Józef Gierowski, Renata Jędrzejowska, Krzysztof Rutkowski, Jan Zdzisław Ryn. Department of Social Pathology, Chair of Psychiatry, Medical College, Jagiellonian University. Summary: Since the year 1959, the Chair of Psychiatry of the Medical College at the Jagiellonian University has been conducting research into the consequences of political persecutions for human health. Initially, the …
Józef Gierowski, Renata Jędrzejowska, Krzysztof Rutkowski, Jan Zdzisław Ryn.
Department of Social Pathology, Chair of Psychiatry, Medical College, Jagiellonian University.
Summary: Since the year 1959, the Chair of Psychiatry of the Medical College at the Jagiellonian University has been conducting research into the consequences of political persecutions for human health. Initially, the research was conducted exclusively among former prisoners of concentration camps. Following the political changes which occurred in Poland at the beginning of the nineties, the research was extended to include also other groups: former Siberian exiles, survivors of the Holocaust and former political prisoners of the Stalinist period. The results of the research have confirmed unequivocally that prolonged exposure to stress and torture, as well as being deprived of food and sleep, separated from one»™s closest family, and forced to slave-like labor and prolonged stay in unhygienic conditions, lead to both mental and physical changes. In the course of their assessment procedures, the employees of the Chair of Psychiatry of the Medical College at the Jagiellonian University often come across the view that post-traumatic disturbances are only hypothetical. One has to firmly state at this point that the occurrence of the above syndromes is undeniable; they are observed among many people; they present a similar clinical picture and consequently, they have been adopted to the classification drawn up by the World Health Organization. The above situation creates a number of ethical and methodological dilemmas.
Key words: forensic-psychiatric assessment, post-traumatic stress syndrome, victims of totalitarianism.
Since 1959, the Chair of Psychiatry of the Medical College at the Jagiellonian University has been conducting research on the consequences of political persecutions on human health. Initially, the research was conducted exclusively among ex-prisoners of Nazi concentration camps, mainly those of Auschwitz-Birkenau (9). Following the political transformation at the beginning of the nineties in Poland, the research was extended to include also other groups: former Siberian exiles, survivors of the Holocaust (1,2,3) and former political prisoners of the Stalinist period (4). The results of the research have confirmed unequivocally that prolonged exposure to stress and torture, going without food and sleep, being separated from one»™s family, being forced to slave-like labor and to living in unhygienic conditions, lead to both mental and physical changes. In most cases, the mental changes take on the form of disturbances such as depression or anxiety. Somatic illnesses are not only direct consequences of physical injury, but also consequences of past contagious diseases and quite different types of illnesses which develop in connection with prolonged exposure to stress. A specific consequence of staying in a concentration camp is premature aging and the consequences of nutritional deficiencies. The different types of symptoms and syndromes were initially referred to as the «KZ-Syndrome» (8,9). At present, the post-traumatic psychological disturbances have been classified as belonging to one of the following groups of syndromes: the post-traumatic stress and permanent personality change following the experience of an extreme situation (5). These often co-exist with other symptoms e.g. that of depression. The above observations have found their confirmation in numerous research works which had been conducted almost all over the world.
The extremely difficult and complex process of forensic-psychiatric evaluation, takes on a special dimension and significance in the case of assessment procedures which are used to determine war-related disability. The legal foundations of this problem for the needs of medical doctors are analyzed jointly by a lawyer and a specialist psychiatrist (6).
In the case of people who were persecuted for political reasons, an expert psychiatrist and psychologist are confronted with a situation in which, unlike in the majority of cases, they are dealing not with the perpetrator of the crime, but with the victim. In addition, it is not a victim of an isolated criminal act of a single perpetrator, but of the functioning of whole criminal systems which permit the possibility of persecutions or even extermination of people for political, racial, or else national reasons. Such patients constitute a part of the population to which there once referred certain strictly defined historical conditions, whereas the assessment procedures usually take place a long time after the persecutions and traumas had taken place (2).
The contemporary state which takes upon itself the responsibility for compensating the victims for the harm which had been done to them, or at least for creating other forms of care as well as suitable legal foundations for doing so, has not solved the problem of victims of persecutions in a satisfactory and unequivocal way. Hence, for instance in the Polish conditions, granting them the prerogatives which are due to them by law is based on the evaluation of the condition of their health and on associating it with the traumatic experiences they had gone through during the period of persecutions. The above situation creates certain specific problems and it often puts the expert in a difficult situation which goes beyond the strictly medical sphere and often touches upon the ethical and moral considerations.
It is quite obvious that an evaluation of the mental condition must be based on medical and psychological criteria. Yet, in the case of victims of political persecutions, besides the ethical dilemmas which are inseparably associated with the role of an expert, one also comes across some other, very specific difficulties which are the result of the special nature of these issues (pensions or compensations). Thus, an expert is faced not only with a «case», a person who is subjected to his assessment, but is also confronted with certain historical facts, in the context of a given person became a victim.
As we have already mentioned, the research on the Polish victims of political repressions comprises a few fundamental groups of people who had been drawn into the course of political events that became a part of the nation»™s history. As is commonly known, the stormy history of our country, the military and political operations which took place here, were associated with different kinds of repressions, as quite regardless of the direct confrontation with an external enemy, there occurred deep internal divisions which brought with them far-reaching consequences.
Among the currently investigated cases of victims of political repressions in Poland, one may distinguish several main groups which illustrate in a way the nation»™s most recent history:
– participants of II World War who fought actively with the occupant in different formations (army, underground units),
– prisoners of Nazi concentration camps,
– survivors of the Holocaust,
– persons who were deported onto the territory of the former USSR,
– political prisoners of the Stalinist period,
– indirect victims, such as e.g. members of the Katyñ Family (8), or widows of ex-prisoners of concentration camps (7,9).
A relatively numerous group of meritorious Polish citizens who had experienced similar tribulations and therefore, fulfill the conditions for obtaining combatant status, remain outside the sphere of the present research, due to the fact that they reside outside Poland. It is exclusively due to this consideration that they are devoid of the possibility of obtaining any benefits. The above problem also calls for a just and equitable solution.
One should mention here one more category of victims, who had been particularly wronged and whose plight reflects certain historical paradoxes. These are people who experienced persecutions and traumatic experiences from both ruling regimes: the Nazi and the Communist one (e.g. a soldier who fought in the defense war of 1939, who subsequently became a prisoner in the German prisoner-of-war camp, then fought in the Home Army units and in the post-war period was again imprisoned for political reasons). This category of victims are particularly sensitive to failure in obtaining the status of war victims and the impossibility of obtaining at least a moral satisfaction for the repressions they had experienced.
In all cases, the role of a court expert, is quite unequivocal: he is to use his special knowledge to prepare a professional and objective opinion in a given discipline. In penal cases, an expert psychiatrist or psychologist who confronts a criminal offence and its alleged perpetrator, cannot but perceive the offender otherwise than through the perspective of the offense which he is accused of. In spite of having to conform to the rule of impartiality, the court expert cannot disregard the whole situational context as well as the consequences of the crime committed by the alleged offender, although at the same time, he has to free himself from evaluating or passing moral judgment on the offender. In the current presentation, there is no room to discuss and analyze the interesting problem of the relations between an expert psychiatrist and the person he has to assess. We only mention this problem in order to point out to the situational difference in assessing victims of political repressions.
The situation in which an expert psychologist is to assess someone to establish the degree of his handicap due to war activity, puts particularly high demands on the expert, on the one hand, and on the assessed patient on the other. Even when the assessed person does not subject himself to such assessment completely of his own will (social insurance commissions, decisions of the Court), in most cases he attaches certain hopes and expectations to this fact. For the expert, such examinations create an additional difficulty which is connected with the very way of conducting psychiatric and psychological examinations in the case of victims of political persecutions.
The attitude of the victims towards this situation is quite varied, whereas building mutual relations between the expert and the patient, depends, to a large extent, on the expert himself. Among the majority of patients, such a situation is conducive to an increase of the already existing feeling of anxiety and tension. For, a medical examination is at the same time an encounter with someone who is a stranger, and an «official» who may exert a significant influence on the patient»™s subsequent plight. As the above group of patients are often characterized by a distrust of people and a withdrawal from social contacts, the very fact of having to undergo an examination, is treated by them as a difficult experience. The victims who in many cases display symptoms of a lifelong trauma, have a distrustful attitude towards the experts; their contacts with them are burdened with considerable difficulties, whereas their description of symptoms is often incomplete and sketchy, also due to their inability to notice certain symptoms in themselves as well as in defining them. This state of things is often the result of the patients»™ bad somatic shape, including the symptoms of premature aging. The negative emotions accompanying the recollections which are unavoidable during the interviews and clinical examinations, are also not without influence. The latter may make it difficult for the expert to strike up a more objective contact with the person subjected to his assessment. Creating such a relationship requires from the expert not only a highly professional attitude, but also a high degree of tact and personal culture. In some cases, the examination is accompanied by some dramatic elements, as bringing back to mind the once experienced trauma constitutes an additional traumatic experience for the patient and the expert should be able to respect this.
It may also happen that the psychiatric examination turns out to be the first opportunity to «give vent» to the pent up emotions and experiences, and the examined person is able to experience a specific type of «purification» which has an important therapeutic value. For cases of patients who were incapable of sharing their experiences from the period of repressions, even with their closest friends and family, are not isolated; this is often caused by the fear of bringing back tragic memories, as well as by the fear of disbelief or a lack of understanding on behalf of the others. Such an attitude (avoidance of traumatic recollections and everything that is associated with them), is one of the typical symptoms of the post-traumatic stress syndrome.
The specific nature of the examination in this group of patients requires particular delicacy and incisiveness from the expert; it also requires an ability to «interpret» the signals which are sent by the assessed person which should allow the expert to reveal the symptoms that have not been directly expressed or named by the patient. Such an examination should at the same time contain a therapeutic element which besides simple human understanding, consists in the very fact of listening to the patient who often blocks out the recollections and feelings for many years. In this difficult situation an expert cannot give in to emotions; it is his duty to preserve a suitable distance to the examination as well as to the person who is subjected to assessment.
Another group of patients is made up of people among whom there predominates a deep sense of wrong, which influences the relations with the expert; the patients in this group hope not so much to attain concrete compensation, but to achieve full understanding for the sufferings experienced during the period of political oppression, as well as for the present ailments which are associated with it.
There is also a group of patients who experience a deep sense of guilt as a consequence of the fact that they have managed to survive the period of oppression and persecution (while so many of their friends have died), as well as of the fact that they have undertaken formal steps to obtain recognition for their tribulations. For these patients, particularly when persecutions had taken place in the effect of their conscious ideological activity, the medical assessment procedure may be especially embarrassing. They often try to «explain» their actions to the expert psychiatrist and quite frequently their attitude toward the efforts they have undertaken is ambivalent.
In this context, the patients who lay claim to compensation and who openly expect the expert to settle their sustained efforts to obtain it, by issuing a suitable opinion and decision, following an examination, belong to a decisive minority. The latter group of patients are strongly convinced that the state and the society owe them compensation for the wrongs which had been perpetrated to them in the past. It is worth pointing out here that such an attitude is often the result of protracted and quite traumatic assessment procedures as implemented by the Polish ZUS Insurance Company as well as by the Polish courts.
Each of the above-described attitudes constitutes a difficulty and danger for the expert in his effort to try and retain his objectivity. No doubt, besides high degree of professionalism, all situations in which experts have to determine the degree of oppression-related handicap, require considerable sensitivity and intuition on their behalf. Wishing to preserve one»™s objectivity, one cannot give in to emotions, nor be deceived by appearances. In all situations, the ability to form proper relations with the assessed person, depending on the way he is perceived, should constitute one of the fundamental abilities of every expert. Whereas when dealing with such a specific category of patients as victims of political repressions, one should remain particularly sensitive to all of the above-presented symptoms as well as to the general picture of health of a given individual which one can derive from them.
Among the many pitfalls which confront an expert assessing victims of political repressions, there is also the danger associated with excessive identification with the person undergoing examination. This may be caused by the feeling of sympathy for the plight of this person, by respect and admiration, or else by personal considerations (professing similar views, family traditions etc.). The reverse of the above situation may be a negative inner disposition, or skeptical attitude towards the patient»™s experiences and its consequences, often due to ignorance, and sometimes even to the expert»™s political convictions. The above-mentioned circumstances may constitute a serious hurdle in the work of an expert psychiatrist and they point out to the need for rejecting all extreme emotions and focusing on the assessed person as well as on the presented symptoms in the course of the assessment procedure; they also call for taking proper advantage of one»™s medical knowledge.
In the context of the above remarks it is worth quoting the accounts of some of the victims of the repressions who in the course of the interviews conducted by us reported some extremely painful experiences which occurred to them during their contacts with the certified medical court experts. The accounts are sometimes quite shocking and make one wonder whether the fundamental principles of conduct in the relations between doctors and patients are at all observed. A lack of competence in the sphere of medical assessment is often compensated for by contempt for the patient and disbelief in his complaints. The patients who are examined so as to determine the degree of their handicap in the effect of political repressions, often experience quite incredible humiliations. They are scorned, ridiculed, and humiliated, and in some cases they even become the butt of crude jokes on the part of the court experts or else the officials representing the state administration. Their complaints are belittled or ascribed simply to the natural process of aging. The victims are frequently requested to present medical documentation from the places of detention or exile, while a lack of documentation dating back to the period after the persecutions, completely discredits their claims concerning the traumas and ailments which they had experienced. All of this leads to further traumatization of the victims of persecutions and from the perspective of our experience constitutes a significant diagnostic and social problem.
In the course of our assessment activity, we sometimes come across views that post-traumatic disturbances are only hypothetical; yet, one has to state very emphatically here that the incidence of these syndromes is unquestionable. They are observed among the majority of patients who had been imprisoned and persecuted; they present a similar clinical picture and therefore, they have been classified by the WHO as a separate illness. One has to remember that these disturbances have a chronic and progressive character. In many cases, they come to the surface after a long period of latency. In our research, we no longer try to verify the hypothesis as to whether such disturbances really do occur, as this is beyond all doubt, but we focus our attention e.g. on describing the clinical picture of these disturbances or on preparing new therapeutic methods.
In the course of our research, we drew attention to the difficulty the patients had in obtaining medical and therapeutic assistance. This encouraged us to set up a specialist counseling center. In 1994 an Out-Patients»™ Department for Persons Who Were Persecuted for Political Reasons had been opened within the Department of Social Pathology of the Chair of Psychiatry, at the Medical College of the Jagiellonian University. The European Union and the Assistance Fund for Torture Victims of the UNO in collusion with the High UNO Human Rights»™ Commissioner, had resolved to subsidize the activity of the Out-Patients»™ Department. Thanks to the University, the UNO and the European Union, all persons who were once persecuted for political reasons, are able to obtain assistance, free of charge. The diagnostic procedure and the therapy is carried out by psychiatrists, psychologists, a doctor specializing in internal diseases, as well as an anesthesiologist and neurologist.
The majority of the people who were once deported and imprisoned are already quite advanced in years, yet this does not justify treating their somatic and mental disturbances as complaints which are exclusively «associated with age». As we have already mentioned before, diagnosing post-traumatic disturbances no longer constitutes a problem. Therefore, one has a right to be particularly incensed by lack of sufficient knowledge or else an aversion to take advantage of it by people who make decisions concerning whether or not somebody should be awarded invalid benefits. It is worth drawing attention to the fact that in view of the authorities»™ denials as to the incidence of traumatic experiences associated with deportation and persecutions during the Stalinist period, none of the victims can prove that in the years 1944 «“ 1989, he or she had undergone treatment due to the consequences of these persecutions.
It is also quite shocking that while preserving the principle of sovereignty of the common courts of law, there do occur cases of unequal treatment of the victims of political repressions. Together with the growing number of the assessed cases, we are able to notice distinct regional differences. The courts in certain provinces have a tendency to draw out and prolong procedures concerning the award of benefits and pensions to victims of political persecutions, or else, they tend to ignore and belittle the problem altogether. In numerous cases there appear experts of the Polish ZUS Insurance Company which often display a lack of competence in diagnosing post-traumatic syndromes. As examples, one may quote assessments in which evident post-traumatic symptoms are described as «symptoms which are due to natural aging of the human organism»; in other instances, evident consequences of traumatic experiences or else advanced symptoms unsuited to the age of the examined victims are simply disregarded. The victims»™ reports in which they mention certain symptoms of mental disturbances are commonly ignored, whereas psychiatric examinations are carried out only after numerous somatic tests which are not always justified by the patients»™ complaints. This leads to unnecessary drawing out of court procedures, an increase of costs and unnecessary exposure of the patients to stress. At the same time, in other regions of Poland, pensions are granted by the courts without drawing out the procedures. Also, some branches of the ZUS Insurance Company try not to block the procedure of granting benefits to victims of political persecutions. The patients are very well aware of the above-mentioned regional differences which only adds to their sense of wrong, injustice and humiliation. The victims complain of unequal treatment; they have a sense of being forced to undergo continual tests and legal procedures and of having to prove their own suffering. Low pensions and high costs of life, force them to look for additional sources of income. For the majority, a hope for an improvement in their material situation lies in being granted a war invalid pension which is granted to persons who were persecuted for political reasons in the years 1939-1956. Unfortunately, in order to obtain it, they have to confirm that in the effect of the above persecutions, their health has suffered. For many of the victims, this is extremely humiliating for as they say «when they fought for Polish freedom or else refused to adopt foreign citizenship, thereby running the risk of becoming deported, they did not think of money and compensations». The only hope for them at the time was future freedom and the wish to live and work in their own free homeland. However, for many years, this was impossible and when it did become possible, they continue to feel oppressed and persecuted «“ this time for financial reasons. This unfavorable atmosphere leads to their feeling of being forgotten, rejected and simply superfluous. Many of the former victims resign from the compensations they are entitled to in exchange for peace and the chance to withdraw from situations which are emotionally awkward for them. For others, the present situation constitutes an opportunity to express in public the feelings of grief and anger and makes them become involved in political activity. At the same time, some of the former victims lead a quieter life by participating in pharmacotherapy and psychotherapy, although only a few of them are able to afford it.
At this point, it is worth remembering the views of Prof. Dr. Adam Szymusik which he had presented in his numerous papers and expert assessments. Namely, Prof. Szymusik pointed out that the problem of compensations for the wrongs and sufferings experienced by the former victims of political repressions has a much wider social context and it should not be limited exclusively to examinations carried out by the ZUS Insurance Company commissions. According to Prof. Szymusik, it would seem more suitable to grant the status of war invalids to all persons who had at one time or another experienced repressions and who possess combatant status, rather than subject them to assessment procedures carried out by the ZUS Insurance commissions. In Prof. Szymusik»™s opinion, such assessments are very expensive and time-consuming and in many cases extremely burdensome to the victims themselves; at times, they are even humiliating and offensive to them. From the simple human or else common-sense point of view, it is difficult to imagine that persons who had suffered repressions for political reasons, had not suffered in one way or another, or did not have to pay a widely understood price for their traumatic experiences. In many cases, these costs go beyond the rigid and strictly defined medical point of view which additionally supports the legitimacy of the view entertained by Prof. Szymusik. In the Chair of Psychiatry of the Medical College of the Jagiellonian University we all identify ourselves with the above opinion.
Furthermore, we hope that in the future the problem of post-traumatic disturbances will become more widely known and that it will be better understood for the good of the patients. At this point, one should express deep regret that at the present moment, an out-patients»™ clinic for the victims of torture and political persecutions has only come into existence in Kraków, and that the interest of doctors and therapists from other parts of the country in this problem is but marginal. The specialist doctors»™ training which is conducted in this respect, does not satisfy the present needs. It is likely that it is only wider propagation of this topic that will eventually contribute to an improvement in the situation of victims. We hope that the above improvement will not come too late.
The above-presented circumstances legitimize efforts to address a petition to the Ministry of Health (and Justice?) with a request for a change in the current procedure of granting invalid status as well as the status of victims of political persecutions. Year in, year out, the population of these victims shrinks, as in the majority of cases, these people are at an advanced age. It is becoming increasingly more difficult to separate in an unequivocal way, the changes associated with age from the symptoms of post-traumatic stress. Within the population consisting of a few thousand former prisoners of concentration camps and a few hundred victims of political persecutions, it is only in a few cases that we were unable to observe a direct connection between the condition of the patients»™ mental health and the traumatic experiences they had gone through.
Taking into consideration the specific physical, mental and social condition of the examined victims, it seems that the most rational solution would be to grant to them the status of war invalids, without the necessity of carrying out specialist medical examinations. It is both humanitarian and economic factors that seem to call for such a solution.
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