The Khmer Rouge Tribunals and PTSD: Human rights law as mental health intervention?

Jeff Sonis (University of North Carolina at Chapel Hill) has published an important paper in the August 5 edition of the Journal of the American Medical Association that has interesting implications for the intersection of human rights and psychology, and for the effects of the Khmer Rouge Tribunals in particular. Using an impressive multistage sampling method, Sonis and a group of Cambodian, Dutch, and South African colleagues recruited a probability-based sample of 1017 Cambodians (the most impressive such sample in Cambodia to date), and asked them about their knowledge and expectations about the Khmer Rouge Tribunals, their desire for revenge on the perpetrators, and administered a measure of posttraumatic stress disorder (PTSD) and mental and physical disability. In order to account for the fact that the majority of Cambodians were not alive during the “Pol Pot time” (1975-1979), they oversampled those older than 35 years old (meaning they increased the proportion of this group in relation to the general population) in order to make sure they could examine how those people who were the direct victims of the Khmer Rouge felt about the tribunals.

Why do this? This is the baseline study of research in which Sonis and colleagues will examine the effects of having the tribunal on Cambodians mental health. Building on therapeutic approaches like Testimony Therapy (developed by Chilean psychologists in the Pinochet era) and really catching fire around the time of South Africa’s Truth and Reconciliation Commission, the idea that human rights tribunals could have direct salutory mental health effects has been very attractive to trauma psychologists. This is in line with the now very popular idea of therapeutic jurisprudence, in which the court’s actions are designed to “treat” the victim of a crime (unfortunately used in the US primarily to justify harsher punishments on perpetrators). Of course, there is the possibility that testimony may bring up painful memories which will cause further distress. Sonis explains it this way in the introduction:

Since anger and desire for revenge have been shown to be associated with PTSD symptoms and functional disability, tribunals might reduce the prevalence and severity of PTSD and impairment in postconflict societies by facilitating feelings of justice and reducing the desire for revenge. However, others have suggested that trials may actually increase PTSD prevalence and severity by “retraumatizing” survivors. (p. 528)

With the type of information they collected and the fact that it was all collected before the tribunals began, Sonis and colleagues can’t really answer the question of whether or not the tribunals were therapeutic (nor would they say they could). So what did they find? Well, the first notable finding was the prevalence rate among the over 35 group (the people present during the time of the Khmer Rouge). Within this group the rate of “probable PTSD” (“probable” because the self report measure is not technically diagnostic) was 14.2%. I usually don’t get excited about epidemiology, but let’s put this finding in context: Of the great killers of the 20th century — Hitler, Stalin, Mao — none were responsible for killing 20% of a population. That award goes to Pol Pot. This is in addition to the slave labor camps and torture chambers that were a part of everyday life under the Khmer Rouge. The fact that among those who survived this era, 14.2% suffer from PTSD is, to me anyway, a pretty optimistic finding. Granted, it’s 35 years later (a lot of PTSD may have been present for a long time and then remitted), but still, the common perception that Cambodians of that age are a traumatized population is simply not true, if you take the definition of “traumatized” as “most have PTSD.” That’s not to say that a higher proportion of Cambodians are affected by PTSD than members of other societies, only that a sizeable majority are not. People, even those who have gone through unspeakable terror, turn out to be pretty resilient. The population rate for PTSD was 11.2% (that’s for both groups combined).

What else? The expectation that the tribunals would deliver justice was inversely associated with probable PTSD. Sonis and colleagues conclude that this means that this “raises the possibility that the trials may be an effective societal-level intervention for reducing PTSD symptoms” (p. 535). However, the authors also found that almost 93% of those who knew about the trials reported that the prosecutions would probably bring up painful memories, and that raises “the possibility that the trials could increase the prevalence and severity of symptoms of PTSD” (p. 536). Hm. This confirms that both arguments made at the beginning of the study might hold water, but doesn’t really say anything more. Sonis ends with a rare instance of foreshadowing in academic writing: “That question can only be answered through a longitudinal study over the course of the trials” (p. 536).

I’m not convinced the two “competing” arguments — justice v. retraumatization — are really in competition. The most effective treatment for PTSD is exposure with response prevention, a process by which the therapist guides the PTSD patient through a retelling of their trauma. this has been shown to be effective in numerous situations, and does not seem to be dependent on the type of trauma causing the problems. If we abstract the individual case to a societal level, we have the tribunals which help the society face their traumatic memories — which may be painful — but come through them to some resolution. Justice and retraumatization, but then resolution.

However, I’m also not convinced that this is what will happen. I actually don’t think that we should expect that either justice or retraumatization will have a significant effect. A tribunal is not exposure with response prevention, particularly since the perpetrator is involved in the tribunal. Justice is good, but it’s not treatment. This is not to say that the tribunal will not make some Cambodians feel better, just that we shouldn’t expect it to cure their PTSD. That Sonis found an inverse proportion between the expectation of justice and PTSD seems evidence to me that people who have PTSD are generally more pessimistic, and that’s not likely to change just because something goes right in their world. This is not blaming the victim, only acknowledging that people with mental health problems see the world with much darker lenses.

Justice is a value in its own right. We don’t need to justify the pursuit of justice with mental health outcomes. It may be that there is some relationship, but they are not the same. Still, I look forward to the next installment from Jeff Sonis to let us know more about the relationship between the two.

3 Responses to “The Khmer Rouge Tribunals and PTSD: Human rights law as mental health intervention?”

  1. 1 Robert August 9, 2009 at 7:11 am

    I don’t pretend to understand all these fancy words and science talk and what not, but kudos to you on your blog. I was intrigued by your entry about the Darfur naysayer Mamdani (sp?). Very interesting. Keep up the good work.

  2. 2 Ken Miller August 12, 2009 at 9:40 pm

    A very interesting reflection on the Sonis et al paper. Kudos to the authors for exploring the link between justice and mental health. And kudos to you, Andy, for noting the optimistic prevalence of pprobable PTSD”, which likely corresponds to an even lower perevalence of actual PTSD (see below, #3). A couple thoughts:

    (1) “Probable PTSD” doesn’t actually exist. Until we have a compelling set of findings showing the predictive power of “probable PTSD” for actual PTSD, this seems like an awfully fuzzy construct.

    (2) The importance of Sonis’ observation that longitudinal data are needed can’t be overstated. Does a desire for revenge have an effect on PTSD? Or does being stuck in a place of traumatization maintain and feed anger and a desire for revenge?

    (3) It’s interesting to note the relationship of “probable PT%SD” to disability. In fact, disability–i.e., functional impairment–is a part of PTSD. Without it, a diagnosis of PTSD can’t be made (according to the DSM, anyway). Yet only 40.2% with probable PTSD had moderate or greater mental disability, and a slightly lower % had physical disability. This would seem to raise the question of whether probable PTSD realy is probable PTSD, or a milder version of the disorder that often lacks functional impairment.

    (4) For the record, Pol Pot was not unique in eradicating 20%+ of a population. Under Adolf Hitler, roughly 33% of the world’s population of Jews lost their lives.


  3. 3 Jeffrey Sonis September 17, 2009 at 9:14 pm

    Thanks to Andy and Ken for interesting comments on our work.

    RE probable PTSD: I believe it is technically more accurate to say that we measured PTSD, though with imperfect sensitivity and specificity. The PTSD-Checklist does not itself include questions on functional impairment but multiple studies have been done comparing the results of the PTSD-Checklist to diagnostic interviews that do include functional impairment items and those studies have consistently shown sensitivity and specificity of about 80%. The criterion for “at least moderate disabilty”, based on the SF-12 (the instrument we used to measure mental and physical disability) is much stricter than the criterion for functional impairment used in any of the diagnostic interviews for diagnosis of PTSD.

    I couldn’t agree more with Andy’s comments that justice is important in its own right. In an earlier draft of the manuscript, before we were asked to cut the length of the manuscript significantly, the last paragraph of the manuscript was: “This paper has focused on PTSD, because it is a common and debilitating disorder in Cambodia. While the possibility that the Khmer Rouge trials might reduce the prevalence of PTSD is intriguing and hopeful, it is important to remember that the trials were designed to bring at least some small measure of justice that has long been denied to the Cambodia people, not to reduce the prevalence of PTSD or any other physical or mental disorder. In this study, we have shown that perceptions of justice and desire for revenge are related to PTSD. But justice, and other social processes such as reconciliation and development of respect for the rule of law, are important outcomes in their own right. We must be careful not to over-medicalize social processes, like the Khmer Rouge trials, lest we fall into the trap of judging their success or failure solely on strict medical grounds.”

    That said, what if trials or truth commissions do reduce PTSD severity? The prevalence of trauma-related disorders and the limited number of trained mental health professionals in many post-conflict societies suggests that individually-oriented treatment models, such as pharmacotherapy and cognitive-behavioral therapy are not appropriate. Other models are clearly needed. Tribunals, truth commissions or indigenous justice models, such as Gacaca in Rwanda, might indeed help survivors and that can only be a good thing.

    On the other hand, if justice mechanisms do not decrease PTSD severity, it doesn’t mean that those mechanisms should not be used by societies aching for justice (since justice is a fundamentally important outcome in itself). In our NIH-funded longitudinal study of Cambodians’ responses to the KR trials, PTSD is an important outcome that we are measuring, but so are perceived justice, desire for revenge, and respect for the rule of law.


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