Abstract
Torture and human rights abuses continue throughout the world and, despite the increasingly draconian policies of Australian governments regarding refugee entry and the asylum-seeking process, there are already very significant numbers of refugee survivors of torture living within our community. There are relatively few texts and a small clinical and research literature available to guide doctors and other health professionals in the management of survivors with medical and psychological sequelae. Hence this book could become a welcome addition. It has several goals. The first is to raise awareness and understanding in clinicians, particularly physicians and psychiatrists, regarding the nature and scope of torture, and this task is attempted in sections one and two of the book. This is handled in a rather superficial and dated manner by a series of contributors which include some of the pioneers of the field such as Lars Weisaeth, Joseph Westermeyer and Inge Genefkc, as well as the senior author. There is no real analysis or discussion of the deeper origins of torture and related phenomena, apart from the recognition of its role as a tool in the suppression of dissent and the maintenance of power. This latter aspect is better understood than when some of the authors began in the field, yet no broader contrast is attempted with other related social evils such as slavery and colonisation. Some recognition of the synergy between the internal capacity for aggression and sadism within individuals and sociopolitical forces would also have been appropriate. A strength of the book is the recognition of a qualitative difference in this form of clinical work from other areas of practice. This relates to countertransference effects similar to other types of trauma work, but also to the strategy of working in a sustainable way with people who have been subject to severe trauma of human origin.
The second task is to provide some clinical guidelines for doctors in particular. While the role of doctors and psychiatrists is in urgent need of strengthening in this country at least, this is an excessively narrow focus given the multidisciplinary nature of the work with survivors. There is a section on assessment, which includes a chapter by Federico Allodi, followed by a section on specific treatments. These mostly have an introductory feel to them, which may be an advantage if one of the aims is to broaden interest, knowledge and expertise among doctors, including primary care physicians. It would have been helpful for the chapters on psychological treatments, both of which were useful, to have been integrated and supplemented by a broader range of therapeutic strategies.
The third task is to convey a sense of the experience of care-giving, especially in the countries where the trauma has occurred. The chapters in the final section, entitled ‘Voices from the Field’, convey some of the realities of this endeavour, and of the pervasive individual and social effects of repression and torture. The ordeal of the relatives of the ‘disappeared’ is particularly well described and has a powerful impact on the reader. For the potential local readership, a description of the experience of providing treatment in countries of asylum would have been of additional interest. Also missing, and adding to the ‘dated’ feel, is a description of the increasingly hostile attitude of Western governments to the plight of even genuine asylum seekers. The latter have the most severe psychiatric morbidity of all with the infliction of a ‘second injury’ with additional layers of morbidity created by the harrowing process of asylum seeking in the country of refuge. This has correspondingly powerful and painful effects on those involved in their care during this process, notably a sense of shame and guilt that one's own society is continuing to abuse the human rights of those who have already suffered greatly. Their access to any care is greatly reduced in most Western countries, especially Australia, and they constitute a highly marginalised group about whom doctors should be made aware for both human rights and ethical reasons. Ethical issues and the responsibilities and vulnerabilities of doctors in particular are the themes of section 5. This has been the crusade of the Danish pioneers in the field in particular, and has applications in other areas of medicine and psychiatry, particularly for those doctors working for the police and military.
Clearly written and structured, this book is a useful general introductory text for doctors who might wish to begin working in the field or whose practice brings them in contact with torture survivors. It does illustrate the range of responsibilities that doctors ideally should consider in their work, as well as highlighting some of the dangerous pressures which can corrupt medical practice. In the Australian context, where altruism seems to be in increasingly short supply, it may help to inspire more doctors, including psychiatrists, to assume some responsibility for improving the care of tortured refugees, including asylum seekers, in this, increasingly ‘lucky for some’, country.