Victims/survivors of genocide, crimes against humanity, and other serious violations of human rights and international humanitarian law often suffer physical and psychological effects, sometimes long after the traumatic events. Massive trauma causes such diverse and complex destruction that only a multidimensional, multidisciplinary integrative framework can adequately describe it, and only such an approach can optimally treat its effects. Typical reactions may be powerful negative feelings, painful physical sensations, or horrific imagery of the events. Many studies document the serious, chronic, sometimes life-long, and even multigenerational effects of massive trauma, including fear, paranoia, depression, anxiety, and personality changes. Starvation, untreated disease, experiences of persecution, psychological shock (or numbing), and head injury may interfere with the recall and verbal description of traumatic experiences.

Although ordinary stressful life events tend to release a strong need for sharing, victims/survivors of extreme traumatic events often encounter a societal imposed silence and thus share neither their experiences nor the aftermath. One study of torture victims by Weisaeth and Lind found that fewer than one out of ten victims disclosed details of their experiences to their close relatives. Even when released from captivity, victims continue to suffer stress over, for example, possible recapture or reprisals from agents of the state who had violated their human rights in the first place. The pervasive conspiracy of silence following trauma is detrimental to survivors' familial and sociocultural (re)integration and healing. It intensifies their already profound sense of isolation and mistrust of society, and makes the task of mourning their losses impossible. Further, survivors' rehabilitation can never be fully achieved if the society in which they live continues to tolerate serious or systematic human rights violations.

However, the needs of victims will require understanding more than their perceptible symptoms. Understanding their specific experience of physical and psychological trauma, the nature of the crime, and their cultural, economic, personal, and group historical backgrounds is also necessary.

Medical and trauma practitioners recognize that approaches to treatment must reflect the victim's personal experience of physical and psychological trauma. Experts, many of whom are vicariously traumatized by survivors' experiences, emphasize a holistic approach in which trust and the doctor/patient relationship are critical. Treatment strategies are most effective when they utilize local sources of social, cultural, and organizational support. Rehabilitation following egregious violations of human rights must not only address the traumatized individual, but also the family, local community, society, nation, and the international community. The individual needs to know that society as a whole acknowledges and understands what has happened. A true healing process includes apology, reparations, education, commemorations, and other ways of acknowledging what has taken place.

Genuine rehabilitation must include redress and justice as well as the restoration of dignity to the victim/survivor, and must be established in a sociopolitical context in which the experience and pain are shared by the larger society. The story must be told accurately, the public records secured, and mechanisms for monitoring and preventive intervention established to ensure nonrepetition and break the intergenerational chain of transmission.

It is increasingly recognized that impunity for perpetrators contributes to social and psychological problems and impedes healing by adversely affecting bereavement, inducing self-blame, and eroding society's moral codes. Justice denied exacerbates the victim/survivor's psychic wounds. Impunity for the wrongdoers becomes an additional traumatic factor that renders closure impossible and leads to a loss of respect for law and government, and an increase in crime. Further systematic exploration of how survivors experience efforts to bring perpetrators to justice and provide compensation, and how these efforts impact healing, is needed.

Despite the widespread recognition of the importance of physical and psychological treatment to aid the recovery process and restore the dignity of victims, their number far exceeds the available services, even in the most developed countries. Often services that do exist come too late. In many of the countries emerging from mass conflict, the few available programs are usually transitory, have not been well integrated into the health and social services sectors of the countries, and are often externally financed. As a result, many laudable initiatives are not sustainable and may not be able to address the long-term and often multigenerational needs of victims of mass trauma. In other cases the special needs of trauma victims have not been dealt with separately and what general services exist are not tailored to meet their needs.

The plight of victims of the worst crimes has created an international impetus to develop a legal framework to guarantee respect for their rights. In 1985 the United Nations (UN) General Assembly unanimously adopted "the Victims' Charter," the UN Declaration of Basic Principles of Justice for Victims of Crime and Abuse of Power. It galvanized support for the recognition of the rights of victims, in particular their rights of access to justice and redress, restitution, compensation, and assistance. This led to the UN Commission on Human Rights' appointment of an independent expert to further study the issue of victim redress. As of 2004 the draft of the basic principles and guidelines on the right to remedy and reparation for victims of violations of international human rights and humanitarian law is under discussion for adoption by the Commission. Most recently the Rome Statute of the International Criminal Court has recognized that justice serves not only a retributive but also a reparative function; it enshrines victims' rights to restitution, compensation, and rehabilitation and provides the Court with a mandate to give effect to these rights.

Significant strides have been made in recognizing the rights of victims of the worst crimes, and there is an increasing appreciation of the complexity of their needs. However, much remains to be done to realize these rights and provide those who have suffered the most abominable crimes with the critical multidimensional and multidisciplinary help they need.

SEE ALSO Compensation; Reparations; Restitution

Yael Danieli