A random system? How Norway (fails to) organize health services to rehabilitate torture survivors

Post co-authored with Moa Nyamwathi Lønning, PhD.

In a fresh off the press article in Journal on Rehabilitation of Torture Victims and Prevention of Torture, Inga Laupstad, Ann Evy Aasnes and ourselves address the provision of rehabilitation services for torture victims in Norway. We engage the topic on three levels: a review of relevant rehabilitation rights and duties, a presentation of the organisation of rehabilitation services in the Norwegian public health care system, and importantly, an evaluation of professional experiences from practice. Our focus is on the plights and rights of migrants who have experienced torture before crossing the Norwegian borders, and is based on qualitative interviews with 46 experts and practitioners across Norway’s four health regions.

We find that the rehabilitation services for torture victims in Norway are fragmented, knowledge is lacking, and the resulting practice highly person dependent.

Background and Norwegian Context

As employees at the Norwegian Red Cross, we started this project in 2019 with a well-founded concern that individuals who have experienced and survived torture before entering Norway don’t receive the rehabilitation that they need and have a right to. Together with the Church City Mission, the Norwegian Red Cross runs two healthcare centres for undocumented migrants in Norway. In contrast to the public health care services, these centres provide health care for undocumented migrants free of charge and with no threshold for treatment. In 2018, 16 percent of the patients at the Oslo centre reported that they had been subjected to torture.

While torture is forbidden in all forms, the International Rehabilitation Council for Torture Victims (IRCT), the largest umbrella organisation for centres and programmes for torture rehabilitation, estimated in 2010 that there were over 400,000 torture victims in the European Union alone. Within Norway, we only have pre-2015 estimates of how many individuals live with the experience and consequences of torture, at 35,000. We know that the share of torture experiences is particularly high among refugees, and expect the number to be significantly higher today, following the so-called refugee crisis from 2015 onwards.

When examining the rights and duties for rehabilitation in a Norwegian legal context, different international human rights treaties are relevant. One of these is the International Covenant on Economic, Social and Cultural Rights’ (ICESCR) (1966) Article 12, stating that every state should “recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health”. Another is the UN Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment’s (1984) Article 14, which states that:

Each State Party shall ensure in its legal system that the victim of an act of torture obtains redress and has an enforceable right to fair and adequate compensation, including the means for as full rehabilitation as possible.

In Norway, the national health care service is the main provider of rehabilitation services for torture victims. In practice, this implies that those with a right to a general practitioner (GP), must approach their GP and get possible referrals to the specialised health care services from there. It also means that they are liable for a user fee until they have paid the annual maximum fee (NOK 2,460 in 2020) and receive an exemption card. This contrasts with the situation at specialised centres elsewhere that provide services free of charge, for torture victims (for instance, Freedom from Torture in the UK), for traumatised refugees (for instance, Dignity in Denmark) and for persons with a refugee background more broadly (for instance, the Red Cross in Sweden).

Despite the system, not because of it

Some of the professionals we interviewed for this study have employers who see the value of their dedication and allow them the necessary time and resources to respond to patients’ complex trauma. Alarmingly, however, many of the 46 Norwegian experts we interviewed, do what they consider their professional duty and moral responsibility towards patients with torture experiences despite the work conditions and frameworks provided by the Norwegian public health care system, not because of it. Several competent professionals stretch far beyond their roles and pay rolls to address the needs of torture victims they meet in their professional capacity. Rather than shying away from a task too tall to handle, they have developed skills and expertise through perseverance, personal initiatives, international networks, and profound dedication in order to help those who have trusted them with their experiences. Overall, we find that torture victims with a refugee background in Norway are far from ensured a satisfactory rehabilitation service.

Fragmented services

Firstly, services are fragmented. There is a general lack of coordination and inclusion of actors that would contribute towards a satisfactory and comprehensive rehabilitation process. As one of the psychologists we interviewed about the organization of services put it: “The so-called Norwegian model [is not] a model. The Norwegian system is a random system.”

Lack of knowledge

Secondly, there is insufficient knowledge about torture and torture injuries among service providers. Relevant services are characterized by insufficient knowledge about ‘torture’ as a topic, and unfamiliarity with international protocols for identification, examination, and rehabilitation – as encapsulated in the Istanbul Protocol. The challenge of identification is illustrated in this quote by a psychologist we interviewed:

Many of my patients were very much in doubt whether I could bear to listen to what they had been subjected to […] Would I be able to listen and to carry the burden of knowing about it? If they told me, would I break into pieces? They did not want to expose me to the strain of listening to what they had been subjected to.

If you do not know what to look for, if you don’t provide a safe space for sharing, and do not ask directly, it is not likely that torture injuries are identified or understood. Our mapping of the content of the professional studies for medicine, psychology, and nursing, revealed that students of these professions receive little to no training on the subject. Without knowledge about torture injuries, it becomes extremely challenging to undertake good identification – a precondition for rehabilitation to take place at all. As a consequence, identification of torture injuries appears arbitrary.

Person-dependent services

Thirdly, the rehabilitation services that are provided, are person dependent, rather than the result of systematic organization or prioritization from national authorities. This is true at all levels, from identification and documentation to treatment and rehabilitation. Practitioners who strive to ensure local rehabilitation services describe a powerlessness when faced with a system that does not facilitate comprehensive rehabilitation. This is arguably the most challenging aspect of providing help, treatment, and rehabilitation to this group.

Health service illiteracy and inaccessibility

Finally, torture victims with a migrant background experience the same barriers that immigrants in general share in accessing public health, care and welfare services, such as different understandings of health, a lack systemic knowledge and health literacy, in addition to issues related to language, inadequate translation services and incorrect use of translators by service providers.

Recommendations for a better rehabilitation service

In order to secure rehabilitation for torture victims in Norway, the shortcomings of the current rehabilitation ‘model’ needs to be addressed. To this end, we propose the following three measures to ensure minimum standards in rehabilitation services in Norway:

  • The Norwegian authorities should develop a national plan of action on torture rehabilitation to secure a systematic, equal, and comprehensive rehabilitation service to people who have survived torture, the
  • Knowledge about documenting, identifying and rehabilitating torture injuries should be included in relevant educations including, but not limited to, medicine, nursing, physiotherapists, psychologist, occupational therapists, dentists, interpreters, social workers, lawyers, and police. In addition, competence should be strengthened in existent service provisions.
  • Specialised and interdisciplinary competency about torture rehabilitation, as regards all levels of service, should be strengthened and gathered in one or more institutionalised professional groups, teams and networks that coordinate and communicate knowledge to strengthen existent and decentralised services.

Want to read more? The article is available, open access, here – as is the Norwegian Red Cross report produced for a Norwegian audience.

Imageries of Self: Guilty Plea Statements in Sexual Violence Cases at the ICTY

During its almost 25 years in operation, the ICTY convicted and sentenced 90 individuals, of which 20 pleaded guilty. Five of these guilty pleas were submitted by defendants who were directly involved in sexual violence. In a new article in International Criminal Justice Review, I investigate the ways that these defendants re-present themselves, their agencies, and their offenses in response to the legal framework within which they talk, building on a narrative expressivist framework.

The defendants’ narratives are wringed in-between individual needs, defense strategies, legal demands, and societal expectations—reflecting the situation’s demand for particular sensemaking. Their individual freedom is on the line, but also their public legacy is at stake. In front of the court, defendants tell a story that becomes a carefully crafted version of who they are, what they have done, and why.  

The analysis draws particular attention to the ways in which defendants consistently silence the sexual crimes they admit to in their guilty plea statements. While public discourse on sexual violence as such often condones, neutralizes, and denies sexual violence; blames victims; and renders most offenders ordinary, once offenders get prosecuted and convicted, or subject to justice campaigns, a large apparatus goes to show that they are deviant, different, monsters. 

The international legal discourse about perpetrators of sexual violence feeds into the hierarchy of violence that constructs conflict-related sexual violence as a particularly heinous crime, and coalesces their character, who they are, with the characterization of their offenses.  

By avoiding reference to a type of violence that, once established, is expected to merge their character with their offense, the silencing of sexual violence in defendants’ statements creates a narrative space that allows defendants to re-present themselves as now moral, rehumanized individuals, “fit to be among us,” detached from the offenses that is expected to essentialize them in the eyes of others.  

They offer personal stories of rehabilitative journeys within the criminal justice system, express hope that the guilty pleas will alleviate pain and contribute to reconciliation, and suggest that their experiences can have a general deterrent effect. The defendants’ statements suggest that their guilty pleas may animate the lives of others by inspiring others to atone for their wrongs and by impacting public imagination of the effect of criminal justice. These imageries of present and future remorseful and responsible selves allude to and confirm the rehabilitative and disciplining purpose of the criminal justice process, and play into the naturalization of criminal justice responses to CRSV

When defendants who plead guilty abide by the rules of the court, and live on according to their stated regrets and remorse, their narrative actions arguably support the legitimacy of the international criminal justice project. Yet, some defendants follow the script convincingly, and later retract their statements and deny their guilt – as is the case with one of the analyzed cases in this article, and is also elaborated on by others.  

Whether their stories help or challenge the prospects of justice and reconciliation, international criminal tribunals provide a platform for defendants to address multiple constituencies. Defendants’ stories matter because of the instrumental purposes they serve rather than in terms of the truth level they entail. And while it is not the task of the article to assess the impact of such statements (as self-serving affronts or not), it stirs questions about the form, role, and place of defendants’ narratives in the international criminal justice project. 

Call for abstracts

STUDYING WAR CRIMES:

The ethics of re-presenting mass violence in research

When do descriptions of harm become academic sensationalism rather than re-presentations of violent materialities? Can academic interest and engagement in mass harm ever avoid voyeurism? How can sensational violence be ethically re-presented in research? Across disciplines theorizing mass harm, a consensus is emerging cautioning against sensationalism in re-presentations of perpetrators, victims, crimes, and sufferings, seeing detailed descriptions of violence as academic voyeurism. Yet, how comfortable a read can research that has violent profusion at its core become, before the distance created by language becomes an ethical – and analytical – challenge in its own right?

This edited volume invites experienced scholars to address thoroughly the ethics of doing research on mass harm in general, and of re-presenting and describing mass violence, harmdoing, trauma, and suffering in their own research in particular. Drawing on a range of methodological approaches and empirical cases, the book will address how mass violence and war crimes are brought into research – both as an ethical, a sensational, and an analytical matter.

We ask contributors to reflect on their re-presentations of mass crimes, violence and justice, seeing re-presentations both as an issue to do with individual and disciplinary research ethics but also as a matter to do with power and material structures of academic knowledge production. The purpose is to encourage active engagement with a research ethics that goes beyond ‘procedural ethic;’ to expand the discussion on responsibility for the stories we hear, read, analyze, and re-tell; and to address in-depth the ethics of listening, seeing, and telling in research on mass violence and war crimes.

The book will be relevant for all researchers who wish to engage ethically with the study of mass violence and war crimes.

We invite abstracts that explore the ethics of re-presenting mass violence in research.

Abstracts may also cater specifically to:

  • The ethics of caring, seeing, listening and re-presenting
  • Selection and exclusion: whose stories are told?
  • Understanding harm/understanding as harm
  • “Thick descriptions” and sensationalism
  • Breaking the silence vs silence as choice
  • Emotions, positionality, and reflexivity

Submission guidelines:

Abstract of no more than 500 words to be submitted by November 30th, 2018 to editors at studyingwarcrimes@gmail.com. We only accept original contributions and the abstract needs to clearly demonstrate the chapter’s contribution to the volume.

Please include a 150-200 word bio highlighting your affiliation, work experience and credentials in the field of war and mass violence research.

Further process:

After an initial screening and by December 15th, 2018, editors will invite 8 contributors to develop their abstract into a full chapter (5-7000 words) to be submitted by April 15th 2019. We will apply for funding for a lunch-to-lunch workshop for contributors in May 2019. The final submission date for full chapters will be in August, 2019.

Routledge (Taylor&Francis Group) initiated our work with this collection, and has expressed a strong interest in publishing the book.

About the editors:

Sladjana Lazic is a post-doctoral researcher at the Center for Peace Studies (CPS) at the Arctic University of Norway (UiT). She holds a PhD in Political Science from the Norwegian University for Science and Technology in Trondheim, Norway, on victims’ perspectives on transitional justice and legitimacy.

Anette Bringedal Houge holds a PhD in Criminology and Sociology of Law from the University of Oslo on conflict-related sexual violence, perpetrator re-presentations, and international criminal justice. She has published her research in e.g., Aggression and Violent Behavior, British Journal of Criminology and Criminology and Criminal Justice. Anette is the Head of Humanitarian Needs and Analysis at the Norwegian Red Cross.

The international criminal justice project through the lense of Narrative Expressivism

In a recently published article in Criminology and Criminal Justice, I set out a framework through which we can address the stories and truths that the international criminal justice (ICJ) project produces about violent pasts, conflicts, perpetrators, victims, crimes, causes and consequences.

By the term ”the international criminal justice project”, as opposed to internatioanl criminal law institutions, I refer both to these institutions (the courts and tribunals, and the stories produced within by prosecutors, judges, counsels, defendants, experts, victims and so on) – but also to the epistemic communities surrounding these courts, enabling them, pushing for them, advocating fortheir existence, for different parties, campaigning for their creation or continued funding, doing research on their work – that is, everyone engaged with the ICJ project in some way or the other.

I call this framework narrative expressivism. Narrative expressivism is situated at the juncture of insights from the analytical and theoretical framework provided by narrative analysis; as well as the body of literature that caters to the quality of the historical record produced by international criminal trials; and as the name also implies, expressive theories of international criminal law.

From narrative theory, and particularly narrative criminology, narrative expressivism sees stories of the past as important for the future, appreciating that stories affect “the way we perceive the social and material worlds“ (Autesserre 2012: 206). And further, the way we perceive the world “orient how we act upon our environment.” That is, stories animate human life. The stories available to us affect our perceived maneuverability for action in given situations, whether or not the stories are true.

From the body of literature engaging an expressive argument for international criminal justice, comes the emphasis on courts as didactic, or educative – communicative – to the wider society.

In my article, which builds on a four-year case study on the ICTY as a site for explaining and managing collective violence – I ask what stories and understandings of international crimes the criminal justice framework allows for and what it means when knowledge from and for court proceedings is used to describe and understand a social phenomenon outside of it.

What I suggest we do, is to look at the ways in which criminal law conceptualizations of the past affect the ways in which we are able or willing to deal with collective violence as societies and communities on the one hand, and as individuals – either politicians or potentially ordinary fighters on the ground, maneuvering possibilities for action in the face of violent profusions.

In my own research in particular, I have focused on defendants and how they are re-presented, and how conflict-related sexual violence specifically, is constructed as a problem of law – what ideas and subjects are called into service for criminal law’s operation through court narratives, as well as in policy and advocacy actors’ framing of conflict-related sexual violence, in order to push criminal prosecutions

Narrative expressivism theorizes international criminal justice as an empirical field for knowledge construction and sees criminal justice as a potent source of information about past crimes – yet also, as a site that impacts on present and future societal understandings of mass violence, promoting a particular structuring of thought. That is, it theorizes the juridification of societal and political understandings of complex collective and social problems.

The whole process of campaigning for the establishing of courts and cases, of adjudicating guilt and innocence, of evaluating evidence, hearing, challenging and sorting stories, establishing facts – the process of ordering chaos through a legal model that streamlines causality, draws individuals out of collectives, and categorizes both them, acts, victims, and contexts – makes a less complex and more comprehensible narrative of what was, through means and under influence of what constitutes legally relevant arguments and according to the courts’ binary logics. Such legal understandings are appealing. As Tallgren (2002: 594) states, “[b]y focusing on individual responsibility, criminal law reduces the perspective of the phenomenon to make it easier for the eye … It reduces the complexity and scale of multiple responsibilities to a mere background.”

What law, and particularly judgments, construct is not an objective history of the past, but the events anew, formed by these constraints and possibilities of the legal framework

Narrative expressivism caters to this reduction, to the processes of inclusion and exclusion of different voices, and to the leveraging and silencing of some stories over others during proceedings and in the epistemic community surrounding ICJ institutions.

Importantly, this way of seeing ICJ, emphasizes all the expressive, or communicative, work courts do or facilitate. This includes all the narratives that the international criminal justice project produces about acts charged as international crimes – either from the inside of its institutions or from the outside by its proponents – whether the narratives morally condemn or deny mass violence, and, importantly, whether they strengthen or challenge the legitimacy and authority of international criminal justice institutions.

While courts through judgments produce normative evaluations of international crimes, leveraged through the authority of criminal law, international criminal courts also provide international, public platforms for protest – as evidenced by the defiant defendants ‘performances’ at the very final proceedings of the ICTY last year.

This way, the common expressive understanding of law changes significance from being primarily a normative theory or argument of purpose (legal expressivism) to a descriptive theory of its function as storyteller and narrative conveyor, weighting the explanations of problematic social phenomena and mass harm and the role of law that it produces (narrative expressivism).

With public proceedings and transcripts, and the access to its goldmine archives for research, the trial at international criminal law institutions becomes a public theatre of different and contesting ideas – a place to test and rename, pronounce and project, and also, establish history about mass harms. Herein is an acknowledgement that “not only is knowledge power, but power is knowledge too”, as Ayoob (2002: 29) has stated. Focusing on power in its discursive forms, involves attention to how specific sets of logics organize and produce knowledge.

Narrative expressivist approaches to international criminal justice would, thus, concern how law and ICJ communities, act as central contributors to “[t]he wider politics of representation.” At the very least, this necessitates attention to questions such as whose representations are these, who gains what from them, what social relations do they draw people into, what are their ideological and political effects, and what alternative representations are there?” (Fairclough, 2013: 549–550).

This take on ICJs influence on our understanding of collective and political violence may appear at first as at odds with recent, and oftentimes well-addressed, critique of the effectiveness and legitimacy of ICJ institutions and selectivity. However, there is a difference between what is understood as and expected from international criminal justice on the one hand, and the realitites that international criminal justice describes when handling crime, ie., the structuring of thought that the criminal law frame feed our understanding with – whether or not it succeeds with its prosecutions.

Defendant perpetrators and conflict-related sexual violence

As the International criminal tribunals for the former Yugoslavia and Rwanda (ICTY and ICTR, respectively) are concluding their mandates, the archives they leave behind comprise an unprecedented historical record about the war years, about the collective and individual harms suffered, and about the development of international criminal law. The tribunals’ legacies will be interpreted, negotiated, and renegotiated as more researchers dive into these materials. Undoubtedly, the archives will keep scholars from a wide array of disciplines busy for years and decades to come.

So what are we to make of these archives? What are they documenting? What are they leaving aside? What kind of historical record do they produce, and what is it that they establish? For whom? On what premises? What are the values of trial truths and the legal narratives they story?

In a recent article in the British Journal of Criminology I engage with these questions by focusing on a specific subset of cases at the trial end of these archives: cases brought to trial and ending in convictions of defendants for their direct participation in sexual violence.

Rather than analysing the production of jurisprudence before these courts, or the treatment of victims and victim witnesses, I ask how these direct perpetrators and the causes of their offenses are constructed within and by these institutions and its primary actors.

Emphasizing arguments that are interpretive or explanatory in terms of the defendants and their participation in sexual violence over those that are descriptive in terms of the offenses, there are two primary narratives in the court actors’ arguments. These explain the defendant either as someone whose personal characteristics and personality deviate from the norm, or they re-present the defendant as an ordinary man/woman, pointing to factors beyond the control of the defendant as explanations for his or her crimes.

Deviant defenders

So-called deviance narratives are either formulated by the prosecution, for which they constitute aggravating arguments. Here, the defendants are portrayed as sadistic opportunists who thrived on the opportunity to rape or sexually torture their victims. These narratives are often repeated in judgments, as in the case against Delić at the ICTY:

The manner in which these crimes were committed are indicative of a sadistic individual who, at times, displayed a total disregard for the sanctity of human life and dignity.

When defense counsels invoke deviance narratives, they do so for mitigating purposes. Thee narratives often involve partial acknowledgement of the crime, while also full or partial denials of responsibility. Typically they are based on the statements of psychiatric experts who account for the defendants’ dependent personalities and their extreme conformity, which in turn inevitably lead to criminal behavior if authority figures ask for it.

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