Department of Psychiatry, University of Stellenbosch, Tygerberg, South Africa
Correspondence: Debra Kaminer, Department of Psychology, University of Cape Town, Private Bag, Rondebosch 7701, South Africa. Tel: 27 21 6503435; fax: 27 21 6897572; e-mail:dkam{at}psipsy.uck.ac.za
Declaration of interest Funded by the Medical Research Council of South Africa and by a Harry and Doris Crossley Award.
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ABSTRACT |
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Aims To examine the degree to which participation in the TRC is related to current psychiatric status and forgiveness among survivors.
Method Survivors (n=134) who gave public, closed or no testimony to the TRC completed instruments measuring exposure to human rights abuses, exposure to other traumatic events, current psychiatric status and forgiveness attitudes towards the perpetrator(s).
Results There was no significant association between TRC participation and current psychiatric status or current forgiveness attitudes, and low forgiveness was associated with poorer psychiatric health.
Conclusions Truth commissions should form part of, rather than be a substitute for, comprehensive therapeutic interventions for survivors of human rights abuses. Lack of forgiveness may be an important predictor of psychiatric risk in this population.
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INTRODUCTION |
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METHOD |
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Participants (n=134) were selected according to the TRC's definition of "a victim of a gross human rights violation" (Truth and Reconciliation Commission of South Africa, 1998). This included people who were themselves violated and those whose family members were violated. It also included several different categories of violations: killing of a family member; torture of self or family member; severe ill-treatment of self or family member; abduction of self or family member; disappearance of family member (without return); and associated violations (police detention, raid on property, damage to property, looting) to self or family member.
The sample was divided into three groups:
Limited resources and lack of access to a list of TRC deponents in the
Western Cape precluded the use of random selection in this study. Participants
were therefore recruited through a combination of media advertising and
networking with community agencies and key community figures. Once the
participants had volunteered, the snowball method was used to reach other
participants. These sampling methods have been employed previously in
empirical studies of the psychological effects of human rights abuses
(Bao
lu
et al, 1994; Thompson
& McGorry, 1995), but the use of a non-random sample implies
some caveats on findings.
The length of time between giving a closed or public statement to the TRC and participation in this study was between 2 and 3 years.
Instruments
Each participant completed the following:
Participants were also asked to rate their degree of religious commitment as low, moderate or high.
Each instrument was translated into Xhosa, the indigenous language of most African people in the Western Cape, and back-translated into English, in order to ensure linguistic and semantic equivalence. The research protocol was approved by the ethics committee of the institution to which the authors were affiliated.
Procedure
Written informed consent was obtained from each participant. Interviews
were administered by Xhosa-speaking researchers (a psychiatric nurse and a
psychologist who received training in the use of the clinical instruments) and
were conducted in a community centre located centrally in each area.
Participants were informed of their right to refuse to answer any question or
to terminate the interview at any point. Participants who were identified as
having a psychiatric disorder or who exhibited marked distress during the
interview or in the days following the interview were offered a variety of
referral options, including both medication and psychotherapy.
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RESULTS |
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Demographic characteristics
With regard to gender, 62 (46.3%) participants were male and 72 (53.7%)
were female. Participants' ages ranged from 25 years to 86 years, with a mean
age of 53 years (s.d.=14.3).
Exposure to HRVs
The average number of violations (to both themselves and to family members)
to which participants were exposed was 8.4 (s.d.=5.4), ranging across the
sample from a low of one violation to a high of 24. With regard to the types
of violations experienced, 90% of the total sample had experienced a violation
to themselves, 82% reported violations to a family member and 72% had
experienced both. The number of violations to the participant him/herself
ranged across the sample from 1 to 17, with an average of 6.1 (s.d.=4.6). The
average number of violations to a family member ranged from none to 24, with a
mean of 2.4 (s.d.=2.4). The frequency of each type of violation is shown in
Fig. 1.
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There were significant gender differences in exposure. Men had a significantly higher mean number of total violations than women (P=0.02). Although men had experienced a significantly greater mean number of violations to themselves than had women (P<0.0005), women had a significantly higher mean number of violations to a family member than men (P<0.0005).
Other traumatic events
All participants had experienced at least one traumatic event that was not
a gross HRV (as defined by the TRC). The total sample had experienced an
average of 9.1 traumatic events other than HRVs (s.d.=4.9). Males had a
significantly higher mean number of other traumas (11.2; s.d.=5.2) than
females (7.3; s.d.=3.9) (P<0.0005). Increased exposure to traumas
other than HRVs was found to be associated significantly with depression
(F1,132=7.56, P=0.01), PTSD
(F1,132=4.80, P=0.03) and other anxiety disorders
(F1,131=13.57, P<0.01). There was no
significant difference in the number of non-HRV traumas between the three TRC
groups (P=0.85).
Psychiatric status
Of the total sample, 63% had a current MINI diagnosis. The most frequent
diagnosis was depression (55%), followed by PTSD (42%); 27% of the sample had
an anxiety disorder other than PTSD. There was a high rate (54%) of multiple
diagnoses in the sample.
There were no significant gender differences in depression
(21=0.38, P=0.54), PTSD
(
21=2.98, P=0.10) or other anxiety
disorders (
21=0.35, P=0.35).
Rates of PTSD, depression and anxiety disorders were compared between
subjects who had only been violated themselves, those who had only had a
family member violated and those who had experienced both. There were no
statistically significant differences across the groups in rates of depression
(22=4.07, P=0.13), PTSD
(
22=0.57, P=0.75), or other anxiety
disorders (
22=2.21, P=0.33).
Only three participants had received a psychiatric diagnosis (depression) and were currently receiving psychiatric medication. None of the other participants had ever received a formal psychiatric diagnosis, although many had been symptomatic for several years. Some were receiving medication for sleeping problems, which had been prescribed by the doctors or nursing sisters at their local clinic, but a psychiatric referral had never been made. None of the participants were currently receiving psychotherapy.
Psychiatric diagnosis and TRC exposure
A 2 test was used to examine whether there were any
differences between the three exposure groups in rates of PTSD. The result was
not significant (
22=3.62, P=0.16).
However, inspection of the contingency table showed that the proportion of
PTSD was 23.8% in the Public group, 47.5% in the Statement group and 41.9% in
the None group. Because the Public group seemed to have a substantially lower
rate of PTSD than the other two groups, which were very similar to each other,
we combined the Statement and the None groups and compared them with the
Public group. The difference was not significant at the 0.05 level
(
21=3.31, P=0.07).
No association was found between TRC exposure and depression
(21=1.63, P=0.44), or TRC exposure and
anxiety disorders other than PTSD (
21=0.54,
P=0.28).
Exposure to the TRC and forgiveness attitudes
One-way analyses of variation (ANOVAs) revealed no significant difference
in mean levels of forgiveness between the three exposure groups
(F2,131=0.39, P=0.68). However, the Public group
showed a distinctly different pattern of forgiveness from the other groups.
Although participants in both the Statement and None groups tended to have a
spread of forgiveness from low, through moderate, to high, participants in the
public group tended to be either very forgiving or very unforgiving. The
distribution of forgiveness scores had a bimodal appearance and the standard
deviation of the Public group (105.6) was substantially larger than for the
Statement group (81.01) or the None group (83.3). Those Public participants
who clustered on the low end of the forgiveness scale were mostly female,
whereas those that clustered on the high end were mostly male. Further
investigation revealed that forgiveness score is associated significantly with
gender (F1,131=6.79, P=0.01), with females being
less forgiving than males. A linear regression then simultaneously examined
the contribution of gender, religion and type of victimisation (self only,
family member only or both) and found that gender was the only variable
associated significantly with forgiveness score.
Forgiveness and psychiatric diagnosis
One-way ANOVAs showed that depression, PTSD and other anxiety disorders
were all significantly higher among participants with low forgiveness scores
when compared with those with high forgiveness scores (P=0.01,
P=0.03 and P=0.04, respectively).
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DISCUSSION |
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Participation in the TRC and psychiatric status
There was no significant difference in the rates of depression, PTSD or
other anxiety disorders for participants who gave public testimony, closed
testimony or no testimony. Although some individuals may have experienced
testifying as either distressing or relieving, it would appear that, for this
sample as a whole, the process of giving either public or closed testimony to
the truth commission did not have a significant effect on psychiatric health
(it had neither a notable therapeutic effect nor a notable counter-therapeutic
effect).
The apparent lack of any significant impact on symptoms suggests that the process of testifying at the TRC may be qualitatively different from that of testimony therapy in the clinical setting. Thus, it may be overly ambitious for truth commissions to have a therapeutic goal, except at the broader national level. It may be argued also that the perceived absence of justice (i.e. punishment of perpetrators and compensation of survivors) in the TRC process, about which many survivors have protested (CSVR & the Khulumani Support Group, 1998; Hamber, 1998), may have been a barrier to recovery. If justice is done, and seen to be done, psychological healing may be facilitated. Finally, the frequent and ongoing exposure to other traumas among this population may also explain the apparent failure of the TRC process to reduce the presence of psychiatric disorder. Any short-term relief associated with giving testimony is unlikely to be sustained in the face of chronically high levels of community trauma.
Participation in the TRC and forgiveness
Our findings indicate that a lack of forgiveness is related to poor
psychiatric adjustment, although the causal nature of this relationship cannot
be established here. It appears that being unforgiving, although an
understandable moral response to being violated, also carries an increased
risk of psychiatric morbidity. However, TRC participation was not associated
with any difference in overall levels of forgiveness, indicating that
additional interventions to promote forgiveness, such as some form of
survivor-perpetrator mediation, may be required.
We noted a tendency for survivors who gave public testimony to be either very forgiving or very unforgiving. Public hearings may have been characterised by a process of self-selection (or selection by the TRC) of survivors who were either very forgiving or very unforgiving. Alternatively, it may be that the process of giving public testimony facilitates a high level of forgiveness when it is effective but a low level of forgiveness when it is ineffective. Because it was found that those public testifiers who were highly forgiving tended to be men, whereas those who were unforgiving tended to be women, the effectiveness of the public process may depend on the deponent's gender. Although women in the total sample were found to be significantly less forgiving than men, the split between very low forgiveness among women and very high forgiveness among men was only apparent in the Public group, and could not be explained by factors such as religion or the type of violation experienced. In general, the association between gender and forgiveness has received little investigation (Worthington et al, 2000), and future research in this area may provide a better understanding of the apparent gender effect found among public testifiers in our sample.
Current psychiatric needs of survivors
The high level of psychiatric disturbance coupled with the low treatment
rate in our sample suggests that survivors in South Africa are currently
underdiagnosed and undertreated by the mental health system. Anecdotal
clinical lore in South Africa indicates that this may be due in part to a
tendency among Black African patients to present with physical complaints
(e.g. sleep disturbance or bodily pain), whereas a range of psychiatric
symptoms remain unreported without more careful screening and assessment. The
healing capacity of the truth commission process, both in South Africa and
elsewhere, may be much enhanced by the provision of adequate, relevant mental
health services. This should include routine screenings at primary care level
for a history of human rights abuses among patients in contexts where such
experiences are prevalent, and the training of primary care physicians and
nurses regarding the psychiatric effects of human rights abuses as well as
available treatment options. Given the high costs of medical and psychiatric
care in a context where resources are scarce, as well as the arguably limited
cultural applicability of Western treatment modalities, indigenous healers and
existing community resources also have an important role to play in the
recovery of survivors of human rights abuses in South Africa.
Limitations
Owing to the non-random sample and retrospective design employed in the
current study, significant findings should be interpreted with some caution.
In addition, several of the instruments used have been developed for use with
Western populations and have not been validated on South African samples. They
may therefore miss important cultural nuances in the expression of psychiatric
illness and of forgiveness (Keane et
al, 1996). Finally, it has been argued that classic PTSD
criteria may not adequately capture the full range of post-traumatic
reactions. The notions of complex PTSD
(Herman, 1992) or
disorders of extreme stress
(Pelcovitz et al,
1997) may be more appropriate conceptualisations of responses to
extreme chronic stress such as that to which South African survivors have been
exposed. The use of random samples, prospective research designs, culturally
sensitive instruments and a broader conceptualisation of post-traumatic
reactions will enhance future research on the impact of truth commissions for
survivors of human rights abuses.
Despite these limitations, our findings provide important preliminary data which have several implications for the structuring of future truth commissions and for intervention with survivors of human rights abuses. First, truth commissions may not be sufficient to reduce psychiatric symptoms and promote forgiveness. Truth commissions should form part of, rather than be a substitute for, comprehensive and ongoing therapeutic interventions for individual survivors. Second, a lack of forgiveness may be an important predictor of psychiatric risk among survivors of human rights abuses. Finally, the psychiatric needs of survivors of human rights violation in South Africa have not been addressed adequately by the existing mental health system. Access to mental health interventions that are culturally appropriate and that address the specific needs of survivors of human rights abuses is a vital adjunct to an effective truth and reconciliation process.
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Clinical Implications and Limitations |
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LIMITATIONS
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Received for publication August 30, 2000. Revision received October 26, 2000. Accepted for publication October 27, 2000.