Severe suffering can come from mental and physical assaults.Getty

The long-term mental anguish caused by psychological torture and humiliating treatment is comparable to that caused by physical torture, a new study indicates. The results, say the study's authors, support the prohibition of psychological torture by international law.

The findings are particularly important given recent debate over how the United States defines torture. The United Nations Convention Against Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment defines it as "severe suffering, whether physical or mental".

But the US Department of Defense has argued for a definition of torture that does not include many acts of psychological abuse, including humiliating treatment, isolation, or deprivation of sleep, food, or medical care. The implication is that these psychological acts aren't as serious, says Metin Basoglu of King's College University in London, lead author of the new study.

To investigate this point, Basoglu and his colleagues studied the effects of psychological abuse in 279 survivors of torture during the war in former Yugoslavia. Nearly all of the participants had been beaten, humiliated and threatened with death. Participants were asked to rank the distress caused by different assaults on a scale of zero to four.

The results, published this week in Archives of General Psychiatry, showed that many forms of psychological abuse ranked as high as physical torture¹. Fondling of genitals or witnessing a sham execution, for example, scored an average 3.7 out of 4, higher than forced extraction of teeth (3.6) and stretching of the body (3.5), and nearly as high as the most distressing assault: rape, which was rated at 3.9.

Participants were also asked to describe how much control they felt they had during each stressor. Overall, the less control the prisoner felt, the more distress they experienced. This mirrors findings from animal research, in which animals exposed to uncontrollable and unpredictable stresses show greater signs of stress.

Clinicians in torture rehabilitation centres have noted this anecdotally for decades, says David Eisenman, a doctor of internal medicine at the University of California, Los Angeles. "People who have the greatest mental distress are not necessarily the people who are physically injured by the event," says Eisenman. "I've seen many patients where a sham execution was the sole event that destroyed them psychologically."

Issues of trust

Data on the effects of torture are hard to come by, says Steven Miles of the Center for Bioethics at the University of Minnesota in Minneapolis. Many centres treating torture victims are reluctant to add the burden of research to an already problematic doctor-patient relationship, he says: clinicians were often involved in the torture itself, making it hard for patients to trust other medics in later life.

"We thought this study would be useful because much of the debate around this issue is not well informed by empirical evidence," says Basoglu. "Basically it's one person's opinion against another's."

The United States government has argued, for example, that classifying an interrogation technique as a cause of "severe mental pain or suffering" requires proof that it triggers post-traumatic stress disorder (PTSD), a complex anxiety condition that sometimes arises after a traumatic event. Their argument is based in part on a previous analysis from Basoglu showing that torture survivors have higher rates of PTSD.

But many observers have decried that definition, saying that torture survivors often experience mental health consequences that are different from PTSD but just as disruptive. Basoglu's new study also refutes this interpretation of his earlier work. Severity of abuse does not correlate with incidence of PTSD in this study, he says.

Development of PTSD depends not only on the form of torture used, but also on the background of the torture victim. Political activists, for example, who have come to expect that they may one day be tortured, typically sustain less psychological damage from torture than an unsuspecting citizen, says Miles.

Expanding definition

Basoglu says that his results demonstrate the need to add psychological abuse to the US definition of torture.

But not everyone agrees this would be useful. Gregg Bloche, a lawyer and psychiatrist at Georgetown University in Washington DC, argues that lumping all forms of psychological abuse into the definition of torture would simply expand the word to include "a lot of other things that are less heinous". "That makes it harder to maintain the strongly negative aura that torture has," he adds.

Bloche says that courts should decide whether psychological abuse rises to the level of torture or not on a case-by-case basis. International tribunals could draw upon Basoglu's data to make a distinction, he adds.

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• References

  1. Basoglu M. & Livanou M. & Crnobaric C.. Arch Gen Psychiatry, 64 . 277 - 285 (2007).