is suffering. The problem is defined as a political and social one outside the individual (Schauer et al. 2005). Survivors create narratives of their lives, including their traumas, which can be very therapeutic. These narratives can also be helpful in documenting human rights violations and hence, are politically and socially meaningful (Bichescu, Neuner, Schauer, & Elbert, 2007