Psychologists and psychiatrists should not be expected to participate in torture as they do not have the expertise to assess individual pain or the long-term effects of interrogation, says an expert on bmj.com today.
The authors, Derrick Silove and Susan Rees, from the University of New South Wales in Australia, say some senior members of the US military have argued that a psychologist’s presence is necessary to protect the prisoner or detainee from the ‘severe physical or mental pain or suffering resulting in prolonged mental harm.’
They add that several leading scientific journals have also published papers by authors who support the presence of mental health professionals as protection for detainees.
But the authors believe that there is no established marker to assess ‘extreme experiences that cause pain or psychological trauma’ and do not believe it is possible for professionals ‘to make accurate assessments of the level of pain or mental trauma being experienced by the detainee.’
The authors conclude that having spent years trying to reveal the damaging effects of torture, it would be ironic if health professionals were called upon to use their skills to participate in this practice.
Derrick M Silove and Susan J Rees ask whether there is any scientific foundation for mental health professionals to claim special expertise in judging the so called torture threshold or in predicting the long term psychiatric outcomes of interrogation practices
Contemporary history is replete with accounts of health professionals being complicit in torture.
The so called war on terror has shown how established ethical prohibitions against such involvement can be eroded when there is a real or perceived threat to a nation.
Although torture occurs in more than a third of countries, until recently, it was assumed that it was confined to nations governed by regimes with scant regard for human rights.
The war on terror marked a historical shift, with US military personnel being implicated in torture carried out in detention centres.
Despite doctors and other medical workers being prohibited from participating in torture – for example, in the World Medical Association’s Declaration of Tokyo (1975) – overwhelming evidence has emerged that during the war on terror, doctors and psychologists were instrumental in advising on ‘enhanced interrogation techniques’ that are known to have included torture.
Health professionals in the interrogation room
How did mental health professionals become willing to participate in torture?
The repeated reference to the psychological domain made in definitions of torture may have set the stage.
The US Senate’s definition of torture referred to ‘severe physical or mental pain or suffering resulting in prolonged mental harm.’
Later, during the war on terror, the US Office of Legal Council gave further weight to the psychological response to interrogation as a criterion for judging the torture threshold.
The emphasis given to the psychological domain in defining torture may have provided credibility to arguments for offering a role to mental health professionals, as the recognised experts in human behaviour, in the interrogation room.
The professional response
After several years of dissent, associations of psychologists and psychiatrists in the United States seem to have reached a consensus that mental health professionals have no role in the interrogation process.
Leaders in the field of mental health have played an active role in advocating this position, and this contributed to the adoption of a 2009 UN resolution strengthening the prohibition of health professionals participating in any activities that may lead to torture.
In addition, the American Medical Association has made representations to the US administration to endorse the principle that ‘participation of physicians in torture and interrogation is a violation of core ethical values.’
Complicity or protection?
In spite of what seems to be an ethical consensus, a recent editorial in Nature offered qualified support for psychologists having a role in interrogations, using the argument that ‘risks of abuse (during interrogation) are ever present, and having a professional present should serve as protection for detainees, provided the professional adheres to, and is held accountable to, the most fundamental medical ethic of all: “do no harm”.’
Also in 2009, senior personnel in the US military attempted to justify an expanded role for mental health professionals in the interrogation process, which included them advising on efficient interrogation techniques and offering protection to detainees against the risk of torture.
Tortured logic: determining a torture threshold
In addition to the ethical problems, there are scientific and clinical reasons to question whether mental health professionals can claim the knowledge or the technical ability to judge the torture threshold.
No objective metric exists for reliably measuring the subjective reaction to extreme experiences that cause pain or psychological trauma.
Behavioural responses to acute trauma vary, depending on influences such as past experience, personal predisposition, cultural background, and context.
Doctors who assess a patient after an acute traumatic event rely primarily on what the patient tells them to judge his or her level of pain or psychological suffering.
The accuracy of that communication depends on a setting of safety, trust, and confidentiality in which the doctor is perceived as acting from a stance of beneficence.
The opposite conditions operate in detention facilities, where there are no foundations for detainees to trust mental health professionals working closely with interrogators.
So how can professionals make accurate assessments of the level of pain or mental trauma being experienced by the detainee?
In such a context, detainees may exaggerate or underplay their level of trauma.
Most serious is when a detainee’s behaviour does not reflect adequately the level of trauma they are experiencing.
Some people may go into shock – becoming detached and unresponsive to their immediate environment.
In its subtle forms, this response is notoriously difficult to assess accurately – the risk being that the detainee will be deemed to be in minimal or no distress.
A stoical response to suffering under interrogation may be expected of those who welcome martyrdom because of their religious beliefs.
Militants who are ideologically prepared may show greater resilience when tortured.
Does that mean that for resilient detainees, the assessing mental health professional should recommend increasing the level of duress and thereby raise the threshold for torture?
Judging longer term consequences
The evidence is extensive that torture is a potent cause of chronic mental disorder.
In addition, factors such as past emotional disorder, family psychiatric history, childhood trauma and female sex increase the likelihood of adverse mental health consequences after exposure to a wide range of traumas.
Nevertheless, we do not yet have the scientific knowledge to predict with any precision what the psychological outcome will be for an individual, particularly at the time of trauma exposure.
The state of shock or dissociation shown is an inexact guide, partly because it is difficult to assess.
Also, some people show only a moderate symptom response in the immediate aftermath of interrogation but develop frank traumatic stress symptoms later – the delayed onset group.
The experience and training of mental health professionals raises further questions about their preparation for assessing the torture threshold in highly politicised settings of detention.
Psychiatrists and psychologists are trained in clinics and hospitals not in political prisons.
Those who work closely with the military or intelligence services are at risk of having their judgment distorted by the institutional pressures under which they work.
Measures such as peer support and the development of guidelines are not likely to overcome the challenge of trying to satisfy two masters – the institution and the ‘patient’.
This conflict of interest usually finds in favour of the most powerful – the institution.
Legitimate role for mental health professionals
Annas has argued that doctors are under special obligation to use their ‘universally recognised and respected role of healers to prevent torture.’
Over several decades, health professionals have played pivotal roles in showing the toxic mental health impact of torture and in establishing rehabilitation services for survivors.
It seems ironic if this accrued expertise has encouraged others (politicians, policymakers, the military, and legal advisers) to exploit the role of mental health professionals in an effort to blur the distinction between interrogation and torture.
The risk is that the presence of mental health professionals in the interrogation room will do little more than provide a moral shield that confers the aura of respectability on practices that may involve torture.
At worst, by participating in interrogation, we may be offering ourselves as scapegoats if anything goes wrong.
If our aim is to protect detainees from torture, we should be honest and humble enough to acknowledge that experts in human rights are far more capable than mental health professionals of making judgments about acceptable interrogation practices.