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Cognitive theories maintain that traumatic stress responses may be mediated by inability to find an acceptable explanation for the trauma (Lifton and Olson, 1976; Ursano et al., 1992; Winje, 1998) and violation of beliefs that the world is a just and orderly place (Janoff-Bulman, 1989; Janoff-Bulman, 1992; Lerner and Miller,1978). Furthermore, lack of redress for trauma, such as investigation of human rights violations, uncovering of truth, punishment of those responsible for human rights violations, and com- memoration and compensation, is believed to aggra- vate social and psychological problems and impede healing processes in survivors (Carmichael et al.,

1996; Gordon,1994; Lagos,1994). We examined the role of such cognitive processes in a pooled sample of 1079 war and 230 torture survivors in former Yugoslavia countries.

The assessment instruments were detailed in the main study report (Başoğlu et al.,2005). To summarize, the impact of trauma on beliefs was assessed by a 48- itemEmotions and Beliefs after War (EBAW) question- naire. A comparison of war survivors with matched controls at two study sites (Banja Luka and Rijeka) demonstrated that EBAW items measured the impact of trauma on beliefs. A factor analysis of the question- naire yielded seven factors, which explained 55% of the total variance. The factors were orthogonally rotated. The items that defined each factor (i.e. with loadings over 0.32; Tabachnick and Fidell,2001) and the item endorsement rates are shown inTable 2.5.

Factor 1 included all the items of theFear and Loss of Control Scale presented earlier in this chapter and represented fear and associated helplessness responses. Factor 2 reflected various emotions associated with perceived impunity for those held responsible for trauma, including demoralization, distress, anger, helplessness, pessimism, sense of injustice, and loss of faith in people. Thisfinding lends further support

to our statement earlier in this chapter that humans respond with anger, hostility, and aggression to threats to physical and psychological well-being (Averill,

1982; Baron, 1977) and that not being able to act on such emotions generates feelings of helplessness. Compared with non-tortured survivors, tortured sur- vivors had significantly higher scores on Factor 1 (mean =−0.15, SD = 0.86 vs. mean = 0.69, SD = 0.98, p< 0.001) and Factor 2 (mean = −0.08, SD = 0.96 vs. mean = 0.35, SD = 0.77, p< 0.001). This finding sug- gests that torture has stronger fear and helplessness effects than other war traumas.

Factor 3 represented fatalistic thinking and increased faith in God and religion, while Factor 4 represented loss of meaning in war cause. The latter factor also seemed to reflect feelings of helplessness and hopelessness arising from a sense of defeat, loss of war cause, and loss of hope for the future of the country. In view of the between-site differences on the mean scores of this factor (Belgrade mean = 0.24, SD = 0.94, Banja Luka mean =−0.12, SD = 0.87, Sarajevo mean = −0.04, SD = 0.86, Rijeka mean =−0.29, SD = 0.88, F = 22.5, p< 0.001), this factor seemed to reflect a sense of defeat in the Serbian war survivors. The other factors repre- sented belief in the benevolence of people and justice in the world, desire for vengeance, and loss of faith in God and religion. A desire for vengeance and beliefs in God, religion and benevolence of people might also be regarded as reflecting to some extent cognitive efforts to regain sense of control over uncontrollable stressor events. Fatalistic thinking as a form of coping response was discussed inChapter 1.

This study also included an 18-item assessor-rated Redress for Trauma Survivors Questionnaire (RTSQ), which obtained information about the survivor’s appraisal of redress for trauma. The items related to telling of trauma story to authorities or NGOs, retrib- utive justice (investigation, trial, and punishment of those held responsible for trauma), compensation for trauma, activities in remembrance of past events, com- munity responses to survivors (recognition of past suffering, contribution to war effort, people’s attitudes towards survivors), meaning attributed to trauma (Was past suffering worthwhile, given the present circumstances of the country?), social and political responses to human rights violations (community protests, international protests, international media coverage, efforts by foreign governments to stop human rights violations, efforts by NGOs to stop

Table 2.5 Emotions and Beliefs after War factors and item endorsement rates (N = 1309)

%a Factor loadings

Factor 1: Fear and loss of control over life (13.4%) I feel I am in danger.

I feel my loved ones are in danger. I sometimes feel I am being followed. I have lost control over my life.

I cannot lead my normal life for fear of the same events happening again. I am frightened when I see someone who might be from the other side. I feel fearful in crowded places.

I fear for my life.

I developed certain fears that I never had before. I am afraid of coming across the perpetrators some day. My life is largely controlled by others.

There is nothing I can change in my life.

13 17 13 22 27 25 24 24 38 26 22 44 0.80 0.72 0.69 0.68 0.67 0.66 0.64 0.63 0.61 0.57 0.56 0.45 Factor 2: Emotional responses to impunity (13.4%)

I feel demoralized when I see the perpetrators getting away with what they did. I feel rage at the thought of perpetrators getting away with their deeds.

I feel distressed by the thought of the perpetrators of such atrocities getting away with what they did.

There is nothing I want more in life than seeing the perpetrators punished.

Everything in life loses meaning when I see the perpetrators getting away with what they have done.

Seeing atrocities go unpunished makes me feel helpless.

The perpetrators getting away with their deeds makes me pessimistic about the future. I feel angry when I think of what they did to me and to my loved ones.

It is great injustice that the perpetrators get away with what they did. So many atrocities going unpunished made me lose my faith in humanity.

The international community’s indifference to and lack of awareness in what happened annoy me. 61 59 78 58 59 57 58 82 92 60 73 0.75 0.74 0.74 0.74 0.73 0.67 0.64 0.64 0.62 0.56 0.54 Factor 3: Fatalistic thinking / Increased faith in God and religion (8.6%)

Suffering for what is right is God’s will.

What happened to me was God’s test of my faith.

If a person suffers for what is right they will be rewarded in the afterlife. What happened to me was God’s will.

I have stronger faith in God.

Faith in God is of great help in difficult times. God is on the side of the poor and the oppressed.

43 34 40 43 58 79 57 0.79 0.77 0.77 0.74 0.72 0.70 0.66 Factor 4: Loss of meaning in the war cause (8.5%)

The struggle for my country and people lost its meaning for me. I believe our cause is lost.

My struggle for this country has been in vain.

I feel hopeless when I consider what we have achieved so far in our struggle. I feel nothing will ever change in the world.

I believe the current situation of my country is not likely to improve. I have no trust in the State.

My comrades have disappointed me.

48 51 56 54 55 54 74 42 0.77 0.77 0.73 0.64 0.57 0.45 0.42 0.41 Factor 5: Belief in the benevolence of people and justice in the

world (4.7%)

I believe good will always prevail over evil. I have faith in justice.

Sooner or later, people find punishment for their bad deeds. I believe in essence people are good.

80 75 79 76 0.77 0.72 0.68 0.52 Factor 6: Desire for vengeance (3.5%)

Sometimes I daydream that I take revenge on the perpetrators. In my dreams I commit acts of revenge against the perpetrators. If I had the chance, I would punish the perpetrators with my own hands.

19 20 38 0.75 0.70 0.52

human rights violations), and global rating of sense of justice (“Considering what you and/or your close ones went through, do you think justice has been served in your case? How satisfied are you with this outcome?” 1 = very dissatisfied, 4 = no effect /don’t know, 7 = very satisfied). The same satisfaction rating was also obtained for each redress event. According to the global rating of sense of injustice, 79% of the study participants were dissatisfied with justice, while 15% were satisfied.

A principal components analysis of the EWSS in the pooled sample yielded 12 components represent- ing captivity and torture events, exposure to shelling and random enemy fire, active combat experiences, displacement and refugee experiences, trauma events (torture, death, disappearance, imprisonment) of close ones, witnessing injury and violent death of close ones, defection of close ones to enemy side, exposure to mass graves and mutilated bodies, rape / witnessing rape of others, stepping on a landmine, sudden destruction of home / exposure to explosions, and combat experience of close ones.

A multiple regression analysis was conducted, including CAPS total scores as the dependent variable. Age, sex, marital status, education, time since trauma, and preparedness for trauma were entered into the equation at step 1, global rating of loss of control during the trauma at step 2, the 12 EWSS component scores at step 3, the 18 RTSQ items at step 4, the scores on all EBAW factors, except the Fear and Loss of Control factor at step 5, and the scores on the latter factor at step 6. The Fear and Loss of Control factor scores were entered after the other EBAW factors to examine the percentage of variance explained by fear- induced helplessness over and above the variance explained by the other EBAW factors. Table 2.6

shows the percentage of variance explained at each step and significant predictors in the full regression model.

Severalfindings are worth noting. First, the helpless- ness variables together explained as much variance (19%) as all trauma exposure variables combined, even when the Fear and Loss of Control factor was entered at the last step. When the latter variable was entered at the second step (not shown inTable 2.6) with the global rating of loss of control during the trauma, together they explained 28% of the variance, while the trauma expo- sure variables explained 10% of the variance. This sug- gests that fear and helplessness during and after the trauma is a stronger predictor of PTSD than the distress experienced during the war events. Second, appraisal of redress explained the smallest percentage of variance (2%). Third, among the EBAW factors, Fear and Loss of Control explained 10% of the variance as opposed to 4% explained by all other factors combined. Thus, help- lessness associated with appraisal of ongoing threat to safety was a much stronger predictor of PTSD than helplessness related to perceived impunity for those held responsible for trauma and sense of defeat and loss of belief in war cause. Fourth, the resilience variable showed significant prediction at the first step (β = 0.06, p< 0.05), although it was no longer a significant predic- tor at subsequent steps when the effect of loss of control during the trauma was controlled for. This reflected shared variance between the two variables. Finally, the strongest predictors in the full regression model were post-trauma fear and helplessness, captivity and torture experiences, and exposure to enemyfire and casualties.

Concluding remarks

Survivor accounts of torture experience reveal striking parallels between inescapable shock experiments in animals and human responses to unpredictable and uncontrollable torture stressors. Psychological responses to torture appear to be primarily geared towards maintaining control over torture stressors through cognitive, Table 2.5 (cont.)

%a Factor loadings

Factor 7: Loss of faith in God and religion (2.7%) I have less faith in religion.

I have lost faith in God. I do not believe in God’s justice.

23 25 40 0.70 0.64 0.37 a_{Endorsement defined as a rating 4 (moderately true) or higher.}

behavioral, emotional, and psychophysiological processes. Both anecdotal data from interviews with torture survivors and empirical evidence from our studies strongly suggest that unpredict- ability and uncontrollability of torture stressors play an important role in acute and chronic post-traumatic stress. Evidence also suggests that immunization against traumatic stressors is possible in humans. Resilience processes not only afford some protection from traumatic stress but also appear to play an important role in natural recovery from torture trauma.

The association between fear-induced helplessness and PTSD is consistent with findings pertaining to earthquake trauma reviewed in Chapter 1. Similar findings from studies of survivors of rape (Regehr et al.,1999),fire (Maes et al.,2001), physical or sexual assault (Kushner et al.,1993; O’Neill and Kerig,2000), childhood sexual abuse (Bolstad and Zinbarg,1997), and nuclear accident (Davidson et al.,1982) suggest that different types of traumas, whether of human design or due to natural causes, share the same mech- anisms of traumatic stress. Thesefindings imply that traumatic stress reactions can be reversed by interven- tions designed to enhance sense of control over fear, as will be detailed inPart 2. The relatively small role of beliefs about justice and trust in PTSD suggests that interventions that focus on fear may be sufficient in recovery from traumatic stress.

Our findings also have important implications on definition of torture. Since the 9/11 events there has been much debate on what constitutes torture. After reports (Amnesty International,2005) of human rights abuses by the US military in Guantanamo Bay, Iraq, and Afghanistan, a US Defense Department working group report (US Defense Department, April 4, 2003) on detainee interrogations and a US Justice Department memorandum (US Justice Department, December 30, 2004) on US torture policy argued for a fairly narrow definition of torture that excludes mental pain and suffering caused by various acts that do not cause severe physical pain. According to this definition, var- ious interrogation and detention procedures, such as blindfolding, hooding, forced nudity, isolation, forced standing, rope bondage, deprivation (of sleep, light, water, food, or medical care), and psychological manipulations designed to break a person’s resistance (e.g., humiliating treatment or other acts designed to create fear, terror, or helplessness in the detainee), do not constitute torture. The implications of our Table 2.6 Multiple regression analysis of factors associated

with PTSD in war and torture survivors (n = 1309)

R2 Change statistics Step 1 0.15 F6,1222= 36.7, p < 0.001 Step 2 0.09 F1,1221= 150.4, p < 0.001 Step 3 0.19 F12,1209= 32.8, p < 0.001 Step 4 0.02 F18,1191= 2.7, p < 0.001 Step 5 0.04 F6,1185= 14.9, p < 0.001 Step 6 0.10 F1,1184= 286.1, p < 0.001 Overall model 0.59 F44,1228= 38.9, p < 0.001 β p Older age 0.08 0.001 Lower education 0.07 0.001 Loss of control during

trauma 0.10 0.001

Captivity- and torture-related

stressors 0.22 0.001

Exposure to enemy fire

and casualties 0.19 0.001 Combat experience

involving acts of killing

0.12 0.001 Loss of resources / Refugee

experience 0.05 0.03

Learning about trauma experiences of close ones

0.04 0.04 Exposure to mass graves and

mutilated bodies 0.05 0.01 Combat experience of close

ones −0.07 0.001

Community’s recognition for

past suffering 0.06 0.04 Emotional responses to

impunity 0.13 0.001

Loss of meaning in the war

cause 0.12 0.001

Less belief in the benevolence of people and justice in the world

0.12 0.001 Desire for vengeance 0.13 0.001 Fear and helplessness 0.37 0.001

findings for an evidence-based definition of torture were reviewed in two recent articles (Başoğlu et al.,

2007; Başoğlu,2009). Although this issue is beyond the scope of this chapter, it is worth briefly summarizing the main points of these articles in the light of addi- tional information provided in this chapter. Most importantly,Table 2.1data show that various stressor events that are said not to involve intense physical pain (e.g. forced stress positions, asphyxiation, sham executions, sexual torture, threats of rape, death, tor- ture, or harm against family, witnessing torture, blind- folding, humiliating treatment, solitary confinement, sleep deprivation, and prevention of urination / defe- cation) can be as distressing as physical torture.

Table 2.3 data suggest that stressor events involving witnessing death, injury, torture, or suffering of close ones and other people are also among the most dis- tressing events experienced by war survivors outside a captivity setting. Thus, it is difficult to make a distinc- tion between CIDT and physical torture events in terms of associated distress. Furthermore, evidence shows that it is fear and helplessness associated with CIDT rather than physical torture that account for chronic psychological damage in sur- vivors. Second, our findings suggest that contex- tual factors need attention in any consideration of what constitutes torture. These procedures, even when they do not involve physical violence, are inherently coercive and potentially traumatic. This is supported by the fact that 47% of the war survivors who had detention or POW experience in our study in former Yugoslavia developed PTSD, even though they were not tortured. Finally, the severity of acute or chronic traumatic stress does not appear to be a reliable criterion in defining torture, considering that resilient survi- vors responded to many stressor events with rel- atively less distress and many did not develop PTSD, despite severe torture. Furthermore, not all stressors perceived as most distressing (includ- ing physical torture) related to PTSD. Yet, it makes neither logical nor moral sense to disqual- ify such events as torture on these grounds, as many of them constitute torture by any definition.

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