Introduction
More than two decades ago, research suggested that describing one's traumatic experiences in a detailed one-session manner, as often required for legal documentation, increased the risk of chronic post-traumatic stress disorder (PTSD)—an extremely disabling mental disorder associated with all-cause mortality, violence towards others, depression and substance abuse. In the mid-1990s, mental healthcare for prevention of PTSD included a type of treatment called ‘debriefing’. This treatment consisted of a single meeting in which a survivor of a recent traumatic event was asked to retell the events in detail to a mental health professional. Research on debriefing found, that rather than preventing PTSD, debriefing more than doubled the risk of persistent PTSD 1 year later, and the same heightened risk of PTSD was still present 3 years later, the longest available follow-up period.1 ,2 While the findings of these studies are controversial, based on concerns regarding their design, analyses and interpretation,3 ,4 debriefing has been eliminated as a recommended treatment for traumatised individuals in most clinical settings.
In contrast, Mollica,5 Jones and Kafetsios6 described the complexity of emotional responses among traumatised human rights survivors and the need for culturally informed, gradual review of the trauma ‘story’ or ‘narrative’ with adults and adolescents. Subsequently, prolonged exposure therapy, which involves a measured review of the trauma narrative over many sessions (averaging 10 sessions of 90 min) has become a current ‘gold standard’ in PTSD psychological treatments.7
Legal context
Human rights legal efforts have proliferated over the past several decades and there are now organisations devoted to providing extensive documentation of human rights law enforcement in most parts of the world. International criminal law has also developed significantly in recent years: the International Criminal Court (ICC) was established in 2002, and is the world's first permanent court with jurisdiction over genocide, war crimes and crimes against humanity. While the ICC does provide psychological support, including services from the Victims and Witnesses Unit and the Trust Fund for Victims (TFV) for the ‘victim-witnesses’ who travel to The Hague to provide testimony, and to groups of in-country survivors (TFV), the majority of the victims providing testimony for the ICC are ‘victim-participants’ who testify without leaving their country of origin. For victim-participants, the mechanisms for supporting mental health before, during and after the process of providing testimony are unclear, nor even mentioned in the ICC guide for prospective victim-participants and their assistants.8
Leading human rights organisations are alert to the dangers of retraumatising survivors during interviews, and many have published ‘best practice’ guidelines which reference the need to avoid retraumatisation. One of the prominent early guidelines was the 1999 Istanbul Protocol: a manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, published by the United Nations Office of the High Commissioner for Human Rights,9 which concluded a section devoted to ‘Risk of re-traumatization of the Interviewee’ by stating: ‘Despite all precautions, physical and psychological examinations by their very nature may re-traumatize the patient by provoking or exacerbating symptoms of post-traumatic stress by reviving painful effects and memories.’ The ICC published regulations in 2009 asserting:The physical and psychological well-being of persons who are questioned by the Office and are considered vulnerable (in particular children, persons with disabilities and victims of gender and sexual crimes) shall be assessed by a psychology, psycho-social or other expert during a face-to-face interview prior to questioning. This assessment shall determine whether the person's condition at that particular time allows him or her to be questioned without risk of re-traumatisation.
Other prominent organisations such as Human Rights Watch, Amnesty International and WHO, have also published guidelines intended to avoid retraumatisation of interviewees.10–12 While these guidelines reflect sensitivity to the potential mental health impact of investigations on survivors of human rights violations, we are not aware of any requirements to monitor or report the actual mental health impact of the investigations. As noted by Amon et al,13 many human rights research organisations do not engage research ethics committees or view human rights documentation as research. With the exception of some organisations which have created their own internal review boards, many human rights organisations do not submit their study plan for independent human subjects protection review, or submit progress reports, with monitoring for, and reporting of, adverse events.
Medical context
At the time when global human rights legal endeavours began, the field of global mental health (GMH) had not yet been founded. Now, the huge burden of mental disorders suffered in low and middle income countries is not debatable.14 ,15 Also, it is not debatable that common mental disorders, including those occurring in the context of traumatic experiences, can be effectively treated in low-resource settings. GMH has evidence-based methods of measuring mental health status across diverse cultural settings, assessing mental healthcare needs and adapting evidence-based treatments such that they are locally acceptable and feasible, as well as effective, using low-cost, scalable delivery models.16–18 Despite the content similarities discussed above, it is possible that the short-term and/or long-term emotional impact of providing legal testimony is different from that of ‘debriefing’. Given that we now have the ability to deliver evidence-based mental healthcare in low-resource settings and partner for sustained scale-up of evidence-based care where few services have previously existed, evaluating for remediable mental health impact has potential benefits for survivors of human rights violations.
Institutional review boards (IRBs) have been used to approve and monitor biomedical and behavioural research involving human subjects in the USA since 1974. Reacting to abuses by Nazi physicians and the Tuskegee Syphilis study, the goal of IRBs is to protect the rights and welfare of human subjects according to the principles of ‘respect for persons’, ‘beneficence’ and ‘justice’.19