Psychiatric and Cognitive Effects of War in Former Yugoslavia:  Association of Lack of Redress for Trauma and Posttraumatic Stress Reactions FREE

In the 20th century, wars and various forms of human rights violations have exposed millions of people to severe psychological trauma. In the last 50 years there have been some attempts in various countries to investigate human rights violations and bring those responsible to justice. These include the Nuremberg trials after World War II, the “Truth Commissions” set up between 1974 and 1994 to investigate the human rights violations in various countries,¹ and more recently, the Truth and Reconciliation Commission in South Africa and the International Criminal Tribunals for Former Yugoslavia and Rwanda.

Impunity is believed to aggravate social and psychological problems and impede healing processes in survivors.^2- 4 Retributive justice processes involving investigation of human rights violations, uncovering of truth, punishment of those responsible for human rights violations, and commemoration and compensation are thought to serve as redress for survivors and facilitate healing processes.⁵ There is no empirical evidence, however, to support these views. Furthermore, no study has yet examined how appraisal of redress relates to posttraumatic stress responses in survivors of war and human rights violations. Study of the mechanisms of traumatic stress may shed light on the level of intervention (eg, sociopolitical vs psychological) required to facilitate recovery from trauma. It may also provide a better understanding of how psychological effects of trauma influence reconciliation processes and how the latter could be facilitated by psychological interventions.⁶

We examined this issue in war survivors from the countries of former Yugoslavia. We obtained detailed data on 4 groups of variables: (1) the survivors’ traumatic war experiences, (2) appraisal of various sociopolitical events with a potential redress effect (hereafter referred to as “redress events”), (3) emotional responses to impunity for those responsible for trauma and beliefs about safety, justice, other people, war cause, and religion, and (4) posttrauma mental health status. Because our study design included matched control groups at 2 study sites, we were also able to examine the psychiatric and cognitive effects of war stressors in a controlled fashion.

Cognitive theories maintain that traumatic stress responses may be mediated by inability to find an acceptable explanation for the trauma⁷ and violation of beliefs that the world is a just and orderly place.⁸ Thus, we also used measures of beliefs about justice, benevolence of people, war cause, and religion to examine other cognitive effects of war trauma. We tested the following hypotheses: (1) Compared with people who had low-intensity or no exposure to war stressors, those with higher levels of exposure show stronger emotional responses to impunity and greater change in beliefs concerning other people, war cause, and religion, and have more psychiatric problems. (2) Controlling for other factors, posttraumatic stress disorder (PTSD) and depression relate to stronger emotional responses to impunity and greater dissatisfaction associated with perceived lack of other forms of redress, perceived ongoing threat to safety, loss of faith in people and justice, loss of meaning in war cause, and change in religious beliefs.

The study included survivor samples from 4 sites in the former Yugoslavia: Belgrade (Serbia and Montenegro), Rijeka (Croatia), Sarajevo (Bosnia-Herzegovina), and Banja Luka (Republic of Srpska, Bosnia-Herzegovina). We recruited from the community survivors who had experienced at least 1 of the following war-related stressors of interest (hereafter referred to as the index stressor event): combat, torture, internal displacement, refugee experience, siege, and/or aerial bombardment. These were among the most common war events in the region, affecting large sectors of the population.

The study design included control groups at only 2 sites (Banja Luka and Rijeka) due to the difficulties in finding people with no exposure to war trauma at the other sites. Although most control participants had been exposed to war scenes on television and/or had relatives or friends who had experience of war events, they had no direct exposure to war stressors. These groups were matched on a 1:1 basis with the community participants on sex, age, and education. Fifteen survivors (6%) in the Rijeka sample and 52 (17%) in the Banja Luka sample for whom appropriate controls could not be found were excluded from the analyses involving controlled comparisons.

We used target sampling⁹ to ensure adequate representation of the survivor groups of interest and sufficient numbers of cases with PTSD in the sample to test our study hypotheses. We attempted to minimize sampling bias within the targeted groups as much as possible by using linkage sampling.¹⁰ This method involved tracing and contacting survivors in the community through key informants (project staff and their acquaintances, contacts in various nongovernmental organizations, and the study participants). To minimize sampling bias with respect to psychological status, key informants were asked to make a list of their friends or acquaintances who had an experience of a particular index stressor, disregarding any available information on their psychological status. These survivors were then contacted and invited to participate in the study. Once the interview was completed, each survivor was asked to list all friends or acquaintances with a similar trauma experience. This “snowballing” process continued until the targeted sample size for a particular index stressor was achieved. This sampling method did not result in groups that were mutually exclusive in terms of the index event that was used to identify them (for recruitment purposes) as combat veterans, refugees, etc, because many participants had experienced more than 1 such event.

Information on the population from which the study groups were drawn, the sampling method, and the flow of cases into the study is presented in Table 1. The inclusion criteria were experience of at least 1 of the main index stressor events, age 18 through 65 years, literacy, absence of past or present psychotic illness, and willingness to give written consent for participation in the study. The number of participants not eligible for the study is not shown because only 1 participant was excluded from the study on grounds of ineligibility. Such a low exclusion rate was due to the fact that the key informants knew about the inclusion criteria and listed for contact only those people who were available for contact and likely to be eligible for the study.

The combat veterans and torture survivors were mainly former army conscripts. The refugees were people who had left their homes in the neighboring countries of former Yugoslavia between 1991 and 1995. The internally displaced people (IDPs) in Belgrade were among the 200 000 Kosovo Serbs who were displaced into Serbia after the North Atlantic Treaty Organization (NATO) bombardment in Kosovo. The IDPs in Banja Luka were among the more than 400 000 Serbs who had left Muslim- or Croat-controlled areas in Bosnia-Herzegovina. The IDPs in Rijeka were mostly Croats from the Vukovar region. The IDPs in Sarajevo had been displaced from the Serb-controlled territories in Bosnia. The siege survivors were residents of Sarajevo, which had come under a 4-year-long siege by the Yugoslav People’s Army and the Bosnian Serb army between 1992 and 1996.

We obtained samples from 4 sites in former Yugoslavia to achieve a more representative picture of the psychological effects of war on the main ethnic groups and communities exposed to war violence. We hypothesized ethnicity-related variations in cognitive and emotional responses to sociopolitical events, possibly reflecting in part the international response to the conflict in former Yugoslavia, the involvement of NATO in the conflict, and the different outcomes of the war for each ethnic group. The information on ethnic status was based on the participants’ self-report.

In estimating the cell size required for comparisons between the survivor and control groups, the expected rate of posttraumatic stress reactions in the survivor group was set to 40%, which is an approximate average of the rates reported in the literature concerning former Yugoslavia (20%-65%). The respective rate in the control groups, on the other hand, was set to 20%, given that the controls had some low-intensity exposure to war stressors. Such a high figure was chosen to ensure sufficient statistical power to detect relatively small differences between the survivor and control groups. A power analysis revealed that the cell size required to detect a between-group difference significant at the .05 level with a degree of certainty of 0.90 is 105. A pooled sample of 1358 cases also provided sufficient statistical power for multivariate analyses of the study measures and regression analyses of factors associated with posttrauma psychological outcome, which require about 10 cases per variable.

We devised the Redress for Trauma Survivors Questionnaire (RTSQ) to measure appraisal of redress. This questionnaire was based in part on a legal definition,⁵ which refers to impunity as a lack of measures designed to provide redress for survivors, including investigation of human rights violations and prosecution of those responsible, implementation of civil sanctions for those responsible, compensation of survivors, and commemoration. The questionnaire elicited information about the survivor’s attributions of responsibility for the most distressing war stressor and appraisal of various redress events, including retributive justice processes, compensation, commemoration, and other social and political events with a potential redress value. The questionnaire also included a global rating of sense of justice (“Considering what you and/or your close ones went through, do you think justice has been served in your case? How satisfied are you with this outcome?” 1 = very dissatisfied, 2 = fairly dissatisfied, 3 = slightly dissatisfied, 4 = no effect/do not know, 5 = slightly satisfied, 6 = fairly satisfied, 7 = very satisfied). The same satisfaction rating was also obtained for each redress event.

For assessment of beliefs, we used the self-rated, 48-item Emotions and Beliefs After War (EBAW) questionnaire, which was also devised for the purposes of this study. It consisted of (1) 13 items assessing appraisal of impunity and associated emotions, (2) 12 items measuring appraisal of threat to safety, (3) 6 items relating to beliefs concerning other people, society, and justice, (4) 7 items assessing change in appraisal of war cause and expectations about the future of the country, and (5) 10 items relating to beliefs about God and religion. All items were rated on a scale from 0 through 8 (0 = not at all true, 2 = slightly true, 4 = moderately true, 6 = fairly true, 8 = very true). A reliability analysis of the EBAW items in the pooled sample yielded a Cronbach α of 0.94 (range of item-total correlations, −0.12 to 0.73). The internal consistency of the scale was thus satisfactory.

Other measures included the Semi-Structured Interview for Survivors of War (SISOW) and the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (SCID-I/NP, version 2).¹¹ The SISOW, modified from an earlier version designed for survivors of torture,¹² included a section on demographic characteristics, an exposure to war stressors scale (EWSS; 54 war-related stressors, each rated as absent or present and also for associated distress; 0 = not at all distressing, 4 = extremely distressing). It also provided a global sense of control rating (0 = completely in control, 4 = not at all in control/entirely helpless) to assess the survivors’ overall sense of control in relation to the stressors reported. The SISOW also included 3 measures of support from close ones, during and after the most distressing event and at present (0 = very much support, 4 = no support at all). A modified version of the questionnaire was used with the control participants.

A reliability analysis of the EWSS using the perceived distress ratings associated with each event (absence of event coded as 0, indicating no distress experienced with respect to that event) showed satisfactory internal consistency (Cronbach α = 0.88; range of item-total score correlations, 0.08-0.59). A principal components analysis of the perceived distress ratings in relation to the 49 items of the EWSS (excluding 6 endorsed by less than 1% of the sample) yielded 13 components (56% of the total variance). An orthogonal (Varimax) rotation yielded components representing (percent variance explained and item loadings higher than 0.40 shown in parentheses) exposure to enemy fire and casualties (9.2%; witnessing others being seriously injured, 0.74; exposure to random fire, 0.70; witnessing violent death of others, 0.65; exposure to sniper fire, 0.63; exposure to shelling, 0.62; dealing with severely injured people, 0.60; combat experience, 0.56; deprivation of vital needs, 0.48), captivity and torture-related stressors (8.9%; torture, 0.86; witnessing torture of others, 0.80; prisoner-of-war experience, 0.74; detention camp experience, 0.73; forced labor, 0.64; witnessing torture of close ones, 0.62; witnessing acts of atrocities, 0.54), loss of resources/forced displacement/refugee experience (5.2%; sudden loss of property, 0.81; loss of status or occupation, 0.63; sudden destruction of home, 0.61; forced displacement, 0.61; refugee experience, 0.55), learning about torture/death/disappearance/imprisonment of close ones (5%; learning of torture of close ones, 0.66; learning of violent death of close ones, 0.59; disappearance of close ones, 0.54; detention/imprisonment of close ones, 0.53; close ones missing in action, 0.45), combat activities involving acts of killing (4.3%; killing enemy in one to one combat; 0.63; being ambushed, 0.58; participation in territory-cleaning missions, 0.57), witnessing injury or violent death of close ones (4.1%; witnessing injury to close ones, 0.72; witnessing violent death of close ones, 0.68; learning of serious injury to close ones, 0.43), rape/witnessing rape (3.5%; rape, 0.82; witnessing rape of others, 0.81), defection of close ones to enemy side/sudden departure of close ones (3%; defection of close one to enemy side, 0.71; sudden departure of close one, 0.67; learning about others’ suicide, 0.44), exposure to mass graves and mutilated bodies (3%; witnessing bodies in mass graves, 0.70; identifying bodies in mass graves, 0.60; dealing with mutilated bodies, 0.44), stepping on a landmine (2.9%; stepping on a landmine during war, 0.71; serious injury to self, 0.53), sudden destruction of home (2.5%; sudden severe damage to home, 0.80; exposure to explosions, 0.40), aerial bombardment (2.4%; exposure to aerial bombardment, 0.72), and combat experience of close ones (2.4%; combat experience of close ones, 0.57; threat of death by suffocation, 0.45). The components showed a fairly clear separation with only moderate overlapping on some items; the highest loading on items showing overlapping was 0.43. The respondents’ scores on the components were computed for use in subsequent analyses.

Information on the validity and reliability of the Serbo-Croatian version of the SCID was not available because we could not find any study of the psychometric properties of this questionnaire in former Yugoslavia. The SCID yields a diagnosis of PTSD when at least 1 reexperiencing, 3 avoidance, and 2 arousal symptoms are present and associated with significant subjective distress or functional impairment. The diagnosis of major depressive episode is met when 5 or more depressive symptoms are present during the same 2-week period, representing a change from previous functioning, and at least 1 of these symptoms is depressed mood or loss of interest/pleasure.

The 3 social support variables relating to support from close ones during and after the most distressing war event and at present showed high correlations with each other (ranging from 0.43 to 0.61, all P<.001) so they were combined into a single measure by summing their scores.

The interviews were conducted by 21 psychiatrists and psychologists from the 4 study sites. The interviews were audiotaped for quality control when informed consent could be obtained (71% of all cases). During the first year of the study, 20% of all audiotaped (about 10 by each assessor) were randomly selected and evaluated for validity of diagnoses, rapport, adherence to the assessment protocol for each instrument, and overall quality of assessment, using a global scale of interview quality (excellent to poor/unacceptable). The concordance rates ranged from 94% to 100% for the SCID (mean κ, 0.72; 0.81 for PTSD, 0.84 for current major depressive episode). Intraclass correlation coefficients for the SISOW items ranged from 0.83 to 0.99. The accordance rate between the principal evaluator and assessors on the RTSQ items ranged from 95% to 100% (mean κ, 0.92, intraclass correlation coefficients ranged from 0.91 to 1.0).

The interviews, conducted between March 11, 2000, and July 30, 2002, were usually completed in 1 or 2 sessions. Written informed consent was obtained for all study procedures. Strict confidentiality was emphasized. All study participants were offered an interview fee of $10 and those in need of help were offered treatment. The study was approved by the Research Ethics Committee of the Institute of Psychiatry, King’s College, University of London.

The 4 study site samples were pooled for the analyses of the redress events and factors related to posttrauma psychiatric outcome. The distribution of all study variables was checked and those showing skewed distributions (only the fear and loss of control items of the EBAW) were square root transformed. In between-group comparisons, independent t tests were used for continuous variables and χ² tests for categorical variables. Bonferroni adjustment of P values was conducted for all analyses involving multiple comparisons.

The between-group comparisons involving the survivor and control groups were conducted using independent t tests and χ² tests. Because of 1:1 matching of the control participants, these comparisons were also conducted using McNemar χ² tests for categorical and paired t tests for continuous variables, but the results of the former analyses are presented because they tend to be more conservative.

Hierarchical logistic regression analyses examined the factors related to the diagnoses of PTSD and depression. The participants’ scores on the EWSS components and 7 factors extracted by a factor analysis of the EBAW items, rather than the scale items, were used as independent variables to reduce the number of variables for the regression analyses. Using uncorrelated variables in regression analyses also avoided problems of multicollinearity posed by high intercorrelations among the items of these scales. At the first step the demographic and personal and family history characteristics, including age, sex, marital status, education, income level, personal and family history of psychiatric illness, and family history of war trauma during or after World War II (0 = absent, 1 = present), were entered. Three dummy variables (coded as 0, 1) representing the Sarajevo, Banja Luka, and Rijeka study sites were also entered at the first step to control for their possible effects on the dependent variable. The trauma-related variables (13 EWSS component scores, time since trauma in months, and global sense of control rating) were entered at step 2, followed by support from close ones at step 3. The RTSQ variables were entered at step 4 and the 7 EBAW factor scores were entered at step 5. The analysis thus allowed examination of the independent contribution of each group of variables to the total variance explained. A total of 52 independent variables were included in the analyses (26 cases per variable).

SPSS 12.0 (SPSS Inc, Chicago, Ill) was used for all analyses.

The pooled sample characteristics (n=1358) and a comparison of the 4 study site samples are presented in Table 2. For all sites combined, the mean (SD) age was 39 (12) years, 806 (59%) were men, 339 (25%) had high school or higher level of education, and most had relatively low levels of income. Of all participants, 789 (58%) were Serbian, 252 (19%) were Croatian, 239 (18%) were Bosniak, and 78 (6%) were of mixed or other ethnic origin. The individual site samples differed with respect to demographic and trauma characteristics, reflecting the fact that they were drawn from different sites and survivor populations.

The overall mean number of war-related events experienced was 12.6. The between-site difference in the mean number of stressor events was in part accounted for by the bombardment survivors in Belgrade, who reported fewer events (mean [SD], 2.8 [2.1]). The overall mean time since trauma was 81 months.

Rates of current PTSD ranged from 16% to 34% and rates of lifetime PTSD ranged from 30% to 41%. Rates of current major depression ranged from 9% to 12%.

Appraisal of retributive justice events was assessed in relation to those held responsible for the most distressing war event reported by the survivors. Responsibility was primarily attributed to politicians in 40% of the cases, enemy army in 18%, leaders of the NATO countries in 12%, paramilitaries in 6%, own army in 5%, leaders of the neighboring communities in 5%, neighbors in 4%, international community officials in 3%, and others in 7%.

The percentages of survivors who reported various redress events and the satisfaction ratings in relation to these events are shown in Table 3. The frequency of reporting of most redress events was low. The survivors were more likely to be dissatisfied than satisfied with respect to all redress events, particularly those concerning retributive justice. This was also reflected in the fact that 79% were dissatisfied because they believed justice had not been served in their case. Fifty percent of the survivors expressed dissatisfaction with respect to the issue of compensation, either because they had not received any compensation or were not satisfied with what they had received. In response to a question about the kind of redress they most desired, 50% of the survivors mentioned some form of monetary compensation. Other responses included privileged access to social, occupational, medical, traveling, and other facilities (8%), retributive justice (5%), recovery of lost home (4%), recognition of their past suffering (3%), and others (2%). On the other hand, 28% of the survivors did not want any compensation.

A comparison of the survivors and controls on the demographic variables and the SCID diagnoses in the Banja Luka and Rijeka site samples is shown in Table 4 and Table 5. The matching procedure resulted in groups similar in sex, age, education, and marital status. At both sites there were marked differences between the survivors and the controls in the rates of PTSD and major depressive episode. Because the rates of the other diagnoses were too low for analysis in the survivor and the control groups at both sites, they were not included in Table 4. A comparison of the survivors and controls on the EBAW items at both sites is available in the online eTable. The majority of the items, except those relating to religious beliefs, showed small but significant between-group differences. These results supported the first study hypothesis.

A factor analysis (principal axis factoring) of the EBAW items in the pooled sample of 1358 survivors yielded 7 factors with an eigen value greater than 1 (54.9% of the total variance), which were rotated orthogonally for simpler solution. Due to space constraints, the results are presented in summary here (details available on request). The rotated factors represented (% variance explained) fear and loss of control over life related to perceived threat from the enemy (13.5% of the variance), emotional responses to impunity (13.4%), fatalistic thinking/increased faith in God and religion (8.6%), loss of meaning in the war cause (8.4%), belief in benevolence of people and justice in the world (4.7%), desire for vengeance (3.5%), and loss of faith in God and religion (2.7%). The components showed a fairly clear separation, overlapping on only a few items. The respondents’ scores on the 7 factors were computed for use in subsequent analyses.

Table 6 and Table 7 show the results of the hierarchical logistic regression analysis using the diagnosis of current PTSD and major depressive episode as the dependent variables in turn (only significant predictors presented). The 18 RTSQ variables used in the analyses are shown in Table 3. Family history of trauma (0 = no, 1 = yes) was included in the analysis to test the view¹³ that the effects of war trauma can be passed down as the family legacy from one generation to another. Thirty-two percent (n = 439) of the survivors reported traumatic experiences of family members during World War II, including loss of close ones, combat, torture, and prisoner-of-war or concentration camp experience.

The largest proportion of variance (27%) in PTSD was explained by the variables entered at the first step (demographic and personal/family characteristics). Exposure to war stressors (step 2) explained the second largest variance (25%). The unique variance explained by support from close ones (step 3) and the RTSQ variables (step 4), although significant, were only 1% and 2%, respectively. The EBAW factors (step 5) explained 9% of the variance. In the full regression model PTSD was most strongly associated with fear and loss of control over life followed by exposure to enemy fire and casualties. None of the RTSQ variables was associated with PTSD.

The largest proportion of the variance in depression was again explained by the variables entered at the first 2 steps (demographic and personal/family characteristics and war stressor exposures) followed by the EBAW variables at the last step. The strongest predictors of current major depressive episode were fear and loss of control over life and family history of psychiatric illness. Unlike PTSD, depression did not relate to age, education, support from close ones, or any of the war stressors. It was unclear whether the factors common to both PTSD and depression reflected the comorbidity between the 2 conditions. Indeed, 98 of the 129 participants (76%) who had major depressive episode also had PTSD. Because of the small number of cases with only major depressive episode, we could not examine the factors associated with individuals with depression but without PTSD. However, the 31 survivors who had major depressive episode without PTSD had significantly higher scores on fear and loss of control over life than did those who had neither major depressive episode nor PTSD (mean [SD], 0.23 [0.91] vs −0.25 [0.79]; t₁₀₄₆ = 3.35; P<.001), suggesting that the association with this variable did not merely reflect confounding of PTSD.

Dissatisfaction with various forms of redress and associated sense of injustice appeared to be prevalent among the survivors. Perceived lack of punishment for those held responsible for trauma was one of the many factors associated with sense of injustice. The most commonly stated reasons were losses suffered during the war; disillusionment with the war cause, leaders, or the outcome of the war; perceived worsening in the social, political, and economic conditions; hardships in daily living; lack of recognition for past suffering; and discontent with national and international political processes that were blamed for current problems. These findings are consistent with those from other studies of war survivors in former Yugoslavia^14- 15 and Rwanda,⁶ suggesting that justice for survivors is much more than criminal trials.

Compared with the controls, the survivors had stronger emotional responses to perceived impunity for those they held responsible for war trauma, including anger, rage, distress, loss of meaning in life, demoralization, desire for revenge, sense of injustice, helplessness, pessimism, fear, and loss of control over life. These results were consistent with previous observations in survivors of war¹⁶ and human rights violations.^2,5,17- 19 The finding that the survivors had less faith in benevolence of people and a just world than did the controls supported the view²⁰ that exposure to trauma is associated with altered beliefs about the world. Consistent with findings from a study of Holocaust survivors,²¹ exposure to trauma was also associated with an increase in faith in religion, possibly pointing to the role of religious beliefs as a cognitive coping strategy. The elevated rates of PTSD and depression among the survivors are consistent with the findings of other studies of refugee trauma,²² mass violence and civilian terror,²³ combat,²⁴ torture,²⁵ and prisoner-of-war experience.²⁶

The factor most strongly associated with PTSD and depression was fear and loss of control associated with perceived threat from those held responsible for trauma. The associations with emotional responses to impunity and other cognitive variables were substantially weaker or not significant. The second study hypothesis was thus only partially supported. The association between torture and PTSD was consistent with the findings of other studies of war²⁷ and torture¹² survivors. The lack of a significant association between family history of trauma and PTSD or depression did not support the view¹³ concerning transgenerational effects of war trauma.

The retrospective nature of our study precludes inferences regarding the causal relationships between the cognitive and psychiatric outcome variables. The psychological responses to impunity and other altered beliefs might well be the consequence rather than the cause of PTSD. Treatment studies²⁸ showing that improvement in PTSD can occur before a change in beliefs support this point. Further prospective research is needed to clarify this issue. It should also be noted that our nonprobability sampling methods might limit the generalizability of the study results.

Do our findings support the widely held view that the problem of impunity is associated with posttraumatic stress responses in survivors? The answer to this question would depend on how impunity is defined. If it is defined solely as a lack of redress for survivors, then it does not appear to be strongly associated with PTSD or depression. On the other hand, if impunity is more broadly defined to include an element of continued threat posed by those held responsible for trauma, then our study results can be regarded as supporting such an association. This definitional issue is important because our results imply that the mental health implications of impunity in countries where those responsible for human rights violations are no longer in power (eg, South Africa) are likely to be different from those in other countries still ruled by an oppressive regime. Our study findings imply that once survivors of human rights violations are in a safe environment, they may not be at serious risk of developing PTSD or depression.

Our findings, together with those of our recent studies of other survivor populations, may have important implications for effective treatments for war survivors. Loss of control over traumatic stressors was the factor most strongly associated with PTSD in all our previous studies of survivors of torture^29- 30 and earthquakes,^31- 32 consistent with findings from a study of war veterans.³³ This finding thus appears to be fairly robust and replicable across different survivor populations. Thus, if loss of control is an important mediating factor in posttraumatic stress, then interventions designed to enhance sense of control over feared situations would be expected to reduce PTSD and depression.³⁴ We have tested this hypothesis in earthquake survivors in a series of clinical trials,^35- 37 using a behavioral intervention (exposure to feared situations) designed to enhance sense of control over earthquake-related fears. Indeed, a single session of this treatment not only significantly reduced PTSD and depression in more than 80% of the survivors but also enhanced resilience against ongoing traumatic stressors. Evidence from case studies^38- 39 suggested that this intervention is also effective in reducing torture-related PTSD, even in a political environment that poses a risk of further torture.³⁸ These findings suggest that treatment of survivors of human rights violations is possible, even under circumstances of continued threat to safety. There is also some preliminary evidence (B.M., E. Şalcıoğlu, M.L., unpublished data, 2005) suggesting that this intervention could be effectively disseminated through self-help manuals. Similar research with war survivors may thus lead to the development of an effective treatment for war-related PTSD.

What do our findings imply for the possible psychological effects of truth and reconciliation processes? The only controlled study⁴⁰ on this issue found that participation in the truth and reconciliation process in South Africa had no effect on the survivors’ posttraumatic stress problems. The authors concluded that perceived injustice arising from lack of punishment for those responsible and no compensation for survivors might have impeded recovery. Our findings do not support this point. Given the finding of a relative independence between appraisal of redress and posttraumatic stress responses, recovery from PTSD and depression does not appear to be likely, even if the truth and reconciliation processes succeed in restoring sense of justice in survivors. The same consideration could also apply to retributive justice processes, such as the International Criminal Tribunal for former Yugoslavia, which was established to bring to justice those responsible for human rights violations in the region and to facilitate healing of “psychological wounds.”⁴¹ As noted earlier, recovery from PTSD appears to require specific interventions designed to enhance sense of control over traumatic stressors. Furthermore, there is evidence^28,42 that a reduction in fear and associated posttraumatic stress responses through behavioral interventions is followed by a change in beliefs about self, others, and the world. This suggests that cognitive processes leading to attribution of blame to the perceived enemy and associated feelings of anger, hostility, and vengeance might also be altered by such interventions. This is a promising area of future research that may have important implications for reconciliation efforts in postwar countries.

In conclusion, our findings suggest that international efforts aiming at restoration of justice, reconciliation, and social reconstruction in postwar settings need to give priority to the survivors’ preferred forms of redress, such as social, occupational, and economic rehabilitation, if any meaningful recovery from the cognitive effects of the war is to be expected. Such cognitive “healing,” however, is unlikely to be paralleled by a reduction in PTSD and depression. The evidence pointing to the importance of fear-induced helplessness and the limited role of other cognitive factors in the development of PTSD implies that psychological interventions designed to enhance sense of control in survivors might be helpful in reducing traumatic stress responses even when the sociopolitical circumstances associated with impunity remain unchanged. Conversely, posttraumatic stress responses in survivors may persist even after a successful resolution of the problem of impunity through political action. Thus, our study highlights the need for an integrated approach to the problem^43- 44 that combines political action against impunity with due attention to the mental health consequences of the problem and effective ways of treating them.