Sunday, December 21, 2014

Psychiatry and Torture

For me - torture has never passed some basic thought experiments.  The first is whether or not there is any information that critical that could be memorized by individuals that would be worth the effort to either conduct torture to get it or resist torture to prevent its disclosure.  Reading Alan Turing's effort  to crack German cryptography  in World War II comes to mind.  Those messages had to do with the deployment of German submarines.  In that case there was a elaborate code that could only be decrypted by a team of geniuses and a computer they invented.  That was 70 years ago.  Is it likely that information in the computer age would be easier and more efficient to hide outside of human memory?  It certainly seems like it to me.  In the case of relationships, wouldn't surveillance be a much more reliable source of information?   The second is the mindset of the person being tortured.  If I knew the information was redundant, carried by multiple sources,  or subject to fail safe why would I not tell any captor what they want to know?  Third, if my captors either did not believe me or decided to proceed for other reasons, why would I not tell them exactly what they want to know or make up any story they wanted to hear to get them to stop?  The cinematic stereotype of resisting any disclosure at all costs while undergoing various forms of torture seems totally irrational to me.  All of these considerations taken to their conclusion would produce information that was accurate but possibly rejected because it was easily obtained or information that was inaccurate but accepted because it was made up under duress.  Either way it seems like a very poor source of information.

The Senate Report on the CIA interrogation and detention methods came out a few days ago and there is the expected media enhanced political furor.  The entire document is 499 pages long.  It is also redacted to remove details that could not be declassified.  I decided to take a look at it because I saw one of Atul Gawande's tweets decrying the involvement of the medical profession that he described as "doctors, psychologists, and others sworn to aid human beings......".  That struck a chord with me because I was aware of this issue and how the American Psychiatric Association reacted to it in 2005.  Then president Steven Sharfstein, MD took the initiative in making it explicit that it is unethical for psychiatrists to participate at any level in torture, enhanced interrogation or even deceptive interview practice.  There was some lag in a similar response from organized psychology but eventually both organizations came out with a joint statement on the issue.

Psychiatry and the CIA have crossed paths on occasion most notably on the notion of being able to profile political leaders.  The original ethical conflict with CIA psychiatrists was the Goldwater Rule (see reference 3). That rule states that it is not ethical to diagnose a person (usually a public figure) without actually interviewing that person and disclosing the information with their consent.  It came about as a result of the 1964 Presidential election.  The candidates were Barry Goldwater and Lyndon Johnson.  One of the more infamous attack ads in political history suggested that Senator Goldwater would put the US at higher risk for involvement in a nuclear war.  A survey of psychiatrists suggest that he was unfit for the office.   That same article points out that even today despite the rule, there appear to be no shortage of psychiatrists willing to offer their opinions about people they have never personally examined.    

I decided to take a course on profiling political figures by one of the original psychiatrists who worked on these methods -  Jerrold Post, MD.  The course was offered at the Door County Summer Institute in August 2003.  He provided a disclaimer at the outset that "psychological interpretation" based on childhood experiences was a scientific fact that could be applied to the analysis of the personality of political leaders.  Over the next 4 days he reviewed personality and its development in political leaders, how personality is a factor in political decisions and decision making in hundreds of different compromised and uncompromised political leaders.   The final day was devoted to a look at terrorism.  He made the argument that terrorists were psychological normal meaning that they had no major psychiatric diagnoses.  He suggested that that there were predominant personality types attracted to terrorism including aggressive sociopaths and angry paranoids and that a common externalizing defense could be observed in both groups.  He discussed theories about personality types that might comprise terrorist groups.  The issue of the Goldwater Rule seemed irrelevant.  Dr. Post presented profiles that were based on actual historical data about the lives of political leaders rather than the self report that typically forms the basis of most psychiatric evaluations.  It was after all his job and he and his cohort of colleagues specializing in the psychology of political leaders developed methods for this work.  It culminated in a text of how this analysis proceeds (see references).  The text provided a fuller appreciation of the limits of this kind of analysis than the PowerPoints:  

"Understanding and predicting the behavior of smart, highly functioning individuals, who are acutely aware of their circumstances and what might be needed to surmount them,  make it a very tricky undertaking.  It is possible that, in spite of their own psychological inclinations, such persons, if not alone, then certainly with the help of many advisers, whose only occupational purpose is to help leaders pursue their own personal and political self-interest."  (p.  300).

Translation: the psychological profiling done by psychiatrists and psychologists with decades of experience is less of a sure thing than the television profilers that you can see on a nightly basis.   At that point I decided that the analysis of the psychology of political figures by the CIA was really not the same as somebody on the local news speculating about the next mass shooter.  In many ways this analysis has much more relevant data than any typical psychiatric evaluation.

The ethics of the psychological profiling of politicians seemed resolved.  What about interrogations and coercion.  It turned out that there was a course the next year  called "A Law Enforcement Approach To Behavior Analysis" taught by Dale Mueller, a 30 year veteran with the FBI.  The course covered crime scene analysis, terrorist personality types and interview strategies, hostage and crisis negotiations,  interviews for deceptive verbal behavior, and interrogation techniques that answer the question: "What does law enforcement do to get a confession?"  That course was an eye opener in terms of the differences between interrogation and a clinical interview.  He described interrogation techniques and the reliability of various observations that suggested a person my be lying.  He described the optimal environments and mindset of the professional conducting the interrogation.  He emphasized good preparation and a non-threatening manner.  Interrogations are not without stress for the person being interrogated because at some point the strategy may become a direct confrontation like:  "Because of A, B, and C you are lying."  The interrogator may stand directly over the the person being interrogated for additional effect.  Some famous interrogations were reviewed and a tape of an interview was shown.  It was a product tampering case.  The suspect had social and possibly psychiatric problems.  The main focus of the interview was to convince her to admit to the crime and she did.  Specific interrogation techniques were discussed for different terrorist personality types.  Interrogation is an alien interaction with people for a clinical psychiatrist like me.  Psychiatrists are clearly not trained in these techniques and generally do not have much interest in who is guilty of crimes or not.  During the actual interrogation of a person who appeared vulnerable, I would probably have veered off to discuss  those problems and solutions rather than focusing on a conviction.  Interrogation seems to be the sole purview of law enforcement and nothing that a psychiatrist would do.

The issue with psychiatrist employees in the CIA or any other organization - even at the contract level is the ever present conflict-of-interest between professional standards and the interest of the organization signing the pay check.  In many cases that is a changing point of reference and it is not always clear.  I have consulted with expert witnesses for example who felt that at some point they were massaged into a position that they really did not want to testify to by the attorney who hired them.  Physicians can clearly be manipulated into doing whatever other entities want them to do and that is why it is imperative that professional organizations take a stand that is unequivocal, based on professional standards and faster than any other response.  In this case, organized psychiatry - specifically former APA President Sharfstein was at the forefront.  I applauded his position then and I applaud it now.  There is always some criticism that this just involved jumping on the bandwagon with everyone else but the public opinion result at the time was far from certain.  After the opinion was public, there was hardly any acknowledgement that anybody cared.  That opinion came out 8 years before the current Senate document.

Searching the document reveals exactly 1 reference to psychiatry/psychiatrist, 56 references to psychologist/psychology, 58 references to medical officer, and 5 references to physician/physician assistant.  The most specific references include this section in the summary about contract psychologists who "devised" the enhanced interrogation techniques.

The political rhetoric is always interesting:

1.  Does torture produce results?  After reviewing the evidence I don't think there is any evidence that it does.  In fact, it is daunting to think about the millions or billions of people who have been tortured at one point or another in human history with this goal in mind.  In retrospect much of the contested information was trivial and meaningless in the course of human history.  I don't recall any major battle or war where the outcome was determined on information produced by torture.  I think there is a stronger argument that terrorism or what used to be called guerilla warfare produces more results than torture.  And let's not forget that a contractor with the National Security Agency probably released more secret data that all of the people tortured since the dawn of time.  And all of that data was accurate.

2.  Does torture inflame the enemy and lead to more adverse consequences for the torturers?  I heard an interesting discussion of this issue on Fareed Zacaria's Sunday morning show on CNN.  The discussant was an Arab from the Middle East and it was clear that his sympathies did not align with the US.  When asked about the impact of this document on public opinion, he said that he did not think it would have much of an impact because of a baseline issue.  Most people had such a low opinion of the United States that they would expect something like this to happen.  There was after all the Abu Ghraib prison incident in 2003.

3.  Are there qualitative differences in torture?  Certainly these techniques were bad but they pale in comparison to the atrocities described in the middle east and the atrocities inflicted by some of these combatants on their own countrymen.  As one of the consulting psychologists pointed out about 48 hours after the report was leaked there is also the question of what is worse a slap in the face during an interrogation or "sending in a Hellfire missile that kills grandma and the kids."  (ABC news Thursday AM show)

4.  How is the release of this document relevant to the concept of American democracy and American life?  Interestingly one of the critics on the Sunday morning show gave the opinion that self disclosures like this report does seem to distinguish American democracy from other political systems and raises the general awareness  that this is true.

5.  How can I make the most of this story?  Certainly media outlets and bloggers are motivated to whip this story up to attract viewers to their sites.  I saw a very funny comedy sketch by a stand up comedian who ranted against "Cheeto eating bloggers.." who were destroying his comedy act by posting politically incorrect experimental pieces that he was trying out in his routine as though he was serious.  The blogosphere likes to see itself as more innovative and more pious than the press but conflicts of interest remain.  It has gone from a corporate conflict of interest to conflict of interest at an individual level.  At many levels bloggers are more strident, argumentative, and hyperbolic.  It is not too surprising that they attract a like-minded following.  That being said, there have been few psychiatric bloggers that seem to have picked up on the torture issue.  It was an active area of discussion on the APA Listserv with several psychiatrists taking the role of human rights advocates.

Professionals often find it difficult to resist government interventions.  I have criticized the lack of an adequate response from organized psychiatry and organized medicine to any number of government interventions.  In other cases, they have come through with an exceptional response.  On the torture issue, Dr. Sharfstein took an unequivocal position on torture.  I was involved in a discussion of the issue at the time and there was speculation that there would be political pressure from "CIA psychiatrists".   There is always the question of whether a small special interest group within an organization can affect its policy.  In this case, the clinical focus of the membership, the maxim to do not harm and the modern conceptualization of the physician-patient relationship.  In the end there was no commentary that I am aware of from CIA psychiatrists.  I am not sure that there are any CIA psychiatrists.  I applied to be a CIA psychiatrist at about 15 years ago and the focus of the position was on interviewing potential employees rather than terrorists.

I think it is important to clarify any role that psychiatrists were involved in these activities.  They are not trained in interrogation techniques and I think that most psychiatrists would balk at the techniques.  On the other hand, it is clear that programs can be developed within government agencies that have little to do with clinical training and may clash with patient centered ethics.  It is also true that psychiatrists or physicians can abandon their usual clinical roles and use their knowledge for other purposes.  I am very skeptical of the science behind any of these techniques.   That sounds like an absurd statement on the face of it, but keep in mind the references to the program being based on a "learned helplessness model".  That is a scientific model that has been used to study depression.  Any review of that model would show that using it to develop an interrogation program is quite a stretch.  Actual human research would not pass the scrutiny of any Human Subjects Review Committee that I am aware of and it certainly is not associated with any standard of care.  The acceptance of these ideas indicates that there is really nobody in the CIA capable of scientifically reviewing a program like this or they just did not care.  As to the ultimate question of psychiatric involvement, I have a more definitive source on order (reference 5) and will report any differences here.  There is also an online database (reference 6) but it does not have much granularity but some of the linked reports contain a some details that I have not seen anywhere else (reference 7).

George Dawson, MD, DFAPA


1.  Senate Select Committee on Intelligence.  Committee Study of the Central Intelligence Agency's Detention and Interrogation Program.  Foreword by Senate Select Committee on Intelligence Chairman Dianne Feinstein.  Findings and Conclusions.  Executive Summary.  Approved December 13,2012.  Updated For Release April 3, 2014.  Declassification Revisions December 3, 2014.

2.  APA Official Actions.  Position Statement on Psychiatric Participation in Interrogation* of Detainees.  Approved by the Board of Trustees, May 2006.  Approved by the Assembly, May 2006

"The American Psychiatric Association reiterates its position that psychiatrists should not participate in, or otherwise assist or facilitate, the commission of torture of any person. Psychiatrists who become aware that torture has occurred, is occurring, or has been planned must report it promptly to a person or persons in a position to take corrective action........"

3. American Psychiatric Association: Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry. Arlington, VA: American Psychiatric Association, 2013 (p.9):

"...On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement."

4.  The Psychological Assessment of Political Leaders: With Profiles of Saddam Hussein And Bill Clinton.  Jerrold Post, MD (ed). The University of Michigan Press, Ann Arbor 2003, 462 pp.

5.  Steven H. Miles.  Oath Betrayed: America's Torture Doctors.  University of California Press, 2009, 312 pp.

6.  Doctors Who Torture Accountability Project.  Link.

7.  Physicians for Human Rights.  Doing Harm: Health Professionals’ Central Role in the CIA Torture Program.

This document is interesting because it has the qualifier "physicians (including psychiatrists)" four times in the report even though it is based on the original Senate Report.

Supplementary Info:

Supplementary 1:  Photo credit as suggested on WikiMedia:  Derived from File:911 - FEMA - Areas debris impact (graphic).png by Therese McAllister, Jonathan Barnett, John Gross, Ronald Hamburger, Jon Magnuson of the Federal Emergency Management Agency (FEMA) of the United States Department of Homeland Security. As a work of the United States government, it was released to the public domain.

Supplementary 2:  I sent Physicians for Human Rights an e-mail on December 21, 2014 to clarify the qualifier they use in their analysis of the Senate document  "physicians (including psychiatrists)".  I will post their response here as soon as I get it.

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