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.