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International Journal of Psychology

International Journal of Psychology International Journal of Psychology , 2017 Vol. 52, No. S1, 57–66, DOI:

International Journal of Psychology, 2017 Vol. 52, No. S1, 57–66, DOI: 10.1002/ijop.12276

The effects of torture-related stressors on long-term complex post-traumatic symptoms in South Korean torture survivors

Hyunjung Choi 1 , Hoon-Jin Lee 2 , and Hwa-Young Lee 3

1 Traumahealingcenter Human Heart, Seoul, Korea 2 Department of Psychology, Seoul National University, Seoul, Korea 3 Institute of Medicine and Human Rights, Seoul, Korea

T his study explored whether perceived distress from specific stressors during and after torture explain long-term complex post-traumatic symptoms of South Korean torture survivors. We conducted a cross-sectional survey of

survivors who had been tortured by the homeland regime from the 1970s to the 2000s. Data from 206 survivors were gathered by key informants using target sampling and snowballing techniques. Project staff designed scales to encompass the specific types of stressors related to torture techniques used in Korea. Frequencies and distress ratings of exposure to torture, post-torture psychosocial stressors and physical damage related to torture were gathered. Psychological symptoms were assessed by the Impact of Event Scale-Revised-Korean version and subscales of the Symptom Checklist 90-Revised-Korean version. Perceived distress from torture stressors was mainly divided into factors representing physical, psychological and deprivation torture by adapting a principal axis factor analysis. Hierarchical regression analyses showed that distress from psychological torture explained post-traumatic stress disorder (PTSD) and that distress from deprivation explained PTSD and anxiety after controlling for demographic variables, psychological preparedness, time span since torture and distress from trauma other than torture. Among post-torture stressors, distress from physical damage related to torture and social exclusion were strong indicators of complex symptoms.

Keywords: Torture; Physical damage; Social exclusion; Complex post-traumatic stress.

The United Nations (1987) defines torture as “inten- tional infliction of physical or mental pain or suffering.” Torture is an extreme violation of human rights that is inflicted to destroy the integrity of an individual and soci- ety. Survivors of torture suffer from physical and psycho- logical distress associated with torture and from stressful life events within the post-torture socio-political environ- ment. Researchers have paid increasing attention to this suffering and have focused on identifying factors related to post-traumatic functioning of survivors. Recent studies on torture survivors have attempted to clarify the con- founding effects of torture type and other stressful life experiences on mental health (Kira, Ashby, Odenat, & Lewandowsky, 2013). Studies concerning the effects of the nature of tor- ture have emerged; not only the severity of torture but

the perceived distress and uncontrollability of torture are related to poor psychological functioning (Ba¸soglu,˘ 2009; Ba¸soglu,˘ Livanou, & Crnobaric, 2007; Ba¸soglu,˘ Paker, Özmen, Ta¸sdemir, & Sahin, 1994). Several stud- ies have examined the specific types of torture associated with post-traumatic functioning. Analysing the impact of each torture component, Ba¸soglu˘ (2009) reported that post-traumatic stress disorder (PTSD) is related to the per- ceived severity of non-physical torture, but not to physical torture. Another similar study by Punamäki, Qouta, and Sarraj (2010) showed that the frequency of psychologi- cal and physical torture and their combination increases PTSD symptoms. Additionally, sexual torture revealed by factor analysis explains PTSD, depression and anxi- ety symptoms better than those of other torture factors (Hooberman, Rosenfeld, Lhewa, Rasmussen, & Keller,

Correspondence should be addressed to Hoon-Jin Lee, Department of Psychology, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul 151-746, Korea. (E-mail: hjlee83@snu.ac.kr). Hyunjung Choi has designed the study, analysed the data and drafted the article. Hoon-Jin Lee has interpreted the results and revised the article critically. Hwa-Young Lee was in charge of the large survey by the National Human Rights Commission of Korea, contacting participants and collecting data. This study was supported by the NHRCK (11-1620000-000322-01).

58 CHOI, LEE, LEE

2007). Such studies have emphasised types of torture other than the physical type and suggest that the definition of torture must be broadened. Evidence from these stud- ies indicates that identifying the torture subtypes related to post-torture psychological symptoms will be useful to predict the aftermath of torture and facilitate identifying people at risk. However, whether torture experience itself is related to chronic psychological dysfunction is controversial. Tor- ture does not predict PTSD after controlling for other traumatic life events (Kira et al., 2006). Another study replicated this result confirming that torture itself is not an independent predictor of PTSD (Hollifield, Warner,

& Westermeyer, 2011). These findings suggest that the

confounding effects of torture and post-torture stressors

should be clarified. Stressors related to the post-torture environment were investigated previously as risk factors for post-traumatic stress. Poor socio-economic status and the absence of social support are important factors related to the post-traumatic responses of tortured refugees and polit- ical prisoners (Ba¸soglu˘ et al., 1994; Emmelkamp, Komproe, van Ommeren, & Schagen, 2002; Maercker, Gäbler, O’Neil, Schützwohl, & Müller, 2013). Another interesting study reported that torture-related chronic injuries fully mediate the relationship between torture and the numbing symptoms of PTSD among survivors of human rights violations (Rasmussen, Rosenfeld, Reeves,

& Keller, 2007). This study points out that physical

injuries may represent the severity of torture, which is intense enough to provoke fear and dissociation at the time of the trauma, and strongly predicts the development of PTSD. Studies about the effects of torture among South Korean survivors, who were persecuted under past mil- itary dictatorship of its own regime, are rare. Research conducted by structured interviews shows a high preva- lence rate of psychological disorders, such as 33.3% for PTSD and 41.6% for depressive disorders (Choi, Lee, & Lee, 2012). Research on South Korean torture survivors needs more attention, and the present study attempted to identify the types of stressors related to long-term com- plex post-traumatic symptoms in Korean torture survivors who had little chance to receive appropriate human rights informed clinical services. The aim of this study was to show the implications of adapting treatment to Korean torture survivors, and to emphasise the need to include various types of torture in the definition of torture. Another important aim was to understand the expe- riences of Korean torture survivors in post-torture environment living in the context of a collective society. According to the developmentally based bi-dimensional trauma framework (Kira, Lewandowski, Chiodo, & Ibrahim, 2014), stressors caused by one social system upon an individual of that group can form traumatogenic

dynamics of social exclusion that can betray an individ- ual’s sense of belonging. This systemic trauma consists of discrimination, stereotyping, loss of support, backlash and acts of domination or subjugation that threatens one’s collective identity. Korea has suffered from numerous historical traumas that may have contributed to the salience of the collective identities of Koreans (e.g. Kira, 2010). In such a collec- tive society, social approval is crucial for life satisfaction and well-being (Suh, Diener, Oishi, & Triandis, 1998). However, ostracism and silencing related to political vio- lence under a very complicated political context persists in South Korea, which constitutes systemic trauma in a collective society. This can result in failure of early med- ical support for victims with severe physical injuries. In addition, a non-supportive environment poses high risks for individuals in danger of further cumulative trauma and negative experiences. Yet, the effect of post-torture stres- sors in a Korean context has not been investigated. In this study, we hypothesised that post-torture experiences related to physical injuries and social exclusion corre- late with long-term post-traumatic psychological symp- toms in Korean torture survivors. As most studies on torture survivors have been conducted on refugees in a post-migratory context, this study is unique in that the par- ticipants were survivors oppressed by the regime of their own country. It is important to mention that stressors were assessed by the participants’ perceived distress rather than by the absence or presence of a particular stressor. Accord- ing to the learning theory (Ba¸soglu˘ & Mineka, 1992), post-traumatic responses depend on the perceptions of uncontrollability and unpredictability of the trauma, rather than mere exposure to them. Individuals differ in their responses during trauma, and these differences affect later functioning. Therefore, assessing the per- ceived distress from stressors as key factors may be more predictive of long-term post-traumatic symptoms than measuring the objective occurrence of stressors.

Participants

METHOD

This study was part of a larger survey of South Korean tor- ture survivors, conducted with the support and approval of the National Human Rights Commission of Korea (NHRCK). From 2005 to 2010, the Truth and Rec- onciliation Commission (TRC) of the South Korean democratic government revealed incidences of human rights violations in South Korea. Survivors who revealed incidences were contacted through key informants who were traced by acquaintances of project staff, various non-governmental organisations and former TRC investi- gators. Additionally, target sampling was used to achieve

adequate representations of groups of interest (politi- cal activist groups and fabricated spy cases); the activist groups shared similar psychological preparedness to tor- ture. However, in fabricated spy cases, ordinary people with less psychological preparation were fabricated into North Korean spies by the South Korean government under the threat of torture, and reported more occur- rences of severe physical torture (see NHRCK, 2011). Acquaintances of the participants were further invited to participate, to adopt a snowballing technique. The partici- pants had experienced torture during the 1970–2000s, but mostly during 1970–1980s when South Korea was under military dictatorship. As the participants had invited their acquaintances to participate, the number of individuals who refused partic- ipation was not recorded. However, of the 213 participants initially contacted, 7 failed to complete the questionnaire. Failure was mostly due to poor education, and difficulties understanding the questions, and they were recom- mended to discontinue or skip several questions to avoid exhaustion. Before consenting to the questionnaire, par- ticipants were informed of the purpose of the study, the right to discontinue the study, and the available aftercare services. Among the 206 participants who completed the questionnaires, 170(82.5%) were men and 36(17.5%) were women. Mean age was 56.7 years (SD = 10.0; range, 32–92 years). Twenty-three (11.2%) participants had a primary school education, 21(10.2%) had a secondary school education, 28(13.6%) had a high school educa- tion, 94(45.6%) were university educated and 36 (17.5%) were postgraduate educated. A total of 102 participants (49.5%) were political activists, 61 (29.6%) were student activists and 43 (20.9%) participants were non-activists related with fabricated spy cases.

Measures

Experienced project staff, who provided legal and psy- chological support for Korean torture survivors, designed the Exposure to Torture Scale (ETS). The ETS was based on the specific forms and “known techniques” of torture committed in South Korea. Physical torture, sexual tor- ture, exposure to extreme discomfort, deprivation of basic needs and psychological torture, such as psychological manipulation, humiliation, isolation and threats were included within the 27 items. Each stressful event was rated as absent or present; additionally, associated per- ceived distress was rated using a Likert scale ranging from 0 = not at all distressing to 6 = very extremely distressing. Post-torture psychosocial stressors were assessed by the Exposure to Psychosocial Stressor Scale designed specifically to assess the presence and perceived distress of stressors in the context of Korea. As the post-torture environment is determined by the context of the society, we designed a tool based on the experience of Korean tor- ture survivors. Project staff gathered information about

TORTURE AND POST-TRAUMATIC SYMPTOMS

59

the post-torture stressors that survivors had typically experienced after captivity. This included information from interviews, and the staff’s experience and obser- vations while providing legal or psychological support, and the most common complaints that emerged from the material were extracted. Post-torture stressors were formulated and organised into experiences such as pro- bation, socio-economic repression and social exclusion. The probation stressor included items for experiences such as limitations in social relationships and travel restrictions due to probation, and continuous confronta- tion with police investigators. Socio-economic repression included items about limitations in career or employment and economic crisis. Social exclusion included items of exclusion and ostracising by acquaintances or neigh- bours, relatives (cousins, aunts, uncles or in-laws), and family members (parents, brothers, sisters, children and spouses), not being able to reveal torture experiences, not being trusted about torture and not being able to receive support or help for the victimisation. The rating form was identical with that used for the ETS. Internal consistency (Cronbach’s alpha) of three items on probation was .892, that for the three items on socio-economic repression was .835 and that for the six items on social exclusion was .816, which were all significant. Distress ratings of each item were averaged for further analyses. Torture-related physical damage was measured by assessing the perceived distress and suffering related to torture injuries. Participants were asked to report phys- ical damage they had due to torture and to rate it for associated perceived distress (from 0 = not at all distress- ing to 6 = very extremely distressing). Twenty questions included musculoskeletal, dermatological, neurological, respiratory, otolaryngology, digestive, ophthalmic and

urogenital symptoms. The distress ratings for each item were averaged for further analyses. Psychological preparedness was self rated by three items defined by “commitment to a political cause,” “po- litical activity prior to captivity,” and “predictability or resolution of captivity/torture” (from 0 = not at all to 6 = very strong). These items were selected from the Psy- chological Preparedness for Trauma Scale (Ba¸soglu˘ et al., 1997). A reliability analysis of the three items showed

a Cronbach’s alpha of .863. The inter-item correlations

were .626 to .760 and the item-total correlations were .866

to .905. Additionally, occurrence and perceived distress (from 0 = not at all distressing to 6 = very extremely distress- ing) from traumatic experiences other than torture (e.g., traffic accident, disaster or traumatic bereavement) were queried. Psychological consequences, such as PTSD symp- toms, were assessed by the Korean version of the Impact

of Event Scale-Revised (IES-K-R; Eun et al., 2005; Weiss

& Marmar, 1997). A factor analysis revealed four fac- tors, including re-experience, hyper-arousal, avoidance

60 CHOI, LEE, LEE

and dissociative symptoms. The IES-K-R shows good reliability and validity for assessing PTSD symptoms (Eun et al., 2005). Other complex post-traumatic symp- toms, such as depression, anxiety, hostility, somatisation and interpersonal sensitivity were assessed by related subscales of the Symptom Checklist 90-Revised-Korean version (SCL90-R-K; Kim, Kim, & Won, 1984). The SCL90-R-K has been used extensively and has good psychometric properties (Kim et al., 1984). Subscales of depression included dysphoric mood and affect, with- drawal of life interest, lack of motivation, loss of vital energy, feelings of hopelessness, thoughts of suicide and cognitive and somatic expressions of depression. The anx- iety subscales included nervousness, tension, trembling and feelings of terror and panic. The hostility subscales included correlates reflecting anger, such as aggression, irritability, rage and resentment. The somatisation sub- scales included various cardiovascular, gastrointestinal and respiratory complaints. Last, the interpersonal sensi- tivity subscales included self-deprecation, uneasiness and discomfort in interpersonal relations (Kim et al., 1984).

RESULTS

Distinction of the torture types by adapting principal axis factor analysis

Frequencies and perceived distress for each exposure to torture stressor are presented in Table 1. A principal axis factor (PAF) of the perceived distress of each tor- ture experience was conducted. We hypothesised corre- lations among perceived distress of torture experiences; therefore, a direct oblimin rotation was selected. PAF explained 45.37% of the total variance and yielded seven factors (eigenvalues >1 and factor loadings >.32). Table 1 shows the rotated factor matrix and the factor loadings of the seven factors. The rotated factors generally showed a meaningful distinction. The first factor involved physical torture. The second factor represented sexual torture and the third factor included one item asking about uncontrol- lable body experiences. The fourth factor involved psy- chological torture. The fifth factor can be described as penetrated/contaminated body experience. Only one item asking about threats of rape or further torture fell under the sixth factor. Finally, the seventh factor was associated with deprivation of basic needs. Among the seven torture factors, perceived distress of physical torture, psychological torture and torture of deprivation were included in further analyses. The other four factors were not entered as they consisted of fewer than three items.

Psychosocial stressors and physical distress related to torture during the post-torture period

Frequencies and perceived distress for each exposure to psychosocial stressors and physical damage related to

torture are presented in Tables 2 and 3. The mean distress ratings of the psychosocial stressors and physical damage showed similar ranges compared to the distress ratings for exposure to torture.

Stressors related to long-term complex post-traumatic symptoms

The correlations among variables are shown in Table 4. Perceived distress from the three major types of torture was significantly correlated with complex post-traumatic symptoms. Post-torture distress from physical damage and psychosocial stressors were significantly related to symptoms. Psychological preparedness, perceived dis- tress of trauma other than torture, and the time span since torture were correlated with symptoms, so they were included in further analyses. Age at first torture was barely associated with any other variables related to the symptoms, so it was not included in further analyses. We conducted a hierarchical regression to determine which type of stressor predicted long-term complex post-traumatic symptom levels. Self-reports of PTSD, depression, anxiety, hostility, somatisation and interper- sonal sensitivity symptoms were the dependent variables. Independent variables, such as sex, age and education, were entered at step 1. Psychological preparedness, time since the first torture event, perceived distress from a traumatic experience other than torture and perceived distress from each three type of torture were entered at step 2. Finally, perceived distress from physical damage related to torture and all post-torture psychosocial stres- sors were entered at step 3. Additionally, we tested for multi-colinearity. The variance inflation factor values for each variable were 1.0–2.7; lower than the recom- mended cut off score of 5.0 (O’Brien, 2007), excluding the possibility of multi-colinearity. Shown in Table 5, the model was significant for all complex symptoms. Physical torture failed to explain all complex symptoms, whereas psychological torture explained increased PTSD symptoms and deprivation explained increased PTSD and anxiety symptoms. Dis- tress from physical damage related to torture explained all complex symptoms and social exclusion was related to all complex symptoms except interpersonal sensitivity. Among predictors other than the stressors, low psycho- logical preparedness explained increased PTSD symp- toms. Shorter time span since the first torture event was related to higher anxiety, somatisation and interpersonal sensitivity. Among the demographic variables, women appeared to experience higher depression, anxiety, hos- tility and somatisation. Lower educational level (less than high school) was related to higher symptoms of anxiety, hostility and somatisation.

TORTURE AND POST-TRAUMATIC SYMPTOMS

61

TABLE 1 Frequencies and perceived distress associated with torture and factor loadings of the principal axis factor analysis

 

Frequency

Perceived distress

 

Factor loadings

n (%)

Rating 5,6 a n (%)

M (SD)

1234

567

Harm body joints Bondage Beating Hanging Water torture and suffocation Deprivation of medical care Slap on face Electric torture Restriction of movement and forced posture Stripping naked and sexual humiliation Torture on sexual organs and sexual assault Verbal abuse, humiliation and mockery Isolation Fluctuation of interrogator’s attitude Forced unwanted behaviour Solitary confinement Witnessing torture Sham executions Injection of unknown chemical Needles under toenails, fingernails and forehead Threats of rape and further torture Deprivation of food and water Sleep deprivation Blindfolding Exposure to extreme sensation Heat torture Threats and violence against family

95 (46.1)

86 (90.5)

5.55 ( .91) 4.71 (1.52) 5.35 (1.14) 5.38 (1.26) 5.64 (.74) 4.72 (1.60) 4.59 (1.45) 5.50 (1.05) 4.61 (1.37) 4.88 (1.29) 5.35 (1.50) 4.57 (1.40) 4.89 (1.32) 4.73 (1.31) 5.01 (1.26) 4.59 (1.43) 4.93 (1.41) 4.79 (1.56) 3.92 (2.25) 5.23 (1.82) 4.72 (1.42) 4.32 (1.69) 5.04 (1.42) 4.23 (1.64) 4.77 (1.59) 4.13 (2.70) 4.73 (1.41)

.71

112 (54.4)

69 (61.6)

.69

170 (82.5)

144 (84.7)

.60

85 (41.3)

75 (88.2)

.58

84 (40.8)

78 (92.9)

.48

100 (48.5)

64 (64.0)

.48

160 (77.7)

92 (57.5)

.45

34 (16.5)

29 (85.3)

 

(.31)

108 (52.4)

66 (61.1)

 

.65

78 (37.9)

53 (67.9)

 

.60

17 (8.3)

15 (88.2)

.51

194 (94.2)

113 (58.2)

 

.67

176 (85.4)

124 (70.5)

.63

157 (76.2)

101 (64.3)

.58

158 (76.7)

117 (74.1)

.54

138 (67.0)

84 (60.9)

.43

147 (71.4)

107 (72.8)

.37

125 (60.7)

88 (70.4)

(.30)

13 (6.3)

5 (38.5)

 

.54

22 (10.7)

19 (86.4)

.44

58 (28.2)

39 (67.2)

.74

66 (32.0)

34 (51.5)

.51

153 (74.3)

119 (77.8)

.51

123 (59.7)

58 (47.2)

.43

62 (30.1)

41 (66.1)

(.27)

15 (7.3)

10 (66.7)

(.31)

109 (52.9)

68 (62.4)

 

(.22)

(.21)

a Ratings refer to extreme distress.

DISCUSSION

This study identified types of torture stressors in South Korean torture survivors and examined the relationships among the specific types of torture-related stressors and long-term complex post-traumatic symptoms. The torture stressors were divided into factors representing physical torture, psychological torture, deprivation of basic needs, sexual torture and other body experiences by adapting a PAF. These results were in line with previous findings on torture types (Hooberman et al., 2007; Kira et al., 2013). Types of sexual torture and other body experiences and their effects on post-torture adjustments could not be con- firmed as the numbers of items were insufficient. How- ever, these torture types are an important aspect of torture as they violate an individual’s physical and psychological intactness. The effects of these torture types need to be evaluated in future studies. The perceived distress from physical torture did not explain any of the complex post-traumatic symptoms when trying to predict long-term complex post-traumatic symptoms and related torture stressors, whereas psychological torture and deprivation explained higher

PTSD symptoms. Deprivation was also related to higher anxiety symptoms. These analyses indicate that after con- trolling for the effects of other life trauma, perceived dis- tress from torture results in long-term suffering. We also confirmed that above physical torture, other torture types representing cruel, inhuman and degrading treatment lead to prolonged symptoms. This result was reported previ- ously (Ba¸soglu,˘ 2009; Kira et al., 2013; Punamäki et al., 2010), and is in line with the suggestion that the distinc- tion between physical torture and other cruel, inhuman and degrading treatment in international law is misleading (Ba¸soglu˘ et al., 2007). Treating emotions and cognition related to the memories of these torture types has clinical implications. Another meaningful result was that distress from phys- ical damage related to torture was the most consistent indicator of long-term complex symptoms. Rasmussen et al. (2007) suggested that physical injury explains PTSD as it represents the severity of physical torture. In this study, perceived distress from physical damage was related to symptoms over the effect of perceived distress from physical torture. Distress from physical damage may represent physical pain or discomfort and

62

CHOI, LEE, LEE

TABLE 2 Frequencies and perceived distress associated with post-torture psychosocial stressors

 

Frequency

Perceived distress Rating 5,6 a n (%)

 

n (%)

M (SD)

Probation Restriction in travelling Limitations in social relations Confrontation with police Socio-economic repression Economic crisis Limitation in employment Limitations in career Social exclusion By acquaintances, neighbours Receiving no support Unable to reveal about torture By relatives Not being trusted about torture By family

142 (68.9)

58 (40.8)

4.00 (1.66)

142 (68.9)

66 (46.5)

3.99 (1.68)

132 (64.1)

59 (44.7)

3.89 (1.75)

166 (80.6)

115 (69.3)

4.76 (1.60)

155 (75.2)

92 (59.4)

4.28 (1.86)

114 (55.3)

61 (53.5)

4.14 (1.92)

136 (66.0)

60 (44.1)

3.98 (1.78)

130 (63.1)

66 (50.8)

4.19 (1.79)

125 (60.7)

45 (36.0)

3.58 (1.80)

122 (59.2)

54 (44.3)

3.84 (1.80)

94 (45.6)

40 (42.6)

3.89 (1.78)

57 (27.7)

26 (45.6)

3.74 (2.06)

a Ratings refer to extreme distress.

TABLE 3 Frequencies and perceived distress associated with physical damage related to torture

 

Frequency

Perceived distress

n (%)

Rating 5,6 a n (%)

M (SD)

Musculoskeletal

Head Neck/Shoulder Arm/Hand Waist Leg/Foot Contusion Punctured wound/Cuts Burns Headache/Dizziness Concussion Cerebral haemorrhage Chronic bronchitis (cough/sputum) Dyspnea (breathing problem) Anal injury Hearing impairment (eardrum rupture) Decreased visual acuity Visual impairment Urinary symptoms Genital injury Genital bleeding

108 (52.4)

66 (61.1)

4.64 (1.48) 4.79 (1.37) 4.84 (1.27) 4.95 (1.22) 4.92 (1.45) 4.94 (12.7) 5.00 (1.37) 5.50 ( .73) 4.40 (1.42) 5.21 (1.14) 5.00 (1.50) 4.55 (1.35) 4.90 (1.34) 4.59 (1.62) 4.51 (1.47) 4.28 (1.46) 4.26 (1.56) 4.58 (1.29) 5.33 (1.03) 5.29 (1.11)

121 (58.7)

78 (64.5)

107 (51.9)

69 (64.5)

123 (59.7)

83 (67.5)

108 (52.4)

77 (71.3)

Dermatological

143 (69.4)

101 (70.6)

22 (10.7)

13 (59.1)

17 (8.3)

14 (82.4)

Neurological

130 (63.1)

68 (52.3)

25 (12.1)

19 (76.0)

9 (4.4)

7 (77.8)

Respiratory

51 (24.8)

29 (56.9)

68 (33.0)

46 (67.6)

Digestive

19 (9.2)

9 (47.4)

Otolaryngology

43 (20.9)

25 (58.1)

Ophthalmic

66 (32.0)

31 (47.0)

19 (9.2)

10 (52.6)

Urogenital

45 (21.8)

25 (55.6)

6 (2.9)

4 (66.7)

7 (3.4)

6 (85.7)

a Ratings refer to extreme distress.

psychological suffering concerning that life and the future have been destroyed. Perceiving dysfunction in the body can prolong psychological symptoms, as it is a constant reminder of the impacts of torture and one’s vulnerability. Therefore, perceived distress of physical damage may involve distress factors other than the severity of physical torture itself. Early medical attention and psychosocial support for these suffering should be treated by proper rehabilitation.

Another important result of our study was that social exclusion was strongly related to poor psychological adaptation. This result is in line with previous studies, emphasising the importance of social support (Ba¸soglu˘ et al., 1994; Emmelkamp et al., 2002; Kira et al., 2014; Maercker et al., 2013) and supports the importance of the systemic trauma concept (Kira et al., 2014). In our study, systemic trauma (such as when social belonging and sup- port are threatened and torture experiences are concealed

.55 ***

.44 ***

.45 ***

.27 ***

.39 ***

.52 ***

.56 ***

.58 ***

.50 ***

.52 ***

.59 ***

.48 ***

.43 ***

.21 **

.18 **

17

.14 *

.37 ***

.25 ***

.35 ***

.38 ***

.28 ***

.24 ***

.39 ***

.50 ***

.31 ***

.36 ***

.28 ***

.24 **

.17 *

.02

.02

16

.45 ***

.30 ***

.40 ***

.32 ***

.33 ***

.34 ***

.34 ***

.26 ***

.26 ***

.38 ***

.22 **

.19 **

.10

.09

15

.70 ***

.41 ***

.62 ***

.33 ***

.66 ***

.47 ***

.35 ***

.57 ***

.53 ***

.48 ***

.55 ***

.22 **

.11

14

.36 ***

.49 ***

.34 ***

.50 ***

.50 ***

.40 ***

.35 ***

.35 ***

.06

.09

.03

.13

13

.35 ***

.38 ***

.49 ***

.40 ***

.53 ***

.34 ***

.38 ***

.16 *

.16 *

.06

.08

12

.41 ***

.39 ***

.45 ***

.56 ***

.43 ***

.26 ***

.47 ***

.18 **

.16 *

.01

11

TABLE 4 Descriptive characteristics and correlations of each variable

.32 ***

.30 ***

.28 ***

.29 ***

.23 **

.23 **

.16 *

.06

.11

10

.27 ***

.46 ***

.30 ***

.24 **

.18 **

.17 *

.10

.13

9

.15 *

.16 *

.10

.00

.02

.06

.08

8

.02

.04

.04

.09

.08

.13

7

.84 ***

.71 *** .79 ***

.81 ***

.72 ***

.72 ***

6

.64 *** .71 *** .81 *** .78 *** .87 *** .79 ***

5

4

.89 ***

.71 ***

3

.75 ***

2

1

28.59 (24.11)

19.91 (13.05)

16.89 (12.95)

17.17 (14.13)

42.15 (23.42)

12.80 (11.54)

12.94 (9.76)

11.97 (5.82)

10.39 (9.20)

29.48 (6.16)

27.45 (7.35)

22.52 (9.44)

1.65 (2.39)

9.78 (6.10)

7.65 (5.38)

8.14 (6.25)

6.79 (6.92)

M (SD)

.001. disorder.

** p < .01. *** p < stress

PTSD Depression Anxiety Hostility Somatisation Interpersonal sensitivity Age at first torture Time span since first torture (years) Psychological preparedness Trauma other than torture Physical torture Psychological torture Deprivation Physical damage Probation Socio-economic repression Social exclusion

p < .05. = post-traumatic

PTSD

9
10

11
12

13
14

15
16

17

1
2

3
4

5
6

7

8

*

TORTURE AND POST-TRAUMATIC SYMPTOMS

63

64

CHOI, LEE, LEE

TABLE 5 Stressors related to each long-term complex post-traumatic symptom

Post-traumatic stress disorder

Depression

 

Step

Adjusted R 2

ΔR 2

F-value

(step 3)

Adjusted R 2

ΔR 2

F-value

(step 3)

1

Sex Age Education

 

.113

.128

8.362 ***

.020

.101

.116

7.505 ***

.173

**

 

.073

.091

.095

.135

2

Psychological preparedness Time since first torture event Trauma other than torture Physical torture Psychological torture Deprivation

 

.453

.354

17.035

***

.173

*

.336

.254

10.795

***

.089

 

.099

.145

.008

.023

.098

.116

.149

*

.065

.184

**

.045

3

Physical damage by torture Probation Socio-economic repression Social exclusion

 

.527

.081

15.904 ***

.229

**

.421

.094

10.734 ***

.346

***

 

.045

.029

.071

.004

.310 ***

 

.227 *

 

Anxiety

Hostility

 
 

Step

Adjusted R 2

ΔR 2

F-value

(step 3)

 

Adjusted R 2

ΔR 2

F-value

(step 3)

1

Sex Age Education

 

.104

.119

7.724 ***

.200

**

 

.084

.100

6.329

***

.148

*

 

.075

 

.177

.136

*

.146

*

2

Psychological preparedness Time since first torture event Trauma other than torture Physical torture Psychological torture Deprivation

 

.386

.298

13.153

***

.043

 

.295

.231

9.083

***

.063

 

.168

*

 

.139

.059

.012

.109

.143

.038

.061

.146

*

.081

3

Physical damage by torture Probation Socio-economic repression Social exclusion

 

.479

.100

13.284 ***

.271

**

 

.367

.083

8.758 ***

.237

*

 

.046

 

.074

.063

.001

.297 **

.318 **

 

Somatisation

 

Interpersonal sensitivity

 
 

Step

Adjusted R 2

ΔR 2

F-value

( step 3)

Adjusted R 2

ΔR 2

F-value

( step 3)

1

Sex Age Education

 

.199

.213

15.446

***

.233

***

.031

.048

2.872 *

.109

 

.022

.023

.186

**

.032

2

Psychological preparedness Time since first torture event Trauma other than torture Physical torture Psychological torture Deprivation

 

.473

.287

18.321

***

.115

.280

.270

8.528

***

.135

 

.145 *

 

.255

**

.001

.015

.156

.065

.002

.137

.061

.074

3

Physical damage by torture Probation Socio-economic repression Social exclusion

 

.593

.123

20.489 ***

.398

***

.358

.089

8.469 ***

.398 ***

 

.039

.031

.003

.001

.296 ***

 

.179

* p < .05. ** p < .01. *** p < .001.

resulting in fewer chances for disclosure and accep- tance) was related to increased levels of post-traumatic symptoms. Similar to the phenomenon arising in refugees who experience systemic trauma in a foreign country (Kira et al., 2010), systemic trauma from discrimination and denial of South Korean torture survivors in their homeland is a serious issue.

The subjective meaning of torture is primarily created by historical and cultural traditions that make sense out of the experiences for the survivors and their communities (Mollica, 1988) and these traditions also affect all stages of coping and adjustment (Marsella & Dash-Scheur, 1998). Social exclusion in a collective society where social self is as crucial as one’s physical integration

influences the meaning of the torture experience and the manifestation of symptoms and plays a huge role regulat- ing distress. Therefore, recognising a broader concept of trauma, such as systemic trauma, inflicted by the interaction between the social system and the individual must be con- sidered. Moreover, Genefke (1994) pointed out that tor- ture paralyses the society into denial and silence, and a society where torture survivors are unaccepted is contin- uing the violation. Probation and economic distress were not signifi- cantly related with any complex post-traumatic symp- toms, which is inconsistent with previous studies among refugees experiencing post-migration stressors that unem- ployment status is related to lower psychological func- tioning (Silove, Sinnerbrink, Field, Manicavasagar, & Steel, 1997). The distress that refugees suffer over their socio-economic status may exceed their psychological resilience compared to survivors in their homelands. Among the controlling variables, time appeared to assist some symptoms of anxiety, somatisation and interpersonal sensitivity. However, the effects of PTSD, depression and hostility did not lessen after decades. Edu- cational disadvantage explained symptoms of anxiety, hostility and somatisation, as cognitive capacity protect individuals from the maintenance of post-traumatic symp- toms (Brewin, Andrews, & Valentine, 2000). Among our sample, less than a high school education may have precluded opportunities to be aware of socio-political conditions that provoked human rights violations and interrupted processing of one’s suffering. Human rights informed rehabilitation services for tor- ture survivors are progressing in South Korea. Managing physical distress through massage, yoga, meditation and sustainable medical support can be helpful for torture sur- vivors in the context of Korea. It is particularly important to provide psychosocial interventions to integrate one’s social self, rebuild connections back to the community and raise social awareness of the impact of torture and the wrongdoings of the past regime. There are important limitations in this study. First, the result cannot be generalised to survivors who did not par- ticipate in the study due to their fear and isolation from social exclusion they might be enduring. Non-contacted survivors may suffer more severe symptoms, particularly those related to interpersonal sensitivity. Results with interpersonal difficulty need confirmation in future stud- ies of participants who were severely isolated from the community. Second, employing a cross-sectional design, conclusions cannot be interpreted as causations. Third, all data were collected through self report questionnaires. Symptom levels obtained from questionnaires may not correspond exactly with a symptom assessment and do not indicate the presence of a particular psychiatric diagno- sis. However, Rucio, Rucio, and Keane (2002) suggested that post-traumatic responses are better conceptualised as

TORTURE AND POST-TRAUMATIC SYMPTOMS

65

a dimensional continuum rather than as a discrete syn- drome. In that case, assessing symptom levels may be more appropriate than differentiating individuals with and without disorders. Fourth, although this study assessed complex symptoms as dependent variables, more accurate assessments and analyses of symptoms related to torture trauma (e.g. dissociation; Kira et al., 2013) are needed in further studies. Last, although the assessments of stressors during torture and post-torture were particularly designed to encompass the experiences in the context of Korea, items including other torture methods, expanded items and factor analyses to more accurately assess post-torture stressors and distress from trauma other than torture should be replicated and verified. The findings should be replicated among different cul- tures and populations to establish the cultural factors involved in the relationships between the stressors and maintenance of related symptoms. The effects of sys- temic trauma may differ among cultures and contexts. For example, survivors from a collective society may suffer from systemic trauma more than survivors whose iden- tity depends on uniqueness and independence. Search- ing for similarities and differences among North and South Korean survivors or refugees and non-refugees also remains an important task. Despite these limitations, this is one of the first empirical studies on South Korean torture survivors. Our results support the association between perceived distress from psychological and deprivation torture, physical damage and social exclusion with long-term complex post-traumatic symptoms. Our results also support discussion on broadening the definition of torture and that a careful evaluation of post-torture stressors that indicate systemic trauma is essential. Specific attention to memories of cruel, inhuman and degrading treatment is needed, as well as emphasising care for distress related to physical injury. These interventions should be conducted in a way to promote social reunion of survivors into the community, as a society unaccepting of torture survivors could be regarded as allowing the violence to continue. Therefore, raising awareness about the cruelty of torture within the society must also be accomplished.

Manuscript received June 2015 Revised manuscript accepted April 2016 First published online May 2016

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