ISTSS' Official Statement on Torture in the Modern World

In response to member concern brought to the ISTSS board's attention by the society ombudsperson, and because torture is a pressing national and international issue that has direct implications for ISTSS's central mission to reduce traumatic stressors and their immediate and long-term consequences, the society has released the following statement, drafted by Stuart Turner, MD, with input from the ISTSS Executive Committee and approved by the board of directors.

Introduction
The United Nations has defined torture as "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, 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." (Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, UN General Assembly, 1984, http://www2.ohchr.org/english/law/cat.htm). Some refer to torture as an example of state terrorism or organized state violence.

Effects
It is intended that torture will be intensely frightening and shocking; it often leads to complex emotional harm (recently reviewed by Turner, 2004). It has been related to the subsequent development of PTSD, although there is more to it than this. Eitinger (1964), following the Holocaust, drew attention to the differences between the immediate effects of extreme violence and the tearing-up of a whole social world, leaving many survivors without any form of "anchorage in the world." Certainly there are often important existential issues for survivors of torture to confront, and these may go well beyond the problems of PTSD. For some people, it can be a struggle simply to survive in a world in which they have experienced the deliberate, systematic and malicious attempt by others to destroy them, using tortures, which for most of us would be unimaginable.

Nonetheless, although responses are more complex than this, PTSD is also strongly predicted by experience of torture, even in low-income settings where there has also been violent civil conflict (de Jong et al., 2001) such as Algeria, Ethiopia, Cambodia and Gaza. This is an important study as it also helps to confirm that PTSD is not restricted to Western communities and cultures. It highlights the need for culturally appropriate and sustainable services in many parts of the world--a topic on which an ISTSS task force has produced some international training guidelines (Weine et al., 2002).

ISTSS
The International Society for Traumatic Stress Studies is an international multidisciplinary, professional membership organization that promotes advancement and exchange of knowledge about severe stress and trauma. This knowledge includes understanding the scope and consequences of traumatic exposure, preventing traumatic events and ameliorating their consequences, and advocating for the field of traumatic stress (article III of our bylaws). Given this mission, our Society promotes prevention of all acts of deliberate violence outside the law. This includes the condemnation of all forms of torture and terrorism, anywhere in the world.

We have taken a leading role in our work and writings in opposing torture and advocating rehabilitation services. For example, past presidents Yael Danieli (2002), Bonnie Green, Matt Friedman and John Fairbank (2003), Terry Keane (2001 & 2003), and John Wilson (2004) have all produced important books dealing with this subject. The Society has a long and honorable history of collaboration with the United Nations and other agencies dealing with human rights.

Special Roles of Health and Social Care Professionals
We recognize that health and social care practitioners often have special knowledge in countries where torture is in routine use. Indeed, it is hard to see how torture could be practiced on any scale without our knowledge. This means that we have some special ethical obligations. Our work needs to be informed by a human rights framework.

The United Nations has set out these ethical principles in a number of documents, for example stating that "health personnel ... charged with the medical care of prisoners and detainees have a duty to provide them with protection of their physical and mental health and treatment of disease of the same quality and standard as is afforded to those who are not imprisoned or detained" (http://www.cirp.org/library/ethics/UN-medical-ethics). It is a gross contravention of our ethics for health professionals "to engage, actively or passively, in acts which constitute participation in, complicity in, incitement to or attempts to commit torture or other cruel, inhuman or degrading treatment or punishment." We support these principles.

Recently, ISTSS has circulated a consultation document in which we have set out some key principles--for example that our members should adhere to relevant professional codes of ethics and to pertinent international, national and local laws governing their activities. In cases where local laws might mandate or encourage unethical behavior that could potentially harm, we as clinicians should seek consultation, try to resolve the situation within the confines of law, try to change the law, and ultimately strive to choose a course of action that maximizes the welfare of the people. We should strive to ensure that any working environment for which we are responsible is consistent with, and encourages, ethical behavior.

Conclusions
ISTSS offers a means of supporting those professionals struggling to oppose torture in their own countries, wherever they are, in the first world or third, through its international focus, its commitment to find ways of preventing traumatic events, its advocacy for the field of traumatic stress and its annual meetings where practitioners and researchers can meet. We do believe that gaining better understanding of the means to prevent and treat trauma, including torture, is one of the "grand challenges" of the modern world (Schnurr et al., 2004) and, in accordance with our mission, we reject any justification for the use of torture.

References
Danieli Y. (ed) (2002), Sharing the Front Line and the Back Hills; Peacekeepers, Humanitarian Aid Workers and the Media in the Midst of Crisis. Baywood Publishing Company: Amityville, New York.

de Jong, J.T.V.M., Komproe, J.H., Van Ommeren, M., El Masri, M., Araya, M., Khaled, N., Van De Put, W.A.C.M., and Somasundaram, D.J. (2001), Lifetime Events and Posttraumatic Stress Disorder in Four Postconflict Settings. Journal of the American Medical Association, 286, 555–562.

Eitinger, L. (1964), Concentration Camp Survivors in Norway and Israel. Allen & Unwin: London.

Gerrity, E., Keane, T.M., & Tuma, F. (2001), The Mental Health Consequences of Torture. Kluwer Academic/Plenum Publishers: New York.

Green, B.L., Friedman, M.J., de Jong, J.T.V.M., Solomon, S.D., Keane, T.M., Fairbank, J.A., Donelan, B. and Frey-Wouters, E. (eds) (2003), Trauma Interventions in War and Peace; Prevention, Practice and Policy. Kluwer Academic/Plenum Publishers: New York.

Schnurr, P.P., Kaloupek, D.G., Turner, S.W., Bloom, S., and Kaltman, S. (2004), Another Grand Challenge: Mental Health (Letter). Science 303, 168-169.

Turner, S.W. (2004,) Emotional Reactions to Torture and Organised State Violence. PTSD Research Quarterly. The National Center for PTSD.

Weine, S.M., Danieli, Y., Silove, D.M., Van Ommeren, M., Fairbank, J., and Saul, J. (2002), Guidelines for International Training in Mental Health and Psychosocial Interventions for Trauma-Exposed Populations in Clinical and Community Settings. Psychiatry, 65, 156–164.

Wilson, J. and Drozdek, B. (2004), Broken Spirits: the Treatment of Traumatised Asylum Seekers, Refugees, War and Torture Victims. Brunner-Routledge: New York.