Civilization and torture: beyond the medical and psychiatric approach

Marcelo N. Vinar Dr Marcelo N. Vinar is a psychoanalyst and trauma expert. He was professor in the Faculty of Medicine at Universidad de la Republica, Montevideo, from 1968 to 1997 and president of the Latin American Psychoanalytic Federation. He went into exile in France in 1976 and returned to Uruguay in 1989


The author argues that torture affects not only its victims, and also that torture is not a disease of the victim but an endemic illness of civilization which has the effect of shattering the social network that makes us human. In order to rebuild healthy social relationships, it is vital to detect and accept the existence of this invisible pathology. We must listen to the intense groan of torture victims and understand them if we are to dare to look at the oppressive order which destroys them.

What do we mean when we speak of torture in this media-saturated, globalized world of the third millennium? We should certainly include under this term domestic violence, prostitution and child pornography, as well as adult and child labour in insalubrious conditions, and slavery. Ideally, we should begin by condemning current market and production systems as the worst and most widespread cause of torture, since, being primarily concerned with profitability and financial efficiency, they ignore the human cost for a very sizeable percentage of our fellow human beings, who are becoming less our ‘‘equals’’ with every passing day. Inequality in access to material goods and cultural opportunities is leading inexorably to a calamitous division of mankind into the ‘‘included’’, who enjoy the fruits of scientific and technological advances and the progress of civilization, and the ‘‘excluded’’, who by remaining on the margins of this Volume 89 Number 867 September 2007 619 affluence become the pariahs whom Z. Bauman calls ‘‘wasted lives’’.1 Exclusion may be defined not only as a situation of want, but also as loss of the right to have rights.2 It leaves the excluded without prospects for the future, with no sense of belonging to a greater humanity, cut off from the active pleasures of the world and isolated from the human condition.

However, the excessively long and complex list of human woes forces us to confine the term ‘‘torture’’ to its most commonly accepted meaning – that is, torture for political purposes as a means of eliminating the adversary, or at least breaking his will. It is the vilest face displayed by an unscrupulous government or group in order to underpin and consolidate its power and to provide a pseudolegitimate basis for clinging to that power and to a given set of sociopolitical, ethnic or religious beliefs, by suppressing the alternative of being different.

A perusal of Elaine Scarry’s book The Body in Pain, 3 the works of my compatriots Daniel Gil and Carlos Liscano4 and my own writings5 might provide a partial insight into the chilling subject of torture. In literature, George Orwell’s magnificent description in 1984, Dalton Trumbo’s Night of the Aurochs6 and Truman Capote’s description of a torturer’s mind are also extremely important,7 as are the books describing life in concentration camps by Primo Levi,8 Robert Antelme,9 Sarah Kofman,10 Jean Amery,11 Elie Wiesel12 and the recent Nobel prizewinner Imre Kertesz.13 Torture is also the central theme of Botero’s pictures showing the hell of Abu Ghraib.

Breaking bodies and minds

Although the horrors of torture are a story as old as human history, they may not be written off as mere ancient savagery. Rather, they must be seen as something that has constantly accompanied the unfolding tale of our species. The wars and genocides of the twentieth century, the Nazi concentration camps, South African apartheid, Pol Pot and Guantanamo Bay all remind us that torture stubbornly recurs. Moreover, its development and refinement go hand in hand with other advances in knowledge. Experts have devised means and procedures of torture which did not exist in the past. The humiliation and physical ill-treatment which has always been employed have been joined by even crueller and more effective techniques. The traditional expedients of making the victim stand on one leg for a long time, waterboarding and other types of near-suffocation, electric shocks and sensory deprivation have all been surpassed by cleverer strategies designed not to kill or destroy victims, or to prolong their agony, but to ensure their survival in order to turn them into willing collaborators. If physical and mental torment is not enough, one can systematically deprive the victim of sleep, food and light while issuing cunning threats, then alternate all this with techniques of persuasion and the promise of rewards. After varying lengths of time – depending on the victim’s endurance – there arises a psychotic state in which victim no longer recognizes himself, and perceives himself as worthless.

The goal

The frightening lesson is that the definition of modern torture cannot be restricted to physical torment and temporary humiliation. The definition lies not in the technical aspects of the process but rather in the goal: demolition by means of a variety of sophisticated methods selected for the individual concerned. In other words, reducing a human being to a state in which he has no control over his thoughts, depriving him of everything that defines him as an individual and, through intense pain and shame, gradually making him a puppet of his master. I stress that when speaking of systematic and sophisticated torture, we must not confine ourselves to listing the means of inflicting physical suffering (extreme pain, hunger, thirst) and psychological torment (isolation, sensory deprivation, sleeplessness) which, when methodically applied for a sufficient length of time, can turn a person into a shadow of his former self. What must be emphasized is the extent to which the suffering of even a few dozen victims can instil terror and panic in the entire target community.

Quite apart from the findings of psychiatric experts and specialists, we have all known since we were small, with our childhood fears, our dreamlike or hallucinatory pre-knowledge of death, pain and suffering, that no direct experience is required to know what agony is. This latent knowledge can quickly be transformed into panic. The torture victim, that is, the resulting shadow of his former self, is cut adrift and deprived of everything that identifies and shapes him as a human being. This demolition, this hallucinatory stage of psychosis artificially induced by torment and sensory deprivation (subtly alternated for a prolonged period) reduces the victim to a pitiful state close to the agony where, as Hannah Arendt said, the person himself does not know if he is alive or dead. The various Volume 89 Number 867 September 2007 621 after-effects experienced by survivors all their lives are similar to an infectious disease which is contagious and transmissible by word and through feelings.

But let us go back to the sources, that is to say the many thousands of victims’ accounts – the groans, the screams, the weeping, these expressions of unparalleled suffering and shame. I believe that there is no need to list the methods of torture which turn a human being into a shadow of his former self. Let us leave this list for textbooks on the perpetrators. During the Salazar dictatorship, a Bolivian colleague, a Dr Domich, found an office set up by torture experts in Lisbon who rented out their expertise as one would any other sophisticated technology. It would seem that the Algerian war of independence in the mid-twentieth century left a handful of torture experts who apparently exchanged know-how and experience with the same conviction and experience as participants in congresses covering other fields of knowledge. Similarly, an anti-subversion unit of the United States military produced textbooks on torture in order to improve its efficiency in waging war. The 1963 Kubark manual is an example of this. We must therefore conclude that today there is not just one tendency in humanity – that exemplified in the identity of a doctor: the humanist desire to struggle against pain and death – but also the opposite endeavour: to produce pain and death at any price.


It is necessary to identify some of the characteristics of systematic, sophisticated torture as a specific aetiological agent of psychological damage. Its techniques and procedures have been refined ever since the Middle Ages, especially in the twentieth century, and have progressed as much as other technologies. The experiments carried out by the Gestapo and the British secret services, the Algerian war, the US School of the Americas in Panama and now Abu Ghraib – all have produced methods and experts of fearsome technical effectiveness. That is why it is necessary to dismiss the idea of primitive barbarity and savagery and to recognize that torture units are not just playful creations and figures of fiction designed for childish entertainment – they are sophisticated organizations occupying a privileged place among the institutions of the modern world.

We cannot imagine the world without schools, hospitals, churches or sports stadiums, yet this array of ordinary institutions also encompasses the secret police and the concomitant reality and fiction of extreme horror. This submission to an absolute power – where Winnicott’s ‘‘primitive agony’’, or nameless dread, seems to exist not just as a vestige of the beginnings of life but as a disturbingly close presence – is part of our image of the world. On the pretext that military intelligence requires information about the enemy, highly perfected means of torture are capable of reducing human beings to the subhuman state of mere suffering flesh. The sentient body has become anonymous and that other human faculty, the very sense of one’s own humanity, has disappeared. The individual has M. N. Vin˜ar – Civilization and torture: beyond the medical and psychiatric approach 622 been dispossessed of his sentient body and of the speech that invests it – ‘‘the body in pain’’, to use the title of Elaine Scarry’s book.14

The perpetrators

In the 1990s, the American historian Christopher Browning published his research, based on personal testimony, into the murderous activities of Reserve Police Battalion 101 during the Third Reich.15 Thirty years after the events he had conducted extensive interviews with 125 of the 250 survivors of a battalion of 500 men whose job it was, for one whole year, to exterminate tens of thousand of Jews in Poland – not using industrial techniques such as gas chambers, but singly by hand, shooting them one by one in the face or the back of the head, men, women and children, after they had been dragged from their homes and made to dig their own graves. A relentless detailed investigation (the descriptions are bloodcurdling) leads the author to the frightening conclusion implicit in the title of his book, Ordinary Men.

How was it that these ordinary men who, before and after the mass killing, led normal lives as clerks or shopkeepers, who had not been chosen because they were ardent supporters of the Nazi regime and who had not been subjected to particular indoctrination – in other words who were a sociological sample of working-class men (from a neighbourhood in Hamburg) – turned into ferocious perpetrators of such crimes? The concluding chapter, after discussing in detail possible causal factors such as propaganda, indoctrination, particular sociopathological traits, submissiveness and fear of authority, emphasizes his conclusion following hundreds of hours of interviews: the dominant reason why ordinary people commit monstrous crimes is the wish to be like the others, to resemble the group to which they belong, and the inability to say ‘‘no’’ for fear of being alone.
Some were able to perform their macabre duty day after day with triumphant arrogance; others had to get drunk to be able to stand it; a few managed to relieve their conscience by allowing someone to escape. The main thing was not to appear scared or to be at odds with the peer group. What would have been extremely difficult was to refuse to comply with the local legal authority’s order to kill several thousand Jews a day. Putting up with the madness and the vile nature of the crime, on the other hand, was what it took to be part of the crowd, rather than paying the price of standing out as an individual: ‘‘the ability to be alone’’, in the words of Winnicott. On the other hand, Leopoldo Bleger says that the wish to be like the others is part of a needed but, at the same time, pernicious identification process. It forges one of the links between the individual and the group and it cannot be declared definitely good or bad, but simply human, and so an open door to the demons of consent.

Browning’s findings agree qualitatively and quantitatively with those of Stanley Milgram’s experiments concerning submission to authority.16 Only 20 per cent of the individuals studied were able to withstand the suggestive persuasion of the local majority in situations of extreme tension – that is, only a fifth could resist the hypnotic power of what the group imposed in the way of correct behaviour, or was discerning enough to disagree and adopt a different line of conduct. The remaining four fifths sank into the torpor of voluntary servitude, yielded to the demons of consent, and bowed to the dominant majorities. The ability to say ‘‘no’’ to group pressure or group complicity is what seems amazing and noteworthy, as when Hannah Arendt introduces us implacably to the thesis of the banality of evil, in which she contends that the monster basically does not possess a malign, perverse personality, but rather is, above all, a manipulated bureaucrat who is charmed secondarily by the enjoyment of the advantages he derives from his position as boss in a skilfully set-up transsubjective system.17

I can rightly be reproached for taking Nazi murderers as prototypes of the human race. I agree that there is something objectionable about this approach, but in my defence I plead that Freud taught us how extreme pathologies can highlight something that in ordinary circumstances is insubstantial and therefore hard to visualize. It is therefore necessary to examine this extreme form of vileness if we wish to understand and change the persistence and recurrence of this facet of collective human behaviour, namely the tendency to allow others to think for them and to be afraid to think for themselves. Perhaps the sad reality of people overwhelmed by tyranny and totalitarianism is the key to other similar patterns of behaviour on which it would be useful to shed light.

It is hard to acknowledge through introspection, given our pride in being rational beings, the extent to which fear and prejudice trap us in the hypnotic notion that other human beings are inferior and can safely be eliminated. At the beginning of his career, Freud abandoned hypnosis and suggestion because, he said, being a poor hypnotist he was unable to achieve his therapeutic aims. An ethical imperative and his own rationalist conviction subsequently led him to compare hypnosis with cosmetic treatment and his method – psychoanalysis – with surgery. Nevertheless, at the end of the First World War he concluded, in Group Psychology and the Analysis of the Ego, 18 that the rationality of the lone individual melts and succumbs to mass hypnosis. History offers us the examples of Galileo Galilei and Giordano Bruno, and any number of anonymous cases, where the truth of the system kills the nascent truth which threatens to shake the temple, where the fear of authority and voluntary servitude direct thought, conduct and destiny and the most important faculty of the human species – that is, the ability to innovate and create – is abandoned.

Illness and torture

Many years ago Maurice Merleau-Ponty pointed out that medicine and torture had a topographical affinity in that both were lodged in and colonized the intimate space of the sentient human body – one to save it, the other to destroy it.19 It is somewhat amazing to think of bracketing together such conflicting notions as medicine and torture. But they both have the power to pinpoint, focus on and render communicative this intimate space where latent ancestral fears, such as the dread of infinite pain, have always lurked. What frightens us is not so much dying, but something even worse: endless suffering. This is a motif for fables, literary phobias, children’s tales and some religious myths from all ages in every part of the world. It is a universal fear which stays with us throughout our lives.

Illness and torture make real and palpable a potential of which we have always been aware, which was there prowling around us, besieging us in silence, signalling one of the basic elements of the human condition: the sentient body and its expression in speech. Dread of the destruction of the message is tantamount to the destruction of the psyche (Gantheret),20 and the hangman’s victory means a return to unbearable memories. For this reason we find raw testimony obscene and psychologically indigestible; it prompts only consternation and alienation, and in these extreme situations there is no room for thought which requires a familiar representation of emotion. When you are terrified you cannot think, you can only survive or succumb. The process we normally call ‘‘thought’’ does not occur during trauma – regardless of whether that trauma lasts a minute or several years – but afterwards, in the subsequent phases we call the development of marks and after-effects

But anxiety about the closeness of the Fates is not the same, although in both cases a dreadful threat pulverizes the comforting feeling of being alive. The sudden onset of an illness unleashes a battle with the unknown forces of destiny. It conjures up the vision of malicious gods bent on upsetting reason as the normal link between causes and effects. But the people around us who support us and buoy us up not only become more visible, but usually become kinder and more caring, which can make us even more human.

The opposite is true of institutionalized torture, which shatters the social network which makes us human. Its source is clear and identifiable: it is our fellow human beings who turn us into small, frightened, cornered animals and it is their triumphant and arrogant will that mires us in interminable suffering. One can even imagine the torturer thinking ‘‘You must die or suffer never-ending torment because you are of a different race, religion or political conviction. You and yours, everything you were, or believed, will be turned to dust.’’ 19

Faced with the rise of barbarity and the media’s use of horror as entertainment, privacy must be restored as a central feature of our lives. It is this secret obscure area, the nucleus of our innermost selves, which is besieged and invaded by torture to a point bordering on madness: ‘‘I won’t be the same … I’ll be different … another person … Will I recognize myself?’’ This spectre of a metamorphosis of the psyche, of its decomposition and ruin, is unbearable. In Orwell’s 1984, the protagonist’s submission to Big Brother typifies the effect of political terror. This definition of the effect of torture seems to me to be closer to the truth and more telling than a technical definition (based on methods for inflicting physical and mental torment). From this point of view, I wish to discuss the usually misguided methods of victimology and medicalization which, with a happy altruism, segregate torture victims and separate them from their status as citizens and equals, and from their alter ego.

Torture is not a disease of the victim, it is an endemic illness of civilization, which is growing and expanding just any other technology that can be perfected and automated. Just like an industry. Modern torture, as Michel De Certeau said,21 is not a primitive form of barbarism but an instrument of power in modern society, a wretched necessity for the maintenance of that power. ‘‘I am not a sick man, but an expression of my times’’, said David Rousset on being freed from a Nazi concentration camp.22 There is a chasm of clinical asepticism between his heartfelt declaration and a list of the symptoms of post-traumatic stress syndrome.

Dealing with torture therefore means talking not just about victims, their stigmata and the after-effects, but also using their stories, their humanity, to denounce a system dependent for its survival on destroying people’s minds and bodies. It we are to have any hope of staunching the wounds of torture victims and restoring them to the status of our equals, it can only be by listening to them and achieving some glimmer of understanding of what they have experienced. Then we have to dare to look more closely at the oppressive order that has destroyed them.

Torture and society as a whole

I take at face value Freud’s words shortly before his death, on the eve of the Second World War, that civilization seemed to have sealed a pact with barbarism23 – a verdict that proved premonitory. The twentieth century, which saw a huge expansion in scientific and technological knowledge, as well as rapid and intense changes in social organization and the degree of our control over nature, at the same time turned out to be the most barbarous century. Violence joined disease and natural disasters as the principal cause of premature death. The causes of mortality have a new supreme champion, namely violent death brought about by calculated human intent to wreak destruction.

This touches on civilization and culture and thus concerns statesmen and citizens alike. It is a universal subject and it would be wrong, from the modest standpoint of psychiatrists or psychoanalysts, to claim that we are especially well placed to explain the causes, effects and consequences of this evil and to work out therapies to remedy it. The consequence of such technocratic vanity and childlike overconfidence in science would be to have experts to decide on everything, thus exempting ordinary citizens from the need to think about society’s problems, enabling them to wash their hands of politics. But all members of society must take part. It is dangerous to promote a division of society into the injured and the unharmed and to confine therapy to medical or psychiatric treatment in specialized institutions.

Communities that have suffered extreme political violence require a lengthy period to repair social bonds. A signal experience has been an upsurge in serious pathologies and after-effects among the children and grandchildren of those who were persecuted and annihilated in the Second World War. There is sufficient clinical evidence in Europe of this phenomenon.

Our professional and civic responsibility is thus not only to care for the victims but also to fight against silence and foster memory, which exorcizes the innermost ghosts of terror and prevents the interiorization of fear. This responsibility is collective. The victims and their descendents cannot be asked to cope with the after-effects of such horror all by themselves.

If the law is much too serious a matter to be left exclusively in the hands of lawyers, war and its effects also exceed our professional abilities and we must avoid being falsely appointed as experts to remedy ills which today – and probably for several generations to come – will impact on the social life and health of those who have suffered extreme political violence. And this impact is one of the most salient aspects of the atrocities of our world.

‘‘Extreme political violence’’ seems to denote a homogenous landscape of cruelty and pain induced by a wide range of agencies capable of causing psychological damage. However, I believe that subtle symptomology can and must be used to catalogue the effects inherent in (and specific to) extreme political violence. They may be summarized as a collapse of the psyche which produces rejection of and revulsion at ‘‘membership of the human race’’.24 We are the only species blind enough to plan its own destruction.

The effect – intended or collateral – of the systematic torture of a given population group is collective panic giving rise to paralysis and the individual’s desire to keep his head down. When faced with omnipresent political absolutism it is impossible to remain neutral or indifferent. There are only three options: humiliating submission, heroic and sacrificial defiance, and tacit or open support for and complicity with the shameful regime. There is no possible escape route and all alternatives have powerful, long-lasting psychological effects. This is why I contend that not only the individual victims suffer but the whole of society. Nowadays, in Latin America, Germany, Spain or Israel, to mention only the cases of which I have direct knowledge, three generations after the actual events the remaining conflicts and after-effects in human and institutional relations are still being grappled with because the after-effects of political violence are still being felt in the families concerned. They are part of these families’ history.

In Latin America, I can say from direct experience (and that of many of my colleagues), the climate and air you breathe during state terrorism is contaminated by people’s horror of what is happening in the dungeons. A few real victims, a handful of human beings who have been broken by torture, are able to infect and contaminate many strata within the affected society. The infection seeps into public and political dealings and even contaminates areas of coexistence which are normally far removed from the world of politics: one’s family, one’s circle of friends, schools and universities – everything is affected. The danger of denunciation and the resulting doubts about doing, or not doing, something all create an atmosphere of fear and suspicion that corrodes the bonds of society. The fact that institutionalized torture and arbitrary imprisonment are an omnipresent option in a society unable to support and uphold democratic institutions generates a latent or virtual state of highly pathogenic mistrust, even if there is no visible or immediate evidence of its effects.

I have had hundreds of hours of conversations with persons who have lived under totalitarian regimes, not only potential victims but also people who got through the years of terror completely unscathed, only to realize many years later, when the threat had lessened or disappeared, how much that unacknowledged violence had affected them. Daily life under a totalitarian regime is diseased in a thousand ways, and like parasites these pathologies contaminate many facets of social life which are apparently far removed from the orbit of politics.

A totalitarian state is always unhealthily suspicious, constantly conjuring up images of the enemy where the boundaries between truth and imagination, between reality and fiction, are difficult or impossible to draw. I am suggesting that because of the psychology of rumour and propaganda, which are so important in today’s world as shapers of opinion and ingredients in the building of an identity, the existence of terror in society (whether in the form of torture, arbitrary imprisonment, kidnapping or disappearances) has harmful effects which are not limited to the potential or actual victims. Rather it functions much like a fragmentation bomb, damaging or at least threatening everything in the surrounding area.

Civilization and barbarity

Just think of the changes that constitute the development of every human being. We are born more defenceless, immature and fragile than almost any other species. Freud calls this quasi-foetal extra-uterine condition of human beings in their first year of life desertion or original helplessness. We are incapable of moving from one place to another, controlling our motor systems or speaking. More or less all a newborn baby can do is smell, hear and suck. For a long time the baby lives in a state of extreme dependence on the care provided by its parents or parental substitutes.

This immaturity, which is the first state experienced by every human being who has ever come into the world, leaves a substantial and lasting imprint on the way our minds function. For no other species are fellow creatures so crucial and so decisively important for the psychological existence of the individual, for the profile of their condition as a subject, or for the cohesion of their mental life. A human being inherits not only what is passed on by the genome and biology, but also a language and a culture with its stories, myths and legends. It is only through life in society that mankind has arrived at the place it occupies on the zoological scale. This marks us for better (because the division of labour and education has enabled humanity to build culture and achieve advances of civilization which no single human being could have managed on their own) and for worse (because we have also created war and barbarity and we are the only species capable of planning the destruction of our fellow beings).

Human society is sometimes rather flippantly compared to a beehive or an ants’ nest on the grounds that these species also live in social groups. This is far from accurate. The fixed roles and behavioural patterns of bees and ants have been immutable over the generations, in contrast to the transformations and influences that humans bring about in others.

People do not just gather in society, they must form a social group in order to live. But war turns civilization into savagery. This makes political violence a very special kind of harm or aetiological agent, when man turns into a manhunting wolf, when fellow man becomes the prey. For this reason, the psychological trauma of war is far greater than that produced by accidents or natural disasters, which prompt solidarity and strengthen social bonds. War corrodes and severs these bonds and infects, with something approaching gangrene, identification with all that is human. The mirrored reflection of the face of a friendly fellow creature, which is so essential for life, provokes crime, sociopathies and other serious disorders.

When lethally traumatic action stems from a methodical, rational and intentional plan devised by human beings for the destruction of other human beings who have become enemies, this imprints itself on the psyche of the defeated, the victims and those responsible for causing their suffering. It produces a stigma of humiliation and vengeance that engulfs not only those directly affected and everyone around them, but impacts on the whole of society for a period lasting several generations. Since Jacques Lacan and his school – and above all since Jean Laplanche’s development of the subject25 – this has been known in psychoanalysis as giving priority to the other in order to shore up the condition of being a subject. Three generations are needed to configure a human being as far as his or her inherited feelings and resentments are concerned.

Mixing the included and the excluded

As Michel Foucault wisely observed, the reaction of conformist society to the pain and scars of victims is to banish them to its fringes in order not to have to see them and to suffer with them.26 This is what is done with the mad and the marginal. I believe that it is crucial to the ethics of mental health workers to combat this approach and to put a stop to the complicity with a social system that allows and even encourages this split between conformist society, which claims to be unaffected, and the affected.

The considerable two-way movement between sectors that want nothing to do with each other – the affected and those who believe themselves to be unharmed – must be a priority objective of our work as a profession. Society’s silence is always the precondition sought to enable authoritarian regimes of dubious legitimacy to attack dissidents and to assign to us psychiatrists the task of tertiary prevention, that of looking after hopeless cases. But it is also to prevent us from carrying out primary prevention, since the more abuse and arrogance are denounced, the more effective the treatment against this chronic disease will be, a disease that requires society’s silence in order to pursue its deadly course. The psychiatrist, who plays a leading role in the mental health field, is ideally placed to demonstrate how and to what extent the vile manifestations of political violence (abuse and arbitrary application of the law, systematic torture, kidnappings and disappearances) profoundly damage the social fabric, and that their after-effects persist for generations.

The European experience of two world wars, from the fateful trenches of Verdun to the concentration camps where millions of Jews, Roma, political opponents and mentally ill people were exterminated, has shown how the aftereffects among the victims and their descendents profoundly mark, for several generations, both them and the society to which they belong. The Balkan war is another indisputable example. The mental health worker’s voice is crucial in the post-conflict period of reconciliation. To look no further than the twentieth century (although we realize that, in doing so, we are disregarding the still extant traces of the cruel evangelization and conquest of the Americas), the torment, torture, arbitrary imprisonment, persecution and uprooting not only of adversaries and enemies, but also of a civilian population drawn willy-nilly into a war (be it international or civil), has wreaked psychological havoc. During the world wars, the wars in Algeria and Indochina, apartheid, the political degeneracy of the communist regimes of eastern Europe, the Stalinist period, the rule of Pol Pot and the more recent wars in the Balkans and the Middle East, the official reason for this tormenting of an acknowledged or secret enemy was to obtain information. It was said to be an indispensable means of espionage and source of military intelligence. Colombia and Guatemala are prime examples of the wretched fate of those afflicted by the military dictatorships of Latin America. This evil has taken on such endemic proportions that all plans for countering it and all efforts to aid the victims seem pale and inadequate.

The human ability to respond

In social psychology and psychoanalysis, people’s ability to respond to the same harmful effects and traumas in a huge variety of ways is well known. Much has been written about and much thought has been given to heroism and cowardice in such circumstances. Stories of heroes and traitors, of honourable men and members of the secret police or informers infiltrate the social fabric of a police or totalitarian state in which victims and perpetrators coexist. And rumours do the rounds, some whispered, others shouted aloud.

Similarly, daily threats in a state where terror reigns are a noxious and terribly effective pathogen whose strength and size has perhaps been partially recognized but insufficiently publicized. I consider it to be the overriding duty of the humanitarian community as a whole to bring the effects of this poison to the attention of a very wide range of public bodies. No less an institution than the US Congress, with all its prestige and power, has just taken a step in the opposite direction by passing a law allowing torture to be used in the war on terrorism and insecurity. I am afraid that what is happening in Guanta´namo Bay and in prisons in Iraq will spread and deeply corrode the libertarian foundations of US society. Publicly to legitimize the right to torture – even if the aim is to sanction officially the act for reasons of internal security – will have harmful repercussions sooner or later.27

In times and places where desolation and terror reign, our work is to little avail and amounts to no more than a Band-Aid on a deep wound. But once the evil has taken root, it has long-lasting effects; and the post-conflict reconciliation period requires our skills for decades and generations. Assuaging psychological and/or somatic symptoms and encouraging a cathartic reaction to the horror experienced are not the only remedies. Resilience and adaptability doubtless also exist in a society driven by extreme political violence, and they enable life and joy to continue.

What I am proposing is not lineal determinism in which things are either completely good or completely bad, but a paradoxical and contradictory reasoning that allows room for inconsistencies. Like humidity in concrete, despite the capacity to adapt and resist adversity, terror corrodes the quality of social bonds.

The urge to live is always powerful, and Adorno’s statement that ‘‘it is impossible to write poetry after Auschwitz’’ cannot be taken literally but must rather be seen as a tragic reminder of the coexistence of lethal factors that poison healthy social relationships.

One debatable issue is the mental health criteria we use in public health and psychiatry. An ethical definition of mental health is crucial for psychoanalysis and psychiatry. Health is not only the absence of visible symptoms. It also means being in complete possession of one’s creative faculties. This last criterion enables us to fine-tune the stimulus of adaptability during a period of terror and to avoid being accomplice to maniacal mechanisms of negation and denial – seeking oblivion, satire aimed at wiping the slate clean, looking to the past – which are practised in the name of a spurious reconciliation but actually disrupt the process of grieving, so essential for the relatives and friends of victims and for society as a whole.

I contend that talking is important for the healing process, and warn against treating the subject in purely medical or psychiatric terms, a strategy which (in my view) is wrong, judging by the approach of international specialists. I have no doubt that it is important to treat severe headaches, sexual impotence or any other organic pathology deriving from the aggression suffered. But this treatment should not serve as a fig leaf preventing us from dealing with psychological conflicts which are the strongest and most usual after-effect and on which our professional attention should focus.

Medicalization is not a conceptual or abstract issue, but a conspicuous emerging tendency in clinics. It leads to a disconnect in the doctor–patient relationship and misunderstandings which can sometimes have sad consequences, although these are easy to correct.

Hans Mayer, a German Jew who turned his name into Jean Amery, gave up his mother tongue and wrote a book, Beyond Guilt and Atonement28 (which simply must be read). It reflects the view that victims feel that they have a message to convey and a report to deliver – that they are the products of their time.

On the other hand, like many professionals, we psychiatrists have the habit or almost the reflex of translating people’s dramatic poignant language into a technical jargon more precise and understandable for us. Terms such as war neurosis (post-traumatic stress syndrome) give us the audacity of Puss in Boots or of Columbus and the conquistadors who baptized these lands while they were in the process of appropriating them.

This game, or misunderstanding, can invade the doctor–patient relationship. Telling a survivor, one or more of whose relatives have been murdered that – the crime itself apart – the perpetrators were full of humiliation and shame towards the victim, or thinking of the patient who reacts to his grief with melancholy or hysteria as being on an emotional rollercoaster – these are things from which no therapist is safe. The groan is so intense and so genuine that it is necessary to consider its impact not only on the victim, but also on the witness, in this case the therapist. That is why there is so much talk of burn-out among the medical staff working in this type of situation. What is needed is not only the ability to cope with the intense emotions of the other person, the patient, but a careful and painstaking exercise in handling one’s own emotions.

Being the child, grandchild or indeed any member of the family of victims of extreme political violence leaves marks and after-effects which, I repeat, last a long time even when they are not the symptoms of a serious pathology. I believe that detecting and accepting the existence of these invisible pathologies is vital if we are to recover the collective memory of a community or whole society and that this restoration and reinstatement of grief and memories is indispensable to building healthy social links now and in the near future.