Journal of Traumatic Stress, Vol. 22, No. 5, October 2009, pp.

358–365 (
C 2009)

Human Rights and the Trauma Model:

Genuine Partners or Uneasy Allies?
Zachary Steel
Centre for Population Mental Health Research and Psychiatry Research and Teaching Unit,
School of Psychiatry, University of New South Wales, Australia

Catherine R. Bateman Steel

Centre for Population Mental Health Research and Psychiatry Research and Teaching Unit,
School of Psychiatry, University of New South Wales and School of Public Health and Community
Medicine, University of New South Wales, Australia

Derrick Silove
Centre for Population Mental Health Research and Psychiatry Research and Teaching Unit,
School of Psychiatry, University of New South Wales, Australia

Since World War II, a comprehensive body of international law has developed to protect and promote human
rights. Three generations of rights can be delineated: civil and political; economic, social and cultural; and
collective rights. The convergence of a medical rights-based campaign in the late 1970s with the emergence of the
new trauma model resulted in mental health professionals playing a prominent role in documenting and protecting
civil and political rights. Economic, social, and cultural rights also emerged as being pivotal, particularly in the
Australian context as mental health professionals began to work with excluded populations such as asylum seekers.
Consideration of third-generation rights raises important questions about the responsibilities facing mental health
professionals applying the trauma model to non-Western settings.

Mental health professionals have played a prominent role his-
torically in documenting the consequences of human rights abuses
such as torture, particularly focusing on populations exposed to
political conflict and mass displacement. In the 1970s and 1980s,
these initiatives led to the development of dedicated centers that
provided care and rehabilitation for survivors of political violence,
with a particular focus on their medical and mental health needs
(Silove, Tarn, Bowles, & Reid, 1991). This medical rights-based
approach in large part preceded the advent of the new trauma
model, heralded by the introduction of the category of posttrau-
matic stress disorder (PTSD) in the third edition of the Diagnostic
and Statistical Manual of Mental Disorders (DSM-III; American
Psychiatric Association, 1980). That category has since emerged as
a pivotal index through which clinical researchers have attempted
to document the effects of human rights abuse on affected popula-
tions. An important question therefore is whether the new trauma
model, in positing a direct link between traumatic exposure and
risk to development of PTSD in particular and psychiatric disorder
more generally, has served to advance the rights-based approach.
Some commentators have warned of the dangers to the rights
of indigenous persons by importing Western notions of trauma
and categories such as PTSD (Bracken, Giller, & Summerfield,
1995; Kleinman, 1995; Pupavac, 2006). In addition, there may
be a risk of “medicalization” of the rights movement by making it
excessively reliant on medical outcomes as the criterion to gauge
the extent or even the claim to validity of reported human rights
abuses (Almedom & Summerfield, 2004). A detailed analysis of
the foundations of a rights-based approach may throw new light on
these assertions, pointing the way to a more coherent integration
of the spheres of human rights and mental health in the trauma
field.
HUMAN RIGHTS AND THE THREE GENERATIONS
OF RIGHTS
Although political and philosophical discourse has considered the
importance of human rights since as early as the 17th century

Correspondence concerning this article should be addressed to: Zachary Steel, Centre for Population Mental Health Research, Level 1, Mental Health Centre, The Liverpool Hospital, Forbes and
Campbell Streets, Liverpool NSW 2170, Australia. E-mail: z.steel@unsw.edu.au.

C 2009 International Society for Traumatic Stress Studies. Published online in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/jts.20449

358
 Human Rights and the Trauma Model
(Cmiel, 2004), the end of World War II (WWII) and the
recognition of the scale of the atrocities committed in that conflict
represented a watershed, ushering in a global movement that was
intent on creating durable and effective international structures
for the protection of rights at a universal level. In 1948, the adop-
tion of the Universal Declaration of Human Rights represented a
milestone in advancing that process (Twiss, 2004). Since then, an
expanding body of international instruments, conventions, and
treaties have enshrined a comprehensive range of rights within
international law (Gruskin, Mills, & Tarantola, 2007).
A fundamental tenet underlying the principles of human rights
is that they are inherent to the dignity of every person. Rights
are universal, inalienable, and indivisible. Rights are principally
concerned with the individual’s relationship to the state, making
states and other duty-bearers answerable for the observance of
human rights.
Conceptually, human rights have been divided into three “gen-
erations” (Iyall Smith, 2008): (a) civil and political; (b) economic,
social and cultural; and (c) collective or group rights. Considera-
tion of this three-tier structure, although a simplification, provides
a potentially useful analytical mechanism through which to un-
derstand the various interactions between human rights principles
and the work of mental health professionals with displaced and
conflict-affected communities. It is critical, however, to note that
human rights should not be considered divisible into more or
less important classes, with a fundamental tenet of human rights
thinking being that the interdependent nature of rights means that
individuals rarely suffer violation or neglect of a particular right in
isolation (Gruskin & Tarantola, 2005; Tarantola et al., 2008 ).
First-Generation Rights: Civil and Political Rights
The most clearly established and widely accepted of the gener-
ations of human rights, civil and political rights, are based on
liberal notions of the individual emerging from the 18th century
onwards. These rights are principally enshrined in the Interna-
tional Covenant on Civil and Political Rights (ICCPR). The five
broad elements comprising this category together encompass the
state’s responsibility to safeguard the dignity and security of the
individual (against transgressions by the state itself or by others).
Key rights include protection of physical integrity (against events
such as execution, torture, and arbitrary arrest); procedural fairness
in law; protection against any form of discrimination; freedom of
belief, association, and speech; and the right to political partici-
pation. A growing body of legal mechanisms (bills, conventions,
international courts, etc.) is designed to guarantee such rights.
Second-Generation Rights: Economic, Social,
and Cultural Rights
This set of rights identifies the conditions necessary for meeting
the basic necessities of human life and dignity in the economic and
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
359
social sphere, such as access to food, shelter, education, health care,
and gainful employment. The relevant international conventions
include the International Covenant on Economic, Social and Cul-
tural Rights (1966/1976), the Convention on the Rights of the
Child (1989), and the Convention on the Rights of People with
Disability (2006). Unlike civil and political rights, which impose
immediate justiciable obligations, economic, social and cultural
rights are subject to the principle of progressive realization, which
is linked to the level of economic development and capacity of
the state to advance such rights. Hence, despite the ratification
of the International Covenant on Economic, Social and Cultural
Rights by 158 states, there has been less consensus as to whether
the identified economic, social, and cultural provisions constitute
“rights” or represent desirable social goals, and as a consequence
should not be the object of binding treaties (Kirkup & Evans,
2009). This may change, however, with the recent endorsement
of an optional protocol to the Covenant by the UN General As-
sembly (December 10, 2008), which obliges signatory countries
to recognize the authority of the Committee on Economic So-
cial and Cultural Rights to consider complaints from individuals
concerning possible transgressions of the Covenant.
Third-Generation Rights: Collective or Solidarity Rights
Third-generation human rights relate to aspects of life that are
collective, reflecting issues of solidarity and culture, rights that
therefore go beyond the relationship between the individual and
the state. The impetus to formalize these rights has come from
the growing recognition of a need to protect the rights of indige-
nous peoples, particularly in relation to maintaining their cultural
heritage and environment, and controling and asserting ownership
over processes that affect their societies. Specific provisions include
the right to self-determination, to economic and social develop-
ment, to a healthy ecosystem, to natural resources, to commu-
nication, to participation in activities that promote and maintain
cultural heritage, and to intergenerational equity and sustainability
(Iyall Smith, 2008). The principles of the third-generation rights
are expressed throughout a number of Conventions and Declara-
tions, most notably the United Nations Declaration on the Rights
of Indigenous Peoples (2007).
Emergence of a Global Human Rights Narrative
Whereas the immediate post-WWII era established the contem-
porary global human rights regime, it has only been during the
last 30 years that there has been any significant progress in the
development of an international framework to codify and opera-
tionalize international human rights law. Pivotal to this process was
the 1976 ratification of the first optional protocol to the ICCPR
establishing a formal complaints framework for adjudicating al-
leged breaches. Another major imperative has been the emergence
of nongovernment organization (NGO) related human rights
360
activism by groups such as Amnesty International and Human
Rights Watch.
The last 30 years also has witnessed a dramatic expansion of
declarations, conventions, and protocols aimed at operationalizing,
codifying, and extending the post-WWII foundational documents
on human rights. Yet, the extent to which this body of international
law will become an effective universal benchmark for regulating
state actions remains uncertain. Despite widespread adoption and
ratification by individual states, there remains substantial practical
resistance to full implementation of the provisions by signatory
countries (Robertson, 2006).
The third generation has been the most contested body of rights
with advocates struggling to achieve their global endorsement. The
second generation, although attracting some level of endorsement,
has received little practical support and promotion. Prevailing eco-
nomic ideologies have played a major role in undermining the
strength of commitment to social welfare programs in many coun-
tries (Kirkup & Evans, 2009) and retarding the adoption of rig-
orous compliance indicators and enforcement mechanisms for the
International Covenant on Economic, Social and Cultural Rights
(Welling, 2008; Whelan & Donnelly, 2007). Thus, the majority
of international human rights organizations have tended to focus
primarily on promoting and safeguarding the rights of the first
generation.
Based on this background, we consider the relationship of men-
tal health issues with each of the specified generation of rights.
FIRST-GENERATION RIGHTS: VIOLENT CONFLICT
AND MENTAL HEALTH
It is notable that the establishment of the category of PTSD and the
consequent preeminence of the modern trauma model has emerged
in an epoch when major advances in first-generation rights came
to fruition. An international focus on the impact of extreme abuses
of human rights began to gain momentum in the late 1970s, with
the documentation of the psychiatric consequences (particularly
of torture) being integral to this movement. In 1975, the UN
produced the Declaration on the Protection of All Persons from
Torture, explicitly prohibiting the use of this inhumane practice in
all circumstances, a landmark that ultimately led to the ratification
of the Convention Against Torture in 1984.
Systematic documentation of the medical and psychological
consequences of torture and forced displacement began soon after
the Declaration in 1975 (Amnesty International, 1977). Reports
of the psychological effects of torture appeared in the psychi-
atric literature in the late 1970s with an extensive survey being
published by the Danish Medical Group in 1980 (Rasmussen &
Lunde, 1980) and a further review being published in 1988 (Gold-
feld, Mollica, Pesavento, & Faraone, 1988). A major development
was the establishment of clinical and research centers for victims
of torture in the late 1970s and early 1980s. The Indochinese
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
Steel, Steel, and Silove
conflict and the concurrent political instability in South and Latin
America (Allodi, 1980) during the mid- to late 1970s proved to
be historic watersheds. The psychiatric focus gained impetus by
reports such as those by Murphy (1977); Kinzie, Fredrickson, Ben,
Fleck, and Karls (1984); Westermeyer, Vang, and Neider (1983);
and Mollica, Wyshak, and Lavelle (1987) that provided early ac-
counts of the mental health of war-affected and displaced South
East Asian refugees. Specialist psychiatric clinics for Indochinese
refugees resettled to the United States were established soon there-
after (Kinzie, Tran, Breckenridge, & Bloom, 1980; Mollica et al.,
1987).
From a clinical perspective, the delineation of the diagnosis of
PTSD offered mental health researchers and human rights advo-
cates alike a new tool to document and quantify the psychological
consequences associated with human rights abuses and organized
violence. By the mid-1980s, detailed descriptions of the posttrau-
matic symptom presentations of Indochinese refugees began to
appear in the literature based particularly on the experiences of
Cambodian survivors of the Pol Pot genocide (Kinzie et al., 1984;
Mollica et al., 1987). In parallel, clinical surveys of torture vic-
tims identified clear evidence of PTSD presentations (Goldfeld
et al., 1988; Weisaeth, 1989). This first wave of research in the
post-PTSD era was soon extended beyond Western countries to
displaced populations residing in refugee camps and postconflict
settings (Mollica et al., 1993). Strong partnerships emerged be-
tween mental health and international humanitarian and human
rights NGOs in a combined approach to protect human rights and
mental health, often with PTSD being a key point of convergence
across the two domains. Political and therapeutic concerns were
clearly inextricably intertwined from the beginning (Cienfuegos &
Monelli, 1983), taking notions of trauma, PTSD, and other post-
traumatic psychiatric outcomes such as depression, into a broader
humanitarian arena beyond the merely medical (Breslau, 2004).
Hence, it may be argued that the introduction of concepts of
trauma and PTSD provided a scientific framework for describing
and quantifying the suffering of displaced and conflict-affected
persons on the global stage, hence providing a strong scientific
foundation for human rights concerns (Breslau, 2004). From a re-
search perspective, momentum in the field created a model for what
Miller, Kulkarni, and Kushner (2006) has described as trauma-
focused psychiatric epidemiology. The upsurge in studies within
this framework published in recent years (Steel et al., 2009) is testi-
mony to the powerful role that psychiatric documentation can play
in raising awareness about the nature, extent, and consequences of
mass human rights abuse.
SECOND-GENERATION RIGHTS: ASYLUM
SEEKERS AND POLICIES OF DETERRENCE
Until the late 1980s, there appeared to be a consensus (and systems
of mutual support) between Western governments and mental
 Human Rights and the Trauma Model
health professionals working with refugee communities affected
by human rights abuses. Dissonance began to appear, however, in
the early to mid-1990s when several Western countries, and Aus-
tralia in particular, began to pursue policies aimed at limiting the
influx of asylum seekers (Silove, Steel, & Watters, 2000). The new
policies of deterrence involved the curtailing of freedoms associ-
ated with civil and political rights, but also extended to violations
of second-generation rights: the right to health, to economic free-
dom, to a reasonable standard of living, and to a positive future.
Substantive restrictions imposed on asylum seekers have included
limitations on work rights, access to welfare support, housing,
health care, and legal support. In several countries asylum seekers
have found themselves destitute or highly dependant on charita-
ble organizations for daily living needs (Silove et al., 2000). Such
restrictions represent a violation of rights that are enshrined in the
International Covenant on Economic, Social and Cultural Rights,
which puts governments under specific obligations to ensure that
all persons, without discrimination, have access to an adequate
standard of living including the right to work, health care, food,
security, housing and family life (Hall, 2006).
In Australia, the government of the time contested the assertion
by mental health professionals that these restrictions were injuri-
ous to the mental health of asylum seekers (Silove, McIntosh, &
Becker, 1993). This challenge extended the focus of the trauma-
focused psychiatric epidemiology movement to a consideration of
the posttraumatic and postmigration factors (relevant to second-
generation rights) that affected the mental health of asylum seek-
ers. In essence, researchers began to test a retraumatization model
in which postmigration, policy-related experiences, such as in-
secure residency, poverty, unemployment, and restricted access
to health care (Schweitzer, Melville, Steel, & Lacherez, 2006;
Steel, Silove, Bird, McGorry, & Mohan, 1999) were postulated
to exacerbate the mental health consequences of premigration
trauma.
A further challenge initiated in Australia in 1992 was the intro-
duction of policies of mandatory detention, applied to all unau-
thorized entrants, including asylum seekers, women, and children.
From a human rights perspective, the policy challenged multiple
established principles including those enshrined in instruments re-
flecting first- and second-generation rights. Yet, in the early period
after the introduction of the detention provisions in Australia, the
government of the time dismissed claims that the policy contra-
vened human rights provisions or endangered the mental health
of asylum seekers.
Mounting concerns about the status of asylum seekers moti-
vated researchers in Australia (Mares & Jureidini, 2004; Momartin
et al., 2006; Steel et al., 2004; Steel et al., 2006) and elsewhere
(Ichikawa, Nakahara, & Wakai, 2006; Keller et al., 2003) to ini-
tiate a series of studies that consistently documented high rates of
psychiatric impairment among children and adults held in immi-
gration detention. These studies were supported by the testimony
of health professionals working within the detention centers. The
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
361
consistency of the emerging data generated a growing consensus
among a diversity of health professional interest groups in Australia
that immigration detention was harmful, particularly to children.
Joint advocacy grew across the country to press for a comprehen-
sive review of the detention policy, a process that took several years
to bear some fruit. There seems little doubt, however, that mental
health advocacy based on research following the trauma-focused
psychiatric epidemiology tradition was instrumental in initiating
this process of reform (Austin, Silove, & Steel, 2007).
The Australian context provides an important example of the
indivisibility and interaction of the generations of rights. In some
settings, it is possible to trace a pattern in which the denial of
first-generation rights provides a rationale for eroding second-
generation rights. This pattern has been clearly evident for asylum
seekers in the United States, the United Kingdom, and through-
out many European States (Malloch & Stanley, 2005; Welch &
Schuster, 2005). In these settings, challenges to the right to pro-
tection against state-sponsored abuses have been extended to the
curtailment of basic freedoms and economic and social rights,
based on claims that asylum seekers are a burden on the host soci-
ety. This case example illustrates the importance of mental health
professionals advocating equally for first- and second-generation
rights, with the latter being of particular importance to marginal-
ized and disadvantaged communities.
THIRD-GENERATION RIGHTS: CROSS-CULTURAL
RESPONSES
As the trauma model gained ascendancy in the psychiatric liter-
ature, so did a growing critique of its application, particularly in
relation to issues that are central to the third generation of human
rights. The key concern expressed was that the uncritical appli-
cation of a Western-derived psychiatric model, with its focus on
the individual and with trauma at its center, could undermine the
fundamental tenets on which many indigenous societies are built.
In particular, one such tenet is the collective construction of expe-
riences of suffering and associated communal strategies to achieve
recovery from epochs of mass conflict (Kleinman, 1995).
The critique has drawn on developments associated with the
“new cross-cultural psychiatry” movement that emerged during the
late 1970s (Kleinman, 1977; Littlewood, 1990). That perspective
highlighted the danger of the “category fallacy” namely, the as-
sumption that the concepts and diagnostic categories of Western
societies can be applied seamlessly to other cultures (Kleinman,
1977). Instead, it is argued that the views and experiences of
distress of culturally diverse societies should be understood from
within the indigenous framework. In particular, it has been argued
that the very concept of trauma and in particular the category of
PTSD may not have universal validity, equivalence of meaning,
or impact on psychosocial functioning across cultures (Bracken
et al., 1995). From this vantage point, PTSD may be regarded as a
362 Steel, Steel, and Silove
“culture-bound” syndrome, whose genesis is traceable to the socio-
historical context prevailing in the United States during an epoch
when advocacy for the recognition of the suffering of stigmatized
Vietnam War veterans became an overweening imperative (Young,
1995). The counter argument points to descriptors of elements of
the PTSD reaction dating back at least to the mid-19th century
(Kinzie & Goetz, 1996; Wilson, 1994). This position also cautions
that the absence of a cultural designation for conditions such as
PTSD or depression does not mean that the relevant constellation
of symptoms is not associated with suffering and/or that key symp-
toms are not recognized by members of that community (Murphy,
1976). The debate between proponents of a universalist trauma
model and its critics has at times become fiercely polarized in a
way that risks obscuring the important humanitarian implications
behind the ongoing controversy (Cabrera-Abreu, 2001; Cohen,
2001; Shalev, 2001; Summerfield, 2001). We consider therefore
whether and to what extent the trauma model may inadvertently
come into conflict with third-generation rights so that the field is
able to adapt appropriately to any legitimate concerns.
Although concerns about the colonial and postcolonial disem-
powerment of indigenous peoples worldwide has a long legacy, it
is only recently that a substantive international legal regime has
been established, embodied in the UN Declaration on the Rights
of Indigenous Peoples (2007). Some of the rights enshrined in this
declaration refer directly to areas that are relevant to mental health,
such as the right to shape the development of health programs and
to maintain access to traditional healing practices.
Indigenous healing systems may differ substantially from
the approaches to treatment popularized by the trauma model
(Kleinman, 1995). Although knowledge is incomplete in this area,
it does seem that PTSD-like syndromes are often not distinguished
from other mental health syndromes in indigenous cultures. For
example, a comprehensive range of terms used by the people of
Timor Leste (East Timor) to describe mental illness do not clearly
map to Western diagnostic categories such as PTSD. (Silove et al.,
2008). Hence, an important tension exists. Although the Timo-
rese can readily endorse symptoms of PTSD if asked, and though
those symptoms are associated with ongoing functional impair-
ment (Silove et al., 2008), a genuine respect for third-generation
rights requires that researchers value, identify, record, and attempt
to understand local constructs where possible. A sole focus on
PTSD may contribute to the undermining of indigenous models
and belief systems in a way that accelerates the alienation of com-
munities from their heritage of healing. There is a commensurate
danger in conceptualizing the trauma experienced by communi-
ties solely in terms of the psychological reactions of the individual,
when in many cultures suffering may be viewed as a complex social,
historical, and political event with multiple meanings.
Hence, there is an evident imperative for an ongoing consen-
sus among professionals in the trauma field to be knowledgeable
about and respectful of the principles enshrined in the Declara-
tion on the Rights of Indigenous Peoples. In essence, these dictate
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
that mental health researchers and clinicians approach work with
refugee and conflict-affected populations in a manner that is fun-
damentally rooted in the local cultural context and in a way that is
genuinely respectful of the rights of participant communities. In
practical terms, this means that the community needs to partici-
pate in giving direction to, and to share ownership of, research and
therapeutic activities. To achieve these outcomes, mental health
practitioners need to be mindful of the immense power differen-
tials that exist between them, in terms of material resources as well
as scientific skills, and those available to most indigenous coun-
terparts working on joint programs, a disparity accentuated by
the fracture of indigenous social structures arising from conflict.
The priority to defend indigenous rights in such settings places
a high level of obligation on practitioners entering local worlds
from other cultures. Mental health practitioners and researchers
need to give central attention to the values of the local world, ac-
cord genuine and deep respect for established cultural knowledge,
and develop strategies to work in an effective relationship with
indigenous healing systems.
In practice this does not preclude assessing morbidity by apply-
ing Western psychiatric methods, especially as persons experienc-
ing chronic PTSD symptoms often go unacknowledged despite
their substantial disabilities and suffering; in that respect, the ab-
sence of a cultural “label” to identify their suffering may result
in the neglect of their needs. A consideration of third-generation
rights instead calls for a complementary or integrative process of
incorporating local understandings and approaches in a manner
that strives for a synthesis of knowledge that is consistent with the
historical, cultural, and political context (Kleinman, 1987).
A growing number of investigators have commenced the task
of addressing the need to reconcile the trauma model with cultural
constructs and other elements of third-generation rights. Hinton
and colleagues have described culturally specific conditions such
as “hit by the wind” experienced by Vietnamese refugees (Hinton,
Hinton, Pham, Chau, & Tran, 2003), and “weak heart” syndrome
among Cambodians (Hinton, Hinton, Um, Chea, & Sak, 2002).
Their detailed investigations allow some bridging of the gap be-
tween Western and indigenous concepts of trauma-related disor-
der. Patel and colleagues have incorporated cultural considerations
into a number of relevant studies, such as an investigation of ex-
planatory models of common mental disorders in Harare (Patel,
Gwanzura, Simunyu, Mann, & Lloyd, 1995); and an examina-
tion of a local Shona idiom of distress—Kufungisisa (thinking
too much; Patel, Simunyu, & Gwanzura, 1995) or more recently
through the use of case vignettes to document the prevalence of
serious mental disorder in a population survey in Mozambique
(Patel, Simbine, Soares, Weiss, & Wheeler, 2007). Bolton and
colleagues (Bolton, 2001; Bolton, Wilk, & Ndogoni, 2004) ap-
plied ethnographic field work to adapt the depression scale of the
Hopkins Symptom Checklist using indigenously defined cases of
a grief syndrome, agahinda gakabije, in Rwanda and a depres-
sion syndrome, Yo’kwekyawa, in Uganda. The research team also
 Human Rights and the Trauma Model
developed an indigenous measure of functional impairment on
the basis of the ability to perform culturally important tasks and
responsibilities (Bolton & Tang, 2002). In an epidemiological
study of mental health needs in Timor Leste, Silove et al. (2008)
utilized indigenous terms for mental illness to identify cases, along-
side a Western-derived set of psychiatric screening tools. Among
Vietnamese in Australia and Vietnam we have combined indige-
nous and Western diagnostic models to improve case identifica-
tion and to map the effects of acculturation (Steel et al., 2009).
Notwithstanding the intricacies involved in approaches that com-
bine anthropological and epidemiological methods, and the in-
cunabular state of research in this specific field, this direction of
research may offer creative ways and the development of novel
methodologies that bridge all three generations of rights and key
mental health concerns.
A final issue that we wish to raise—and one that is worthy of
future elaboration—is that mental health indices should not be ex-
tended to the point that they supplant core human rights principles
in deciding whether a violation has occurred or not. An example of
this tendency to overmedicalize human rights is the contemporary
debate on torture where the psychological element—the degree of
pain and suffering inflicted—formed the basis of arguments ad-
vanced by the U.S. State Department to determine whether harsh
interrogation techniques could be used without breaching human
rights provisions. The implication of this line of argument is that
whether an act constitutes torture or not depends substantially on
demonstrating adverse psychological consequences. Clearly, there
are extreme dangers in this tendency as noted by Basoglu, Livanou,
and Crnobaric (2007). It is our view that even in settings where
adverse mental consequences are common and severe, as is the case
for torture, decisions as to whether the violation occurred or not
should be based entirely on human rights considerations, not on
medical or psychiatric outcomes.
CONCLUSION
The imperative to recognize and respect human rights remains a
critical focus for mental health professionals working in the trauma
field. In the present overview, we suggest that these professionals
may be more familiar with transgressions of first-generation rights,
for example, relating to abuses such as torture. As indicated by re-
cent work with asylum seekers, there is a growing need to be
cognizant of and focus on second-generation rights relating to so-
cial and economic well-being and how these interact with exposure
to past trauma relevant to first-generation rights. Recognition that
violations can lead to a progressive erosion of rights extending into
multiple generations of rights, as has occurred with asylum seek-
ers, serves to forewarn trauma professionals of the vulnerabilities
of the populations relevant to their work. Early identification of
this progressive process of erosion of different levels of rights may
be instrumental in preventing the most damaging forms of human
rights abuse by state authorities. Health professionals must also be
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
363
cognizant of the dangers of relying too heavily on mental health
evidence to test claims of human rights violations. Although they
are a potentially important tool for advocacy, the obligations on
state parties to protect and enable the fulfillment of human rights
are sufficient in themselves without resort to consequentialist ar-
guments relating to adverse health or mental health outcomes. We
have highlighted the special issues for the trauma field in relation
to third-generation rights, particularly when working across cul-
tures. Trauma workers in these contexts need to give particular
consideration to the world views and concepts of healing that are
particular to each context. Creativity and innovation are needed to
bring together constructs and expertise derived from Western set-
tings and those that are inherent in indigenous cultures, a careful
process that should not inadvertently risk undermining the very
rights to care and recovery for populations that professionals in the
field aim to promote.
REFERENCES
Allodi, F. A. (1980). The psychiatric effects in children and families of victims of
political persecution and torture. Danish Medical Bulletin, 27, 229–232.
Almedom, A. M., & Summerfield, D. (2004). Mental well-being in settings of
‘complex emergency’: An overview. Journal of Biosocial Science, 36, 381–388.
American Psychiatric Association. (1980). Diagnostic and statistical manual of
mental disorders (3rd ed.). Washington, DC: Author.
Amnesty International. (1977). Evidence of torture: Studies of the Amnesty Inter-
national Danish Medical Group (No. PUB 72/00/77). London: Author.
Austin, P., Silove, D., & Steel, Z. (2007). The impact of immigration detention on
the mental health of asylum seekers. In D. Lusher & N. Haslam (Eds.), Seek-
ing asylum in Australia: Yearning to breathe free (pp. 100–112). Melbourne,
Australia: Melbourne Federation Press.
Basoglu, M., Livanou, M., & Crnobaric, C. (2007). Torture vs other cruel, inhu-
man, and degrading treatment: Is the distinction real or apparent? Archives of
General Psychiatry, 64, 277–285.
Bolton, P. (2001). Cross-cultural validity and reliability testing of a standard psy-
chiatric assessment instrument without a gold standard. Journal of Nervous &
Mental Disease, 189, 238–242.
Bolton, P., & Tang, A. M. (2002). An alternative approach to cross-cultural function
assessment. Social Psychiatry & Psychiatric Epidemiology, 37, 537–543.
Bolton, P., Wilk, C. M., & Ndogoni, L. (2004). Assessment of depression preva-
lence in rural Uganda using symptom and function criteria. Social Psychiatry
& Psychiatric Epidemiology, 39, 442–447.
Bracken, P. J., Giller, J. E., & Summerfield, D. (1995). Psychological responses
to war and atrocity: The limitations of current concepts. Social Science &
Medicine, 40, 1073–1082.
Breslau, J. (2004). Cultures of trauma: Anthropological views of posttraumatic
stress disorder in international health. Culture, Medicine & Psychiatry, 28,
113–126.
Cabrera-Abreu, C. (2001). Post-traumatic stress disorder–Questions about current
status of psychiatric classification systems arise. British Medical Journal, 322,
1303.
Cienfuegos, A. J., & Monelli, C. (1983). Testimony of political repression as a
therapeutic instrument. American Journal of Orthopsychiatry, 53, 43–51.
Cmiel, K. (2004). The recent history of human rights. American Historical Review,
109, 117–135.
364 Steel, Steel, and Silove
Cohen, J. (2001). Post-traumatic stress disorder–Doctors should relieve suffering
not debate its existence. British Medical Journal, 322, 1301–1302.
Goldfeld, A. E., Mollica, R. F., Pesavento, B. H., & Faraone, S. V. (1988). The
physical and psychological sequelae of torture: Symptomatology and diagnosis.
Journal of the American Medical Association, 259, 2725–2729.
Gruskin, S., Mills, E. J., & Tarantola, D. (2007). History, principles, and practice
of human rights. Lancet, 370, 449–455.
Gruskin, S., & Tarantola, D. (2005). Health and human rights. In S. Gruskin, M.
Grodin, S. Marks, & G. Annas (Eds.), Perspectives on health and human rights
(pp. 3–58). New York: Routledge.
Hall, P. (2006). Failed asylum seekers and health care: Current regulations flout
international law. British Medical Journal, 333, 109–110.
Hinton, D., Hinton, S., Pham, T., Chau, H., & Tran, M. (2003). ‘Hit by the
Wind’ and temperature-shift panic among Vietnamese refugees. Transcultural
Psychiatry, 40, 342–376.
Hinton, D., Hinton, S., Um, K., Chea, A., & Sak, S. (2002). The Khmer ‘Weak
Heart’ syndrome: Fear of death from palpitations. Transcultural Psychiatry, 39,
323–344.
Ichikawa, M., Nakahara, S., & Wakai, S. (2006). Effect of post-migration detention
on mental health among Afghan asylum seekers in Japan. Australian & New
Zealand Journal of Psychiatry, 40, 341–346.
Iyall Smith, K. E. (2008). Comparing state and international protections of in-
digenous peoples’ human rights. American Behavioral Scientist, 51, 1817–
1835.
Keller, A. S., Rosenfeld, B., Trinh-Shevrin, C., Meserve, C., Sachs, E., Leviss,
J. A., et al. (2003). Mental health of detained asylum seekers. Lancet, 362,
1721–1723.
Kinzie, J. D., Fredrickson, R. H., Ben, R., Fleck, J., & Karls, W. (1984). Post-
traumatic stress disorder among survivors of Cambodian concentration camps.
American Journal of Psychiatry, 141, 645–650.
Kinzie, J. D., & Goetz, R. R. (1996). A century of controversy surrounding
posttraumatic stress-spectrum syndromes: The impact on DSM-III and DSM-
IV. Journal of Traumatic Stress, 9, 159–179.
Kinzie, J. D., Tran, K. A., Breckenridge, A., & Bloom, J. D. (1980). An Indochinese
refugee psychiatric clinic: Culturally accepted treatment approaches. American
Journal of Psychiatry, 137, 1429–1432.
Kirkup, A., & Evans, T. (2009). The myth of Western opposition to economic,
social and cultural rights? A reply to Whelan and Donnelly. Human Rights
Quarterly 31, 221–238.
Kleinman, A. (1987). Anthropology and psychiatry: The role of culture in
cross-cultural research on illness. British Journal of Psychiatry, 151, 447–
454.
Kleinman, A. (1995). Violence, culture, and the politics of trauma. In A. Klein-
man (Ed.), Writing at the margin (pp. 173–192). Berkeley, CA: University of
California Press.
Kleinman, A. M. (1977). Depression, somatization and the “new cross-cultural
psychiatry.” Social Science & Medicine, 11, 3–10.
Littlewood, R. (1990). From categories to contexts: A decade of the
‘new cross-cultural psychiatry’. British Journal of Psychiatry, 156, 308–
327.
Malloch, M. S., & Stanley, E. (2005). The detention of asylum seekers in the
UK—Representing risk, managing the dangerous. Punishment & Society,
International Journal of Penology, 7, 53–71.
Mares, S., & Jureidini, J. (2004). Psychiatric assessment of children and families in
immigration detention: Clinical, administrative and ethical issues. Australian
& New Zealand Journal of Public Health, 28, 520–526.
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
Miller, K. E., Kulkarni, M., & Kushner, H. (2006). Beyond trauma-focused psy-
chiatric epidemiology: Bridging research and practice with war-affected popu-
lations. American Journal of Orthopsychiatry, 76, 409–422.
Mollica, R. F., Donelan, K., Tor, S., Lavelle, J., Elias, C., Frankel, M.,
et al. (1993). The effect of trauma and confinement on functional health
and mental health status of Cambodians living in Thailand-Cambodia
border camps. Journal of the American Medical Association, 270, 581–
586.
Mollica, R. F., Wyshak, G., & Lavelle, J. (1987). The psychosocial impact of
war trauma and torture on Southeast Asian refugees. American Journal of
Psychiatry, 144, 1567–1572.
Momartin, S., Steel, Z., Coello, M., Aroche, J., Silove, D., & Brooks, R. (2006). A
comparison of the mental health of refugees with temporary versus permanent
protection visas. Medical Journal of Australia, 185, 357–361.
Murphy, J. M. (1976). Psychiatric labeling in cross-cultural perspective. Science,
191, 1019–1028.
Murphy, J. M. (1977). War stress and civilian Vietnamese: A study of the psycho-
logical effects. Acta Psychiatrica Scandinavica, 56, 92–108.
Patel, V., Gwanzura, F., Simunyu, E., Mann, A., & Lloyd, K. (1995). The ex-
planatory models and phenomenology of common mental disorder in Harare,
Zimbabwe. Psychological Medicine, 25, 1191–1199.
Patel, V., Simbine, A. P. F., Soares, I. C., Weiss, H. A., & Wheeler, E. (2007).
Prevalence of severe mental and neurological disorders in Mozambique: A
population-based survey. Lancet, 370, 1055–1060.
Patel, V., Simunyu, E., & Gwanzura, F. (1995). Kufungisisa (thinking too much):
A Shona idiom for non-psychotic mental illness. Central African Journal of
Medicine, 41, 209–215.
Pupavac, V. (2006). Humanitarian politics and the rise of international diaster. In
G. Reyes & G. A. Jacobs (Eds.), Handbook of international disaster psychology
(Vol. 1, pp. 15–34). Westport, CT: Praeger.
Rasmussen, O. V., & Lunde, I. (1980). Evaluation of investigation of 200 torture
victims. Danish Medical Bulletin, 27, 241–243.
Robertson, G. (2006). Crimes against humanity—The struggle for global justice
(3rd ed.). New York: New Press.
Schweitzer, R., Melville, F., Steel, Z., & Lacherez, P. (2006). Trauma, post-migration
living difficulties, and social support as predictors of psychological adjustment
in resettled Sudanese refugees. Australian & New Zealand Journal of Psychiatry,
40, 179–187.
Shalev, A. Y. (2001). Post-traumatic stress disorder–Disorder takes away human
dignity and character. British Medical Journal, 322, 1301.
Silove, D., Bateman, C., Brooks, R., Zulmira, F. C. A., Steel, Z., Rodger, J., et al.
(2008). Estimating clinically relevant mental disorders in a rural and urban
setting in post-conflict Timor Lest. Archives of General Psychiatry, 65, 1205–
1212.
Silove, D., McIntosh, P., & Becker, R. (1993). Risk of retraumatisation of asylum-
seekers in Australia. Australian & New Zealand Journal of Psychiatry, 27,
606–612.
Silove, D., Steel, Z., & Watters, C. (2000). Policies of deterrence and the mental
health of asylum seekers. Journal of the American Medical Association, 284,
604–611.
Silove, D., Tarn, R., Bowles, R., & Reid, J. (1991). Psychosocial needs of torture
survivors. Australian & New Zealand Journal of Psychiatry, 25, 481–490.
Steel, Z., Chey, T., Silove, D., Marnane, C., Bryant, R. A., & van Ommeren,
M. (2009). Association of torture and other potentially traumatic events with
mental health outcomes among populations exposed to mass conflict and
displacement: A systematic review and meta-analysis. Journal of the American
Medical Association, 302, 537–549.
 Human Rights and the Trauma Model
Steel, Z., Momartin, S., Bateman, C., Hafshejani, A., Silove, D. M., Everson, N.,
et al. (2004). Psychiatric status of asylum seeker families held for a protracted
period in a remote detention centre in Australia. Australian & New Zealand
Journal of Public Health, 28, 527–536.
Steel, Z., Silove, D., Bird, K., McGorry, P., & Mohan, P. (1999). Pathways
from war trauma to posttraumatic stress symptoms among Tamil asylum
seekers, refugees, and immigrants. Journal of Traumatic Stress, 12, 421–
435.
Steel, Z., Silove, D., Brooks, R., Momartin, S., Alzuhairi, B., & Susljik, I.
(2006). Impact of immigration detention and temporary protection on
the mental health of refugees. British Journal of Psychiatry, 188, 58–
64.
Steel, Z., Silove, D., Giao, N. M., Phan, T. T. B., Chey, T., Whelan, A., et al.
(2009). International and indigenous diagnoses of mental disorder amongst
Vietnamese living in Vietnam and Australia. British Journal of Psychiatry, 194,
326–333.
Summerfield, D. (2001). The invention of post-traumatic stress disorder and
the social usefulness of a psychiatric category. British Medical Journal, 322,
95–98.
Tarantola, D., Byrnes, A., Johnson, M., Kemp, L., Zwi, A., & Gruskin, S. (2008).
Human rights, health and development. Australian Journal of Human Rights,
13, 1–32.
Twiss, S. B. (2004). History, human rights and globalization. Journal of Religious
Ethics, 32, 39–70.
United Nations (1948). Universal Declaration of Human Rights. New York:
Author.
United Nations (1966/1976). International Covenant on Economic, Social and
Cultural Rights. New York: Author.
United Nations (1966/1976). International Covenant on Civil and Political Rights.
New York: Author.
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
365
United Nations (1975). Declaration on the Protection of All Persons from Being
Subjected to Torture and Other Cruel, Inhuman or Degrading Treatment or
Punishment. New York: Author.
United Nations (1984/1987). Convention against Torture and Other Cruel, Inhu-
man or Degrading Treatment or Punishment. New York: Author.
United Nations (1989/1990). Convention on the Rights of the Child. New York:
Author.
United Nations (2006). Convention on the Rights of Persons with Disabilities.
New York: Author.
United Nations (2007). United Nations Declaration on the Rights of Indigenous
Peoples. New York: Author.
Weisaeth, L. (1989). Torture of a Norwegian ship’s crew: The torture, stress reac-
tions and psychiatric after-effects. Acta Psychiatrica Scandinavica, 355(Suppl.),
63–72.
Welch, M., & Schuster, L. (2005). Detention of asylum seekers in the UK and
USA—Deciphering noisy and quiet constructions. Punishment & Society,
International Journal of Penology, 7, 397–417.
Welling, J. V. (2008). International indicators and economic, social, and cultural
rights. Human Rights Quarterly, 30, 933–958.
Westermeyer, J., Vang, T. F., & Neider, J. (1983). Refugees who do and do not seek
psychiatric care. An analysis of premigratory and postmigratory characteristics.
Journal of Nervous & Mental Disease, 171, 86–91.
Whelan, D. J., & Donnelly, J. (2007). The West, economic and social rights, and
the global human rights regime: Setting the record straight. Human Rights
Quarterly, 29, 908–949.
Wilson, J. P. (1994). The historical evolution of PTSD diagnostic criteria: From
Freud to DSM-IV. Journal of Traumatic Stress, 7, 681–698.
Young, A. (1995). The harmony of illusions: Inventing post-traumatic stress dis-
order. Princeton, NJ: Princeton University Press.