Burma’s silent struggle: ensuring mental health of tortured political prisoners

Assistance Association for Political Prisoners (AAPP), Burma

Earlier this year the United Nations (UN) High Commissioner for Human Rights stated that whilst Burma had promised to end the era of political prisoners it “now seems intent on creating a new generation by jailing people who seek to enjoy the democratic freedoms that have been promised.”[1]There are currently 170 political prisoners[2] behind bars in Burma’s prisons. With a further 443 activists awaiting trial, and arrests of activists showing no sign of abating, the situation of this new, post-junta era of political prisoners in Burma looks bleak, especially considering the government refuses to officially recognize their existence.

Growing doubt over the authenticity of government reforms has led to a widespread consensus that reforms in Burma have now stalled; the continued existence of political prisoners is demonstrative of the government’s backsliding on its supposed transition towards democracy. In fact, the steady rise in the number of political prisoners in Burma over the last year makes clear that the Government of Burma is increasingly cracking down on fundamental freedoms in the run up to the 2015 election.

It is evident that the government will stop at nothing to silence its critics – in the last year alone there have been multiple accounts of torture in detention, inhumane treatment and extrajudicial killings of civilians.[3] Whilst those participating in the struggle for freedom and democracy are arrested, detained, mistreated and even tortured, the perpetrators of such gross abuses enjoy the pervading culture of impunity that continues to exist in Burma.

Even when political prisoners are released, restrictions placed upon them by the government in addition to lingering effects of imprisonment pose as major barriers to their reintegration into society. Faced with physical, social and economic obstacles to rebuilding their lives, former political prisoners and their families continue to face difficulties even after their release. In particular, the effects of torture have a hugely detrimental impact on reintegration efforts, and even when the physical wounds have healed, victims may be left with long-lasting or even permanent psychological damage.

In the absence of government-led programs to assist former political prisoners and victims of human rights abuses, organizations such as the Assistance Association for Political Prisoners (AAPP) work to fill the gap, assisting victims and their families to overcome the effects of unjust imprisonment and abuse. The AAPP’s Mental Health Assistance Program provides mental health services to former political prisoners (and their families) affected by trauma, depression and anxiety as a result of torture and other mistreatment endured during incarceration, in order to equip victims with a variety of methods to overcome their mental health issues so they can rebuild their lives.

Political prisoners in Burma

Since the 1962 military takeover to date, Burma has remained under military rule in one form or another. Fundamental freedoms such as civil and political rights have been routinely quashed as the military regime has sought to stifle even the slightest opposition within the country. It is within that context that over the last five decades, thousands of activists, journalists, and individuals attempting to defend their rights have been systematically imprisoned, and subject to torture and gross mistreatment.

President TheinSein’s quasi-civilian government has, since 2011, instigated a number of political reforms in Burma, which initially looked to see the improvement in the political prisoner situation in Burma. Thousands were released in a series of political prisoner amnesties and furthermore, TheinSein promised that all political prisoners would be released by the end of 2013.[4]

However, even under the current government, the judiciary remains under the de facto control of the military and government, characterized by institutionalized corruption and inefficiency.[5] Through the continued use of draconian legislation, arbitrary detention and failure to provide detainees with fair trials, the government is able to criminalize and impede the activities undertaken by those that seek to protect their civil and political rights. In stark contrast to the commitment made by TheinSein, by the end of 2013, 30 political prisoners remained, a number that has steadily risen over the last 18 months.

A recent violent crackdown in March against student protestors and subsequent reports of torture are indicative of the government’s attitude towards those attempting to exercise their basic rights. Calling for amendments to be made to the National Education Bill,[6] 133 protestors were arrested in Letpadan in a violent crackdown. Additional protestors were arrested in the aftermath of the crackdown. Currently 78 protestors remain in prison awaiting trial, while a further 61 await trial from outside of prison.[7] Alarmingly, reports of torture[8] of the student protestors in prison have come to light, and the students have largely been denied medical treatment for injuries received during the violent arrest, and from alleged torture.

In fact, the use of torture in Burma – in particular against political activists -remains widespread; despite the Government of Burma stating in January 2014 its intention to sign United Nations Convention Against Torture (UNCAT) by September that same year. The UNCAT remains unsigned and the government’s failure to fulfill yet another commitment clearly signifies its lack of interest in addressing the gross human rights abuses that continue to permeate Burma’s political landscape. Dissident citizens of Burma will continue to endure torture and other human rights abuses until the perpetrators are held accountable and brought to justice.

Making apparent the government’s complete lack of interest in the political prisoner issue is the fact that the body tasked to deal with the issue – originally named the Prisoners of Conscience Affairs Committee – has yet to meet this year. Rather than actually attempting to address the alarming political prisoner situation, key members of the previous committee have been excluded and the current committee remains mired by irrelevant bureaucracy such as the ongoing reform of its name. Moreover, it is difficult to comprehend how a committee chaired by the Deputy Home Minister can take seriously the issue of political prisoners when the Home Affairs Ministry has been responsible for the recent violent crackdown against student protestors and subsequent arrests.

Torture of political detainees

The practice of torture[9] to not only extract information and false confessions, but also to punish, degrade and humiliate political detainees, has a long history in Burma and has been widely employed by successive military regimes. Evidencing the widespread and systematic nature of torture in Burma is AAPP’s data collection on 1,621 former political prisoners arrested and imprisoned between 1962 and 2013.[10] The majority of the former political prisoners surveyed revealed experiences of enduring torture while in detention; of those that responded to the question, 72% of respondents reported having been subject to physical torture, whilst 75% reported having been subject to psychological torture. 90% revealed that they had no access to medical treatment during this time.

The practice of torture continues to be utilized by the current government, despite provisions in both domestic and international law intended to protect detainees from harm. Whilst Burma has yet to sign UNCAT, and the 2008 Constitution provides no explicit provisions prohibiting torture and other ill treatment, there are certain guarantees provided for by the Burma Penal Code that protect detainees; for example, Articles 330 and 331 prohibit “hurt” and “grievous hurt” during interrogation.[11]

Moreover, there are international standards that provide such protections, which Burma is obliged to adhere to. Prohibition against torture is widely accepted to form part of customary international law as jus cogens, under which no derogation is ever permitted.[12] Not only is prohibition against torture stipulated by UNCAT, it is also firmly embedded within several other major human rights instruments including the Universal Declaration of Human Rights (UDHR); the International Covenant on Civil and Political Rights (ICCPR); and the Convention against Torture or Other Cruel, Inhuman or Degrading Treatment or Punishment.

Yet, the Government of Burma continually flouts both domestic and international law and political prisoners are physically and psychologically tortured throughout the country at the hands of the authorities in police stations, detention centers, interrogation centers and prisons. Of the 50 former political prisoners surveyed by AAPP that were arrested and imprisoned between 2011 and 2013, over half reported having been subject to both physical torture and psychological torture. In addition, there have been numerous reports of the torture of activists in Burma perpetrated by the authorities since 2011,[13] further adding weight to the basis that TheinSein’s government continues to torture its opposition in a widespread and systematic manner.

The authorities utilize a wide range of torture techniques to physically and mentally torture political detainees, often used in conjunction with each other to maximize suffering. During interrogation, political detainees are often blindfolded or hooded[14] to cause sensory deprivation, and then subjected to a wide range of interrogation methods that constitute torture including beating, being made to stand in stress positions for prolonged periods of time, being tied upside down from the ceiling, being burnt with lit cigarettes, water torture, electric shock torture and sleep deprivation.[15]AAPP’s data collection on former political prisoners has revealed that the same methods of interrogation that have been utilized for decades in Burma continue to be practiced by the current government.

Despite the ample evidence that exists exposing grave instances of torture of political detainees in Burma, the perpetrators continue to enjoy complete impunity from their actions. Until Burma takes concrete steps towards eradicating torture, such as signing UNCAT and holding perpetrators accountable, Burma’s citizens will never be afforded the right to be free from torture.

Effects of Torture on Mental Health

While political prisoners no doubt suffer from lasting physical injuries as a result of torture, survivors of torture, ill treatment and unjust imprisonment suffer a range of mental health symptoms at varying levels of severity. Upon release, many political prisoners find it difficult to relate to others who do not share similar experiences as they feel they can never fully understand or appreciate what they endured. Thus, it can be challenging to maintain relationships with friends and family. Heightened feelings of distrust and anger as a consequence of their unjust imprisonment further exacerbate feelings of detachment and marginalization. Feelings of guilt are not uncommon as family members may blame the political prisoner for economic hardships faced by the family during the time of imprisonment.[16]Feelings of guilt, hopelessness and worry over the future are a cause of sleeping difficulty as recurring thoughts or memories of the most hurtful or terrifying events can keep political prisoners awake, or manifest in nightmares.

It is not uncommon for former political prisoners, especially those who were tortured, to exhibit symptoms of depression and anxiety, such as increased susceptibility to feeling sad and crying, abusing alcohol and drugs, becoming easily angered and irritable, feeling isolated and hopeless about the future, being reserved and losing concentration easily. It is not surprising that former political prisoners experiencing the symptoms of depression and anxiety often have difficulty coping with daily life.

Many former political prisoners who experienced torture suffer from post-traumatic stress disorder (PTSD), a disorder which develops following a terrifying ordeal that involved physical harm or the threat of physical harm, and as such, political prisoners who have endured physical or psychological forms of torture are prone to developing PTSD. Former political prisoners suffering from PTSD may experience flashbacks, nightmares, feelings of fear, and angry outbursts. Re-experiencing symptoms triggered by words, objects, or situations that are reminders of the event can cause problems in the political prisoners’ daily routines as sufferers often attempt to avoid places or events that may act as triggers. PTSD is often accompanied by depression, substance abuse or other anxiety disorders. Moreover, those that have close and loving relationships with the individual who experienced the traumatic event are also at risk of developing PTSD.[17] Thus, it is vital to recognize that family members of the former political prisoners who were tortured may also need access to mental health services and support.

Mental Health Services for Victims of Torture

While the political detainees are routinely subject to both physical and mental torture, upon their release they have no access to physical or mental health support. Mental health issues amongst victims of abuse are often overlooked due to a deep stigma that many in Burma attach to anything directly related to mental health. Counseling is commonly associated with full psychosis or HIV, and differing forms of mental illness are not understood. Due to a history of political repression, fear, the belief that talking does not help, a lack of understanding about mental health, avoidance of symptoms, shame, and culture, discussing mental health in Burma is difficult. Former political prisoners in particular do not believe they need counseling as they are strong willed and have fought against Burma’s military and quasi-civilian regimes.

In 2010, researchers from John Hopkins University’s Bloomberg School of Public Health (JHU) conducted a qualitative trial in Mae Sot to test the Common Elements Treatment Approach (CETA), a transdiagnostic psychotherapy for low-resource settings. The sample group of 150 people included survivors of imprisonment, torture, and related traumas, and all met severity criteria for depression and or/PTSD. The group was randomly divided into two: the control group and the treatment group. Lay workers delivered CETA to participants with flexibility based on client presentation. Outcomes were assessed using locally adapted standard measures of depression and PTSD (primary outcomes) and functional impairment, anxiety symptoms, aggressions, and alcohol use (secondary outcomes). CETA participants experienced significantly greater reductions of baseline symptoms across all outcomes with the exception of alcohol use. Overall the results revealed that, compared to no treatment, CETA had a large effect on the symptoms of depression and post-traumatic stress experienced by the trial participants, indicating that CETA provided by lay counselors is a highly effective treatment for comorbid mental health disorders compared to no treatment.[18]

Following the success of the trial, since 2011 AAPP’s Mental Health Assistance Program (MHAP) – in collaboration with JHU and with funding from USAID’s Victims of Torture Fund -has provided free counseling to former political prisoners and their families in Mae Sot utilizing CETA to treat symptoms of trauma-related mental health disorders including depression, anxiety and PTSD. JHU developed a sustainable model whereby mental health professionals train the local MHAP counselors – largely former political prisoners – to deliver the mental health counseling. Local clinical supervisors provide on-going supportand training to the counselors, who in turn receive support and technical assistance from AAPP and JHU. In 2013 MHAP expanded CETA into Burma and since, hundreds of former political prisoners and victims of torture have received treatment. Clients are identified through AAPP’s vast network of former political prisoners and supporters inside Burma. Each client receives counseling over eight to 12 regular sessions, usually over the course of two to three months.

A major component of CETA is that it provides skills to deal with life stressors, helping the former political prisoners to learn to differentiate thoughts from feelings, and recognize the impact of these on behavior. These skills include engagement, psychoeducation, anxiety management strategies, behavioral activation, cognitive coping/restructuring, suicide/homicide/danger assessment and planning, and screening and brief intervention for alcohol abuse.[19]

Case study

KoHtun was 33 years old when, in 1988 the Burma Army arrested him after a search of a foreign journalist in Rangoon revealed interview footage of KoHtun discussing his involvement in the 1988 pro-democracy protests.Following his arrest he was sent to the Moulmein Military Intelligence Center for interrogation where he was hooded, handcuffed, suspended upside down from the ceiling by a rope, and tortured severely by both repeated beatings and electric shock torture. During this time he was denied food, water and medical treatment for his injuries. His interrogation lasted for approximately one month.

Following his interrogation, a military court sentenced KoHtun to the death penalty and he was transferred to prison. A year later, he was transferred to a different due to his participation in a prison strike, and was beaten and tortured again. He was released in 2009, after spending 21 years of his life in prison.

While in prison his wife divorced him and his children grew up, married and started their own families. Upon his release, his children wanted no involvement with him, and when KoHtun turned to his siblings for support, they too shunned him. With nowhere to live he was forced to seek refuge in a monastery, where he began working as a driver for the head monk.Shunned by his family and haunted by his experiences in prison, KoHtun suffered from symptoms typical of depression and PTSD.

In June 2014, an MHAP counselor who knew KoHtun from prison went to visit him at the monastery. After explaining the MHAP program to him, KoHtun agreed to undergo an assessment. After hearing the diagnosis from the assessment he broke down in tears, but the counselor gave him support and assured him MHAP could help.

After reassurance, KoHtun was eager to receive counseling and a total of eight sessions were scheduled over two months. Although he had to miss one session due to work commitments, he responded well to the counseling, openly sharing his traumatic experiences and completing tasks assigned to complete outside of the sessions. According to the baseline and final assessments, KoHtun experienced a reduction in his symptoms. In addition, he gave positive feedback for the CETA counseling and has affirmed that he will use the skills he learnt to deal with life stressors in the future.

MHAP currently has six teams carrying out mental health services operating in Yangon, Mandalay and Mae Sot. Each typically comprises of four lay counselors – usually former political prisoners – and one clinical supervisor. In 2014, MHAP provided mental health services to 514 former political prisoners and their families.[20]The ToT (Training of Trainers) program is under way in both Yangon and Mandalay, and MHAP hopes that in the future it can expand further in order to provide counseling services in war-torn and disaster-hit regions of Burma.

Conclusion

According to the International Criminal Court, torture is defined as a crime against humanity when it is “committed as part of a widespread or systematic attack directed against any civilian population, with knowledge of the attack.”[21] A widespread attack is defined as “on a large scale, meaning that the acts are directed against a multiplicity of victims”, whilst a systematic attack is one which occurs following a “preconceived plan or policy”, which results “in the repeated or continuous commission of inhumane acts”.[22]It is worth noting here that to constitute a crime against humanity the torture can be either widespread or systematic and need not be both. Nonetheless, AAPP’s research on former political prisoners provides robust evidence that torture over the last six decades in Burma meets both components of the criteria, thus constituting a crime against humanity,

Signing UNCAT is an essential step in ending the systematic torture of political prisoners in Burma. In signing UNCAT, the Government of Burma is legally bound to implement and enforce the convention, and victims of torture will be afforded the right to submit complaints and inquiries to the UN Committee Against Torture under Article 22.[23]Moreover, provisions under UNCAT would provide victims of torture in Burma increased access to support to redress their suffering.

In addition to taking steps to end the systematic use of torture in Burma, the government must begin to provide social support for former political prisoners, especially in the way of implementing rehabilitation programs and mental health assistance.  Until that time, for those former political prisoners suffering from mental health issues as a result of torture and mistreatment, small-scale programs such as MHAP are their only hope.

[About the Assistance Association for Political Prisoners (AAPP)

Founded in 2000 by former political prisoners living in exile in Thailand, the AAPP is a human rights organization based in Mae Sot, on the Thailand-Burma border. The AAPP is dedicated to campaigning for the release of all political prisoners. They also provide support and aid to current political prisoners, former political prisoners and their families. Staffed by former political prisoners, the organization has extensive experience and knowledge of the conditions faced by political prisoners inside prison and after their release, and the effects incarceration has on their families and livelihoods.

To alleviate some of the physical, mental and financial trauma caused by imprisonment, AAPP runs a range of assistance programs inside Burma, including mental health counselling, educational and vocational opportunities for former political prisoners and their families. It also documents and reports on cases of human rights violations by the government against political prisoners and activists. The AAPP continuously stress the importance of releasing all the political prisoners as part of the country’s transition to democracy and national reconciliation.]


[1]OHCHR, “Myanmar “needs urgently to get back on track” – Zeid”, (February 2015) http://www.ohchr.org/EN/NewsEvents/Pages/Media.aspx

[2]Figures accurate as of June 22, 2015. All individuals meet AAPP’s political prisoner criteria – see AAPP & FPPS, “Press Release on the Definition of a Political Prisoner” (August 2014) http://aappb.org/2014/09/aapp-fpps-press-release-about-the-definition-of-a-political-prisoner/

[3] For information on cases of torture, inhumane treatment and extrajudicial killings in the last year see: ND-Burma,  “To Recognize and Repair” (2015) p29-39 http://nd-burma.org/reports/to-recognize-and-repair/ and AAPP, “AAPP Condemns the Use of Violence and Torture in Burma and Demands the Immediate Unconditional Release of all Political Prisoners” (2015) http://bit.ly/1LdzwRG

[4]Humanitarian Aid Relief Trust, “Burma: TheinSein visits UK and promises to release all political prisoners” (July 2013) http://www.hart-uk.org/blog/burma-thein-sein-visits-uk-and-promises-to-release-all-political-prisoners/

[5]United States Department of State, “Burma 2013 Human Rights Report” (2013)http://www.state.gov/documents/organization/220394.pdf

[6]Student protestors deem the National Education Law to be undemocratic and overly centralized. They call for decentralization and democratization of the law with specific demands to recognize student unions as legal entities, to allocate 20% of the national budget for education, and to remove the clause that bars students from participating in political activities. For more information see: Burma Partnership, “Updates: National Education Law – Student Protests” (2015) http://www.burmapartnership.org/updates-national-education-law-student-protest/

[7]Figures accurate as of June 26, 2015

[8]AAPP, “AAPP Condemns the Use of Violence and Torture in Burma and Demands the Immediate Unconditional Release of all Political Prisoners” (March 2015) http://www.burmapartnership.org/2015/03/aapp-condemns-the-use-of-violence-and-torture-in-burma-and-demands-the-immediate-unconditional-release-of-all-political-prisoners/

[9]AAPP defines torture as per the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (1987) http://www.ohchr.org/EN/ProfessionalInterest/Pages/CAT.aspx

[10]Data was collected in 2014 throughout Burma. For more information see: AAPP, “Documentation Project Interim Report” (February 2015) http://aappb.org/wp-content/uploads/2015/02/AAPP-FPPS-Documentation-Project-Interim-Report-Eng.pdf

[11]Myanmar Penal Code, 1861, http://www.burmalibrary.org/docs6/MYANMAR_PENAL_CODE-corr.1.pdf

[12] Human Rights Watch, (March 2003), “The Legal Prohibition Against Torture”, http://www.hrw.org/news/2003/03/11/legal-prohibition-against-torture#laws

[13]ND-Burma,  “To Recognize and Repair” (2015) p36-39 http://nd-burma.org/reports/to-recognize-and-repair/ and AAPP, “AAPP Condemns the Use of Violence and Torture in Burma and Demands the Immediate Unconditional Release of all Political Prisoners” (2015) http://bit.ly/1LdzwRG

[14]The practice of the intentional sensory deprivation via blindfolding and hooding is widely recognized as a form of torture and/or cruel, inhuman and degrading treatment by international and regional human rights bodies. The UN Committee Against Torture has determined that hooding, when used in conjunction with other coercive interrogation methods, constitutes torture. See: Committee Against Torture, Concluding observations of the Committee Against Torture: Israel (May 2009) UN Doc. A/52/44http://www2.ohchr.org/english/bodies/cat/docs/cobs/CAT.C.ISR.CO.4.pdf

[15]For more information on commonly used torture techniques in Burma see: AAPP, “The Darkness We See” (2005) p.28-56 http://aappb.org/wp-content/uploads/2014/03/The-darkness-we-see.pdf

[16]For more information on the general mental health effects of imprisonment for former political prisoners and their families, see: AAPP, “The Darkness We See”, p.90-98

[17]National Institute of Mental Health, “Post-Traumatic Stress Disorder (PTSD)” (2015) http://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd/index.shtml

[18]P. Bolton et al, “A Transdiagnostic Community-Based Mental Health Treatment for Comorbid Disorders: Development and Outcomes of a Randomized Controlled Trial among Burmese Refugees in Thailand”, PLOS Medicine,Vol. 4, Issue 11 (November 2014) http://www.plosmedicine.org/article/fetchObject.action?uri=info:doi/10.1371/journal.pmed.1001757&representation=PDF

[19]John Hopkins Bloomberg School of Public Health, “Mental Health Assessment Project on the Thailand-Burma Border (MHAP)” (May 2014) https://clinicaltrials.gov/ct2/show/NCT01459068

[20]AAPP, “Annual Report 2014”, (2014)http://aappb.org/wp-content/uploads/2015/03/AAPP-Annual-Report-2014Eng.pdf

[21]Rome Statute of the International Criminal Court, Article 7(f) (1988) http://www.icc-cpi.int/nr/rdonlyres/ea9aeff7-5752-4f84-be94-0a655eb30e16/0/rome_statute_english.pdf?wptouch_preview_theme=enabled

[22]Report on the International Law Commission to the General Assembly on its work of its 48th Session, (1996)http://legal.un.org/ilc/documentation/english/A_51_10.pdf

[23]Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, Article 22 http://www.ohchr.org/EN/ProfessionalInterest/Pages/CAT.aspx

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