Trauma Rehabilitation After War and Conflict: Community and Individual Perspectives

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Trauma Rehabilitation After War and Conflict

Erin Martz Editor

Trauma Rehabilitation After War and Conflict Community and Individual Perspectives

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Editor Erin Martz Rehability Portland, OR USA [email protected]

ISBN 978-1-4419-5721-4 e-ISBN 978-1-4419-5722-1 DOI 10.1007/978-1-4419-5722-1 Springer New York Dordrecht Heidelberg London Library of Congress Control Number: 2010923780 © Springer Science+Business Media, LLC 2010 All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com)

Reflections on Healing

How people survive in a circle of hell I’ll never know. How they trust again in the human family I’ll never know. How they can smile once more after seeing evil deeply and repeatedly I’ll never know. How they let the horrors fade and live for the future I’ll never know. How they learn to trust themselves again and find their voices– this I know. Erin Martz

Acknowledgments

A researcher meets many minds along the path of investigation. While the ideational influence of many researchers is acknowledged by citations in this book, other individuals have been influential by their interaction with me at various stages of the development of this book; these include, but are limited to, the following people. I would like to thank the Organization of the Security and Co-operation in Europe (OSCE) in the Czech Republic for opening their archives to me during my time as a Researcher-in-Residence in the summer of 2008 and to thank Alice Nemcova at OSCE for her enthusiastic help. I would also like to thank Dr. Pam Cogdal for encouraging me to move forward with the idea that I had for this book in 2007, which was at a time when I did not want to tackle such a new mountain. I would also like to thank Samantha Daniel, who helped me retrieve some articles and books for this research. Thanks are due to Jennifer Hadley (the current) and Carol Bischoff (the previous), Senior Editor at Springer of New York; they both have been friendly and supportive during the writing of both of my books. Thanks also are due to Dr. Hanoch Livneh for providing valuable feedback on Chapter 2 (by Martz and Lindy). Thanks also go to friends (Hanoch, Catherine, Zehavit, Kakali among numerous others), for their support, humor, and memorable conversations during the 3-year process of creating this book. I would like to thank my parents for providing encouragement and creating earlylife conditions, in which I could expand my mind, absorb ideas, and eventually explore the international sphere (even though the latter may have caused them a lot of anxiety); I am dedicating this book to them out of appreciation. And a hearty thank-you goes to all of the chapter authors for their dedication and hard work— I learned a lot from you! Echoes of the horror of war prompted my writing of the preceding poem called “Reflections on Healing” that seemingly ‘fell out’ of me after visiting a former site of World War II atrocities.

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Contents

1 Introduction to Trauma Rehabilitation After War and Conflict . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Erin Martz 2 Exploring the Trauma Membrane Concept . . . . . . . . . . . . . Erin Martz and Jacob Lindy

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3 Forgiveness and Reconciliation in Social Reconstruction After Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Everett L. Worthington and Jamie D. Aten

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4 A Public-Health View on the Prevention of War and Its Consequences . . . . . . . . . . . . . . . . . . . . . . . . . . Joop T. de Jong

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5 Community-Based Rehabilitation in Post-conflict and Emergency Situations . . . . . . . . . . . . . . . . . . . . . . . Arne H. Eide

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6 A Systems Approach to Post-conflict Rehabilitation . . . . . . . . . Steve Zanskas

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7 Human Physical Rehabilitation . . . . . . . . . . . . . . . . . . . . Pia Rockhold

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8 Psychological Rehabilitation for US Veterans . . . . . . . . . . . . Thomas A. Campbell, Treven C. Pickett, and Ruth E. Yoash-Gantz

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9 Psychological Rehabilitation of Ex-combatants in Non-Western, Post-conflict Settings . . . . . . . . . . . . . . . . Anna Maedl, Elisabeth Schauer, Michael Odenwald, and Thomas Elbert 10

Psychosocial Rehabilitation of Civilians in Conflict-Affected Settings . . . . . . . . . . . . . . . . . . . . . . Laura McDonald

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Contents

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Shame and Avoidance in Trauma . . . . . . . . . . . . . . . . . . . K. Jessica Van Vliet

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Psychosocial Adjustment and Coping in the Post-conflict Setting . . . . . . . . . . . . . . . . . . . . . . . Erica K. Johnson and Julie Chronister

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Helping Individuals Heal from Rape Connected to Conflict and/or War . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Meghan E. McDevitt-Murphy, Laura B. Casey, and Pam Cogdal

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The Psychological Impact of Child Soldiering . . . . . . . . . . . . Elisabeth Schauer and Thomas Elbert

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The Toll of War Captivity: Vulnerability, Resilience, and Premature Aging . . . . . . . . . . . . . . . . . . . . . . . . . . Zahava Solomon and Avi Ohry

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Trauma-Focused Public Mental-Health Interventions: A Paradigm Shift in Humanitarian Assistance and Aid Work . . . Maggie Schauer and Elisabeth Schauer

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Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Contributors

Jamie D. Aten University of Southern Mississippi, Hattiesburg, MS, USA, [email protected] Thomas A. Campbell VA Medical Center, Richmond, VA, USA, [email protected] Laura B. Casey University of Memphis, Memphis, TN, USA, [email protected] Julie Chronister Department of Counseling, San Francisco State University, San Francisco, CA, USA, [email protected] Pam Cogdal University of Memphis, Memphis, TN, USA, [email protected] Joop T. de Jong VU University Medical Center & Boston University School of Medicine, Amsterdam, The Netherlands, [email protected] Arne H. Eide SINTEF Health Research, Oslo, Norway, [email protected] Thomas Elbert University of Konstanz, Konstanz, Germany; vivo International, Konstanz, Germany, [email protected] Erica K. Johnson Western Washington University, Bellingham, WA, USA; University of Washington, Seattle, WA, USA, [email protected] Jacob Lindy University of Cincinnati, Cincinnati, OH, USA, [email protected] Anna Maedl University of Konstanz, Konstanz, Germany, [email protected] Erin Martz Rehability, Portland, OR, USA, [email protected] Meghan E. McDevitt-Murphy University of Memphis, Memphis, TN, USA, [email protected] Laura McDonald Psychiatric Epidemiology, Johns Hopkins University Bloomberg School of Public Health in the Mental Health, Baltimore, MD, USA, [email protected]

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Contributors

Michael Odenwald University of Konstanz, Konstanz, Germany, [email protected] Avi Ohry Tel Aviv University, Tel Aviv, Israel, [email protected] Treven C. Pickett VA Medical Center, Richmond, VA, USA, [email protected] Pia Rockhold Consultant to World Bank and EU; Chair of the North South Group for Poverty Reduction, Ashton, MD, USA, [email protected] Elisabeth Schauer Department of Psychology, University of Konstanz, Konstanz, Germany; vivo International, Konstanz, Germany, [email protected] Maggie Schauer Center for Psychiatry Reichenau, University Konstanz, Konstanz, Germany, [email protected] Zahava Solomon Tel-Aviv University, Ramat-Aviv, Israel, [email protected] K. Jessica Van Vliet University of Alberta, Edmonton, AB, Canada, [email protected] Everett L. Worthington, Jr. Virginia Commonwealth University, Richmond, VA, USA, [email protected] Ruth E. Yoash-Gantz VA Medical Center, Salisbury, NC, USA, [email protected] Steve Zanskas The University of Memphis, Memphis, TN, USA, [email protected]

About the Contributors

Jamie D. Aten, Ph.D., is an assistant professor of counseling psychology in the Department of Psychology at the University of Southern Mississippi. He is the co-editor of Spirituality and the Therapeutic Process: A Comprehensive Resource from Intake Through Termination (2008). He also served as the representative to the Committee on Early Career Psychologists and currently serves as Newsletter Editor for Division 36 (Psychology of Religion) of the American Psychological Association. His current research on the role of faith communities in overcoming disaster mental health disparities is being supported by grants from the Department of Health and Human Services, Pew Charitable Trusts, Episcopal General Convention, United Jewish Communities, and Foundation for the Mid South. Thomas Campbell, Ph.D., is a rehabilitation neuropsychologist in the TBI/Polytrauma Rehabilitation Center of the McGuire VA Medical Center in Richmond, Virginia, and is an affiliate professor in the Department of Psychology at Virginia Commonwealth University. He graduated from Virginia Commonwealth University with a degree in Clinical Psychology and also trained at the Minneapolis VA Medical Center. He is actively involved in research examining the effects of PTSD and mild and moderate TBI on neuropsychological and psychological functioning in veterans and active-duty service members. Laura Baylot Casey, Ph.D., BCBA, NCSP, NCC, is an assistant professor of special education at the University of Memphis. She is co-director of the applied behavior analysis program at the University of Memphis and on the board of directors of the Autism Society of the Mid-south. Research interests include parents’ experiences related to raising a child with autism, PTSD in parents of children with disabilities, applied behavior analysis in the classroom, and assessment/intervention of disabilities in written expression. Julie Chronister, Ph.D., is an assistant professor in the Department of Counseling at San Francisco State University, where she is the coordinator of the rehabilitation counselor training program and project director for a RSA long-term rehabilitation counselor training grant. She is co-editor of the book, Understanding Psychosocial Adjustment to Chronic illness and Disability: A Handbook for

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Evidence-Based Practitioners in Rehabilitation. She received the CSU VicePresidential Scholarship award in 2009 and was awarded the 2009 research award by American Rehabilitation Counseling Association. Her primary research interest is in the area of social support and psychosocial adjustment, particularly, the meaning, measurement, and application of social support within the context of disability. Pam A. Cogdal, Ph.D., is currently the coordinator for clinical practice in counseling at the University of Memphis and coordinates all counseling practica and internship experiences in the Department of Counseling, Educational Psychology, and Research at the University of Memphis. Pam is also a clinical associate professor and co-directs a suicide prevention grant and research laboratory. Previous to this, Dr. Cogdal served as the coordinator for psychological assessment in the Center for Rehabilitation and Employment Research and also served 8 years as the director and chief psychologist for the campus’ counseling center. Throughout her career Dr. Cogdal has contributed to a number of publications and national presentations related to career, trauma, women’s issues, resilience, and coping. Joop T.V. de Jong, M.D., Ph.D., is professor of cultural and international psychiatry at the VU University in Amsterdam and adjunct professor of psychiatry at Boston University School of Medicine. He is Principal Advisor of Socio-medical Projects and Public Mental Health of the Amsterdam Municipality. He was the founder and director of the Transcultural Psychosocial Organization, an NGO that developed psychosocial and mental health programs in over 20 countries in Africa, Asia, Europe, and Latin America. Dr. de Jong publishes in the field of cultural psychiatry and psychotherapy, epidemiology, public mental-health, and medical anthropology. Arne H. Eide, Ph.D., is chief scientist at SINTEF, an independent Norwegianbased research foundation. He is also professor in rehabilitation at Sør-Trøndelag University College in Norway and honorary professor at Stellenbosch University, South Africa. His background is from Health and Social Policy and Behavior Epidemiology. Dr. Eide has been engaged in international research collaboration for more than 20 years, in particular in sub-Saharan Africa. His main research interest is disability research, in particular disability statistics. Thomas Elbert, Ph.D., is professor of clinical psychology and neuropsychology at the University of Konstanz, Germany. His publications focus on the self-regulation of the brain and on neuroplasticity and their relation to behavior and psychopathology. In laboratory and field studies, Dr. Elbert examined how adverse conditions and stress affect brain, mind, and behavior via neuroplastic reorganization. Together with his colleagues, Drs. Neuner and Schauer, Dr. Elbert developed Narrative Exposure Therapy (NET), a culturally universal, short-term intervention for the reduction of traumatic stress symptoms in survivors of organized violence, torture, war, rape, and childhood abuse; this treatment has been field tested in war-torn areas. Dr. Elbert has worked in crisis and war-torn regions, such as the Democratic Republic of Congo, Uganda, Somalia, Sri Lanka, and Afghanistan.


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Erica K. Johnson, Ph.D., is an instructor and clinical director of the graduate program in Rehabilitation Counseling at Western Washington University and a researcher with the University of Washington Health Promotion Research Center’s Managing Epilepsy Well Prevention Research Center. Dr. Johnson is a recipient of the Roger F. and Edna F. Evans’ Epilepsy Foundation Pre-doctoral Research Training Fellowship and has received Distinguished Service Awards from the American Psychological Association Division 22 (Rehabilitation Psychology) for her work mentoring students and advancing women’s issues in rehabilitation psychology. Her research and published work is in the areas of neurological disabilities, epilepsy self-management, treatment of depression, vocational, psychosocial, and neuropsychological assessment, and coping and adjustment to disability. Dr. Jacob Lindy, M.D., is professor of psychiatry at the University of Cincinnati and a training and supervising psychoanalyst at the Cincinnati Psychoanalytic Institute, where he has been the director for 8 years. He was previously the clinical director of the University of Cincinnati Traumatic Stress Studies Center and Past President of the International Society for Traumatic Stress Studies. He has edited and co-edited four books, with a fifth in preparation. He is winner of the Harding Hospital award for teaching excellence and the Sarah Haley award for clinical excellence in trauma. Anna Maedl has an M.A. in Conflict Resolution (University of Bradford, 2005), an M.A. in Psychology (University of Bamberg, Germany, 2007, Diplom Psychologe), and is a Ph.D. candidate at the University of Konstanz, Germany. Her main research interests include the psychology of armed groups, and Disarmament, Demobilization, Reintegration (DDR). Her research locations have included the Democratic Republic of Congo, Rwanda, and Somaliland. Erin Martz, Ph.D., C.R.C., the editor of this book, was an associate professor of rehabilitation counseling at the University of Memphis until December 2009. Prior to that, she worked as an assistant professor of rehabilitation counseling at University of Missouri, Columbia. She co-edited a book with Dr. Hanoch Livneh, which was published in 2007, entitled Coping with Chronic Illness and Disability: Theoretical, Empirical, and Clinical Aspects. She received a Fulbright Research Fellowship for Russia from the US Department of State in 2006 and a Switzer Merit Fellowship from the National Institute on Disability and Rehabilitation Research in 2001. Her research interests include the topics of coping with adaptation to disability, disability and employment, and international rehabilitation. Meghan E. McDevitt-Murphy, Ph.D., is a clinical psychologist and an assistant professor of psychology at The University of Memphis. She has studied posttraumatic stress disorder in veteran and civilian populations for over 10 years. She currently conducts research on PTSD and co-occurring substance-use disorders among veterans of the wars in Iraq and Afghanistan. Laura McDonald is a Ph.D. candidate at the Johns Hopkins University Bloomberg School of Public Health in the Mental Health Department (Psychiatric

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Epidemiology). She has a Masters of Arts in Law and Diplomacy (M.A.L.D.) from the Fletcher School of Law and Diplomacy, Tufts University. She has worked in various capacities for the Harvard Program in Refugee Trauma, the World Food Program, and the World Bank. Her main research interest is mental health and psychosocial outcomes among survivors of conflict and effective interventions to address related needs. Michael Odenwald, Dr., Diplom Psychologe, is clinical psychologist and cognitive behavioral therapist and currently leads a research project on addiction among migrants at the University of Konstanz and the Center for Psychiatry in Reichenau, Germany. He has worked in a range of clinical and research settings with populations such as ex-combatants, refugees (in a variety of international settings), and individuals with schizophrenia, addiction, brain injury, epilepsy, and posttraumatic stress disorder (PTSD). His current research interests include PTSD, substance abuse, and psychosis in post-conflict regions and among refugees and migrants in Western countries. He received a 2008 “College on Problems of Drug Dependence” Early Career Investigator Award. Avi Ohry, M.D., is a professor in the Faculty of Medicine at Tel Aviv University, Israel, and is director of Rehabilitation Medicine at Reuth Medical Center in Tel Aviv, a position which he has had since 1999. Dr. Ohry served as the head of the Department of Neurological Rehabilitation at Sheba Medical Center from 1985 to 1999. He has published extensively, including 95 articles and 10 book chapters. His research interests include the following: spinal cord injury, medical ethics, history of medicine, philosophy and medicine, late effects of disabilities and captivity, Jewish–Polish medicine between the World Wars, rehabilitation medicine, and the contribution of physicians to non-medical fields. Treven Pickett, Psy.D., ABPP-RP, is a neuropsychologist and board-certified rehabilitation psychologist at the Richmond VA Medical Center. He has worked clinically on the TBI/Polytrauma Rehabilitation Center since October 2004. Dr. Pickett is currently the Associate Chief and Supervisory Clinical Psychologist for the Mental Health Service at McGuire VA Medical Center. He is a graduate of the Virginia Consortium Program in Clinical Psychology. Fellowships were completed at the Concussion Care Center of Virginia, the Department of Clinical and Health Psychology at the University of Florida, and the VA Brain Rehabilitation Research Center (BRRC). Dr. Pickett holds faculty appointments in Psychology, Psychiatry, and PM&R at Virginia Commonwealth University. His research involvements include serving as Co-Investigator for the Defense and Veterans Brain Injury Center in Richmond and Principal Investigator on a study investigating the neuro-cognitive sequelae of TBI (with and without PTSD). His other research interests include the development of evidence-based treatments for the neuro-cognitive sequelae of TBI. Pia Rockhold, M.D., Ph.D., has a degree in Medicine, a Masters in Public Health, and a Ph.D. in Epidemiology. She is a specialist in Public Health and Epidemiology with over 30 years of experience in International development. She has lived and


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worked in conflict-affected countries in sub-Saharan Africa for over 20 years. During her recent work with the World Bank’s Disability and Development team, she spearheaded a global review of rehabilitation in conflict-affected countries. Elisabeth Schauer has a Ph.D. in Clinical Psychology, M.A. in Education, M.P.H. with a focus on International Health and a post-graduate degree in Adult Education. In addition, she is a certified Client-Centered Counselor, Gestalt-trainer, and Gender Trainer. She has worked for organizations such as UNICEF, UNIFEM, WHO, and UNAIDS in African, Eastern European, Central-, and South-Asian countries. Since 2001, Dr. Elisabeth Schauer has taken over the coordination of vivo, an international NGO that aims at research, prevention, and therapy of the consequences of traumatic stress on conflict-affected individuals and communities. Her interests include the field of psychotraumatology (e.g., implementation of trauma treatment approaches), women and children’s health, violence and human rights, and helping to conceptualize community-based, public mental-health structures after conflict and disasters. Elisabeth is also part of the University of Konstanz, Department of Psychology’s working group on psychotraumatology. Maggie Schauer, Ph.D., heads the Psychological Research and Outpatient Clinic for Refugees at the University Konstanz’ Center for Psychiatry Reichenau. She is a clinical psychologist specializing in the field of psychotraumatology. Dr. Maggie Schauer is a founding member of the NGO vivo and was vice-president of vivo Germany from 2004 to 2008. She has worked both in research and clinical settings and in field missions during and post-conflict and disasters, which includes work in Iran, Macedonia, Romania, Somalia, Thailand, Turkey, Uganda, and among others. She cooperates in projects investigating possible treatments for survivors of extreme and/or prolonged stress (e.g., after torture, genocide, childhood sexual abuse), as well as for the rehabilitation of forensic populations. She also has a clinical and research interest in the transgenerational impact of life stress. Zahava Solomon, Ph.D., is a professor of psychiatric epidemiology and social work at the Tel-Aviv University. Dr. Solomon served as head of the I.D.F (Israeli Defense Force) Research Branch in the Medical Corps between the years 1981 and 1992 and was ranked as lieutenant colonel. During 1994–1996, she was Dean of the Social Work School at Tel-Aviv University and Dean of the special programs at Tel Aviv University from 1997 to 2001. Dr. Solomon has been acting as head of the Adler Center for the Study of Child Welfare and Protection from 1997 to 2009. Her research focuses on traumatic stress, especially the psychological sequel of combat stress reactions, war captivity, and the Holocaust. She has published six books on psychic trauma-related issues, in addition to publishing over 300 articles and more than 60 chapters. Dr. Solomon was a member of the DSM-4 Advisory subcommittee for PTSD and has earned numerous Israeli and international awards and research grants, including the Laufer Award for Outstanding Scientific Achievement in the field of PTSD, presented by the International Society of Traumatic Stress Studies. In 2009, Dr. Solomon was awarded the Prize of Israel for research in social work.

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K. Jessica Van Vliet, Ph.D., R.Psych., is an assistant professor in counseling psychology at the University of Alberta. Her areas of expertise include emotional resilience, trauma, and theories of the self, with particular interest in processes and therapeutic approaches that facilitate recovery from shame. In addition to her teaching and research, she has extensive experience in trauma therapy and has a small private practice as a registered psychologist in Edmonton, Alberta. Everett L. Worthington, Jr., Ph.D., is a professor of psychology in the American Psychological Association-Accredited Counseling Psychology Program at Virginia Commonwealth University. He served as executive director (1998–2005) of A Campaign for Forgiveness Research (www.forgiving.org), in which capacity he helped raise over $3 million to support research in forgiveness, managed grants awarded by the Campaign, and served as a media spokesperson to promote forgiveness and reconciliation worldwide. He has written widely, including the book, Forgiveness and Reconciliation: Theory and Application (Brunner-Routledge). Ruth Yoash-Gantz, Psy.D., ABPP-CN, is a clinical neuropsychologist at the Hefner VA Medical Center in Salisbury, NC and is an assistant clinical professor at Wake Forest University School of Medicine in Winston-Salem, NC. She is boardcertified in clinical neuropsychology. She is director of psychology training for the Hefner VAMC MIRECC Fellowship Program. In addition, she is the site PI for several multi-site VA research projects examining PTSD and TBI among returning veterans. Steve Zanskas, Ph.D., C.R.C., is an assistant professor of rehabilitation counseling and the graduate coordinator of the Rehabilitation Counseling Program at The University of Memphis. Dr. Zanskas has staff privileges at the Med Regional Medical Center, a Level 1 Trauma Center, in Memphis, Tennessee. He has been a practicing Certified Rehabilitation Counselor since 1979. His primary research interests include the psychosocial aspects of disability, resilience, and system approaches to rehabilitation.

Chapter 1

Introduction to Trauma Rehabilitation After War and Conflict Erin Martz

If a meaning is to be assigned to life after trauma. . .the meaning of the future could be as important as that of the past. . . rehabilitation [is] in line with this concept of healing forward. Shalev (1997, p. 421, emphasis added).

Abstract This book investigates the topic of individual-level and community-level rehabilitation after war or armed conflict, with an emphasis on human rehabilitation on a psychological and physical level. In this chapter, the multidimensional concept of rehabilitation is explored and the definitions of disability and the multidimensional trauma membrane (intrapsychic, interpersonal, and communal) are described. In addition, the topics of the psychosocial effects of war on individuals and communities and the possible interventions to address the ripple effects of war on individuals and communities are reviewed. This chapter also introduces and references the topics that are explored in other chapters of this book. The present chapter will examine several theoretical models and intervention frameworks that encompass human rehabilitation interventions on both the individual level and the community level. Because rehabilitation interventions consist of processes to facilitate healing on multiple aspects of human life, human rehabilitation in the post-conflict context can help individuals and communities regain their functioning after experiencing severe traumas and numerous losses.

Introduction Ursano, Fullerton, and Norwood (1995) called war the “oldest human-made disaster” (p. 197). There are huge costs connected to war and armed conflict: The World Bank (2009) estimated that the yearly economic cost of global conflict is around $100 billion. The global psychological costs of war have not been quantified E. Martz (B) Rehability, Portland, OR, USA e-mail: [email protected]

E. Martz (ed.), Trauma Rehabilitation After War and Conflict, C Springer Science+Business Media, LLC 2010 DOI 10.1007/978-1-4419-5722-1_1,

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and may not be quantifiable. How do individuals and communities recuperate from the terror, fear, loss, and destruction caused by war and armed conflicts? War and armed conflicts often create humanitarian disasters and crises by violence, leading to injuries, deaths, displacement of individuals and groups, the disintegration of civil and social organizations, and the destruction of physical infrastructure of a country; hence, there are both direct and indirect consequences of war and armed conflict for individuals. Because war and armed conflicts create a ripple effect and cause a range of stressors on multiple levels—not only psychological stress, but also physiological, economic, and social stress—a multidimensional perspective is then needed when examining post-conflict/post-war recovery. Rehabilitation theory and practice offer multidimensional approaches to facilitating recovery after trauma, injury, or disability. While many definitions of rehabilitation can be found (e.g., building rehabilitation, economic rehabilitation), this book will examine post-conflict human rehabilitation from an interdisciplinary approach, which includes a variety of viewpoints, philosophies, and a multidimensional lens by which issues are examined. The major purpose of this book is to analyze the multi-level processes and programs that have led to the successful protection and rehabilitation of both individuals and communities after armed conflicts or wars. The present chapter will examine several theoretical models and intervention frameworks that encompass human rehabilitation interventions on both the individual level and the community level. The definitions of concepts, such as rehabilitation, disability, and the trauma membrane, will also be presented in this chapter.

Boundaries of This Book This book is delimited to a focus on the human-made disaster of war and armed conflict, not natural disasters. A natural disaster (e.g., earthquakes, hurricanes) may have some similar elements as an armed conflict, in that the outcomes may look the same on a physical level (e.g., extensive destruction of personal and communal property and deaths). Natural disasters, for the most part, do not involve the same types of tensions, anger, and intentional violence that create, and result from, the national or international armed conflicts and wars. A meta-analysis conducted on 160 studies on traumatic stress indicated that traumas caused by humans (e.g., mass violence) are associated with a higher level of psychological distress than those caused by environmentally caused disasters (Norris et al., 2002). Also relevant to this book is Norris and colleagues’ findings that psychological impairment after trauma was more likely among individuals in developing versus developed countries, although their meta-analysis only included studies that investigated the consequences of one-time events, not chronic exposure to trauma, such as may be found in war-torn countries. This book will cover the community-level (i.e., after war-related humanitarian disasters) and individual-level (i.e., after accidents or injuries) rehabilitation interventions that can be implemented after war or armed conflict. The coping resources

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of an individual or a community are often exceeded after widespread violence; hence, external support, in the form of people, agencies, and humanitarian aid, is temporarily needed until individuals are able to more fully and adaptively cope with the trauma of the events. Chapter 2 (by Martz & Lindy) will discuss the “trauma membrane,” which is a concept that depicts intrapsychic, interpersonal, and communal processes that may occur after traumatic events to protect individuals from experiencing further stress. This book is also delimited to primarily examining adults’ reactions to trauma. There already exists a large body of research on the topic of the effects of war on children; however, one exception to the limited scope of this book is Schauer and Elbert’s chapter (Chapter 14) on child soldiers. This chapter was included because child soldiers were forced into participating in adult, war-related roles, and hence, the topic was deemed appropriate for inclusion in this book. Further, this book is delimited to examining the effects of armed conflicts or war, not tragedies at the hands of a few individuals (e.g., multiple homicides in the workplace or at a school, suicide bombings). Those kinds of incidences rarely last more than a few hours or days, unlike war and armed conflict; while they are horrific and may result in permanent physical and psychological consequences, these types of events do not typically require community-wide systemic interventions and processes to rebuild social infrastructures and thus are not included in this book (interested readers can refer to Wilson & Raphael, 1993). Numerous other areas could be covered in this book, such as developing educational systems in postconflict situations (World Bank, 2004), rebuilding economies and political systems, or post-conflict peacebuilding (Schnabel & Ehrhart, 2005; Williams, 2005). Yet, not all issues could be included in this book, due to restricted space and the focus on rehabilitation topics. The term “post-conflict” is used in this book with the understanding that postconflict environments “do not necessarily imply a completely peaceful atmosphere” (Isturiz, 2005, p. 75) or complete cessation of all violence. The term “conflictaffected” is also employed in this book to reflect the unfortunate fact that some conflicts appear to be cyclical or difficult to resolve.

Creating a Trauma Membrane The concept of a multidimensional trauma membrane, which acts as a type of posttrauma buffer zone that shields an individual or groups of individuals from further psychological stress, is explained more thoroughly in Martz and Lindy’s chapter (Chapter 2), and is referenced in other chapters. Briefly, the concept of a “trauma membrane,” as outlined by Lindy, Grace, and Green (1981) and Lindy (1985), originally referred to the interpersonal protection that individuals (e.g., family, friends, or even mental-health professionals) provided to individuals after trauma. Yet, after armed conflicts and war, communities’ physical and social infrastructures may be destroyed or damaged, consequently decreasing the naturally occurring process of a protective, interpersonal “trauma membrane” to individuals. Martz and

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Lindy described in more detail the description of the concept of an intrapsychic membrane, which may occur within individuals after trauma that protects them against traumatic memories. Rehabilitation interventions, as planned interventions that are performed with individuals and communities, can be viewed as actions taken to create trauma membranes around those who have survived a conflict or war. Multiple international agencies (the United Nations, Organization for Security and Co-operation in Europe [OSCE], the European Union) and local and international non-governmental organizations (NGO) have, for years, provided humanitarian assistance of various forms in war-torn countries. Though not called as such, their work could be viewed as creating trauma membranes around displaced, homeless, traumatized, and/or injured populations. Thus, the “trauma membrane” perspective is implicit in international agencies and NGO’s work. Their humanitarian work also includes rehabilitation; yet, in such contexts rehabilitation is poorly defined as acknowledged by many agencies and individual researchers, (OSCE, 2000). Despite the fact that post-conflict rehabilitation can facilitate healing and encourage stability on multiple levels and thus may help to prevent future conflicts, some researchers have noted that humanitarian relief money often is invested in “hard” reconstruction projects, and not the “soft” projects related to the social side or the human dimension of rehabilitation (Pugh, 1998). This reflects a trend that post-war investment often targets the rebuilding of the physical components of a society— with less effort invested into the humanitarian aspects of helping to rebuild people’s lives. Yet, the psychological component of rebuilding is acknowledged by Williams (2005, p. 268), who said that “the critical determinants of successful peace-building and sustainable recovery will always be internal [within a country or community, because being]. . .supported by the donor community cannot serve as a substitute for the willingness of local actors to renounce violence and to devote domestic resources to reconstruction.” Thus, the treatment of the human factor, which not only acknowledges the influence of human motivation, volition, and choices but also focuses on healing human physical and psychological factors, is essential for rebuilding countries. If the human factor is not acknowledged in post-conflict reconstruction, it may disrupt the process; one example is the situation in which interpersonal violence is not reduced to manageable levels or violence restarts between warring parties after conflict, causing international humanitarian relief to be withdrawn from areas that are no longer deemed safe for international aid workers. In summary, the trauma membrane involves more than providing physical sustenance and resources after a traumatic event: it involves a form of psychological first aid, aimed at temporarily supporting individuals and communities after trauma. Because the psychological healing of communities is a more invisible aspect of community-level reconstruction after war or conflict, it receives less financial investment, which may reflect a lack of awareness of the impact of non-physical needs on the healing of individuals and communities. Yet, the targeted facilitation of human healing after war by means of rehabilitation interventions may contribute to a longer-lasting peace.

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War and Disability Disability is ubiquitous in all cultures, and individuals with disabilities are the world’s largest minority (United Nations, 2009b). It is estimated that 10% of the world’s population has a disability (caused by a variety of factors); this percentage increases to an estimated 20% disability among the poorest communities (United Nations, 2009b). Disability is generally defined in terms of the functional limitations of an individual that arise due to impairment in the bodily or cognitive systems. For the purpose of this book, the term disability can also be loosely applied on a community level; that is, communities can become “disabled” due to an impairment in social or civil processes. For example, war may cause community-level (i.e., country-level) destruction of its infrastructure, hence impairing operations and creating functional limitations of the government or civil structures, which have ripple effects on the functioning of individuals. The term “complex emergency” is used to describe when multiple factors create compounded social stress, such as an armed conflict coexisting with a famine; this term reflects multiple traumas on the community level, but not the coexistence of an individual-level trauma (e.g., disability) and a community-level trauma (e.g., war). War and armed conflict can cause lasting harm to individuals—not only from the psychological shock of war-related trauma but from physical injury and disability as a result of the war. According to the United Nations (2009c), the most important way throughout the world to prevent disability is the avoidance of war. The main focus of this book is not preventing war, but on helping individuals who are living with the consequences of war or armed conflict. The toll of war is high, in that for “every child killed in warfare, three are injured and acquire a permanent form of disability” (2009b, p. 3). The World Bank (2009) estimated that 40% of post-conflict countries will relapse into conflict within 10 years of ceasing hostilities. Yet, multiple authors in the present book assert that resolving psychological trauma may help to reduce the reoccurrence of war. Weisaeth (1995) noted that during a disaster or accident, individuals may experience severe physical stress—“the worst of which is the serious physical injury” (p. 407). Not only does an individual with a physical injury or disability have to deal with the physical and psychological stress related to disability, but often there are economic consequences of having a disability, in addition to the poor economic conditions created by a war or armed conflict. For example, the United Nations Economic and Social Council (2009, p. 2) noted that “there is a strong bi-directional link between poverty and disability”: disability can cause poverty (e.g., by lack of employment for individuals with disabilities) and that poverty can cause disability (e.g., due to poor nutrition, lack of adequate health care). Poverty and disability may exponentially increase individuals’ stress loads when added to the traumatic events that can occur in a war zone (e.g., loss of living quarters, witnessing death, experiencing rape, or other kinds of interpersonal violence). Please see McDevitt-Murphy, Casey, and Cogdal’s chapter (Chapter 13) for an overview on healing from the trauma of rape in conflict-affected areas.

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Referring to the treatment of disability in war, the International Federation of Red Cross and Red Crescent Societies (2007) noted that war-related disasters create disability and that those with disabilities that existed before the war may become marginalized and excluded even more than prior to its occurrence (e.g., individuals with war wounds might receive more services and attention than those with disabilities that existed prior to the war). This agency noted that those with injuries sustained during the war or armed conflict may be vulnerable to developing a permanent disability, due to the lack of medical services, social support services, malnutrition, a changed environment, inaccessible and discriminatory humanitarian aid services, or even discrimination among individuals with disabilities in receipt of services. The International Federation of Red Cross and Red Crescent Societies also described how the existence of a disability can create difficulties in disaster risk-reduction measures, ranging from trying to secure one’s house before a disaster strikes (i.e., in the context of war) to conducting post-disaster cleanup, or not receiving appropriate warning information about a disaster or conflict because the information was not put in formats that were accessible for certain types of disabilities.

Posttraumatic Reactions and Disability Regarding reactions to traumatic events, Terr (1991) posited that there were two types of traumatic stress responses that individuals may experience after a trauma: type 1 traumatic responses following unanticipated, one-time events (e.g., hurricanes, rapes) and type 2 traumatic reactions to long-term, repeated traumatic exposure (e.g., childhood sexual abuse, political torture). Terr also noted the existence of “cross-over” traumas, which she defined as sudden events that cause a disability and that may trigger both type 1 and 2 traumatic reactions because the onset of a disability may be a one-time event with long-term, continuous consequences. This indicates that the psychological response to an injury or disability may consist of a complex set of traumatic reactions. Individuals with disabilities have many factors that make them more vulnerable to traumatic events and may increase their traumatic stress reactions. Factors may include being unemployed and thus often not living in secure, safe environments, being isolated and visibly vulnerable (e.g., to attacks or robberies), being dependent on others for care and/or being in institutions and thus more vulnerable to abuse (Mueser, Hiday, Goodman, & Valenti-Hein, 2003). In addition, in situations of conflict or disaster, individuals with disabilities may not be able to flee dangerous environments, to navigate in destroyed streets and buildings, and to obtain supplies (e.g., food and water) from outside sources; these physical and medical challenges are in addition to the previously existing “obstacles in the social landscape of their communities” (Mueser, Hiday, Goodman, & Valenti-Hein, 2003, p. 136), such as social stigma and discrimination. There is a huge body of research on posttraumatic stress disorder (PTSD) and the kinds of traumatic events that have the most psychological impact on individuals. In

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a second article about their meta-analysis of trauma studies, Norris, Friedman, and Watson (2002) documented the association, found in numerous studies, between injury and poor psychosocial outcomes; they also stated that injury (and threat of or loss of life) was one of four event factors in disasters that appeared to exhibit the greatest impact and to require widespread, professional mental-health interventions, in order to curtail the risk of severe, chronic psychological impairment. In Hobfoll and de Vries’ (1995, Appendix A) list of risk factors for developing PTSD or other forms of mental issues, some of these factors were related to disability or injury (i.e., experiencing physical harm or injury during a disaster, the intentional harm of an individual, or the visibility of an injury to others). Hobfoll and de Vries also listed other risk factors for PTSD as including whether individuals were members of a group that lived on the “margin” of society or were part of a group that is likely to be overlooked, which is often the case with individuals with physical or psychiatric disabilities. Ursano, Fullerton, and Norwood (1995) depicted physical injury (measured by number of injured and type of injury) as one indicator of the severity of a disaster. They also stated that physical injury is a risk factor for the development of a psychiatric disorder, “reflecting both their high level of exposure to life threat and the added persistent reminders and additional stress burden accompanying an injury” (p. 199). They noted that not many empirical studies have been published on this topic. Ursano, Fullerton, and Norwood described other physical ramifications of disasters that may add to an individual’s stress load, which can include injuries, head trauma, metabolic problems due to disturbed food and water intake, infections, water-borne illnesses, and lack of access to regularly taken medications. The aforementioned research suggests that as part of post-conflict rehabilitation, disability-related trauma must be addressed on the individual level, in addition to providing community-focused interventions. There is a growing trend among researchers and field clinicians to assess for and treat not only traumatic stress reactions, such as PTSD, but other psychological consequences of surviving war and conflict, such as anxiety, depression, and a array of adaptive or non-adaptive coping responses. In a chapter on PTSD and co-occurring disorders, McFarlane (2004) described a range of models (e.g., Psychodynamic Model, Common Diathesis Model, Interactional Model) that suggest ways of understanding the existence of multiple psychological disorders after a traumatic event. Tanielian and Jaycox’s (2008) extensive document on the “Invisible wounds of war” listed PTSD, depression, and traumatic brain injury (TBI) as primary mental-health and cognitive disorders arising from participation in a war zone. Campbell, Pickett, and Yoash-Gantz’s chapter (Chapter 8) in the present book describes the processes by which U.S. veterans are assisted. In addition, Chapter 11 by Van Vliet and Chapter 12 by Johnson and Chronister detail research that examines other aspects of the psychological sequelae of war, and Chapter 15 by Ohry and Solomon describes research on the psychological impact of being a prisoner of war. Readers, who are interested in the range of possible psychological responses after the onset of disability, should refer to texts in the field of rehabilitation psychology (e.g., Frank & Elliott, 2000; Livneh & Antonak, 1997; Martz & Livneh, 2007);

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Wright, 1983). Other chapter authors in this book also emphasize that PTSD should not be the sole psychological focus after war or armed conflicts (e.g., Chapter 15 by Ohry & Solomon, and Chapter 16 by Schauer & Schauer).

Psychological Reactions After War or Armed Conflict As previously mentioned, even if individuals do not experience the direct physical impact of war or armed conflict in the direct form of injury, or disability, or other interpersonal losses, such as family and friends, they may experience stressful effects resulting from the destruction of a part of a country’s infrastructure, such as the loss of jobs, health care, and normally available resources (e.g., food, clean water, electricity). The stress caused by the breakdown of political, social, and economic systems can multiply the effects of individually experienced stress; for this reason, a sole focus on identifying and treating posttraumatic stress reactions (e.g., PTSD) would provide an imbalanced perspective, which not only discounts the numerous environmental stressors after war (e.g., fighting for basic survival, seeking food, water, and shelter), but also frames psychological reactions primarily in terms of pathological processes. Some literature on posttraumatic adaptation and growth has been published. Tedeschi and Calhoun (1996) reviewed such literature, as well as created an instrument called the Posttraumatic Growth Inventory. This scale was based on the concept that growth can occur after trauma and that positive events after trauma may occur in three areas: (a) alterations in the self-perception, such as emotional growth and a new sense of strength; (b) changes in relationships with others, such as a greater appreciation of and sensitivity to one’s relationships, an awareness of how quickly those relationships can be lost, a greater emotional expressiveness, and learning how to develop more positive intimate relationships with others; and (c) changes in the philosophy about life and in some of the assumptions about life, such as a greater appreciation and enjoyment of life, living a more fulfilling and meaningful life, and developing a heightened spirituality. Unwanted recalling of traumatic memories, such as intrusions and flashbacks, do not necessarily have to be viewed as pathological, but as part of a psychological healing process; this will be explained in more detail in Martz and Lindy’s chapter (Chapter 2). For example, Freud’s concept of the defense mechanism of “repetition compulsion,” which was an extension of his stimulus barrier formulation, explained the revisiting of traumatic events as active efforts to cope with and master the situation, rather than the passivity of the trauma when it was first experienced (Brett, 1993). The concept of a non-adaptive response to trauma gradually evolved into a reactive process to trauma that did not necessarily reflect an underlying psychological disorder in one’s personality. Currently, PTSD is viewed by some trauma researchers as a process of adaptation to trauma (Lifton, 1988; McFarlane, 2000; O’Brien, 1998; Van der Kolk, McFarlane, & Van der Hart, 1996). Lifton (1988, 1993) depicted PTSD as a normal adaptive process of reaction to extreme stress or an abnormal situation. Yet, the low prevalence rates of PTSD

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assessed in some traumatized populations demonstrate that PTSD is not necessarily a normative reaction to trauma. Though many researchers continue to debate whether PTSD should be viewed as a mental disorder versus as a reactive, adaptive process to trauma, Wilson (1995) commented that “the psychopathology of traumatic reactions is discerned when the presence of the symptoms persists and exerts an adverse effect on adaptive functioning” (p. 19). Lifton (1988) viewed posttraumatic stress reactions as “an effort or restore or create anew the reintegration of the self” (p. 30). According to Lifton, posttraumatic symptoms are both adaptive and necessary for the traumatized part of the self to be integrated into the larger self. Mastery over psychological trauma is evident when individuals have authority over the memory processes and can choose whether or not to think about the trauma (Harvey, 1996), in contrast to intrusive memories of the trauma that may impinge upon the person without apparent control over such occurrences. In addition, an individual’s emotional reactions related to the trauma will no longer consist of overwhelming memories with the “terrible immediacy and fierce intensity” as they used to have (Harvey, 1996, p. 12). According to Harvey, the following conditions reflect mastery over traumatic memories: (a) traumatic memories are experienced as controllable; (b) other emotions are tolerable and are differentiated from the affective reactions to the trauma; (c) other symptoms related to the trauma may be present or occur sometimes, but they are predictable and manageable, such as reactions to stimuli that remind the person of traumatic events; (d) restoration of self-esteem and self-caring behaviors; and (e) the pursuit of a self-fulfilling life. In addition, if trauma has included the victimization and betrayal of trust by others, the possible reaction of isolation and avoidance of interpersonal relations will be replaced by an expansion of their social networks, a new striving to trust people, and views “the possibility of intimate connectedness with some degree of optimism” (Harvey, 1996, p. 13). Harvey proposed that a final sign that individuals have healed from their trauma is their ability to name and grieve their traumatic pasts, while finding meanings that are both “life-affirming and self-affirming” (1996, p. 13), such as finding new strength, compassion, social action, or spiritual growth. While a body of research is rapidly expanding about the psychological consequences of trauma, such as in the aftermath of war (Tanielian & Jaycox, 2008; Wilson & Raphael, 1993), the reverse of the aforementioned association may also be true: psychological disequilibrium can lead to war. That is, unresolved, inter-group psychological issues (e.g., hatred, disagreements over boundaries, intergroup hostilities, or aggression against other groups) can create conditions that lead to widespread violence and escalating conflict. In Solomon, Greenberg, and Pyszczynski’s (2003) Terror Management Theory, they argued that three psychological factors—the psychological threat posed by others who are different than ourselves, the tendency to scapegoat others, and rigid adherence to one’s identities (e.g., as part of a certain cultural identification)—contribute to war and inter-group conflict. Olweean (2003) noted that “psychological and emotional injuries may be the most enduring effects of war” but often are the “least addressed” (p. 271). He also noted that “communal psychological wounds are one of the most—if not the most—powerful fuel of war and violent conflicts” (p. 271). Based on their clinical

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experiments, Solomon, Greenberg, and Pyszczynski asserted that ultimately the aforementioned three factors arise from humans’ fear of death and from a projection of that fear on others, such as by asserting power or annihilating those who do not share our particular worldview. While post-war medical and physical issues are often given priority over the mental-health ramifications of exposure to psychologically traumatizing events, it is understandable that agencies address the urgent need to provide sanitation, water, food, and other necessities of living over psychological ones after conflict or war. International organizations, such as various United Nations (UN) branches, and humanitarian non-governmental organizations (NGO) have focused on providing the basic necessities of survival and treatment of acute medical needs after natural or human-made disasters. Yet, Mollica, Cuit, McInnes, and Massagli (2002) commented that one consequence of this focus on acute aid responses is a general neglect of the mental-health needs of individuals in post-conflict zones. In this book, Schauer and Schauer (see Chapter 16) presented strong arguments for providing evidence-based psychological rehabilitation, which they assert may help to interrupt the cycles of violence and under-development in countries. They and others propose that the treatment of mental-health issues on the individual and communal level may help to prevent future armed conflicts and thus should be considered as an integral part of post-conflict rehabilitation. Further, learning how to reach reconciliation, which is the topic of Worthington and Aten’s chapter (Chapter 3), also can prevent the reoccurrence of armed conflicts. As del Castillo (2008, p. 270) noted, “One thing the UN cannot do—or anybody else for that matter—is to impose reconciliation” on populations in post-conflict environments.

A Multidimensional Approach to Rehabilitation Interventions Rehabilitation interventions can be discussed on two levels: responses to the stress created by injuries and disabilities (individual-level rehabilitation) and the responses to the destruction of a community or country’s infrastructure (communitylevel rehabilitation) after war or armed conflict occurs. In view that there is an interaction between the many disturbances and stressors that can occur on these two levels, multidimensional models of intervention will be discussed as a means of understanding the ripple effects of war or armed conflict on human lives.

Definition of Individual-Level Rehabilitation Generally speaking, rehabilitation is viewed as a time-limited intervention to facilitate more independent functioning for individuals with injury or disability. Thus, while there may be various shades of meaning in different cultures, individual-level rehabilitation is viewed as a holistic intervention for helping individuals live with an injury, chronic illness, or disability; the intervention can encompass multiple aspects

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of an individual’s life (e.g., vocational, social, familial, economic, recreational). The United Nations (2009a) defined rehabilitation for individuals as the following: [A] goal-oriented and time-limited process aimed at enabling an impaired person to reach an optimum mental, physical and/or social functional level, thus providing her or him with the tools to change her or his own life. It can involve measures intended to compensate for a loss of function or a functional limitation (for example by technical aids) and other measures intended to facilitate social adjustment or readjustment.

For decades, rehabilitation philosophy has been viewed as holistic and multidimensional; its perspective includes understanding the effects of the person interacting with their environment (Wright, 1983). Some models of rehabilitation (i.e., the “social model”) have claimed that it is an inaccessible environment, not individual factors, that “disables” individuals. Yet, the World Health Organization’s (2009a) latest definition of disability includes an interaction of both individual factors and environmental factors, which are explained in the context of a continuum of health; this will be the definition of disability that is adopted in this book. Individual-level rehabilitation interventions may include the following types of services (United Nations, 2009c): a diagnosis of disability, which may necessitate medical care and treatment; social, psychological, and other types (e.g., interpersonal) of counseling; training in activities of daily living (i.e., self-care), which may include mobility, communication, and self-care and may require specialized forms of accommodations (e.g., hearing aids or sign language, Braille print, mobility aids); and vocational rehabilitation services, which may include training and assistance in obtaining and maintaining employment. While individual-level rehabilitation interventions can occur in many different forms, physical rehabilitation and vocational rehabilitation are the two most commonly known. For a detailed overview of human physical rehabilitation, please refer to Rockhold’s chapter (Chapter 7) in this book. Zanskas’ chapter (Chapter 6) mentions vocational rehabilitation, while three other chapters (Chapter 8 by Campbell, Picket, & Yoash-Gantz; Chapter 9 by Maedl, Schauer, Odenwald, & Elbert; and Chapter 10 by McDonald) examine, in detail, various aspects of psychological rehabilitation. In the twentieth century, numerous countries passed national laws to protect individuals with disabilities from discrimination and to provide a minimal level of community accessibility (e.g., the U.S.’s 1991 Americans with Disabilities Act). Groups of nations, such as those participating in the Organization for Security and Co-operation in Europe (OSCE), have made agreements on policies about how to treat individuals with disabilities. For example, OSCE-participating states made an agreement in 1991 to protect the human rights, equal opportunities of, and access to programs and services specifically by individuals with disabilities, in addition to vocational and social rehabilitation (OSCE, 2005). The International Labor Organization (ILO) also has worked for many years to improve the rights and treatment of individuals with disabilities in the workplace (ILO, 2009). More recently, the United Nations Convention of the Rights of People with Disabilities (United Nations, 2009d) entered into force as an international treaty covering the human

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rights of individuals with disabilities in multiple areas of their lives. This extensive convention includes one section related to rehabilitation. Despite international and national laws banning discrimination against individuals with disabilities, their experiences in a war zone may be full of extreme difficulty. For example, if most of the community or country is living in a survival mode due to society-wide destruction during war, it is possible that individuals with disabilities may be viewed as a lower priority group for assistance and humanitarian aid. This may occur because individuals with disabilities might be perceived as requiring the most help (and sometimes sustained help) to function independently. Thus, help and resources may be directed to those without disabilities, who are viewed as able to become independent more quickly. This diversion of resources is one reason why there has been a movement to intentionally include disability as a cross-cutting issue in programs such as poverty-reduction strategies (Handicap International and Christoffel-Blindenmission, 2006).

Definition of Community-Level Rehabilitation In contrast to individual-level rehabilitation, broad-based or community-level rehabilitation is an intervention with the community as its focus. This form of rehabilitation should be distinguished from community-based rehabilitation (CBR), which is a form of rehabilitation that is practiced with individuals in developing countries (CBR is the subject of Dr. Eide’s research, Chapter 5). According to the Commission of the European Communities (1996), community-level rehabilitation can be defined as An overall, dynamic and intermediate strategy of institutional reform and reinforcement, of reconstruction and improvement of infrastructure and services, supporting the initiatives and actions of the populations concerned, in the political, economic and social domains, and aimed towards the resumption of sustainable development. People—both victims and participants in violent conflicts—must be reintegrated into civil society, in its economic, social and political aspects (p. 7).

The Commission of the European Communities (1996) defined rehabilitation on the community level as consisting of “restoring productive capacities and providing everyone with a certain access to basic means of production (land, seeds, tools)” (p. 13). Further, the New Partnership for Africa’s Development (2005) defined community-level rehabilitation as [A]ction aimed at reconstructing and rehabilitating infrastructure that can save or support livelihoods. It overlaps with emergency relief and is typically targeted for achievement within the first two years after the conflict has ended (p. iii).

OSCE-participating states have agreed that the OSCE “has to be an integral part of the complex rehabilitation effort” (2001, p. 35) by addressing multifaceted issues, such as economic rehabilitation, institution-building, rule of law, encouraging civic

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participation, and helping to address the environmental impact of armed conflicts. All of these suggested activities reflect community-level interventions. Community-level rehabilitation can be distinguished from two other types of community-level interventions: (1) the humanitarian aid that is given in response to acute disasters and (2) the more long-term programs of development. The Commission of the European Communities (2001) noted that the first type of assistance (humanitarian aid for acute crises) was typically provided through nongovernmental organization and international aid organizations, while the latter type (i.e., developmental programs) was created by programs in collaboration with the partner country, in order to agree upon development policies and strategies. Rehabilitation can be viewed as the intermediate “link” between relief assistance for emergency situations and the developmental planning. This continuum of community-level interventions can be simply described as “emergencyrehabilitation-development” (Commission of the European Communities, 1996, p. 12). Or, in another model, it is called “emergency-transition-development” (New Partnership for Africa’s Development, 2005). Yet, De Zeeuw (2001) cautioned that calling rehabilitation as the intermediate link is an artificial distinction and that a large amount of overlap exists between relief assistance, rehabilitation, and developmental programs. Further, he noted that this “continuum” model has largely been discredited and that a “conceptually a more integrated and multi-directional approach for relief, rehabilitation, and development is being put forward. . . [that] takes into account the more inclusive, coexisting, and even overlapping aspects of relief, rehabilitation, and development and channels the appropriate mix of assistance activities to a specific conflict situation” (De Zeeuw, 2001, p. 12). The United Nations Relief and Rehabilitation Administration (UNRRA) was an example of broad-based community rehabilitation. UNRRA had a short existence (1943–1949), but provided billions of dollars to help multiple countries after the end of World War II (Yale Law School, 2008). Modern-day efforts in assisting the rehabilitation of countries still occur and typically require extensive funding. According to Lefèbvre (2003), the European Union funded international projects for the post-conflict and socioeconomic rehabilitation sector totalled 277,236,341 Euros. Yet, economic rehabilitation appears to be the primary or typical focus of post-war reconstruction efforts. For example, in an extensive grid that mapped out post-war interventions, the United States Department of State (2005) mentioned rehabilitation only once, and economic rehabilitation was the sole type of rehabilitation that was listed. However, the importance of an economic focus should not be derided. After war or armed conflict ends, the process by which community-level restoration occurs typically begins with implementing the political agreements that ended the war, which then proceeds toward economic re-establishment. Yet, it is noted that this process is not linear: Field experience from post-conflict rehabilitation confirms that the resolution of regional conflicts is a precondition for large-scale political and economic co-operation, but that, conversely, economic activities can also give a decisive thrust to the peace process (OSCE, 2001, p. 38).

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Reconstruction is a term that should be distinguished from rehabilitation. On the international level, reconstruction is defined as a broad-based rebuilding of countries after conflict or war, especially in terms of rebuilding infrastructure (e.g., governmental functioning and physical resources, such as roads). Reconstruction can be viewed as part of development. Rehabilitation, on the other hand, refers to the healing and repair on a human dimension (both psychological and physical). This may include interventions on the individual level, such as for psychological trauma or physical injuries/disabilities of individuals, to interventions on the community level, such as the economic, social, and political restoration and reintegration of groups of people.

Frameworks for Individual-Level Interventions The International Disability and Development Consortium (2000) published a multifaceted report on disability and conflict—ranging from suggestions on actions to take in pre-conflict to post-conflict situations—framed in terms of what, how, and who. They noted that in post-conflict situations, the government structure is typically very fragile and not able to provide specialized services and that nongovernmental organizations (both national and international) play a big role in providing services to individuals with disabilities. Mueser, Hiday, Goodman, and Valenti-Hein (2003) also made recommendations of how to address disability issues on various levels (i.e., international/national, community, institutional, families, and individuals) in times of war and peace. The layered nature of their proposed interventions focusing on disability-related issues reflected a multidimensional framework of rehabilitation interventions. Regarding other specialized kinds of individual interventions, programs have been developed that focus on assisting individuals who were former combatants (whether in formal military groups or non-state military organizations). These are called disarmament, demobilization, reintegration (DDR) programs, or disarmament, demobilization, rehabilitation, and reconstruction (DDRR) programs. The United Nations agencies coordinate a program called the “4R’s”: repatriation, reintegration, rehabilitation, and reconstruction (United Nations Development Program, 2009). The topic of DDR types of interventions on the individual level will be addressed in Chapter 9 by Maedl, Schauer, Odenwald, & Elbert. Del Castillo (2008) noted the difficulties in reintegrating targeted groups: No peace process has ever succeeded without the reintegration of former combatants, as well as other groups affected by the conflict, taking place in an effective manner. This is because effective reintegration promotes security by limiting the incentives to these groups to act as spoilers. Reintegration, however, is the longest and one of the most expensive reconstruction activities. . .[and] is typically neglected, as major donors shy away from open-ended commitments to the costly social and economic programs that are often essential for sustainable peace (p. 257).

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Vocational Rehabilitation As an Intervention From the point of view of psychiatry, it is important that these individuals [who have traumatic memories] should be re-engaged at any cost in some form of activity (Kardiner, 1941, p. 236).

Vocational rehabilitation is a small but growing field that focuses on helping individuals with physical or psychiatric disabilities to obtain competitive employment as a means for greater independence and economic stability. While vocational rehabilitation is typically defined as an individually tailored intervention, it reflects the intersection of individuals with communities: that is, it is an intervention provided to individuals with disabilities for not only becoming economically more independent, but also for integrating into the community. Such an intervention also can cause changes in the community. For example, helping individuals with disabilities obtain employment may be one of the best forms of social inclusion and devices to change negative attitudes toward individuals with disabilities that exist in the community. A substantial amount of empirical research and books has been published in recent years on the topic of vocational rehabilitation for those with psychiatric disorders (for overviews and intervention ideas, see Anthony, Cohen, & Farkas, 2001; Fischler & Booth, 1999; Pratt, Gill, Barrett, & Roberts, 2007), but the topic of trauma has not yet been integrated into this research. Limited research has been conducted on employment after post-conflict situations. The International Labor Organization (1998) is one exception; they have worked in the area of employment in post-conflict environments. Further, in Mollica, Cuit, McInnes, and Massagli’s (2002) research among Cambodian refugees (n = 993), the only significant risk factor for depression (after controlling for demographics and trauma) was having a non-working status. They suggested that “work introduced during the early phases of the refugee crisis may have a significant antidepressant effect on traumatized refugee survivors” (p. 164) and that vocational rehabilitation interventions can be a beneficial shift away from a focus on trauma or pathology. This research suggests that vocational rehabilitation can be a powerful intervention that can assist individuals in recovery after war or armed conflict. However, there is a paucity of empirical studies specifically on disability and employment in post-conflict environments. Reintegration programs can be described as an individual-level intervention, although they require systemic planning (as do other forms of individual rehabilitation) and targets certain groups, such as former combatants. Del Castillo (2008) observed that There can be different avenues for reintegration. Reintegration often takes place through the agricultural sector, micro-enterprises, fellowships for technical and university training, and even through the incorporation of former combatants into new police forces, the national army, or political parties. Reintegration programs for the disabled are particularly important. These involve not only short-run emergency medical rehabilitation. . . .but also programs to reintegrate as many as possible into the productive life of the country. . . (p. 259).

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Frameworks for Community-Level Interventions Psychosocial Interventions The concept that conflict and war cause community-wide stress seems evident; yet, the study of post-conflict stress reactions is often framed in terms of individual trauma. One theory, which was not based in the field of traumatic stress studies, but which may be useful for this book, is Brofenbrenner’s (1979) socio-ecological theory. It is a multilayered model for understanding individuals in their contexts. His model depicted a nested hierarchy—from a microsystem (e.g., two or more people and their bidirectional interaction) to the macrosystem (e.g., cultural values, customs, and laws of society), which is the ecological environment. The mesosystem represents the interactions of an individual’s microsystems. The exosystem is the environment of the larger social system with which an individual does not directly interact. Further, the chronosystem is the time-related elements of an individual’s life, which could include internal factors (e.g., one’s own development) or external factors (e.g., the occurrence of a major event in the environment). For a more detailed elaboration concepts related to systemic rehabilitation, please see Zanskas’ chapter (Chapter 6). The following multidimensional, multi-level models that focus on traumatic stress are some of the few models that address multiple systems and their interacting dynamics. Jerusalem, Kaniasty, Lehman, Ritter, and Turnbull (1995) proposed a three-tiered model for understanding stress reactions; they acknowledged that individual and community stressors are overlapping phenomena, but proposed the following heuristic: (a) individual-level stress, which does not cause communitylevel stress ; (b) moderate community stress, which involves a transition stage, in which the public becomes aware of the problem, but communal coping efforts are not required; (c) high community stress, in which the community is propelled into distress, thus triggering communal coping efforts. Wars are categorized as community stressors (level three). In the third stage, communities need assistance for coping with their stressors. In the situation in which infrastructure is destroyed, there is a trickle-down effect to the level of individuals, such that they may experience secondary stress, even if they have not experienced direct effects of the war or disaster. Jerusalem and colleagues noted that after a war ends and the community recovers, more level-one stressors may emerge, as public aid diminishes and individuals still struggle to cope with their stressors. It is a given fact that the physical and economic resources in all communities are not limitless and may be overwhelmed in times of social upheaval, such as war. In a model called “Conservation of Resources,” Hobfoll, Briggs, and Wells (1995) described how stress can develop on a community level. A brief overview of their model highlights how community stressors can be understood in a multidimensional manner. In this theory, resources have four main categories (note that resources can overlap categories): objects, conditions, personal characteristics, and energy. This model depicts stress as arising from three basic conditions: when resources are threatened by loss, when resources are lost, and when the investment of resources

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does not produce a net gain of resources. Note that resource gain does not generally create psychological distress. “Loss cycles” can occur from investing in resources to offset loss, which subsequently results in a vulnerability to other losses as a result of depleted resources. Hobfoll’s Conservation of Resources theory helps to explain why communitywide loss (e.g., the destruction of buildings) typically has more powerful ramifications than the developmental types of gains (e.g., the construction of buildings) in communities. One explanation for this is that loss is more salient than gain (e.g., people notice it more readily) and that often losses occur much more swiftly than gains (Hobfoll, Briggs, & Wells). In addition, a breach of trust accompanies the losses and consequently, losses are a threat to a community’s values. In a different article, Hobfoll, de Vries, and Cameron (1995) remarked that some of the individual forms of coping (e.g., problem-solving), when put in a community context, may have harmful consequences for other people (e.g., pushing others aside for one’s own safety; not following emergency instructions). Hence, the assumption that individual forms of coping bolster communal coping should be viewed cautiously. In summary, the Conservation of Resources theory can serve as a basis to understanding effective community-level interventions by its explanation of trends in community-level responses to traumatic events. Several researchers have proposed broad-based frameworks for understanding psychosocial interventions in communities. De Jong (1995), summarizing and expanding the U.S. Committee on the Prevention of Mental Disorders’ framework used a tripartite definition of public-health intervention as follows: (a) primary intervention as prevention (e.g., to eliminate potential sources of problems, diseases, or disorders); (b) secondary intervention as treatment (e.g., to identify and then address problems, diseases, or disorders, once they occur); and (c) tertiary intervention as maintenance (e.g., reduce long-term effects, complications, or chronicity). The prevention phase is divided into universal and selective interventions: universal interventions apply to the general public and selective interventions apply to certain individuals or subgroups, who are at an elevated risk for psychosocial problems. Most tripartite intervention frameworks place rehabilitation in the tertiary phase. See De Jong’s writing (Chapter 4) for an elaboration of this intervention model. Another framework for psychosocial intervention was proposed by Olweean (2003), who described a Catastrophic Trauma Recovery (CTR) model for helping societies heal after trauma. This model consisted of 11 major areas of intervention: (a) brief therapies for individuals; (b) creating support groups that are peer-run; (c) crisis phone lines and drop-in centers; (d) triage of needs and assessment of available community resources; (e) provision of stress management for relief workers; (f) support groups for counselor/trainers; (g) development of community support for victims (i.e., support and advocacy from religious, spiritual, cultural, and community leaders) to prevent re-victimization; (h) general education about trauma and psychological health; (i) mediation of community armed conflicts; (j) library/resource center for trainers; and (k) regional/international consultation and team support for local trainers.

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In their chapter on psychosocial rehabilitation of refugees and asylum seekers, Ekblad and Jaranson (2004) created detailed chart (see pp. 618–619) that lists suggested, multidimensional, rehabilitation interventions, varying from the individual to community level. Their model uses Silove’s (1999) ecological framework that identifies five systems of health that can be damaged by traumatic events: attachment, security, identity/role, human rights, and existential/meaning. Ekblad and Jaranson adapted Silove’s ideas by delineating the threats, possible psychological reactions and disorders, the levels of impact, and the possible interventions by level for each of the five areas of health of refugees and asylum seekers.

Other Forms of Interventions Regarding interventions focused on disability in post-conflict zones, the World Health Organization (2009b) published a brief framework on helping individuals with injuries or disabilities, grouping interventions into two phases. These interventions include both individual-level and community-level actions: (1) the acute phase, in which the main responses focus on identifying and treating medical needs related to disability, and (2) the reconstruction phase, which includes mapping community resources, rebuilding medical infrastructure and therapy services, creating community-based rehabilitation, and creating economic and social opportunities for individuals with disabilities. In a chapter on the role of military forces in post-conflict, peace-building activities (or peace-support operations), Isturiz (2005) noted the dissonance of having military involved with peace-building activities. However, he suggested that the military can aid in security-sector reform, the rehabilitation of ex-combatants, and humanitarian missions, all of which may require new types of training in military forces that focus on building, not the destroying of the “target” groups. A different kind of community-level intervention is a focus on economic projects. Sharon Morris (personal communication, August 1, 2009), who works for the international NGO Mercy Corps, described how this agency intentionally brings two formerly warring groups together to work on economic projects. Morris reports that a joint economic project is viewed as a place to start for promoting better dialogue and working together; though the parties are told that they do not have to like each other in order to work together, it is, of course, hoped that the parties learn better communication and resolution patterns than previously used. Also emphasizing the role of economics, Del Castillo (2008) described how the community-level intervention of rebuilding the infrastructures of countries after war-related destruction can provide a source of short-term employment to the local population, as long as the work is not given primarily to foreign contractors. Del Castillo stated that providing employment, especially to former combatants, will help strengthen peace in the following process: “The provision of basic infrastructure will facilitate the reactivation of productive activities in the private sector. This, in turn, will promote longer-term employment, which will facilitate reintegration” (p. 266).

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Future Time Orientation of Rehabilitation Interventions Promoting a future-orientation . . . should support more effective rehabilitation (Zimbardo, 2002, p. 5).

For decades, clinicians and researchers have observed that during and after experiencing trauma, an individual’s sense of time is altered, often becoming more present oriented and less future oriented. This reflects a change in an individual’s future time orientation, also known as future time perspective. While this concept may appear to be simply a phenomenon that is clinically interesting, time alterations may interfere with an individual’s ability to set goals or engage in long-term planning because of a foreshortened sense of the future. This section will provide a brief overview of some research findings and suggest how a foreshortened sense of the future may impede rehabilitation interventions. A foreshortened sense of the future (or truncated future time orientation/perspective) is defined as an inability to make plans or to imagine having a career, family, marriage, or normal life span after experiencing a severe trauma (APA, 2000). This foreshortening of one’s future perspective is one symptom that is included as one (of many) symptom present in PTSD. Freud (1935) observed this phenomenon, commenting that “[P]ersons may be brought to a complete standstill in life by a traumatic experience which has shaken the whole structure of their lives to the foundations, so that they give up all interest in the present and the future, and live permanently absorbed in their retrospections” (p. 244). Interest in future time orientation and future time perspective has received some degree of research interest (Melges, 1982; Zaleski, 1994), especially in the context of trauma. Terr (1983) reported the types of time distortions as including misperceptions of time duration (typically a lengthening of time during the trauma unless a trauma of long duration), time confusion (disorientation of distinctions of simple time sequences, such as day versus night), time skew (reordering of events around the time of the trauma), omens (attempting retrospectively to determine warning signs of trauma or “pre-sifting”), sense of psychic or predictive powers of future events, and a foreshortened sense of the future (belief that they would die young, experience another disaster, or be unable to envision a career, marriage, or family). Terr noted that 11 of the 30 clients that she interviewed expressed a foreshortened sense of the future and that these were individuals who had experienced a serious injury or who had seen death and destruction. Time alterations are discussed in several paragraphs of Wilson and Keane’s (1997) book on PTSD, but primarily in terms of (a) “telescoping” or the compression of time when events are reported to have occurred more recently than when they actually occurred (p. 145) and (b) dissociative responses that alter the sense of time while the traumatic event is occurring (pp. 414–415) or distortions of “temporal continuity” (p. 430), as manifested primarily by intrusive flashbacks of the

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traumatic event. Yet, a foreshortened sense of the future is distinct from the above two types of temporal confusion. A limited future time perspective does not necessarily reflect an inability to set goals, because a truncated future time perspective may be a defense mechanism against an anxiety-provoking future (Martz & Livneh, 2003; Pollak, 1979; Terr, 1983) and may cause distress. Holman and Silver’s (1998) research indicated that greater psychological distress was related to a lowered future orientation among three samples (adult survivors of childhood incest, Vietnam veterans, and survivors of fires). However, the consequences of foreshortened sense of the future may have an impact on a person’s work-life, as well as the social areas of life, because an individual that lacks of future time perspective may fail to plan and possibly even to act. As Feifel (1961) noted, “behavior is dependent not only upon the past but even more potently, perhaps, by orientation toward future events” (p. 62). In the context of the psychological treatment of traumatic memories, a foreshortened sense of the future may be addressed by encouraging individuals to shape their futures by choosing goals and planning the steps needed to reach them, which is part of the rehabilitation process. Relevant to the vocational aspects of rehabilitation, a trend evident in decades of research is that time alterations may occur during unemployment. In the 1930s, Jahoda and colleagues examined the unemployed individuals in Marienthal, an Austrian town that had experienced massive layoffs, concluding that the unemployed had experienced a disintegration of the sense of time (Jahoda, Lazarsfeld, & Zeisel, 1971/1933). Eisenberg and Lazarsfeld’s (1938) extensive literature review on the effect of unemployment listed the following as common time-related responses to unemployment: individuals lost their sense of time, felt isolated, purposeless, without an identity, had low self-esteem, and were bored. According to Feather and Bond (1983), unemployment may lead to a greater risk of “temporal disintegration and purposelessness” (p. 250); they suggested that mental health in unemployment is associated with the ability to use time purposefully and meaningfully. The research on a foreshortened time perspective is pertinent to this book, because in the aftermath of war and armed conflict, unemployment may be high, and people may be focusing on survival. It is understandably difficult for individuals in such circumstances, especially if a disability is present, to think about their future plans and goals (Martz, 2004; Martz & Livneh, 2007b). While unemployment causes a profound uncertainty about the future (Fryer & Payne, 1986), experiencing a disability can also cause similar reactions, due to the concern that the medical or psychiatric condition may worsen and cause job or other types of losses. However, integral to rehabilitation processes is a survey of individual goals and a development of a plan on how to achieve those goals. This can be viewed as a process on both an individual and community level—not only do communities necessitate immediate, middle, and long-range planning for reconstructing what was lost in a war or armed conflict, but individuals also may need assistance in developing their residual skills and abilities after the onset of disability or other forms of major trauma and loss.

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Summary The World Bank (2003) noted that conflicts are “development in reverse” because armed conflicts and war break down the infrastructures that have taken years of development work to create. Rehabilitation interventions can help to bridge the gap between humanitarian aid that is provided to address acute needs and the developmental funds that are expended to rebuild countries and societies after war or conflict. As described in this chapter, the philosophy of rehabilitation is holistic and multidimensional. Although the term “rehabilitation” has been used in many human contexts (e.g., political rehabilitation, drug rehabilitation) and non-human contexts (e.g., building rehabilitation), the emphasis in this book is on individual-level and community-level rehabilitation after a conflict or war, with an emphasis on human rehabilitation—on a psychological and physical level. Rehabilitation processes consist of multidimensional interventions with the goal of restoring individuals and/or large groups of individuals (i.e., communities/nations) to the highest level of functioning possible. Both individual-level and community-level rehabilitation may be necessary after armed conflict or war. Although these topics will be discussed separately in this book, the processes of individual-level and community-level rehabilitation interventions should be viewed as interwoven, because individuals are intricately linked with the societies in which they live. Rehabilitation, as a process to facilitate healing on multiple aspects of human life, consists of interventions that can help individuals and communities regain their functioning, despite major traumas and losses.

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Chapter 2

Exploring the Trauma Membrane Concept Erin Martz and Jacob Lindy

Abstract As part of the healing process in the aftermath of catastrophic stress, the trauma membrane forms as a temporary psychosocial structure to promote adaptation and healing. The trauma membrane acts as an intrapsychic and interpersonal mediator, interfacing between the person and the traumatic memories and everyday reminders of the traumatic event from the external world. Therapists work at the boundary of this psychological buffer zone. The multidimensional concept of a trauma membrane reflects intrapsychic, interpersonal, and communal processes that protect individuals and communities, such that a survivor network or individual survivor will invite or block access to mental-health intervention. The intrapsychic mechanism protects traumatized individuals from being subsequently overwhelmed by intrusive memories by cordoning off those memories until they can be handled by the individual’s adaptive psychic processes. This chapter will explore the definition and history of the trauma membrane concept, the similarities and differences between the stimulus barrier and trauma membrane, its value as a metaphor, and how the recovery environment can facilitate its formation in the aftermath of a trauma. As a flexible analogy, the multilevel trauma membrane can help researchers and clinicians explain trauma-related processes and their clinical applications.

Definition The trauma membrane is a temporary psychosocial structure, a buffer zone or covering that protects traumatized people as part of the healing process in the aftermath of catastrophic stress. This term reflects intrapsychic, interpersonal, and communal processes that protect individuals and communities, such that a survivor network or individual survivor may invite or block access to mental-health intervention. The trauma membrane phrase calls attention to a potential healing space – both social E. Martz (B) Rehability, Portland, OR, USA e-mail: [email protected]


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and psychological – that permits naturally occurring healing processes over time. Yet, if these processes are not functioning over time (e.g., individuals are unable to process the traumatic event), the trauma membrane, like the surface of any wound that is not properly attended to, may complicate recovery (e.g., the wound festers and becomes infected). The trauma membrane conveys the idea of healing processes within this space or buffer zone and of governing principles with structures with which it interfaces. It follows a natural course and has long-term consequences for survivors and their communities.

Domains of Application In this book, the concept of trauma membrane will be used to refer to three levels: the community, the interpersonal, and the intrapsychic. War and social conflicts (in addition to man-made disasters, which will not be covered in this book) are traumatic to entire communities, leaving them torn, displaced, dependent, and dysfunctional. On the interpersonal level, wars and armed conflicts create animosity between groups or individuals as a consequence of personal loss or injury, witnessing or experiencing interpersonal horrors, and the stress of living with an existential threat to life. On an individual or intrapsychic level, an individually experienced traumatic event can be experienced as a sharp, sudden, deep wound to the psyche, leaving a tear in the tissue of the holistic self. On all three levels, trauma disrupts ordinary defensive patterns and systems, leaving only emergency ones; if these remain after their initial use, they are often non-adaptive (e.g., dissociation long after the traumatic events end). After major psychological upheavals, the psychic continuity of the self over time can be severed. Thus, trauma, to both the community and to the self, requires time and the presence of therapeutic elements for repair. The concept of trauma membrane will be applied in this book to a wide variety of post-conflict situations with implications both for traumatized communities and for individuals. As applied in these broad contexts, the term suggests that individuals and communities can re-invest themselves with new, healthy energy to repair the wounds of trauma. The medium of a healthy trauma membrane offers hope for healing and thus is a way to facilitate recovery after a major traumatic event disrupts individuals and communities. We will first review the context in which the phrase itself originated, in order to better understand the concept.

The Concept of the Trauma Membrane The concept of a traumatic membrane was first used to depict an external, psychosocial protection barrier that individuals (e.g., family, friends, or even mental-health professionals) provided to traumatized individuals (Lindy, Grace, & Green, 1981; Lindy, 1985). Individuals, such as family members or other individuals who experienced the same trauma (e.g., a survivor network), formed an interpersonal

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Exploring the Trauma Membrane Concept

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trauma membrane around survivors of trauma. Thus, the trauma membrane was first viewed as a post-trauma buffer zone in the environment, which shielded an individual from unnecessary exposure to further psychological stress. The formation of a trauma membrane can be understood as “multi-cellular,” in that it forms around groups of people, as well as around individual survivors (Lindy, 1985). As such, the trauma membrane might be open or closed to professionals attempting to gain access to traumatized individuals; this access depended on specific interpersonal and community dynamics (Lindy, Grace, & Green, 1981). The trauma membrane can be considered as interfacing closely with the recovery environment – the latter includes factors related to the “extent of devastation, disruption of social networks, and cultural factors” (Lindy, 1985, p. 154) and the cause of the disaster (i.e., natural vs. man-made). In addition to representing an interpersonal protective barrier, the trauma membrane can also be viewed as an intrapsychic phenomenon, in which an individual’s psyche forms a membrane around traumatic memories, in order to facilitate the healing from trauma. This concept and its distinction from the “stimulus barrier” (Freud, 1920/1955) will be explored later in this chapter. The above paragraphs describe the concept of a trauma membrane from both intrapsychic and interpersonal perspectives. This suggests that both personal (i.e., intrapsychic) and environmental (i.e., interpersonal and social) factors influence the traumatic response. Other traumatic stress researchers have emphasized the importance of taking a multidimensional viewpoint when examining trauma and its effects. For example, Harvey (1996) proposed a person × event × environment model for understanding trauma. Terr (1991) suggested there were several types of traumatic stress responses, based upon the type of trauma: (1) traumatic responses after unanticipated, one-time events (e.g., hurricanes, rapes); (2) traumatic reactions after long-term, repeated, traumatic exposure (e.g., childhood sexual abuse, political torture); and (3) trauma responses to “crossover” traumas, which she defined as sudden events that cause a disability. This book will focus on the second and third types of trauma – those involving repeated, long-term exposure (e.g., war zones) and those that cause permanent consequences (e.g., disability). In summary, the ripple effects of war and armed conflicts can cause trauma on many levels (e.g., injury was incurred, a family member was harmed, a house was destroyed, and one’s employment setting was ruined after a traumatic event). Hence, a multidimensional approach to the trauma membrane concept is needed, in view of the fact that an event may contain multi-leveled aspects that are traumatizing.

Unpacking a Metaphor Like a newly developing outer-surface of an injured cell, the trauma membrane forms to guard the inner reparative processes of the organism to protect it from noxious stimuli. Work at the surface of the membrane keeps out any foreign matter, which would further disturb the injured cell and selectively permits entrance to those agents which will facilitate healing (Lindy, 1985, p. 155).

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The “trauma membrane” as a term is, of course, a metaphor. Like any metaphor, it has entailments or overlapping, multi-layered, implicit meanings (Lakoff & Johnson, 1980). Trauma implies wound. In order for a wound to have a membrane form on its surface, it implies a natural event like coagulation forming a scab on a cut. Thus, the membrane covers a wound and forms its new outer edge. As a living biological membrane, the term also calls to mind the microscopic activity that occurs between a membrane and its outside surface. These meanings are consistent with the function of a semi-permeable membrane, which permits entrance of certain items and extrudes others, as well as the biological activity at the surface that permits and governs this activity. Each of these layers of meaning deserves some elaboration. The trauma membrane, as a biological metaphor, describes a natural covering surface over the tear. As such, it arises spontaneously. It serves dual functions: as protective barrier keeping noxious substances away from contaminating or exacerbating the wound; and as a conserving edge, covering that keeps healing materials inside. The membrane is thin, hardly visible, and, at least initially, easily broken. A membrane as a biological metaphor implies organic, natural functions that mark the body’s edge, not artificial constructs inserted from the outside. When intact and well-functioning, the membrane serves as a biological pump, carrying out a transport function in which noxious materials are expelled and healing elements introduced. As a psychological metaphor, the trauma membrane concept at an intrapsychic level reflects that individuals may disavow, dissociate, or split off the traumatic memories until they are ready to face their traumatic memories. In the process of integrating the traumatic memories, individuals may respond to present-day, neutral events with affect that does not match the stimuli. In such circumstances, the neutral events “function as if they were enzymes with a special molecular configuration. Such configurations tend to draw to them and fix traumatic memories and precipitate their being ‘metabolized’” (Lindy, 1985, p. 154). The trauma membrane metaphor allows us to imagine first a single layer of cells covering the injury, but expanding over time to include multiple layers – including the social, the interpersonal, and the intrapsychic (Lindy, 1985). Like the covering on a physical wound at a cellular level, the psychological trauma membrane permits healing from the inside outward, such that psychological healing helps to prevent long-term, damaging ramifications for individuals. This psychological metaphor parallels the physical healing that occurs when a single layer becomes multiple layers of granulation tissue (e.g., coping abilities are discovered and strengthened); by this process, there is a decrease in the size of the wound (i.e., psychologically speaking) and ultimately, the wound (e.g., traumatic memory) is covered with a minimum of scar tissue (e.g., less rigid defense mechanisms).

A Brief History of the Concept Between 1970 and 1980, changes occurred in the way mental-health professionals came to view trauma, its aftermath, and the roles they might play with individuals and communities. There was no diagnostic entity legitimizing the emotional effects

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arising specifically from trauma exposure until 1980, when posttraumatic stress disorder (PTSD) was added to the Diagnostic and Statistical Manual (DSM; American Psychiatric Association [APA], 1980). Peterson, Prout, and Schwarz (1991, p. 3) observed that “there was not a single mention of any type of trauma-related disorder, not even traumatic neurosis or combat neurosis in the DSM-I (APA, 1952) or DSM-II (APA, 1968).” Certainly, there was no place in professional lexicon for the concept that posttraumatic states can create a chronic mental-health problem. There were a few innovative programs foreshadowing the future of the traumatic stress field’s programs, which found ways for mental-health professionals to act as consultants to the volunteers, who were engaged in aftermath counseling (Hartsough, Zarle, & Ottinger, 1976). By the end of the 1980s, the assumptions about the reasonableness of a laissez-faire attitude about responses to traumatic events in communities on the part of mental-health professionals – a professional posture, which could be viewed as institutionalized trauma avoidance (Wilson & Lindy, 1994) – were changing. While working with survivors of several disasters during the 1970s, Lindy and his colleagues at the University of Cincinnati Traumatic Stress Study Center began using the phrase “trauma membrane,” first in terms of its environmentally oriented reference, namely to describe the newly forming surface over a traumatized community. As this group of clinicians and researchers assisted multiple traumatized communities, they became increasingly aware of the different ways that survivors subjectively viewed the investigators and clinicians. That is, in some post-disaster environments, mental-health assistance and research studies were welcomed, while in others, investigators and clinicians were overtly rejected. Hence, the trauma membrane term was created to explain some of the challenges faced in attempting to reach and help survivors with severe psychological reactions after a disaster (Lindy, 1985). The reasons for these different reactions were not immediately self-evident. For example, at Buffalo Creek, investigators and clinicians from the Cincinnati group expected to be viewed as outsiders, as they were hardly mountaineers from West Virginia, yet they came to be accepted within the trauma membrane. The people of Buffalo Creek hollow in West Virginia had been overwhelmed when a slag dam burst at the head of the valley, dumping millions of gallons of black water on the homes below it (Erikson, 1976). As the wall of water careened from one side of the valley to the other, homes were randomly destroyed and spared. Hundreds were killed and thousands displaced; the community itself destroyed. The inhabitants were outraged when the governor pronounced the disaster as an “act of God”; not so, the victims argued, the disaster was the direct consequence of neglect by the coal companies: It was “an act of man” (Lindy & Titchener, 1983). Two years later the owner of the local gas station began advocating for the trauma survivors. He engaged a Washington law firm who, in turn, asked 40 mental-health professionals from the University of Cincinnati to evaluate 200 survivors for the plaintiffs. At the same time, psychiatric evaluations for the defense were carried out on the inhabitants of the valley, who objected to the evaluations as being impersonal and blaming (Stern, 1976). Attorneys, together with local leaders (e.g., the gas station owner at Buffalo Creek and a leader of an informal survivor network),

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had consolidated a well-functioning trauma membrane in the 2 years after the flood. The investigators and clinicians from the University of Cincinnati Traumatic Stress Study Center, as outsiders, expected a guarded reception at best, certainly suspicion or even rejection at worst. But that was not the case in Buffalo Creek. In trailer after trailer, survivors welcomed them almost like family. They showed the investigators and clinicians the fragments that remained of lost family members and the personal possessions that had defined their former life and told their stories freely to the investigators and clinicians. The investigators and clinicians observed a healing process or space that bound similarly traumatized individuals and families and felt fortunate that they had been invited beneath its surface. Three years later, the same clinician/researcher team responded to survivors of the Beverly Hills Supper Club fire in Southgate, Kentucky, only minutes from downtown Cincinnati. Like Buffalo Creek, hundreds were killed (Titchener, Lindy, Grace, & Green, 1981). This time, they were expecting that their mental-health outreach efforts to survivors and their families would be welcomed – because they thought of themselves as part of the same community that experienced the trauma. Yet, while some small family units welcomed the efforts of professional investigators and clinicians, they discovered to their surprise that others were overtly rejecting. A gospel group was initially quite open to researchers meeting with them, but soon feared that the efforts to explore emotional reactions would lead to social hysteria, and hence, pushed the researchers outside the trauma membrane. Another instance of being outside the trauma membrane related to the Kentucky fire was evident when the University of Cincinnati Traumatic Stress Study Center’s telephone outreach team often received responses such as, “I think about it 24 hours a day; how can I afford to talk with you about it?” One way of interpreting this was that these survivors refused contact because they feared that even well-intentioned reminders of the trauma would lead to being out of control. Or, in clinical terms, contact from the team, for either therapeutic or research purposes, might activate traumatic memory leading to further regression. Survivors of trauma are often “eager for help yet frightened by the effect of any remembrance of the event” and that “from the survivor’s vantage point, professionals interested in treating or studying posttraumatic stress threaten to disturb a fragile equilibrium. Fear of affect overload makes the survivor wary. . .” (Lindy, 1985, p. 154). As a result, the door of access that leads into the survivors’ trauma membrane was shut, despite the clinicians and researchers reaching out to the survivors. Even members of the faculty at University of Cincinnati, who had worked with next of kin at the temporary morgue and retained close contact with survivors after the fire, protected their own “families” from further injury by discouraging them from participating in psychological research activities, convinced that it would be intrusive and disruptive. Here, the researchers’ own colleagues, who were working as it were on the edge of the trauma membrane, were part of a trauma membrane that kept others away, barring access to traumatized individuals. The University of Cincinnati Traumatic Stress Study Center researchers realized that having been invited to operate inside the trauma membrane at Buffalo Creek was a major asset and that operating outside that membrane, as in many of the sub-populations at the

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fire in their local community, was a significant problem in outreach, which needed to be overcome in order to be able to conduct research work. What were some of the differences in the two disasters that might contribute to the understanding of different reactions at the trauma membrane? First, the mentalhealth intervention at Buffalo Creek occurred 2 years after the catastrophe, whereas the response to survivors at Beverly Hills fire was immediate. Did it take time for a more effective and permeable trauma membrane to form at Buffalo Creek, one in which spontaneously identified leaders could act at its surface? Second, survivors at Buffalo Creek were surrounded by a community of fellowship in the disaster. There was no one immune from its effect. In contrast, survivors and their kin at Beverly Hills returned to a large city, where most had little or no connection with the disaster on a personal level. Had this distinction in the quality of fellowship of the survivors created a different type of trauma membrane? Third, the survivors at Buffalo Creek saw mental-health professionals as advocates for their cause in a lawsuit; in contrast, survivors at Beverly Hills were suspicious of the research motives of mental-health professionals and felt the need to protect the injured from further harm that might be created by accessing unwanted traumatic memories. A fourth possibility might be found in differences in cultural norms for dealing with adversity in the two settings. The trauma membrane, on a community level, seemed to be a generalized phenomenon that applied to all the traumatized populations with which the Cincinnati group worked, e.g., the Buffalo Creek dam break, Xenia tornado, Beverly Hills Supper Club fire, and American veterans of the Vietnam War. Two terms describing disasters may help in understanding the concept of trauma membrane. Centrifugal disasters (i.e., localized destruction, such as a fire in a nightclub or a bus crash, where people have convened temporarily at the site of disaster but would eventually return home to diverse areas) seemed to contribute to a weaker and less effective trauma membrane. In contrast, centripetal disasters (i.e., more extensive destruction in larger areas, such as tornados and hurricanes, where survivors must recover in a damaged community, but one that contains neighbors who are fellow survivors, and thus who understand the trauma) tended to form a stronger and more effective trauma membrane (Lindy, Grace, & Green, 1981). In centrifugal disasters, survivors are more isolated. They are surrounded by a community of non-survivors, who may not understand their post-trauma reactions. In such circumstances, mental-health professionals are also likely to be perceived as outsiders and thus, are not invited into the multiple levels of the trauma membrane. In contrast, after centripetal disasters, survivors are more united, such that the boundaries of the trauma membrane, in time, become stronger and also more functional, allowing competent professionals inside to help survivors. In such a situation, “trauma membranes around individual survivors may fuse together to form an inclusive community-wide trauma membrane” (Lindy, Grace, & Green, 1981, p. 475). Early work with the trauma membrane on a community level suggested that the time, nature, and duration of catastrophe, damage to community structures, attitudes toward the event, communication among survivors, emergent survivor

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leadership, and the culture of recovery are factors that influence the functionality of the trauma membrane. This book allows further exploration of these and other variables that make a difference in establishing the quality and effectiveness of a given trauma membrane. The next sections will explore various dimensions of the trauma membrane.

The Trauma Membrane at the Level of the Intrapsychic Structure A trauma is broken into bits to be integrated, digested, or repressed. (Krueger, 1984) The psychic organism is capable in its own time of breaking down the impact of traumatic stressors and their associated affect states into manageable amounts that permit gradual intrapsychic processing (Lindy, 1986, p. 198).

Typically, an individual cannot process the traumatic memory related to a trauma or disability immediately and fully, because the event is incomprehensible to the individual and because the information about its present and future implications may overwhelm an individual’s psychological capacity if it were faced all at once. Hence, the trauma memories are titrated by means of a trauma membrane, which protects the person’s psyche from being overloaded and allows time for processing the trauma. The intrapsychic application of the trauma membrane originated when Lindy and his colleagues realized a second use of the trauma membrane term while reviewing the individual reports of psychotherapy with former American combat veterans of the Vietnam War, who were being treated by psychoanalysts from the Cincinnati Psychoanalytic Institute. This second perspective of the concept was defined as an intrapsychic structure, namely a temporary, posttraumatic, psychological layer that covered a damaged perceptual apparatus of the survivor. From this perspective, the trauma membrane is an internal mechanism, developing within an individual’s psyche after trauma (Lindy, 1985). It is “a semi-permeable membrane which covers the space left in the repression barrier by the trauma experiences” (Lindy & Wilson, 2001, p. 436). The trauma membrane is semi-permeable in the sense that the traumatized individual decides who to let under the membrane and into their “phenomenal reality,” but at the same time, the individual also chooses who to deny access and thus, “use[s] ego defenses to protect their perceived and experienced sense of vulnerability” (Lindy & Wilson, 2001, p. 436). Hence, the traumatic membrane permits selective access to the traumatic memories – both in the intrapsychic and in the interpersonal sense.

The Formation of an Intrapsychic Trauma Membrane When one encounters memories of events that still cannot be accepted lovingly, peacefully, and comfortably, one may be driven to continue to promote the painful affective responses

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and renew the struggle against objects from the past that now patently reside nowhere but in one’s own mind. Unmastered memories represent unhealed “wounds,” which keep generating painful affects. Memories that cannot be accepted may have to be reinterpreted or modified in a kind of self-detoxification (Krystal, 1985, p. 156).

We could summarize the development of the trauma membrane: After a traumatic event, a psychological membrane enfolds the traumatic memories. The purpose of this intrapsychic membrane is to cordon off the internally or externally generated components that would interfere with the naturally occurring psychological healing related to the trauma. This psychic separation of the traumatic memories from a person’s normal psychological processing may permit the individual to function despite the traumatic event. In an internal process, the individual titrates access to his or her own traumatic memories, in order to be able to gradually absorb and process the traumatic memories. At the same time, the individual decides to whom to grant access to the traumatic memories, as a way of mediating who or what elements would facilitate healing (i.e., maintaining the interpersonal trauma membrane). Thus, because traumatic memories can be stress provoking, the trauma membrane acts as an ego defense against re-traumatization by titrating exposure to traumatic memories that may originate from internal or external sources. Some trauma therapies use imaginal exposure to trigger a titrated recall of traumatic events; the individual permits the therapist to breach the trauma membrane in controlled circumstances (i.e., a therapy session) if the trauma membrane appears faulty (i.e., if intrusive memories are occurring at a distressing rate). Intrusive memories can be understood as when traumatic memories leak across this membrane without the individual’s volitional, conscious control. The trauma membrane is not rigid and thus, trauma memories cross the trauma membrane, which is part of the intrapsychic processing traumatic events. When the trauma membrane is fragile, individuals may experience a flooding of traumatic memories into their consciousness, which can include flashbacks or intrusive, non-verbal memories (e.g., smells, sights, sounds). Because intrusive memories are a repetition of the trauma and hence traumatizing, an individual will work to protect against such occurrences by internal defense mechanisms (e.g., using denial; Livneh, 2009), as well as external defense mechanisms (e.g., avoiding stimuli that may trigger reminders of the trauma). Internal defenses, which the individual can quickly use when a “tear” occurs in the individual’s trauma membrane, include denial, disbelief, dissociation, and disavowal. Using the trauma membrane concept in this intrapsychic manner draws attention to the perceptive apparatus as the site of psychological injury in trauma and offers clinical opportunities for new foci in the treatment. When not encapsulated by a trauma membrane, reminders pierce the injured surface, producing acute physiologic hyperarousal and dysphoric states that recapitulate the traumatic experience. The resulting abreaction is disorganizing to the survivor and does not lead to healing; abreaction per se does not help, as it does not occur in a healing context. Kardiner (1941) explained that abreaction has no curative value for treating traumatic neurosis because “the whole ego structure has been altered in these chronic cases” (p. 216, emphasis added), making abreaction “irrelevant” for curing traumatic

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neurosis. Kardiner’s quote reflects an understanding of the power of trauma to cause changes in an individual’s intrapsychic functioning. To facilitate psychological functioning after a traumatic event, the intrapsychic trauma membrane encapsulates a traumatic memory that consists of verbal and nonverbal memories, which range from narratives of the event to affective reactions to sights, sounds, smells, and physical sensations of a trauma. The containment of the trauma memories is supported by ego defenses until the individual is ready and able to psychologically process or “work through” the trauma (Horowitz, 1976; Lindy, 1986). Working through the trauma is a naturally occurring process, according to many researchers, including Freud and Horowitz (see the followings sections). As the two quotes at the beginning of this section reflected, memories of a traumatic event need to be assimilated gradually, because they are often highly distressing and intellectually incomprehensible. The following sections will present an overview of various theorists’ perspectives on how this integration of traumatic memories occurs. The concept of the trauma membrane owes much to these investigators. We begin with a brief section on trauma neurosis and Freud’s idea of the stimulus barrier.

Freud’s Ideas on Trauma Neurosis According to Freud (1935), an event could be defined as traumatic if [W]ithin a very short space of time [the event] subjects the mind to such a very high increase of stimulation that assimilation or elaboration of it can no longer be effected by normal means, so that lasting disturbances must result in the distribution of the available energy in the mind (p. 243).

A person’s stimulus barrier acts as a protective filter for physiological and psychological stimuli, according to Freud (1920/1955). This stimulus barrier can be penetrated by traumatic events: We describe as “traumatic” any excitations from outside, which are powerful enough to break through the protective shield. It seems to me that the concept of trauma necessarily implies a connection of this kind with a breach in an otherwise efficacious barrier against stimuli. Such an event as an external trauma is bound to provoke a disturbance on a large scale in the functioning of the organism’s energy and to set in motion every possible defensive measure. At the same time, the pleasure principle is for the moment put out of action. There is no longer any possibility of preventing the mental apparatus from being flooded with large amounts of stimulus, and another problem arises instead – the problem of mastering the amounts of stimulus which have broken in and of binding them, in the psychical sense, so that they can then be disposed of (pp. 33–34).

The intrapsychic structure of the stimulus barrier, when functioning, keeps away the images and experiences (i.e., trauma-related) that would otherwise might overwhelm it. Freud (1920/1955) depicted the stimulus barrier as functioning by protecting against stimuli and receiving stimuli. It can also be used to deal with stimuli originating from within, the stimuli that are treated as originating from the outside (i.e., the defense mechanism of projection), and externally generated stimuli.

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Freud (1920/1955) thought that the piercing and the collapse of the ordinarily protective stimulus barrier were responsible for feeling overwhelmed in traumatic states. In the aftermath of trauma, the stimulus barrier becomes broken and nonfunctional. Freud viewed the disorder of traumatic neurosis as originating from a stimulus barrier that was overwhelmed or extensively ruptured by environmental forces, due to the intensity of the traumatic event. The roots of the construct of posttraumatic stress disorder (PTSD) in the concept of trauma neurosis may be traced to the psychoanalytic theories of Freud, in addition to several of his contemporaries, which will be explored in the following section. In his eighteenth lecture, Freud (1935) analyzed the traumatic neurosis of individuals, who were veterans of war and who fixated on their traumatic experiences. He stated that not all fixations will lead to a neurosis, but that all neuroses have fixations. Freud asserted that these individuals reproduced the trauma in their dreams because they have not been able to sufficiently deal with the situation (i.e., traumatic memories). Freud (1920/1959) noted that individuals with traumatic neurosis may experience intrusive dreams that are repetitive and that return to the time of the accident/trauma. He explained that even in view of his theory of the pleasure principle (i.e., that individuals seek pleasure and avoid pain), the repetition of unpleasant matter may occur in the mind, in order to allow traumatic events to be recollected and faced. This process of repeating trauma, noted Freud, works independently of and is more primitive than the pleasure principle, yet can operate simultaneously with the pleasure principle. Freud described that the compulsion to repeat certain traumatic material in the present does not bring pleasure, just as the event was not pleasurable when it occurred in the past. Freud also noted the phenomenon that the repetition of repressed material occurs as if the event was occurring in the present period of time, instead of a memory of the trauma as a past event. Freud (1920/1955) wrote [The patient] is obliged to repeat the repressed material as a contemporary experience instead of, as the physician would prefer to see, remembering it as something belonging to the past. . . [the physician] must see to it, on the other hand, that the patient retains some degree of aloofness, which will enable him, in spite of everything, to recognize that what appears to be reality is in fact only a reflection of a forgotten past (p. 19).

According to Gediman (1971), Freud proposed as early as 1895 that the existence of a stimulus barrier was a requirement for the survival of an individual in the world, due to the many forces impinging upon the individual. Gediman depicted Freud’s concept of a stimulus barrier as a primitive defense mechanism that served as a precursor to the more sophisticated ego defense mechanisms. In Gediman’s analysis, Freud described the stimulus barrier as having a dual function of protection and reception of stimuli. Yet, it was not clear, over the course of decades of his writing, whether Freud viewed the barrier as solely a neurological one or as a psychological one (or both), according to Gediman. Gediman (1971) proposed that the concept of stimulus barrier should be defined as a complex ego function with multiple factors. She argued that the stimulus barrier is not a simple concept, because of the evidence that the stimulus threshold

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can be lowered (i.e., sensitization) or raised (i.e., adaptation) with traumatic stimuli. Further, several researchers have proposed that the stimulus barrier can be both passive and active by the receptive and protective functions respectively. For example, Brett (1993) depicted Freud’s explanation of “repetition compulsion” as an active defense mechanism that allows individuals to develop mastery over trauma, in contrast to the passivity and helplessness that may have been experienced during the occurrence of a trauma. Gediman (1971) noted that “agitated or chaotic motor behavior and sleep disturbances are among the most reliable indicators we have that the stimulus barrier tends towards the maladaptive” (p. 254). According to the present-day diagnostic criteria of PTSD (APA, 2000), these symptoms of non-adaptive motor discharge reflect the hyperarousal cluster of the PTSD cluster. Later theorists (Gediman, 1971; Krystal, 1985) reasoned that the stimulus barrier is active and integrative. Gediman noted that the protective function involved active accommodation to stimuli with the passive receptive function (e.g., thresholds) and concluded that the stimulus barrier was both a sensory/perceptual threshold, as well as an adaptive ego function. This contrasts with Freud’s view that the stimulus barrier was a precursor to the ego. Gediman’s summary definition of the stimulus barrier is that it “may be reformulated as a complex ego function measurable along a dimension of adaptiveness–maladaptiveness. It refers to the structures and functions which enable a person to regulate amounts of inner and outer stimulation so as to maintain optimal homeostasis and adaptation” (Gediman, 1971, p. 254). In their discussion on war neurosis, Ferenczi, Abraham, Simmel, and Jones (1921) defended Freud’s perspective that war (and peacetime) traumatic neurosis had sexual origins. Yet, the understanding of war neurosis gradually evolved, with Kardiner writing extensively on the concept two decades later (see the next section). Kardiner (1941) noted that the most important idea that Freud advanced regarding the traumatic neurosis is that “the normal defense against stimuli (Reizschutz) had been broken through, and that the neurosis consisted of the consequences of this rupture, and the subsequent efforts at mastering the vast quantity of stimuli that overwhelm the subject” (p. 137). With the work of Freud, Gediman, and Brett in mind, we understand the trauma membrane to represent a dynamic, temporary, complex, protective structure that bridges a broken stimulus barrier, protecting the psyche as it moves from trauma toward healing and homeostasis. Thus, the wound in the stimulus barrier is healed by means of the trauma membrane, which temporarily bridges the gap in the stimulus barrier as it is structurally repaired.

Kardiner and Traumatic Neurosis Kardiner’s monograph (1941) on traumatic neurosis included 24 case studies on the topic. He commented that Freud did not elucidate how the stimulus barrier was constructed, how it was manifested in individuals, nor how it fit with the Freudian idea on instincts (the “yet undefined ego instincts, ‘Eros’ or life instincts”;

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p. 136). Instead of using the Freudian viewpoint on traumatic neurosis and sexual instincts, Kardiner wrote that traumatic neurosis involved an instinct (or drive) for self-preservation and that traumatic neurosis was a syndrome that consisted of both drive and action. He noted that in traumatic neurosis, a contraction of the ego occurred along with a cognitive disorganization. Kardiner (1941) defined trauma as involving inhibition (or the ceasing of specific functions), which was a primary symptom: [A] trauma is an external influence necessitating an abrupt change in adaptation, which the organism fails to meet, either being destroyed entirely by the external agency or in part, and that this destruction may involved not tissues but adaptation types. The predominant alteration of adaptation found in the stabilized forms of the traumatic neurosis are inhibitory processes which can destroy the utility value of an organ or its functions (p. 81).

In addition to Kardiner’s definition of trauma as requiring a change in an individual’s adaptation, he defined traumatic neurosis as “[A] type of adaptation in which no complete restitution takes place but in which the individual continues with a reduction of resources or a contraction of the ego” (p. 79). Further, he defined adaptation in the following manner: Adaptation is a series of maneuvers in response to changes in the external environment, or to changes within the organism, which compel some activity in the outer world to the end of continuing existence, to remaining intact or free from harm, and to maintain controlled contact with it (p. 141).

While Kardiner noted that “the psychological fabric of the neurosis remains very thin” (p. 87), he stated that individuals with traumatic neuroses are able to respond in an organized, adaptive manner, but also may experience continued symptoms as a consequence of the trauma: [T]he adaptation of the individual shows an organized effort at restitution by continuing the protective devices used on the original occasion of the trauma. However, that is not all. This evidence points very strongly to the fact that the individual is really in a continuous state of heightened vigilance and that his conception of the outer world and himself have undergone considerable change (1941, p. 84).

Elaborating on traumatic neurosis, Kardiner claimed that a person with such a neurosis can be explained from dual perspectives: “from the physiological point of view, there exists a lowering of the threshold of stimulation; and, from the psychological point of view, a state of readiness for fright reactions” (1941, p. 95). Individuals with traumatic neurosis may experience the perception that “he has lost command of the more highly integrated forms of defense against [the trauma], and what remains is nothing but two primitive modes – violent and disorganized aggression, or abject helplessness” (p. 95). The aggression is that “he annihilates or is annihilated” (p. 94). Further consequences from experiencing trauma include “. . .that portion of the ego which normally helps the individual to carry out automatically certain organized aggressive functions of perception and activity on the basis of innumerable successes in the past is either destroyed or inhibited” (pp. 116–117; emphasis added). Hence, experiencing trauma may cause some alteration in functioning, and sometimes it can be psychologically paralyzing.

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Brett (1993) summarized Kardiner’s two stages or mechanisms that explained the five main symptoms found in stress disorders (i.e., nightmares, trauma fixation, startle response, aggression, and a decrease in general functioning): (a) a failure or destruction of adaptive functioning, including a withdrawal of the processes that govern the individual’s interaction with the environment and a “massive” psychological and physiological constriction; (b) a reorganization of an individual’s capabilities, in order to regain adaptive capacities. Brett described Kardiner’s theory as containing the activating principle of “primary adaptive failure” (p. 67), causing withdrawal, constriction, and eventually an effort at restitution. Keeping Kardiner’s ideas in mind, we see damage to the trauma membrane during the potential recovery period as interrupting adaptation, and as re-initiating non-adaptive emergency defenses that are brought into play in the service of survival at the time of the original trauma.

Integrating Traumatic Memories Pierre Janet, in his L. automatisme psychologique in 1889, proposed that a failure in information processing was a key to the development of non-adaptive reactions to trauma (Powers, Cruse, Daniels, & Stevens, 1994; Van der Kolk, Brown, & Van der Hart, 1989). That is, the key issue underlying posttraumatic syndromes, according to Janet, is the inability to integrate traumatic memories (Van der Hart, Brown, & Van der Kolk, 1995). According to Pierre Janet, there may be a “phobia” or avoidance of the traumatic memories, resulting in a resistance for integrating the traumatic memories and in a continuance of those memories as isolated fragments that are split off from ordinary consciousness (Van der Kolk et al., 1989). Janet’s clinical observations of traumatized individuals provided evidence that the human consciousness can develop into two or more “separate, dissociated streams of consciousness, each with a spectrum of mental contents such as memories, sensations, volitions, and affects” (Van der Kolk et al., 1996, p. 84, citing Nemiah). Thus, Janet asserted that PTSD was a result of psychological insufficiency and the decreased ability for synthesis and integration of the trauma, not a result of an anxiety reaction (Van der Kolk et al., 1989). The intrapsychic trauma membrane, as presented in this chapter, can be viewed as a psychological barrier that moderates the integration of traumatic memories. In order to integrate traumatic memories and stimuli, the psychological membrane would need to be permeable, allowing for the dosing of psychological trauma fragments into one’s primary stream of consciousness. According to Janet, there were two memory systems, which work somewhat independently from each other and in which intense emotional experiences were stored: (a) the autobiographical, verbal memory and (b) implicit memory that contains the sensory and emotional imprints of events (Van der Kolk, 2004). While the autobiographical memory may be altered over time, the implicit memory

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preserves traumatic memories without much alteration, such that individuals may re-experience those emotions and sensory experiences in a manner that closely resembles the original trauma. This distinction between the two memory systems is one reason why therapeutic techniques, which depend highly on the cognitive ability to revisit and reframe past events, may not be very effective for dealing with trauma, due to not addressing the implicit memory (Van der Kolk). Janet viewed the core problem related to trauma as helplessness from failing to take appropriate action against threats. This lack of action at the time of trauma requires that traumatized individuals create a verbal representation of the trauma, in order become active and transform trauma into a memory that is tolerable (Van der Kolk et al., 1989). Brown, Macmillan, Meares, and Van der Hart (1996) explained the divergence of the theories of trauma as proposed by Freud and Janet: Janet viewed non-conscious processes as divided laterally, while Freud depicted non-conscious processes as divided vertically, or in terms of depth or layers of consciousness. According to Janet, there existed a central core of active consciousness that may have peripheral, passive states of subconscious awareness. There can be times when these peripheral, subconscious states can become conscious and active, such as after the occurrence of a trauma. Janet proposed that these subconscious states may operate independently from the central core of active consciousness. Further, Janet proposed a three-stage process of “posttraumatic hysteria” (Brown et al., 1996). The first stage involves an acute stage of high emotions in which the trauma is not yet assimilated. This is followed by a second stage in which traumatic memories are dissociated from consciousness and operate as “fixed ideas.” This stage involves a narrowing of consciousness and the intrusion of trauma-related images and experiences, which alternates with avoidance of the stimuli that trigger intrusions. The third stage consists of emotional exhaustion, in which non-specific psychological states, such as depression, may occur. According to Janet, “posttraumatic hysteria” was a process in which there was an increasing lack of integration, creating even a broader range of problems in personality functioning and synthesis. This refers to one of the primary differences in viewpoints between Freud and Janet: Janet’s perspective focused upon psychological integration and dissociation, while Freud’s concepts centered upon the activity of the ego and its defenses. Thus, Freud’s views were more “illness-oriented,” whereas Janet’s perspectives were more oriented toward health, growth, and integration of the self (Brown et al., 1996 p. 487). In addition, according to Brown et al., Freud’s viewpoints generally did not include factors from the environment because of his focus upon the deterministic, internal states of mind, while Janet’s theories tended to be more multidimensional, including biological (i.e., sensory), psychological, and social factors.

Information Processing Views on PTSD Rivers (1918) described the development of a traumatic neurosis, suggesting that repression, or the process by which some part of an individual’s mental content

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is pushed out of one’s memory, leads to a state of inaccessibility of part of one’s memory to manifest consciousness (often called “dissociation” or splitting of consciousness). Fairbanks and Nicholson (1987) noted that psychoanalytic conceptualizations of trauma were based on the idea that traumatic neurosis arose from energy overload and that the individual’s ego attempted to release this energy by binding or abreacting. These concepts, and concepts such as Janet’s explanations on the failure to integrate traumatic memories, eventually evolved into the concept of trauma as an information overload, which required that the individual integrated the trauma and its meaning into the individual’s self-concept and worldview. The information processing perspective on traumatic neurosis is typically represented by Horowitz’s theories. Horowitz and Kaltreider (1979) wrote that adaptation to loss is the ideal goal after trauma, but that there is a difficult interval that follows recognition of loss, in which individuals may waver among certain cognitive perspectives as new views of the world are formed and new information is processed. Horowitz proposed that responses to trauma often trigger a cycle of reactive phases that involve grieving for and facing losses, which may entail a “dosed” response to the trauma that is moderated by control mechanisms. If an individual is able to balance these modulations of phases, it may lead to new states that are adaptive. Horowitz (1997) asserted that responses to trauma are “known, phasic, and recognizable” (p. 2). Horowitz (1986) proposed six reactive phases to a traumatic event, which may overlap: event and immediate coping, outcry, denial, intrusion, working through, and completion; he also detailed their pathological intensifications (see p. 27). Horowitz (1997) stated that clinical and experimental studies reported a set of polar responses to trauma, which included the following: (1) intrusive and repetitive emotions, thoughts, and behaviors and (2) avoidance, denial, numbing, and behavioral constriction. Horowitz (1986) depicted the process of adaptation to trauma as occurring in phases, in which an individual may experience thoughts and feelings with various themes related to the trauma – some of which may be contemplated and processed, while others that are too threatening will be denied. The themes that are denied or warded off may appear later in intrusive-type episodes. When themes are warded off, they become part of a dynamic unconsciousness, in which they are “preserved in active memory, [thus] they tend toward repeated representation and processing” (Horowitz, 1986, p. 97). Horowitz also noted that both psychological and biological factors interact when an individual attempts to integrate the traumatic event. Yet, he emphasized that personality and trauma history will always play a role in whether an individual reacts non-adaptively to trauma, because “previous concerns and conflicts will always be caught up in an associative matrix with the meaning of events” (1986, p. 166). Fairbanks and Nicholson (1987) depicted Horowitz’s theory of PTSD as an alternation between defensive under-control (i.e., intrusive images) and over-control (i.e., avoidance, numbness). They noted that integration of traumatic experiences is the ultimate goal of any psychodynamic treatment of PTSD, though the techniques by which this is achieved will vary according to clients and the phases of

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PTSD. Brett (1993) depicted Horowitz’s theory as composed of a principle of a “completion tendency of cognitive processing” (p. 67). Keeping Horowitz’s contributions in mind, we believe that part of what enables the re-working of trauma, in measured doses rather than repeated abreactions, is the presence of a well-functioning trauma membrane, including a positive relationship with a therapist or other nurturing guides. A robust trauma membrane will lead to perceptions that are limited and focused, and affect that is dosed and regulated.

Other Models of Processing Traumatic Memories Brett (1993) proposed a distinction between two types of PTSD theoretical models. The first type of model, such as Freud’s and Horowitz’s, consisted of two alternating states that were immediate reactions to trauma. These states involved the tendency to repeat the trauma and the tendency to avoid or defend against the trauma. According to Brett, the explanatory scheme of Freud’s model involved memories that led to painful affect and thus, to a defense against this affect. The explanatory scheme of Horowitz’s model consisted of information leading to painful affect and then controlling against this affect, which oscillates until the cognitive processing of the trauma is completed. In contrast to a PTSD model of alternating states, a second type of PTSD was a “progressive unfolding of one process” (Brett, 1993, p. 67). According to Brett, this progressive unfolding type of PTSD model was used in other scientists’ theories, such as Kardiner’s. This kind of PTSD model proposed that trauma triggered a comprehensive failure in a person’s adaptive system. Resulting from the “crippling” or failure of adaptation, the intrusions of the trauma were secondary processes and stemmed from the lack of defensive ability against traumatic memories (Brett, 1993). Models of cognitive processing depict individuals as maintaining a certain mental framework that contains past experiences, beliefs, and expectancies (Creamer, Burgess, & Pattison, 1992). When traumatic events occur, individuals have to integrate these experiences into their inner schema. Until the trauma can be assimilated mentally, the trauma and information related to it will be stored in active memory and will continue to intrude. In order to empirically examine a cognitive-processing model of traumatic events, Creamer and colleagues conducted a longitudinal study among 158 individuals at 4, 8, and 14 months after witnessing an incidence of workplace violence, in which 8 people died. These researchers argued that intrusion precedes avoidance symptoms, because intrusion occurs when a trauma or fear network is formed. This fear network includes stimuli cues about the trauma, cognitive, affective, physiological, and behavioral responses, and interpretive information about the trauma. These researchers found that scores on the intrusion and avoidance subscales (as measured by the Impact of Event scale) mediated the severity of exposure to trauma (measured as a dichotomous score) and the resulting symptom levels (as measured by the Global Severity Index), which they interpreted as a

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possible indicator that individuals were processing their trauma cognitively. Further, intrusion was negatively related to and a good predictor of GSI scores on all three assessments, which Creamer, Burgess, and Pattison interpreted as support that the fear network was activated and that intrusive thoughts resulted in more global dysfunction, rather than vice versa. The relationship between levels of avoidance and symptom levels dropped over time, such that avoidance predicted GSI levels at 4 months, but did not at 14 months. The researchers interpreted this as an indication that avoidance, as a short-term mechanism, interferes with processing and therefore causes higher symptom levels, yet in the long term, avoidance may be a useful coping strategy for some people. In terms of the relation of processing traumatic memories and the traumatic membrane, the process of working through traumatic experiences within the context of a well-functioning trauma membrane, according to Lindy (1986), involved three tasks: (a) pinpointing affect-laden memories of the trauma, (b) ascribing meaning to the traumatic memories, and (c) recreating a psychological connection with one’s past. Yet, such a process requires a level of ego strength and cohesion, which may have been disrupted by the psychological traumatization. If an individual’s ego strength is diminished, then reminders of the traumatic event may pose as a psychological threat and thus, be avoided instead of being integrated. Hence, the processing of traumatic membranes in the intrapsychic trauma membrane may need to be facilitated at the level of the interpersonal trauma membrane, i.e., with the help of therapists or other individuals who are providing psychosocial support.

Processing Traumatic Memories and the Trauma Membrane Concept Most researchers and clinicians would agree that the first step in integrating a trauma experience consists of processing the psychological shock of the trauma. If this shock is overwhelming, then individuals will attempt to cordon off the memories of the trauma; this process of creating an intrapsychic membrane around traumatic memories is exemplified by a case report, in which a survivor – in order to deal with the guilt, sadness, and anger – “organized herself to ward off, wall off, and encapsulate the feelings and the conflicts about them” (Lindy & Titchener, 1983. p. 91). Krystal (1971, 1985) noted that while the mastery of the traumatic event may have to do with working through the ideational implications of the event (i.e., the psychic reality of it, the meaning of it, the unconscious fantasy mobilized by it), the crucial issue at the time of the onset of the traumatic experience is affect tolerance. In order to prevent the initiation of the traumatic syndrome, the individual has to be able to tolerate the affective responses to trauma. Krystal noted that these responses are developed at the time with intensity high enough to lend the experience the feeling of reality, but not so high that it overwhelms a person and drives him or her to use primitive defenses. If the individual’s affect tolerance is exceeded, the person

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may have to ward off the affect by becoming depersonalized, i.e., by developing a massive “numbing” through isolation of the affect (p. 17). In terms of the trauma membrane, the affect tolerance is a psychological threshold value that determines whether the trauma membrane will be permeable, as far as the exchange of traumatic memories past the trauma barrier. Krystal (1971) depicted the function of traumatic neurosis or posttraumatic stress symptoms as serving a purpose. One purpose for the trauma membrane is its continuing to ward off the traumatic memories, because those memories have not been integrated into a person’s psyche: [T]he need, when the affect had been so frightening, [is] to repeat the experience in word and deed, and in dreams and daydreams, and then gradually to increase the tolerance of the affect, thus overcoming the fear of it. Sometimes, however, this effort is not successful, and there remains a lifelong compulsion to repeat the experience and relive the affect, especially in dreams (p. 18).

Rachman (2001) wrote about emotional processing and its cognitive processes, especially in reference to PTSD. He described PTSD as a long-term reverberation (i.e., re-experiencing) of emotional experiences. The flashbacks “are a vivid example of. . .unexpected fragmentary returns of emotional experiences” (p. 165). Further, the neutralization of emotion-provoking stimuli involves “cognitive changes and these promote the breaking-down of incoming stimulation into manageable proportions, which can then be absorbed over time” (Rachman, 2001, p. 170). He lists the following as a direct indication of incomplete emotional processing of traumatic memories: [T]the persistence or return of intrusive signs of emotional activity, such as obsessions, flashbacks, nightmares, pressure of talk, inappropriate expressions or experiences of emotions that are out of context or out of proportion, maladaptive avoidance. The indirect signs include an inability to concentrate on the task at hand, restlessness, irritability and other indicators of the heightened arousal that is characteristic of PTSD (p. 165).

Further, Rachman (2001) noted that successful processing (i.e., traumatic memories moving across the trauma membrane) is reflected by adaptation, for which individuals are able to converse about, see, listen to, or experience reminders of trauma-related stimuli, while experiencing a decline in distress, disturbed behavior, or non-adaptive cognitions, and a return of customary behavior. Rachman noted that four groups of factors can lead to problems in emotional processing: state factors (e.g., illness, perceived threat), non-adaptive cognitions (e.g., negative appraisals, inflated sense of responsibility, “sense of permanent disability,” p. 169), personality factors (e.g., extreme introversion, neuroticism), and stimulus-related (i.e., trauma-related) factors (e.g., large stimulus inputs). In summary, the trauma membrane can be viewed as a temporary psychological structure that forms on the surface of a damaged perceptual apparatus (i.e., stimulus barrier), covering and protecting this primary site of psychological injury in its aftermath. The semi-permeable nature allows traumatic memories to cross the trauma membrane and enter into an individual’s consciousness, in order to be ascribed new meaning and to be gradually assimilated or integrated. The theories about how this

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processing occurs are distinct, yet can be viewed as useful for understanding how an individual processes traumatic memories so that they do not become or remain psychologically paralyzing.

Interpersonal Facilitation of the Trauma Membrane As outlined earlier, at the level of intrapsychic structure, the trauma membrane replaces a damaged perceptual apparatus or stimulus barrier and interfaces the damaged psyche of the survivor with potential reminders of the trauma. This interface mediates between everyday reminders of the traumatic event in the external world and the internally held traumatic memories. The survivor tends to react to these external stimuli in the present as though the trauma were recurring, without processing the difference in degree of danger. Therapists work at the boundary of this trauma-membrane interface: . . .[T]herapy is an effort to remove the blocks to an essentially spontaneous healing process. In order to this, he must be invited to the boundary of the trauma membrane, be permitted entry, and maintain that as healing space, dosing or titrating traumatic memory and its processing. . .[Entering beneath a client’s trauma membrane] is an extremely tentative and gradual process, but once complete, is remarkably enduring (Lindy, 1986, pp. 200–201).

The concept of the trauma membrane is useful to therapists, as they balance their client’s need for processing trauma while having a fear of loss of control, which is stirred by approaching stimuli that might trigger a traumatic reaction. In such clinical situations, the trauma membrane forms slowly like a single layer of epithelium along the surface of the open wound, implying, at best, a limited vocabulary of defensive operations, such as dissociation. The resumption of a more complex, rich, adaptive vocabulary of defenses (i.e., multi-cellular) in the aftermath of trauma can replace that thin, all-or-nothing defensive response (i.e., only one cell deep); this may occur only after appreciable psychological work has been accomplished. Hence, the reactive, rigid defense mechanisms can be eventually replaced by higher-order defense mechanisms as the traumatic memories are processed. Empathy in the form of natural supports or in the person of the therapist reinforces this thin layer around the traumatic memories, until a sturdier granulation tissue (on a psychological level) has formed and the survivor can re-establish a more adaptive defensive repertoire. Therapists have noted that “some patients with PTSD fear that treatment itself will overwhelm a fragile barrier protecting the patient from his traumatic memories. Such patients will flee lest continuing contact with the therapist make this an unmanageable psycho-economic state” (Lindy, Green, Grace, & Titchener, 1983, p. 600). The flip side of having too rigid of a trauma membrane is that the client will be resistant to therapy and the interpersonal process that therapy entails (Lindy et al., 1983). So long as defenses are in the service of reinforcing disavowal, the therapist does not have permission to make links to the trauma situation. If the therapist aggressively tries to penetrate the trauma membrane, harm may occur. If the therapist is

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guided by a strategy of digging out the trauma content, he or she is at risk of plunging past these fragile defenses and exacerbating not a dosed trauma segment, but an overwhelming traumatic reenactment and a potential fracture of the therapeutic alliance – in short, of causing harm (Lindy & Wilson, 2001, p. 439): [Therapists’] fingers are metaphorically on the window to the trauma, opening it only so far as the patient is ready to tolerate. And we measure this readiness, as does he in the relative strength and flexibility of those defenses. This is the central message of “do no harm” (Lindy & Wilson, 2001, p. 440).

The theoretical structure of the trauma membrane allows the client the opportunity to place the therapist in such a healing position as the treatment proceeds. A therapist’s attention to the forming of the trauma membrane requires a special emphasis on the clinician’s use of pacing and the dosage of exposure. This titration of exposure to traumatic memories should be based on the readiness of the trauma membrane to absorb and process stimuli more adaptively. By this process, the therapist, working as though within the trauma membrane, finds a useful position to move the treatment in the direction of mastery. To illustrate this process, during a post-treatment interview of a traumatized Vietnam veteran, a former client was asked to describe the impact his therapist had on him (Lindy, Spitz, Macleod, Green, & Grace, 1988, p. 315): Vince thought for a moment and then described the following experience. “Before the treatment, certain sounds, like a helicopter, or weather conditions such as a sultry day, or an image along a tree line, set me off. I would get agitated and knew I might get out of control and do something violent. Now,” he said, “I ask myself, what would Dr. S (my therapist) say about this? Dr. S. would remind me that I am in Cincinnati not in Vietnam and the year was 1982 and not 1968. Then I would begin to relax and no longer feared I would lose control.”

This vignette illustrates how the client, Vince, had placed his doctor as an auxiliary presence at the periphery of his sensory apparatus, which helped the client discriminate between dangerous and indifferent stimuli. That is, the client had placed Dr. S. at the very site of an internal, intrapsychic, trauma membrane, which had permitted the therapist to function as auxiliary discriminator between dangerous and neutral input. Although this is an interpersonal process between the client and the therapist, the psychological work was conducted at the intrapsychic level of the client’s trauma membrane. It is challenging for therapists to work with survivors of traumatic events; they have to face the existential despair of their clients and the multi-faceted nature of their questions. An example of the multitude of profound questions that a client may ask is as follows: In the overwhelming nature of the experience, the survivor asks “Where is order?” In the grotesqueness that continues to invade his or her mind, he or she asks “Where is peace?” In the helplessness of being unable to prevent the catastrophic events, he or she asks, “What did I do?” In the complex emotions surrounding impossible choices, he or she asks, “What else should I have done?” In the pain of loss amidst fire explosion and death, the grieving relative asks, “How did he die?” In the anguish of an altered world, the survivor asks, “How can I ever understand myself in relation to this new world?” (Lindy & Lindy, 2004, p. 576)

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In the pressure to have answers to the above questions, the therapist may overreact by fulfilling the client’s wish for an all-knowing, all-comforting guide, may distance him/herself from the client by refusing to respond, or may become overwhelmed by the client’s existential despair (Lindy & Lindy, 2004). Therapists may make such choices, instead of quietly bearing witness to the survivor’s testimony (Felman & Laub, 1992). The concept of an interpersonal trauma membrane may also apply to the counselor/therapist. That is, when traumatic stories of unimaginable pain and abuse break through the stimulus barrier of the therapist, he or she may create a trauma membrane to regulate the impact of these client narratives, in order to protect against absorbing the un-metabolized trauma and consequently experiencing secondary victimization. The therapist may also use distancing or avoidance of the client’s pain, colluding with the client so as to block hearing more trauma-related details; these may be forms of counter-transference resistance/defenses. On the other hand, some mental-health professionals, who work at disaster sites and who have more actionoriented personalities, may respond to helping survivors of traumatic events in a different manner: As such, they may become overly involved and find themselves identifying too much with the survivors. The middle ground of therapeutic response contains a “wish to preserve the healthy denial all people need to dare to get out of bed every morning” (Lindy & Lindy, 2004, p. 574). In summary, the creation of an interpersonal trauma membrane, which is offered by an individual (e.g., a therapist) or individuals (e.g., family, friends, other survivors, or helping professionals in the recovery environment), is distinct from the intrapsychic trauma membrane because it is, in a sense, a psychological “human shield” that is offered to the survivor of trauma. Yet, the interpersonal trauma membrane contains parallels with the intrapsychic trauma membrane, because each represents a cordoning off of traumatic memories that occurs, in order to protect an individual’s mind from being overwhelmed from the horror of and psychological harm caused by the traumatic event.

The Recovery Environment Facilitating a Trauma Membrane Implicit in the metaphor is that a trauma membrane must exist at the interface between two entities, whether it is between the part of the individual that contains the traumatic memory and the part of the normally functioning person, or between the client and the therapist. At the community level, the trauma membrane interfaces a potential network of traumatized survivors with the recovery environment. The fundamental purpose of the trauma membrane is to protect individuals from further psychic tension and/or overload: This may be accomplished in different ways – by means of the individual’s own defenses, by the assistance of therapists or counselors, or by means of community-based support systems, such as other survivors. The recovery environment (Lindy & Grace, 1985; Luchterland, 1971) consists of the overall psychological climate of the community of non-victims, their attitudes

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toward the catastrophic events and those victimized by it, the status of pre-existing or emergent community structures that care for the survivors, and the caring or noncaring behaviors to which survivors are exposed. Ideally, these two structures – the trauma membrane and recovery environment – work in concert with each other facilitating healing of the survivor and the community. However, following particular disasters, tension at the interface between these two structures can be considerable. For example, the welcoming environments, which were sympathetic with the cause and the sacrifice of American veterans at the end of World War II, contrasted sharply with the blaming environment that greeted returning veterans from Vietnam, in which warriors were confused with an unpopular war. In other types of traumatic events, differences in the character of recovery environments between centrifugal and centripetal disasters may exist, which were previously discussed. The Cincinnati trauma group continued to observe tensions at the interface between survivor networks and recovery environments at a number of sites where they were invited to work. Following a tornado in Lubbock, Texas, when immediate relief efforts were at the disposal of socially more advantaged Caucasian individuals, their experience was that of a smooth interface between the survivors and the recovery environment. However, for Hispanics in the same city, who experienced relief efforts as delayed on the basis of prejudice, theirs was an experience of tension at the interface. In other communities, where residents and workers connected with nuclear power plants were informed that they had been exposed to radioactive contamination, as outside Sacramento, California and Fernald, Ohio, researchers noted that affected inhabitants split into two groups: Some feared that information about contamination might be true but preferred to remain in denial, while others were convinced they were at risk for health hazards (Green, Lindy, & Grace, 1994). It was as though two separate trauma membranes had formed dividing survivors from each other. However, in either case, there were those outside the radius of potential contamination, who sadistically joked about those inside the dangerous circumference, claiming they “glowed in the dark.” It was as though neighbors, who could have been part of a recovery environment, feared being contaminated by the survivors, and thus isolated them; this was reminiscent of the shunning of survivors at Hiroshima and Nagasaki. At the Beverly Hills Supper Club fire, non-victims from the same churches as the survivors blamed victims for breaking God’s commandments regarding alcohol and dance. Both of these examples reflect a recovery environment that is non-supportive, even toxic, for helping the trauma survivors to heal and for the development of a trauma membrane. In contrast, sometimes sub-populations within a disaster formed a stronger trauma membrane when a strongly held belief or myth emerged regarding a special reason for their being spared. For example, the African-American population at Buffalo Creek experienced a particularly rapid recovery. One factor, according to some of the survivors, was the way the tragedy came to be understood as a modern-day “passover” event, in that no African-Americans were killed in the random careening of the water from the slag-dam collapse. This was viewed as a positive message from God, unifying these survivors within a strengthened trauma

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membrane. In this context, shared beliefs in the cosmic forces at work in the disaster created a sequestered and supportive recovery environment. In summary, recovery environments are complex, with positive and negative forces at work at the surface of the trauma membrane. Looked at from the point of view of the survivors, the larger recovery environment might be toxic or it might be helpful. It is up to those leaders functioning at the surface of the trauma membrane to determine whether a given outside force should or should not be let inside and to remove those interpersonal “toxins” already present.

Reaching Across the Trauma Membrane Those who guard the trauma membrane are wary of permitting interactions between survivors and stimuli from the outside world, which might exacerbate their symptoms, including mental-health professionals. They fear the contact may reactivate the trauma and counter the effort to ward off memories of the trauma. The result, at times, reinforces a survivor’s avoidance of professional help. Hence, keeping the trauma membrane concept in mind informs us, as researchers and clinicians, as to how and when to proceed. Such sensitivity to the trauma membrane permits us, to the best of our abilities, help create a climate in which we could be invited within that boundary – rather than be rejected because we are outside it, or because there is a threat that we may pierce it with negative results. Efforts to help traumatized individuals may be threatening, due to the possibility of disturbing the “fragile equilibrium” (Lindy, 1985, p. 154). Hence, if clinicians and/or researchers are perceived as facilitative of the healing process, then they will be invited to cross the trauma membrane. The flip side of this process is that if individuals view the clinicians and/or researchers, who are focusing on the trauma, as a threat to psychological stability after the trauma, then understandably, these professionals will be avoided or not invited to enter the trauma membrane. The idea of mental-health professionals as functioning at this interface between the trauma membrane and the recovery environment leads to interesting possibilities in the aftermath of trauma. For example, when young people died in a crowd crush at the Coliseum, preparing to see a rock concert by “the Who” in Cincinnati, members of the University of Cincinnati Traumatic Stress Study Center’s team wrote editorials and went on national television to counter a view that the deaths were the work of “young barbarians” (as they were being portrayed in earlier media exploitation, because some had stampeded the more vulnerable among them). Instead, it was emphasized that there were many contributing factors in the disaster such as closed doors, false-start announcements, theater seating, and insufficient number of police. These advocates emphasized heroic stories of youngsters who acted to save lives, and called the theater-goers “our own children”; they encouraged community empathy by constructing a narrative that connected the recovery environment with the experience of the grieving families.

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Attending to potential discrepancies – between the interpersonal trauma membrane on the one hand and the recovery environment on the other – provides a rational guide for discovering new roles for mental-health professionals in postdisaster environments. There are a number of roles that could help facilitate an interface between a negative recovery environment and the trauma membrane. One example of this would be participating in the media coverage of the event, so as to minimize the distance between a harmfully judging public and an empathic understanding of the survivors’ experience. Traumatized individuals, who were contacted for outreach and research, were best able to utilize communication by printed matter such as newspaper articles, rather than media, such as television or radio, or unsolicited human contact (Lindy et al., 1981). This trend appeared to reflect the survivor’s ability to control the exposure to the traumatic memory when the message was printed, whereas the electronic media could be a form of unwanted intrusion. Finally, it was clear that when mental-health professionals joined all those who were offering assistance to the survivors, such as may be found in a “one-stop center,” then the recovery environment was helped. Working with other types of helping professionals at the site of the traumatic event added a psychological component to the necessary, acute interventions, such as those related to food, housing, and medical needs. The innovation of combining mental-health efforts with emerging, trauma-specific care settings and one-stop centers was part of this effort, which served to create an even stronger recovery environment than what would be provided by individuals working by themselves, rather than helping to holistically address multiple levels and aspects of life that were affected by traumatic events.

Conclusions The trauma membrane can be viewed as a multidimensional concept. First, it can be understood as a protective, interpersonal shield that is formed around trauma survivors in several ways – on a community level or on an interpersonal level (e.g., therapist–client). Second, it can be viewed as intrapsychic mechanism that protects traumatized individuals from being subsequently overwhelmed by traumatic memories that have broken through the person’s stimulus barrier. The trauma membrane cordons off those memories until they can be handled by the individual’s adaptive psychic processes. The content of this chapter explored the definition and history of the trauma membrane concept, the similarities and differences between the stimulus barrier and trauma membrane, its value as a metaphor, and how the recovery environment can facilitate its formation in the aftermath of a trauma. As a flexible analogy, the multilevel trauma membrane can help researchers and clinicians explain trauma-related processes and their clinical applications.

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Van der Kolk, B. A. (2004). Psychobiology of posttraumatic stress disorder. In J. Panksepp (Ed.), Textbook of biological psychiatry (pp. 335–344). Hoboken, NJ: Wiley-Liss. Van der Kolk, B. A., Brown, P., & Van der Hart, O. (1989). Pierre Janet on post-traumatic stress. Journal of Traumatic Stress, 2 (4), 365–378. Van der Kolk, B. A., McFarlane, A. C., & Van der Hart, O. (1996). A general approach to treatment of posttraumatic stress disorder. In B. A. Van der Kolk, A. C. McFarlane, & L. Weisaeth (Eds.), Traumatic stress: The effects of overwhelming experience on mind, body, and society (pp. 417–440). New York: Guilford Press. Wilson, J. P., & Lindy, J. D. (1994). Countertransference with the treatment of posttraumatic stress disorders. New York: Guildford Press.

Chapter 3

Forgiveness and Reconciliation in Social Reconstruction After Trauma Everett L. Worthington, Jr. and Jamie D. Aten

Abstract We examine social reconstruction after human-caused trauma – with a focus on warfare, civil disquiet, or conflict. Specifically, we examine the roles of forgiveness and reconciliation in social reconstruction. Forgiveness promotes both trustworthy and trusting behavior, which can lead to reconciliation. Forgiveness and reconciliation help heal past memories, restore present trust, and thus pave the way for breaking future cycles of trauma. Forgiveness and reconciliation happen in the present but affect the future. They arise from the crucible of conflict and trauma in which people’s hopes can be squashed. Yet, forgiveness and reconciliation can also renew crushed spirits, which can lead not only to inner peace within an individual but to peace within a country torn apart by conflict. We suggest a model of aggression and related model of peacemaking and reconciliation. We also offer a series of societal and diplomacy recommendations that are meant to facilitate forgiveness and reconciliation following social traumas. Peaceworker John Paul Lederac (2001) noted that one cannot build a bridge of reconciliation by starting in the middle. Each party must build toward the middle from his or her side. This type of philosophy would seem especially relevant in times of social and societal trauma. Social and societal trauma can exist anywhere that a group of people exists. Brounéus (2008) reported, for example, that during the years 1989–2006, the number of armed intrastate conflicts that were recorded in the Uppsala Conflict Data Program ranged between 25 and 50 annually. However, the number of armed interstate conflicts ranged between 0 and 2. In this chapter, and in the present book, the focus is on recovery and rehabilitation after armed conflict, which in most cases, involve people within a country killing, maiming, and harming their fellow citizens – not perpetrating harm on citizens of a different country. In the present chapter, we are concerned with social reconstruction E.L. Worthington (B) Virginia Commonwealth University, Richmond, VA, USA e-mail: [email protected] Chapter submitted for Erin Martz (Ed.), Post-conflict Rehabilitation: Creating a Trauma Membrane for Individuals and Communities and Restructuring Lives After Trauma.


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after human-caused trauma – with a focus on warfare, civil disquiet, or conflict. Specifically, we examine the roles of forgiveness and reconciliation in social reconstruction. We also offer a series of societal and diplomacy recommendations that are meant to facilitate forgiveness and reconciliation following social traumas.

Forgiveness and Reconciliation After Social Trauma Individual traumas threaten people’s lives and psychological existence. Their psychological structures may be destroyed, damaged, or deformed, which can lead to seriously impaired functioning. Social and societal traumas threaten the survival of organizations as societal structures are destroyed, damaged, or deformed, which can also lead to seriously impaired functioning for both the organizations and the people within them. Social trauma can occur across a continuum, from as small as a couple hurt by infidelity to an entire nation maimed by war. For example, the nation of South Africa experienced widespread traumas due to the control of the Nationalist party with apartheid philosophy. Even after Nelson Mandela’s government took over, the society was in a state of disrepair and social reformation. The relationship between Germany and Israel has been distant as a result of the Holocaust (Schimmel, 2002). Germany and the United States experienced tension due to the events of World Wars I and II. Relationships between the Japan and countries in China and Southeast Asia still are tense due to events occurring in World War II. By no means is this a comprehensive list of societal traumas, but rather are illustrative examples of conflict within and between countries. As can be seen in the aforementioned examples, one cannot heal society without attending to the past. Traumatic memories are vivid in individual’s minds because the nervous system stamps emotion around the memory and triggers powerful defensive responses in the body (LeDoux, 1996). At the social level, people construct narratives that describe what happened and who was to blame, as well as who needs to do what so that justice may prevail (Hicks, 2001). These memories are codified into social narratives, which are passed along to each new generation (Chapman & Spong, 2003). Thus, if these memories are not dealt with and healing is not experienced for the past, then the next generation of children will almost certainly replay the conflicts when they have reached young adulthood. Harboring negative feelings, biases, and prejudices against non-group members, these young adults will feel justified in seizing opportunities to recreate conflict, likely perpetrating new traumas on the next generation (Cairns, Tam, Hewstone, & Niens, 2005). Forgiveness and reconciliation help heal past memories, restore present trust, and thus pave the way for breaking future cycles of trauma. Forgiveness promotes both trustworthy and trusting behavior, which can lead to reconciliation. Forgiveness and reconciliation happen in the present but affect the future. They arise from the crucible of conflict and trauma in which people’s hopes can be squashed. Yet, forgiveness and reconciliation can also renew crushed spirits, which can lead not only to inner peace within an individual but to peace within a country torn apart by conflict.

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Therefore, in the present, structures must be created that allow the society to function and protect all parties who are in vulnerable positions, due to the instability of the society. Such actions require attention and focus on future plans. Leaders must have plans for how society is to be reconstructed. Leaders must attend to how plans can be formulated to motivate the people to endorse and embrace them. Mechanisms must be thought of that bring about the plans and create a reconstructed society. To reconstruct a social or societal entity after the pieces of the society have been knocked asunder by misdeeds – often on both sides – necessitates attention to past, present, and future. Before these mechanisms are discussed, however, we describe our basic terms.

Foundational Constructs and Definitions In the following, we highlight foundational constructs that underpin the rest of the chapter. These constructs provide insight into the complexities of forgiveness, reconciliation, and social trauma. Furthermore, they are critically intertwined with possible solutions that may offer healing after societal traumas.

Trauma According to the Diagnostic and Statistical Manual-IV-TR (DSM-IV-TR; American Psychiatric Association, 2005) trauma involves a psychological or physical injury to a person that threatens the person’s physical or psychological existence. We apply this same definition to societal groups and will speak throughout using the terms social trauma to describe a relationship between two or more people interacting with each other and societal trauma to apply to relationships that involve organized societal groups. Part of the core definition of a trauma is that it is a stressor that threatens the person or community’s sense of survival. Often, the identity or the very life of the person or group is threatened. When genocide occurs, for example, the individuals in the targeted group are in real danger of being killed (Staub, 2005).

Forgiveness Forgiveness is viewed by virtually all social scientists as an individual phenomenon and not as a social phenomenon (Worthington, 2005). Still, while being localized within a person’s body, forgiveness occurs in and is affected by social or societal context. Forgiveness is thought to be of two types and can be conceptualized as decisional or emotional forgiveness (Worthington, 2006). Decisional forgiveness is a behavioral intention statement to act pro-socially toward the offender in the future. Thus, the victim decides to put aside negative and vengeful acts. Avoidance of the offender should be discouraged. Rather, conditions should be set up where it is safe

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for the victim to interact with the offender to create opportunities for healing to take place. The person might also decide to engage in helpful or other pro-social acts toward the offender. A person may experience decisional forgiveness toward an offender yet remain emotionally unforgiving toward the offender. The unforgiving person harbors resentment, bitterness, hostility, hatred, anger, and fear, which are called unforgiving emotions (Worthington, 1998). The person, thus, may experience a second type of forgiveness called emotional forgiveness. Emotional forgiveness is the emotional replacement of negative, unforgiving emotions with positive, other-oriented emotions, such as empathy, sympathy, compassion, or love for the offender. For example, a soldier involved in and wounded during a civil war, through perspective shifting, may come to a point of being able to see the humanity in the soldier who wounded him, despite perhaps still disagreeing with the offending soldier’s political convictions. The experiences of decisional or emotional forgiveness occur inside an individual (Worthington, 2005). Let us not confuse the experience of forgiveness with talk about transgressions. For example, a person may say that he or she “grants forgiveness” to an offender, but in fact may be secretly plotting revenge. On the other hand, a person may say he or she does not forgive an individual because the person is trying to manipulate the offender through guilt. What a person says about forgiveness occurs at the social or societal level. That may or may not reflect the internal process of forgiving (Baumeister, Exline, & Stillwell, 1998).

Reconciliation Reconciliation is the restoration of trust in a relationship where trust has been violated, often repeatedly (Freedman, 1998). Reconciliation is not an individual phenomenon. It is a social or societal phenomenon. Reconciliation cannot be granted to someone else. Rather, both people, through mutually trustworthy behaviors, contribute to reconciliation. Certainly, reconciliation may be initiated by one party, who may labor more assiduously for reconciliation than does the other. But, eventually, if reconciliation is to occur, it requires mutually trustworthy behaviors.

Transgressions During reconciliation, people often talk about transgressions or offenses during a series of interchanges (Goffman, 1969). When a transgressor commits an offense against a victim, the victim will often make a reproach to the transgressor. A reproach is a request to explain the cause of the offense (Schönbach, 1990). It may be made in ways that encourage mitigating or aggravating accounts. For example, a forthright accusation of wrongdoing typically elicits defensiveness from the transgressor.

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A transgressor will respond with an account. Schönbach (1990) identified four unique types. Refusals or denials reject the idea of wrongdoing or deny that anything untoward happened. Justifications admit to one’s actions and to responsibility for one’s actions but claim that the actions were not wrong, and they may blame the victim for previous offenses. Excuses admit to wrongdoing but claim that mitigating circumstances should be considered. That is, because the offender’s actions were not motivated by harmful intent, the offender does not believe that his or her actions are worthy of blame. Finally, concessions or confessions admit to wrongdoing and may attempt to repair the relationship through apology or offer of restitution.

Justice Justice is a social and societal construct (Pittman, 2008). Procedures are established and followed so that fairness is made more likely. Distributive justice describes how resources are equitably distributed. Forensic justice describes how civil disputes and putative criminal acts are adjudicated. Procedural justice stipulates the specific procedures by which people attempt to bring about distributive and forensic justice. Whereas justice is social and societal, individuals judge the degree that justice has occurred (Fox, 1997). We will call this one’s perception of justice to show that it is an individual construct, not the social construct, justice. When injustices are perceived, the perception of net injustice is represented mentally by the size of the injustice gap. The injustice gap is the perception of the difference between the way that a person might wish an injustice to be resolved relative to the way the person perceives the situation at present (Exline, Worthington, Hill, & McCullough, 2003). The injustice gap is an ongoing subjective evaluation of degree of residual injustice. It is affected by actions and events after the original transgression. Thus, this concept is particularly relevant for ongoing conflicts, such as those in the Middle East. Sometimes, new transgressions can be factored into an original injustice gap, increasing the sense of injustice. At other times, a subsequent additional injustice might be considered separate and require its own resolution for a perception of justice to reign. Overall, the injustice gap may be reduced through ways that move a person’s evaluation of the current situation closer to the person’s idealized situation (e.g., seeing civil or criminal justice realized) or by changing one’s idea about how the situation might be resolved (e.g., accepting and moving on; deciding to turn the matter over to God, etc.; Worthington, & Drinkard, 2000).

Structures In some ways, the societal or social group is like the inner psychological working of an individual. In both cases, there are structures, or psychological patterns of interacting, that are present at the individual, social, or societal group levels

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(Worthington, 2009). For example, some psychological structures include memories, action plans, expectations, or response patterns to particular stimuli. Social structures (recall, we are using this to refer to interactions between two people) might include husband–wife patterned interactions, boss–employee conferences, or employee–employee seniority hierarchies or practiced interactions around projects. Societal structures might include laws, political hierarchies, police procedures, church hierarchies, treaties between countries or groups in conflict, customs, and traditional celebrations. In individual, social, or societal interactions, the events currently in focus lead the person to think along the lines of one mental structure or lead the dyad or group to act along the lines of one social or societal structure. Exposure to one set of structures over a protracted time can encourage a person, or society, to keep thinking in a particular way. Structures have the property of being relatively permanent, so unless something shifts attention, group members, like individuals, will continue to follow the beaten path.

Triggers A trigger is an internal or external event that has psychological meaning and shifts attention of individuals or groups to emotionally loaded structures (Tedeschi & Felson, 1994). That is, triggers are cable of precipitously shifting attention of an individual or group. What seemed settled yesterday can, through some provocative event, absolutely explode into violence today. A trigger can focus societal attention on a pre-existing conflict that people had assumed had been dealt with successfully (Worthington, 2009). It would also appear that strong situations (e.g., Milgram obedience experiments) – instead of eliminating personal beliefs and values – trigger thoughts and attention to one set of beliefs and values. By doing so, however, attention is shifted away from other beliefs and values. Situational triggers therefore direct attention to one set of structures and away from other sets (Milgram, 1974).

Assumptions About Societal Recovery from Trauma Before introducing recommendations for facilitating societal forgiveness and reconciliation, several crucial propositions that undergird understanding societal trauma are identified. These assumptions have evolved out of or our own personal observations, research, and experiences of working with trauma. First, societies are made up of individuals who deal with transgressions in diverse ways. Individuals also differ in personalities, beliefs, values, ways of coping, responses to trauma, and injustices. As such, individuals differ within themselves at different times according to how the feel, think, remember, experience physically, and act regarding an injustice. Thus, societies, which are a collection of individuals, should likewise be expected to fluctuate widely in societal reactions to trauma. Second, civil conflicts spur diverse and varying opinions among groups. From those

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opinions a variety of advocates will evolve. Advocates for unequivocal peace, violence, negotiation, and isolation will emerge. Third, when threats to identity occur a number of predictable events happen: (a) People become frozen in their beliefs and attitudes (Hicks, 2001), (b) Each group cuts off relationships with the other group, (c) Frozen beliefs about identity and interpersonal histories carry over even after the conflict mitigates (Hicks, 2001). Fourth, after conflicts, there is always the danger that extremists will trigger violence by acting violently. Fifth, there is power in numbers, and individuals in a close-knit group trigger each other. For instance, when one person in a group publicly acts, that tends to direct attention of others in the group to acting similarly. Finally, many options exist for handling transgressions pro-socially. These include avenues of justice, acceptance, forbearance, and relinquishing judgment to God (Worthington, 2006). Forgiveness is merely one of the avenues. Thus, our position is that forgiveness should never be coerced within victim communities. Forgiveness should always be presented as a possibility that can promote reconciliation and healing.

Societal Recommendations for Facilitating Forgiveness and Reconciliation The following set of recommendations is based on the forgiveness and reconciliation literature and research. Likewise, these recommendations are based on the authors’ experiences of working with communities affected by the South African apartheid (Worthington) and experience of working with underserved minority communities affected by Hurricane Katrina (Aten). Recommendations that can be implemented at various societal levels (e.g., small pairings of people, communities, etc.) are provided. Moreover, recommendations that can be used to guide diplomacy efforts will follow. 1. To forgive and reconcile, societal triggers or structures must be changed. To help a society promote social and societal healing after a period of conflict, violence, and turmoil, we must (a) provide triggers that direct people to more socially beneficial reconciliative structures, (b) make the reconciliative structures more attractive and rewarding than are the structures that maintain animosity, (c) build new reconciliative structures, and (d) build in triggers that will direct attention to those structures. As recommended by McCullough (2008), these structures should help people see the mutual value of relationships across formerly warring groups, show groups that each other is worthy of care, and show groups that each is safe. Otherwise, conflictual structures will persist, ready for a trigger to activate them in the future. The practical problems with establishing the awareness of valuable relationships, careworthiness, and relative safety are daunting. These conditions must be established through engineering interactions across groups and through discussions instigated by opinion leaders within each group separately. 2. To forgive and reconcile, the societal trauma membrane should be considered. According to Lindy and colleagues (Lindy, 1985; Lindy, Grace, & Green, 1981)

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a trauma membrane is a defensive protective layer that trauma survivors establish to protect themselves after experiencing a trauma. The trauma membrane may be thought of as an individual layer of defensiveness or as a social or societal layer of defensiveness. The intent of the individual or society is to protect itself. The social or societal trauma membrane may develop at an unconscious or conscious level to defend oneself against future traumas and to permit healing. The trauma membrane may also develop as the result of a strong emotional reaction, in which case, it tends to minimize alternative perspectives. Furthermore, the trauma membrane includes a set of coping reactions, which one of the stress-and-coping theories postulates can be adaptive or non-adaptive (Lazarus, 1999). These coping reactions may be more or less under control of conscious processes. They may be aimed at different objectives such as to regulate emotion, to solve problems, or to make meaning out of the stress. In our schema, the trauma membrane is a particular self-defensive set of structures designed to protect the self, social dyad, or society from intrusive harm in the present and from harm that might occur in the future. 3. To forgive and reconcile, the structure of identities under attack must be dismantled. To promote the possibility of forgiveness and reconciliation during a post-conflict time, threats to the identity must be dealt with. First, it is absolutely necessary that violence, mass killing, attempted genocide, and systematic marginalization of the other group must be wholly or substantially ended. Second, the problems in overcoming the frozen identity differ in high-power groups from those in low-power groups, thus lending themselves to different solutions. In high-power groups, often the strength of numbers has resulted in significant systematic wrongdoing. To heal from the trauma, people in high-power groups must examine themselves for their wrongdoing. Of course, this can be difficult because many people who fall into the high-power groups may develop self-protecting defenses, in which they believe their actions were justified (Lindy, 1985). Such defensive structures suggest that the people in high-power groups have been correct in their defensiveness. Thus, examining themselves opens the possibility that they have been incorrect. Being able to engage in such self-reflection can feel extremely threatening. If self-examination is to occur, the threat must be reduced. This can be done in part with both high-power and low-power groups, in which attempts are made to normalize experiences through describing how genocide and mass killing has occurred in various societies throughout history and humanity (Staub, 2005). Members of high-power groups also need to examine themselves in light of their religious or spiritual beliefs (e.g., before God or their belief in a higher power). Typically, as more crimes against humanity are admitted, people experience a spiritual crisis. They realize more readily that they have defiled the sanctity of humanity, have violated the moral character of the Divine, and have transgressed the laws of nature by murdering countless people. Still, it should be noted that there are those whose religious interpretations actually justify killing in the name of their religion or the Divine, which can make this process more burdensome or prolonged, though not impossible. People must expose their faults within their own in-group. That requires that high-status leaders of the genocide or mass killing must admit they were wrong. This is difficult. Leaders who admit wrongdoing will inevitably lose status in their

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group. In fact, their position in the social hierarchy can be completely reversed. For example, Eugene deKoch of South Africa was the chief architect of police repression in the Nationalist party apartheid era. DeKoch admitted to over 100 killings and as a consequence has suffered incarceration and public scorn for his admissions of guilt (Gobodo-Madikezela, 2003). Once group members have confessed to in-group members, they must continue to dismantle societal structures by making public confession. Those confessions should include confessions to the victims of the perpetration. To promote the self-examination necessary for high-power group members to confront their wrongdoing, an environment that reduces the punitiveness of confession is needed. In the South Africa Truth and Reconciliation Commission (SA TRC), amnesty was offered to those who committed politically motivated crimes but not to those who carried out private crimes (Chapman & Spong, 2003). Amnesty was complete if the person cooperated fully with the Commission. In Colombia, people who confess to their crimes, public or private, have been assured that they can be incarcerated no more than 8 years (Diaz Ferrer, 2005; Navaez Gomez, 2005). Thus, in the Colombian solution, justice is not eliminated (in the service of mercy) by full amnesty, but rather is served through a limited amnesty. The other part of dismantling societal structures involves low-power groups. The dynamics in low-power groups are different from those in high-power groups. Low-power groups often continue to be characterized by fear and anxiety over the possibility of continued harm (Montville, 1990). Like members of high-power groups, members of low-power groups also tend to interact with other in-group members and thus reduce the possibility of changing their attitudes. They need some intervention to allow new information to be assimilated and accommodated. Typically, this will require receiving information by other in-group members. Though there may already be an exchange of information between in-group members, some in-group members may be hesitant to share new information or offer alternative perspectives for fear of being perceived as going against their own group. Thus, the obvious person with the most potential impact is the leader of the group. If the group leader can participate in structured interactions with people from the high-power group and build a mutual sense of empathy, then the leader can return to his or her in-group with an experiential knowledge of the other group. The leader can convey his or her beliefs that reconciliation may be possible and that forgiveness might be one route to reconciliation. That leader can provide a safe way for new information to be assimilated in the rank and file grassroots members of the low power in-group. 4. To forgive and reconcile, trust between in-group and out-group members needs to be restored. For this to occur, mutually trustworthy interactions need to take place (Freedman, 1998). However, before initiating interactions across groups, it is helpful to train in group members in effective reconciliation skills (Worthington 2006; Worthington & Drinkard, 2000). These might include ways to (a) make decisions about whether one might pursue reconciliation, (b) talk about transgressions, (c) forgive, and (d) detoxify the past relationships including re-narrating memories and acting positively toward the other group members.

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Both groups, the victims and offenders, must move from beliefs that “they are bad” to “we also have contributed to this evil” (Botcharova, 2001), from “they are other” to “we and they do not want to repeat on this trauma” (Botcharova, 2001) and from “we in our in group must stick together against them” to ‘we and they must pull together to recover from this trauma” (Botcharova, 2001). 5. To forgive and reconcile, the logic of aggression and how it can be turned toward the logic of peacemaking must be explored. There is logic to the cycle of aggression based on threats to self and group identity that occur because of suffering. People respond to this threat by suppressing weakness and by masking this fear through expressions of anger and shows of strength. Though this defensiveness is part of the self-protective trauma membrane, the logic of aggression is not inevitable. People can learn the logic of peacemaking at every point in the cycle of the aggression process. The challenging part is identifying what prevents the logic of peacemaking from prevailing. To trigger the logic of peacemaking, one key change must occur: both parties or groups need to consider the others’ experiences of threat and sense of injustice. The cycle begins with aggression and is depicted in Fig. 3.1. Aggression leads to suffering of others. As people suffer, they attempt to cope. At first, they are prone to cope defensively by suppressing weakness. This leads to coping by enacting strength. For example, terror management theory suggests that groups will strengthen their worldview beliefs when threatened (Pyszczynski, Solomon, & Greenberg, 2003). The aggression cycle is a cycle because often the way that people enact their strength

Aggression

Cycle of Aggression

Suppress Aggressive Acts • Turn other cheek • Legal • International Appeal

Coping: Enacting Strength

Strengthen Communities • Build New Structures

Cycle of Peacemaking

Weakness Turned to Strength • Solidarity • Turn to God

Defensive Coping: Suppress Weakness

Fig. 3.1 Cycles of aggression and peacemaking

Reconceptualize Suffering • Anything good • Redemptive

Suffering

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or defend against weakness is to aggress against the other group. The inner circle in Fig. 3.1 begins by forswearing aggression. This cycle suggests that peacemaking can occur at every step of the aggression cycle. For example, the members can choose to suppress aggressive acts against the other group. If they are victims, they can turn other cheek, pursue justice through legal channels, make international appeals for help, or employ Gandhi’s non-violent resistance methods. In the aggression cycle, suffering is viewed negatively. In the logic of peacemaking, however, suffering can be re-examined. This is labeled recasting suffering. The intent is to determine what good might come from the experience (e.g., character was strengthened). People cope through suppressing their weakness in aggression; whereas in peacemaking, people might embrace their weakness and other ways of being and perspectives. Several positives may in fact develop from embracing weakness, such as renewed religious or spiritual beliefs, solidarity, and sense of community. Finally, in the cycle of aggression, people may cope by acting in strength. In peacemaking, strength can be found in community. People can build new, more socially just societal structures that can inhibit a repetition of social and societal trauma and will make peacemaking more likely. 6. To forgive and reconcile, track-one diplomacy is necessary to halt hostilities. When hostilities are underway, they must be brought to an end if the society is going to heal (Botcharova, 2001; Lederac, 1997; Montville, 1990). Track-one diplomacy is negotiation at the level of a state’s leaders and the leaders of peacekeeping bodies (such as non-governmental organizations, NGOs, or intervening nations) that work together to craft agreements that will end violence and (hopefully) promote peace. If warring parties broker their own cease-fire and adhere to agreements, outside intervention is not usually necessary (still, this falls within track-one diplomacy). For most intrastate conflicts, the warring parties have little capability to regulate violence unless one force is simply overpowering the other and mass killing or genocide exists (Staub, 2005). However, global policymakers often tend to follow a predictable course with intervention in intrastate conflicts (Botcharova, 2001). They usually ignore warnings that mass killing, genocide, or intrastate war is about to erupt or has erupted. After it is in progress, they may long close their eyes to the violence. When intervention is almost inevitable to prevent massive loss of lives, they usually intervene militarily. Then, when peace is secured through foreign structures and paper agreements (which are imposed and enforced by force), the peacekeeping forces are withdrawn (often without regard to the likelihood of peace being maintained), although the peace is unstable. Botcharova (2001) describes why these do not usually serve as a good solution to intrastate violence: Even though one may realize that partnership in a solution (the idea vigorously supported by outsiders and often perceived as insulting by deeply victimized groups and individuals) is the only way to stop further tragedies, one may still not be able to disconnect from one’s emotions and to betray [one’s] principles. . . . People forced by their leaders to fight with each other only yesterday cannot readily shake hands today just because their leaders finally draw lines on maps and put their signatures on important papers prepared in America, Paris, or Geneva. Alas! Only a paper peace can be reached on paper. (p. 271)

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Troops might effectively suppress military activities and reduce (but not usually eliminate) violence. Rarely can troops heal trauma, promote a re-establishment of the emotional bond between conflicting parties, and promote forgiveness and reconciliation, including the reduction or elimination of prejudices. Strategies for bringing about peace are often imposed by peacekeeping bodies. The people affected by an imposed solution frequently do not truly buy into the actions. Sometimes what is perceived as a puppet government is established. This may or may not include elections, and even if elections are held, they rarely promote community buy-in. Overall, the decisions are simply too far removed from the people. Track-one diplomacy usually is aimed at established leaders. Political, military, and police leaders are usually entrenched. They have vested interests – often in the status quo associated with conflict. They have taken public and often lucrative positions. To change their stance is highly unlikely unless pressure is applied. Peacekeepers can apply pressure, but if a leader knuckles under to foreign peacekeepers, the leader usually does not succeed in future local politics. A different kind of pressure must be brought to bear – one based within the grass roots. This suggests that another type of diplomacy is needed. 7. To forgive and reconcile, track-two diplomacy is needed. Track-two diplomacy attempts to promote understanding, cooperation, empathy, and good-will among opinion leaders of the formerly divided communities. The hopes are two-fold. First, opinion leaders – such as community leaders, clergy, university professors, or local politicians – who meet with and develop empathy for members of the other side, understand and gain respect for them, can apply pressure on national, party, or tribal leaders to work out agreements. Second, and perhaps more importantly, opinion leaders can carry their empathy back to the communities that they represent. Because they have local credibility, they can influence people toward more positive, accepting, and healing attitudes and behaviors. As Botcharova (2001) summarized, “When a critical mass of medium-level and top grassroots enthusiasts manages to heal its traumas, process its sense of victimhood, and come to forgiveness, there will be hope that the war mentality in the society will gradually be changed” (p. 273). One way to help opinion leaders to change is to use empathy-based groups (Staub, 2005). Empathy-based groups bring opinion leaders from both groups together in a common location. They share their stories and get to know each side of the story. Opinion leaders gain a different experiential view about the other group members and bring that experience-based knowledge back into their local communities. There, they might set in motion groups and experiences that would promote healing within their community. There are a number of models for such track-two groups. Staub (2005) described groups used with success in Rwanda. The groups educated attendees on experiences of genocide and mass killing, which normalized their experiences for group members. As we mentioned earlier, both sides need their experiences normalized for many members to move beyond the defensiveness to assimilate new information. Non-threatening approaches are therefore needed, such as psycho-educational

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approaches. Staub (2005), for example, described a fictional radio drama that captures in metaphorical terms the experiences of the members of the Hutu and Tutsi tribes that were at the root of the Rwandan genocide in 1994. The use of metaphor helped reduce the threat in Rwanda and allowed the trauma membrane to be permeated by new interpersonal experiences instead of hardened by defensiveness. Skillful group facilitation is necessary to productive inter-group empathy building meetings. If groups are relatively unsupervised, then the experiences of a single person can often serve as a trigger that stimulates emotional responses, memories, beliefs, and expectations of possible future traumatic events. For example, in 1996 (co-author), Worthington conducted conferences in South Africa. At one workshop, he constituted four ethnically intermixed groups. Two of the four worked well. They seemed to promote excellent inter-group reactions. In both groups, members ended with their arms around each other praying together. The other two groups, however, had at least one member who was outspoken and had hard attitudes. The public expression of blame and, on the other side, the expression of lack of regret for the South African Apartheid era led to negative feelings and reactions within the group. Most group members in those groups left feeling that the group was not helpful at promoting reconciliation. 8. To forgive and reconcile, track-three diplomacy should be utilized to provide either direct or indirect avenues for healing within communities. Once opinion leaders are on board for promoting societal rehabilitation, then programs and persuasion can be employed in the community. These community meetings are open to the public and invite the participation of members in the community. They aim to promote reconciliation and to provide a space for willing community members to seek forgiveness, experience decisional and perhaps some emotional forgiveness, and express forgiveness and acceptance of forgiveness either privately or between perpetrator and victim or publicly with observers. Track-three diplomacy programs may be aimed directly at some sort of justice, truth-telling, or forgiveness and reconciliation.

Examples of Justice-Based Track-Three Diplomacy Truth Commissions Numerous countries have formed truth commissions after the end of intrastate violence and aggression. Truth commissions are charged with seeking testimony that brings out a truthful narrative. Truth, however, is dependent on different perceptions by different parties. Thus, a single accepted narrative will not arise from a truth commission. The truth commission can at best summarize major perspectives and yield a more balanced view of the perspectives than any individual is likely to hold. Furthermore, because truth commissions operate in public and are supervised by parties’ representative of both sides, the findings will often be seen as more balanced than a partisan view.

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South Africa’s Truth and Reconciliation Commission (SA TRC) Perhaps one of the most innovative peacemaking strategies has been the SA TRC (Chapman & Spong, 2003). It consisted of three types of hearings: (1) Human rights hearings sought victims’ stories; (2) hearings considered amnesty for people who agreed to tell the whole truth (they were promised amnesty for politically motivated crimes); and (3) hearings considered reparation about fair ways to compensate people who had been damaged through apartheid. The SA TRC has been criticized on a number of grounds (Chapman & Spong, 2003). Some have criticized the insistence of its lead commissioner Desmond Tutu that forgiveness should be stated publicly. Some people, in retrospect, reported an informal coercion to say that they forgave the perpetrators. The commission also has been criticized because the amnesty hearings did not attract the leaders of the Nationalist party. Those leaders were reluctant to admit to any wrongdoing. Finally, the reparation hearings were criticized because many people felt that the compensation for losses to have been too small.

Rwandan Gacaca Hearings In Rwanda, the solution to their problem was different, as necessitated by the unique Rwandan problem (Staub, 2005). About 800,000 people were massacred in 100 days. A huge number of people participated in those massacres. If a formal set of hearings, such as the SA TRC, had been established to hear each case for amnesty, the court system would be bogged down for decades. Thus, amnesty hearings were moved into the local communities. The hearings were called gacaca hearings, which were public hearings for justice and amnesty within the communities in which the violence took place. Brounéus (2008) has described some of the problems that have arisen with the gacaca hearings. For example, people who testified against those who perpetrated violence were sometimes intimidated before or after testimony. Witnesses, thus, do not feel safe. Thus, the likely truth value that came from the gacaca trials was to some degree compromised, as was the ability to reconstruct a coherent narrative from the transcripts. For example, because some witnesses may have not felt safe, they may have modified their testimonies (e.g., held back important facts) for fear of repercussions, which may have tainted the narratives shared in the hearings.

Examples of Forgiveness-Based Track-Three Diplomacy Irish Catholic and Protestant Forgiveness Education There are also a number of efforts at track-three diplomacy using forgiveness education to promote intrastate healing after conflict. For example, Enright has conducted a number of groups in Northern Ireland to bring northern Irish Catholics and Protestants together. Forgiveness interventions using Enright’s process model have been conducted in the schools. Then Catholic and Protestant children who have gone

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through the program in their individual schools are brought together for interaction with each other. South American Forgiveness Education Naváez Gómez (2005) has conducted forgiveness education in at least ten South American countries to promote intrastate forgiveness and reconciliation. Naváez Gómez typically has people on both sides of a conflict go through an educative process of 50 or more hours to learn forgiveness and reconciliation skills. He has used this with warring parties, criminals who have confessed to political crimes, and other people who have done violence. The approach is tailored to the country and situation in which the problem exists.

Conclusion As should be evident from the analysis in the present chapter, forgiveness and reconciliation can promote healing of memories and social relationships after conflict and social trauma. They work well when justice is insured through other track-three diplomacy programs such as restorative justice-based programs. Whereas reconciliation is one of the major societal goals after a social trauma has ended, forgiveness is not something that should be expected of every person. Rather forgiveness is a single pathway (among many) to reconciliation. It may be the only pathway that can fully close the injustice gap for all parties involved in the conflict. However, not everyone values forgiveness. Thus, forgiveness should be advocated as only one of many possible ways to restore social harmony after social trauma. Forgiveness is intimately bound up with empathy of members of one group for members of the other group. Forgiveness is promoted by empathy; yet forgiveness promotes more empathy. Forgiveness can reduce the motive to harm the members of the other group. It therefore makes violence less probable, thus allowing the members to interact more and to experience increased empathy for each other. This contributes to the socially useful peacemaking cycle that can promote healing and rehabilitation after the social trauma.

References American Psychiatric Association (2005). Diagnostic and statistical manual of mental disorders (4th ed.) – Text revised. Washington, DC: American Psychiatric Association. Baumeister, R. F., Exline, J. J., & Sommer, K. L. (1998). The victim role, grudge theory, and two dimensions of forgiveness. In E. L. Worthington, Jr. (Ed.), Dimensions of forgiveness: Psychological research & theological perspectives (pp. 79–104). Philadelphia: Templeton Foundation Press. Botcharova, O. (2001). Implementation of track two diplomacy: Developing a model of forgiveness. In R. G. Helmick & R. L. Petersen (Eds.), Forgiveness and reconciliation: Religion, public policy, and conflict transformation (pp. 269–294). Philadelphia: Templeton Foundation Press.

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Brounéus, K. (2008, June). Reconciliation in the Great Lakes region: Some thoughts on key topics, agendas, and challenges. Paper presented at the meeting of the John Templeton Foundation ad hoc Task Force on the Possibility of Research in Rwanda, Nassau, Bahamas, June 3, 2008. Cairns, E., Tam, T., Hewstone, M., & Niens, U. (2005). Intergroup forgiveness and intergroup conflict: Northern Ireland, a case study. In Everett L. Worthington, Jr. (Ed.), Handbook of forgiveness (pp. 461–475). New York: Brunner-Routledge. Chapman, A. R., & Spong, B. (Eds.). (2003). Religion and reconciliation in South Africa. Philadelphia: Templeton Foundation Press. Diaz Ferrer, J. E. (2005). Reconciliación y reincorporación, paz en el vecindario sin indiferencia en la interpretación. In D. Villamizar, J Cuesta, C Sánchez, & R. Morales (Eds.), Desmovilización, un camino hacia la paz (pp. 61–72). Bogotá, D. C., Colombia: Librería y Editorial Filigrana. Exline, J. J., Worthington, E. L., Jr., Hill, P. C., & McCullough, M. E. (2003). Forgiveness and justice: A research agenda for social and personality psychology. Personality and Social Psychology Review 7, 337–348. Fox, D. (1997). Psychology and law: Justice diverted. In D. Fox & I. Prilleltensky (Eds.), Critical psychology: An introduction (pp. 217–232). London: Sage Publications. Freedman, S. (1998). Forgiveness and reconciliation: The importance of understanding how they differ. Counseling and Values, 42, 200–216. Gobodo-Madikezela, P. (2003). A human being died that night: A South African story of forgiveness. Boston: Houghton-Mifflin. Goffman, E. (1969). Strategic interaction. Oxford, England: University of Pennsylvania Press. Hicks, D. (2001). The role of identity reconstruction in promoting reconciliation. In R. G. Helmick & R. L. Petersen (Eds.), Forgiveness and reconciliation: Religion, public policy, and conflict transformation (pp. 129–150). Philadelphia: Templeton Foundation Press. Lazarus, R. S. (1999). Stress and emotion: A new synthesis. New York: Springer. Lederac, J. P. (1997). Building peace: Sustainable reconciliation in divided societies. Washington, DC: U. S. Institute of Peace Press. Lederac, J. P. (2001). Five qualities of practice in support of reconciliation processes. In R. G. Helmick & R. L. Petersen (Eds.), Forgiveness and reconciliation: Religion, public policy, and conflict transformation (pp. 183–193). Philadelphia: Templeton Foundation Press. LeDoux, J. (1996). The emotional brain: The mysterious underpinnings of emotional life. New York: Simon and Schuster. Lindy, J. D. (1985). The trauma membrane and other clinical concepts derived from psychotherapeutic work with survivors of natural disasters. Psychiatric Annals, 15 (3), 153–155, 159–160. Lindy, J. D., Grace, M. C., & Green, B. L. (1981). Survivors: Outreach to a reluctant population. American Journal of Orthopsychiatry, 51, 468–478. McCullough, M. E. (2008). Beyond revenge: The evolution of the forgiveness instinct. San Francisco: Jossey-Bass. Milgram, S. (1974). Obedience to authority. New York: Harper & Row. Montville, J. V. (1990). The arrow and the olive branch: A case for track two diplomacy. Lexington, MA: Lexington Books. Naváez Gómez, L. (2005). Elementos básicos del perdón y la reconciliación. In D. Villamizar, J Cuesta, C Sánchez, & R. Morales (Eds.), Desmovilización, un camino hacia la paz (pp. 73–86). Bogotá, DC., Colombia: Librería y Editorial Filigrana. Pittman, C. T. (2008). The relationship between social influence and social justice behaviors. Current Research in Social Psychology, 13, 243–254. Pyszczynski, T., Solomon, S., & Greenberg, J. (2003). In the wake of 9/11: The psychology of terror. Washington, DC: American Psychological Association Books. Schimmel, S. (2002). Wounds not healed by time: The power of repentance and forgiveness. New York: Oxford Press. Schönbach, P. (1990). Account episodes: The management or escalation of conflict. New York: Cambridge University Press.

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Staub, E. (2005). Constructive rather than harmful forgiveness, reconciliation, and ways to promote them after genocide and mass killing. In Everett L. Worthington, Jr. (Ed.), Handbook of forgiveness (pp. 443–459). New York: Brunner-Routledge. Tedeschi, J. T., & Felson, R. B. (1994). Violence, aggression, and coercive actions. Washington, DC: American Psychological Association Books. Worthington, E. L., Jr. (1998). The pyramid model of forgiveness: Some interdisciplinary speculations about unforgiveness and the promotion of forgiveness. In E. Worthington (Ed.), Dimensions of forgiveness: Psychological research and theological perspectives (pp. 107–138). Philadelphia: Templeton Foundation Press. Worthington, E. L., Jr. (Ed.). (2005). Handbook of forgiveness. New York: Brunner-Routledge. Worthington, E. L., Jr. (2006). Forgiveness and reconciliation: Theory and application. New York: Brunner-Routledge. Worthington, E. L., Jr. (2009). A just forgiveness: Responsible healing without excusing injustice. Downers Grove, IL. Intervaristy Press. Worthington, E. L., Jr., & Drinkard, D. T. (2000). Promoting reconciliation through psychoeducational and therapeutic interventions. Journal of Marital and Family Therapy, 26, 93–101.

Chapter 4

A Public-Health View on the Prevention of War and Its Consequences Joop T. de Jong

Abstract Political violence, armed conflicts, and human-rights violations are produced by a variety of political, economic, and sociocultural factors. Conflicts can be analyzed in an interdisciplinary way to obtain a global understanding of the relative contribution of risk and protective factors. A public-health model is presented to address these risk factors and protective factors. The model results in a matrix that combines Primary, Secondary, and Tertiary interventions with their implementation on the levels of the Society-at-large, the Community, the Family, and Individual. Subsequently, the risk and protective factors are translated into multi-sectoral, multimodal, and multi-level preventive interventions involving the economy, governance, diplomacy, the military, human rights, agriculture, health, education, and the media. After this classification, the interventions are fitted in their appropriate place in the matrix. The interventions can be applied in an integrative and eclectic way by international agencies, governments, and non-governmental organizations (NGOs) and moulded to the requirements of the historic, political-economic, and sociocultural context. The framework maps the complementarities between the different actors, while engaging themselves in preventive, rehabilitative, and reconstructive interventions. The framework shows how the economic, the diplomatic, the political, the criminal justice, the human rights, the military, the physical and mental-health sectors, and the rural development sectors can collaborate to promote peace or prevent the aggravation or continuation of violence. A major increase in understanding is needed of the relations between risk and protective factors and of the developmental pathways of generic, country-specific, and culture-specific factors leading to political violence.

J.T. de Jong (B) VU University Medical Center & Boston University School of Medicine, Amsterdam, The Netherlands e-mail: [email protected]


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Introduction Population growth, technological advancement, economic interdependence, and ecological vulnerability, combined with the availability of weapons and the contagion of hatred and incitement to violence, make it urgent to find ways to prevent disputes from turning massively violent. Armed conflicts have significantly damaged social, physical, and human capital in conflict-related countries and hampered their economic development during and after the conflict (Stewart, Cindy, & Michael, 2001). In the post-Cold War world, wars within states vastly outnumber wars between states. These internal conflicts commonly are fought with conventional weapons and rely on ethnic expulsion or annihilation. The cumulative effect of multiple risk factors, a lack of protective factors, and the interplay of risk and protective situations predispose countries to move from a stable condition to increased vulnerability, then to political violence, and finally to full-blown civil conflict or war. Preventive strategies from the realm of public health can restore the balance between risk and protective factors. The prevention of civil conflict or war rests on a few generic public-health principles, where the word disease can be substituted by the word violence: uncovering knowledge about violence and reacting early to signs of trouble; using a comprehensive approach to alleviate risk factors that trigger or maintain violent conflict; addressing the underlying root causes of violence; and implementing, monitoring, and evaluating interventions that appear promising (Carnegie Commission, 1997). Paraphrasing Sackett et al.’s (1996, p. 72) definition of evidence-based medicine, evidence-based prevention of collective violence is defined here as the “conscientious and judicious use of current best evidence in making decisions about preventive interventions for communities, countries, and regions to reduce the incidence of political and economic violence and to enable people to regain control, to improve their wellbeing, and live in peaceful coexistence.” The World Health Organization (WHO; 2002) divides violence into three broad categories according to characteristics of those committing the violent act: self-directed violence, interpersonal violence, and collective violence. Collective violence is subdivided into social, political, and economic violence. Political violence includes war and violent conflicts, state violence, terrorist acts, and mob violence. Economic violence includes attacks by larger groups motivated by economic gain (WHO, 2002). This chapter addresses political violence and its sequelae. Yet, different types of violence are strongly interrelated and can best be understood within an ecological or contextual paradigm. In 2000, an estimated 1.6 million people worldwide died as a result of violence. Nearly half of these deaths were suicides, one-third were homicides, and one-fifth were war related (WHO, 2002). Between 2009 and 2019, Disability-Adjusted Life Years (DALYs), related to war injuries, will likely increase (Murray & Lopez, 1997). In modern warfare, 10% of the people who are killed are soldiers, 90% civilians, and one-half of these are children. Armed conflict is often associated with reduced agricultural production and forced displacement of people. This contributes

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to increasing poverty, hunger, and malnutrition (Farmer, 2003; Kleinman, Das & Lock, 1997). A local conflict can spill over into national conflicts, which sometimes spill over into neighboring countries, and thus may destabilize a whole region (Murdock & Sandler, 2002; Pinstrup-Andersen & Shimokawa, 2008). At the global level, the total number of armed conflicts rose steadily from the early 1950s until 1994 and then declined sharply until 2004 (Hewitt, 2008). Further, the end of the Cold War at least partly influenced the decline in armed conflict. This decline was largely due to the resolution of old conflicts, rather than the prevention of new conflict, and many dormant societal conflicts reoccurred after 2004. Political violence often is the outcome of steps along a continuum of antagonism (Staub, 1993). A progression of mutual retaliation may start with small acts that escalate, resulting in a “malignant social process” (Deutsch, 1983). The escalation of conflict is often the result of “us-them” differentiation and group-think. Group-think creates an illusion of invulnerability that leads to excessive optimism and risk-taking, a collective rationalizing of warnings that might temper a position, an unquestioned belief in a groups moral superiority, negative stereotypes of an out-group making negotiation unfeasible, direct pressure on dissenters from group ideology, self-censorship of deviation from an apparent consensus, a shared illusion of unanimity, and the emergence of self-appointed “mind guards” to protect group from adverse information, so that dissent to violence is voiced at risk of death (Janis, 1982). Examples of “us-them” include oppositions between Aryan-Jew, Tutsi-Hutu, Israeli-Palestinian, Indian-Pakistani, Arab-“West,” Han Chinese versus other ethnic groups, and Serbs-Bosnians. If a societal self-concept is based on superiority, self-doubt, or their combination, it may give rise to war-generating motives (e.g., Germany after WW-I, the Khmer Rouge dreaming of restoring the old Khmer empire). A societal self-concept often designates disputed territories as part of a nation (China claiming Tibet, Israelis and Palestinians claiming Jerusalem, Iraq claiming Kuwait, or Argentina reclaiming the Falklands). Or part of the territory may want to split off from a country to which it “belongs” (Biafra from Nigeria, East-Pakistan from WestPakistan, Eritrea from Ethiopia, South-Sudan from the North, Kurdistan from Turkey, Iran, Iraq, and Syria). Groups, like individuals, project unacceptable aspects onto others (Pinderhughes, 1979); those who are repudiated become “bad,” whereas the group that projects remains pure and good (Staub, 1993) (e.g., the genocide of the Armenians in Turkey; the tensions in South Africa or Congo leading to witchcraft accusations; the accusations of “parasitism” to the Jews in pre-WWII Europe, to Indians in East Africa, or the Chinese in Indonesia; Mozambique’s Renamo claiming to restore traditional values that were felt to be derogated by Frelimo). The ratio of involvement in collective violence of low-to middle-income countries versus high-income countries is 10 to 1 (WHO, 2002). The probability of armed conflict onset is higher in countries with low socioeconomic status, low economic growth, and especially in countries with unequal income distribution. The poor may feel that they have less to lose from armed conflict, compared to the rich,

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and thus may have a higher predisposition to conflict. Health and nutritional indicators also are important determinants of conflict onset: child mortality rates are 102% higher, child malnutrition rates are 50% higher, and under-nutrition rates 45% higher than in non-conflict countries (Pinstrup-Andersen & Shimokawa, 2008). Moreover, armed conflict is a major deterrent to economic development and poverty alleviation, leaving countries in a poverty-conflict trap. Given the very high costs of armed conflict in both economic and humanitarian terms, it is important to find ways to reduce the risk of conflict onset. Therefore, achieving the United Nations’ (U.N.) Millennium Development Goals, pro-poor policies, and prioritization of agriculture and health will contribute to reducing the risk of armed conflict (Pinstrup-Andersen & Shimokawa, 2008). Leaders have great power to shape relations between nations. They have the capacity to enlist the loyalty of their citizens and may initiate a cycle of hostility. Citizens rarely criticize the hostile acts of their own country, but they are aroused to patriotic fervor by hostile acts against their country, even retaliatory ones (Staub, 1993). The process of leadership may produce faulty decision making, e.g., as a result of group-think. In addition to the United Nations, there are only a few institutions (e.g., Organization of Security and Cooperation of Europe), whose purpose is to restrain hostile acts against another nation. Although some of these institutions adhere to a public-health paradigm, to my knowledge, no one so far has tried to develop a public-health framework. The objectives of this chapter are (i) to develop a concise yet fairly comprehensive public-health model that (ii) integrates economic, political, humanitarian, and military elements, which are thought to be important for the primary, secondary, and tertiary prevention of armed conflict and its consequences.

Methods The selective literature review for this chapter has been described elsewhere (De Jong, 2010). In short, a PUBMED and Psychinfo search was done and studies were included, based on the following criteria: the study (a) contains original data or is a systematic review, (b) makes specific reference to political violence, war, armed conflict, or civil war, (c) focuses on one of the aforementioned domains (economy, military, health, mental health, education, etc.). Books, book reviews, editorials, and additional reports were identified through other sources. Only English-language publications were included. In addition, I added observations and experience of almost four decades of engagement in post-conflict and disaster areas. Results were entered in the prevention matrix that was designed by combining primary, secondary, and tertiary interventions with their implementation on the level of the society-at-large, the community, the family, and individual. On the level of primary prevention, the framework distinguishes universal, selective, and indicated preventive interventions. Preventive interventions were classified to fit in the appropriate cell of a nine-cell matrix.

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Risk Factors for Collective Violence Prevention requires identifying risk factors and determinants of collective violence and developing approaches to resolve conflicts without resorting to violence. A range of the most important risk factors for major political conflicts was identified and listed – without the pretension of being exhaustive – in Table 4.1 (Baker & Ausink, 1995; Carnegie Commission, 1997; Davenport & Stam, 2004; Esty, Goldstone, Gurr, Surko & Unger, 1995; Hegre & Sambanis, 2006; Hewitt, 2008; Lim, Metzler, & Bar-Yam, 2007; Staub, 1993). An accumulation of risk factors or a critical mass of these symptoms increases the likelihood of collective violence. Table 4.1 suggests that there is a linear relation between risk factors, signs, and consequences of collective violence. In reality, the relations are circular and the different categories of indicators influence each other in a systemic way. A typical example is a low-income country that has previously privatized its economy within the framework of the Washington consensus with its fiscal discipline, tax reform, privatization, deregulation, reorientation of public expenditure etc., imposed by the World bank and the IMF (Rodrik, 2007). Its social safety net deteriorates and it has a large stratum of unemployed youth, which compares its bleak future with a corrupt, undemocratic government of politicians and military that bypasses the laws and competes over access to resources. A rebel movement with an ethnicreligious background mobilizes the youth to overthrow the regime that is known for its human-rights violations. A tedious war produces a few hundred thousand refugees and Internally Displaced Persons (IDPs) and results in a pillaging of the remaining resources by all parties. The gross national product and the health and education budget have dropped close to zero, people are hungry and impoverished, child mortality increases sharply, rape is rampant (because of the presence of soldiers and rebels), an overall war-fatigue sets in, and a U.N. intervention is called upon to redress the plight of the country. This fictitious example shows the cumulative weight and the potentiating effect of different risk factors. This example shows that many ingredients of collective violence are universal and global, but that its prevention and resolution are particular to the local context and its human and other resources.

Prevention Table 4.2 shows the matrix of the relation between primary, secondary, and tertiary prevention, with three intervention levels (i.e., society-at-large, communities, and families/individuals). The matrix offers a generic, eclectic framework addressing the complementarity of important players, such as the different U.N. agencies, governments, and Civil Society (e.g. Non-Governmental Organizations (NGOs), International NGOs, Community Based Organizations (CBOs), Grassroot Organizations, and My own NGO (MoNGO)). The first of the three intervention levels is the macro-level, the society-at-large, including (inter)national agencies and governments. Interventions at this level are meant for all countries and belong

Darfur

Uganda, Angola, Mozambique, Zepa (Balkan) Rwanda, Burundi Liberia, S Leone, S Lanka, Sudan, Tigray

Rapid changes in population structures including large-scale movements of refugees and IDPs

High rates of (infant) mortality

Rapidly changing demographic characteristics

Excessively high population densities High levels of unemployment, especially among youth Insufficient supply of food or access to safe Eritrea water Disputes over territory or environmental Ethiopia, Eritrea resources claimed by distinct ethnic groups or governments

Widening social and economic inequalities, Former USSR and Yugoslavia both between and within population groups. Globalization, failed states, privatization, decline of social safety nets, deprivation, competition for resources, increased availability of weapons and landmines Struggle over access to resources such as Angola, Congo, S Leone, Chad, Nigeria, oil, diamonds, gems, timber, and rivers Sudan, Cambodia, Indonesia Struggle over access to illicit drugs Afghanistan, Columbia, Myanmar

Inequality

Examples

Signs

Indicators

Pre/post-conflict massive population movements (e.g., refugees, IDPs) and competition for resources in areas into which people move. Environmental degradation Decline vaccination coverage, increase infectious diseases, reduced access to health services Overcrowding, resource depletion, environmental degradation, high exposure to vectors, high risk of HIV infection, poor nutrition, increased risk diseases Discontent, recruitment into rebel forces Conscription or looting of farmers, destruction water and sanitation infrastructure Create a climate of warfare and involve civilian populations

The state is unable to manage political challenges and to maintain control over the use of force Increased mortality and physical disability, high death rates among civilians National army and rebel/guerilla forces engage in armed conflicts to secure access to the resources. Manipulation of resource shortages for hostile purposes (e.g., using water as a weapon). Competition for income from narco-traffic

Consequences

Table 4.1 Indicators of states at risk of collapse and internal conflict with examples and sequelae

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Signs

Violations of human rights Criminalization or de-legitimization of the state Corrupt governments, faulty leaders Political Rapid changes in regimes instability Ethnic composition of the ruling elite differing from the majority A legacy of vengeance –seeking group grievance Ethnic Political and economic power exercised – composition of and differentially applied – according to ruling ethnic ethnic or religious identity group different Desecration of ethnic or religious symbols from the population at large or ethnic groups straddling interstate boundaries Deterioration of A decline in the scope and effectiveness of public services social safety nets designed to ensure minimum universal standards of service Severe economic Uneven economic development decline Grossly unequal gains or losses between population groups or geographical areas resulting from large economic changes Massive economic transfers or losses over short periods of time Cycles of violent A continued cycle of violence between rival revenge groups

Lack of democratic processes

Indicators

Reduced public expenditure on, e.g., health and education

Rise of complex humanitarian emergencies

Great Lakes region of Africa

Poverty, deprivation, discontent, and subsequent involvement in armed struggle

Inter-ethnic strife

Torture, imprisonment, mutilation High military expenditures Use of violence to survive or to achieve their aims Failed states Protracted cycles of violence and eruptions of ethic clashes

Consequences

West Africa, Great Lakes Region of Africa

Somalia, East Congo, Liberia, S Leone, Angola, Mozambique Rwanda, Burundi Balkan (Bulgaria, Hungary, Romania, Slovakia) Rwanda, Burundi, S Lanka, Balkan, Caucasus, Nagorno-Karabakh/ Azerbaijan, Afghanistan Tibet

Bhutan, Cambodia, Iran Yugoslavia, Guatemala, Iraq, Mozambique, S Leone, Ethiopia

Examples

Table 4.1 (continued) 4 A Public-Health View on the Prevention of War and Its Consequences 79

Primary prevention: eliminate a conflict or problem before it can occur

Universal preventive interventions Economy, governance, and early warning Free media and press Resolve underlying root causes of violence (Inter)national laws Defining and condemning human-rights violations Research into events and their consequences Setting standards for intervention and training Expanding security institutions Military’s role of last resort Reinforcing peace initiatives and conflict resolution Arms and landmine control Prevent the re-emergence of violence Transnational collaborative projects Selective preventive interventions Humanitarian operations War tribunals and the persecution of perpetrators Peacekeeping forces Indicated preventive interventions Human-rights advocacy

Society-at-large/(inter)national Universal and selective preventive interventions Rural development and food production Community empowerment Decreasing dependency and learned helplessness Public health and education Peace education and conflict resolution in schools Public education Security measures

Community

Universal and selective interventions Include women and children in the distribution of economic growth Family reunion/family tracing Family/network building Improvement of physical aspects Public health and education

Family and individual

Table 4.2 Matrix showing the relation between Universal, Selective, and Indicated Preventive Interventions, and Primary, Secondary, and Tertiary Preventiona

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Conflict prevention & resolution Crisis intervention Vocational skills training

Reconciliation and mediation skills between groups

Humanitarian relief operations Reparation and compensation Voluntary repatriation (Co-occurring) Natural disasters: quality standards

Peacekeeping and peace-enforcing troops. Peace agreements

Community

Involve the family in rehabilitation and reconstruction

Prevention of recruitment of child soldiers Reparation and compensation for afflicted families Public (mental) health and disease control Crisis intervention

Family and individual

a Some of the cells are compressed by taking universal, selective, and indicated interventions together, in order to facilitate reading. Moreover, some interventions apply to primary, secondary, and tertiary intervention on a national and community level, e.g., reinforcing peace initiatives

Secondary prevention: shorten the course of a conflict or problem Tertiary prevention: prevent a conflict from becoming chronic, to recur, and to contribute to rehabilitation and reconstruction

Society-at-large/(inter)national

Table 4.2 (continued)

4 A Public-Health View on the Prevention of War and Its Consequences 81

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to the realm of the U.N. and its Security Council, United Nations Office for the Coordination of Humanitarian Affairs (UNOCHA), governments, politicians, policy-makers, and several (I)NGOs. Interventions on the second level, or the community level, aim at the total population in a conflict zone, including refugees and Internally Displaced Persons (IDPs). Interventions at the community level are often provided by more specialized international agencies, such as United Nations Refugee Agency (UNHCR), World Food Program, Food and Agricultural Organization, United Nations Development Program, World Bank, local governments, (International) NGOs, and advocacy groups. On the third level are the families and individuals. Interventions at this level aim to relieve the plight of families and individuals. These activities are mostly covered by specialized U.N. agencies, such as United Nations Children’s Fund (UNICEF), WHO, United Nations Development Fund for Women (UNIFEM), governments, local, southern NGOs, and community-based organizations. Depending on political will and socioeconomic resources, many interventions at the community, family, and individual level could be realized within a 5–10 years period, whereas interventions at the level of the society-at-large will likely take substantially more time.

Primary, Secondary, and Tertiary Prevention The framework described in this chapter distinguishes primary, secondary, and tertiary preventions. The goal of primary prevention is to eliminate a conflict or problem before it can occur. Universal, selective, and indicated preventive interventions are included within primary prevention. Universal preventive interventions are targeted to the community of nations, the general public, or a whole population group. Selective preventive interventions are targeted to nations or states, whose risk of developing collective violence is higher than average, based on the risk factors mentioned in Table 4.1. Indicated preventive interventions are targeted to high-risk countries, regions, or sub-regions that show signs of collective violence that foreshadows a serious armed or ethnic conflict (cf. U.S. Committee on Prevention of Disorder, 1994). Secondary prevention seeks to shorten the course of a conflict through early (crisis) intervention and case identification, and refer the conflict to relevant authorities, such as the United Nations or governments. Tertiary prevention includes interventions to prevent a conflict from becoming chronic, to prevent the conflict from reoccurring, and to contribute to rehabilitation and reconstruction. Application of the matrix in Table 4.2 implies that some preventive strategies fitting the matrix are operational (i.e., are applicable in the face of or in the aftermath of crisis) and others are structural (i.e., ensure that crises do not arise). Italics in the text below refer to interventions that are mentioned in the matrix in Table 4.2 (cf. De Jong, 2002).

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Primary Prevention in the Society-at-Large Universal Primary Preventive Interventions at the Level of the Society-at-Large 1. Economy, governance, and early warning. Preventive policies to reduce the potential for violent conflicts should address civil society and the quality of policy-making decisions. Moreover, it should develop legal standards, reduce inequality between groups, develop regimes for controlling destructive weaponry, and embrace development strategies that reduce poverty (Carnegie Commission, 1997; Addison, 2000). Economic growth per se does not prevent collective violence, but equitable access and economic opportunities do help to inhibit deadly conflict (Collier et al., 2003). Economic goals include growth, price-shock regulation, and diversification decreasing dependence on natural resources. Economic prevention also includes rebel financing and so-called Commodity Tracking Systems (e.g., for gold, coltan, or gemstones) (Bannon & Collier, 2003). Economic reconstruction aims at integrating external and internal efforts to restore essential services and restart economic activity. Governance goals include addressing corruption, weak and unaccountable government, secessionist movements, financial and political transparency, cessation of illicit trade by armed groups, and building better corporate practices. Multi-party political systems are more important then democracy per se, because multi-party systems are more inclusive and stable and have a lower probability of civil war (Reynal-Querol, 2005). Collier (2009) calls the exaggerated expectations of democracy ‘Democrazy’. Multi-track diplomacy is useful in building relationships between conflicting parties and governments by offering training in diplomacy and conflict resolution. The U.N. could more often use Article 99 of the U.N. charter (i.e., that the U.N. Secretary-General “may bring to the attention of the Security Council any matter which in his opinion may threaten the maintenance of international peace and security”). The aforementioned escalation of conflicts necessitates an early warning system that provides updated analysis of developing trends, political consultations to establish preventive engagement, a pragmatic course of action to respond to the warning signs, and a flexible repertoire of political, economic, and military measures. It implies preventive diplomacy, negotiation by mediators, a rapid reaction-force that is guided by the U.N. charter, and economic measures, such as sanctions, inducements, and economic conditionality. Inducement implies the granting of benefits, in exchange for a policy adjustment, and makes cooperation more appealing than aggression. An example of economic conditionality, i.e., linking non-violent behavior with reward, is attaching good governance to development assistance by donors. Both inducements and economic conditionality should more often been sought by the United Nations and its financial institutions, such as the World Bank and the International Monetary Fund (Carnegie Commission, 1997). Economic pressure

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can only become effective when donor states harmonize their policies. Although every bilateral donor conditions aid on conflict, some countries decrease their aid based on either harbouring or bordering a conflict, while others increase their aid. For example, Belgium, Canada, France, New Zealand, Portugal, Switzerland, Spain and the United Kingdom decrease aid, while the United States, Russia, Denmark, Finland, Germany, Ireland, Japan, the Netherlands, and Norway increase their aid (Balla & Yannitell-Reinhardt, 2008). The international donor community should have more insight on how much funding is spent on specific sectors, such as education and health, and on the rationale of having “donor darlings” (e.g., a focus on Tanzania versus countries such as Laos or the Guineas). The French anthropologist René Girard (1976) contends that an individual desires an object, not for itself, but because another individual also desires it. This mimetic desire plays a role both among perpetrators and among donors. For example, donors may compete over resources, over previous colonies, or over the preference in language (Francophone, Anglophone, Lusophone, or other linguistic background). Regarding perpetrators, when violence is introduced, it is mimetically returned through reciprocated abductions, gender-based violence (GBV), the destruction of homes, mass killings, or ethnic cleansing. The result is mistrust, mutual hatred, and extreme stress, necessitating reconciliation to transform ongoing cycles of vengeance to co-existence. The media and local NGOs are often the first to be aware of grievances or social processes that may result in violence. This leads to the next intervention: 2. Free media and press. Free journalism and free media are able to provide an important contribution to the recognition and the dissemination of information about events and human-rights violations. Instead of addressing hatred-induced emotions (e.g., as what happened in Rwanda), the media can play a role of featuring conflicts in a way that engenders constructive public considerations and ways to avoid violence (cf. Staub, 2003). Journalists and humanitarian workers may have firsthand knowledge of abuse and can play a role in bearing witness (Orbinski, Beyrer & Singh, 2007). 3. Resolve underlying root causes of violence. To strengthen structural prevention (i.e., ensure that crises do not arise), one has to address the root cause of violence. Structural prevention or peace-building comprises strategies to reduce unemployment, ensure fundamental security, well-being, and justice, temper discrimination and ethnic contradictions, and rebuild societies. Structural prevention requires a state with an accountable bureaucracy and with a macroeconomic management structure that opens the country to the international community and to the global economy. In addition, the state should address the issue of well-being, that is, remove barriers to equal opportunity by providing access to basic necessities, such as health services and education. The state should also provide an opportunity to earn a livelihood, such as by stimulating poverty reduction and protecting the environment. International laws are needed to deal with the four main sources of insecurity worldwide: (1) access to land and resources, (2) nuclear and other weapons of mass destruction, (3) confrontation between militaries, and (4) sources of internal violence, such as terrorism, organized crime, insurgencies, and repressive regimes.

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4. (Inter)national laws. To contain internal violence, such as terrorism, organized crime, and active insurgencies, states need laws, an effective police authority, an accessible grievance-redress system, and a fair penal system. International laws should emphasize three areas: human rights, humanitarian laws, and non-violent alternatives for dispute resolution. Humanitarian laws include the need to provide legal underpinning for U.N. field operations and should also address the needs of vulnerable groups, the freedom of religion, and the right to preserve non-harmful cultural practices. 5. Defining and condemning human-rights violations. A good example of protecting a vulnerable group such as torture victims, is the United Nations’ definition of governmental torture. Health and mental-health professionals should be trained to abstain from any involvement in human-rights abuses such as torture. 6. Research into the prevalence of events and their consequences. Measuring war-related events may result in a reduction of the frequency of these events. Interdisciplinary research can help to verify facts, disclose the truth, and improve interventions. Research can be regarded as a form of non-monetary reparation that serves the moral welfare of the survivors. There is a lack of understanding about many aspects of collective violence, such as the relative contribution of biology and culture to aggressive behavior, descending from the macro-level of society to the micro-level of cognition and emotion; about the contribution of cultural and social neuroscience to transcend the nature-nurture dichotomy, about intergroup relations, hybrid and multiple identity, ethnocentrism, prejudice, racism, and about ways to change the cognitive map of a declared enemy; about child development, socialization, and pedagogic approaches to stimulate nonviolent conflict resolution across cultures; or about the origins and closures of wars, and about effective long-term strategies of arms reduction and control. 7. Setting standards for intervention and training. Setting standards by the United Nations, international foundations, and the NGO community may help to increase the quality of all types of interventions at all levels. 8. Expanding security institutions and strengthening non-violent means of preventing and ending armed conflict. Regional mechanisms require long-term action. It aims at a complex set of measures, including expanding global and regional security institutions, and strengthening non-violent means, such as cooperation, dialogue, and confidence building. Because most current conflicts occur within – rather than between states – the regional efforts should monitor and subsequently focus on warring factions and parties in their region. In addition, (inter)regional security mechanisms can offer the following: 9. Clarify the military’s role of last resort for preventing and ending armed conflict. 10. Reinforcing peace initiatives and conflict resolution. Political leaders may be able to diminish hostility and can be stimulated by the international or regional community to build an atmosphere for social reconstruction or reconciliation (e.g., Gorbachev-Reagan, Mandela-de Klerk, and the Dalai Lama). 11. Arms and landmine control. This includes creating military barriers to limit the spread of the conflict and to deny belligerents the ability to resupply arms and

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refraining outsiders from providing weapons, funds, and landmines. Despite the 1981 Land Mines Protocol, one out of every 236 Cambodians and one out of 1250 Vietnamese has a disability due to landmines or Unexploded Ordnance (UXO) (Asia Watch & Physicians for Human Rights, 1991). 12. Prevent the re-emergence of violence. Create a secure environment in the aftermath of conflict with stabilizing security forces that separate enemies. Restore legitimate political authority, i.e., install functioning police, judicial, and penal systems. 13. Transnational collaborative projects, such as educational, cultural, and scientific exchange. Scientific, cultural, and educational exchanges can help to overcome prejudice, ethnocentrism, and nationalism and can help to promote the free exchange of ideas. Selective Primary Preventive Interventions at the Level of the Society-at-Large 1. Humanitarian operations. Provide humanitarian aid to innocent victims (e.g., refugees, IDPs). Make sure that the crisis response integrates humanitarian, economic, political, and military elements. 2. War tribunals and the persecution of perpetrators. In the aftermath of collective violence, the legitimacy of reconciliation is essential. Three common approaches to bring perpetrators to justice are (1) the visible use of the existing judicial system; (2) the establishment of a truth and reconciliation commission; and (3) the reliance or the establishment of international tribunals. 3. Peacekeeping forces. Peacekeeping and peace-enforcing play an important role in the prevention or re-escalation of armed conflicts. A standing, rapid-reaction force of 5–10,000 troops with an operational headquarters and equipment can respond quickly to social conflict. Indicated Preventive Interventions at the Level of the Society-at-Large Human-rights advocacy. Human-rights advocacy is an indicated preventive measure for survivors of human-rights abuses, including torture and GBV. Every state has the responsibility to redress human-rights violations.

Secondary Prevention in the Society-at-Large 1. Humanitarian relief operations. Food, shelter, water supply, and public-health efforts provide relief, restore the social safety nets that were destroyed before violence broke out, and buffer economic tensions and ethnic contradictions. 2. Reparation and compensation. Every state has the responsibility to redress human-rights violations and to enable victims to exercise their right to reparation (Van Boven, Flinterman, Grünfeld, & Westendorp, 1992).

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3. Voluntary repatriation. Another universal preventive activity is to work toward political solutions that allow for voluntary migration or repatriation to the place of origin. 4. Co-occurring natural disasters: quality standards. Natural or climatological disasters may co-occur or may be superimposed on the effects of political violence. A number of (inter-)national initiatives and disaster-preparedness training of the disaster-prone segments of the population can have a preventive effect, e.g., setting quality standards for building in earthquake or landslide-prone areas or river beddings, or setting higher quality standards for the construction of nuclear power stations. Better accessibility of land in areas with land slides, better alarm systems for floods, cyclones, or hurricanes, and better sheltered areas and evacuation plans in areas that are hit by volcano eruptions or typhoons.

Tertiary Prevention in the Society-at-Large 1. Peacekeeping and peace-enforcing troops. Peacekeeping missions can help monitor, supervise, and verify cease-fires and settlement terms and restrain tense situations. The “Thin Blue Line’s” (i.e., U.N. police forces) preventive deployments may prevent the spread of hostilities under the aegis of the Security Council. 2. Peace agreements. Peace agreements should focus on implementing long-term change, mechanisms for consensus-building (e.g., constituent assemblies), ongoing relationships between former warring parties, power-sharing arrangements, economic reconstruction, and justice.

Primary Prevention at the Community Level Universal and Selective Primary Prevention at the Community Level 1. Rural development and food production. Rural-development initiatives help local populations, refugees, and IDPs to enhance their economic capacities and increase their food security, resiliency, and quality of life. Rural development aims at improved rural infrastructure, better living conditions, and a more secure livelihood for the population. This can be achieved through increasing food production, improving its distribution, and by setting up small-scale income-generating projects; if focused on areas with simmering instability or increasing grievances, these agricultural policies can play a critical role in reducing the risk of armed-conflict onset, including riots triggered by high food prices (Hegre & Sambanis, 2006). These projects may compensate for a lack of land and prevent envy between local populations and IDPs or refugees. Rural development is one aspect of empowering a community. 2. Community empowerment aims at revitalizing helping skills that are not utilized by the local people, due to demoralization, collective apathy, or a lack of appropriate knowledge. Empowerment activities involve community members to

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help themselves, their families, and their neighbors. These interventions lead to communal pride – a psychological sense of community (Sarason, 1974), and stimulate “resource gain cycles” (Hobfoll, 1998). Rural development and empowerment help to diminish dependency. 3. Decreasing dependency and learned helplessness, which often tend to develop after human-made disasters, and which are often initiated and reinforced by relief organizations. Currently, instead of being regarded as victims, survivors are more likely regarded as resilient people from cultures that have developed ingenious coping strategies. Reduction of dependency and autonomy can be stimulated by involving local people in community interventions, health and educational activities, and in management and administrative issues. Religious leaders and healers should be stimulated to continue their rituals and ceremonies. Musicians, dancers, and storytellers should be allowed to organize leisure activities in closed communities, like refugee and IDP camps. 4. Public health and education. The impact of conflict on health-care and education services is wide-ranging. Military action often undermines public-health and disease-control programs that extend well beyond the period of active warfare, with reduced health-sector spending, and reduced surveillance, prevention, treatment, and vector control (Beyrer, Villar, Suwanvanichkij, Singh, Baral & Mills, 2007; Ghobaraha, Huthb, & Russettc, 2004; Pedersen, 2002). Access to health and education is often reduced, due to (1) security reasons and to reduced geographic and economic access; (2) the service infrastructure, the logistics, and equipment being affected or deliberately destroyed, and; (3) a scarcity of human resources because personnel flees from the area, leaves the country, or is targeted by armed forces (as happened during the Khmer Rouge in Cambodia, Renamo in Mozambique, or the Lord’s Resistance Army in Uganda). Health, education, and other sectors can further stimulate reconciliation and collaboration by (1) setting a policy and strengthening equitable health and educational services; (2) reconstructing the former infrastructure; (3) developing human resources by a cascade of training levels; (4) supplying educational materials, food and nutrition, medicines, and vaccines; and by (5) creating a monitoring and surveillance system. There are several good examples of “peace through health” programs (e.g., http://www.humanities.mcmaster.ca/peace-health). 5. Peace education and conflict resolution in schools. Education is a force for reducing intergroup conflict by enlarging social identifications and by creating a basis for fundamental human identification across a diversity of cultures. Pivotal educational institutions, such as the family, schools, community-based organizations, and the media, have the power to shape attitudes and skills toward decent human relations – or toward hatred and violence. Much of what schools can accomplish is similar to what parents can do – employ positive discipline practices, teach the capacity for responsible decision making, foster cooperative-learning procedures, and guide children in pro-social behavior outside and in schools. They can convey the fascination of other cultures, making respect a core attribute of their outlook on the world.

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6. Public education is a community intervention with a potential to reach large numbers of people and help them to obtain information about aid, about legal rights, or any numbers of issues that will help them cope with their particular situation. In humanitarian crises, public education can be used to quell rumors and help the community to have a more realistic view of the situation. Public education and community campaigns can involve the education of citizens on how to prevent violence of all types, including toward children, spouses, the elderly, and individuals with disabilities. In addition, young people can be trained in methods of conflict resolution and can help those who are more vulnerable because they lost a family member or their possessions. 7. Security measures. Survivors of wars and other types of disasters are often retraumatized by robbers or gangs of armed bandits. Shelling, ambushes, land mines, and unexploded ordnance (UXO) are additional plights and dangers and these need to be addressed, in order to create a safe environment, especially in camps that consist of a majority of women and children.

Secondary Prevention at the Community Level 1. Conflict prevention and resolution. Local NGOs, community, or faith-based organizations may (1) monitor conflicts and provide early warning; (2) convene adversarial parties; (3) undertake mediation between the parties and or the population groups involved; (4) develop and train conflict resolution, e.g., by hybridization of traditional or academic ways of conflict resolution (e.g., the gacaca in Rwanda); (5) strengthen institutions for conflict resolution involving local and religious leaders, healers, and the ritual complex; and (6) foster the development of the rule of law. 2. Crisis intervention by police forces or peacekeeping troops, when tensions between local groups erupt or when there are armed activities by paramilitary forces, rebels, or criminals. 3. Vocational skills training may help the local community to develop economic activities. Farmers may have lost their land, civil servants their jobs, and demobilized soldiers and ex-child soldiers their positions or sources of income. Many of them have to learn a new trade or develop additional skills, in order to set up income-generating activities.

Tertiary Prevention at the Community Level Reconciliation and mediation skills between groups. The aforementioned peace education and conflict-resolution skills can be expanded to adults, religious, and community leaders.

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Primary Prevention at the Level of the Family and the Individual Universal and Selective Primary Prevention at Family Level 1. Include women and children in the distribution of economic growth. In vulnerable societies, women are an important source of community stability and vitality. Even under adverse circumstances, women are often engaged in small-scale trade or horticulture around the house. Woman-operated businesses, micro-credit programs, education for girls, and involvement of women in decision making are important. For children, it is important to have access to education as the main vehicle for stabilization and healing. In addition, children should have access to basic health services and not be exploited economically. 2. Family reunion/family tracing. A supportive network, preferably the family, is the main vehicle for healing. Western-style orphanages or children’s villages should be regarded as a last resort – e.g., in cases of massive loss of family members due to the war or AIDS – because these facilities may create additional problems and can easily become a breeding place for bandits or prostitution. In collaboration with other organizations, abandoned or orphaned children should be accommodated within their extended family or within foster families, and international and local organizations should assess whether one or both parents or other first or second-generation family members are alive. 3. Family/network building. It promotes the family network or other types of networks to help families with similar problems to help each other, to share certain rituals, or to get involved in human-rights work (c.f., de Jong, 2002, and the empowerment section above). 4. Improvement of physical aspects. For the well-being of families, it is important that they are involved in the development of their life-world, including the physical aspects of their habitat or refugee camp. This includes discussing acceptable amounts of water, decreasing overcrowding, allotting land to grow vegetables, varying diets, drainage of the terrain, and providing space for children to play and for mothers to take care of their babies or infants. Sometimes relief agencies are not aware of the cultural taboos surrounding the disposal of waste or excrements. 5. Public health and education. This is similar to what was mentioned subprimary prevention at the community level. The focus is to emphasize facilitation of linkages between health-care and education ministries and NGOs, promote equitable social structures, expand capacity building, and develop information systems.

Secondary Prevention at the Level of the Family and the Individual 1. Prevention of recruitment of child soldiers. Children are often recruited when there are no other means of subsistence and hence become easy targets for government armies and rebel forces. This type of prevention includes (1) ensuring

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vocational skills training for child soldiers; (2) addressing the transition from a “combat mode” to a “civil mode,” such as using reconciliation and cleansing rituals to reintegrate children in their communities; (3) developing rehabilitation services for their combat-related injuries, such as loss of hearing, sight, and limbs (Machel, 1996); and (4) addressing psychosocial problems and poor control of aggression. 2. Reparation and compensation for afflicted families. Compensation is a form of reparation that is to be paid in cash or to be provided in-kind. The latter includes health and mental-health care, employment, housing, education, and land. 3. Public health and disease control: Control of infectious diseases such as measles, tuberculosis, and HIV is warranted when the service delivery system is destroyed and morbidity and mortality are on the increase. 4. Public mental health: 4(a) Self-help groups. Self-help groups assist people with similar problems in helping each other and thus eliminating the need of a trained helping person. The book “War, Trauma, and Violence” (De Jong, 2002) shows examples of organizing these groups for ex-combatants, ex-child soldiers, widows, unaccompanied minors, survivors of rape and torture, mothers of the vulnerable, such as mothers with children with disabilities, the elderly, and Alcoholics Anonymous (AA) groups for individuals who have alcoholism or other addictions. 4(b) Counseling. In view of the scarcity of mental-health professionals in situations of collective violence, para-professional counselors are recruited among the target population. They provide problem-solving and supportive counseling for psychosocial and mental-health problems. Counseling is either offered in the home of a client or in community-based counseling centers. Counseling may be conducted in a family setting, a group setting, or on an individual basis. 4(c) Individual and family therapy. Psychotherapy requires extensive training and supervision. The amount of people requiring this form of treatment is small but present. Examples include trauma therapy, testimony work, group therapy for survivors of violence, including children, and systemic family therapy. In countries with a considerable number of psychologists, professionals may want to use forms of psychotherapy that are commonly used in high-income countries. These would include a culturally appropriate version of cognitive-behavioral therapy, including exposure therapy, cognitive therapy, cognitive processing therapy, stress inoculation training, systematic desensitization, narrative therapy, relaxation training, and eye movement desensitization and reprocessing. 4(d) Pharmacotherapy can be used, alone or in combination, with psychotherapy or counseling (e.g., tricyclic antidepressants or selective serotonin reuptake inhibitors [SRRIs], inhibitors of adrenergic activity, and mood stabilizers). 5. Crisis intervention. A crisis team can intervene when health emergencies, suicide, domestic violence, or attacks by rebels, the army, or paramilitary forces occur. A quick response calms and supports the family, assists in referral, and activates community and family support for victims.

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Tertiary Prevention at the Level of the Family and the Individual The goal of tertiary prevention is to reduce anomia, apathy, and chronicity of disabling conditions through active rehabilitation and developing skills for peaceful conflict resolution. Collective violence in low-income countries often takes place in collectivistic and interdependent cultures where – as long as family members are around – rejection by the family is an exception, rather than a frequent occurrence. Hence, there are ample opportunities to involve the family in rehabilitation and reconstruction.

Discussion This chapter shows a concise model that accommodates a variety of preventive interventions that address consequences of political violence. The model shows how multi-sector, multi-modal, and multi-level preventive principles involving the economy, governance, diplomacy, the military, human rights, agriculture, health, education, and journalism can be applied in an integrative and eclectic way. This public-health approach also shows how prevention can be moulded to the requirements of the specific historic, political-economic, and sociocultural context. Moreover, it may help to clarify the complementarity between the United Natiuons and the (non)governmental actors. It also shows how the diplomatic, the political, the criminal justice, the human rights, the military, the health, and the rural development sectors can collaborate to promote peace and prevent the aggravation and continuation of violence. Further, the model may help to identify gaps in our knowledge and to guide the future elaboration of a preventive approach. In the field of public-health, randomized controlled trials are used to study causal influences in a controlled context for evaluating clinical or preventive interventions. Prevention of political violence addresses whole communities, populations, or regions. It is obvious that randomized community designs are not feasible for ethical and political reasons. However, quasi-experimental studies, such as using matching techniques to reach comparability or time-series designs, offer an alternative. We certainly need to better comprehend the micro-, meso-, and macro-levels of political, economic, social, cultural, and historical processes. Further efforts are needed to continue expanding the spectrum of effective preventive interventions, to improve their effectiveness and cost-effectiveness in varied settings, and to continue strengthening the evidence base. This requires a process of repeated evaluation of preventive policies and their implementation. The presented framework also has some serious flaws. It is prototypical and needs elaboration. The list of predictors of political violence is not exhaustive. The framework does not define the directionality of the relationships between risk factors, moderators, mediators, and dependent variables; nor does it suggest how it can be tested and validated, or which milestones can be used for each preventive

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intervention. One may also question whether the distinction between primary, secondary, and tertiary preventive interventions fits the real world, and whether certain interventions should be located in another place in the matrix. For example, when the international court decides to prosecute a president – such as Bashir of Sudan – this may be regarded as a secondary and tertiary preventive intervention (i.e., to shorten the conflict, to prevent the conflict from becoming chronic, and to contribute to rehabilitation and reconstruction of the afflicted regions). Simultaneously, prosecuting a president has a primary preventive objective, i.e., warning politicians that in the current world, impunity does not exist. But the reverse may happen: the president may feel threatened by his political peers, fear a coup d’état, hide his involvement, and decide to intensify hostilities. Prosecuting a president without further steps may thus aggravate hostilities, which is contrary to the objective of the initial action of the international court. This is related to the circularity of the contributing factors in a complex system. One of the differences in today’s world, compared to events in places such as Cambodia, My Lai, Angola, East Timor, Chechnya, Sri Lanka, Sierra Leone, Burundi, Rwanda, Srebenica or Tibet, is that the world knows about political violence, genocide, and massacres and that the world has started to act. To do this in an effective and balanced way requires a huge, coordinated, and long-term effort and commitment. The matrix described in this chapter may offer one means of organizing efforts to address, confront, and intervene in many pressing issues on multiple dimensions of human life that are faced daily by people who try to survive in areas of armed conflict and wars.

References Addison, T. (2000). Aid and conflict. In F. Tarp (Ed.), Foreign aid and development: Lessons learnt and directions for the future (pp. 329–408). London: Routledge. Asia Watch & Physicians for Human Rights (1991). Land mines in Cambodia: The coward’s war. New York/Boston. Baker, P. H., & Ausink, J. A. (1995). State collapse and ethnic violence: Toward a predictive model. Parameters, 26 (1), 19–36. Balla, E., & Yannitell-Reinhardt, G. (2008). Giving and Receiving Foreign Aid: Does Conflict Count? World Development, 36 (12), 2566–2585. Bannon, I., & P. Collier (Eds.). (2003). Natural resources and violent conflict: Options and actions I. Washington, DC: The World Bank. Beyrer, C., Villar, J. C., Suwanvanichkij, V., Singh, S., Baral, S. D., & Mills, E. J. (2007). Neglected diseases, civil conflicts, and the right to health. Lancet, 370, 619–27. Carnegie Commission on Preventing Deadly Conflict (1997). Preventing deadly conflict: final report. New York, NY: Carnegie Corporation. Collier, P. (2009). Wars, guns and votes. Democracy in dangerous places. New York: Harper Collins. Collier, P., Elliott, V. L., Hegre, H., Hoeffler, A., Reynal-Querol, M., & Sambanis, N., (2003). Breaking the conflict trap: Civil war and development policy. World bank policy research report. Washington: World Bank and Oxford University Press. Davenport, C., & Stam, A. (2004). Understanding genocide through time and space. Retrieved August 13, 2009, from http://www.bsos.umd.edu/gvpt/davenport/genodynamics/

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De Jong, J. T. V. M. (Ed.) (2002). Trauma, war and violence: Public mental health in socio-cultural context. New York: Plenum-Kluwer. De Jong, J. T. V. M. (2010). A public health framework to translate risk factors related to political violence and war into multilevel preventive interventions. Social Science and Medicine, 70, 71–79. Deutsch, M. (1983). The prevention of WW-III: A psychological perspective. Political psychology, 4, 3–31. Esty, D. E., Goldstone, J. A., Gurr, T. R., Surko, P. T., & Unger, A. N. (1995). Working papers: State failure task force report. November 30. Farmer, P. (2003). Pathologies of power: Health, human rights, and the new war on the poor. California: University of California press. Ghobaraha, H. A., Huthb, P., & Russettc, B. (2004). The post-war public health effects of civil conflict. Social Science and Medicine, 59, 869–884. Girard, R. (1976). Deceit, desire and the novel. trans. Yvonne Freccero. Baltimore: Johns Hopkins University Press. Hegre, H., Sambanis, N. (2006). Sensitivity analysis of empirical results on civil war onset. Journal of Conflict Resolution, 50 (4), 508–535. Hewitt, J. (2008). Trends in global conflict, 1946–2005. In: J. Hewitt, J. Wilkenfeld, T. Gurr, T. (Eds.), Peace and conflict 2008. Boulder: Paradigm Publisher. Hobfoll, S. E. (1998). Stress, culture and community: The psychology and philosophy of stress. New York: Plenum Press Janis, I. (1982). Victims of groupthink (2nd ed.). Boston: Houghton-Mifflin. Kleinman, A., Das, V., Lock, M. (1997). Social suffering. Berkley: University of California Press. Lim, M., Metzler, R., Bar-Yam, Y. (2007). Global Pattern Formation and Ethnic/Cultural Violence. Science, 317, 1540–544. Machel, G. (1996). Impact of armed conflict on children: Report of the expert group of the secretary general. New York: United Nations. Murdock, J. C., Sandler, T. (2002). Economic growth, civil wars, and spatial spill-overs. Journal of Conflict Resolution, 46 (1), 91–110. Murray, C. J. L., Lopez, A. D. (1997). Alternative projections of mortality and disability by cause 1990–2020: Global burden of disease study. Lancet, 349, 1498–1504. Orbinski, J., Beyrer, C., & Singh, S. (2007). Violations of human rights: Health practitioners as witnesses. Lancet, 370, 698–704. Pedersen, D. (2002). Political violence, ethnic conflict, and contemporary wars: Broad implications for health and social well-being. Social Science and Medicine, 55, 175–190. Pinderhughes C. A. (1979). Differential bonding: Toward a psychophysiological theory of stereotyping. American Journal of Psychiatry, 136, 33–37. Pinstrup-Andersen, P., & Shimokawa, S. (2008). Do poverty and poor health and nutrition increase the risk of armed conflict onset? Food Policy, 33, 513–520. Rodrik, D. (2007). One economics, many recipes. Globalization, institutions, and economic growth. Princeton, NJ: Princeton University Press. Reynal-Querol, M. (2005). Does democracy pre-empt civil wars? European Journal of Political Economy, 21, 445–465. Sackett, D. L., Rosenberg, W. M., & Gray, J. A. et al. (1996). Evidence-based medicine: What it is and what it isn’t. British Medical Journal, 312, 71–72. Sarason, S. B. (1974). The psychological sense of community: Prospects for a community psychology. Washington, DC: Jossey-Bass. Staub, E. (1993). The roots of evil: The psychological and cultural origins of genocide and other forms of group violence. Cambridge: Cambridge University Press. Staub, E. (2003). The psychology of good and evil: why children, adults and groups help and harm others. New York: Cambridge University Press. Stewart, F., Cindy, H., & Michael, W. (2001). Internal wars: An empirical overview of the economic and social consequences. In: F. Stewart & V. Fitzgerald (Eds.), War and underdevelopment –

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Volume 1: The economic and social consequences of conflict (pp. 67–103). Oxford: Oxford University Press. U.S. Committee on Prevention of Disorder (1994). Reducing risks for mental disorders: Frontiers for preventive intervention research. Washington, DC: National Academy Press. Van Boven, T., Flinterman, C., Grünfeld, F. & Westendrop, I. (Eds.) (1992). Seminar on the rights to restitution, compensation and rehabilitation for victims of gross violations of human rights and fundamental freedoms. Maastricht: University of Limburg. World Health Organization (2002). World report on violence and health. Geneva: World Health Organization.

Chapter 5

Community-Based Rehabilitation in Post-conflict and Emergency Situations Arne H. Eide

Abstract Experience in a number of situations of armed conflict and consequently post-conflict situations suggests that CBR has a constructive role to play in delivering services and promoting the rights of people with disabilities. Although not particularly designed for post-conflict and emergency situations, there are several good reasons for this. First, CBR has developed from a health-service delivery model for people in rural, poorly serviced areas into a model for community development, which also incorporates human rights, democracy, and a gender-based perspective within its ambitions. Such core values are under strong pressure in postconflict situations, and CBR may be regarded as an important tool for ensuring a rights-based development with particular attention to those most at risk of poverty and abuse. Second, CBR is a flexible strategy operating at different levels and can easily adapt to different contexts and stages of conflict and post-conflict. Third, utilizing human resources within a community ensures a perspective that is based on local expertise and cultural understanding. Fourth, the central role of people with disabilities in CBR adds further to a needs-based approach and makes individuals with disabilities visible in their communities. Lastly, CBR will often be the only service focusing on individuals with disabilities, thus making sure that they are not forgotten and neglected. Although CBR may contribute positively in postconflict and emergency situations, it is nevertheless important to develop particular responses to such situations in order to ensure that the needs and rights of people with disabilities are addressed and protected when times are difficult and extreme. Community-based rehabilitation (CBR) has developed and diversified into a large number of contexts in the developing world over the last 20 years (Miles, 1993; Thomas & Thomas, 1999, 2002). The population in many of these different contexts is being or has been exposed to conflicts, wars, displacement, and emergency situations following human or natural disasters. According to the International Disability

A.H. Eide (B) SINTEF Health Research, Oslo, Norway e-mail: [email protected]


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and Development Consortium ([IDDC], 2000, p. 5), “. . .. in conflict situations, disability increases and people with disabilities become even more vulnerable. Conflict situations are increasing, yet the needs and rights of people with disabilities are either ignored or dealt with very inappropriately.” Experience in a number of situations of armed conflict and consequently post-conflict situations (Afghanistan, Bosnia-Herzegovina, Central America, Sri Lanka, West Bank, and Gaza) suggests that CBR has a constructive role to play in delivering services and promoting the rights of people with disabilities (Boyce, 2000). Drawing on existing literature and personal experience with CBR in post-conflict areas, this chapter explores the role of CBR in post-conflict zones and how CBR, as a multifaceted and flexible strategy for community development, may constitute a viable strategy for people with disabilities in post-conflict and emergency situations.

The Evolution of CBR CBR was promoted in the early 1980s by the World Health Organization (WHO) and other United Nations (UN) agencies for service delivery and the rehabilitation of people with disabilities who had no access to services (UN, 1983; WHO, 1981). A statement on CBR by the International Labor Organization (ILO), United Nations Educational, Scientific and Cultural Organization (UNESCO), and World Health Organization (WHO) in 1994 was followed by a revised joint position paper in 2004, outlining an updated strategy for CBR (ILO, UNESCO, & WHO, 2004). While originally being introduced as a service-delivery model for people in rural, poorly serviced areas (Finkenflügel, 2008), today the prevailing view is that CBR is a preferred strategy for community development: “CBR is a strategy within community development for rehabilitation, equalization of opportunities, and social integration of all people with disabilities” (ILO, UNESCO, & WHO, 2004, p. 2). Furthermore, the joint statement states that “CBR is implemented through the combined efforts of people with disabilities themselves, their families and communities, and the appropriate health, education, vocational, and social services” (p. 2). CBR has developed from an extension of primary health care (PHC) and rehabilitation services for disadvantaged communities to a comprehensive strategy for community development and change (Thomas & Thomas, 2003). At this stage, however, it is necessary to underscore that although we may talk about a “generalized” and “holistic” CBR model, CBR programs vary tremendously in their organization, ambitions, and priorities. In this text, the definition of CBR is generally understood according to the joint statements by ILO, UNESCO, and WHO (1994, 2004). The development of CBR during the last 10 years has incorporated human rights, democracy, and gender perspectives within the ambitions of CBR programs. Although the individual with a disability is the main target for CBR, solutions to individual problems or the potential for solving these problems are often found within the family (awareness, attitudes, and practice), within the local community (awareness, attitudes, practice, adaptations, and integrated programs), and also at

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higher regional, central, and political levels (e.g., through law-making, regulations, and equal rights) (Eide, 2006). Kuipers, Kuipers, Mongkolsrisawat, Weawsorn, and Marungsit (2003) have analyzed a range of CBR programs and have suggested the following foci of CBR service delivery: individual, family (micro), community (meso), structures (exo), and attitudes (macro). Comprehensive CBR programs are complex in design and, by consequence, also in implementation and in the results they produce (Mitchell, 1999). Specific CBR programs are established and developed in many different ways, implying that the focus will vary between different programs. CBR ideally comprises many aspects or strategies, including medical or therapy, educational, vocational, and social responses. The priorities of a CBR program will depend on a number of different factors, as described by Kuipers et al. (2003, p. 142): – – – – –

The identified and expressed needs and goals of persons with disabilities; Their functioning, activities, and participation; Their community context; The particular issues at hand; The physical, cultural, social, and economic realities of the broader community and society; – The nature of service systems and structures within the country; – The skills and resources of the CBR worker; – The capacity and structure of the organization. The purpose of the joint position paper on CBR (ILO, UNESCO, & WHO, 2004) was to describe and support the concept of CBR as it is evolving, with a clearer emphasis on human rights and a call for action against poverty that affects many people with disabilities. The major objectives of CBR, according to the joint position paper (pages 2–3), were the following: (i) To ensure that people with disabilities are able to maximize their physical and mental abilities, to access regular services and opportunities, and to become active contributors to the community and society at large; (ii) To activate communities to promote and protect the human rights of people with disabilities through changes within the community, for example, by removing barriers to participation. It follows from the above that CBR contains a great deal of flexibility, with contextual and cultural factors playing a crucial role in the shaping of each program. CBR is not designed particularly for contexts in post-conflict situations, but primarily for disadvantaged populations in developing countries. The post-conflict contexts are in many cases politically unstable and under threat of new conflicts. Although CBR may be viewed as suitable for such unstable conditions, due to its flexible and decentralized character, it is also the case that CBR as a strategy for community development could be further expanded in order to meet the particular challenges posed by unsettled post-conflict situations. Up to the present time, this aspect has not

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been very much in the forefront in the discourse on CBR and in the development of new guidelines expected to be launched in 2009. The security and protection of civilians may be examples of fundamental needs in post-conflict situations that should have been developed within the framework of CBR. The joint position paper (ILO, UNESCO, & WHO, 2004) is explicit on human rights, gender issues, and poverty, as well as inclusive communities, participation, and the activation of organizations for people with disabilities as major areas of action for CBR. This development reflects the content of important international documents regarding the rights of people with disabilities, such as UN Standard Rules on the Equalization of Opportunities for Persons with Disabilities (UN, 1994) and the more recent International Convention on the Rights of Persons with Disabilities (UN, 2006). The evolution of CBR is furthermore influenced by the international discourse on disability, culminating with the adoption of the International Classification of Disability, Functioning and Health (ICF) (WHO, 2001).

CBR in Conflict Situations Conflicts may be short term or long term, may be situations of “fragile peace,” and may have pre-conflict, acute-conflict, and post-conflict stages (IDDC, 2000). In the pre-conflict stage, CBR may play a crucial role in preparations for conflict, ensuring that, for example, plans for evacuation, safe shelter, and distribution of food are inclusive of the needs of people with disabilities. During conflicts, people with disabilities may experience multiple problems related to limited community resources or attention: that they are ignored in evacuation and refugee situations, that their particular needs are overshadowed by the emergency needs of the population as a whole, or that emergency responses are inadequate to reach out to people with disabilities (Kett, Stubs and Yeo, 2005; Parr, 1987; WHO, 2005). Emergencies disproportionately place people with disabilities (PwDs) in vulnerable situations and can create an insecure environment resulting in new disabilities. During emergency responses, PwDs are often invisible and excluded from accessing emergency support and essential services, such as medical care and water and sanitation facilities. Environmental, societal, and attitudinal barriers result in PwDs’ needs not being met, causing extensive and long-term consequences. There are, however, many examples of good practice through involvement of CBR in the organization of emergency relief (Boyce, 2000). The post-conflict stage will typically entail specific problems, which can range from a difficult relationship between government, civil society, and NGOs due to separate infrastructures and resource competition, displacement and repatriation, discrimination between disability groups, extreme vulnerability of particular groups, to lack of services – including essential rehabilitation – and democratic processes (IDDC, 2000). The content of Table 5.1 is drawn from IDDC (2000). An addition that can be made to this overview is that of emergency situations (human and natural

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Table 5.1 Different types of chronic conflict situations

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Civil war Occupation Segregation Mined areas Displacement Frontier war Emergency bombings Fragile peace and ceasefire Regional conflicts (threats) Internal conflicts Derived from IDDC (2000)

disasters, such as the 2004 tsunami disaster, earthquakes, famine). Conflict situations are thus diverse, with various factors of instability, insecurity, displacement, and breakdown requiring responses to the needs of people with disabilities that are adapted to the particular situation, context, and culture in question. Key actors in such situations are communities, civil society organizations (CSOs), disabled peoples organizations (DPOs), non-governmental organizations (NGOs), international NGOs (INGOs), rehabilitation workers, governments, media, military, religious organizations, United Nations (UN) agencies, and donors such as the World Bank, the European Union (EU), and bilateral organizations. While all these actors may play crucial roles in post-conflict situations, the IDDC (2000) and others (Boyce, 2000; Yeo & Moore, 2003) emphasize the crucial role of DPOs and the need for consulting people with disabilities. DPOs will, in many situations, be the most important and often the only channel for communicating the needs of people with disabilities and represent knowledge and experience of crucial importance for designing and delivering appropriate response in specific contexts. As CBR has developed into a broader concept of community development incorporating issues like human rights, democracy, and gender, the role of DPOs in CBR has also become increasingly important. While DPOs in many countries in the developing world are relatively weak, DPO involvement in CBR may also constitute a vehicle for increased influence and strengthening of organizations representing the most severely affected in post-conflict situations. For instance, in Gaza and the West Bank, the CBR program run by NGOs has established strong links with DPOs and the General Union of Disabled Persons and, by this connection, has contributed strongly to increased status, recruitment, and thus the impact of DPOs (Eide, 2001). Fundamental to CBR is the training and activation of existing local human resources, i.e., primarily families, in order to provide individuals with disabilities basic qualified services to reduce functional and health problems and thus improve the possibilities for full participation in society. This core activity is integrated into action at local community and regional/national levels. CBRs’ direct reliance on the population affected by post-conflict situations or underdevelopment makes CBR robust during times and situations when professional and institution-based services are either not developed or are unable to service the population due to effects of conflict, weak or destroyed infrastructure. CBR provides support to disabled

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persons and their organizations and utilizes and mobilizes community resources. Its de-centralization offers self-sufficiency. CBR is empowering, creates advocates and focal points in the community, and raises social responsibility (IDDC, 2000). The mobilization of resources is a key issue in post-conflict situations and also a fundamental aspect of CBR, with particular methods being information dissemination, supporting voluntary initiatives, co-ordination, co-operation, and networking, using databases and mapping, advocacy and targeted lobbying on common issues, capacity building and training, and supporting victims of conflict. As early as 1991, both Rehabilitation International (RI) and UNICEF recommended CBR as a strategy in areas hit by war (RI/UNICEF, 1991).

Case Studies Involving CBR Eide (2001, 2006) argues that the CBR program in the West Bank and Gaza is particularly suited for the situation in those areas, due to their decentralized structures and flexibility. Through the development of CBR in these two areas, largely self-driven regional and local structures have been established that are not so easily affected by restrictions in movement, due to the conflict with Israel. Even the particularly difficult situation in Gaza, where the population of more than 1.5 million is severely restricted in their movement outside the area, has been overcome by the CBR structure, combined with modern communication technology like cell phones, video conferences, and the Internet. An important aspect of CBR in the West Bank and Gaza is that it is run by several NGOs and thus not dependent on a state structure, which in this case is too weak to deliver services to the extent that CBR has been able to do. In Eritrea, physical movement also has been restricted in certain areas. The population has experienced 30 years of war, followed by ongoing conflict with Ethiopia and thus permanent mobilization for war. The state machinery in Eritrea is functioning and is the implementing agency for CBR. The level of poverty in the population and the restrictions put on the civil society make the state structure the only viable one for implementing CBR in this particular context. While both the NGO and the government “models” may be viable for implementation of CBR, the promotion of human rights and democratic principles may be problematic if these actions imply opposition to the regime. This may force CBR to operate in more “traditional” ways, i.e., focusing on individual rehabilitation only and to avoid activities in the households and the local community that may be regarded as political opposition. Eritrea, with its repressive regime, is an example of the latter, while CBR in the West Bank and Gaza has been able to successfully promote human rights and democratic values. CBR is based on the human and community resources available in a particular context. As situations in various geographical areas differ from each other, the flexibility in CBR allows for a necessary adaptation to the particular context as shown in the examples from Eritrea and the West Bank and Gaza. Another example is from

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Bosnia, where there was a highly developed rehabilitation infrastructure prior to the war. In this country, CBR was used to orient the reconstruction of the entire system (Boyce, 2000). In Afghanistan, there were very limited rehabilitation services prior to the Soviet invasion and repeated armed conflicts have destroyed much of the country’s infrastructure. Thus, the CBR focus has been to develop a critical mass of basic trained personnel across the country (Boyce & Ballantyne, 1997). The above examples illustrate some of the strengths of CBR in post-conflict situations, as opposed to professionalized, and often institutionalized, rehabilitation service in Western countries.

People with Disabilities During Post-conflict Periods Disability affects the whole family, and in post-conflict situations where many families have experienced losses and been torn apart, having a relative with a disability has even more serious consequences. Several authors have demonstrated that war and conflict not only do lead to more people being disabled (directly with injury through mines, bombs, assaults and indirectly through breakdown of health and other infrastructures) but also easily drown out the attention to the needs of people with disabilities (Kett, Stubs, & Yeo, 2005; Stone, 1999). According to Stocking (2003), “People with disabilities are often made invisible by society, and invisibility can be lethal in situations of armed conflict or natural calamity” (p. 8). Parr (1987) states that past experience of disaster management shows that people with disabilities are the most affected group and emergency responses are inadequate to reach out to people with disabilities. Conflict creates instability, insecurity, fear, collapse of a country’s infrastructure and services, a breakdown of resources, changes in priorities, shifting agendas, and abuses of human rights (IDDC, 2000). Important infrastructure is often destroyed or damaged, leaving in many cases the individuals with disabilities to fend for themselves without any support at all. The following describes the key factors that make people with disabilities more vulnerable during an emergency situation (Handicap International, 2004, p. 8):

– PwDs tend to be invisible in emergency registration systems. – Lack of awareness is one of the major factors for PWDs to not comprehend disaster and its consequences. – PwDs are often excluded from emergency response efforts and are particularly affected by changes in terrain resulting from emergencies. – Because of inadequate physical accessibility, lack of assistance, and loss/lack of mobility aids, PwDs are deprived of rescue and evacuation services, relief access, safe location/adequate shelter, water and sanitation facilities, and other essential services.

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– Emotional distress and trauma caused by an emergency often has long-term consequences for PwDs. – Misinterpretation of the situation and communication difficulties make PWDs more vulnerable in disaster situations. In addition, people with disabilities are, according to Harris and Enfield (2003), particularly exposed to sexual abuse and violence during conflict. In the aftermath of a conflict or disaster, people with disabilities may find their situation exacerbated by moving to inaccessible houses and neighborhoods, by the loss of family members and caregivers, loss of mobility and other aids, food, water, sanitation, and other infrastructure (Edmonds, 2005). Different types of impairments will create different challenges for individuals during post-conflict situations, requiring a variety of specific measures. For example, Kvam (2005) has described the situation for deaf people in the West Bank and Gaza, who have problems in receiving warnings when violent threat is imminent or when accessing resources after conflict. Other impairment-specific problems in emergency situations may be the following: – Mobility problems when it is urgent to evacuate; – Blind people may be thrown into an unfamiliar context and thus have their sense of orientation dramatically reduced; – Persons with mental retardation may not understand how to act in a critical situation; – People with mental-health problems may react inadequately, at a time when it is a matter of life and death to hide or move away from dangerous situations. The above examples illustrate the need for (i) sensitivity to the situation and particular needs for specific impairments and (ii) the importance of involving people with disabilities and their organizations directly in CBR, as they will be the experts on the situation for people with disabilities and a communication channel for particular needs. CBR will, in many cases, be the only active structure that focuses on the needs of people with disabilities during post-conflict periods. Attention to the individual with a disability and their families is one important aspect of this. Ensuring basic training, education, and services during conflict and post-conflict is extremely important to avoid increasing the impact of impairments. In addition, it is important to note the role CBR workers play in creating awareness about the rights of the person with a disability, in the family, as well as in the local community, and thus contributing positively to improve the status of people with disabilities. This may reduce the danger of people with disabilities being excluded or deliberately neglected to the advantage of individuals without disabilities in future emergency situations. In refugee settlements, for example, people with disabilities may not have access to relief services because of difficulties moving around, carrying, and queuing. Water points, feeding centers, and supplies of wood and building materials may not be accessible for people with disabilities without

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strong advocates and a generally positive attitude toward disabled in the affected population. Poverty is a key issue in post-conflict situations, not only because it affects the person with a disability directly (on both mental and physical levels) like everyone else in the same community, but also because it directly affects the resources needed for an individual with a disability and his/her family to compensate for the functional problems, for activity limitations, and for restrictions in social participation. In Northern Uganda, following two decades of war, Whyte and Muyinda (2007) observed that reduced mobility for people with disabilities increased poverty, while poverty prevented the social arrangements that might improve mobility. It is thus argued that war and conflict lead to an amplification of the poverty–disability relationship, underlining the critical need for disability-related strategies during post-conflict situations to avoid further development of poverty. It is in the above background one can argue that CBR may play a particularly important role in conflict-related situations. The additional importance of CBR is due to the increased danger of negligence of people with disabilities, as well as the negative impact on resources needed by the person with a disability and his/her family to avoid (increased) poverty. The fact that CBR in many such situations may be the only service directed toward individuals with disabilities further increases its importance in post-conflict situations.

CBR and Mental-Health Services Another important aspect is the moral and psychological support that CBR may provide individuals and families, giving them hope for an improvement in the situation even when disaster strikes or during the often long and difficult return to a normalized situation. The mental stress caused by living under constant threat, by displacement and other effects of war and conflict, is a concern for all living in such situations. According to Médecins Sans Frontières (1997), anyone affected by disasters or conflict is vulnerable to psychological stress, on the basis of which they may be further excluded from the community. Even in times of peace, CBR has a serious challenge when it comes to mental-health services (Eide, 2006), as the attention to such problems is complicated, time consuming, and requires skills that community rehabilitation workers do not possess. Based on existing knowledge about mental-health effects of war, conflict, and disasters (Inter-Agency Standing Committee, 2007), it is well known that its effects on a large number of individual survivors are disabling and may have serious long-term effects. Although not widely studied, current research suggests that major depression and post-traumatic stress disorder (PTSD) are prevalent and chronic among refugee and displaced populations (World Bank, 2003). It can thus be assumed that people with disabilities are even more at risk from these issues than individuals without disabilities, due to the former group’s particularly vulnerable situation. The active role a CBR worker can play in supporting a family may contribute to identifying such problems when

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they are developing and thus bring the attention to special mental-health needs in the population. The support from CBR workers to the individuals and the families will, in many instances, in itself imply psychosocial support of great importance for persons living under constant pressure and isolation. Many CBR programs do not include people with mental-health problems, and there is a lack of experience as well as capacity in this field (Davies, 2009). Awareness and capacity building in this area is thus highly needed. WHO (2003) states that mental-health problems should be addressed by the general primary health care, supported by mental-health experts, and linked up to the community as an important arena for intervention. CBR can clearly have a role in such a chain of services also during wars and post-conflict situations. In reality, post-conflict situations put individuals with disabilities and their families under double pressure, i.e., problems related to living with a disability and problems arising from the conflict situation itself. The risk of being isolated and neglected is a general problem for people with disabilities, particularly in contexts of poverty. The existence of a conflict or emergency situation increases the risk of negative impact on people with disabilities and their families. In a post-conflict situation, many of the problems that a person with a disability experienced in his/her daily life prior to conflict and destruction will be amplified, due to multiple possible reasons, such as a breakdown of services, increased mobility problems due to destruction and security problems, mental stress on the person with a disability himself/herself and his/her family, or simply due to the fight for survival coming into the forefront, rather than it being a common procedure to obtain a decent standard of living – like everyone else in the same context.

Community Mobilization According to the Joint Position Paper by ILO, UNESCO, and WHO (2004, p. 4) CBR promotes the rights of people with disabilities to live as equal citizens within the community, to enjoy health and well being, to participate fully in educational, social cultural, religious, economic, and political activities. CBR emphasizes that girls and boys with disabilities have equal rights to schooling, and that women and men have equal rights to opportunities to participate in work and social activities.

With the recently adopted UN Convention on Rights of Persons with Disabilities (UN, 2006), these issues have been brought to the center of any disability policy and practice, including CBR. The impact assessment of CBR in the West Bank and Gaza (Eide, 2001; Eide, Harami, & Greer, 2005) demonstrated that the efforts made by the program have had direct impact on the level of social integration and the participation of individuals with disabilities and their families within their local communities. This particular CBR program targets human rights, democracy, and gender issues at different levels. Creating awareness and changing attitudes at the family and individual level are important ingredients in bringing individuals with disabilities and their families out of “hopeless” situations.

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Due to lack of education, low awareness about disability rights, superstition, established practice, and other suppressing mechanisms, changing the attitudes among individuals with disabilities themselves and their families is a first important and necessary step in improving the status of people with disabilities. Further, engaging individuals and families in training, activities, and social participation may bring them out of social isolation, passivity, and hopelessness into active, socially productive roles. Awareness building in local communities is a second prerequisite for establishing environments conducive for participation of people with disabilities. At this level, access to education, health services, social arrangements, and decision making are all important milestones toward full social integration. Existing international conventions on disability rights are actively used by the CBR program to change attitudes and practices in the community. Combining this with increased engagement from individuals with disabilities, their families, and DPOs has contributed not only to improve the situation for people with disabilities but also to combine “traditional rehabilitation” with educating communities and pursuing human rights and democratic ideas and practices. Thus, the CBR program seeks to invest these important values in the community by promoting equality, tolerance, democratic processes, and respect for human rights. Eide et al. (2005, p. 7) argued that [The] social integration of the most vulnerable into society has tangible effects on the quality of social relations in general. Inclusion of this group (people with disabilities) and consideration of their interests foster a sense of responsibility and maturity in attitudes and in decision-making processes that also include social distributional aspects.

Furthermore, the authors argue that such a value-based strategy is essential in establishing a good foundation for a future democratic state. An example of this is that the activation of individuals, families, and local communities – combined with political lobbying at the national level – has had direct impact on legislation and policy in the West Bank and Gaza to the benefit of people with disabilities. This example from the West Bank and Gaza highlights the multidimensionality of human rights and democracy as central ingredients in CBR strategy. In times of post-conflict, this not only contributes to activate and improve the conditions for people with disabilities but also implies building a foundation for a future peaceful situation, in which full integration of people with disabilities will be an important ingredient in society. Such an integration will most likely have an impact on the strong link between disability and poverty (Yeo &Moore, 2003).

Discussion The type of CBR promoted by WHO, as a strategy within community development, is difficult to achieve even without the problems caused by conflict. In post-conflict situations, and particularly in early stages of post-conflict, the priorities of local communities will be to secure emergency relief aid: food,

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clothing, water and sanitation, shelter, and medicines. Not only will it be problematic to focus on the long-term core CBR activities within the chaotic context of post-conflict rebuilding, but people with disabilities will be more at risk of being exposed to emergency problems during conflict and post-conflict situations. Moreover, it may be expected that communities’ openness toward the particular needs of people with disabilities will be reduced as most people struggle for their own survival. There is even a danger that extreme hardships will stimulate negative attitudes and practice toward people with disabilities. On one hand, CBR will have a very important advocacy role to play when basic services for the population have broken down. The role of CBR in post-conflict situations will necessarily differ from a broad community development strategy and will concentrate on the fundamental emergency needs of the population – and to ensure that people with disabilities are not left to fend for themselves. The flexibility of CBR makes it suitable for different types of situations. Although promoted as a broad community development approach, it may also be adapted to a post-conflict situation with a much narrower and different focus for its operation, without compromising on fundamental values, such as participation and human rights, that are inherent in the CBR concept. One important concern in this regard is the need for particular attention to women and children with disabilities, who are often hardest hit by conflict. CBR may play a crucial role not only to promote the needs of people with disabilities in general relief programs but also to ensure a necessary individual differentiation – as various types of impairments that require a range of responses. For example, a person who is mentally impaired will need a different type of support to ensure that basic needs are met during a post-conflict situation, in comparison to someone in a wheelchair. This kind of differentiation will not likely take place without special attention to the rights of people with disabilities, which a CBR program, generally speaking, represents. As the examples from the West Bank and Gaza and Eritrea suggest, CBR may be organized both separately by NGOs and directly as a service that is integrated into the government structure. These two strategies have different weaknesses and strengths, and in many cases there will be some kind of mixed model, with the particular model chosen depending on political and other contextual circumstances. In post-conflict situations, government structures will typically be fragile and not be able to cater for special needs (IDDC, 2000), while an NGO or a group of NGOs will devote their full attention to people with disabilities. Post-conflict situations may even be seen as an opportunity for strengthening of NGOs and DPOs into organizations that can play a crucial role in the reconstruction of infrastructure in a society hit by conflict. This may represent a turning point in the role of people with disabilities in a particular society. The mobilization of human resources, being a fundamental aspect of CBR, may open the way for new and more progressive solutions through strengthening of civil society.

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References Boyce, W. (2000). Adaptation of community based rehabilitation in areas of armed conflict. Asia Pacific Disability Rehabilitation Journal, 11(1). Boyce, W., & Ballantyne S. (1997). Community based rehabilitation in areas of armed conflict (pp. 65–67). Paper presented at the 8th World Congress of the International Rehabilitation Medicine Association. Davies, M. (2009). Major issues related to mental health and CBR. CBR Workshop: CBR and Mental Health. AIFO: Bangkok, February 2009. Edmonds, L. J. (2005). Mainstreaming community-based rehabilitation in primary health care in Bosnia-Herzegovina. Disability and Society, 20(3), 293–309. Eide, A. H. (2001). Impact assessment of the community based rehabilitation programme in Palestine. (SINTEF Report no STF78 A014512). Oslo: SINTEF Unimed. Eide, A. H. (2006). Impact of community-based rehabilitation programmes: The case of Palestine. Scandinavian Journal of Disability Research, 8(4), 199–210. Eide, A. H., Harami, G., & Greer, C. (2005). A community-based approach to rehabilitation in Palestine and its implications for social life, human rights and democracy. Bridges, 1(2), 4–8. Finkenflügel, H. (2008). From community-based to inclusive development programs:Searching for evidence and instruments. Presentation at IASSID 13th World Congress, Cape Town, August 2008. Handicap International (2004). How to include disability issues in disaster management: Following floods 2004 in Bangladesh. Bangladesh: Handicap International. Harris, A., & Enfield, S. (2003). Disability, equality and human rights: A training manual for development and humanitarian organisations. Oxford: Oxfam GB. Inter-Agency Standing Committee (2007). IASC guidelines on mental health and psychosocial support in emergency settings. Geneva: Inter-Agency Standing Committee. International Disability and Development Consortium (2000). Disability and conflict. Report of an IDDC Seminar, May 29th–June 4th. ILO, UNESCO, & WHO (2004). CBR: A strategy for rehabilitation, equalization of opportunities, poverty reduction and social inclusion of people with disabilities. Joint Position Paper: International Labor Organization (ILO), United Nations Educational, Scientific and Cultural Organization and World Health Organization. Geneva: World Health Organization. ILO, UNESCO, & WHO (1994). Community-based rehabilitation for and with people with disabilities. Joint Position Paper, International Labor Organization (ILO), United Nations Educational, Scientific and Cultural Organization (UNESCO) and World Health Organization (WHO). Geneva: World Health Organization. Kett, M., Stubbs, S., & Yeo, R. (2005). Disability in conflict and emergency situations: Focus on Tsunami-affected areas. (IDDC Report). London: International Disability and Development Consortium. Kuipers, P., Kuipers, K., Mongkolsrisawat, S., Weawsorn, W., & Marungsit, S. (2003). Categorising CBR service delivery: The Roi-et classification. Asia Pacific Disability Rehabilitation Journal, 14(2), 115–128. Kvam, M. H. (2005). Organizational development and other initiatives for the deaf in Palestine. (SINTEF Health Report No STF78F034502). Oslo: SINTEF Health Research. Médecins Sans Frontières (1997). Refugee health. London: McMillan. Miles, M. (1993). Different ways of community-based rehabilitation. Tropical and geographical medicine, 45(5), 238–241. Mitchell, R. (1999). Community-based rehabilitation: The generalized model. Disability and Rehabilitation, 21, 522–528. Parr, A. R. (1987). Disasters and disabled persons: An examination of the safety needs of a neglected minority. Disasters, 11, 2.

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Rehabilitation International/UNICEF (1991). Effects of armed conflict on women and children: relief and rehabilitation in war situations. One in Ten, 10, 2–3. Stocking, B. (2003). Preface. In A. Harris & S. Enfield (Eds.), Disability, equality,and human rights: A training manual for development and humanitarian organizations. Oxford: Oxfam GB. Stone, E. (1999). Disability and development in the majority world. In E. Stone (Ed.), Disability and development: Learning from action and research on disability in the majority world. Leeds: The Disability Press. Thomas, M., & Thomas, M. (1999). A discussion on the shifts and changes in community-based rehabilitation in the last decade. Neuro-rehabilitation and Neural Repair, 13, 185–189. Thomas, M., & Thomas, M. (2002). Some controversies in community-based rehabilitation. In S. Hartley (Ed.), CBR: A participatory strategy in Africa. London: University of London. Thomas, M., & Thomas, M. (Eds.) (2003). Manual for CBR planners. Asia Pacific Disability Rehabilitation Journal Group Publication. Bangalore: National Printing Press. United Nations (1983). World program of action concerning disabled persons. New York: United Nations. United Nations (1994). The standard rules on the equalization of opportunities for persons with disabilities. New York: United Nations. United Nations (2006). The international convention on the rights of persons with disabilities. New York: United Nations. Whyte, S. R., & Muyinda, H. (2007). Wheels and new legs: Mobilization in Uganda. In B. Ingstad & S. Whyte (Eds.), Disability in local and global worlds. Berkeley: University of California Press. World Bank (2003). Conflict prevention and reconstruction. (Social Development Notes, No. 13, October 2003). Washington, DC: World Bank. World Health Organization (1981). Training in the community for people with disabilities. Geneva: World Health Organization. World Health Organization (2001). International classification of functioning, disability, and health. Geneva: World Health Organization. World Health Organization (2003). Mental health in emergencies: Mental health and social aspects of health of populations exposed to extreme stressors. Department of Mental Health and Substance Dependence. Geneva: World Health Organization. World Health Organization (2005). WHO, disasters, disability, and rehabilitation. Geneva: World Health Organization. Yeo, R., & Moore, K. (2003). Including people with disabilities in poverty reduction work: Nothing about us, without us. World Development, 31, 571–590.

Chapter 6

A Systems Approach to Post-conflict Rehabilitation Steve Zanskas

Abstract War represents the ultimate breakdown of communication, relationships, and societal systems. The purpose of this chapter is to introduce the basic concepts of systems theory, discuss how this framework transcends the separation between mental health and psychosocial trauma rehabilitation, review the pertinent research regarding collective trauma rehabilitation, and outline the recommendations and model interventions that have evolved as a result of the implementation of this meta-theoretical framework.

The Extent of the Problem War represents the ultimate breakdown of communication, relationships, and social systems. War traumatically exposes normal populations to disability, loss, and death (Lindy, Grace, & Green, 1981). According to the World Health Organization (WHO, 1999) there were an estimated 50 million refugees or displaced people throughout the world, and the vast majority of them are women and children from low-income countries. WHO also reported that approximately five million of these displaced individuals have chronic pre-existing mental disorders and another five million experience psychosocial problems that are either personally disruptive or disturb the person’s community. Between 2.5 and 3.5 million displaced people also have disabilities (Women’s Commission for Refugee Women & Children, 2008). As a group, people with disabilities are more likely to experience violence and are either unable to access or are excluded from assistance (Cusack, Grubaugh, Knapp, & Frueh, 2006; Women’s Commission for Refugee Women & Children, 2008). Following traumatic exposure, individuals can develop symptoms of posttraumatic stress (de Jong, 2000; Harvey, 1996; Lindy et al., 1981), among other psychiatric issues. The incidence of post-traumatic stress disorder (PTSD), which S. Zanskas (B) The University of Memphis, Memphis, TN, USA e-mail: [email protected]


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is a diagnosis indicating difficulties in processing traumatic memories, reportedly ranges between 4 and 20% of all people exposed to mass violence (Silove, Ekblad, & Mollica, 2000). Epidemiological studies suggest PTSD is prevalent in post-conflict settings (de Jong, Komproe, & van Ommermen, 2003; van Ommermen, Saxena, & Saraceno, 2005). Results of de Jong et al.’s (2003) study of 3048 participants from the post-conflict countries of Algeria, Cambodia, Ethiopia, and Palestine indicated that common mental disorders were prevalent and exposure to armed conflict was a principal risk factor for these disorders. The common mental disorders studied included mood disorders, somatoform disorders, PTSD, and anxiety disorders. In Algeria, Ethiopia, and Palestine, PTSD was the most frequently reported problem by those individuals exposed to armed conflict (de Jong et al., 2003). PTSD has also been associated with an array of other life stressors, including deprivation, disruption of support networks, uncertainty, and general conditions in refugee camps (WHO, 1999). Mental-health services that focus exclusively on violence associated with armed conflict were unlikely to address these other factors, according to WHO. Silove et al. (2000) noted a variety of risk factors for severe mental illness (i.e., psychiatric disorders) in populations exposed to armed conflict. These factors include exposure to chronic communicable diseases; poor health and nutrition; inadequate peri-natal care; birth injuries; separation from caregivers or other support systems; risk of traumatic epilepsy; and prolonged exposure to stress. On average, half of all refugees present with some form of trauma, distress, or mental-health disorder (WHO, 1999). Considering the extent of the problem and resource limitations, mental-health professionals who are working with survivors need to develop a multidimensional perspective that includes an understanding of the survivors’ physical, psychological, social, historical, and cultural environments. Adopting a systems approach allows mental-health professionals to develop a comprehensive understanding of the impact war has upon survivors and facilitate a holistic approach to treatment by targeting multiple domains of relevance (de Jong, 2002; Fairbank, Friedman, de Jong, Green, & Solomon, 2003; Hershenson, 1998; van Der Veer, 1998). The purpose of this chapter is to introduce the basic concepts of systems theory, discuss how this epistemological framework transcends the separation between mental health and psychosocial trauma rehabilitation, review the pertinent research regarding collective trauma rehabilitation, and outline the recommendations and model interventions that have evolved as a result of the implementation of this meta-theoretical framework.

Systems Conceptualizations General Systems Theory Systems theory is the study of relationships. The primacy of relationship in systems theory is reflected by the early writings of Lewin (1951) and Bertalanffy

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(1952). Lewin (1951) considered the person and their environment as interdependent regions of life space with a permeable boundary between the psychological and physical world. Bertalanffy (1952) conceptualized systems as mutually interacting components that were connected through relationships. Relationships between members of a system increase exponentially faster than the actual number of members in the system. From this perspective, cause becomes a reciprocal concept that can be found at the intersection of the interaction between the individual and their system (Cottone, Handelsman, & Walters, 1986). Even in the smallest system, a system that consists of two members, a third factor exists: the relationship between the two members (Cottone, et al., 1986). Understanding the importance of relationships is fundamental to our understanding of the intrapsychic, interpersonal, and psychosocial aftermath of war. Conceptualized as a holistic process, rehabilitation theory in its application has often been implemented as a clinical–medical or psychological model that focuses on the individual (Cottone, 1986). However, individuals exist within a social context. Although disability can be isolating, it does not occur in isolation (Cottone, 1986). Relationships are central to the study of phenomena in context, and rehabilitation is concerned with the relationship between society and individual trauma (Cottone, 1987; Shontz, 1975; Wright, 1983). Trauma, stress, and disease can be linked to the impact of conflict between individuals or groups during war. Our contextual understanding of the primacy of a traumatic event requires analysis of intrapsychic, interpersonal, and psychosocial factors. Systems theory offers a meta-theoretical framework for post-conflict trauma rehabilitation (Cottone, 1986; Harrison, 2006; Hudson, 2000). Cottone (1987, p. 169) identified eight systems’ principles related to the process of rehabilitation: 1. A system is an aggregate of mutually interacting components. These components are connected by relationship and the movement among components is recursive. 2. Social systems are interdependent. 3. Systems are self-preserving. 4. Cause is not a linear process. 5. Systems behave in patterns that reflect rules and roles. 6. Social system rules can be explicit and implicit. 7. Social systems are driven by communication and information. 8. Systems are either open or closed. Although they vary by extent, all social systems are open systems, importing and exporting information external to their boundaries. Open systems involve permeable boundaries. Closed social systems have reduced communication and serve to minimize the formation of new relationships. However, as a social system, even the most repressive totalitarian regimes are not true closed systems. Conceptually, the interpersonal trauma membrane, which forms around survivors of trauma, can model either open or closed systems, in that sometimes professionals can gain clinical access to survivors, while in other circumstances, they cannot obtain access (Lindy, 1985).

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Although all social systems are open, the extent that they are permeable can be viewed on a continuum. This continuum is evident in Lindy’s (1985) description of the trauma membrane. The survivor community’s receptiveness to the clinician’s therapeutic intervention and research following the Buffalo Creek disaster exemplifies an open system (Lindy, Green, Grace, Titchener, 1983). In contrast to the therapeutic team’s acceptance following the Buffalo Creek disaster, community leaders were reluctant to allow therapeutic intervention or research following a different disaster – the Beverly Hills Supper Club fire (Lindy, 1985). Despite the fact that a few leaders in the community allowed the therapeutic team access to the survivors of the Beverly Hills fire, the trauma membrane functioned as a closed system and clinical access to survivors was often precluded. Lindy (1985) observed that therapeutic access following mass trauma is a result of a complex array of circumstances, including the approval of community leaders, who often function at the boundary of the trauma membrane (Lindy, 1985). Lindy et al. (1981) classified disasters by their location and their impact upon the survivors’ support networks. A survivor’s receptiveness to therapeutic intervention was hypothesized as being contingent upon whether the disaster was classified as centrifugal or centripetal. Survivors of centrifugal events return to their homes with generally intact social networks that are dispersed from the location of the conflict. In centrifugal traumatic events, multiple trauma membranes develop. Outreach efforts following centrifugal disasters can be perceived as intrusive by those creating a trauma membrane around survivors. In contrast to centrifugal disasters, centripetal disasters involve destruction of large areas, devastating the survivors’ familial and social support networks. According to Lindy et al. (1981), in these instances, the boundaries of the trauma membrane become permeable and the survivors of centripetal conflict become receptive to the assistance of mental-health practitioners. Centripetal disasters produce open systems. The complex web of cultural, environmental, historical, and interpersonal relationships produced by war can involve either centrifugal or centripetal disasters.

Complex Systems General systems theory emphasizes a hierarchical arrangement of systems and subsystems (Hudson, 2000). A simple system involves fewer members and interactions among members than complex systems. A system is considered simple if its components have a specific role with defined component responses that are centrally coordinated (Harrison, 2006). Simple systems tend to be static, seek balance, and yield relatively predictable outcomes, whereas complex systems are primarily characterized by diversity and decentralization (Harrison, 2006). Unlike members of simple systems, the members of a complex system have discretion in their choice of behavior (Harrison, 2006). This discretionary behavior necessitates a description of the system’s members, the range of possible choices, and the rules governing the choices of individual members. Clearly, centralized decision making simplifies the complexity of systems (Harrison, 2006).

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Communities, countries, and governments are not closed systems. They are influenced by cultural, economic, environmental, internal, social, and technological systems. Rather than possessing a specific identity and predictable interests, they are dynamic, open systems that are inherently unpredictable (Harrison, 2006; Livneh & Parker, 2005).

Ecological Perspective: A Pragmatic Approach The proportion of psychological problems and psychological dysfunction that survivors of mass violence experience varies with the type and extent of the conflict, personal and community resilience, socio-cultural factors, and the environmental context (WHO, 1999). Ecological models provide humanitarian workers with a method of conceptualizing the various influences upon a survivor’s recovery environment and the timing and application of potential interventions. One theory that may be useful is Bronfenbrenner’s (1979) bio-ecological systems theory, which describes four environmental systems that can be used to conceptualize the recovery environment. Bronfenbrenner (2001) added the chronosystem as a final layer to his system to represent the reciprocal influence of time on the survivor and their recovery environment. The first layer, the microsystem, includes the survivors’ immediate environment, their activities, roles, and interpersonal relationships. Relationships among the survivors’ microsystems comprise the mesosystem. The survivors’ exosystem encompasses their larger social system. Survivors might not have direct involvement with this larger social system, although their immediate environment is impacted by these relationships. The survivors’ macrosystem consists of the cultural values, mores, and laws that affect the relationships among the previously noted systems. Rehabilitation has primarily been considered a tertiary intervention; however, rehabilitation strategies can be conceptualized as including primary, secondary, and tertiary approaches (Hershenson, 1990; Maki & Riggar, 2004). As early as 1984, Stubbins contended that the problems experienced by people with disabilities could not be adequately addressed through an individually based clinical model of service delivery. He urged rehabilitation professionals to adopt an ecological perspective, expanding their domain of reference to address the larger social system issues that are experienced by people with a disability. Ecological models for service delivery in rehabilitation settings and trauma rehabilitation began to appear in the 1990s (Harvey, 1996; Hershenson, 1998). Ecological models appear to offer practitioners interested in trauma rehabilitation a pragmatic bridge between general and complex systems theory, as sophisticated quantitative skills are not required (Hudson, 2000). Harvey (1996) outlined an ecological model of psychological trauma, treatment, and recovery, based on the principles of community psychology. Violent conflicts are viewed as threats to both individual and collective coping and resilience. Described as a multidimensional approach, this model attributes individual

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differences in post-traumatic response and recovery to the interactions among the person, event, and environment. Emphasis is placed on the social, cultural, and political context of the survivor with the community as a source of resilience. The effectiveness of treatment interventions can be evaluated within the context of how well they improve the relationship between the individual, their environment, and to the extent that they achieve an ecological fit. Harvey’s model assumes that individuals experience trauma in a unique manner, that treatment access is variable, and that clinical interventions will not always afford recovery. Further, according to Harvey (1996), resilient individuals in a supportive environment may recover from trauma without any form of intervention. However, the timing and type of intervention matter, because clinical interventions interact with other aspects of a client’s system to promote or obstruct recovery. Harvey operationally defined recovery as improvement in any one of the following domains: the survivor’s authority over the remembering process; their integration of memory and affect, affect tolerance, symptom mastery, self-esteem and cohesion, safe attachment; and one’s ability to develop a sense of meaning from the event. Further, a person’s resilience is evident when strengths in one or more of the preceding domains promote recovery in another domain.

Trauma Interventions Objectives and interventions vary with the domain of relevance and the timing of the intervention (de Jong, 2002; Fairbank et al., 2003; van Der Veer, 1998; Watters, 2001; Young, Ford, Ruzek, Friedman, & Gusman, 1998; Young, Ruzek, & Gusman, 1999; Young, 2006). Immediately following any conflict, establishing a safe environment and finding shelter are essential foundations for the survivor’s mental health. Several weeks after the outbreak of violence, interventions generally focus on community education, in order to develop community awareness of the potential effects of the event, to foster community resilience, and to promote methods of coping. Approximately 4 months after the event, which is during the restoration phase of trauma rehabilitation, more traditional mental-health services are employed (NIMH, 2002; Young et al., 1998; Young et al., 1999). Hershenson (1998) developed a systemic ecological model for rehabilitation counseling practice. In his model, the client, the functional aspects of one’s disability, the provider, and the context are brought together by the traumatic event. Each client subsystem consists of the interaction among each client’s unique personality, competencies, and goals. Prior to implementing services, Hershenson (1998) recommended that the characteristics of each client’s system and subsystem be analyzed in terms of the client’s attitudes and values, behavioral expectations and skills demands, potential resources and supports, physical and attitudinal barriers, and opportunities for rewards in order to develop appropriate interventions. Prior to beginning any intervention, a comprehensive needs assessment is essential (Figley, 1995; Friedman, 2005; Vella, 2002; WHO, 2001).

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Rehabilitation counseling interventions, as one form of counseling that can be offered in post-trauma situations, involve five core functions that can be applied to post-conflict trauma rehabilitation: counseling, coordinating, consulting, case management, and critiquing (Hershenson, 1998). Rehabilitation counselor functions and interventions are described according to their targeted domain of relevance in Table 6.1 (Hershenson, 1998). The rehabilitation process is iterative, rather than static, and the role of the rehabilitation worker includes determining which function will be the most effective with their client at any point in the process (Hershenson, 1998). It is important to note that each of the core functions and broad service interventions can be provided separately or combined depending on a client’s needs.

Table 6.1 Rehabilitation counseling process Target for intervention

Nature of intervention

Primary counselor function

Client Personality Goals Competencies Environment Family Learning Peer group Independent living Work Conception of disability Cultural–political–economic context Provider Rehabilitation services delivery Rehabilitation counselor

Reintegrate

Counsel

Reformulate Resolve or replace

Counsel Coordinate

Restructure Restructure Restructure Restructure Restructure Restructure Restructure

Consult Consult Consult Consult Consult Consult Consult

Realize Revise

Case manage Critique

Reprinted from Hershenson, D., Systemic, ecological model for rehabilitation counseling. Rehabilitation Counseling Bulletin, 42, page # 48. © 1998 The American Counseling Association. Reprinted with permission. No further reproduction authorization authorized without written permission from The American Counseling Association.

Applying Hershenson’s (1998) model, a humanitarian worker would employ counseling as a primary function when attempting to reintegrate a survivor’s personality or during their reformulation of goals. As the counselor attempts to assist survivors to restore or replace pre-conflict services, coordination becomes the primary intervention. Advocacy and consultation become appropriate functions when a humanitarian or mental-health worker attempts to restructure a survivors’ cultural, economic, political, and social environment. Case management, as a function, is necessary to ensure that the other functions realize their objectives, ensure the service integration, and facilitate organizational effectiveness. Finally, humanitarian workers need to continuously monitor and critique the effectiveness of their interventions as a provider, revising their functions and interventions as needed, in order to meet the survivors’ needs.

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Although a broad range of social and mental-health interventions have been supported by research, the value of mental-health-care services in resource-poor countries has been controversial (Ager, 1997; Fairbank, et al., 2003; Summerfield, 1999a; Summerfield, 1999b; Summerfield, 2001; van Ommeren, Saxena, & Saraceno, 2005; Watters, 2001; WHO, 1999). Silove et al. (2000) expressed concern that the theoretical debate about the value of mental health and psychosocial programs could compromise the provision of necessary care. Despite the ongoing debate, there is emerging agreement about the best practices for public mental-health services. This consensus has emerged as a systems approach to trauma rehabilitation, represented by the development of the Sphere Project’s (2004) standards for mental and social aspects of health. The role of mental-health professionals before the outbreak of violence includes capacity building, training, collaboration, establishing structures for rapid assistance, and policy development (Balagna, 2003; Green et al., 2003; Hershenson, 1990; Maki & Riggar, 2004; NIMH, 2002; White, Fox, & Rooney, 2007). Further, the reallocation of resources through policies and programs that promote social development in the community can prevent a source of traumatic events. As conceptualized by Hershenson (1998), humanitarian workers during this preparatory phase are engaged in advocacy and consultation. By interventions such as restructuring the cultural, economic, and political context through capacity building, humanitarian workers can establish a societal trauma membrane that facilitates the development of resiliency. Baker and Ausink (1996) have developed a predictive model that humanitarian workers and NGOs can use to identify failed states, compare and analyze conflicts at various stages of development, identify potential outcomes, and to suggest the necessity of intervention. Monitoring demographic pressures, refugee movements, economic development, historical violence, government corruption, economic distress, exodus of a country’s middle class, deterioration of public services, the legal system, and protective services can provide an early warning about the outbreak of potential violence. As one form of post-trauma intervention, training can be provided for professionals and paraprofessionals, who are engaged in early intervention. This training may include response structures and processes, disaster mental-health resources, intervention considerations, vulnerable populations, cultural concerns, outreach and how to deal with the media. A case study of New York’s response to the World Trade Center attack revealed participants preferred sequential training. Participants valued this type of training, which was facilitated by individuals with experience in disaster response and which incorporated real life examples and role-play (Norris, Watson, Hamblen, & Pfefferbaum, 2005). The goal of this type of training was to convey information and provide the opportunity to develop confidence in the application of skills (Norris, et al., 2005). As another form of post-trauma intervention, education can be provided to survivors of disaster; yet, the effectiveness of this has not been empirically established (Ehlers et al., 2003; Eisenman et al., 2006). Education, however, can contribute to the normalization of the trauma experience for survivors of mass violence (Young, 2006). The majority of post-disaster education is informal (Young, 2006). It

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initially occurs through conversation with survivors, emphasizing information relevant to the presenting person, providing flyers or similar written material to supplement the conversation, and when feasible offering follow-up (NIMH, 2002; Young, 2006). Basic educational content for the survivors of mass violence may include the nature of traumatic stress reactions, normal reactions to stress, risk factors associated with serious problems, methods of coping, available services, and what can be expected from the array of available services (NIMH, 2002; Young, 2006; Young, Ruzek, & Pivar, 2001).

The Intrapsychic Trauma Membrane While the humanitarian worker is working, counseling and coordination are examples of humanitarian-worker functions that can be emphasized, in order to address the survivors’ intrapsychic trauma membrane. Yet, limited controlled, randomized research has been available to support any particular psychological intervention for collective trauma, which is operationally defined as those traumatizing experiences that arise from disaster or war, following mass violence (NIMH, 2002; Watson, 2004; Young, 2006). Common methodological issues, related to studies on psychological intervention for collective trauma, include the use of multiple measures, lack of clearly defined target symptoms, treatment adherence, blind evaluators, random assignment, and the absence of specific treatment programs that are manualized and replicable (NIMH, 2002). The research that has been conducted on psychological intervention following collective trauma can be organized into the following sections delineating studies on debriefing, individual or group therapy, and the use of medications.

Debriefing Interventions There have been mixed findings regarding the impact of psychological debriefing within 1 month of the collective traumatic event. Amir, Weil, Kaplan, Tocker, and Witzman (1998) studied the collective traumatic experience of 15 women, who were not physically injured, within 1 month after a terrorist attack in Israel. The participants attended a weekly group session that addressed abreaction, normalization of their feelings, coping with symptoms, and cognitive restructuring. The participants’ full-scale scores on the Impact of Event Scale (IES) were significantly higher in the 2 days post-trauma assessment than at their 2- and 6-month assessments. Despite the passage of time, increased interpersonal sensitivity, which is a measure of one’s feelings of personal inadequacy, inferiority, and discomfort during interpersonal interactions, was noted on the Symptom Checklist-90 (SCL-90). A one-session, psycho-educational group intervention, which focused on the symptoms of PTSD, normal reactions to trauma, resource availability, and debriefing, was provided to 42 British soldiers, who were responsible for identifying and

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the handling of bodies during the Gulf War (Deahl, Gillham, Thomas, Searle, & Srinivasan, 1994). Twenty soldiers, who were unable to participate in the session, were used as a control group. Nine months following the intervention, 42% of the control group and half of the treatment group reported symptoms of anxiety related to life threat and a history of psychological problems. However, there was no difference between those participating in the debriefing and the control group on the IES or the General Health Questionnaire–28 (GHQ-28). In a study of formal psychological debriefing, 106 British soldiers serving in Bosnia were randomly assigned by their commanding officers to either an assessment-only control group or a single, 2-hour, formal group-debriefing session (Deahl et al., 2000). When comparing the intervention group with the control group, the assessment-only control group was found to have higher anxiety scores and total scores on the Hospital Anxiety and Depression Scale (HADS) and the IES. Followup assessment 1 year later revealed that those assigned to the control group had more overall symptoms reported on the Symptom Checklist-90 (SCL-90) and higher alcohol consumption ratings on the CAGE Questionnaire than the soldiers who participated in one, 2-hour, formal debriefing session. This suggests that the debriefing intervention was effective and maintained its efficacy over 1 year. Response to immediate or delayed debriefing was also studied among bank employees, who had been working at the time of a bank robbery (Campfield & Hills, 2001). Employees were randomly assigned to groups that received either an immediate debriefing (< 10 hours) or delayed debriefing (> 48 hours). Although the number and severity of PTSD symptoms did not differ significantly immediately following debriefing, those individuals receiving immediate debriefing reported fewer symptoms 2 days, 4 days, and 2 weeks post-robbery than those who participated in delayed debriefing. Several studies suggest that debriefing shortly following exposure to mass violence can abate symptoms. Jenkins (1996) offered Critical Incident Stress Debriefing (CISD) to 36 emergency medical personnel, who worked at the site of a mass shooting. Participation in the debriefing session appeared to be correlated with lower depression and anxiety 1 month after the shooting. In a different study, 39 Israeli soldiers were asked, within 48–72 hours of their exposure to direct combat, to participate in a 2.5-hour, historical group debriefing by Shalev, Peri, Rogel-Fuchs, Ursano, and Marlowe (1998). The participants were evaluated before and after the debriefing. The pre–post debriefing scores reflected that debriefing was correlated with the reduction of anxiety symptoms on the State-Trait Anxiety Inventory (STAI) and improved self-efficacy on the Self-Efficacy Questionnaire (SELF-C). In contrast, police officers responding to a plane crash in Amsterdam, the Netherlands, were provided intervention immediately following the crash (Carlier, Lamberts, Van Uchelen, & Gersons, 1998). Structured interviews regarding PTSD did not reveal any differences between the 46 officers who participated in the group debriefing intervention and the control group that was composed of 59 officers. However, 18 months following the crash, those officers who did participate in the debriefing showed significantly more disaster-related symptoms than officers that did not participate in the debriefing intervention.

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Individual and Group Counseling Interventions The National Institute of Mental Health’s (2002) review of the literature related to collective trauma suggests there is some support for the effectiveness of brief, early, and targeted psychotherapeutic intervention. Cognitive-behavioral approaches are also promising to reduce the duration, incidence, and intensity of stress disorders and depression experienced by trauma survivors (Watson, 2004; Young, 2006). A complete review of the various individual and group counseling interventions for survivors of trauma is beyond the scope of this chapter. Readers interested in comprehensive coverage of these therapeutic topics are referred to the works of Foa, Hembree, and Rothbaum (2007), Follette and Ruzick (2006), Schauer, Neuner, and Elbert (2005), Scott and Stradling (2006), and Taylor (2006). Reviewing the ISTSS (2008) treatment guidelines regarding cognitive-behavioral therapy for adults with PTSD reflects that effective therapies generally consisted of individual sessions held once or twice weekly, 60–90 minutes duration per session over the course of 8–12 sessions. According to the ISTSS, those cognitivebehavioral approaches that involve exposure therapy, cognitive processing therapy (CPT), and stress inoculation training (SIT) have sufficient research to be recommended as primary treatments for chronic PTSD. However, early intervention focusing on the forced recall of events or associated emotions appears inconsistently effective at reducing future symptoms and may even increase the potential for their development (Chemtob, Tomas, Law, & Crieniter, 1997; NIMH, 2002; Rose & Bisson, 1998).

Pharmacology According to the National Collaborating Centre for Mental Health (2005), psychotherapy is the current treatment of choice for PTSD. However, medications are often used in conjunction with therapy to reduce the symptom features of PTSD and co-occurring disorders (Cukor, Spitlanick, Difede, Rizzo, & Rothbaum, 2009). Although no specific drug or combination of drugs has been found to prevent the emergence of an acute stress disorder or prevent PTSD, almost every class of psychotropic medication has been prescribed for those experiencing PTSD (Vieweg et al., 2006; ISTSS, 2008). The majority of the literature regarding the pharmacological treatment for PTSD involves the class of anti-depressants known as selective serotonin reuptake inhibitors (SSRIs) (Ravindran & Stein, 2009). SSRIs are the only medications in the United States to have Food and Drug Administration approval for the treatment of PTSD (ISTSS, 2008; Ravindran & Stein, 2009; Vieweg et al., 2006). This class of anti-depressants has been demonstrated to reduce or eliminate the clinical symptoms of re-experiencing, avoidance/numbness, and hyper-arousal (Albucher & Libergon, 2002; APA, 2004; ISTSS, 2008; Stein, Ipser, & Seedat, 2006; Vieweg et al., 2006). In addition to reducing the symptom complex of PTSD, SSRIs, such as sertraline, paroxetine, and fluoxetine, have been effective with the symptom of co-occurring

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disorders. Serotonin norepinephrine reuptake inhibitors (SNRIs) are another class of anti-depressants that are considered a first-line treatment for PTSD (Ravindran & Stein, 2009). Venlafaxine, an SNRI, has been found as effective as the SSRIs in the treatment of PTSD and when targeting co-occurring depression (ISTSS, 2008; Ravindran & Stein, 2009). Individuals with PTSD, who are being treated with SSRIs or SNRIs for PTSD and who are also experiencing hypervigilance, paranoia, aggressiveness, social isolation, or other trauma-related symptoms, have also benefited from augmentative therapy using atypical anti-psychotics such as risperidone or olzanapine (Bartzokis, Turner, Mintz, & Saunders, 2005; Hamner et al., 2003; ISTSS, 2008; Stein, Kline, & Matloff, 2002; Vieweg et al., 2006). The relatively few, controlled, randomized clinical-trial studies, which have been conducted on the effectiveness of medication following combat-related PTSD, suggest medication represents a later form of treatment and has yielded equivocal results (NIMH, 2002). Petty et al. (2001) studied the response of 30 Vietnam and Gulf War veterans with combat-related PTSD to olanzapine that was prescribed for a period of 8 weeks. The mean duration of PTSD was 6 years prior to entering the study with a range of 1–17 years. Overall, the participants reported a 30% decline in symptoms on the Clinician-Administered PTSD Scale (CAPS). Serynak, Kosten, Fontana, and Rosenheck (2001) investigated the effects of anti-psychotic medications for combat-induced PTSD among 831 inpatient and 554 outpatient male veterans. A 12-month comparison study of the veterans, who received antipsychotic medications, and the control group did not reveal any significant changes between the two groups on reported PTSD symptoms, the number of psychiatric symptoms, alcohol or drug use, employment, or subjective distress. Another pharmacologic treatment that has shown promise includes the use of antiandrenergics (ISTSS, 2008). Prazosin has been effectively used to reduce posttraumatic nightmares, as well as the overall symptoms of PTSD (Raskind et al., 2007; Taylor, Freeman, & Cates, 2008; Taylor, Martin, et al., 2008; Thompson, Taylor, McFall, & Raskind, 2008). Large, controlled, clinical trials are necessary to address its role in prevention of acute or post-traumatic stress disorder, alone or as an adjunct to psychotherapy (Ravindran & Stein, 2009). The Sphere Standards for Health Services (2004) provide informational guidance for the prescription of medications. In general, health-care workers are advised to refrain from the extensive administration of benzodiazepines to survivors experiencing acute post-conflict distress, due to their addictive potential. However, individuals with pre-existing psychiatric disorders or those requiring urgent psychiatric care for bipolar disorders, depression, psychoses, or dangerousness to oneself or others should have access to essential psychiatric medications through primary-care providers (Sphere, 2004).

Model Systems Approaches to Intervention War has a disproportionate, long-term effect on people with existing and acquired disabilities (WHO, 2005). Survivors with existing disabilities may lose assistive

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devices (in the chaos of a war zone), have increased difficulty accessing basic lifesurvival needs, and are affected by the loss of the infrastructure that previously provided rehabilitation services. According to the World Health Organization (2005), an appropriate response to post-conflict rehabilitation includes institute-based rehabilitation (IBR) and community-based rehabilitation (CBR). IBR involves the provision of medical rehabilitation services following immediate trauma care. The emphasis of CBR is on community development and inclusion for people with disabilities (see Chapter 5). The post-conflict response to prevent new disabilities and support people with existing disabilities can be classified into acute and reconstruction phases (WHO, 2005). The acute response involves the identification of people with existing disabilities, responding to their specific health needs, identification of those requiring and providing appropriate trauma care to mitigate disability, transferring people with severe injuries to centers with specialists for medical rehabilitation, and establishing multi-disciplinary task forces that consider available resources, in order to prepare a long-term rehabilitation program. During the reconstruction phase, longterm responses include the identification and assessment of the immediate and future needs of people with newly acquired and pre-existing disabilities; resource mapping to determine community abilities for addressing basic existence, health care, and rehabilitation needs; infrastructure development to provide medical rehabilitation services; development of community-based rehabilitation services to ensure equal access to services; ensuring the integration of people with disabilities into the community and the opportunity for employment; and implementation of universal design during the reconstruction of the community’s infrastructure. WHO (2003) established the following principles for providing mental-health services during the acute and reconstruction phases of rehabilitation following emergencies: prior planning and preparation; conducting a needs assessment; collaboration; integrating of services into primary health care; ensuring access to all; training and supervision of community paraprofessional and professional service providers; adopting a long-term perspective; establishing indicators; and monitoring the efficacy of services. Recognizing the broad, systemic implications of conflict, a group of humanitarian NGOs, the International Red Cross, and Red Crescent movement began the Sphere Project in 1997 (Sphere, 2004). The project’s mission is to improve the quality of assistance provided to people affected by disasters and to enhance the accountability of the humanitarian system in disaster response. It is based on two fundamental principles: that all possible steps should be taken to alleviate human suffering arising out of calamity and conflict and that those affected by disaster have a right to life with dignity and assistance. Sphere (2004) describes itself as being comprised of three things: a handbook, a process of collaboration, and a statement of commitment to quality and accountability. Acknowledging their reciprocal relationship, Sphere distinguishes between social and psychological intervention (Sphere, 2004). Sphere acknowledges the reciprocity of the two interventions – that social intervention can have secondary psychological effects and that psychological interventions have secondary social effects, as the term “psychosocial” suggests. Significant social problems can be

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pre-existing, conflict-induced, or a result of humanitarian aid efforts (IASC, 2007). Examples of pre-conflict social problems include ethnic or other discrimination, marginalization, and oppression. Social problems also result in the disruption of families and other social networks, employment, or the broader community due to conflicts. At times, culturally insensitive humanitarian aid efforts have compromised traditional community-support systems. Social interventions refer to those activities that primarily have effects on the development of the survivors’ interpersonal and communal trauma membrane. Access to activities that facilitate inclusion in social networks is fundamental to the development of a recovery environment. Sphere considers social interventions particularly important during the acute-response phase to disaster. Emphasis is placed on reuniting and keeping intact families, as well as communities. Community participation in the decisions, design, and activities directed toward the reconstruction of the devastated community is essential to long-term success of the reconstruction process. Survivor access to credible information related to the relief efforts is considered a fundamental human right and a primary method of mitigating anxiety (Sphere, 2004; IASC, 2007). The information provided should include the depth and breadth of the disaster and the efforts taken to reestablish a safe environment for the community. Restoration of cultural and religious activities is also considered vital to the development of a recovery environment. Culturally appropriate opportunities for grieving and bereavement promote closure and are more beneficial for survivors than allowing the unceremonious disposal of the deceased. In order to foster a sense of purpose and structure, Sphere recommends that survivors participate in activities that are of shared interest, such as emergency efforts for adults or access to education and recreation for children. Consistent with their immediate post-disaster emphasis on social interventions to restore a sense of normalcy, the Sphere Project (2008) entered a companionship agreement with the Inter-Agency Network for Education in Emergencies (INEE). Sphere (2008) indicated that the INEE Minimum Standards for Education in Emergencies, Chronic Crises, and Early Reconstruction (2008) should be used as guidelines to restore educational systems, in conjunction with Sphere’s standards for disaster response. The Sphere Humanitarian Charter and Minimum Standards describe key psychological and psychiatric intervention indicators (Sphere, 2004). Any intervention should be based on an assessment of the existing resources and socio-cultural context, in collaboration with the community’s leaders and indigenous healers. WHO developed the Rapid Assessment of Mental Health Needs and Available Resources (RAMH) as a tool to assess the health needs of refugee and host populations affected by conflict and in post-conflict situations (WHO, 2001). The instrument can be used during the emergency intervention phase and post-conflict situations. The assessment results can be used to develop recommendations for a community-based, appropriately timed, mental-health program. Consistent with Hobfoll’s (1989) conservation of resources model of stress, the RAMH results provide a description of the available individual, family, community, human, financial, political, and material resources. A particular strength of the instrument is its evaluation of the cultural,

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religious, and ethnic factors to be considered for both the refugee and the host communities (WHO, 2001). Survivors, and those engaged in providing aid to survivor populations, often experience acute distress following their exposure to the traumatic stressors of war. Psychological “first aid” provided through the community or primary health-care services are recommended for this type of acute distress (Sphere, 2004; Watson, 2004; Young, 2006). The primary objectives of psychological first aid include establishing a sense of safety, reducing stress-related reactions, and coordinating resources to replace or restore lost services (Young, 2006). Basic listening skills, assessing and ensuring that basic needs are addressed, encouraging but not compelling the survivor’s interaction with family or friends, and protecting the individual from further exposure are considered effective psychological first aid techniques. Humanitarian workers providing these basic, non-intrusive services establish an interpersonal trauma membrane and foster a recovery environment protecting survivors from additional exposure to the stress of conflict (Lindy et al., 1981; Lindy, 1985; Sphere, 2004). Psychiatric conditions, such as dangerousness to self or others, psychoses, or severe depression, warrant urgent care through the primary health-care system (Sphere, 2004). The Sphere standards indicate that whenever possible, individuals with pre-existing psychiatric disorders continue to be provided treatment. Community-based collaboration with indigenous healers and leaders, self-help groups, and the training and supervision of community workers are recommended to assist with outreach to vulnerable populations and to assist practitioners with their caseloads. When it appears the conflict might become protracted, additional planning is necessary to develop a comprehensive array of community-based psychological services. The United Nation’s Inter-Agency Standing Committee (IASC) developed guidance for mental health and psychosocial support during emergency situations (IASC, 2007). The IASC suggests that these guidelines complement the Sphere Project (2004) standards and that their implementation can contribute to the achievement of those standards. The core principles of the IASC approach to mental health and psychosocial support highlight the importance of human rights and equity, participation of those affected, doing no harm, the integration of support systems, and the development of a multi-layered system of complimentary supports. Conceptually, the IASC (2007) recommends concurrent implementation of all layers in a system of complementary supports. The suggested system of supports includes the reestablishment of basic services and security, community and family supports, focused non-specialized supports, and specialized services. Basic services and security form the foundation for all other mental health and psychosocial support. Mental health and psychosocial support (MHPSS) interventions, targeting basic community supports, include advocacy for basic services such as food, shelter, water, and basic health-care services (IASC, 2007). The advocacy effort should attempt to ensure that the services are provided in a manner that facilitates health and to document their impact on the people’s mental health and psychosocial conditions. Interventions designed to restore community and family supports include family tracing and reunification, mourning and healing ceremonies, outreach

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communication regarding effective methods of coping, restoration of educational and employment activities, and initiation of social networks. Focused, nonspecialized services include psychological first aid and basic mental-health services, which can be provided by primary health-care workers. This final layer of support is for those whose suffering cannot be allayed by the other systems of support; the problems presented by this population require referral for specialized services or implementation of training and supervision for primary health-care providers. The IASC guidelines do not focus exclusively on traumatic or post-traumatic stress. They emphasize a balanced approach to the diverse range of social and psychological problems that people experience following war or other emergencies. Among the reasons cited for this broad-based approach is the potential to overlook other substantial mental health and psychosocial issues and the ongoing controversy among organizations and professionals regarding an exclusive focus on traumatic stress (IASC, 2007). The IASC (2007) provides a matrix of interventions describing relevant actions, functions, and domains considered important for facilitating mental health and psychosocial support. Each intervention is organized by the category of response: emergency preparedness, minimum response, and comprehensive response. Emergency preparedness actions are designed to expedite service implementation in response to war or other emergencies. Each minimum-recommended response can be provided during the acute response to war, as well as in conjunction with a comprehensive response occurring during the phases of stabilization and reconstruction. Functions which occur across all domains include coordination; assessment, monitoring, and evaluation; protection and implementation of human rights standards; and the development of human resources. Core mental health and psychosocial support domains include community mobilization and support, capacity building in the areas of education, health services, and information dissemination. Response timelines are not provided, as the humanitarian response to the aftermath of war or armed conflict is not linear. Noting the increasing consensus that psychosocial concerns cross all sectors of humanitarian response to a conflict, the IASC’s (2007) guidelines also address areas that have not been a traditional concern of mental-health providers, such as a population’s basic food, shelter, water, and sanitary conditions. Although the depth and breath of the guidelines are beyond the scope of this chapter, their significance is based upon the IASC’s recognition that a coordinated system of interagency response is necessary to address the trauma and devastation of war. The IASC Guidelines (2007), in conjunction with the 2004 Sphere Project Minimum Standards, currently represent a best-practice model of post-conflict systems rehabilitation. They incorporate complementary mental health and psychosocial interventions to support the survivors of mass conflict by addressing the intrapsychic, interpersonal, community, and societal systems. As model systems, both the IASC Guidelines and the Sphere Standards continue to evolve with our increased understanding of the needs of survivors. Despite the comprehensiveness of the Guidelines and Standards, people with disabilities remain “the most hidden, marginalized, socially excluded and vulnerable” among the displaced populations

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(UNHCR, 2004, p. 6). Incorporating the needs of people with disabilities in future revisions of these model systems would enhance their humanitarian objectives (UNHCR, 2004).

Conclusions The trauma membrane represents a protective system for survivors of post-conflict trauma. This chapter introduced the basic concepts of systems theory, described how this epistemological framework incorporates the complementary concepts of mental health and psychosocial trauma rehabilitation, reviewed the relevant research regarding collective trauma interventions, and outlined the model guidelines and the minimum standards for a systems approach to post-conflict trauma rehabilitation. It is anticipated that humanitarian workers and mental-health professionals who adopt an ecological systems approach to post-conflict rehabilitation will develop a comprehensive understanding of the impact war has upon survivors and facilitate a holistic approach to their support and treatment.

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Ravindran, L. N., & Stein, M. B. (2009). Pharmacotherapy of PTSD: Premises, principles, and priorities. Brain Research, 1293, 24–39. Rose, S., & Bisson, J. (1998). Brief early psychological interventions following trauma: A systematic review of the literature. Journal of Traumatic Stress, 11, 697–710. Schauer, M., Neuner, F., & Elbert, T. (2005). Narrative exposure therapy: A short-term intervention for traumatic stress disorder after war, terror, or torture. Gottingen, Germany: Hogrefe & Huber. Scott, M. J., & Stradling, S. G. (2006). Counselling for post-traumatic stress disorder. London: Sage Publications, Inc. Serynak, M. J., Kosten, T. R., Fontana, A., & Rosenheck, R. (2001). Neuroleptic use in the treatment of post-traumatic stress disorder. Psychiatric Quarterly, 72, 197–213. Shalev, A. Y., Peri, T., Rogel-Fuchs, Y. Ursano, R. J., & Marlowe, D. H. (1998). Historical group debriefing after combat exposure. Military Medicine, 163 (7), 494–498. Shontz, F. C. (1975). The psychological aspects of physical illness and disability. New York: Macmillan. Silove, D., Ekblad, S., & Mollica, R. (2000). The rights of the severely mentally ill in post-conflict societies. The Lancet, 355, 1548–1549. Sphere Project. (2004). Humanitarian charter and minimum standards in disaster response. Retrieved August 2, 2008, from http://www.sphereproject.org Sphere Project. (2008, October 23). Sphere and INEE sign a companionship agreement. Retrieved from The Sphere Project Web site http://www.sphereproject.org/content/view/ 377/32/lang,english/ Stein, D. J., Ipser, J. C., & Seedat, S. (2006). Pharmacotherapy for post-traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews, Issue 1. Art. No.: CD002795. DOI: 10.1002/14651858.CD002795.pub2. Stein, M. B., Kline, N. A., & Matloff, J. L. (2002). Adjunctive olanzapine for SSRI-resistant combat-related PTSD: A double-blind, placebo controlled study. American Journal of Psychiatry, 159, 1777–1779. Stubbins, J. (1984). Vocational rehabilitation as a social science. Rehabilitation Literature, 45, 375–380. Summerfield, D. (1999a). A critique of seven assumptions behind psychological trauma programmes in war-affected areas. Social Science and Medicine, 48, 1449–1462. Summerfield, D. (1999b). Bosnia and Herzegovina and Croatia: The medicalisation of the experience of war. The Lancet, 354, 771. Summerfield, D. (2001). The invention of post-traumatic stress disorder and the social usefulness of a psychiatric category. British Medical Journal, 322, 95–98. Taylor, H. R., Freeman, M. K., Cates, M. E. (2008). Prazosin for treatment of nightmares related to posttraumatic stress disorder. American Journal of Health-System Pharmacy, 65 (8), 716–722. Taylor, F. B., et al. (2008) Prazosin effects on objective sleep measures and clinical symptoms in civilian trauma posttraumatic stress disorder: A placebo controlled study. Biological Psychiatry, 63 (6), 629–632. Taylor, S. (2006). Clinician’s guide to PTSD: A cognitive-behavioral approach. New York: Guilford Press. Thompson, C. E., Taylor, F. B., McFall, M. E., Barnes, R. F., & Raskind, M. A. (2008). Nonnightmare distressed awakenings in veterans with posttraumatic stress disorder: Response to prazosin. Journal of Traumatic Stress, 21 (4), 417–420. United Nations High Commissioner for Refugees (2004). Handbook for repatriation and reintegration activities. Retrieved July 31, 2008, from http://www.undp.org/cpr/we_do/ 4r_approach.shtml van Ommeren, M., Saxena, S., & Saraceno, B. (2005). Mental and social health during and after acute emergencies: emerging consensus? Bulletin of the World Health Organization, 83 (1), 71–75.

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van Der Veer, G. (1998). Counseling and therapy with refugees and victims of trauma: Psychological problems of victims of war, torture, and repression. New York: John Wiley & Sons, Ltd. Vella, J. (2002). Learning to listen, learning to teach: The power of dialogue in educating adults. San Francisco: Jossey-Bass. Vieweg, W. V., Julius, D. A., Fernandez, A., Beatty-Brooks, M., Hettema, J. M., & Pandurangi, A. K. (2006). Posttraumatic stress disorder: Clinical features, pathophysiology, and treatment. The American Journal of Medicine, 119, 383–390. Watson, P. J. (2004). Behavioral health interventions following mass violence. Traumatic Stresspoints, 18 (1). Retrieved August 13, 2009, from http://www.istss.org/ publications/TS/Winter04/index.htm Watters, C. (2001). Emerging paradigms in the mental health care of refugees. Social Science and Medicine, 52, 1709–1718. White, G. W., Fox, M. H., & Rooney, C. (2007). Nobody left behind: Report on exemplary and best practices in disaster preparedness and emergency response for people with disabilities. Retrieved June 14, 2008, from www.nobodyleftbehind2.org/findings/pdfs/bestpractices_3-21072.pdf Women’s Commission for Refugee Women and Children. (2008). Disabilities among refugees and conflict-affected populations. Retrieved September 6, 2009, from http://www. womenscommission.org/pdf/disab_full_report.pdf World Health Organization (1999). Mental health of refugees, internally displaced persons and other populations affected by conflict. Retrieved August 2, 2008, from www.who.int/hac/techguidance/pht/mental_healthrefugees/en/ World Health Organization (2001) Rapid assessment of mental health needs of refugees, displaced and other populations affected by conflict and post-conflict situations, and available resources. Retrieved July 15, 2009, from www.who.int/hac/techguidance/pht/7405.pdf World Health Organization (2003). Mental health in emergencies: Medical and social aspects of health of populations exposed to extreme stressors [Electronic Version]. Retrieved August 2, 2008, from www.who.int/mental_health/media/en/640.pdf World Health Organization. (2005). Disasters, disability, and rehabilitation. Retrieved July 31, 2008, from http://www.who.int/violence_injury_prevention/other_injury/disaster_disability2. pdf Wright, B. A. (1983). Physical disability – A psychosocial approach. New York: Harper & Row. Young, B. H. (2006). The immediate response to disaster: Guidelines for adult psychological first aid. In E. Cameron Ritchie, P. J. Watson, & M. J. Friedman (Eds.), Interventions following mass violence and disasters: Strategies for mental health practice (pp. 134–154). New York: The Guilford Press. Young, B. H., Ford, J. D., Ruzek, J. I., & Gusman, F. D. (1998). Disaster manual health services: A guidebook for clinicians and administrators. St. Louis: National Center for PTSD, Department of Veteran Affairs Employee Education System. Young, B. H., Ruzek, J. I., & Gusman, F. D. (1999). Disaster mental health: Current status and future directions: New directions for mental health services. In G. W. Currier (Ed.), New developments in emergency psychiatry: Medical, legal, & economic (Vol. 82, pp. 53–64). New York: Jossey-Bass Publishers. Young, B. H., Ruzek, J. L., & Pivar, I. (2001). Mental health aspects of disaster and community violence: A review of training materials. Menlo Park, CA: National center for PTSD and Washington, DC: Center for Mental Health Services.

Chapter 7

Human Physical Rehabilitation Pia Rockhold

Abstract The impact of conflict-related, complex emergencies on human health is widely documented, but poorly quantified, as most data collection and registration systems cease to function in conflict-affected situations. Modern conflict, which in increasing degrees, affects the civil population and is estimated to be one of the top ten causes of global mortality. The direct effects of war and conflict on health are due to land mines, exploded remnants of war, active combat, small arms, forced amputations, forced military recruitment, sexual and gender-based violence, and other violent acts. The indirect effects of war impact health through a myriad of ways, including social, political insecurity, environmental degradation, and human rights violations. Conflicts are major causes of injuries, violence, and disability and place a large economic burden on the individual, the family, and the society. Human rehabilitation is an essential investment that minimizes the health and disability consequences of conflict and enables people to live healthy and economically productive lives. The often large investments in medical rehabilitation made during or immediate after a conflict need to be retained and further developed as an integrated part of the health and social systems, when the country moves toward more sustainable development and peace. These systems not only ensure the necessary continued access to rehabilitation for people affected by conflict and others living with disabilities, but further address the more long-term needs for rehabilitation due to road traffic injuries, chronic illnesses, and age-related disabilities, as the country becomes increasingly more developed post conflict.

Introduction This chapter focuses on the impact and mitigation of damage to the human body as a result of conflict-related injuries. Mass violence and conflict increase the overall morbidity, disability, and mortality among a population in a myriad of ways. First, P. Rockhold (B) Consultant to World Bank and EU; Chair of the North South Group for Poverty Reduction, 17950 Pond Road, Ashton, MD, USA e-mail: [email protected] E. Martz (ed.), Trauma Rehabilitation After War and Conflict, C Springer Science+Business Media, LLC 2010 DOI 10.1007/978-1-4419-5722-1_7,

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this chapter will describe current knowledge of the impact of conflict-related, complex emergencies on human physical health, focusing primarily on conflict-related, intentional injuries. Second, it will emphasize the importance of human rehabilitation to mitigate the short- and long-term impact of conflict-related, complex emergencies on health and disability, not only as part of the emergency response but as a key part of a more long-term, systemic response. While the term “complex emergencies” sometimes is used to describe natural and man-made disasters, it is here used to describe emergencies that are associated with violent conflict, many of which have strong political affiliations. According to the Inter-Agency Standing Committee (IASC) for Coordination of Humanitarian Assistance in Response to Complex and Major Emergencies, a complex emergency is “a humanitarian crisis in a country, region, or society where there is total or considerable breakdown of authority resulting from internal or external conflict and which requires an international response that goes beyond the mandate or capacity of any single agency and/or the ongoing United Nations country program” (UNHCR, 2004, p. 5).

Estimating the Impact of Conflict on Human Health The impact of conflict-related, complex emergencies on population health is widely documented, but difficult to quantify (Babic-Banaszak et al., 2002; Coupland, 2007; Human Security Report, 2005; Levy, 2002; McDonald and Rockhold, 2008). “The fundamental challenge in quantifying the health impacts of conflict is that health information systems, particularly civil registration systems that record the event and cause of death, often cease to function in populations affected by conflict” (Murray, King, Lopez, Tomijima, & Krug, 2002, p. 324). Further the direct impact of conflict on health includes a large number of non-fatal injuries with an estimated ratio of 2 to 13 people being injured for each person killed in modern conflicts (Coupland & Medding, 1999). According to WHO (WHO, 2004), there were an estimated total of 57 million deaths worldwide in 2002. Approximately 700,000 of these were due to violence inflicted on others, including conflict-related deaths. More than 80 percent of these deaths were in males and the mortality rate was higher in low- and middle-income countries, compared to high-income countries (Payne, 2006). Globally, conflict caused an estimated 310,000 deaths in the year 2000; more than half occurred in sub-Saharan Africa and about 20 percent in Southeast Asia (WHO, 2001). In that same year, WHO estimated the global burden of disease (including years of life lost and years of life lived with disability) directly due to conflict to be 0.7 percent, compared to 2.8 percent due to road traffic injuries; 1.31 percent due to self-inflicted injuries; and 1.09 percent due to homicide. It is recognized that these estimates were based on very limited data and that they are likely to be severe underestimates of the actual direct effect of conflict on mortality, morbidity, and disability. In addition, these estimates do not attempt to

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include any information on the indirect impact of war and conflict in terms of increased mortality, morbidity, and disability. There is a serious need for more reliable data to quantify the impact of conflict on health. While social and political science literature on peace and security has suggested a decline in the total number of conflicts and conflict-related deaths since World War II, studies using an epidemiological approach to measure the effect of conflict on public health have provided more precise and accurate evidence suggesting that conflict-related deaths are on the increase. Modern conflict is, in an increasing degree, affecting the civil population. More civilians are dying or acquiring a conflict-related disability in recent times than during the time of the World Wars. Professor Chris Murray, who estimates conflict to rank among the top ten causes of death worldwide, believes that social and political science literature often severely underestimates the number of conflict-related fatalities (Murray cited in Dye & Bishai, 2007), as most of these reports rely on analysis of press reports of eyewitness accounts or official announcements of combatant deaths. Further, the definition of conflict varies between the various reports and databases (i.e., the Uppsala Conflict Data Program1 ) and many which use secondary data or cities data from other reviews (Murray et al., 2002). As an example of the problematic reporting of deaths, the estimated total number of deaths from a few of the ten largest conflicts in the 1990s range from (a) Rwanda, 500,000 to one million (1994); (b) Angola, 100–500,000 (1992–1994); (c) Somalia, 48–300,000 (1991–1999); (d) Bosnia, 35–250,000 (1992–1995); (e) Liberia, 25–200,000 (1991–1996); and (f) Burundi, 30–200,000 (1993) (Murray et al., 2002). Between 2000 and 2004, the International Rescue Committee (IRC) conducted four mortality surveys to evaluate the humanitarian impact of the conflict in Democratic Republic of Congo (DRC), and as part hereof the direct and indirect health impact of the conflict on human health. The first two surveys were confined to the five eastern provinces (Roberts, 2000; Roberts et al., 2001); the latter two covered all 11 provinces (Roberts et al., 2002; Roberts & Zantop 2003). In aggregate, these four studies “estimated that 3.9 million excess deaths had occurred between 1998 and 2004, arguably making the DRC the deadliest humanitarian crisis since World War II” (Coghlan et al., 2009, p. ii). Less than 10 percent of the deaths were directly attributable to violence. The vast majority of Congolese died from the indirect public-health effects of conflict, including higher rates of infectious diseases, increased prevalence of malnutrition, and complications arising from neonatal- and pregnancy-related conditions. Overall, the actual number of death due to conflict was considerably higher than that estimated by WHO and that indicated in the Uppsala Conflict dataset within the same time period (Coghlan et al., 2009). Further the majority of the death due to conflict were not directly caused by violence (direct

1 The Uppsala Conflict Data Program has collected data and conducted empirical analysis on conflict since 1946. Much of the information generated by this data program is regularly featured in international journals and books. Uppsala Conflict Data Program is an online database accessed for free (Uppsala Conflict Data Program, 2009).

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impact of conflict on health), but to a much larger extent due to the indirect effect of conflict on human health. Similar epidemiological studies, using a standardized household survey approach that included “verbal autopsies” to measure combat-related (direct) and noncombat-related (indirect) mortality in conflict-affected zones, estimated the warrelated Iraqi deaths from the time of the US invasion in 2003 to July 2006 to be approximately 655,000; this is more than ten times higher than the previous estimate of no more than 50,000 Iraqi deaths (Dye & Bishai, 2007).

The Direct and Indirect Impact of Conflict on Health Complex emergencies impact human health through a range of direct and indirect pathways, leading to increased morbidity, disability, and mortality. Conflict not only increases the number of battle deaths, as a direct effect of the conflict, but has even greater impact by the overall indirect mortality during and long after the conflict among others due to increased disease transmission and a general breakdown of services (Murray et al., 2002). According to the previous Iraqi Interim Health Minister Dr. Alawan, more Iraqis have died over the past 15 years as a result of misguided health policies and a neglected health sector than directly from wars and violence (Dyer, 2004). The direct effects of war and conflict can include that individuals are wounded by land mines or exploded remnants of war (ERW), active combat, small arms, forced amputations, forced military recruitment, sexual and gender-based violence (SGBV), and other violent acts. Indirect effects of war and conflict may impact health through a myriad of ways, including (1) social, political, and food insecurity, (2) violations of human rights, (3) migration of populations, (4) undermining of social networks with increased violence, substance abuse, (5) destruction of infrastructure and damage of system and services (including health, education, water, sanitation, and transport), and (6) degradation of the environment (Leaning, 1991). Thus, the largest portion of conflict-related deaths, illness, and disability are not due to the direct impact of conflict-related intentional injuries. Rather, they are caused by the complex interaction of various features that typically characterize the conflict setting, such as disorganization, abandonment, and destruction of the health and educational systems, and key networks and resources, i.e., water, food, electricity, fire wood, and transportation. The individual’s psychosocial, physical, sensory, and mental health is affected through a myriad of interlinked pathways, as is the well-being of households, the community, and the entire society, all of which increase mortality, morbidity, and disability (Levy & Sidel, 2008). Military operations, rebels, and government soldiers target, loot, and destroy housing, schools, water sources, health facilities, and other key infrastructure (Hoeffler & Reynal-Queral, 2003; Loretti, 1997). Such systemic damage, combined with the resulting inadequate access to functional health services, leaves populations at higher risk for malnutrition, epidemics, and poor health (Neumayer & Plumer, 2006).

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Conflict further tends to exacerbate already existing patterns of extreme poverty, limited access to services, and low national Human Development Indices factors, which characterize most countries affected by conflict already prior to the actual conflict. As a country’s resources become sparser, their external dependency on assistance increases; trained professionals, such as health workers, start to migrate to safer areas or are abducted and as a result, health management systems deteriorate and fail (Special Program for Tropical Disease Research [TDR], 2002). The quality and quantity of health-care services, such as the availability of essential medical supplies and medicines, are often greatly reduced in conflict-affected settings, as the security situation worsens. Further, health prevention and intervention programs, such as outreach services and disease control programs are disrupted (TDR, 2002). Examples of the damage of war on health systems are the finding that (a) more than 40 percent of the health centers in Mozambique were destroyed during the conflict from 1982 to 1986 (Pavignani, 2005) and that (b) in Liberia, the population access to health services decreased from 30 percent pre-conflict to less than 10 percent post-conflict (Liberia, 2006). Armed conflicts have been and still are a major factor in the causation of food insecurity and hunger, thus facilitating the onset of health problems and exacerbating any current health conditions. Harsh and inhospitable climates naturally hamper agricultural productivity in conflict-affected countries, such as Eritrea, Ethiopia, Kenya, and Somalia, where about 70 million people suffered from malnutrition, food insecurity, and famine (DaSilva, 2000). Food insecurity and malnutrition in Rwanda, Angola, Sierra Leone, Burundi, Liberia, and former Yugoslavia were largely the consequence of social instability and armed conflict, and not due to shortage of natural resources. Conflict disrupts the food systems, due to displacement of farming communities, plundering, and problems with transportation and access to market places (Liberia, 2006). Conflict creates a ripple effect, which increases the hardship for the individual, the family, the community, and the overall society, as insecurity, violence, and lack of human rights affects even the most basic needs for safety, clean water, food, energy, shelter, health care, information, and education. Arguably, the core of these losses is a violation of individuals’ human rights: Human rights violations are pervasive in most emergencies. Many of the defining features of emergencies – displacement, breakdown in family and social structures, lack of humanitarian access, erosion of traditional value systems, a culture of violence, weak governance, absence of accountability and a lack of access to health services – entail violations of human rights. The disregard of international human rights standards is often among the root causes and consequences of armed conflict (IASC, 2007, p. 50).

Key public-health goods are damaged or entirely destroyed, including the provision of clean water and sanitation (Liberia, 2006). This type of destruction threatens public health long after the conflict ends. Essential services, such as immunization and maternal and child health, are often jeopardized (Neumayer & Plumper, 2006), increasing infant, child, and maternal morbidity, disability, and mortality, not only in the short term but also causing serious, adverse, negative impact on the more long-term physical and socio-economic outcomes for survivors. As

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surveillance systems breakdown, the incidence and spread of disease cannot be treated or tracked adequately. Further, the total breakdown of disease surveillance, the inability of vaccination programs to reach insecure areas, and the incomplete reporting provide the opportunity for disease outbreaks. Health outcomes are also affected by disruptions to others sectors, such as education. That is, with a reduced provision of health education and promotion, preventable negative health outcomes are likely to occur, which have an adverse impact on health across the lifespan (McDonald & Rockhold, 2008). The deliberate destruction of health systems and the workforce characterizes most conflicts (World Health Report, 2006). One example is that in the DRC, all sides of the warring parties intentionally targeted hospitals and health clinics; this was done either to steal equipment and supplies or to penalize personnel for their perceived aid to other warring factions or to thwart them from providing such aid in the future (Human Rights Watch, 2002). Armed conflict also serves to undermine the national health workforce in many developing countries, as part of or along with the global ongoing, massive migration of health workers from lower to higher income countries and from countries with a high prevalence of HIV/AIDS. While qualified health providers are essential for supplying general and specialized services to populations affected by the conflict, protracted conflicts have led to an acute scarcity of trained health-care professionals (UNICEF, 2008). In Angola and Mozambique, approximately 70 percent of the health network was lost to the war; this adversely impacted population health long after conflict ends (Loretti, 1997). The diversion of health resources is common in conflict-affected settings. For example, in less than 20 years, military expenditure in Ethiopia tripled from 11.2 percent in 1973/1974 to 36.5 percent in 1990/1991, while the health budget was halved from 6.1 to 3.2 percent (Kloos, 1992). In the DRC, the national budget allocated to education was reduced from 15.1 to 1.3 percent from 1972 to 1990 (Peemans, 1997). In the Sudan (from 1990 to 1993), the amount of GDP allocated to “defense” was 54 times that allocated to health (i.e., 15 percent compared to 0.3 percent) (Loretti, 1997). Most conflict-affected countries suffer when scarce national resources are diverted away from the promotion and protection of health and productive activities toward the physical destruction of groups or nations in conflicts (Liberia, 2006; McDonald & Rockhold, 2008). Conflict’s impact spills across national borders, often throughout neighboring regions, leading to massive flux of populations and, in turn, to large refugee camps.2 These are often characterized by high rates of morbidity, disability, and mortality, as a result of poor sanitation, shifts in endemic features, overcrowding, reduced access to safe drinking water, and high rates of malnutrition (Cutts et al., 1996; Goma Epi Group, 1995; Liberia, 2006). Internally displaced persons (IDP) are

2 The US Committee for Refugees (USCR) found that “warehousing” of refugees, where they are forced to reside in temporary settlements and where basic needs are not met, is a common occurrence among a large proportion of the world’s refugees.

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particularly vulnerable as they lack legal protection that is afforded to refugees and are “without the benefit of an international agency mandated specifically to watch over their rights and interests” (Maslen, 1997, p. 2). Residing in camps, which are characterized by hopelessness, desperation, and limited socio-economic opportunity, significantly increases vulnerability to mental illness, substance abuse, and risk-taking (McDonald & Rockhold, 2008). While the direct impact of conflict often affects men more than women, as most combatants are men, the indirect, possibly long-term impact of conflict tends to affect women more than men. This is particularly the case during and after ethnic conflicts in failed states, where female often are more exposed to sexual and genderbased violence, including forced prostitution (e.g., in military brothels) and sextrafficking (Neumayer & Plumer, 2006).

Violence, Death, and Injury Violence is defined as “the intentional use of physical force and power, threatened or actual against oneself, another person, or against a group or community that either results in or has a high likelihood of resulting in injury, death, and psychological harm, mal-development, or deprivation” (WHO, 1996, p. 5). Violence is a dominant component of all conflicts and can be categorized into broad categories, according to who commits the act (i.e., self-directed, interpersonal, or collective) and the nature of the violent act (i.e., physical, sexual, psychological, and/or deprivation and neglect) (WHO, 2002). While all types of violence increase in situations of war, the most dominant increase is in collective violence, which exists in three forms: (1) armed conflict, terrorism, and other violent political conflicts within or between states; (2) state-perpetrated violence, such as genocide, repression, disappearances, torture, and other abuses of human rights, and (3) organized violent crime, such as banditry and gang warfare. Globally, an estimated 1.64 million people die annually from violence-related deaths; the large majority (1.49 million) in low- and middle-income countries, especially in the sub-Saharan Africa region (WHO, 1996). The number of officially registered, war-related fatalities is relatively low; however, it excludes all indirect fatalities and is attached to considerable measurement errors. In 2001, for example, only 208,000 people (or 3.5 per 100,000) globally were registered with conflict as the main cause of death (WHO, 1996). The average rate of war-related fatalities per year was less than three per 100,000 in all regions of the world, with the exception of Africa, where there were 28 war-related fatalities per 100,000 people. This is about more than nine times higher than in any other region, and the overall highest fatality rate in the world. Land mines, Explosive Remnants of War, and Improvised Explosive Devices In 2007, the Landmine Monitor (LMM) recorded 5,426 new casualties caused by mines, explosive remnants of war (ERW), and improvised explosive devices (IED).

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Of that number, about 1,400 people were killed and close to 4,000 injured; the large majority, more than 3,660 of the casualties, were civilians (LMM, 2008). Despite that these data most likely underestimate the actual number of people killed or injured due to land mines,3 it illustrates the large proportion of injured survivors, compared to the lesser proportion of actual fatalities registered; that is for each person injured and killed, additional four people are injured, but survive (4:1). While the number of new causalities has been steadily decreasing (e.g., from 6,873 in 2005 to 5,425 in 2007) since the introduction of the Landmine Ban Treaty, which entered into force on March 1, 1999 (UN, 1997), the number of survivors living with functional limitations and disabilities is steadily increasing. ERW and IED are considered to be one of the main reasons for war-related injuries, because these devices are, in fact, designed to injure and not to kill. On average, there are an estimated 15,000 and 20,000 new land-mine casualties each year (LMM, 2008). Survivors of such explosions often require long-term support in terms of health care, rehabilitation, and management of functional limitations and disabilities. The global number of land-mine survivors alone in need of rehabilitation and lifelong assistance was estimated to be more than 470,000 in August 2007 (LMM, 2008). Small Arms and Light Weapons It is unknown how many people have been killed, injured or violated directly or indirectly by small arms (i.e., assault rifles, machine guns, hand grenades, and other weapons designed for military use by an individual combatant, or commercial firearms, such as handguns and hunting rifles), as well as light weapons (i.e., portable weapons designed for use by several people serving as crew, such as heavy machine guns, mounted grenade launchers, portable anti-aircraft guns, portable antitank guns, portable launchers of anti-tank missiles, and mortars). According to Jayantha Dhanapala, the UN Under-Secretary-General for Disarmament Affairs, “Small arms are responsible for over half a million deaths per year, including 300,000 in armed conflicts and 200,000 more from homicides and suicides” (Dhanapala, 2002, p. 163). The issues posed by small arms are further depicted: Unlike major weapons systems, the availability of small arms and light weapons is subject to few internationally recognized rules and their regulation poses particular challenges. In contrast to weapons that have been banned because they violate the basic norms of international humanitarian law—such as anti-personnel mines—small arms are not in themselves unlawful weapons. Most small arms have legitimate uses, including for law enforcement and national defense. A prohibition is therefore not a solution. What is required instead is adequate regulation of their availability and use (ICRC, 2006).

An estimated 90 countries around the globe are currently involved in some aspect of small arms production (Small Arms Survey, 2004). The USA, the Russian 3 Out of the 78 countries and areas with casualties in 2007, only 48 had some form of data collection mechanisms, but most were unable to provide complete data. Further, most casualties were reported by the media (LMM, 2008)

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Federation, and China are the world’s largest producers of small arms and light weapons. Other significant producers are found in almost every region, with the majority in Europe and Asia. The total annual value of global legal trade in small arms is about four billion US dollars (USD) (Small Arms Survey, 2002). The illicit trade may be worth about one billion USD per year, which, in sum total, constitutes less than 14 percent of the total value of the conventional arms trade. But the bottom line is that small arms are responsible for the majority of casualties in armed conflicts (Small Arms Survey, 2001). In some countries, use of small arms is the leading cause of death, disproportionately affecting women. The widespread availability of small arms is a factor, which not only has coerced more than 300,000 children under 18 to fight in armed conflict in over 30 countries but also have enabled them to become ruthless killers, rapists, and perform amputations (Security Council, 2007). It is estimated that the global economy loses between 95 and 163 billion USD each year through productivity lost due to armed violence (Geneva Declaration, 2008). This figure does not include the direct and indirect costs of wars and similar situations (International Action Network on Small Arms (IANSA), 2009). As UNICEF (2001) reported Armed conflicts have left populations vulnerable to appalling forms of violence, including systematic rape, abduction, amputation, mutilation, forced displacement, sexual exploitation and genocide. The wide availability of light, inexpensive small arms has contributed to the use of children as soldiers, as well as to high levels of violence once conflicts have ended (p. 1).

Individuals with Disabilities Nowadays, the conceptualization of health and disability is moving away from diagnosis alone toward a more holistic understanding of the determinants and the consequences of health conditions, framed in term of disabilities that are experienced at the level of the body, person, and the overall social context. Subjective health experiences (quality of life) occur in specific contexts and cannot be divorced from personal and environmental factors, which may differ from one geographical and cultural setting to another. Disability is a universally used, yet ambiguous term. Categorizing the level of functional limitation, impairment, or disability is confounded by the availability of assistive devices, personal help, cultural expectations, and environmental modifications and adaptations. According to the International Classification for Functioning, Disability, and Health (ICF), individuals’ functionality, disability, and health are assessed and classified at three levels: (1) impairment of the body function and structure (e.g., missing a leg); (2) activity limitations and participation restriction (e.g., unable to dress oneself or difficulties with interpersonal relations); and (3) the environmental factors (e.g., attitudes or systems and policies) (WHO, 2001). There are an estimated 650 million people with disabilities worldwide and the number is steadily increasing, which is creating an overwhelming demand for health and rehabilitation services (WHO, 2005). Conflicts, land mines, small arms,

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SGBV, and poor access to health services are major causes of injuries, violence, and disability in Iraq, Occupied Palestine Territories, Algeria, Afghanistan, Vietnam, Cambodia, and many countries in Africa (McDonald & Rockhold, 2008). As described in this book, conflict is associated with a high prevalence of mental and psychosocial health problems, including depression and post-traumatic stress disorder (PTSD). These “hidden” disabilities affect a large proportion of the general population over a long period of time, and it is likely that the economic and social impact can be quite devastating unless addressed early on (McDonald & Rockhold, 2008). Recent research reveals that in post-conflict societies, mental-health disorders represent a major obstacle to economic development through lost productivity, loss of learning capacity, and cost of treatment and care (World Bank, 2005). Disabilities place a large economic burden, not only on the individuals living with a disability but the entire family. Failure to address disability during conflict, reconstruction, and in more long-term development efforts might leave a society vulnerable to violence and diminish the returns from efforts to rebuild social capital and enhance sustainable social and economic development (Elbadawi, 2008) In conflict-affected situations, where physical and social infrastructure often is destroyed and the overall accessibility to essential services severely reduced, people with disabilities face additional barriers in access and are often forgotten during evacuations, emergency relief, needs assessments, collection of baseline data and statistics for planning and management of resources, service delivery, education, employment, and livelihood assistance 4 (Kett, Stubbs, & Yeo, 2005; Oosters, 2005). Beyond the “basic needs” of everybody else, people with temporary or more longterm disabilities require access to rehabilitation and special assistance, based on their physical, sensory, and mental functions. Disability is largely preventable, but while primary prevention of disease receives a large amount of attention, most societies and health systems fail to provide adequate secondary and tertiary prevention (e.g., emergency services, trauma care, and rehabilitation to reduce the impact of injury or illness). Early access to emergency and trauma care and early and sustained rehabilitation minimize the health and disability impact of injuries and prevent or reduce disabilities that may arise due to acute or chronic disorders. Rehabilitation further enables people, who are born with or who acquire temporary or long-term, physical, mental, intellectual, or sensory impairments, to minimize their functional limitations and enhance their participation in society to achieve optimal health and quality of life. Despite the escalating growth in the global need for emergency medical care and rehabilitation services to prevent disability in people with congenital or acquired impairments, the international community remains largely uninformed and unaware

4 The reasons for exclusion of people with disabilities are multiple: They might be hidden by their families, or be unaware of or unable to attend distributions and community meetings, as they might be unable to hear, see, or understand announcements or have problems with access due to poor terrain; lack of mobility aids; impaired sight; emotional distress; mental illness, or several of these combined, the factors often are caused or aggravated by the trauma of the crisis, thus severely hindering them from gaining access to relief, distributions, and development decisions for themselves and their families (Oosters, 2005).

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of the potential positive impact of medical rehabilitation on health and quality of life. The direct and indirect human and financial implications of this ignorance may be inestimable.

Rehabilitation Rehabilitation refers to a very wide range of strategies and activities, only some of which occur within the health sector (WHO, 1969). There is, however, no single or agreed upon definition for rehabilitation. While habilitation aims to enable children born with functional impairments, rehabilitation aims to restore capacity and ability in people who acquire functional limitations. Habilitation and rehabilitation are often time-limited processes that may include medical, psychological, social, and vocational support enabling the individual to live an economically and socially productive life. The definition of rehabilitation has changed over time. In 1969, WHO defined rehabilitation as “The combined and coordinated use of medical social, educational and vocational measures for training or retraining to ensure that the individual reaches the highest possible of functional ability” (WHO, 1969, p. 6). Currently, the aforementioned ICF does an effective job of explaining the factors that come together to create disability, but it does not actually define rehabilitation (Seidel, 2003). From a public-health perspective, it is useful to view rehabilitation as one of the key health-care strategies that includes health promotion and prevention, early diagnosis, treatment, and rehabilitation, and support. Within the context of the ICF, rehabilitation is a health and social strategy that applies and integrates biomedical, engineering, psychosocial, vocational, and other approaches to optimize a person’s capacity, resources, and strengths, provides a facilitating environment, and develops and enhances the individual’s performance in interaction with the environment (Stucki, Cieza, & Melvin, 2007): a. Over the course of a health condition; b. Along and across the continuum of care (acute, emergency, intensive stabilization to rehabilitation, reintegration, and inclusion into the family, the community, and the society); c. Across sectors (including health, education, labor, legal, information, and social affairs); d. With the goal of enabling people with health conditions and functional limitations, who are at risk for experiencing disability, to achieve and maintain optimal functioning at the individual level, and in interaction with other individuals and the environment. Rehabilitation focuses on the individual, as well as the context (environment) in which that person lives (Dahl, 2002). Rehabilitation goals include (1) minimizing impairments of body structure and function (e.g., by attempting to improve strength or range of motion) and by compensating for impairments (e.g., through provision

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of a wheelchair, prosthetic, or orthotic devices) and (2) addressing environmental barriers (e.g., by preventing or removing physical barriers in buildings and transportation, ensuring inclusive education and information with use of sign language and Braille, reducing stigma and negative attitudes, and encouraging legislation and policies that promote inclusive societies). Rehabilitation is an essential component of secondary and tertiary prevention. That is, while most primary prevention strategies aim to prevent the occurrence of injuries, rehabilitation aims to minimize the health and disability consequences of the initial injury or acute episode of an illness (secondary prevention) or enable a person with disability (tertiary prevention) to better function (Mock, Quansah et al., 2004). Historically, the need for rehabilitation has always been present, but after World War II, thousands of peoples incurred disabilities in Europe, Japan, and America. These countries naturally promoted the development of rehabilitation services in response to war-related injuries. Initially, these services were provided in special rehabilitation facilities, but they gradually became absorbed into the general hospitals. Nowadays, all industrialized countries provide medical treatment and some level of medical rehabilitation within the facilities of the national health systems, as well as in specially staffed, technologically advanced rehabilitation centers, such as for people with spinal cord injuries, brain injuries, or stroke survivors. Various types of rehabilitation therapists were trained to help the large number of people with disabilities after the two World Wars. Most of these cadres, such as physiotherapists, occupational therapists, and prosthetic and orthotic technicians, remained as part of the national health-care systems in most high-income countries. Other types of specialized health personnel, who are available both within and outside the hospital settings, are clinical psychologists, social workers, public-health nurses, optometrists, opticians, and podiatrists. In most low-income countries, these cadres are often much more sparse, if at all existing. Most countries with national social security systems provide special provisions for help to people with more severe disabilities. These are mainly oriented to vocational rehabilitation, enabling people with disabilities to work under protected conditions or with supports in more competitive employment settings. Policies and laws help to ensure employment, social security, and pensions of individuals with various degrees of disabilities. In some countries, organized home care enables people to maintain living in their homes (Roemer, 1993). Rehabilitation services exist in most countries, but they are often inadequate in quality and quantity. The vast majority is too centralized and their capacity too low to meet the need. Further, most low-income countries face additional problems, such as inappropriate technologies, poorly skilled staff, and extremely limited resources (ICRC, 2006). Hence, while rehabilitation services are an integrated part of most health and social systems, they tend to only constitute a small, fragmented component of the health-care system that often receives substantial support from NGOs (e.g., in Kenya and Bangladesh) or are added externally by the private sector, as in Cambodia and the Occupied Palestine Territories (World Bank, 2008b).

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Beyond the emergency phase, there seems to be little global and national awareness of the importance of rehabilitation as a continuous, essential strategy and tool to prevent the development of disability in individuals with injuries, chronic conditions, and other body impairments. Human rehabilitation is rarely mentioned as a specific outcome included in national overall and health policies, strategies, and plans. Part of the problem is the fact that the term of rehabilitation has become a diffuse concept, covering many types of activities (i.e., including everything from fittings for prosthetic devices, to the inclusion of children with disabilities in schools, to income-generation schemes for adults with disabilities). The consequence is that it is hard to determine whether medical rehabilitation is occurring in a country or not (World Bank, 2008b). The need for clear definitions, norms, standards, strategies, and indictors within the area of rehabilitation enabling countries to ensure the provision, monitoring, and quality assurance of rehabilitation services is internationally recognized. WHO and other international partners are presently working on a global report on disability and rehabilitation to address this and other needs (WHO, 2005). The recent United Nations’ Convention on the Rights of Persons with Disabilities (CRPD) (UN, 2008, Article 26), which includes people with long-term physical, mental, intellectual, and sensory impairments, legally binds all ratifying states to the following: (1) Organize, strengthen, and extend comprehensive habilitation and rehabilitation services and programs in the area of health, employment, education, and social services, in such a way that these services and programs: • Begin at the earliest possible stage, and are based on the multidisciplinary assessment of individual needs and strengths; • Support participation and inclusion in the community and all aspects of society, are voluntary, and are available to individuals with disabilities as close as possible to their own communities, including in rural areas. (2) Promote the development of initial and continuing training for professionals and staff working in habilitation and rehabilitation services. (3) Promote the availability, knowledge, and use of assistive devices and technologies, designed for individuals with disabilities, as they relate to habilitation and rehabilitation. Human physical rehabilitation, or medical rehabilitation as a component of rehabilitation, tends to focus on minimizing and compensating for impairments of body function and structure, although it may address environmental barriers as well. It often occurs when impairments or disabling conditions are new or changing. Medical rehabilitation is frequently referred to as physical rehabilitation; this term, however, is inaccurate as medical rehabilitation does not focus exclusively on physical concerns, but also include sensory, mental, and psychosocial issues. These services can be provided by various rehabilitation providers, including physiotherapists, occupational therapists, speech therapists, prosthetic and orthotic technicians, counselors, social workers, and vocational specialists.

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Rehabilitation activities aim to (1) minimize the impact of impairments (e.g., by muscle strengthening and fine-motor coordination improvement); (2) prevent secondary consequences of the condition (e.g., pressure sores or contractions); and (3) provide adaptations designed to compensate for impairments (e.g., use of prosthesis, adaptive feeding equipment, home or workplace modification to support function). Many of these rehabilitation activities can be undertaken in hospitals, specialized rehabilitation centers, and community-based programs. Rehabilitation can also occur in school settings (to assure inclusive education), the workplace (to assure employment of people with disabilities), and other public settings (to assure full participation and inclusion of all members of society). Other important factors that may serve as enablers or barriers to individuals with disabilities include societal and cultural attitudes (e.g., stigma can be a major barrier to actual outcomes); leadership at high levels (e.g., a country’s ratification of UN Conventions related to disability); involvement of individuals with disabilities in decisions affecting policy and services; and country infrastructure and demography (e.g., urban/rural patterns, accessibility of transportation system, universal design in buildings and roads, communication systems, financing of health system, and availability of disability insurance or benefits) (World Bank, 2008b).

Rehabilitation from a Health Sector Perspective The quality and effectiveness of any rehabilitation system is often determined early on by the quality and effectiveness of the emergency medical services and the trauma care system within the respective country (Mock, Quansah, et al., 2004; Mock, 2003). Emergency medical services, which aim to stabilize the patient to prevent death and to minimize further injuries or secondary complications, are provided in a range of settings based on the place of the injury and the availability of access to services. Once the patient is stabilized, trauma care, if available, is generally provided at a hospital level, as it often includes various types of specialized care, such as anesthesiology and surgery, which are usually not available at the health center level and below (Mock, Quansah, et al., 2004). Emergency medical services and trauma care are often inadequate in low-income countries. In fact, 90 percent of all trauma deaths occur in low- and middleincome countries, not only due to high injury rates but even more so due to poor access to and limitations in the quality and quantity of emergency and trauma care (Kobusingye et al., 2006). Limited emergency and trauma care also mean that there is considerable injury-related disability for survivors of injuries in low-income countries (Mock, Joshipura, Goosen, Lormand, & Maier, 2005). This is true for children, as well as adults (Bickler, & Rode, 2002). Appropriate emergency and trauma care with basic essential surgery and anesthesiology at district hospitals would most likely help to decrease the fatality and disability rates, due to conflict-related injuries and other emergencies, and increase the overall cost-effectiveness of health care in low-income countries (Kobusingye et al., 2006).

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The Guidelines for Essential Trauma Care, which was published by the WHO in collaboration with the International Society of Surgery and the International Association for the Surgery of Trauma and Surgical Intensive Care (Mock, Lormand, Goosen, Joshipura, & Peden, 2004), identifies a core list of 11 essential trauma care services that realistically can be offered to injured people, even in very low-income countries. Further, the Guidelines have an entire section devoted to rehabilitation as a core component of trauma care (see Mock, Lormand, et al., 2004, pp. 45–47). Rehabilitation often begins in the acute-care setting. That is, rehabilitation of people with injuries (e.g., fractures, burns, land-mine accidents, gun wounds, and road traffic accidents, and strokes) should be initiated as early as possible to optimize recovery and early autonomy and to avoid complications, such as pneumonia, thrombosis, and pressure ulcers (Stucki, Stier-Jarmer, Grill, & Melvin, 2005). Typical medical rehabilitation in the acute-care setting includes splinting (to prevent contractures), range of motion and strengthening exercises, activities designed to improve mobility, and to assist individuals to begin gaining independent function in self-care tasks. These therapy activities might include the use of assistive devices to facilitate improved functions. Physiotherapists and occupational therapists are some of the key personnel specialized in rehabilitation, but it might be reasonable to train other personnel groups to provide some of these services (Mock, Lormand, et al., 2004). After a person has become medically stabilized, but still has functional limitations or impairments, he/she should be able to access special rehabilitation units or centers that may be hospital-based or in rehabilitation centers in the community. Ongoing physiotherapy and occupational therapy help the person continue to regain functional skills and to begin to learn how to compensate for impairments. People in need of assistive devices can be fitted for prosthetics and orthotics and be trained in their use, or learn how to use wheelchairs and other assistive devices. Psychological counseling, preferably by mental-health workers (but paraprofessionals may be trained to provide some of this service), is typically needed after trauma or serious illness, which many people surviving conflict have experienced (Bhuvaneswar, Epstein, & Stern, 2007). Some clients will also need speech, vocational, neuropsychology, or occupational therapy to address cognitive and perceptual impairments, as well as to address problems with communication and swallowing (e.g., after cerebral vascular accident or head injury) (World Bank, 2008b). In fact, given the mental distress of injury and the resulting high incidence of post-injury psychological problems, counseling or therapy services should be an integrated part of medical rehabilitation. In Cambodia, a study of children with disabilities found that more than half of the children (including those with mobility impairments) had emotional and behavioral problems that interfered with everyday function (Vanleit, Channa, & Rithy, 2007). In reality, mental-health services are often provided in separate systems beyond the medical health care, as an afterthought, or not at all. Bangladesh is one of the countries that seem to actively recognize the importance of integrating psychosocial services and to make

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a conscious effort to address these issues as part of rehabilitation (Khan, Noman, Anisuzzaman, & Borg, 2008). Other countries (India, Kenya, and Bangladesh) refer clients to psychosocial counseling in both the public and private sector, but it is difficult to ascertain how much they actually provide. Cambodia provides limited, if any, psychosocial services (de Mey, 2008). Rehabilitation can be a complex, multidisciplinary, and relatively long process (e.g., neuro-rehabilitation), during which psychological and socio-cultural aspects are just as important as the medical issues. Evidence suggests that a pragmatic, functional, and task-oriented approach often is more effective than the traditional impairment-oriented approach. That is, the focus on training of practical activities, such as dressing and washing oneself, is often more effective than trying to reverse the underlying impairment through gait retraining (Lin, Wu, Tickle-Degnen, & Coster, 1997; Wade & de Jong, 2000). As the individual becomes increasingly mobile and able to manage on his/her own, the continuous rehabilitation should be moved to the home, the community, the school, and the workplace, thus reintegrating the individual into his/her daily activities. This is often referred to as Community-Based Rehabilitation (CBR) (see Chapter 5). CBR recognizes that rehabilitation involves more than the individual and that the family and community have an important role to play in the process. While medical rehabilitation is a part of CBR, CBR typically describes an array of strategies and interventions that go well beyond the health sector and focusing more on environmental barriers to participation, rather than solely on impairments (Rockhold & Hayashi, 2008).

Human Physical Rehabilitation in Conflict-Affected Settings Conflict-affected settings can be divided into three phases with the corresponding objectives and components of service, varying according to each phase. Rehabilitation and CBR must aim to address these needs in each development phase and link the initial steps that address emergency-aid needs to the more long-term objectives of sustainable peace. The three phases are the following (Rockhold & Hayashi, 2008): (1) Immediate post-conflict phase with short-term objectives of addressing the most basic human needs, such as water, sanitation, food, shelter, and health care; (2) Intermediate post-conflict phase with medium-term objectives of restoring local capacities, such as improving infrastructure, education, livelihood, and economic growth and promoting the integration of all community members in the reconstruction and peace-building process. This phase can also promote new forms of local governance that is based on inclusion, representation, and accountability; (3) Long-term post-conflict phase with long-term objectives of strengthening systems and services to ensure sustainable peace and development.

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International NGOs are typically the main providers of humanitarian emergency services during the immediate and intermediate post-conflict phase. Much of this assistance often focuses on physical rehabilitation with an emphasis on device production and fittings, and with some limited psychosocial support. With the support of local and international partners, these NGOs often become key organizers of local capacity-building, including organizational development and training of human resources in rehabilitation, which are conducted based on standardized guidelines and manuals. However, while consensus on technologies and standards has been developed, the coordination, collaboration, and sustainable integration of rehabilitation into the national health system remains weak. The capacities for rehabilitation services are often not institutionalized and are rarely integrated into long-term policies, strategies, and plans for development of the health sector. Presently, most national governments put the Ministries of Social Welfare in the lead for a broad array of rehabilitation services, while the role of the Ministry of Health often remains limited. This occurs despite the fact that emergency services, trauma care, and medical rehabilitation are core responsibilities of the Ministry of Health. The need for rehabilitation services in crisis situations (e.g., epidemic numbers of land-mine victims) or in currently ongoing conflicts (e.g., in Iraq and the Occupied Palestine Territories) or post-conflict countries (e.g. Sierra Leone) is often sudden and of an overwhelming proportion. Yet, it is not surprising and it is possible to prepare for it. In such circumstances, the need for rehabilitation is often recognized by the international community and large amounts of resources are used to strengthen the temporary provision of rehabilitation services, especially to landmine survivors and ex-combatants. For example, the Multicountry Demobilization and Reintegration Program (MDRP) in the Great Lakes Region of sub-Saharan Africa, which amongst others aims to assist ex-combatants with rehabilitation services, is financed by 11 donors incl. the World Bank, and further involves 30 partner organizations (World Bank, 2008a). International organizations that are involved in emergency relief, such as International Committee of the Red Cross (ICRC) and Handicap International (HI), have for a long time played very important provider roles in multiple conflict and disaster-affected countries around the world, as they rapidly build up technically sophisticated rehabilitation systems for emergency use and take action to strengthen local capabilities (ICRC, 2006). However, despite that these NGOs often support local structures and work in close collaboration with local partners, these emergency rehabilitation systems are rarely included into the national health-care system, which often is very rudimentary during the end of the conflict and the immediate post-conflict phase. Even as the health-care system is rebuilt and evolves during the intermediate post-conflict phase, rehabilitation is often forgotten, despite its key function as part of essential primary health-care and overall health interventions. Large amounts of trained personnel, equipment, and resources, which could have been used to strengthen the national rehabilitation system, are often wasted during the longterm, post-conflict phase in the transition from conflict toward more long-term,

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sustainable development. This most likely occurs, due not only to limited coordination between humanitarian and development aid but even more so due to an overall lack of understanding and knowledge among most development partners about the importance of rehabilitation. Ensuring a smooth transition from the investment made by humanitarian agencies during the immediate post-conflict phase into the more long-term post-conflict phase towards sustainable development is essential in ensuring sustainable rehabilitation services as an integrated part of the more long-term and ongoing strengthening of the health and social systems and services (Rockhold & McDonald, 2009). Providing rehabilitation services to all individuals, not only ex-combatants but to the entire population of individuals with injuries and disabilities, is of upmost importance. This is especially true in countries affected by conflict, but even more so also over the long term as the country develops and road traffic injuries, strokes and other conditions related to injuries and non-communicable disease, becomes increasingly more prevalent. All of these factors increase the need for emergency and trauma care, as well as rehabilitation (Rockhold & McDonald, 2009). Cambodia provides a classical example of how rehabilitation systems, which are constructed during and immediately after the conflict by international NGOs and other partners, often end up “as stand-alone systems” with limited, if any, links to the overall health and social care system. International agencies regularly end up having created a separate medical rehabilitation system of care, and years later, medical rehabilitation still ends up as not being part of the public-health sector (de Mey, 2008). In countries that have not faced similar catastrophic or sudden increases of trauma (e.g., India, Kenya, or Bangladesh), the issue revolves around how to help governments recognize new priorities (e.g., associated with traffic accidents and other types of injuries) and implement or expand services that have never been identified as important in the past, including an integrated, emergency medical system, trauma care, and medical rehabilitation (World Bank, 2008b). The lack of data on injuries, violence, functional limitations, impairment, and disabilities in the general population often misguide the needs assessment, planning, monitoring, and evaluation in post-conflict settings, thereby creating an underestimation of the need for rehabilitation and psychosocial support, not only in conflict-affected settings, but also during more long-term sustainable development in post-conflict countries.

Summary and Implications The need for continuity and harmonization, in the transitioning from the immediate post-conflict phase toward long-term sustainable peace and development, is internationally recognized, but often overlooked, as most partners rush to provide humanitarian assistance that often is based on incomplete data and with limited consideration for the intermediate and more long-term needs for rehabilitation. That emergency rehabilitation services should be integrated into more longterm-sustainable health systems and development planning was recognized and recommended by the United Nations already in 1991:

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There is a clear relationship between emergency, [overall] rehabilitation and development. In order to ensure a smooth transition from relief to [overall] rehabilitation and development, emergency assistance should be provided in ways that will be supportive of recovery and long-term development. Thus emergency measures should be seen as a step towards long-term development (UN, 1991, Annex I, paragraph 9).

Establishing and developing a program for physical rehabilitation of human beings is a long-term commitment. Physical rehabilitation is not a short-term objective to be achieved during the immediate and intermediate post-conflict phase, but an essential part of any health and social system that aims to ensure the recovery and full reintegration into society of people with temporary or chronic health conditions or disabilities. Sustainable access to human physical rehabilitation is an essential part of ensuring “the health for all peoples (which) is fundamental to the attainment of peace and security and is dependent upon the fullest co-operation of individuals and States,” as noted in the Constitution of WHO (2006, p. 1). As conflict-affected countries continue to develop during the long-term post-conflict phase, the sustained rehabilitation of human beings is an essential part of ensuring peace and sustainable development for all. The rehabilitation systems built during the immediate and intermediate phases provide a solid foundation for the development of sustainable rehabilitation systems, as an integrated part of the country’s overall social and health systems. These systems not only ensure the necessary continued access to rehabilitation for people affected by conflict but further address the more long-term needs for rehabilitation in relation to injuries and chronic health conditions. The latter becomes increasingly more prevalent as the society moves toward sustainable peace and development, due to the increase in road traffic injuries, chronic illnesses and disabilities, and age-related functional limitations and disabilities. An estimated 80 percent of individuals with disabilities live in developing countries, especially in countries affected by conflict. Less than five percent of these people presently have access to rehabilitation services (WHO, 1999). The fundamental rehabilitation needs of the large majority of people living with poor health or disability could be satisfied at the community level through CBR. Only a proportion (an estimated 20 percent) of people with temporary or more long-term disabilities will need access to specialist facilities at some point in their life or continuously. Well-functioning specialist facilities, however, provide the spring board for well-functioning CBR (Rockhold, P., & Hayashi, S. (2008)). Medical rehabilitation needs to go hand in hand with the physical reconstruction of a more accessible society with prevention of environmental barriers, which have the potential to turn individual impairment into disability at the individual level (Vanleit, 2008). People with mobility impairments benefit more from wheelchairs if they live in a country where transportation and physical facilities are accessible. For countries to enhance the inclusion of individuals with conflict and non-conflictrelated disabilities, it is necessary to think multi-dimensionally (Vanleit, 2008). The attention to social and environmental barriers is important, but may have eclipsed

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the fact that medical rehabilitation is one of the strategies needed to address the personal needs of individuals with injuries, functional limitations, and disabilities. Further, data about where and how medical rehabilitation is provided are lacking in most countries. Better statistics that help to clarify causes and types of functional limitations, impairments, and disabilities, as well as the numbers of people, who could benefit from medical rehabilitation services, would also be of assistance to understand the systemic needs. National governments and international donors and organizations need to increase local and global investment in sustainable rehabilitation systems – as an essential part of secondary and tertiary prevention. If nothing is done to prevent disabilities, large proportions of government budgets will be expended in less cost-effective interventions, such as social protection and general care of people with disabilities. Resources that are invested into emergency medical services, trauma care, and medical rehabilitation can synergistically help address broader health-care needs as well. For example, a good emergency response system would not only address needs of victims of intentional and unintentional injuries, but would also be useful in reducing maternal mortality that is associated with obstructed delivery. Medical rehabilitation is also important for poverty alleviation. Investments in emergency services, trauma care, and rehabilitation in developing countries could benefit the poor proportionally more than the rich as poor people are more exposed to primary causes of injuries, chronic poor health and disability, and more likely to have poor access to health services, rehabilitation, and social support, and as a consequence, poor people are more likely to become disabled. Likewise, people living with a disability are more likely to become poor (Elwan, 1999). Thus, investments in medical rehabilitation are likely to be a pro-poor policy for countries that are struggling with a high burden of injuries, chronic health conditions, and disabilities (World Bank, 2008b). There is an urgent need for global research and consolidated action to improve the present awareness, data collection, and knowledge base pertaining to the identification and evaluation of essential medical rehabilitation services; these studies also need to research the quality of care, affordability, and cost-effectiveness, and the impact of secondary and tertiary rehabilitation prevention strategies on poverty alleviation. In addition, we need to expand and strengthen global actions for investing in more sustainable, integrated services and systems for emergency and trauma care and rehabilitation. These activities should strive to ensure access to essential services for all, including people with amputations, spinal cord injuries, and other types of injuries and chronic poor health conditions, which accompany conflict, but also occur in settings that are working on long-term sustainable development and peace.

Conclusion Extensive investments in human and institutional development, for the strengthening of human physical rehabilitation services and systems during the post-conflict emergency response phase, and adequately responding to health needs in the

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short-and long-term period following conflict need to be retained and institutionalized as an integrated part of the more long-term, national health-care system. The health sector plays a key role not only in the prevention, early diagnosis, and cure but also in the rehabilitation and management of people with temporary or permanent functional limitations, impairments, and disabilities. To ensure health for all and contain the cost of care, there is an urgent need for joint action (internationally, nationally, and locally) to strengthen the coordination and sustainable integration of rehabilitation into health-care systems. That is, there is a critical need to retain and further utilize the investments made during the emergency phase in countries affected by conflict and disaster to address the health-care needs of populations with high prevalence of intentional injuries (i.e., land mines and guns) and non-intentional injuries (i.e., road traffic accidents). Other populations in urgent need of more systemic approaches and increased sustainable funding for rehabilitation are those undergoing demographic and epidemiological transitions, such as aging populations experiencing increases in chronic conditions and stress-related health problems. The impact of conflict on human health, disability, and development might be the biggest and yet largely unrecognized challenge facing global international development of today. We, therefore, need to enhance our efforts in addressing the fundamental challenge of quantifying the actual direct and indirect impacts of conflict on health. Increased global awareness of the importance of conflict prevention and management is best achieved through improved access to evidence-based information, Meanwhile, rehabilitation, as a holistic approach to assisting those injured by war or conflict, facilitates reintegration of individuals with impairments or disabilities into the family and the community, thus enhancing the overall social and economic productivity and quality of life. A more systemic and long-term approach to human rehabilitation can help to alleviate the short- and long-term impact of conflict-related, complex emergencies and disasters, as well as other injuries and chronic conditions, on health disability and overall development. Action for more integrated holistic approaches to rehabilitation is urgently needed.

Recognition This chapter is largely build on lessons learned through 4 years of work with the World Banks’ Disability and Development Team (2004–2008), a time during which the author spearheaded a large multi-partner and country study on rehabilitation with financial support from JICA, World Bank, and DANIDA. The author would like to recognize the following persons for their valuable inputs: Nedim Jaganjac and Piet de Mey for their general support and the study of respective Bosnia Herzegovina and Cambodia; A.H.M. Noman Khan, Nazmul Bari, Dr. M. Anisuzzaman, and Johan Borg for the study of Bangladesh; Suddhasil Siddhanta, and Debasish Nandy with support of Asha Hans (Santa Memorial Foundation) for the study of India; Gideon Muga, Robert Buluma, Raphael Owako, Vane Lumumba, Francis Kundu, and Thomas Maina for the study of Kenya; Abdul Muti Al Azzeh for his study

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of Occupied Territories of Palestine (West Bank Gaza); Padmani Mendis and Chintha Munasinghe for their study of Sri Lanka; ICRC (Claude Tardif), Handicap International (Wendy Batson), WHO (Chapal Khasnabis), Christoffer Blinden Mission (Andreas Pruisken and Hubert Seifert), SINTEF (Arne H. Eide), Swedish Handicap Institute (Anna Lindstrom), USAID (Anne Hayes and Rob Horvarth), GPDD (Maria Reina), ISOP (Sten Jensen), Betsy Vanleit, Ian Bannon, Daniel Mont, Charlotte McClain-Nkhlapho, Laura McDonald, Sanae Hayashi, Rosangela Biermier, Judith Heumann, and PADECO, Japan.

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Chapter 8

Psychological Rehabilitation for US Veterans Thomas A. Campbell, Treven C. Pickett, and Ruth E. Yoash-Gantz

Abstract The cycle of military deployment can be a stressful experience that is associated with a number of adverse impacts. This chapter details psychological stressors and their sequelae during the cycles of deployment, beginning with predeployment stressors, followed by stressors that occur in the military theater of deployment, and finally focusing on post-deployment mental-health issues. During the pre-deployment phase, the service member often is attempting to handle multiple competing social, vocational, and emotional demands. Family responsibilities and pressures often mount during this time. To prepare for stressors that may be faced in the military theater, service members may undergo resiliency training. While in the war theater, service members may face a host of stressful experiences, including military combat. The psychological impact of these stressors, while apparent at times during deployment, may not be fully felt until the service member has returned from deployment. After deployment, service members may seek and receive treatment for a number of mental-health conditions, including posttraumatic stress disorder (PTSD), depression, substance abuse, and adjustment following traumatic brain injury (TBI). This chapter outlines the various ways that these conditions are being addressed among post-deployed service members in the USA

Introduction The cycle of military deployment can be a stressful experience that is associated with a number of adverse impacts. Whether a veteran has been involved in direct combat situations or not, there are a host of psychological stressors that can cause clinically significant disruption to both the individual and the family system (Hosek, T.A. Campbell (B) VA Medical Center, Richmond, VA, USA e-mail: [email protected] The views expressed in this chapter are those of the authors and do not necessarily reflect the views or policy of the Department of Defense or the Department of Veterans Affairs.


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Kavanagh, & Miller, 2006). The following chapter outlines the cycles of deployment as described by Logan (1987) and presents information regarding the specific stressors and mental-health issues that are associated with each phase of the cycles and how these issues are being addressed from a psychological perspective. The descriptions of these deployment cycles have been refined by others (e.g., King, King, Foy, Keane, & Fairbank, 1999; Pincus & Nam, 1999; Pincus, House, Christensen, & Adler, 2001), such that more recent conceptualizations of the deployment cycle are in three distinct phases: pre-deployment (the period from notification to departure), deployment (the period from departure to return), and post-deployment (the period after return). The pre-deployment phase has been referred to as a “ramping up” period preceding actual deployment (American Psychological Association, 2007). This is a phase typified by the service member’s attention and focus becoming increasingly centered on mental preparation and readiness for the upcoming mission. In the deployment phase, the service member is physically removed from the immediate family context and, in the case of those serving in Operation Enduring Freedom (OEF; Afghanistan) and Operation Iraqi Freedom (OIF; Iraq), often working in a stressful, dangerous, and malevolent environment. The post-deployment phase encompasses the period of time in which the service member returns home and is reunited with family and community. Whereas in previous conflicts, this phase was seen as terminal, in more recent military operations, service members and their families have been increasingly exposed to multiple deployments and consequently repeated deployment cycles and subsequent effects.

Pre-deployment Mental-Health Issues The multiple competing social, vocational, and emotional demands of the predeployment phase can be more stressful than the actual deployment (Hosek et al., 2006). Prior to deployment, service members contend with escalating demands from their military command structure, with requests including completion of predeployment screenings and evaluations to ensure mental and physical readiness. Simultaneously, family responsibilities and pressures mount as service members are challenged by both pragmatic (e.g., finalizing wills and powers of attorney, arranging childcare) and emotional (e.g., anticipated separation) considerations. The pre-deployment time frame may be as short as a few weeks or longer than a year. Tanielian, Jaycox, Adamson, and Metscher (2008) reported that service members can work up to 16 hours per day during the pre-deployment period. Whereas the predeployment cycle for the service member is characterized by increasing pressure to focus on the military mission, the family system is tasked with preparing for the anticipated departure of the service member and the uncertainty about when (or if) they will return (National Military Family Association (NMFA), 2005). Some

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theorists describe the psychological experience of the family in the pre-deployment phase as one of “ambiguous loss,” in that the service member is physically present, but increasingly emotionally inaccessible (e.g., Boss, 1999). As the service member feels mounting pressure to focus on the mission and prepare the family for his/her period of absence (family resilience-building), the family may be experiencing emotional distress, in that they perceive the service member as emotionally missing. Interestingly, the concept of “ambiguous loss” has also been used to describe the experience of family members who struggle to reconcile the physical presence, and the relative cognitive or emotional absence, in a family member who has sustained a severe traumatic brain injury (TBI), or who has been diagnosed with posttraumatic stress disorder (PTSD) or a host of other psychiatric disorders (Weins & Boss, 2006). In the pre-deployment phase, families prepare for separation and increased independence. Role adjustments are paramount to optimal adjustment of the family system, as the spouse or other immediate/extended family members may be asked to adjust work schedules, oversee financial matters, and/or assume primary parenting responsibilities. Marital disagreements are common during this pre-deployment period, especially in young enlisted families (Logan, 1987; Pincus & Nam, 1999; Pincus et al., 2001). As might be reasoned, there may be expressed or latent concerns about marital problems, potential infidelity, and the potential impact of deployment on the social, emotional, or academic functioning of the children. Compounding these stressors, there are uncertainties in recent military operations surrounding the actual timeline or length of deployment. As a result, service members and their families may not have a clear sense of the deployment timeline, which in turn heightens worry about the potential for combat-related injury or death.

Pre-deployment Mental-Health Screenings The Department of Defense (DoD) has three health assessments during the deployment cycle that screen for mental and physical health: (1) a pre-deployment health assessment that is used as a baseline measure, (2) a post-deployment health assessment (PDHA) that is conducted immediately upon return from deployment, and (3) a post-deployment health reassessment (PDHRA) that is conducted 3–6 months following return from deployment (Department of Defense, 2010). The predeployment health assessment will be discussed in this section, while the PDHA and PDHRA will be presented in the following sections. There are minimum mental-health standards that service members must meet in order to be deployed. When a service member has been diagnosed with a mentalhealth condition that does not preclude deployment, it is generally expected that the service member should be free of “significant” mental-health symptoms associated with the condition for at least 3 months prior to deployment. While making a “fitness for duty” assessment, health-care providers are encouraged to consider

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contextual stressors of deployment and whether continued mental-health treatment will be available in the war theater. Some identified mental-health disorders may preclude a service member’s deployment. Bipolar disorder is one such example. The prescription use of specified psychotropic medications, such as antipsychotic or anticonvulsant medications used to control bipolar symptoms, and certain types of tranquilizers and stimulant medications may also limit or preclude deployment (Department of Defense, 2006). The pre-deployment health assessment and medical record review serve as the two primary mechanisms in the pre-deployment phase to screen for mental-health conditions and ensure that standards are utilized in making deployment determinations (Department of Defense Task Force on Mental-Health, 2007).

Pre-deployment Resiliency Building As would be expected, deployed service members have increased risk of exposure to combat experiences. Data suggest that exposure to combat experiences increases the risk of developing posttraumatic stress disorder (PTSD) or other mental-health conditions (Lapierre, 2008). Furthermore, the risk for developing a diagnosable mental-health condition compounds with multiple deployments. Hoge et al. (2004) noted that more than half of the OEF–OIF Army or Marine Corps ground combat units reported being shot at (or receiving small-arms fire), seeing dead or seriously wounded Americans, or seeing ill or injured women or children, whom they were unable to help. Other findings were that nearly 90% of OIF service members reported being either attacked or ambushed, over 60% reported that they were in a threatening situation and unable to respond in accordance with US Forces Rules of Engagement (ROE), and 85% reported someone they personally knew being injured or killed. More than 50% of Marine Corps service members and almost half of army service members reported killing an enemy combatant. Resiliency-focused training modules have been developed for military service members’ use during the pre-deployment phase. “Battlemind Training” (United States Army, 2009) is one such approach, in that it is intended to foster resiliency by developing self-confidence and mental toughness, enhancing character strengths, and reinforcing specific behaviors that service members can engage in to cope with the stressors of combat (Castro, Hoge, & Cox, 2006). The expectation is that completing pre-deployment resiliency training, like Battlemind, will have an effect of attenuating combat-stress symptoms in the immediate aftermath of (or during) a traumatic experience, thereby buffering against in-theater or post-deployment onset of a diagnosable mental-health condition. There are unique modules within this training for soldiers, leaders, reservists, and families. One study examining the effectiveness of Battlemind training found that those soldiers who received the training reported fewer mental-health problems than those who did not (Mental-Health Advisory Team V, 2008).

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In-Theater Mental-Health Issues Predictors of Psychological Impairment Even with formal resiliency-building training, repeated deployments can contribute to clinically significant mental-health challenges. Nevertheless, research evidence points to the stressors associated with combat exposure as being the primary risk factor for psychological impairment among military personnel (Hosek et al., 2006; Schell & Marshall, 2008). In addition to combat exposure, length of deployment (even when controlling for the amount of combat exposure) has also been found to be associated with the presence of post-deployment mental-health problems (e.g., Schell & Marshall, 2008). Adler and Castro (2001) found increased prevalence of PTSD symptoms in military personnel deployed for longer than 4 months, and also in those involved in non-traditional combat duties, such as handling dead bodies and disarming civilians (Adler & Castro, 2001). Other PTSD literature ties the severity of the trauma exposure to the persistence and extent of posttraumatic symptoms (Brewin, Andrews, & Valentine, 2000; Ozer, Best, Lipsey, & Weiss, 2003). It is not surprising that many military service members and their families are contending with mental-health difficulties in the wake of OEF–OIF operations. One potential limitation of prevalence data obtained, however, as aggregated by brief screening instruments (e.g., Post-Deployment Health Assessment [PDHA], Post-Deployment Health Reassessment [PDHRA]), is that these screening instruments interrogate symptoms of PTSD rather than more formal Diagnostic and Statistical Manual – 4th Edition (DSM-IV; APA, 2000) diagnostic criteria. The psychological needs of service members may change drastically in the war theater. Each military branch has specific combat-stress and deployment mentalhealth support programs available during deployment. Each of these programs aspires to provide support tailored to the service’s mission and risk factors their personnel might face. In addition, cross-functional planning teams bring together subject-matter experts from across the services, the Joint Staff, and DoD. For example, the Army Combat Stress Control (CSC) is embedded into elements of separate brigades, divisions, or medical battalions. The CSC uses a multi-faceted approach, including unit consultations, system intervention, stress control briefings, suicide prevention briefings, and unit needs assessments. The air force has a mobile, comprehensive system of combat-stress and deployment mental-health teams that can deploy with air force units. The Navy and Marine Corps approach is to educate and provide the necessary resources to leaders, Marines, and their families, in order to create a community support system to address stressors early, and to prevent, identify, and treat combat/operational stress injuries before, during, and after deployment (Department of Defense, 2009). Addressing the mental-health needs of service members serving in Iraq and Afghanistan remains a major focus for DoD leadership. According to a recently released report, there are more than 230 mental-health providers working in Iraq and Afghanistan [Mental-Health Advisory Team (MHAT V), 2008]. Mental-health providers working in deployment areas may include psychologists, psychiatrists,

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psychiatric nurses, social workers, occupational therapists, and mental-health technicians (Moore & McGrath, 2007). The primary goals of mental-health professionals in the war theater are to keep service members mentally focused during deployment and to foster resilience that encourages individuals’ reliance on both individual and unit strengths (Munsey, 2007). In response to the growing need for mental-health services during deployment, the Navy and Marine Corps have adopted an approach called “Operational Stress Control and Readiness” (OSCAR) (Nash, 2006). The program matches psychologists with Marine regiments in pre-deployment cycle, and these psychologists remain attached to the regiment throughout the deployment and post-deployment phases. Army psychologists and combat stress control teams are readily accessible to deploying soldiers, in part to institute stress control training and to survey separate units for problems (Munsey, 2007). The Air Force deploys both a rapid response team (for mental-health needs) and an augmentation team (for non-emergency mental-health concerns) to implement combat stress control principles for the purpose of prevention and to provide intervention to deployed airmen when necessary (Department of the Air Force, 2005). Psychologists in the combat zone also help military leaders to understand problems related to low morale and to assist in the management of interpersonal difficulties within units. Multi-faith chaplains are an integral part of the military community. They provide family counseling and care for the spiritual needs of the military community and may deploy with their units. The chaplain’s primary role is to maintain a spiritual presence and to offer confidential counseling in a safe environment to those who are in need of someone to talk to during difficult times. Chaplains provide much of the education related to return and reunion for the Army and Marine Corps deployment cycle support programs, in addition to playing an important role in the suicide prevention efforts for all the services.

Post-deployment Mental-Health Issues Studies examining the prevalence of mental-health conditions for post-deployed service members have shown differing rates of mental-health diagnoses for different deployments and eras. In OEF–OIF conflicts, depression, PTSD, and TBI (a physical injury that results in cognitive changes) are the most common post-deployment mental-health conditions (Ramchand, Karney, Osilla, Burns, & Caldarone, 2008). Hoge, Auchterlonie, and Milliken (2006) found that 5% of service members returning from OEF (Afghanistan) screened positive for PTSD and 3% for depression, whereas 10% of those returning from OIF (Iraq) screened positive for PTSD and 5% screened positive for depression. Studies examining lifetime prevalence rates of mental-health conditions from the Vietnam War found that 30% of veterans of this war met criteria for PTSD (Kulka et al., 1990). Arguably, one reason for discrepant findings is that there are differences in the length of time since deployment, total duration of deployment, or whether there were multiple deployments. While there

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have been relatively few peer-reviewed studies examining the rate of TBI among post-deployed service members, Vasterling et al. (2006) found that 8% of OIF veterans screened positive for some degree of TBI. While the statistics may vary, these and other studies make it clear that military deployment can increase risks for some diagnosable mental-health conditions, relative to population base rates that were published in the DSM-IV. This is not surprising in that there are expected stressors in deployment irrespective of increased risk for trauma exposure, TBI, or other physical injury, and because all of these risks are present in a malevolent contextual environment (e.g., extreme heat, potential for sleep disruption, potential for injury).

The Post-deployed Wounded in Action For some service members, the transition from in-theater to post-deployed status occurs secondary to becoming wounded in combat or combat-related activity. “Polytraumatic injuries” are traumas to one or more physical region or organ system that result in physical, cognitive, psychological, or psychosocial impairments and functional disability (Department of Veterans Affairs, 2009). When active duty, deployed military personnel sustain polytraumatic injuries in the field and are evacuated from the war zone, they are often transported to a larger military treatment facility (MTF) (typically in Germany) and then onto one of several military hospitals in the USA, including National Naval Medical Center (NNMC), Walter Reed Army Medical Center (WRAMC), or Brook Army Medical Center (BAMC). Upon medical stabilization and interdisciplinary agreement that a patient will benefit from further acute rehabilitation services, the service member with polytraumatic injuries may be referred to a VA Polytrauma Rehabilitation Center (PRC). The Department of Veterans Affairs (VA) has a memorandum of agreement with the DoD to provide acute rehabilitation care to returning, active duty service members with polytraumatic injuries. For these severely injured service members, the emphasis is on providing a seamless transition between the DoD and the VA health-care systems. To assist with this process, each PRC site has one or more military liaison(s) on-site to assist with the coordination of care and supports for the family system. Currently, there are four PRC sites within the VA Polytrauma System of Care (PSC), located in Richmond, VA, Minneapolis, MN, Tampa, FL, and Palo Alto, CA. There are 18 additional Polytrauma Network Sites (PNS) within the PSC. These out-patient PNS sites, located throughout the country and in Puerto Rico, provide post-acute rehabilitation and case management for service members and their families, often helping them to identify local VA and non-VA services for which they qualify. One study, which sampled patients in the four PRCs during the first 4 years of OEF–OIF, found that 56% of those patients had blast-related injuries and that symptoms of PTSD were more common in these patients than in those with combat injuries of other etiologies (Sayer et al., 2008).

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Post-deployment Screening for Mental-Health Conditions and Service-Seeking Among Veterans There are several systems in place to identify and refer those in need of mentalhealth services in the post-deployment cycle. In part as an initiative to assess and track medical and mental-health problems that are associated with deployment in the aftermath of the first Gulf War, the DoD began assessing all service members prior to deployment and immediately following deployment using the Pre-Deployment Health Assessment and the Post-Deployment Health Assessment (Department of Defense, 2010). In 2005, the DoD began reassessing post-deployed service members 3–6 months following their return from OEF–OIF deployment using the PDHRA. Data are published monthly on the PDHA and PDHRA in the Medical Surveillance Monthly Report, and these data yield valuable information that can greatly benefit those working with post-deployed active duty service members and veterans. DeFraites, Rubertone, Tobler, Brundage, and Wertheimer (2008) found that a majority (59% immediately upon return from deployment and 52.5% 3–6 months following return) of post-deployed service members reported their health in general as “excellent” or “very good.” A smaller but notable percentage (6.7% immediately upon return from deployment and 13.8% 3–6 months following return) rated their health as “fair” or “poor.” While increased rates of physical and psychological symptoms may be expected given the obvious physical and psychological strain of deployment, data suggestive of overall health deterioration at the 3–6 month reassessment time point were less expected. Because a large percentage of this increase was attributable to mental-health concerns, this trend illustrates that mentalhealth symptoms may not be evident (or may be under-reported) immediately post-deployment (DeFraites et al., 2008). Importantly, symptoms of psychological distress may take months to be recognized by the individual. For some, there may be a reluctance to seek help for mental-health symptoms, even after they are recognized as contributing to psychosocial or vocational disruption. The post-deployment cycle often involves transitioning from active duty military to reserve status or to veteran status. During these periods of transition, service members and veterans may be vulnerable to confusion about how to access mental-health treatment. Some studies have illustrated access difficulties among those transitioning into different statuses (e.g., Tanielian et al., 2008). The DoD, VA, and state agencies are working proactively to maximize the timely and appropriate access to mental-health services for veterans and their families. Consistent with the civilian literature, even with the best mental-health assessment and referral system in place, some service members and veterans may not be inclined to pursue mental-health assessment or intervention services. Perceived societal attitudes and stigmas, which surround the admission of mental-health diagnosis or treatment-seeking, may account for some of this reluctance. Alternatively, it may be that rather than seeking care outside of their close circle of military comrades in a large and foreign health-care milieu, they prefer to insulate within a more proximal

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trauma membrane (Lindy, 1985). Schell and Marshall (2008) found that only 53% of those meeting criteria for PTSD or depression sought mental-health treatment in the past year. Earlier studies showed that an even smaller percentage sought treatment (Hoge et al., 2004). This trend places a premium on mental-health outreach across the continuum of the health-care system and also suggests the need to continue striving toward optimal access for veterans and their families, who might benefit from mental-health assessment, intervention, and/or ongoing case management. Research has demonstrated that within the different branches of the military, there are differences in the percentage of those who indicate a need for mentalhealth services. One study utilizing the PDHA showed that members of the Army were more likely to indicate the need for mental-health services than members of the other branches, and members of the Air Force were least likely to seek treatment (Armed Forces Health Surveillance Center, 2008). At the time of the PDHRA (3–6 months following return from deployment), members of the Army and Marine Reserves indicated the greatest need for mental-health treatment, followed by active duty army and Marines and active duty and reserve Navy personnel. Air Force personnel, both active duty and reserves, were significantly less likely to indicate the need for such services. One possible explanation is that in the most recent OEF–OIF conflicts, Army and Marine personnel have more frequently been in the immediate proximity of combat situations. Studies have shown that level of combat exposure is significantly correlated with mental-health conditions (Schell & Marshall, 2008); yet there is little or no data showing the rates of those seeking mental-health services among the different branches when controlling for amount of combat exposure.

The Mental-Health Consequences of Deployment That military deployments and combat exposure can lead to psychological disorders is not new to modern warfare. Accounts of combat-stress reactions were identified and written about at least as early as the US Civil War, and likely earlier (Mareth & Brooker, 1985). Terms such as shell-shock, soldier’s heart, and gas hysteria are all terms that have been used during historical military operations to describe an acute or prolonged stress reaction to a combat situation. While combat-stress reactions and the prolonged psychological disorders that develop from them are perhaps the most well-known post-deployment psychological challenges, they are, by far, not the only ones facing US veterans today. It is important to note that while some psychological and cognitive disorders may be a direct result of stressors encountered during the deployment (e.g., PTSD, depression, TBI), many of the disorders seen and treated in VAs are not. Often, these result from a combination of historical biological, psychological, and sociological precursors (i.e., “biopsychosocial”; Kiesler, 1999) that are aggravated by or even present before the stresses of deployment. Although this chapter focuses mainly on those diagnoses that are most likely to be attributable to the stresses inherent in stages of the deployment cycle, it is important to permit an adequate recognition and accessibility of a broad spectrum of mental-health conditions in the military and VA health-care systems.

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There are increased rates of depression, PTSD, and TBI in post-deployed OEF– OIF military and veteran populations, relative to their non-deployed counterparts (Hoge et al., 2004; Tanielian et al., 2008). Hoge and colleagues (2004) found that about 17% of those returning from OIF and 11% of those returning from OEF met criteria for a psychological disorder, while 9% of their non-deployed counterparts met these same criteria, a statistically significant difference among the three groups. Schell and Marshall (2008) found that 31% of previously deployed personnel met criteria for depression, PTSD, or TBI. They also found a strong correlation between PTSD and depression (r = 0.60) and moderately substantial correlations between TBI and depression (r = 0.26). These results showed that deployments, especially those involving combat operations, can have a significant psychological or cognitive impact. TBI and PTSD have been called the signature injuries of the current wars in Afghanistan and Iraq (Tanielian et al., 2008). Much of our understanding of PTSD comes through research and clinical treatment of veterans from the war in Vietnam (e.g., Kulka et al., 1990). Currently, the VA screens veterans at risk for developing PTSD by using the Primary Care PTSD Screen, which is a four-item measure that roughly corresponds to the DSM-IV-TR’s (American Psychiatric Association, 2000) broad criteria for PTSD. TBI especially has been the focus of intense study and scrutiny since OEF–OIF began. TBI can result from either penetrating or closed-head injures (PHI or CHI, respectively). CHI can be further subdivided into three distinct severity classifications: mild, moderate, and severe. These classifications are based on indicators, such as the duration of loss of consciousness and posttraumatic amnesia, or on-site measures of responsiveness, such as the Glasgow Coma Scale (GCS; Jennett & Bond, 1975). The American Congress of Rehabilitation Medicine (ACRM) has a broadly acceptable classification system to grade the severity of TBI (ACRM, 1993). TBI is caused by the brain rapidly accelerating, decelerating, and striking the inside of the skull. For OEF–OIF veterans, blast exposure is the primary cause of TBI. The rapid change in atmospheric pressure caused by these blasts is hypothesized to be an additional mechanism of injury in CHI (Warden, 2006). There is currently much debate over the long-term cognitive and psychological impacts of mild TBI and its relationship to other disorders, such as depression and PTSD. This debate centers on the diagnosis of post-concussive syndrome (PCS). Some studies have suggested that PTSD symptoms account for the cognitive and psychological symptoms that have often been attributed to PCS, due to their cooccurrence (Hoge et al., 2008; Schneiderman, Braver, & Kang, 2008). However, none of the studies to date can shed light on the causality of these correlations (Nelson, Yoash-Gantz, Pickett, & Campbell, 2008). Substance-use disorders (SUDs), while not a direct result of deployment stressors, are often co-occurring with PTSD, depression, and TBI (Dansky, Saladin, Brady, Kilpatrik, & Resnick, 1995; Karney, Ramchand, Osilla, Caldarone, & Burns, 2008). Individuals with psychological disorders, such as PTSD, are more likely to report using substances to cope with negative interpersonal stressors, while substance abusers without PTSD are more likely to report using substances in response

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to environmental cues (Ouimette, Coolhart, & Funderburk, 2007). These findings suggest that individuals with psychological disorders may have reduced coping abilities to deal with stressors. Substance-abuse disorders are likely to complicate treatment for other disorders, such as PTSD and depression (Ford, Hawke, Alessi, Ledgerwood, & Petry, 2007), because those with co-occurring PTSD or depression are more likely to drop out of substance-abuse treatment early or to continue abusing substances further into the course of treatment. Another reaction to the stressors of military deployment is a somatoform disorder (e.g., Somatization Disorder, Conversion Disorder, Pain Disorder, and Hypochondriasis). Somatoform disorders are suspected when one has physical symptoms that cannot be explained by any medical condition, the direct effects of a substance, or another mental-health condition (APA, 2000). Data on the prevalence of this disorder in returning veterans is extremely sparse. One recent study found that of the 10% of medical evacuees from OEF–OIF combat zones, who were referred for mental-health treatment, only 3% met criteria for a somatoform spectrum disorder (Rundell, 2007). This is less than 1% of the total number of medical evacuees. It is likely that many of patients with somatoform spectrum disorders go misdiagnosed or undiagnosed for some time, because the symptoms can often mask as other disorders. Data also indicate an increase risk of suicide among veterans. One epidemiological study conducted after the start of OEF–OIF found that male veterans were twice as likely to die of suicide when compared to the general population (Kaplan, Huguet, McFarland, & Newsome, 2007). Simpson and Tate (2005) reported that 26% of those with TBI reported making at least one suicide attempt. It is known that a diagnosis of depression and/or PTSD can increase the risk for suicide (Oquendo et al., 2007). Substance-use disorders may also increase the risk for suicide (Simpson & Tate, 2005). One recent report by the Centers for Disease Control and Prevention (CDC, 2008) indicated that about 20% of all suicide deaths in the USA were among veterans. To reduce the risk of suicidal behavior among veterans, each VA Medical Center and large community-based out-patient clinic (CBOC) maintains a suicide prevention coordinator (SPC), who tracks and reports on veterans determined to be at high risk for suicide and veterans who attempt suicide. The SPC also works to train VA staff and those in contact with veterans in the community in how to get immediate help for veterans who are expressing suicidal ideation or intent, in order to ensure that veterans who are at increased risk are receiving proper care (Department of Veterans Affairs, June 2008).

Mental-Health Treatment and Rehabilitation The Department of Veterans Affairs is divided into the Veterans Health Administration (VHA) and the Veterans Benefits Administration (VBA). The VHA is tasked with providing medical and psychological care, as Abraham Lincoln stated in his second inaugural address, to “him who shall have borne the battle.” Today,

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the VHA provides services to veterans discharged under “other than dishonorable conditions” regardless of combat experience (Department of Veterans Affairs, 2009). It is divided into 21 Veterans Integrated Service Networks (VISNs), with 153 medical centers, 731 community-based out-patient clinics, 135 nursing homes, 209 readjustment counseling centers, and 47 residential rehabilitation treatment programs (Department of Veterans Affairs, 2008). By means of this extensive network, VHA provided health-care services to 5.5 million unique patients in 2007 (Department of Veterans Affairs, 2008). In the early stages of psychological treatment at the VA, the focus was largely on in-patient populations of mostly World War II veterans with serious and persistent psychological disorders. In 1947, the VA reported that 58% of hospital beds were occupied by patients with psychological disorders (VA, 1947; as cited in Baker & Pickren, 2006). Since that time, there has been a dramatic shift, both in VA hospitals and in the larger psychological treatment community, from in-patient to out-patient treatment and rehabilitation. Indeed, some VHA facilities have time-limited, inpatient treatment programs or partial psychiatric hospitalization treatment programs, in which the patient spends 6–8 hours per day in treatment (but does not stay in the hospital as an in-patient). In the aftermath of the war in Vietnam, VA psychologists mobilized to identify and treat a particular cluster of symptoms common to many combat veterans. These veterans were reporting dramatic and unwanted re-experiencing of memories and nightmares that were associated with particularly traumatic experiences, hypervigilance, increased anxiety, and avoidance of environmental cues of the traumatic experience. This disorder was classified as PTSD in the DSM-III (American Psychiatric Association, 1980), and knowledge of it largely grew from work conducted at VA medical and VA-affiliated research facilities. Today, the VA operates the National Center for PTSD (Department of Veterans Affairs, 2010), comprised of seven divisions across the USA that specialize in the research and dissemination of empirically supported treatment techniques for the psychological sequelae of traumatic stress. In the wars in Afghanistan and Iraq, some service members sustained a TBI, which caused cognitive impairments that lingered far beyond the initial injury. As discussed previously, the VA responded in 2005 by establishing four polytrauma rehabilitation centers to assess and treat the cognitive sequelae of TBI. The interdisciplinary treatment teams at these centers provide specific treatments and care for the service member, but also work to provide support for family of the veterans with injuries. Psychologists are extensively involved in providing support to family members, leading family support groups, working one-on-one with family members, and facilitating communication between the service member’s family and the treatment team. This focus on including the family members of veterans adds another dimension to the way psychological treatment and rehabilitation are conducted. Collins and Kennedy (2008) identified several stressors, which are faced by families and which affected their responses to their family member being polytraumatically injured, including the effects of deployment, treatment course, accessibility to familiar support systems, and loss of military environment and

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culture. In in-patient rehabilitation settings, the trauma membrane that forms around the injured service member via the family can be readily apparent. Without the proper support and education during the process of rehabilitation, family members may have a tendency to consciously or unconsciously regard certain intervention efforts by a health-care provider (or team) as disrupting a layer of protection that they are forming around their loved one. In these cases, the psychologist may work with the family to establish trust and eventually enter into the trauma membrane to facilitate the patient’s recovery. The VA is currently attempting to ensure that empirically supported psychological treatments are available to all veterans with PTSD (Department of Veterans Affairs, June 2008). Currently, two such treatments, Cognitive Processing Therapy (CPT; Resick & Schnicke, 1992) and Prolonged Exposure (PE; Foa & Rothbaum, 1998), are being disseminated through national trainings and at VA-sponsored training sites. These two therapies have been shown through a number of randomized controlled trials (Foa et al., 2005; Monson et al., 2006). Similar initiatives are underway to ensure that all VA facilities have mental-health clinicians, who are trained in empirically supported treatments for other psychiatric disorders, such as Seeking Safety, Dialectical Behavior Therapy, and Acceptance and Commitment Therapy. It has been suggested that employing these evidence-based treatments, by reducing direct and indirect costs associated with PTSD and depression, actually costs less than providing no treatment at all (Eibner, Ringel, Kilmer, Pacula, & Diaz, 2008). Both CPT and PE, to an extent, address the way information about the trauma is processed to elucidate the mechanisms of change. As no study to date has shown that a majority of those who experience a traumatic event will develop a psychological disorder, the normative psychological response to a traumatic event is recovery. Green (1993) found that an average of 25% of those experiencing traumatic events develop PTSD. PTSD, therefore, can be viewed as the result of insufficient recovery from the traumatic experience. CPT focuses on both the non-adaptive cognitions and the fear-laden memories surrounding the traumatic event, while PE’s focus is mainly on the fear-laden memories themselves. In this way, the concept of the trauma membrane is very much consistent with the theoretical underpinnings of these therapies. As Martz and Lindy described earlier in this book, the trauma membrane, instead of being a protective factor, can exacerbate psychological distress when not properly attended to, thereby impeding the recovery process.

Importance of VA Research, Training, and Dissemination to the Non-VA Clinician Because many veterans eligible for services at VA medical centers will choose to seek treatment elsewhere in their communities, it is critical that the VA conduct research and trainings on veterans’ health issues that can be disseminated to the larger mental-health community. The VA has been a leader in the training of psychologists and the dissemination of effective therapies for decades. Baker and

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Pickren (2007) calculated that the VA has trained over 36,000 psychologists through its various training programs. While many of these individuals choose careers in VA psychology positions, many choose to work in other settings. In addition, many of the training seminars and workshops that the VA provides are attended by members of the psychological community outside of the VA. Clinicians in state and private institutions rely on these trainings to serve veterans in their practices as well. VA facilities have affiliations with 107 medical schools, 55 dental schools, and over 1,200 other schools throughout the country (Department of Veterans Affairs, 2009). In this way, VA research and clinical training programs serve all veterans, including those that receive health-care outside the VHA setting.

Summary and Conclusions Active duty military personnel and veterans of military service face a host of experiences that can strain one’s coping resources and lead to both physical and mental-health conditions and chronic disorders. The US military and the Department of Veterans Affairs have responded by providing mental-health prevention and treatment at the various stages of the deployment cycle. Programs, such as Battlemind, that attempt to build resiliency and coping strategies for the multitude of stressors that a service member will face on deployment are also provided. During deployment, prevention is still a major focus of mental-health services, but resources shift to acute treatment as well. All military branches have a mental-health component embedded or attached to them, in order to manage the mental-health needs of those deployed. Upon returning home from deployment, military personnel and veterans are at increased risk for a spectrum of psychiatric conditions, such as PTSD, depression, somatoform disorders, substance abuse, and the cognitive sequelae of one or more concussive injuries. While the VA is one of the main resources for the treatment of veterans’ mental-health conditions, many veterans choose to seek care at other places in their community. In order for the VA to fulfill its mission of caring for those who have carried the burden of war, initiatives to train both VA and non-VA mental-health professionals about phases of the deployment cycle and the psychological impacts and risks inherent in these phases are important undertakings. By using a multi-pronged approach, the mental- and physical-health issues of returning service members and veterans are being addressed more fully than in previous decades, in addition to the provision of better screening for stress-related issues and training to build mental resiliency before entering the war zone.

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Lindy, J. (1985). The trauma membrane and other clinical concepts derived from psychotherapeutic work with survivors of natural disasters. Psychiatric Annals, 15, 153–160. Logan, K. V. (1987). The emotional cycle of deployment. Proceedings, Feb, 43–47. Mareth, T. R., & Brooker, A. E. (1985). Combat stress reaction: A concept in evolution. Military Medicine, 150, 186–190. Mental-Health Advisory Team (MHAT) V (2008, February). Operation Iraqi Freedom 06–08: Iraq Operation Enduring Freedom 8: Afghanistan. Retrieved April 6, 2009, from http://www.armymedicine.army.mil/reports/mhat/mhat_v/Redacted1-MHATV-4-FEB-2008Overview.pdf Monson, C. M., Schnurr, P. P., Resick, P. A., Friedman, M. J., Young-Xu, Y., & Stevens, S. P. (2006). Cognitive processing therapy for veterans with military-related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 74, 989–907. Moore, B. A., & McGrath, R. E. (2007). How prescriptive authority for psychologists would help service members in Iraq. Professional Psychology: Research and Practice, 38, 191–195. Munsey, C. (2007, September). Serving those who serve: Transforming military mental-health. APA Monitor on Psychology, 38. Nash, W. P. (2006) Operational stress control and readiness (OSCAR): The United States marine corps initiative to deliver mental-health services to operating forces. In Human dimensions in military operations – Military leaders’ strategies for addressing stress and psychological support (pp. 25-1–25-10). Meeting proceedings RTO-MPHFM-134, paper 25. Neuilly-sur-siene, France: RTO. Retrieved February 10, 2010, from http://ftp.rta.nato.int/public//pubfulltext/RTO/MP/RTO-MP-HFM-134/MP-HFM-134-25.pdf National Military Family Association (2005). Report on the cycles of deployment: An analysis of survey responses from April through September, 2005. Retrieved June 12, 2008, from http://www.nmfa.org/site/DocServer/NMFACyclesofDeployment9.pdf?docID=5401 Nelson, L. A., Yoash-Gantz, R. E., Pickett, T. C., & Campbell, T. A. (2008). Relationship between processing speed and executive functioning performance among OEF/OIF veterans: Implications for post-deployment rehabilitation. Journal of Head Trauma Rehabilitation, 24, 32–40. Oquendo, M., Brent, D. A., Birhmaher, B., Greenhill, L., Kolko, D., Stanley, B., et al. (2007). Posttraumatic stress disorder comorbid with major depression: Factors mediating the association with suicidal behavior. American Journal of Psychiatry, 162, 560–566. Ouimette, P., Coolhart, D., & Funderburk, J. S. (2007). Participants of first substance use in recently abstinent substance use disorder patients with PTSD. Addictive Behaviors, 32, 1719–1727. Ozer, E. J., Best, S. R., Lipsey, T. L., & Weiss, D. S. (2003). Predictors of posttraumatic stress disorder and symptoms in adults: A meta-analysis. Psychological Bulletin, 129(1), 52–73. Pincus, S. H., House, R., Christensen, J., & Adler, L. E. (2001, April–June). The emotional cycle of deployment: A military family perspective. Journal of the Army Medical Department, 615–623. Pincus, S. H., & Nam. T. S. (1999, January–March). Psychological aspects of deployment: The Bosnian experience. U.S. Army Medical Department Journal, 38–44. Ramchand, R., Karney, B. R., Osilla, K. C., Burns, R. M., & Caldarone, L. B. (2008). Prevalence of PTSD, depression, and TBI among returning servicemembers. In T. Tanielian, & L. H. Jaycox (Eds.), Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery (pp. 87–115). Santa Monica, CA: RAND. Resick, P., & Schnicke, M. (1992). Cognitive-processing therapy for sexual assault survivors. Journal of Consulting and Clinical Psychology, 60, 748–756. Rundell, J. R. (2007). Somatoform-spectrum diagnoses among medically evacuated “Operation Enduring Freedom” and “Operation Iraqi Freedom” personnel. Psychosomatics, 48, 149–153. Sayer, N. A., Chiros, C. E., Sigford, B., Scott, S., Clothier, B., Pickett, T., et al., (2008). Characteristics and rehabilitation outcomes among patients with blast and other injuries sustained during the global war on terror. Archives of Physical Medicine and Rehabilitation, 89, 163–170.

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Schell, T. L., & Marshall, G. N. (2008). Survey of individuals previously deployed for OEF/OIF. In T. Tanielian & L. H. Jaycox (Eds.), Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery (pp. 87–115). Santa Monica, CA: RAND. Schneiderman, A. I., Braver, E. R., & Kang, H. (2008). Understanding sequelae of injury mechanisms and mild traumatic brain injury incurred during the conflicts in Iraq and Afghanistan: Persistent post-concussive symptoms and posttraumatic stress disorder. American Journal of Epidemiology, 167, 1446–1452. Simpson, G., & Tate, R. (2005). Clinical features of suicide attempts after traumatic brain injury: Demographic, injury, and clinical correlates. Psychological Medicine, 32, 680–685. Tanielian, T., Jaycox, L. H., Adamson, D. M., & Metscher, K. N. (2008). Introduction. In T. Tanielian & L. H. Jaycox (Eds.), Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery (pp. 3–17). Santa Monica, CA: RAND. United States Army (2009). Battlemind training. Retrieved June 19, 2009, from https://www. battlemind.army.mil/ Vasterling, J. J., Proctor, S. P., Amoroso, P., Kane, R., Heeren, T., & White, R. F. (2006). Neuropsychological outcomes of army personnel following deployment to the Iraq war. Journal of the American Medical Association, 296, 519–529. Warden, D. (2006). Military TBI during the Iraq and Afghanistan wars. Journal of Head Trauma Rehabilitation, 21, 398–402. Weins T. W., & Boss, P. (2006). Maintaining family resiliency before, during, and after military separation. In C. A. Castro, A. B. Adler, & C. A. Britt (Eds.), Military life: The psychology of servinc in peace and combat [Four Volumes]. Bridgeport, CT: Praeger Security International.

Chapter 9

Psychological Rehabilitation of Ex-combatants in Non-Western, Post-conflict Settings Anna Maedl, Elisabeth Schauer, Michael Odenwald, and Thomas Elbert

Abstract Disarmament, demobilization, and reintegration (DDR) programs are part of most international peace-building efforts and post-conflict interventions in developing countries. Well over a million former combatants have participated in DDR programs in more than 20 countries, the vast majority of them in sub-Saharan Africa. The impact, however, has remained disappointing. A significant portion of ex-combatants suffer from mental-health issues, caused by repeated exposure to severe psychological distress. Individuals with PTSD, depression, substance dependence, or psychotic conditions are heavily impaired in their daily functioning. It is often difficult for them to reintegrate into civilian society, and they are less able to support the process of reconciliation and peace-building within their communities and postwar areas at large. Others, who as child combatants adapted to a culture of violence and aggression, have never been taught the moral attitudes and the behavioral repertoire that are required in peaceful settings. These failures to adjust fuel cycles of violence that might reach across generations. Psychological components of DDR programs are frequently neither sufficiently specific nor professional enough to address reintegration failure and the threat of continuing domestic or armed violence. This chapter presents examples from post-conflict settings, in which specific and targeted mental-health interventions and dissemination methods have been successfully evaluated, including Narrative Exposure Therapy and Interpersonal Therapy. It suggests a comprehensive, community-based, DDR program, which offers mental-health treatment for affected individuals, as well as community interventions to facilitate reintegration and lasting peace.

A. Maedl (B) University of Konstanz, Konstanz, Germany e-mail: [email protected]


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Introduction: Violent Conflicts on a Worldwide Scale Currently 34 large-scale armed conflicts and 3 wars are being fought worldwide (Harbom, Melander, & Wallensteen, 2008). Most of them can be found in non-Western countries, and 13 major wars were recorded in the last decade in Africa alone (Harbom & Wallensteen, 2008). The type of warfare has profoundly changed since World War II. The so-called new wars (Kaldor, 2004) or ‘complex political emergencies’ (Ramsbotham & Woodhouse, 1999) mainly take place as internal conflicts in non-developed countries. Warring factions largely rely on irregular forces, forced recruitments, and the use of fear and violence to gain control over the population and to maintain their power within their own fighting forces. Crimes against humanity, like mass rape, mutilations, and torture, are not an exception, but a deliberate strategy in this context. As a result, the social and economic bases of whole regions are completely destroyed and millions of people are displaced. The UNHCR (2008) estimates that by the end of 2007, about 42 million people had fled their homes from violent conflict. Furthermore, internal conflicts in developing countries tend to be repetitive phenomena, involving neighboring countries in a downward spiral that leads to the continuous suffering of whole regions. Research on the causes of repeated civil war outbreak and duration has identified poverty as one of the main conditions (Collier, 2003; Hegre & Sambanis, 2006). The breaking of the conflict trap is a common theme in current political science and, like the deployment of international peace forces, disarmament, demobilization, reintegration (DDR) programs are tools in this context to prevent re-recruitment of former combatants, to stabilize a country, and to enable peaceful development (Collier, 2003). For peace-building and post-conflict rehabilitation in developing countries, the importance of the individual’s transition from active war participation to civilian life cannot be underestimated. Post-conflict countries are faced with enormous economic problems, which, for the majority of its inhabitants, translate into a daily struggle to meet basic needs. This is a major challenge for ex-combatants, who have to reintegrate into civilian societies.1 It is even more difficult for the large number of those who suffer from war-related psychological disorders, which may seriously impair social relations and the ability to work. The 300,000 child soldiers, who are thought to be deployed in these wars (UNICEF, 2008), and others who were forcefully drafted or were driven to join armed forces by poverty, present an urgent humanitarian call to attend to their plight. Within currently implemented programs, the focus on the rehabilitation of individuals is still weak, compared to the societal, macro-economic, and political perspective of stabilizing a country or region. The metaphor of the ‘trauma membrane’ (Lindy, 1985; Lindy & Wilson, 2001) helps us to understand how communities and individuals struggle to cope with experienced war stressors, in order

1 While in Western countries, the term ‘readjustment’ is frequently used to describe this transition process, the term ‘reintegration’ is used in the international context.

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to manage daily survival in a harsh environment, and how wounds often do not heal under the thin surface of re-established ‘normality.’

Realities of Ex-combatants in Countries Affected by Civil War In countries and regions suffering civil war and violent conflict, about half of the ex-combatants participating in DDR programs belong to rebel movements or irregular forces (Caramés, Fisas, & Luz, 2006) and have served in them for many years of their lives. Although political motives are frequent, ex-combatants often became members of an armed group either because of ethnic relations or in an attempt to earn an income. In some wars, abduction and forced drafting lead to a high number of persons who did not voluntarily become members of an armed group. At the time when individuals enter their first war arrangement, they are often below the age of 18 and qualify as child soldiers. Furthermore, ex-combatants are not only single individuals: behind each person who carries a gun, there are usually family members who live together with the combatants in bush camps. During ongoing conflict, combatants and their dependents face situations of hunger, as well as lack of medical assistance and schooling for children. After the end of the conflict, the basic needs of former combatants and their families rarely are secured. Social-welfare systems (e.g., health insurance, welfare benefits) are often inexistent or inaccessible to former combatants (e.g., because of their status or ethnic background). Further, most returning ex-combatants have no or little access to housing, schooling, vocational training, and medical assistance. They struggle to meet their basic nutritional needs, while the post-conflict communities in which ex-combatants re-settle often offer no job or economic opportunities other than subsistence farming, if agricultural land is available. Many former combatants have no or little education or professional training, but are accustomed to use their weapons to generate income (Arnold & Alden, 2007). Furthermore, former combatants are likely not to have ‘home’ communities to which they can return because they themselves and their families might have lived for decades or for their whole lives in typical war arrangements, such as refugee or IDP camps or non-permanent bush settlements of warring factions. Furthermore, in most post-conflict countries, the general population faces the same harsh conditions as the returning ex-combatants. In order to facilitate peace agreements (i.e., to convince combatants that they will somehow benefit from handing in their guns) and postwar stability (i.e., to avoid the dissatisfaction that can cause former combatants take up their guns again), DDR programs were established. However, tension arose where certain assistance was restricted to ex-combatants, because civilians had the same needs that were not addressed.

Disarmament, Demobilization, and Reintegration Programs Since 1989, disarmament, demobilization, and reintegration (DDR) programs have taken place in the course of international peace-building and post-conflict

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interventions in developing countries, in order to support war-to-peace transition processes (Kingma, 2000a). DDR is also referred to as DDRR (disarmament, demobilization, repatriation/reinsertion, and reintegration) and as DDRRR or DD-triple R (reconstruction, rehabilitation, and reintegration) or as D & R (referring to all the ‘D’s and ‘R’s named). To keep confusion to a minimum, we use the original term ‘DDR’ to refer to all programmed steps in the combatant-to-civilian transition process. In 2005 alone, over a million individuals participated in DDR programs in 20 countries; the vast majority of them were in sub-Saharan Africa (Caramés et al., 2006). The largest single donor of such programs is the World Bank, while several Western states and the European Union also make significant contributions. In 2005, this amounted to about 1,900.00 million U.S. dollars spent on DDR for about 1,129,000 beneficiaries, who participated in DDR programs (Caramés et al., 2006). DDR programs have a number of classical steps that are implemented by international agencies, in cooperation with national bodies (e.g., a demobilization commission) and NGOs. The typical first steps are to collect the combatants’ weapons (disarmament), to gather the combatants in encampment areas and formally discharge them from their fighting unit (demobilization), and finally to settle them in selected communities with the aim to re-engage them in civil life (reintegration). Repatriation specifies the process whereby former combatants are brought back to their countries of origin, when warring factions have crossed international borders. When ex-combatants are transferred to their new communities (i.e., reinsertion), they usually receive a ‘starter kit’ with essential tools and items (e.g., a hoe, soap, cooking pan, and blanket) and/or a cash payment to support them in their first weeks and months of living as a civilian. Sometimes, in these first months or during the encampment phase, ex-combatants are offered reintegration programs that especially aim at building up an economic base for the individual. Reintegration has been defined as ‘. . .the process whereby former combatants and their families are integrated into the social, economic, and political life of civilian communities. . .’ (Knight & Ozerdem, 2004, p. 500). Reintegration refers to a number of typical program tools that are designed to help former combatants and their families start such a civilian life. They usually include training opportunities, such as vocational training courses, rural reintegration components, micro-credit schemes, integration into government forces, or pension schemes for elderly or beneficiaries with disabilities. Up to today, the reintegration component in DDR remains the weak point (Mogapi, 2004) due to a number of reasons. First of all, reintegration is part of the overall process of conflict transformation and reconciliation, which is needed after a large-scale violent conflict. It is thus interwoven with the countries’ overall societal and economic recovery. While the success of a DDR program might depend to a large extent on these two processes, these processes cannot easily be influenced by DDR itself (Ayalew, Dercon, & Kingma, 2000; Kingma, 2000a). Furthermore, reintegration is a long-term endeavor, which requires a long-term commitment, financial and otherwise, by the donor community and DDR agencies (also see ‘Brahimi Report’; UN, 2001). Finally, a number of factors, and especially mental-health problems, can impair individuals’ reintegration success (Kingma, 2000a). Typically, child combatants, female veterans, or ex-combatants

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with disabilities have a particularly high risk to be left out or marginalized by international programs in the reintegration process (Colletta, Boutwell, & Clare, 2001). They are especially vulnerable for reintegration failure. Only in recent years, the needs of these vulnerable groups and the fact that ex-combatants in postconflict countries suffer from psychological problems have been recognized. The acknowledgment that many of them are unable to profit from standard reintegration tools, due to severe psychological distress, daily malfunctioning, and gender-based discrimination led to the inclusion of special program steps for this group.

Mental Health of Ex-combatants in Post-conflict Settings Currently, there is very little empirical information on the mental health of active and former combatants in countries affected by armed conflict and organized violence. However, increasing evidence suggests that years after the end of a war, a large proportion of former combatants are impaired in their everyday functioning, due to war-related psychological disorders. For many, the psychological wounds of war actually never heal, but get even worse over time or lead to a breakdown in a severe psychiatric disorder and in dysfunctional behavior. As summarized below, traumarelated disorders are common and, in combination with drugs, may lead to a spiral of worsening conditions. For example, in a large cross-sectional household survey involving 4854 randomly selected persons of the general population of Hargeisa, Somaliland, we found that 12 years after the end of the liberation war and 6 years after the last fighting, 16% of the ex-combatants were severely impaired by complex psychological suffering, mostly severe psychotic disorders intermingled with drug abuse, trauma-related disorders, and emotional problems (Odenwald et al., 2005). In most cases, uncontrollable behavior, like aggressive outbreaks, led to the situation that helpless family members had chained them for years to concrete blocks or trees in their compounds or that they had ended up in prison. Among the male adult population, we compared former combatants with civilian war survivors and persons who never had been confronted with war (i.e., those who managed to flee abroad before the war). The 8% rate of male civilian war survivors with severe mental disabilities was only half of that of male ex-combatants and reached less than 3% in those without direct war exposure (p = 0.007). Most ex-combatants had never received adequate medical treatment for a sufficient period of time. We believe that this study shows an end point of the postwar mental decline for the subgroup of the most severely affected persons, in addition to a sizeable group of less affected individuals, e.g., those who maintain a certain degree of functioning despite war-related problems such as PTSD or major depression disorder. These two disorders, in combination with substance abuse/dependence, are generally considered the most frequent consequences of war-related traumatic experiences (also see Chapter 5). PTSD involves three clusters of symptoms: (1) unwanted memories in the form of intrusions, like flashbacks and nightmares; (2) avoidance of reminders of the

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traumatic event, which includes feeling of numbness (avoidance of bodily reminders); and (3) permanent readiness to initiate an alarm response, resulting in sleeping difficulties, alertness, and hyper-reactivity. Further somatic symptoms, like tension headache, are very common. A few studies demonstrate prevalence rates between 16 and 60% of PTSD among different groups of former combatants in post-conflict countries (Bayer, Klasen, & Adam, 2007; Johnson et al., 2008; Odenwald, Hinkel et al., 2007; Okulate & Jones, 2006; Seedat, le Roux, & Stein, 2003). In reintegration programs, ex-combatants with PTSD are considered a specially problematic group, because they have difficulty in concentrating, are easily hyper-aroused and aggressive, and are unable to establish and maintain social and intimate relationships (Mogapi, 2004). Among civilian survivors of war, PTSD prevalence rates are usually somewhat lower than among ex-combatants. In a large household-based survey (N = 3323) in the West Nile, some of us (Karunakara et al., 2004) estimated the population prevalence of PTSD to be 48% in Southern Sudan, 46% for Sudanese refugees, and 18% for West Nile Ugandan nationals. De Jong, Scholte, and colleagues (De Jong et al., 2001; De Jong, Scholte, Koeter, & Hart, 2000; Scholte et al., 2004) found that 37% of the civilian respondents fulfilled the diagnosis for PTSD in Algeria, 28% in Cambodia, 18% in the Gaza, and 20% in Eastern Afghanistan. The experience of one or a few traumatic events is usually not sufficient to elicit a PTSD (Kolassa et al., 2010). However, the likelihood of suffering from this disorder increases with each traumatic event that one experiences in one’s life (Mollica, McInnes, Poole, & Tor, 1998; Neuner, Schauer, Karunakara et al., 2004; Schauer et al., 2003; Steel, Silove, Phan, & Bauman, 2002). Our group (Neuner, Schauer, Karunakara et al., 2004) found that there is a strong correlation between the cumulative exposure to traumatic stress and PTSD prevalence: in refugees who report more than two dozen traumatic events, the prevalence reaches 100%. This dose–effect relationship of cumulative exposure makes ex-combatants and other persons living in areas of ongoing conflict or instability a highly vulnerable group, as they are exposed to a high number and remarkable diversity of traumatic stressors. Furthermore, studies from Western countries, such as with WWII veterans or political prisoners, found that PTSD has a high long-term stability – up to 40 years after the trauma (Bichescu, Neuner, Schauer, & Elbert, 2007; Bichescu et al., 2005; Lee, Vaillant, Torrey, & Elder, 1995) (Table 9.1). Though PTSD is the most extensively studied psychological consequence of war, it is clearly not the only one. Often survivors also suffer from depression, suicidal ideation, drug abuse/dependence, and other anxiety disorders (Baingana & Bannon, 2004; Bhui et al., 2003; Bichescu et al., 2007; Bichescu et al., 2005; Catani, Jacob, Schauer, Kohila, & Neuner, 2008) or psychosis (Davidson, Hughes, Blazer, & George, 1991; Odenwald et al., submitted), as well as numerous medical conditions (Boscarino, 2006; Neuner et al., 2008). Ex-combatants with PTSD have usually a higher prevalence of these co-occurring disorders than others who have survived the war theater (Keane & Kaloupek, 1997; Kulka et al., 1990; Lapierre, Schwegler, & Labauve, 2007), and this seems to be the case in all war-related scenarios investigated (Boscarino, 2006; Johnson et al., 2008; Odenwald, Lingenfelder et al., 2007). Although not fully understood, there is some evidence that the development of

ECOMOG missions 1990–1994

Internal violence since 1986 Internal and cross-border war/violence since 1997 Ongoing peacekeeping duty

Internal War 1988–1991

Internal and cross-border war 1976–1992

1989–2004 internal violence and cross-border war

Nigeria

Northern Uganda

Somalia

Mozambique

Liberia

a Conflict

to which study relates

South Africa

Eastern DRC, Uganda, and Rwanda

Conflicta

Country

Johnson et al. (2008)

Odenwald, Lingenfelder et al. (2007) Boothby (2006)

Seedat, le Roux, & Stein (2003)

Bayer et al. (2007)

Ertl et al. (2007)

Okulae & Jones (2006)

Study

Former combatants (40.4% DDR participants)

Active soldiers of the South African National Defense Force Veterans on government payroll Child soldiers

Veterans with traumatic experiences in in-patient treatment Former child combatants Former child combatants

Group

Yes

No

No

No

No

No

No

Representative?

549

39

62

198

169

40

878

N

Not assessed

17%

Not assessed

2.5%

Not assessed

% MDD

Widespread psychological distress reported, no DSM diagnosis 57% 52%

16%

26%

35%

12.5%

22%

% PTSD

Table 9.1 PTSD and depression rates in different samples of (ex-)combatants in non-Western post-conflict countries

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major depression and other psychiatric disorders after an exposure to a traumatic event is not independent of PTSD (Breslau, Davis, Peterson, & Schultz, 2000; North et al., 1999; Prigerson, Maciejewski, & Rosenheck, 2002). Drug use and abuse often develops as a means of coping with PTSD (Chilcoat & Breslau, 1998; Shipherd, Stafford, & Tanner, 2005); this is also the case in war-torn countries (Maslen, 1997). Gear (2002) notes that substance abuse can be seen as a way to escape the emotional burden associated with extreme poverty and unemployment, at the same time as being an attempt to cope with trauma-related symptoms, that is, as a form of self-medication. In several samples of Somali (ex-)combatants, we found that those with PTSD use more drugs, especially those who indicate that drug use helps to forget stressful war experiences (Odenwald et al., 2009; Odenwald, Lingenfelder et al., 2007). The main drug (ab)used in Somalia is the leaves of the khat shrub that contain amphetamine-like cathinone. In these studies, we clearly demonstrated that PTSD led to higher khat intake and this, in turn, led to a higher risk for the development of psychotic symptoms such as paranoia. In summary, the response to war-related trauma by ex-combatants in countries directly affected by war and violence is complex and frequently leads to severe forms of multiple psychological disorders.

Psychological Malfunctioning and Reintegration Success From the data presented above, it is evident that large numbers of ex-combatants suffer from psychological conditions with different levels of severity, causing a varying degree of impairment in functioning on a daily basis. It can also be assumed that the chances of successful reintegration into the wider community are severely jeopardized by psychological consequences of war and violence. Difficulties at the Level of the Individual Psychological malfunctioning for many ex-combatants means that they are unable to take care of themselves and/or provide for their families, to establish and sustain social relationships, or to contribute to income generation. Savoca and Rosenheck (2000) found for U.S. veterans that substance abuse as well as PTSD, anxiety disorders, and major depression are associated with significant negative effects on employment: U.S. veterans with these disorders were less likely to be employed and if so earned significantly less. Prigerson, Maciejewski, and Rosenheck (2002) found that combat exposure itself has a direct negative effect on employment, which was not mediated by a psychiatric condition. Employment possibilities are already very scarce in postwar societies, and Heinemann-Grüder, Pietz, and Duffy (2003) and Gear (2002) report that finding a job is even more difficult for ex-combatants. Mogapi (2004) reports from the South African DDR program that ex-combatants, who suffer from trauma spectrum disorders, have noticeable difficulties on the job, such as concentration problems and aggressive reactions in difficult situations, which eventually lead to job loss.

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In turn, the situation of unemployment can cause feelings of helplessness and thus aggravate symptoms of depression. High rates of unemployment are common in postwar societies and thus, it would be unrealistic to expect the creation of thousands of jobs for ex-combatants in the framework of rehabilitation programs. It is therefore all the more important to not only facilitate the development of excombatants’ professional skills but also help them become psychologically fit, in order to compete in the job market and to gain the ability to bear setbacks. Thus, psychological rehabilitation efforts in DDR programs are mandatory, in order to reduce clinically significant suffering and to remedy dysfunctional behavior, and thus to allow ex-combatants to become proactive and full civilian members of society. Difficulties at the Level of the Family and Community U.S. veterans with PTSD display increased impulsive aggression toward their intimate partners (Byrne & Riggs, 1996; Jakupcak et al., 2007), as well as strangers (Begic & Jokic-Begic, 2001; Silva, Derecho, Leong, Weinstock, & Ferrari, 2001). In addition, increased alcohol consumption has been shown to increase physical violence (Savarese, Suvak, King, & King, 2001). Findings on the relationship between alcohol abuse and inter-family violence among civilians in Sri Lanka indicate a significant link between fathers’ alcohol intake and maltreatment toward their children (Catani, Schauer, & Neuner, 2008). Our research has shown patterns of high psychological disorders in parents and children of survivors of the conflict in North-Eastern Sri Lanka. A significant finding in this data set is the highly elevated rate of family violence to which these children are exposed. In our sample in Afghanistan, we found a similar pattern of increased postwar violence in the family, which presents additional adverse factors of vulnerability (Catani, Jacob et al., 2008; Catani, Schauer et al., 2008). On the communal level, the reintegration of ex-combatants is a reciprocal process that happens within the host communities where the former fighters are settled. The attitudes of the host communities toward the ex-combatants are of particular importance for reintegration success (Kingma, 2000a). In some cases, because of assumed or actual abusive violence that combatants have perpetrated against civilians during war times, the attitudes of host communities toward former combatants are negative. Psychiatric distress and malfunctioning, especially when expressed as outward aggression, irritation, or acting out of intrusions (e.g., flashbacks, dissociation), further exacerbate ex-combatants’ difficulties in reintegrating into communities and the wider society. Ex-combatants, who are suffering from psychiatric distress, might face double stigmatization for having engaged in combat and for being noticeably psychologically affected. In the United States, attitudes of the home environment were found to have a high impact on the ex-combatants’ ability to cope with war and trauma and the subsequent development of psychological disorders. This effect has been conceptualized as ‘home-coming reception’ (Fontana & Rosenheck, 1994; Johnson et al., 1997). Individuals belonging to a faction that was very abusive toward civilians during the civil war in Sierra Leone had a significant negative effect on reintegration (Humphreys & Weinstein, 2005). However, the impact of

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psychological problems was not measured. One common fear of local communities is that newly arriving ex-combatants might engage in criminal activities. Collier (1994) showed that in rural Uganda, those communities in which ex-combatants had no access to land where they could grow food were affected by a short period of increased criminality after the arrival of demobilized ex-combatants. This result should implicate that reinsertion assistance to ex-combatants is important for the integration into communities. This assertion is supported by other reports that indicate that unemployed demobilized ex-combatants turn to criminal activities, such as drug trafficking, in order to survive (UNODCCP, 1999). Social isolation and the formation of ex-combatants as a distinct civilian subgroup are consequences of the combined effects of factors, which include host communities’ negative attitudes toward ex-combatants and the ex-combatants’ psychological problems causing difficulties in social interaction. Hagman and Nielsen (2002) warn that when ex-combatants see themselves as such a distinct group, their reintegration is further impeded and might cause them to continuously call for special benefits and economic support, which in turn provokes envy and the feeling of injustice among the civilian population (i.e., that former ‘perpetrators’ receive benefits while the former ‘victims’ are left without support). Furthermore, the risk of re-recruitment is high when ex-combatants fail to reintegrate economically and socially into their new host communities. In war-to-peace transition periods, economists point toward the ‘peace dividend,’ which refers to the additional growth of the national economy when a war finds its end. While this is mostly associated with increased influx of external aid money and the reduction of the defense budget, it should also contain the new economic activities and energies that come from individual and collective actors who have previously engaged in the war and its economy. When a large number of former combatants and of civilians are affected by war-related psychological problems, however, the opportunity to initiate substantial economic development, and thus increase the standard of living, might be substantially reduced. In sum, the social and traumatic stress caused by war and violence has severe negative impacts for the reintegration of ex-combatants on several levels. Rehabilitative efforts on all related levels are needed to increase the successful reintegration of former combatants into civil society.

War-Related Stress and the Cycle of Violence The extent and duration of many conflicts, as well as the repeated occurrence of mass violence in certain regions, suggest that large-scale violence occurs within cycles. The risk for new conflicts has been found to be higher in regions with a history of recent conflict, compared to regions that benefited from peace and stability for many years (Collier, 2003). Opportunity factors, like the availability of weapons, cannot fully explain this relationship; rather, psychological and societal consequences of war have to be taken into account. Where ex-combatants fail to reintegrate into society, the consequences are far reaching for the entire post-conflict

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region (Keen, 2008). It is well known that good economic and societal conditions and the participation of large parts of the population as active members of civil society are important for political stability and peace. A most likely, but largely unstudied, driver of the cycle of violence might be the detrimental impact of massive violence on individuals’ psychological functioning and the related social dynamics and consequences for communities. Reconciliation and peace-building might be impeded or blocked by the psychological problems of a critical mass of individuals. In particular, large-scale violence may cause distorted patterns of emotional and cognitive processing, which might feed into further violence. War-related severe stress, even though transient, indelibly changes an individual on various levels (Elbert et al., 2006). On a cognitive level, traumatic experiences shatter the most fundamental beliefs about safety, trust, and self-esteem, which lend instability and psychological incoherence to the individual’s internal and external worlds (Janoff-Bulman, Berg, & Harvey, 1998). As a consequence of a shattered belief system, the world is perceived as basically unsafe, frightening, and evil. Victims feel weak, dependent, and without the control and competence that is vital for the psychological and cognitive coping with the environment. Furthermore, war-related psychological stress has a profound impact on individuals’ view on reconciliation and feelings of revenge. Bayer et al. (2007) showed that former Ugandan and Congolese child soldiers with PTSD were less open to reconciliation and had more feelings of revenge than former child soldiers who did not suffer from PTSD. A recent epidemiological survey in Rwanda (Pham, Weinstein, & Longman, 2004) also confirmed a relationship between exposure to traumata, PTSD, and specific attitudes toward violence and reconciliation: Respondents with PTSD were less likely to trust the community and socially interact with other ethnic groups. In former Yugoslavia, Basoglu et al. (2005) also found that PTSD severely impedes processes of reconciliation and reintegration: War survivors, who were exposed to war-related traumata, displayed stronger emotional responses to perceived impunity of those held responsible for the trauma, including anger, rage, distress, and desire for revenge, than those who did not experience war. Moreover, traumatized survivors showed less belief in the benevolence of people and reported demoralization, helplessness, pessimism, fear, and loss of meaning in and control over life. Although unstudied, individuals with PTSD might be especially vulnerable to accepting simplistic models of ‘good versus bad,’ a black and white worldview, which is a known cognitive distortion. First support of this idea has been reported by our group (Glöckner, 2007) in interviews of former child soldiers, who had been formerly abducted by the Ugandan Lord’s Resistance Army. We found that children’s identification with the armed group was stronger the more time they spend in abduction; time spent in the bush was also a predictor for psychological suffering. Furthermore there is evidence that traumatic experiences not only affect the individual but can also be transferred to the next generation. For survivors of organized violence such as the Jewish Holocaust in Germany or the Turkish-Armenian genocide in the early 1900s, the impact of traumatization was evident even in the second and third generations (Rowland-Klein & Dunlop, 1998; Shmotkin, Blumstein, &

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Modan, 2003; Sigal & Weinfeld, 1987; Sorscher & Cohen, 1997). However, there is a lot of controversy around these hypotheses (Kellermann, 2001; van Ijzendoorn, Bakermans-Kranenburg, & Sagi-Schwartz, 2003). Also, the transgenerational influence of trauma on reconciliation and the feelings of revenge have not yet been studied, except for some reports on psychological distress in children. Daud, Skoglund, and Rydelius (2005) showed that children of torture survivors presented with attention deficiency, anxiety symptoms, as well as non-adaptive behavior, and depressive and post-traumatic stress symptoms. Similarly, Yehuda, Bell, Bierer, and Schmeidler (2008) emphasize that the transgenerational transmission of trauma can manifest not only in PTSD symptoms but in depression and other disorders, such as anxiety and substance abuse. However, understanding the mechanisms of transgenerational transmission of trauma-related psychological disorders requires further research. The bodily and cerebral alterations caused by repeated frightening and lifethreatening experiences may become engrained in the genetic regulation: epigenetic factors that regulate the potential for anxious behavior and its inhibition may be set during pregnancy in the offspring, if the mother was confronted with chronic stressful or life-threatening events. The structure and functioning of the brain, including the immunological and hormonal stress-response systems of the offspring, seem to be tuned to a mode of ‘survival preparedness.’ Once a distinct epigenetic pattern has been set, it may persist across further generations, even if they develop under safe conditions (Meany & Moshe, 2005). In summary, research suggests that the psychological consequences of organized violence will obstruct postwar recovery and feed into new cycles of violence for current and future generations.

Attempts to Cope with Psychosocial Problems in DDR Today, most DDR programs aim to address vulnerable groups, as well as the mental health of all DDR participants. Table 9.2 covers six major DDR programs, which taken together account for two-thirds of all beneficiaries in 2005 (Caramés et al., 2006). All these programs had separate components for people with disabilities, female, and underage ex-combatants. Only Eritrea did not demobilize child soldiers, because the DDR program focused on its own army, and Liberia did not have a special program for ex-combatants with disabilities. Other programs, however, which did have programs for people with disabilities, did not always recognize severe psychiatric conditions as a disability. All programs offered psychosocial components. Most programs include some form of programmatic responses to the excombatants’ inability to make use of the standard reintegration tools, such as using pension schemes or increased monetary support in the reinsertion or reintegration phase for those with disabilities. In most cases, the additional benefits granted to excombatants with disabilities are typically not sufficient to provide for sheer survival.

Angola

Country

1975– 2002

Conflict (latest) from – to

União Nacional para a Independência total de Angola (UNITA) Government forces

Conflict parties 04/2002– present

DDR from–to 138,000 From which: 105,000 UNITA, 33,000 government forces

Number of beneficiaries targeted Single payment, micro-credit support, employment in infrastructure rehabilitation, vocational training, business training and business advisory services, job placement, agricultural support to gain self-sufficiency

Economic reintegration modules Trauma counseling, psychosocial care, traditional ceremonies For children: recreational activities, community-based support network, family tracing and reunification

Psychosocial modules

Table 9.2 Examples of current demobilization programs in sub-Saharan Africa

Porto, Parsons, & Alden (2007) n = 603 (574 male, 29 female, UNITA DDR participants and non-participants) Self-report instrument and focus groups No assessment of mental-health status

Examples of follow-up studies on reintegration success


Burundi

Country

1996– 2002


Conseil National pour la Défense de le Démocratie/ Force pour la Défense de le Démocratie, Forces Nationales de Libération – Parti pour la Libération du Peuple Hutu and other rebel groups Government forces


DDR from–to 85,000 From which: 21,500 paramilitary

Number of beneficiaries targeted Integration in armed forces, cash payments in installments, in-kind support, on-the-job and professional training, support to selfemployment, access to national reconstruction and employment creation programs, access to land, formal education For children: formal education

Economic reintegration modules


Community sensitization, fostering reconciliation with community For children: community preparation, support to vulnerable biological families, support to communitybased care arrangements, provision of community-based psychosocial support


Uvin (2007) n = 63 (60 male, 3 female, DDR participants and non-participants) Qualitative interviews No assessment of mental-health status


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DR Congo

Country

Ongoing


Maï-Maï, Forces Démocratiques de la Libération du Rwanda (FDLR), Rally for Congolese DemocracyKingsanganiMovement for Liberation (RCD-K/ML; including all splinter groups) Government and UN forces


DDR from–to 150,000 Congolese nationals (combatants on foreign soil managed by separate programs)

Number of beneficiaries targeted Integration into government forces, single payment, starter and shelter kit, production kit, vocational training, income generating activities, access to micro-projects, employment in infrastructure rehabilitation, humanitarian aid to host communities For children: minimal education, skills-oriented training



Psycho-social support, community sensitization For children: recreational activities, religious activities, family tracing, community building, sensitization and training, family tracing


Molina (2007) n = 364 (362 male, 2 female, all DDR participants) Questionnaire No assessment of mental-health status



1998– 2000

1999– 2003

Eritrea

Liberia

Country


National Patriotic Front of Liberia, Liberation Movement for Democracy in Liberia Liberians United for Reconciliation and Democracy (LURD), Movement for Democracy in Liberia (MODEL) Government forces (& ECOMOG?)

Eritrean and Ethiopian government forces

Conflict parties

12/2003– present

10/2002– present

DDR from–to

107,000 From which: 15,600 pro-government paramilitary

200,000 government forces and paramilitaries

Number of beneficiaries targeted Monthly payment for 1 year, grants, on-the-job training, job placement, agricultural settlement projects, business startups Payment in two installments, micro-loans, formal education, vocational and professional training, agricultural training, work in public sector



Counseling, reconciliation, traditional rituals, community sensitization, For children: family reunification

Counseling


Pugel (2007) n = 590 (471 male and 119 female, DDR participants and non-participants) Questionnaire No assessment of mental-health status, attempt to measure self-esteem as proxy for psychological reintegration

?


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1991– 1999

Country

Sierra Leone

Revolutionary United Front, Civil Defense Force (Kamajor) Government forces

Conflict parties 10/1999 – 01/2002 (01/2005)

DDR from–to 72,500

Number of beneficiaries targeted Psychosocial modules

Reintegration into Social and trauma armed forces, cash counseling payments, rural integration support, vocational training/ apprenticeship, formal education, agricultural support, job placement



Humphreys & Weinstein (2005, 2007) n = 1043 (935 male, 108 female, DDR participants and non-participants) Questionnaire No assessment of mental-health status



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In countries where the general population lives in extreme poverty, the assistance paid to ex-combatants is typically not thought to put them in a better economic position. Psychosocial counseling is often implemented in the context of DDR. This refers to a ‘talking intervention’ by specially trained staff (‘counselor’ or ‘therapist’) to assist individuals or groups of individuals (‘clients’) by listening to their problems, providing emotional support, and giving information. Typical topics for counseling are orientation talks to prepare for periods of transition (e.g., career change), HIV/AIDS, managing one’s DDR benefits, or even psychological problems, like PTSD or drug abuse.

Vulnerable Groups Some groups of beneficiaries are considered especially vulnerable because they have a higher burden and worse starting conditions in the reintegration process. Usually, the following groups are treated with special attention within DDR programs: former child combatants and abductees2 (Kingma, 2000b; Verhey, 2001), female ex-combatants (De Watteville, 2002), as well as ex-combatants with disabilities, like those with physical or psychiatric disorders (Ayalew et al., 2000; Bieber, 2002; Ejigu & Gedamu, 1996; Gear, 2002; Mehreteab, 2002; Mogapi, 2004). In most DDR programs, resources are very limited. The emergency character of DDR leads to support structures, which are often designed as temporary institutions – although services to support the rehabilitation and reintegration of vulnerable groups are needed with a long-term focus (Colletta et al., 2001). Such programs and services are even more necessary, because in most resource-poor countries, the majority of the civilian population is equally in need of psychological rehabilitation support, and adequate national mental-health services and structures are missing. Although it is frequently recommended to link emergency interventions to longterm socioeconomic development measures, most DDR programs do not manage to cross short- and medium-term perspectives. Annan, Blattman, and Horton (2006) suggest a shift in attention from large-scale programming to programs for the most vulnerable groups, while Caramés et al. (2006) estimate that only 1–5% of DDR budgets is allocated to children, women, and persons with disabilities altogether. Child Combatants and Children Associated with Armed Groups International organizations estimate that about 300,000 children and adolescents (under the age of 18) are abused as child soldiers on a worldwide scale. Children are recruited by ‘regular’ armies or abducted by irregular armed groups for a multitude

2 To avoid stigmatization and the exclusion of children who might not have carried a weapon, the literature also refers to this group as ‘children associated with fighting forces’ or ‘formerly abducted children.’

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of tasks and/or they are dependants of combatants. While some are forced to take part in combat, others have to work as messengers, domestic servants, carriers of heavy loads, and/or sexual slaves. When children are recruited or abducted at a young age into rebel groups or military structures, their natural, healthy development will be impaired and a multitude of physical, psychological, and mental problems will result. Furthermore, early recruitment prevents the young from regular schooling and training, learning social rules and norms, building peer networks, and acquiring the skills for healthy, intimate relationships. Although the UN principles on children associated with armed forces, known as the Paris Principles (UN, 2007), clearly demand specialized psychosocial care for children at all stages of the DDR process, the current approaches in reality focus on brief vocational training, family tracing, and reunification. It is often assumed that if a child lives with his or her family again, the psychological wounds will automatically heal. This is, however, not the case for many children who suffer from severe mental distress and are in need of specialized care (Annan et al., 2006) (Box 9.1).

Box 9.1 Case Study – Uganda For more than 20 years, the conflict in northern Uganda between the LRA (Lord’s Resistance Army) and the Ugandan government led to thousands of deaths and the internal displacement of about 1.6 million civilians. An estimated number of 25,000 abducted children were involved as forced fighters, porters, and sex slaves on the side of the rebels. Annan, Blattman, and Horton (2006) found in their Survey for War Affected Youth in Uganda that about one-quarter of the children and youth in northern Uganda, whether formerly abducted or not, suffered from high levels of emotional distress. In most of the formerly abducted children in Uganda, PTSD is accompanied by signs of depression, substance abuse, as well as severe personality and developmental disorders (Amone-P’Olak, 2005; Derluyn, Broekaert, Schuyten, & De Temmerman, 2004; Magambo & Lett, 2004). In a large research project by the international NGO vivo and the University of Konstanz, Germany (Biedermann, 2007; Glöckner, 2007), the PTSD prevalence rate reached 12.5% in reception centers, a major depressive episode was diagnosed in 2.5%, and suicide risk was present in 17.5% of the 40 interviewed formerly abducted children. Nevertheless, there were strong hints that a full-blown picture of PTSD might emerge in many of the children after having left the reception center, once they were reintegrated back in the community. Therefore, a trauma-focused treatment, namely narrative exposure therapy (NET), was initiated for formerly abducted children with PTSD diagnosis, as well as abductees not presenting with a diagnosis. Expert follow-ups after 3 months and 1 year revealed very positive effects of NET in reducing the PTSD symptom load in formerly abducted children with PTSD. Furthermore, a randomized controlled prevention trial showed the tendency that NET is

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even capable of reducing sub-syndromal PTSD symptom load, suggesting a preventative effect. These results confirm that thorough, high-quality screening is the key to identifying former child soldiers with PTSD, as well as sub-syndromal cases at high risk for developing PTSD. Women Only in recent years, women were included in DDR programs. Women, who are associated with armed groups, are either female combatants (although they are often a small group), dependants of male combatants, or abducted women kept in slavery. The women (both combatant and non-combatant) assume domestic duties in the group, and many are forced to serve as wives or sexual slaves. Because many women are abused and raped by armed forces, such as in the Eastern DRC, special support programs outside DDR have begun to emerge. Returning women, who are perceived to have had sexual relations with other combatants – whether by force or by voluntary choice – and/or who bring back children from such encounters, belong to the most stigmatized group of survivors. In many non-Western cultural settings, they are unable to get married or find a new supportive partnership, within which to bring up their children in civilian life. It is important to understand that for female ex-combatants, demobilization is often linked to a change in their gender role and identity, which is accompanied by a loss of decision-making power and self-sufficiency. Though many female combatants suffer sexual abuse (Engdahl, de Silva, Solomon, & Somasundaram, 2003), they are at the same time freed from patriarchal gender roles to a certain degree (UNDP & UNFPA, 2006). After they leave their fighting faction, many women ex-combatants settle in urban centers to escape pressure from their families and communities to once again fit into discriminatory roles (Mehreteab, 2002). Unfortunately, this often alienates them further from society and frequently leaves them in poverty and socially isolated, which once again acerbates the psychological problems caused by organized violence. Women combatants need special reintegration tools, which take into account that they need to make their living in a society that most definitely will discriminate against women. To date much has been written about and little has been done in taking gender-differentiated needs in DDR seriously (De Watteville, 2002). Particular attention has to be paid to women ex-combatants and victims of sexual violence and/or gender-based violence. Furthermore, cultural attitudes toward widows and culturally appropriate ways of respecting and seeking the views of women have to be developed (Box 9.2).

Box 9.2 Case study – Angola The Angolan Demobilization and Reintegration Program (ADRP) is funding a business training and micro-finance project for 400 widows and female

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ex-combatants. Nearly 3,000 women ex-combatants or women associated with ex-combatants are receiving reintegration support under the project. While a relatively small percentage of registered ex-combatants are women (3%), the project caters to women associated with the fighting forces and other vulnerable women in the communities where ex-combatants have settled. In their report ‘Struggling Through Peace: Return and Resettlement in Angola,’ the Human Rights Watch (2003) expressed concern that the DDR process excluded women, in particular the wives and widows of former UNITA combatants, women abandoned by UNITA combatants, and women and girls abducted during the war and forced to join UNITA forces as ‘wives,’ porters, or in other functions. These women are still suffering the social and psychological effects of the war.

People with Disabilities and the Elderly After the end of an armed conflict, there are usually large numbers of people with disabilities or elderly ex-combatants who are not able to survive on their own. In the course of demobilization, they typically lose their means of living, such as salary and group membership first, because armed groups have an interest in discharging this group of persons quickly. Due to their disability or age, they might not be able to participate in standard reintegration programs. Nowadays, the standard intervention for people with disabilities or elderly ex-combatants is to offer additional payments, such as pension schemes or compensation payments. Often DDR programs do not have the financial resources to address the disability itself, such as offering treatment or rehabilitation. Less severe cases can profit from counseling opportunities, but the solutions for the most severe cases are usually unsatisfactory. A referral service to adequate medical treatment or counseling services is in most cases absent. This is also true for the local civilian population of landmine survivors and war-wounded individuals. Furthermore, a referral to services requires an actual functioning and accessible national health sector; because of the destruction of infrastructure and limited government budgets, these services are only very limited. One suggestion is to closely link DDR to development programs, especially because not only former combatants but also civilian war survivors are in great need for such services. At the same time, international organizations have to be aware that war factions might misuse DDR to get rid of their least-fit militias and their obligation to care for them (Box 9.3).

Box 9.3 Case Study – Somalia In Northwest Somalia, the German Technical Cooperation (GTZ) was successfully implementing a reintegration project for former combatants from

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1994 to 1996, when it was interrupted by the outbreak of violence. In April 2000, a new initiative started and was managed by GTZ International Services (GTZ IS). During the implementation of the DDR project activities, it became clear that a significant number of security personnel, who were selected to be demobilized, presented with physical and/or mental impairments. In 2002, the NGO vivo was contracted by GTZ IS, at first, to train local staff to reliably identify potential beneficiaries with mental disturbances in order to exclude them from the pilot program activities. In the course of several consultancies, the original assignment was extended to the development of guidelines on how to deal with beneficiaries, who were mentally affected, within the pilot DDR activities. Studies conducted on Somali ex-combatants found that the group who were severely mentally affected could hardly be integrated into civil life by applying standard DDR tools: about one-third of Somaliland’s armed personnel, who were at that time on government payroll, suffered from PTSD, depression, and other psychological problems. In addition, a total of 16% of all former ex-combatants, on government payroll or not, suffered from severe forms of mental illnesses (mostly psychosis) with complete impairment of daily functioning; psychotic disorders accounted for about 80% of these cases (Odenwald et al., 2005). Furthermore, addiction explained why many ex-combatants failed to successfully participate in standard reintegration (Odenwald et al., 2002). As a response to the needs of this group of ex-combatants, the program piloted additional components, like the treatment of narrative exposure therapy (NET), to reduce war-related traumatic symptoms by trained local project staff. Making use of the strong sense of kinship in Somaliland, caretakers of the most severely psychologically disturbed beneficiaries were invited to participate in the reintegration program, and a traditional religious ceremony was conducted, in order to ensure that they continued to care for their impaired ex-combatant relatives in the future.

Absence of an Evidence Base The major problem with psychosocial tools in DDR programs is that they are usually ill-defined and there is very little evidence of their impact and efficacy. The overall hypothesis is twofold: that DDR programs improve the reintegration success and compensate for the disadvantages of disability. However, no empirical study to date has been conducted to scrutinize the postulated relationship between reintegration success and assistance – whether monetary or psychosocial – among people with disabilities and vulnerable ex-combatants. This, in turn, leads to the situation that recommendations for best-practice interventions for the psychosocial

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reintegration components of DDR programs cannot be defined and that programs cannot be improved on the basis of empirical evidence. But even DDR programs themselves were rarely subjected to impact or outcome evaluation at the micro-level. Very few scholars tried to use empirical research designs and data assessment strategies, which would allow an estimation of the impact of DDR on the reintegration of individual ex-combatants (Ayalew et al., 2000; Collier, 1994; Humphreys & Weinstein, 2005; Stavrou, Vincent, Peters, & Johnson, 2003). All these studies are subject to criticisms, because they were designed as external evaluations, faced enormous organizational difficulties (e.g., keeping track of beneficiaries, motivating them to participate), had a very narrow focus, lacked practical and methodological experience, and defined target outcome variables poorly or limited the outcome variables to proxies for economical success and social networks. None of these studies managed to assess the mental-health status of DDR participants sufficiently.

What Evidence Exists for the Treatment of Psychological Stress in Post-conflict Regions? It has been emphasized in this chapter that the DDR sector, as well as relevant other sectors, has insufficient awareness on the psychological consequences of organized violence and limited capacities to address them and their effects on different levels. Individual ex-combatants and others suffering from mental distress remain speechless, because they are unable to talk about their traumata. They are isolated, and their experiences are not integrated into a societal process of peace-building. Existing psychosocial care is often unspecific, badly defined, ill coordinated, and typically not sufficiently harmonized between different providers, such as NGOs, religious-based initiatives, public health structures, DDR programs. This fragmentation is also reflected in the fact that psychosocial activities may take place without any attempt to conduct impact evaluation and thus without the plan to develop evidence-based best-practice models. The absence of adequate interventions to aid victims of organized violence, including ex-combatants, goes hand in hand with a lack of scientific research and of systematic efforts to introduce evidence-based methods. In order to develop a proposal for a feasible and effective psychosocial intervention within DDR programs, we will therefore first look at evidence-based interventions in similar postwar, low-resource settings.

Implications from Research with Refugees, Genocide Survivors, and School-Based Approaches Because little empirical work exists for the group of former combatants in postconflict regions, it is of interest to examine the experiences of other groups of war-affected individuals, beyond ex-combatants. The following sections will briefly summarize some key experiences and main insights.

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Refugees and IDPs This group often faces similar challenges as former combatants when it comes to returning and reintegrating into home or host communities. Similarly, forced migrants are often extremely burdened by psychological stress (Karunakara et al., 2004; Onyut et al., 2005). In a series of studies in Ugandan refugee camps, at first with refugees from Sudan, later with refugees from Rwanda and Somalia, our group implemented treatment programs that aimed at reduction of symptoms of the trauma spectrum (specifically PTSD and depression) and improvement of everyday functioning. All programs included a screening tool, in order to identify individuals who fulfilled the DSM-IV diagnosis of PTSD. In a randomized controlled trial with Sudanese refugees, clinical experts delivered three sessions of a narrative trauma-focused therapy (narrative exposure therapy [NET], see later) or supportive counseling, such as is employed in many post-conflict zones (Neuner, Schauer, Klaschik, Karunakara, & Elbert, 2004). In a 1-year follow-up, almost all participants were traced and re-interviewed. The PTSD symptom severity of the NET group clearly improved, in comparison to the group that received supportive counseling. And most importantly, significantly more subjects from the NET group had left the refugee camp and had gone back to their home communities, where they were able to grow food or where they found a job in local trading centers and thus did not depend on food aid any more. In a treatment project with refugees from Rwanda and Somalia, all of whom had DSM-IV PTSD diagnoses, local staff was recruited from among the refugee communities and trained to deliver trauma-focused therapies (Neuner et al., 2008). After 1 year, the two active treatment conditions, NET and Trauma Counseling, achieved a clear symptom reduction compared to a monitoring control group; furthermore, participants of the NET group showed an astonishing improvement of their physical health compared to the other groups. Survivors of the Rwandan Genocide Subsequently, our colleagues conducted two randomized controlled trials with orphans, who survived the Rwandan genocide and who fulfilled the DSM-IV PTSD diagnosis (Schaal & Elbert, 2006; Schaal, Elbert, & Neuner, 2009). The first study showed that NET, in contrast to interpersonal therapy, restored functioning and reduced the PTSD rate by 80%. Both treatments improved depressive symptom load in genocide orphans. In a second controlled, dissemination trial, local psychologists were trained to deliver the therapy; they also managed to achieve clear symptom improvement, reducing the PTSD rate by about 60%. The Rwandan psychologists were also instructed to be trainers of NET. The second generation of local therapists delivered treatment to widows of the genocide and achieved an equally clear symptom reduction compared to a control group (Jacob et al., in preparation). School Children in Sri Lanka Several studies report on effective school-based, mental-health programs for traumatized children, which rely on trained teachers (Berger & Gelkopf, 2009; Cox

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et al., 2007; Dybdahl, 2001; Layne, Pynoos, & Saltzman, 2001; Layne et al., 2008; Tol et al., 2008; Yule, 2000; Yule, 2002) or involve mothers (Dybdahl, 2001). During the past decades, children in North-Eastern Sri Lanka were exposed to war between government troops and the Liberation Tigers of Tamil Eelam (LTTE), as well as to the tsunami, which killed tens of thousands of people and destroyed hundreds of villages in Sri Lanka alone. Our group has worked in Sri Lanka since 2002. During the 2002–2006 ceasefire, we found a high PTSD prevalence and related functional impairment among pupils (Neuner, Schauer, Catani, Ruf, & Elbert, 2006). Additionally, domestic violence and physical abuse in families, who were exposed to war and natural disasters, emerged as a wide-spread problem, which further increased the psychological stress of children (Catani, Jacob et al., 2008; Jacob, 2007; Neuner & Elbert, 2007). As part of an evaluation of the implementation of a large school-based, psychological cascade-service structure, two controlled treatment dissemination trials with traumatized children (who had a DSM-IV diagnosis of PTSD, depression, and/or suicidality) were implemented. KIDNET (i.e., narrative exposure therapy for children) and an active meditation–relaxation program were found to be effective in reducing the symptom load in all three categories in a 1-year follow-up (Neuner et al., 2006; Schauer, 2008; Schauer et al., 2007). Therapies were delivered by highly trained teachers (master counselors), who were supported through a close supervision and referral structure. In every school, at least one of the teachers was further trained to recognize trauma symptoms and to carry out first-level social counseling and family support. These ‘befrienders’ were regularly supervised by the master counselors, who took supervision responsibility for several schools. Master counselors, in turn, were closely coordinated by a team of psychologists and psychiatrists from mental-health service institutions in Jaffna, Northern Sri Lanka. This structure allowed skill capacity enhancement, such as trauma and depression treatment, grief counseling, family-based social interventions, as well as awareness-raising campaigns on domestic violence and drug abuse. Successful interventions, like the above, lead us to assume that (a) traumafocused short-term psychotherapy can be successfully delivered in resource-poor conflict zones, (b) local staff (medical and non-medical) can be trained to deliver such treatment, and (c) sustainable (1-year follow-up) symptom reduction can be achieved with individuals suffering from trauma spectrum disorders, who remain living in unsafe and difficult conditions. The improvement of everyday functioning at all levels is an especially significant finding, which strongly suggests that engaging in trauma therapy work with populations in post-conflict settings is effective.

Traditional Rituals and Healing Methods In many countries, psychological suffering is explained and treated in traditional categories with close connection to local culture, ethnic groups, and traditional religions (Harlacher, Okot, Obonyo, Balthazard, & Atkinson, 2006). Often, these rituals seem to have important functions, such as facilitating the reception of ex-combatants in their communities (Annan et al., 2006), helping to

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shift the collective role from a combatant to a civilian, and assisting a coming to terms with the past. Gear (2002) explains that if individuals have participated in traditional rituals to be equipped with special combat powers, then it is important for them to be cleansed of these powers once the conflict is over. He quotes an excombatant, who explains: ‘I have to undergo the same rituals to get rid of it because if I don’t do that, I will always be gun crazy.’ Numerous reports of healing and the subjectively reported helpfulness of traditional rituals for the emotional adjustment of the individual should not lead to the conclusion that there is solid (i.e., more than anecdotal) evidence that these procedures have any lasting effects. Nevertheless, some psychologists and psychiatrists recommend including traditional rituals or cooperating with traditional healers in psychosocial projects (see Engdahl et al., 2003; Stark, 2006). What has been established in the scientific literature is that traditional rituals cannot be considered sufficient treatment, especially for those individuals with severe mental disorders (Annan et al., 2006; Somasundaram, van de Put, Eisenbruch, & de Jong, 1999).

Evidence-Based Treatment Approaches Narrative Exposure Therapy (NET) Since the end of the last century, the international group of mental-health workers and scientists, who later founded the NGO vivo, developed a narrative approach for treating trauma-related psychological disorders in refugees and torture survivors. In their initial work, they encouraged survivors to document the human rights violations that they experienced in detailed reports of their whole lives, from birth to the present. They clearly found that the chronologic, narrative elaboration with a special focus on the most traumatic events created a verbal memory account for formerly ‘unspeakable’ and fragmented memory contents, such as feelings, thoughts, and body sensations (‘hot memory’). This led to remarkable changes: not only did typical symptoms like dissociation, intrusions, sleeping problems, or aggressive outbursts diminish sharply, but the cognitive evaluation changed in the sense that the survivors started to find new meaning in their past. The extension of this approach, including theoretical reasoning, based on cognitive and affective neuroscience models, was published as narrative exposure therapy (NET; Schauer, Neuner, & Elbert, 2005). The first NET therapists learned that the most crucial point is that survivors overcome avoidance and, in doing so, stay emotionally connected in the here-andnow in a safe relationship and setting, while telling and re-experiencing their stories. The emotional closeness with the therapist allows prompt intervention as soon as a barrier between therapist and client starts to appear, that is, if dissociative reactions or intensive reliving occurs, in which survivors are unable to speak. In these moments, clients are supported by therapists so that the connection is re-established. The NET therapist’s attitude is empathic and non-judgmental and, at the same time, guiding and directing as often necessary. The therapist accompanies the client and wants to fully understand; thus, she/he continuously engages, asks, verbalizes, and

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mirrors. Simultaneously, every part of the traumatic event is documented in detail. The narration of the survivor’s whole life is written down and handed over ritually at the end of the therapy. The effectiveness of NET for the treatment of PTSD has been confirmed in a number of studies with child and adult refugees and asylum seekers in Germany (Hensel-Dittmann, 2007; Neuner et al., 2009; Ruf, 2008; Schauer et al., 2006), in the Balkans (Neuner, Schauer, Roth, & Elbert, 2002), in former political prisoners in Eastern Europe (Bichescu et al., 2007), in inhabitants of African refugee camps (Neuner et al., 2008; Neuner, Schauer, Klaschik et al., 2004; Onyut et al., 2005; Schauer et al., 2004), in former child soldiers and internally displaced persons (A. Pfeiffer, personal communication), in genocide survivors (Schaal & Elbert, 2006), and with children in Sri Lanka (Neuner et al., 2006; Schauer, 2008). In these studies, NET produced significant and stable improvement of psychological health – even under conditions of insecurity, such as under camp conditions, in situations when asylum seekers were not safe from forced deportation, and during ongoing conflict. Symptom reduction proved stable beyond 12 months posttreatment, despite a very short active treatment phase (i.e., usually a NET treatment is completed within four to eight sessions, within a timeframe of 2–6 weeks). Non-medical staff could be effectively trained to deliver the NET therapy within an adequate supervision and peer-consulting structure. NET was compatible with the different cultural explanations for psychological suffering. For example, in Uganda, formerly abducted child combatants explained their nightmares and intrusions by the idea that the spirits of the people they had killed were haunting them. Dissociative episodes are usually seen as the spirit of a killed person taking over control of the patient. NET could also be applied across a wide range of ages; the youngest person so far in our research was 6 years of age (a refugee child in Germany) and the oldest was 89 years (a genocide widow in Rwanda). Interpersonal Therapy (IPT) Individuals, who are depressed, generally isolate themselves socially due to the very nature of the disorder. The approach of IPT suggests that depression symptoms are caused by social and interpersonal problems, in particular by grief, interpersonal conflicts, changes of one’s role, and interpersonal deficits (Weissman, Markowitz, & Klerman, 2000). Therefore, the focus of therapy, according to IPT, lies on the evaluation and improvement of interpersonal relationships in order to achieve symptom reduction and to strengthen personal contacts. As a short-term therapy, IPT takes place in a group setting, where proposals to solve specific personal problems are collectively discussed with other therapy participants. Thus, the setting itself already aids in overcoming social exclusion. Therapists are trained to develop treatment goals, together with affected individuals, and do so by expressing warmth and empathy, thereby modeling the positive impact of relationships. IPT has the advantage that it can be applied in a group format (G-IPT) which requires fewer resources. However, it is important to note that while G-IPT has proven some effectiveness in treating depression symptoms in adults in developing

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countries, it does not abate core trauma symptoms. It has been implemented in Uganda (Bolton et al., 2003; Verdeli et al., 2003) and Rwanda (Schaal et al., 2009). However, in contrast to NET, IPT seems to be insufficient to restore functioning in trauma-stricken contexts.

An Evidence-Based, Postwar, Peace-Building Initiative for Rwanda – A Suggestion Rwanda is a small country in central Africa with 10 million inhabitants. Its recent history is overshadowed by the conflict between groups of Hutu and Tutsi, which led to genocide in 1994, during which about 1 million Tutsi and moderate Hutu were killed by extremist Hutu. This massacre ended with the victory of the Tutsi-led rebel faction called the Rwandan Patriotic Front, which seized power in mid-1994. Since then, Hutu and Tutsi militia continue their war in neighboring Eastern Congo (DRC), a war that also involves other armed groups, where they fight over territory and natural resources that are illegally extracted and brought to the world market. In the past years, this conflict claimed 5 million lives in the DRC, mostly among the civilian population. In the mid-1990s, the international community initiated the multi-country DDR program in this region to contribute to peace and stability by demobilizing (amongst others) Rwandese fighters in the DRC, repatriating them to and reintegrating them into Rwanda. On request of the Rwandan Commission for the Demobilization of Former Combatants, we proposed a psychological rehabilitation strategy that may assist the peace-building in this complex conflict. The following outline is based on a commissioned piece of work that our group delivered to the World Bank in 2007 (Multi-Country Demobilization and Reintegration Program, 2008). Because trauma-related processes involve the individual, the community, and the whole society and because individual healing is strongly related to communal and societal processes and vice versa, we proposed interventions on all these levels. Our experiences with survivors clearly show that at the community level, counseling centers with trauma counselors, social workers, and nurses can be established, for example, within existing rural health-care centers. Counseling services should be open and accessible to all trauma-affected members of society, including children, adults, victims, perpetrators, civilians, and ex-combatants. These centers can facilitate individual healing. The centers’ staff should be trained in standardized diagnostic procedures and manualized, evidence-based interventions (such as NET, in combination with IPT). The most diverse life experiences of clients should be documented with the help of NET. At the level of the local communities, trained center staff and elected community leaders should be encouraged to actively carry out public awareness-raising activities to promote the reintegration of ex-combatants. At the district level, master counselors should provide supervision for the staff of community health centers, and teams of mental-health professionals from the existing health structures should be trained and involved in a referral structure. On

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the local level, health personnel (e.g., doctors, nurses, midwives) should be trained in understanding mental-health and somatic indicators related to trauma spectrum disorders, treatment interventions, and adequate pharmacotherapy. On the national level, we propose the establishment of a Center for Mental Health and a Center for Conflict Management in Rwanda. The two centers should collaborate closely to carry out action research directly related to training, implementation of services, and outcomes on the individual and community levels. The Center for Mental Health would further function as the hub for development and organization of trainings, including supervision for trainers, and capacity reinforcement for psychiatrists and doctors at the national decision-making level. Information from community-based therapy (e.g., individual narratives and group counseling protocols originating from ex-combatants, as well as other members of vulnerable groups and affected persons) can be gathered and analyzed by the two proposed centers. Findings would be prepared for presentation to the public and fed back into society via channels of awareness raising, in order to present the experiences from members of different groups in a way that encourages empathy. The narratives generated by NET offer an insight into different perspectives – of victims and perpetrators, young and old, women and men, combatants and civilians – and can therefore change the meaning and sense of diverse, historical events. A collective reflection of important historical events helps postwar societies in understanding underlying conflict mechanisms; these societies are expected to modify the existing collective explanations and guard against the establishment of unbalanced and one-sided views and interpretations and thus to avoid new lines of conflict. National history can be re-written collectively. The proposed Center for Conflict Management would be charged with developing appropriate educational programs and the provision of respective training and supervision for teachers and others conducting peace education. The counselors and their former clients, who have completed treatment, could carry the information of the narration analysis directly into the workshops and could give personal testimony. This would improve exemplification and give clients the status of ‘survivors’ who have overcome the past. The participation of the ex-combatants, as well as their family members, as speakers in the workshops and schools will further enhance their active reintegration into society. The implementation of this reintegration framework must be dynamic to be successful. This means that elements are adapted and improved continuously, based on emerging evidence. Therefore, the evaluation of the program must be in-built and include implementation, outcome, and process evaluation.

Conclusions Throughout this chapter, we have demonstrated that a large portion of former excombatants suffer from severe psychological distress, including PTSD, depression, substance dependence, and psychotic conditions. These ex-combatants are heavily

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impaired in their daily functioning and are therefore at a high risk for failing to reintegrate into civilian society. This not only strips them of their ‘peace dividend’ but also has far-reaching consequences for the process of reconciliation and peacebuilding within their communities and postwar areas at large. It might even fuel cycles of violence that reach into the next generation. While formal DDR programs frequently recognize the need to make special provisions for psychologically affected ex-combatants, these are often not sufficient and not specific or professional enough. Even more important, psychosocial interventions within DDR programs have, to date, not been rigorously evaluated and thus, their effectiveness and efficacy remain unproven. We have presented examples from other fields, in which specific and targeted mental-health interventions and dissemination methods have been successfully evaluated. A particular focus was put on narrative exposure therapy (NET), because its efficacy and effectiveness in addressing trauma-related psychological stress have repeatedly been proven within post-conflict settings. Furthermore, it has been shown that this therapy can be taught to non-medical, lay personnel with various cultural backgrounds. NET has therefore been chosen as an essential part of a proposal for an intervention model to address trauma-related psychiatric disorders in DDR in Rwanda. In summary, many ex-combatants are in need of targeted mental-health interventions. It seems possible to deliver those within the framework of comprehensive, community-based DDR. The main challenge that remains is the evaluation of psychosocial care in DDR programs and the development of evidence-based, mental-health interventions.

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Chapter 10

Psychosocial Rehabilitation of Civilians in Conflict-Affected Settings Laura McDonald

Abstract Civilians worldwide are exposed to traumatic events as a result of mass violence, often in the context of conflict-affected settings. These individuals are often forcibly displaced and suffer extreme loss and violence. In most cases, they are likely to remain in conflict-affected and/or developing country settings that are characterized by limited resources and various competing priorities. The mental-health consequences of conflict have a far-reaching impact on multiple domains of life and community. In the past, mental health assistance to conflict-affected populations focused primarily on providing specialized mental health services to individuals with psychiatric disorders. Recently, however, there is growing acknowledgement that such interventions alone cannot promote full recovery and rehabilitation of traumatized populations and the war-torn societies in which they live. Current understanding of needs in the aftermath of trauma can provide a framework for promoting the psychosocial recovery and rehabilitation of conflict-affected populations. This chapter, in addition to providing background on the mental health consequences of conflict, focuses on the potential contribution of “social” considerations and activities in promoting recovery and rehabilitation of survivors of conflict. These activities can pay a large part in promoting feelings of safety, individual empowerment, and a “return to normalcy” – each of which is central to recovery from trauma. A number of principles for assistance are emphasized in this chapter, including strong cross-sector collaboration, the input of participants at all stages of design and implementation, and attending to cultural and religious features of the conflict-affected population, among others. Given the wide diversity of needs among conflict-affected survivors, the options for psychosocial care and recovery should be expanded and implemented in humanitarian and development assistance to conflict-affected populations.

L. McDonald (B) Psychiatric Epidemiology, Johns Hopkins University Bloomberg School of Public Health in the Mental Health, Baltimore, MD, USA e-mail: [email protected]


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Introduction Civilians in every region of the world are affected by armed conflict. Fear, displacement, loss, injury, illness, and death most often characterize their plight. While they have always been affected by conflict, a significant shift has occurred since the early 1900s and since World War II, whereby deaths among civilians have become increasingly more common. In the 1990s, non-combatants accounted for an estimated 90% of all casualties of armed conflicts, compared to approximately 15% at the turn of the century (Carnegie Commission on Preventing Deadly Conflict, 1997). Civilian populations are directly targeted in conflict (Newman, 2004). Frequently, they suffer physical injuries, which result in disability and/or death as well as psychological trauma. Often referred to as the “invisible wounds” of war (Mollica, 2000), the mental-health consequences of conflict are harrowing and take an immeasurable toll on the health and well-being of populations and their societies. Efforts to treat or to “dress” these wounds are critical in ensuring adequate recovery and rehabilitation of individuals in the settings in which they live. Research has advanced whereby there exist evidence-based clinical treatments, which are largely effective in treating mental disorders that can result from or be further exacerbated by traumatic events. Often, providing these treatments to all individuals who have experienced traumatic events is not feasible, given the prevalence of need and the often very limited resources that characterize conflict-affected settings. Further, in order to promote and ensure the long-term psychosocial rehabilitation of traumatized individuals and to promote healing of the larger society, clinical interventions – while certainly necessary for part of the population – alone are not enough to treat a wounded society. This chapter describes, in addition to clinical interventions, an ecological approach, which focuses on the importance of addressing the holistic needs of individuals surviving conflict in an effort to promote sustainable psychosocial rehabilitation. This approach – founded on an awareness of and attention to clinical, social, and economic elements of an individual’s life with consideration for the realities of conflict-affected settings – can play a key role in promoting psychosocial recovery and health among traumatized individuals in the societies in which they live.

Background Civilians worldwide are exposed to traumatic events as a result of mass violence, often in the context of armed conflict. Civilians, that is, individuals who are not combatants (i.e., not members of military or paramilitary groups), also experience traumatic events in settings that are not affected by armed conflict, but are impacted by widespread violence and instability, more generally. A large body of literature documents the severe mental-health consequences of exposure to violence and traumatic events (e.g., loss of a child due to malnutrition, or random violence) in those settings, which are not characterized by formal armed conflict or are not

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conflict-affected but are nonetheless violent and characterized by significant loss. For example, often individuals in inner-city areas in industrialized settings have been found to be exposed to various traumatic events (see Parson, 1994). Such events, particularly given the intersection of violence, crime, drug use, and poverty in these settings, can and often do have dire consequences for an individual’s mental health. This chapter, however, focuses primarily on mental-health issues and interventions in settings involving war or armed conflict. The term conflict-affected, rather than post-conflict, is used in this chapter to describe settings (either countries or regions), given that armed conflicts do not, in many cases, have precise endings. Rather, they often remain protracted with countries, regions, and populations, experiencing shifts in and out of armed conflict over years and even decades. Such protracted situations are common today, affecting millions of people worldwide (Smith, 2004). This reality greatly complicates the provision of assistance to populations in such settings. In addition to significant need for assistance in extremely poor and unstable settings, there are also shifts in type of needs from short term to more long term, which need to be met by external organizations, sometimes in collaboration with other actors. Further, there are continual changes in individuals’ access to such services. Moreover, organizational mandates can make more difficult, flexible, and quick responses to such shifts in needs.

Responses to Trauma Despite common features of experiencing trauma, the impact of psychological injury, as with all health and mental-health outcomes, can differ across individuals, having different short-term and long-term influence on cognitive, emotional, physical, and behavioral effects. A large body of research to date emphasizes the role of risk and protective factors, which may influence an individual’s response to a traumatic event. Some risk factors include a family history of psychiatric disorder, prior traumatization, female age, education level and poverty (Halligan & Yehuda, 2000 as cited by SAMHSA, n.d.). Some protective factors include a supportive family, sense of belonging, having a pro-social peer group, economic security, a sense of purpose, and social skills. Some of the most common mental-health disorders, which develop in response to trauma include acute stress disorder (ASD), posttraumatic stress disorder (PTSD), other anxiety disorders (of which PTSD is one), as well as depressive and substanceabuse disorders. (For diagnostic criteria, see the Diagnostic and Statistical Manual, Fourth Edition, Text Revision (DSM-IV-TR) (APA, 2000)). Herman (1997) describes the symptoms of posttraumatic stress, which research has found may follow ASD (Classen, Koopman, Hales, & Spiegel, 1998). Posttraumatic stress is manifested in the following ways, as described by Brahm (2004), initially as hyperarousal, “which stems from continual vigilance in hopes that the experience will not occur again.” In addition, “the traumatic memory is omnipresent in the mind of the traumatized. The memory repeatedly occurs as a flashback, which can occur at any time, and the victim is unable to distinguish the

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memory from actually experiencing the event again.” Further, people who survive trauma may seem “indifferent in order to mask the feelings of vulnerability and helplessness.” Second, they manifest as traumatic memories that are omnipresent in the mind of the traumatized (often as a flashback). And, third they manifest as indifference. In this way, traumatized individuals mask feelings of vulnerability and helplessness.” The resultant emotions and sequelae of trauma are far-reaching.

Exploring and Measuring Trauma In terms of traumatic events endured by civilian populations, the type of violence individuals experience can vary to some degree, depending on setting and/or culture. For example, the Bosnian version of the Harvard Trauma Questionnaire (HTQ) asks if an individual has been “used as a human shield,” while this question is not included in other culturally adapted versions of the HTQ (Staub, Pearlman, Gubin, & Hagengimana, 2005, p. 312). However, the shared features of trauma provide a framework for understanding both psychological harm and the necessary steps for the recovery and rehabilitation of individuals and societies. The term trauma is derived from Greek in which the term means “a wound” as well as “damage” or “defeat.” The age-old concept is defined as an event that evokes a “feeling of intense fear, helplessness, a loss of control, and the threat of annihilation” (Saddock & Saddock, 1999, as cited in Augustyn & Groves, 2005, p. 273). According to Lindemann (1944), traumatization occurs when individuals face uncontrollable life events and cannot change the outcome of them. A traumatic event often is life-changing and can have deleterious short-term and long-term effects for an individual’s health and overall well-being. There are numerous instruments used to assess the extent and type of trauma experienced by individuals. These include, as noted above, the HTQ, the War Trauma Scale, and the Survivor of Torture Assessment Record, among others (see Hollifield et al., 2002 for an in-depth review). In many cases, these instruments have been culturally adapted and validated in various settings among a number of populations, and researchers and clinicians can utilize them after receiving permission from the authors. To assess psychological distress and features of PTSD, depression, and anxiety, a number of instruments exist, including HTQ, the Hopkins Symptom Checklist-25 (HSCL-25), the General Health Questionnaire-28 (GHQ-28), the Short Form Health Survey-36 (SF-36), and the Self-Reporting Questionnaire-20 (SRQ-20), among others. To ensure the accuracy of findings, instruments should be culturally adapted and the appropriate cutoff scores determined with consideration for the population, culture and setting. Interested readers can find more information on these issues and processes in Flaherty et al. (1998).

Mental-Health Outcomes Among Conflict-Affected Populations While research and public opinion to date have largely focused attention on stress disorders – specifically and most commonly on PTSD as a key mental-health

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response among traumatized and/or conflict-affected populations – this may not be as much attributable to the prevalence of these disorders among conflict-affected populations as to the historical origins of research in this area. Military scientists were the first to conduct large-scale studies on the mental-health response to conflict (Lopes Cardozo & Fricchione, 2005). Veterans returning from war suffered posttraumatic stress symptoms, which were called by various terms, including “wounded heart” and “battle fatigue.” Indeed, research shows that PTSD is prevalent among conflict-affected populations in various parts of the world (de Jong et al., 2001). However, research has also found that depression, which is characterized by sadness, anger, irritability, and loss of interest in daily activities (Hyman, Chisholm, Kessler, Patel, & Whiteford, 2006), is also highly prevalent among conflict-affected populations in a number of contexts. For example, the prevalence of depression found among Cambodian refugees living in Thai–Cambodia border camps was 37.2%; and among Bosnian refugees in Croatia, 26% (Mollica et al., 1993; Mollica et al., 1999; Mollica et al., 2004). The high prevalence of depression might be in large part attributable to specific level and type of exposure to trauma that conflict-affected populations experience, or to the experience of loss on a large scale (of family, friends, homeland). It also may be related to the difficulties characteristic of conflict-affected environments, which are likely to hamper recovery or exacerbate the invisible wounds or war; such characteristics include poverty, limited access to basic needs, and political insecurity. Despite the tendency to focus on PTSD among conflict-affected populations, a shift, which has been noted by researchers, has occurred among experienced “international emergency practitioners,” who increasingly see “traumatic stress as only one of numerous issues. . .” (Wessells & van Ommeren, 2008, p. 214). These authors further acknowledge that both “grief and depression are often greater problems that often receive little attention” (Ibid.). Substance use and abuse among war-affected population, moreover, has received inadequate attention as affecting conflict-affected populations (McDonald, 2002). Yet, this is a major issue, which can affect various areas of an individual’s life and well-being and is linked to numerous social issues, including high-risk behaviors, violence, neglect, and infectious diseases (Affinnih, 1999; Strathdee et al., 2006). In 2008, the United Nations High Commissioner for Refugees (UNHCR) and the World Health Organization (WHO) jointly published the Rapid Assessment of Alcohol and Other Substance Use in Conflict-Affected and Displaced Populations: A Field Guide, further emphasizing that substance use is a key issue among conflict-affected populations and providing important guidance.

Resilience and Recovery Research highlights that a proportion of individuals who experience trauma will heal or work through the recovery process without external support (Kleber & Brom, 1992). Often, “people’s reactions will be transient. . .and will be managed through people’s use of existing coping strategies, support networks and material resources”

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(NSW Health, 2000, p. 27). Such a view emphasizes that stress reactions are normal responses to abnormal or traumatic events, although coping resources are needed in order to facilitate resolution of stress reactions. Further, such an emphasis on resilience underscores that war-affected individuals are not helpless victims – a perspective that can reduce their sense of empowerment. The importance of recognizing resilience and an individual’s and a society’s capacity to recover is quintessential in designing and providing assistance interventions. The concept of resilience, however, must be carefully considered. First, perceived features of resilience in the short term may not indicate resilience in the long term, nor do studies of resilience explore all variations in response to trauma and/or other behaviors that might manifest as a result of trauma. For example, the impact of undetected trauma or mental disorders on once-healthy relationships and/or substance-use behaviors could be significant. While acknowledging the resourcefulness and strength of trauma survivors, the potency of trauma should not be underestimated, particularly in light of overwhelming loss. Some individuals in conflict lose immeasurably, such as loss of family and friends, their livelihoods and homes, and many other things familiar to and deeply valued by them. Commenting about people who have survived unimaginable trauma, Dr. Richard Mollica, Director of the Harvard Program in Refugee Trauma, noted that “We found that people who face mass violence or torture cannot be expected to snap back to good mental health on their own. . . .” (Harvard Medical School, 2001, p. 1). Other trauma researchers agree on the potency of trauma. Levine (2008) asserted that, if left unresolved, the lives of survivors of trauma “can be severely diminished by its effects. . .the result for many. . .is often described as a ‘living death’” (p. 31). Just as any wound is a normal response to injury – any wound still and, in many cases, can benefit from appropriate assistance. Individuals have a tremendous capacity to heal, but this can be facilitated by means of a variety of interventions.

Far-Reaching Impact of Mental Disorders How precisely can trauma affect an individual’s life and well-being? The answer is in many different ways. In addition to diagnosable mental disorders the range of symptoms and impact it can have is wide. A WHO study (Omayando, 2004) of Liberian girls and women (N = 412), who had survived sexual and gender-based violence (SGBV) in two counties in Liberia, describes common experiences among subjects (separate from any diagnoses). The study found a variety of symptoms were experienced by respondents including, among others, feelings of humiliation (91.5%), insomnia (72.8%), confusion and embarrassment (70.6%), feelings of hatred (37.4%), frustration (28.6%), fear and worries about the future (26.7%), floating anxiety (29.4%), feelings of rejection (23.5%), and a sense of powerlessness (22.1%). Trauma and ensuing mental disorders often have a serious impact on an individual’s physical and mental health, their socio-economic well-being, and overall quality of life, and that of their families. A number of mental disorders are

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characterized by significant functional impairment. Reduced functioning is a key diagnostic criterion of most of these disorders in the DSM-IV-TR (APA, 2000). One study by Buist-Bouwman et al. (2005) found that mental disorders are associated with similar or higher levels of disability in most domains, than arthritis and heart disease. Other research has found evidence that a number of these mental disorders are associated with poor health outcomes and possibly premature mortality. For example, PTSD is associated with poor health (David, Woodward, Esquenazi, & Mellman, 2004), as well as later medical co-occurring disorders and mortality (Boscarino, 2008a, 2008b). Depressive disorders are also associated with the onset of illness, including cardiovascular disease (Musselman, Evans, & Nemeroff, 1998), and diabetes (Eaton, Armenian, Gallo, Pratt, & Ford, 1996), and other negative health outcomes. A growing body of research has further explored the toll of this type of reduced functioning on a global scale. Murray and Lopez’s (1996) Global Burden of Disease (GBD) study highlighted the toll of depression in terms of disability, or more specifically, Disability Adjusted Life Years (DALYs). The GBD study explored the impact of major diseases in terms of disability, using the newly defined DALYs measurement based on years lived with a disability (YLD) and years of life lost (YLL).1 Five of the ten leading causes of disability in 1996, as measured by YLD, were psychiatric conditions: unipolar depression, alcohol abuse and dependence, bipolar disorder, schizophrenia, and obsessive-compulsive disorders (Fleishman, 2003). The 1996 GBD study estimated that by 2020, unipolar depressive disorder (major depressive disorder) would be the third leading cause of disability (using the DALYs measurement) in developed regions. This topic was assessed again in 2004 (WHO, 2008a,b). In its 2008 report that used data from 2004, WHO identified depression as the principal international cause of years of health that were lost to disease for both men and women. According to Daly (2009, p. 7), “Major depression was the eighth leading cause of loss of health in low-income countries and the primary cause of loss of health in high and middle-income countries.” While the YLD and DALY measurements are understandably controversial – as they place a value on a year of life lived with a disability as worth less than a year lived without disability – the major contribution of these studies was that they showed for the first time the impact that depression was having on individuals’ lives globally. Other studies (Frank & Koss, 2005; Kessler et al., 2008) have aimed to quantify the impact of mental disorders (most often depression and/or anxiety) on economies, in terms of reduced productivity. It is important to note that the GBD studies and most of the other studies on the economic impact of mental disorders come from industrialized and stable settings (one exception to this is Kirigia & Sambo, 2003). Moreover, most of the research on these issues has not focused on some of the disorders that appear to be common in conflict-affected settings (e.g., PTSD). This paucity of research underscores the need for more studies to examine the possible

1 Years lived with a disability (YLD) is a measurement of time when an individual is living in a reduced state of health. Disability-adjusted life years (DALYs) is based on a complex math formula, accounting for both YLD and YLL (years of life lost) (see Fleishman, 2003).

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impact that various mental disorders have in terms of reduced functioning in settings that are rampant with violence and loss. Research has also found that traumatic events and subsequent mental disorders can have a long-term impact on families, influencing the mental health and wellbeing of future generations through inter-generational transmission (Danieli, 1998). Moreover, mental disorders can be transmitted from parent to child in many ways, some of which may have biological origins, while others may have psychosocial origins. For example, mental-health problems in mothers are linked to impeded child development through low birth-weight (UNFPA, 2008). Health, a “state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO, 1948) is a human right as stipulated in the 1948 UN Declaration of Human Rights (UNDHR). The UNDHR asserts (Article 25, Item 1) that “everyone has the right to a standard of living adequate for the health and well-being of himself and of his family. . . and the right to security in the event of unemployment, sickness, disability. . . .or other lack of livelihood in circumstances beyond your control.” Taken together, the numbers of people affected, the impact of such wounds on health and well-being, combined with the widely accepted view of health and the human right to health, suggest that the psychological health and rehabilitation of individuals affected by armed conflict merit attention and an effective response.

Environments for Recovery The environment plays a key role in recovery. Helping professionals and programs which aim to provide psychosocial assistance must have an adequate appreciation of the realities of an environment where recovery is supposed to occur. The types of environment which characterize a Western setting – from where a large body of research on this area comes – are likely in many cases to look quite different than those environments faced by a large majority of people who survive conflict and trauma. In view that an estimated four out of five of the world’s refugees were residing in developing countries in 2008 (UNHCR, 2009), efforts to promote healing and any guidance given in their development must take into account the field-level realities of a conflict-affected setting. The large majority of individuals affected by armed conflict live in resource-poor settings, with limited if any access to a clinical setting and where cultural variations in the meaning of and requirements for recovery from trauma exist. Conflictaffected settings are typically characterized by devastated physical infrastructure (roads, bridges, key buildings), a reduced number of trained professionals in many sectors, a torn social fabric, abandoned and over-populated areas as a result of forced displacement, and high levels of insecurity. Forced displacement extends the range and domain in terms of the variety of environments where recovery efforts will be needed. For example, populations might cross national or international borders temporarily and/or

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permanently, therein requiring recovery interventions to adapt to these settings. Or, such individuals might reside in transitory settlements for short and more likely, long periods of time. Most frequently, however, displaced populations often remain within developing country settings, as UNHCR (2009, p. 4) reports that more than three quarters of the world’s refugees “seek asylum in neighboring countries or the immediate region.” Though this is changing, the dominant thrust of research has been on assessing the mental-health needs of and exploring effective responses to displaced individuals, who are resettled or are residing in industrialized countries. Such information is essential for others assisting refugees in these settings and useful in a general understanding of potential needs and features of responses across individuals and cultures. It does not, however, account for the real-world settings in which most assistance programs must operate. Such research does not reflect the realities of the conflict-affected setting; consequently, this kind of research cannot prescribe precise interventions for populations living in such settings, which are characterized by constant insecurity, violence, loss of family, and extreme poverty. Research shows that each of these factors can impact mental health (Watters, 2001). Montiel (2000) acknowledges the reality of most environments where recovery efforts must take place, holds that efforts to promote healing occur in dangerous and poor areas, not those that are comfortable and safe. It is with the knowledge of human needs and available responses, combined with awareness of the reality of recovery environments, that feasible strategies and approaches can be designed, implemented, and evaluated. It should be emphasized that difficult settings that constrict research and limitations in resources do not absolve the mental health, relief, and/or development communities from taking an appropriate response – in the same way that the location and circumstances, in which most individuals with HIV/AIDS live, do not absolve health professionals from providing adequate and appropriate health care. It is widely acknowledged that the design and implementation of social (and other human capital-focused) activities and programs to assist conflict-affected populations, just like many other efforts related to recovery and rehabilitation, are not without difficulty. In fact, as a former director of Bosnia-Herzegovina World Bank operations asserted, “The easy part of any Bank operation is reconstructing the bricks and mortar; the hard – but more essential – part is. . . restoring the human capital, and societal bases of a post-conflict society” (Kreimer, 1998, p. 23). Braced with the realities and complexities of conflict-affected settings, the next section focuses on describing some key human needs in the aftermath of trauma.

Acknowledging and Identifying Needs and Responding Effectively Significant scientific research has identified a number of human needs that are central in trauma’s aftermath. These include, but are not limited to, safety, calm, sense of being able to solve problems for oneself or as part of a group; connectedness to

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social support; and hope (Hobfoll et al., 2007). Herman (1997) asserts that recovery from trauma occurs in three stages, each which has its own central task: (a) establishing safety, (b) remembrance and mourning, and (c) reconnecting to ordinary life. Besides these key domains of recovery, individuals who have survived traumatic events as a result of armed conflict live within settings that are characterized by devastation and extremely limited resources and opportunities and, as such, they have other health, social, and general human needs that must be addressed, in addition to what Herman suggested, to promote their mental health. Abraham Maslow’s (1943) Hierarchy of Needs, a theory central to understanding human motivation, maps the five categories of needs, including physiological, safety, love/belonging, esteem, and self-actualization, onto a pyramid shape. The hierarchy aims to show some insight into the relative importance of needs to every individual, with needs at the bottom of pyramid being more primordial than those at the top. In a conflict-affected setting, it is useful as a framework for understanding the totality, complexity, and multifaceted nature of human needs. An individual, who experiences trauma and who survives conflict, should be supported in each of these stages of recovery; an optimal approach to assistance will aim for providing all of these core needs as soon as possible. While meeting basic needs is a minimum standard for assistance – it is not optimal, and in the long term is likely inadequate for meeting needs, as needs are often not static but can multiply in situations of severe deprivation. Severe deprivation occurs, for example, when millions of individuals are “warehoused” in emergency settings for several years (Smith, 2004). The issues of meeting minimum standards as an inadequate benchmark for meeting individual needs were noted in a review of UNHCR’s efforts to provide assistance to refugees in Kakuma, Kenya; in that circumstance, it was noted that the same amount of goods that were determined adequate in an emergency context would be considered an inadequate response if provided years later (Jamal, 2000). The needs found in such settings are varied, but are consistent with general human needs – including health and overall well-being – of which mental health is a key feature. Too often, mental health is not considered a key priority in the provision of assistance to conflict-affected populations. And, in some cases, efforts to address the “invisible wounds” of conflict have been narrowly focused. Van Ommeren, Saxena, and Saraceno (2005, p. 71) acknowledge that “foreign clinicians often arrive to promote PTSD case-finding and trauma-focused treatment in the absence of a system-wide public health approach that considers pre-existing human and community resources, social interventions, and care for people with pre-existing mental disorders.” For the multifaceted nature of human needs, the design and implementation of programs to address these needs and overall psychosocial recovery necessitates a broadened perspective. Such a view is gaining strength (IASC, 2007; WHO, 2003a). A holistic approach requires a far reach, with attention to the social domain of need and interventions as well. As Watters (2001, p. 1716) points out in prescribing paradigms of care, “within a holistic approach there is considerable blurring and overlap between the realms of social care and mental health.” This is particularly true in

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settings where entire societies, livelihoods, and meanings have been destroyed and individuals require a broad range of assistance. The importance of acknowledging the realities of the environment and the internal experience of conflict-affected populations was emphasized by Mehraby (2002, p. 6), who described the importance of meeting the practical and psychological needs of traumatized Afghans: “Since advice and material support may be what Afghan clients expect when seeking help, the encouragement to talk needs to be balanced with practical assistance.” As Bowles (2001, p. 2330) asserts, “The inner and outer turmoil experienced by refugees is linked, both aspects must be addressed. Talking with clients about their feelings when they have nowhere to live does not address the most salient issue. At this time, only addressing practical concerns is unlikely to be successful, as internal chaos of refugees may continue to destabilize their life.” Mental-health professionals themselves have, in recent years, emphasized the importance of cross-sector collaboration, underscoring the limitations of approaching mental-health issues and recovery through a psychiatric lens alone without consideration for the whole picture. For example, Bloom (1997) is explicit in her support of the social aspect of psychological rehabilitation, advocating an emphasis on features of the environment, or social context, as a key issue in understanding psychological distress and in facilitating recovery. While mental-health professionals have an important role to play, full, holistic healing cannot – and should not – rely solely on the shoulders of mental-health professionals. Many mental-health professionals have acknowledged this for a long time now. As Brody wrote more than three decades ago . . .the major dilemma for mental-health professionals lies in the fact that primary prevention of mental handicaps and the assurance of overall community health is [sic] total. It involves the whole social system and thus is beyond his power as well as expertise. . . (1973, p. 587)

This necessitates close collaboration across sectors. Van Ommeren et al. (2005, p. 4) noted that “as social interventions tend to deal with important factors influencing mental health, health and mental-health professionals should work in close partnership with colleagues from other disciplines (e.g., communication, education, community development, and disaster coordination) to ensure that relevant social interventions are fully implemented.” Mental-health professionals and paraprofessionals can play an important role in guiding and informing psychological interventions, but optimal healing and overall recovery requires the contribution of those from other fields. This certainly makes assistance efforts more complex and reliant on communication, coordination, and clear assignment of responsibilities – but optimal treatment may require nothing less. As Watters suggests, treatment specifically for conflictaffected refugees may “consist of help with welfare benefits, accommodation, health or mental health care, education and training and incorporate a wide range of approaches.” While the urgency of providing basic medicines is undeniable among people with severe mental disorders, assistance programs must go further – as in industrialized countries – to meet other social needs.

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Close collaboration across sectors and experts must be the hallmark of efforts to promote the full recovery and rehabilitation of conflict-affected populations. With this in mind, the next section focuses on various types of programs, which have been found to be effective or which provide some promise of effectiveness in promoting recovery.

Possible Options for Responding There exist a number of documents that provide guidance on assessing needs in various conflict-affected settings (see WHO, 2001; Johns Hopkins University & International Federation of Red Cross and Red Crescent Societies, 2007). The effectiveness and accuracy of findings from assessments rely on the use and appropriate application of culturally relevant instruments. A thorough discussion of needs assessments and key considerations is beyond the purview of this chapter, which aims to focus more specifically on options for interventions, in order to address various needs of traumatized individuals. In the fieldwork of providing psychosocial assistance for countries, a pyramid framework is used to illustrate that “people are affected in different ways and require different kinds of supports” (IASC, 2007, p. 12). These supports, as noted by IASC, should be implemented concurrently to meet the needs of different groups. At the bottom of the pyramid (accounting for the largest proportion of needs found in emergency settings) is basic services and security, followed on the next level by community and family support. Focused, non-specialized support is the third step of the pyramid, with specialized services placed at the top of the pyramid. This framework is useful in determining priority interventions for individuals; yet, individuals’ needs are diverse, complex, and ever-changing. A portion of the population may need clinical interventions of a psychological nature, but that does not mean that they should be excluded from other broad, more socially focused interventions. The determination of the most appropriate assistance must be carefully considered and targeted appropriately. While some interventions are described in separate categories below, a number of interventions have components that respond to each of these categories. Some of these very promising approaches and integrated activities are discussed later in the chapter.

Clinical Approaches There is a large body of research documenting effective clinical treatment of mental-health disorders among survivors of trauma and mass violence. In particular, studies have found cognitive behavioral therapy (CBT) to be effective in reducing symptoms of and treating ASD, PTSD, depressive disorders, and other anxiety disorders (see Hyman et al., 2006; Stanley et al., 2009). Studies have found evidence

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showing that improvement can be the greatest when such therapies are combined with pharmacological treatment (Pampallona, Bollini, Tibaldi, Kupelnick, & Munizza, 2004). In Western and non-Western settings, there is evidence that points to the potential for CBT to lead to improvements in psychological status (Khodayarifard, Shokoohi-Yekta, & Hamot, 2009; Ohaeri, 1997). Evidence has found that group interpersonal psychotherapy reduces symptoms of depression among some individuals (Bolton et al., 2003; Bolton et al., 2007), and narrative exposure therapy (NET) helps to reduce symptoms of PTSD (Neuner, Schauer, Roth, & Elbert, 2002; Schaal, Elbert, & Neuner, 2009). Many trauma researchers and clinicians working with highly traumatized populations have emphasized the centrality of relating the individual’s trauma story in a safe environment, to reexperience it in safety, in order for the re-telling to be a cathartic experience in his/her own healing (Turner &McIvor, 1997). Interventions, such as narrative exposure therapy, must be adapted to the setting in which they are delivered, with consideration for the culture and the type of trauma that individuals have experienced (e.g., rape, forced amputation). Clinical treatments, including psychiatric and/or behavioral interventions combined with the provision of psychotropic medicine, may be perceived by governments or non-governmental organizations (NGOs) as a “non-essential” treatment. Such views often arise in a context of a resource-poor setting where needs must be prioritized. Like for any other health issues, the belief that pharmacological treatment for psychiatric disorders is not a necessity can have harmful and damaging consequences. For some individuals, not ensuring the provision of necessary medications may not be “optional” – just as providing assistance to an individual with HIV is inadequate without the provision of antiretroviral medicines (ARVs). For a portion of individuals in a conflict-affected setting, more clinically focused assistance (e.g., psychological therapies, medication, or both) are requisite for mental health and well-being. In addition to the availability of such services, it is moreover essential to establish mechanisms for effective screening, identification, and referral of individuals at an accessible place, to ensure people in need can access these services.

Healing Interventions This section includes additional clinical interventions, as well as those that are broader interventions with a social component. They are described according to the primary objective of the intervention itself as it fits in the three phases of recovery from trauma as described by Herman (1997): establishing safety, remembrance and mourning, and reconnecting to ordinary life. The interventions described do not necessarily have the discrete purpose of addressing a sequential phase, but they can incorporate elements of various phases concurrently. Each relies on the support of mental-health workers and others to a different extent.

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Ensuring Physical Safety, Promoting Psychological and Social Safety According to Herman (1997), the most important step in trauma recovery is ensuring an individual’s physical safety. In addition, promoting psychological and social safety should also be objectives in the aftermath of trauma. Promoting feelings of safety among traumatized individuals is critical, because any previously held sense of safety has been largely disrupted through the experience of a threat of annihilation. Such safety is both physical and social – and a safe environment is essential in promoting healing and recovery. As noted by Staub et al. (2005, p. 302), “healing can begin when there is at least limited security, that is, when physical conditions are relatively safe.” The integral role of creating a “sanctuary” to promote healing is emphasized by Bloom (1997). She describes her efforts in detail to create such a sanctuary for her traumatized patients in a Massachusetts clinic. Bloom maintains that attention to the healing environment is both essential and practical, for “as there are many more traumatized people than there ever will be individual therapists to treat them. . .We must begin to create naturally occurring healing environments that provide some of the corrective experiences that are vital for recovery” (p. 117). While Bloom is likely referring more generally to a safe societal setting, the idea behind creating a safe space implies physical safety, as well as the metaphorical condition of nonthreatening surroundings that promote a sense of psychological, social, and moral safety among trauma survivors. Psychological safety is thought to be strengthened by restoring an individual’s sense of empowerment, control, self-efficacy, and enjoyment. Herman (1997) noted that “helplessness and isolation are the core experiences of psychological trauma,” just as empowerment is one of “the core experiences of recovery” (p. 197). How can both “psychological” and “physical” safety be promoted in settings characterized by some degree of instability, violence, and insecurity? These psychological and physical safe spaces can be created with various types of actions and can look quite different – ranging from few to numerous activities and approaches. In some settings, psychological safety can be promoted by assuring people that their reaction is a normal and expected response to traumatic events. As noted by Mehraby (2002, p. 6) when working with Afghani survivors of torture, “the common phrase that PTSD is a ‘normal reaction to an abnormal situation’ often help[ed] Afghan clients to realize that they are responding to the traumatic events that have happened to them” and allays their fears of being labeled as “mad” or abnormal. They feel safe and understood. In Liberia, promoting safety was a focus of work by the American Refugee Committee (ARC, 2005). In establishing programs to prevent SGBV and to respond to the needs of SGBV survivors, ARC provided psychosocial assistance, medical care, and information on available options to survivors of SGBV. Further, staff took steps to raise awareness of SGBV among all segments of the population. They ran a program focused on promoting self-empowerment of women, who were SGBV survivors or those who were identified as vulnerable, by targeting them for participation in income-generating activities (IGA). Their safety was promoted not only

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through both counseling and care but also through efforts to change their environment and to provide them the possibility for increased economic agency and empowerment. Such safety can also be promoted through group forums. For example, in Iraq, Catholic Relief Services (CRS) (Sheahen, n.d.) supported the establishment of small psychosocial groups of Iraqi women, who met once a week to share their fears, sorrows, and anxiety, with the direction of a trained leader. This group gave them support and strength to “begin to heal and rebuild their lives” (p. 3). In Darfur, Sudan, women’s centers were established to provide assistance to survivors of SGBV. In addition to psychosocial counseling and referrals for medical services, these centers “provided thousands of women with a safe space in which to receive such diverse training on such issues as literacy and advocacy skills” (Verveer, Brimmer, & Carter, 2009, p. 5). One specific intervention, which provided a safe space to assist women, was implemented by Medica Mondiale in Kabul, Afghanistan (Manneschmidt & Griese, 2009). Using a holistic, multidisciplinary, and women-centered approach, the program applied four strategies to facilitate healing: psycho-education to help the women understand their reactions and behaviors, training on removal of or relief from distressing symptoms, teaching of new social skills (e.g., problem solving skills), and the development of new support networks among counseling group members. Importantly, this intervention was evaluated and found that over 90% of the participants (N = 109) described an improvement in their social life or their general health. Remembrance and Mourning Having been assured of physical safety and having taken steps to promote psychological safety, individuals will undertake the difficult work of remembrance and mourning. As an individual feels safer, he/she may then feel comfortable in reconstructing and/or telling his/her story of trauma, as mentioned above. It is, according to Mollica (1988; as described by Turner & McIvor, 1997, p. 213), the “workingthrough of the traumatic process that permits the development of a new story that is no longer about shame, humiliation, or guilt.” In Western settings, this is often done in the therapist–client relationship, in which the narration of one’s trauma story in the presence of another can be therapeutic. It can, and often, lead to “acknowledgement, apology, forgiveness and [/or] reconnection” (Herman, 1997 cited by Brahm, 2004, p. 3). Such a narration allows traumatic “memories to be incorporated into the victim’s life story” (Brahm, 2004, Ibid.). Many of the interventions described in the previous section include narrating, sharing, and remembering the trauma story. As noted, many groups can be quite effective in providing a setting for exchanging feelings surrounding trauma, loss, and hardship. In addition to those efforts described above, there are other programs which support this area of recovery. For example, the organization Trauma Healing and Reconciliation Services (THARS) in Burundi was launched in 2000. Managed by a coordinator, who is trained in counseling, and a support team, THARS conducts

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workshops, operates “listening centers,” and facilitates support groups (THARS, 2007). In many settings, remembrance and mourning requires attention to spiritual, religious, and ritual practice. The importance of attention to the religious component in healing is critical in many societies. For example, it has been found that practices among Afghani survivors of trauma, such as reciting verses from religious text like the Qu’ran, were considered beneficial when frightened (Mehraby, 2002). In many instances, religious and cultural views and practices prescribe that the dead be buried within days (see Mehraby, 2002). Emotional distress may be triggered in many societies as a consequence of not being able to carry out ritual practices to honor the deceased (Faust, cited by Kwon, 2006). One form of reclaiming involves reburial, which can be a real or metaphorical process. In Rwanda, a majority of individuals did not have the opportunity to see the remains of their family and friends, to bury them, and/or to perform mourning ceremonies. This had a major impact on the bereavement process, preventing it from taking its natural course (Hagengimana, 2001). A large body of literature documents efforts to promote rituals related to mourning and remembrance as important components in healing. One intervention in Eritrea, in addition to creating schools and youth associations, involved creating coffee and memorial meetings that were focused on supporting the mourning of the camp’s widows (Kalksma-Van Lith, 2007). An evaluation of the project found that “the quality of the daily life of the children in the camp had improved and community coping mechanisms had been reinstated or strengthened” (Ibid., p. 13, citing Bragin, 2005). Honwana (2006) described in detail the ritual and indigenous healing processes, which were promoted in Mozambique to heal the emotional and psychological wounds of survivors. Honwana (1997) and others (Richter, 2003; WHO, 2003b) have emphasized the important role of traditional healers in promoting health and well-being.

Reconnecting to Ordinary Life – A Return to Normal Activities Herman (1997) refers to the central task of the third stage in recovery as returning to normal activities – while safety, remembrance, and mourning precede this stage. These activities should provide opportunities for consistency and a sense of daily normal activities, which promote empowerment, hope, self-efficacy, and social growth. This area draws heavily on types of activities, which are important in promoting and protecting mental health, but which are often somewhat outside the lens of psychology and psychiatry. These social activities (e.g., daily social activities, educational and training activities, cultural and community development activities) require input from various sector specialists, including mental-health workers and various other specialists. The idea of promoting a “return to normalcy” is used to describe a frequently mentioned key objective in trauma recovery. In some conflict-affected settings, this may be an appropriate guideline – in others it may not. In countries where populations experienced severe poverty and/or violence, a return to a previous status should not be an objective, in view of the undesirable conditions that previously existed.

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Herein, actors concerned with community health and well-being can assist in promoting sustainable change and growth, while achieving the recovery of previous positive outcomes. The following activities are reliant on cross-sector collaboration and are suggested for their potential to promote a “return to normalcy” (i.e., a return to activities of daily life) and to enable populations to achieve those goods (e.g., an education) and outcomes (e.g., a job), which conflict and limited resources have prevented them from accessing. These interventions are not necessarily discrete, and components of each can be included in a single assistance program (note that some examples of such approaches are described later in the chapter). This overview is not comprehensive, but provides insight into some possible interventions to achieve these objectives. Educational and Vocational Activities. In resource-poor settings, such as displacement camps and among resettled refugees, the (re-)establishment of educational activities, including but not limited to literacy, vocational, and skills training, can play an important role in restoring empowerment and hope. It provides an opportunity for people to work toward their future. Education and vocational activities should be designed and implemented on the basis of those individuals who will be participating and on the basis of knowledge of the local economy and labor market opportunities (IRIN, 2007, p. 11). Productive Activity. Self-efficacy – or the perception that one is able to affect change – is critical to an individual’s mental health and well-being. Selfactualization, which is a broader concept than self-efficacy, is a core human need and is included in Maslow’s hierarchy of human needs (see above). Providing an opportunity for people to engage in productive activity provides an opportunity for self-actualization. It can provide empowerment at the same time as strengthening people’s sense of self-efficacy, in order that they can play an important role in positively impacting the future. Such activities are essential in restoring hope to survivors of conflict, which is essential to recovery. The importance of promoting entry or re-entry of disadvantaged populations (including individuals with psychiatric disorders) into work has been widely acknowledged in industrialized settings. It is also more and more becoming a component in psychosocial assistance. WHO, for example, in Mental Health in Emergencies (2003a), asserts that economic development initiatives should be encouraged, including “(a) micro-credit schemes or (b) income-generating activities [IGA] when markets will likely provide a sustainable source of income” (p. 5). Furthermore, productive activity or employment is often an explicit concern of conflict-affected populations themselves. For example, in the aforementioned study in Afghanistan by Manneschmidt and Griese (2009), when participants in the study were asked about the steps they wished to take to make their lives better, half of the answers (50.9%) related to the women’s wishes to find employment. The establishment of IGA, employment, and other productive activities has been undertaken in various settings. Participation in micro-credit programs and similar IGA allows individuals to take care of themselves and their dependents. When these types of community-lending programs are undertaken, extra effort should be made

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to ensure that beneficiaries are made aware of repayment requirements and potential difficulties. The psychological distress, for example, associated with debt and difficulties in repayment should not be underestimated, as seen in the wave of suicides a few years ago among farmers unable to repay loans in Andhra Pradesh (Mathew, 2004). Altruistic Activity. In some settings, particularly in transitory settlements, creating productive activity and employment can be more difficult, given limited resources and political, economic, and physical constraints imposed on residents. In such settings, efforts can include giving camp residents responsibilities within the camp. Additionally, providing individuals with support in practicing altruistic behavior in a camp setting might result in improvements in mental health (Mollica, Cui, McInnes, & Massagli, 2002). The impact on mental health by providing support for altruistic activity in conflict-affected settings has not been widely studied and should be given further consideration and attention. People can benefit from contributing to the world and those individuals around them. Indeed, existing research has found an association between altruistic social interest behaviors and better mental health (Schwartz, Meisenhelder, Ma, & Reed, 2003). Like productive activities, such interventions can likely play an important role in restoring both hope and dignity to conflict-affected populations. Engagement with Local Tradition, Cultural, and Religious Practice as Desired. The importance of attention to local practices and traditions is critical, as noted in the section above on Remembrance and Mourning. It also can play an important role in promoting a return to normalcy. It is widely acknowledged that in a large majority of countries throughout the world, individuals do not turn to mental-health professionals when experiencing psychological distress. People and their communities turn to support from religious structures and leaders, traditional healers, and local healing practices. Thus, in addition to incorporating views and practices of indigenous healing systems, individuals should be given an opportunity, as soon as possible, to participate in spiritual and traditional activity, as they desire. It is possible, as noted by Moran (2009, p. 16) that “having a purpose in life. . .appear[s] to be associated with resilience. . .after a traumatic experience.” This view is consistent with IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings (2007). A number of interventions, which include a hybrid of Western treatment approaches and traditional healing, have demonstrated effectiveness in treating psychological distress. As is requested or desired by beneficiaries, religious and traditional healers should be involved in various aspects of recovery. For example, WHO estimated that in some Asian and African countries “80% of the population depend(s) on traditional medicine for primary health care” (2003b, p. 1). Further, in some settings, it has been found that traditional healers play an important role in the counseling aspect of care (e.g., among individuals with HIV/AIDS; Richter, 2003). Traditional healers have been given further training in the context of various programs to identify and to address psychological distress among war-affected

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populations. Two organizations which have emphasized the importance of including indigenous and traditional healers in mental-health recovery are the Harvard Program in Refugee Trauma and the Peter C. Alderman Foundation. Social Connection. As a result of trauma, individuals may experience that any previously experienced feeling of safety and trust with others is largely destroyed. It is widely acknowledged that social connection and support are critical to recovery from trauma (Herman, 1997). Social support can be restored through group sharing of trauma stories, as described above, and can also be facilitated through activities that aim to restore normalcy, e.g., sports, clubs, activities, education, and training activities. Social connection can be promoted in many ways. For example, WHO (2003a) describes the potential beneficial functions of self-help support groups that are community based. They can function as a source for sharing problems, brainstorming for solutions, as well as promoting collective and/or traditional coping and support. Further, it is possible that these groups can serve as a foundation for community initiatives, whether they are focused on IGA, rebuilding and the rehabilitation of infrastructure, or other types of activities. Various types of activities have been established among conflict-affected populations. For example, the psychosocial support to children and adolescents project, which began in 1994 and which was supported by Medicins sans Frontieres, provided activities to support both parents and children, including creativesocialization activities (e.g. radio group, art workshop), in addition to providing mental-health treatment (UNICEF, n.d.). Programs were set up in secondary or boarding schools and individuals were provided with recreational and creative activities (games, music, literature, painting), as well as the opportunity to participate in socio-therapeutic groups. Community and positive connection can be promoted through various activities; in addition to establishing community support networks, it can be fostered through efforts, which specifically emphasize collaboration among individuals, such as a community gardening program or a sewing cooperative. Promoting Fun and Reducing Stress. There has been continual emphasis on the value of fun and play activities in improving the lives and promoting mental health and well-being among conflict-affected populations. In some settings, depending on age of individuals as well as culture, this has meant the establishment of art activities or the design of puppets and puppet shows. In other settings, this might include sports activities, games, clubs, and entertainment. Creative play can be useful in managing and reducing stress in managing and reducing stress (Henninger, 1995). There is significant evidence on the positive impact of physical activity for health, both mental and physical (Richardson et al., 2005; Fox, 1999). More research is, however, needed in assessing its impact among conflict-affected populations. For example, a recent study found that creative play had no effect in reducing depression severity among conflict-affected adolescents in Uganda (Bolton et al., 2007). Research must continue to evaluate such activities, in order to further strengthen our understanding of this area.

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Examples of Effective Interventions The following provides an overview of two interventions in this field, which incorporate a number of elements that address mental health and well-being through both clinical and social activities. This is not a comprehensive overview, but provides some practical examples of actions that hold promise in this area.

Training the Healers: Healing Survivors and Communities The Center for Victims of Torture (CVT) in West Africa has implemented the Community Sensitization and Psychosocial Activities, using a multi-layered approach. On a community level, they aim to raise awareness of the impact of trauma and the role that the community can play in the healing process, and to identify those who could benefit from either small-group counseling or individual counseling. Further, non-counseling activities are provided on a daily basis in communities. These activities include play therapy, games, drama, arts, and crafts and sports activities. CVT has worked closely with relevant governmental ministries to provide training and referral services. The program is implemented with paraprofessional psychosocial counselors, who are given extensive training, who learn alongside professional clinicians while working with clients on a daily basis, and who are continually supervised. Assessments were made at various points as follow-up to the program; the initial evaluation found that there were statistically significant and meaningful improvements in various indicators, including a reduction in depression, anxiety, and somatic-type symptoms, and an increase in supportive relationships (CVT, 2006).

Avoiding a Fragmented Approach: Addressing Psychosocial and Economic Needs Weyermann (2006) described an approach that combined both psychosocial and economic support undertaken by an NGO, which was aimed at providing support to Palestinian women in the Gaza strip. Some of these women had been political prisoners and some had experienced domestic violence and lived in difficult economic circumstances. This undertaking was guided by a perception that too often, organizations were addressing these needs separately, which in turn, prevented women from “convert[ing] their skills into income or to improve their psychosocial situation” (Ibid., p. 35). For these women to recover from traumatic and disempowering experiences, the organization believed “they must gain the power to control their personal situation and address and reduce social injustice” (Ibid.). In addition to providing group-therapy sessions, the NGO focused on promoting economic empowerment on an individual basis. In the group discussions, the women would share their situations, their fears, and hope for change. A situational analysis, based on each individual’s economic needs, social relationships, and emotional problems, was utilized to develop “individual empowerment plans” jointly with the facilitator

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and participant. These plans would be used in deciding, for example, what activities and trainings a woman might participate in, rather than giving everyone the same training or course. The group continued to meet, regardless of their individual empowerment plans, once a week throughout the year in which they were working with the NGO. These meetings were critical, as they provided a “space where women build trustful relationships and experience the power that comes from sharing and building solidarity” (Ibid., p. 37). This approach required “close cooperation across professional and organizational boundaries”. The author stresses that “psychosocial counselors must be aware of clients’ economic realities, while skills trainers must understand their emotional makeup” (Ibid., p. 38). Care and Rehabilitation of People with Psychiatric Disorders The St. Camille Association in Benin and Cote d’Ivoire, in addition to other projects, focuses on assisting people with mental disorders and facilitating their “emancipation, care and rehabilitation” in community settings (Foundazione St. Camille de Lellis, 2009). The St. Camille Association, with the support of the Foundazione St. Camille de Lellis, has established care and rehabilitation centers to provide shelter and needed pharmacological treatment to individuals with mental disorders. These rehabilitation centers aim to provide vocational training to clients, in order to facilitate their reintegration into society. They have been able, in some settings, to track the success of former clients, who completed their social reintegration process by means of professional activities, e.g., weaving and animal breeding. Many of the individuals who work in the rehabilitation centers are former clients themselves.

Principles of Assistance Emphasize Resources and Capacity, Not Limitations. Efforts to promote psychosocial rehabilitation of conflict-affected populations need to consider the significant resources that the community can provide and to emphasize the community’s ability to cope and to heal. Effective assistance should promote this healing. Individuals in such settings should not be perceived as helpless victims, but as survivors and as people who want to invest and contribute to the world around them. Mollica maintains that treating someone as or viewing them as a victim is not helpful, because “Even the poorest person in Indonesia who’s had terrible losses doesn’t want to be seen as a victim” (as cited in Gewertz, 2005, p. 1). Too often individuals who are defined as refugees (e.g., according to their transient status) are the same people that are expected to do the difficult work of recovery and rehabilitation of their society following conflict (Mollica & McDonald, 2002). Multifaceted Nature of Need Calls for Commensurate Response. People can benefit from various types and approaches of interventions, as noted above. Clinical, mental-health assistance can be critical for some – but alone, it is not enough to ensure sustainable and holistic recovery and rehabilitation. Efforts to address mental health must also work within and address the realities in which these individuals

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live and are asked to undertake the difficult task of recovery. Further, individuals heal in various ways. Within the aforementioned study of survivors of SGBV in Liberia (Omayando, 2004, p. 30), when respondents were asked to list “other things that might be helpful to them in coping with their experience,” they most frequently suggested “trying to forget about their experiences (60%); going to the support group (59.2%); talking it over with family (47.8%); and going to religious authority for spiritual counseling (45.2%). Medical assistance was cited by only 31.4% of the respondents.” Ensuring the most effective approach will require considering those interventions, which are viewed as a prerequisite for health and recovery in industrialized settings, as feasible and critical in conflict-affected settings (e.g., supported employment). It requires thinking outside of the traditional focus of mental-health care, as it also calls for addressing various aspects which influence mental-health care in each setting. Mental health and psychosocial care are influenced by various features in a society, as noted in “Project 1 Billion” and its accompanying action plan to promote mental-health healing following conflict. To promote sustainable and effective change, the following areas must be addressed: policy/legislation, financing, science-based mental-health services, multidisciplinary education, role of international agencies, linkage to economic development and human rights (Mollica & McDonald, 2003); McDonald, Bhasin, & Mollica, 2005). Promoting Culturally Appropriate and Informed Care. Given the cultural features of traumatic experience and views related to the experience and meaning of trauma, it is important to ensure that cultural considerations in the healing processes be considered, and as much as is possible, incorporated in supportive efforts. Often interventions have been criticized for using “outside” techniques that are not culturally appropriate or adequate. For example, there is criticism that some Western professionals have applied Western therapeutic techniques in non-Western settings (Summerfield, 1999), which may be inappropriate and ineffective. Consideration for local culture, practice, knowledge, and perception is of utmost importance. One effective way to assure a culturally appropriate approach is by collaborating closely with the local community – both the general population and those with healing roles (e.g., the health and mental-health practitioners, religious leaders, and traditional healers). To date, a number of effective practices have been used when working with local communities to respond to mental-health needs in conflictaffected settings, and these are well-documented and are mentioned above (e.g., Harvard Program in Refugee Trauma and the Peter C. Alderman Foundation). By building up and building upon in-country capacities and working with local experts (e.g., through training, program development, and participatory assessments) – by not supplanting or bypassing local expertise – the effectiveness, appropriateness, and sustainability of a program are more likely to result. Such considerations should also be heeded in determining the most effective modality for service delivery. For example, in Rwanda, given the country’s long history of oral tradition, clinicians might seek to incorporate this process into interventions. The need to incorporate local practices is emphasized by Dubrow and Nader (1999, p. 3): “views toward and reaction to traumatic experiences and to health and mental-health interventions in

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general, vary across cultures. Understanding beliefs and practices is important to all phases of effective intervention.” Beneficiaries as Decision Makers Equals Empowerment. Charged with the difficult task of recovery in the face of immeasurable loss, program beneficiaries should play a key decision-making role in the design and implementation of assistance programs. This is a key consideration to ensure the effectiveness, adequacy, and sustainability of any intervention, as it also can provide an opportunity for empowerment. It has been noted that by “taking away responsibilities previously held by the survivor in an attempt to help him/her may enhance feelings of helplessness and impotence” (Tribe, 2007, p. 31). Having a sense of mastery of one’s life appears to be associated with resilience and recovery in the aftermath of trauma (Moran, 2009). Interventions, which provide individuals with an opportunity to engage in decision making, might play an important role in recovery from trauma. The participation of women survivors of SGBV in a sewing cooperative in Congo, which allowed them to make decisions about their futures, is one effort which aims to promote healing and self-sufficiency (Bentley, 2009). A number of boys in Kakuma camp in Sudan felt that their education was important, as they believed it was an important wish of their deceased parents. Information such as this can be invaluable to program design and implementation. Knowledge of these needs and ways to meet these needs would never have been known without the appropriate dialogue between provider and participant. Programs can best respond to individuals’ needs and promote their healing by hearing their perceptions and listening to their requests – as adequately as they can – despite limited resources. The importance of listening to refugees’ perspectives, for example, in the design of mental-health care services for them has been emphasized in detail by Watters (2001). The information acquired is critical in terms of designing an appropriate intervention. For example, in commenting on war-injured ex-soldiers in Nicaragua, Summerfield (1999, p. 1454) observed that “what interested them was their prospects for work and training.” Attention to Specific Needs and Vulnerable Groups in Settings. While this chapter describes interventions for general populations and includes examples of programs for specific vulnerable groups within each setting, efforts must be made to ensure that all individuals have access to services. Vulnerable individuals (e.g., people with disabilities, the elderly) are often excluded from mainstream efforts – in effect, “disabling” them and isolating them even further. Information should be provided in accessible formats, and steps taken to ensure the physical accessibility of common areas. Further, while this chapter focused primarily on adults, efforts should be taken to ensure that appropriate care is provided to children and adolescents who are in need. Promoting Justice and Human Rights. Any discussion of healing must necessarily take into account the larger context in which people live. This often necessitates attention to issues of justice and reconciliation (Summerfield, 2000). Healing is a very different task if an individual is forced to live in a society where perpetrators of mass human rights’ violations have not been held accountable (e.g., most of the perpetrators of vicious crimes against humanity in Cambodia during the reign of

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terror of the Pol Pot Regime were not brought to court or punished for decades). In many currently conflict-affected settings, perpetrators may still live within the community. As Staub et al. (2005, p. 302) note, “healing and reconciliation need to go together, especially when the groups that have engaged in violence against each other continue to live together.” Empowerment can ensure the voices of traumatized individuals are heard. This can lead to awareness raising in society, holding people legally accountable for their actions, and changing policy and legislation in the short term and long term. Ensure Monitoring, Evaluation, and Reporting. The future of helpful humanitarian assistance relies on a growing body of evidence, which demonstrates the effectiveness of such interventions in improving individual outcomes – not only those related to health, but also those related to overall individual and community well-being (e.g., productive activity, social integration). The existing knowledge base and catalog of effective practices must continue to grow. The importance of building evidence-based and best practices has been emphasized in the field of psychosocial assistance – but more evidence remains to be produced. The future development of the psychosocial field and emphasis on mental health and social activities, such as those described above, requires the same evidence-based research that has been responsible for moving forward interventions in other realms of assistance. Research should explore the impact of such interventions on various outcomes and should focus on short-term and long-term outcomes as is possible. Despite the professed parity of mental health among health workers and organizations, mental health often becomes less of a priority in the face of competing needs and limited resources. Without evidence to prove otherwise, the importance of mental health in recovery work is in jeopardy of becoming a lower priority, given that other areas have a significant research base and numerous evidence-based interventions.

Conclusion As noted in this chapter, a number of approaches to address the invisible wounds of war are available and have been undertaken among various populations suffering from trauma and related mental-health sequelae. There exist various sources for more detailed guidance in addressing these wounds, including the collaborative IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings (IASC, 2007). Just like targeted physical-health interventions, clinical mental-health interventions are urgently needed for civilians suffering from mass violence, especially for those who are experiencing difficulties in healing from their trauma. Further, while clinically focused interventions may be a priority for some survivors, those types of interventions alone are not adequate to restore, protect, and promote the health and well-being among traumatized populations – just as clinical interventions alone are not enough to address the needs of individuals with severe psychiatric disorders. Various types of interventions, including productive and/or social

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activities, as have been described in this chapter, can provide important mentalhealth benefits to an extremely vulnerable population. Concern for the mental health of conflict-affected populations must be equal to that afforded to physical health – both are equally present in the definition of health (WHO, 1948) and both are essential to achieving an individual’s overall well-being and quality of life. Because individuals’ mental health has clear implications for their physical health, their participation in the world around them, and their overall quality of life, the tendency to see mental health as distinctly separate from physical health must be avoided. Further, any difficulties faced in determining feasible, culturally appropriate, and effective interventions should not deter organizations and individuals from undertaking such efforts. The necessity for various approaches – clinical as well as those which join the psychological and the social – are clear, given the far reach of trauma. As Herman (1997) asserts, “because trauma affects every aspect of human functioning from the biological to the social, treatment must be comprehensive” (p. 156). Therefore, an understanding of the wide diversity of needs and options for psychosocial care and recovery should continue to be strengthened and included in the toolkit for humanitarian and development assistance to conflict-affected populations.

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WHO. (2003b). Traditional Medicine. Fact Sheet No. 134. Revised May 2003. Retrieved from September 27, 2009, from http://www.who.int/mediacentre/factsheets/2003/fs134/en/. WHO. (2008a). The global burden of disease: 2004 update. Part 4: Burden of Disease: DALYs. WHO: Geneva. (pp. 40–51). Retrieved September 5, 2009, from http://www.who. int/healthinfo/global_burden_disease/2004_report_update/en/index.html. WHO. (2008b). The global burden of disease: 2004 update. Retrieved September 14, 2009, from http://www.who.int/healthinfo/global_burden_disease/GBD_report_2004update_full.pdf. WHO & International Labor Organization (ILO). (2000). Mental health and work: impact, issues and good practices. Nations for Mental Health. Geneva: WHO & ILO. Retrieved August 31, 2009, from http://www.who.int/mental_health/media/en/712.pdf. World Health Organization (WHO). (1948). Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19–22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.

Chapter 11

Shame and Avoidance in Trauma K. Jessica Van Vliet

Abstract Shame is a painful emotion that often arises in the face of traumatic life events. In the context of war and armed conflict, trauma survivors may experience shame in response to their actions or as a consequence of their powerlessness to defend against attack. Shame can also result from injuries and disabilities sustained during conflict. If left unresolved, shame can interfere with recovery from trauma and prevent people from accessing vital sources of social support. Avoidance, a common defensive strategy for coping with shame and trauma, can be highly adaptive in the short term. As part of an intrapsychic trauma membrane that buffers shame and traumatic memories, avoidance may help reduce excessive emotional arousal, allowing the trauma survivor to bolster resources and process intrusive stimuli at a manageable pace. For helping professionals working with trauma survivors, an awareness of the possible presence of shame, as well as an understanding of the protective functions of avoidance, is essential. Gradual processing of traumatic and shame-eliciting material is necessary to avoid perforating the trauma membrane and causing further harm. For helping professionals working with the survivors of violent conflict, an understanding of shame and avoidance in response to trauma is essential. Shame is a basic human emotion that commonly arises during or after traumatic events. This emotion can be highly adaptive in promoting moral and pro-social behavior and in alerting individuals to threats to their relationships and social standing (Gilbert, 1998; Izard, 1977). However, shame may also pose a significant threat to the integrity of the self and trigger a range of psychological defenses and coping strategies. Avoidance, as one of the main defenses against shame and trauma, serves the vital function of reducing excessive emotional arousal activated by distressing events. It may also help preserve self-esteem in the face of significant loss and disruption. Along with its positive functions, however, avoidance can hinder the healthy resolution of trauma. This chapter provides an overview of shame and its relation to K.J. Van Vliet (B) University of Alberta, Edmonton, AB, Canada e-mail: [email protected]


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posttraumatic stress, followed by an exploration of avoidance, both in the general context of trauma and in the specific context of shame. The chapter ends with a discussion of guidelines and implications for post-conflict interventions.

Definition and Conceptualization of Shame Shame is an emotional state in which a person’s self-concept comes under intense attack. In the experience of shame, consciousness is directed toward perceived or actual deficiencies in the self’s behaviors, character, or bodily characteristics (Andrews, Qian, & Valentine, 2002). This negative self-focus is accompanied by the belief in having fallen short of self-ideals (Lewis, 1992; Tangney, Niedenthal, Covert, & Barlow, 1998). The entire self is judged as flawed, and there is a painful sense of being exposed to the outside world (Katz, 1997; Lindsay-Hartz, de Rivera, & Mascolo, 1995; Van Vliet, 2009). Gilbert (1998) has offered a useful distinction between internal shame and external shame. With internal shame, consciousness is directed at how people appear to themselves, from their own perspective. With external shame, the focus is on how one appears to others. Specifically, the individual feels exposed, unattractive, and lowered in other people’s eyes (Gilbert, 1997, 1998), and there is an overwhelming urge to hide from public view (Lewis, 1971; LindsayHartz et al., 1995; Van Vliet, 2008). Both internal and external shame typically result in a sense of separation from others or what Kaufman (1989) has described as the “breaking of the interpersonal bridge.” Significantly, a sense of alienation or emotional estrangement from others is also one of the hallmarks of posttraumatic stress disorder (PTSD; American Psychiatric Association [APA], 2000). While shame often co-occurs with guilt, and both involve a painful selfconsciousness along with negative self-appraisals, an understanding of the differences between these two emotions is important. Shame involves negative judgments about the entire self that disrupt and often damage the individual’s identity. Guilt, on the other hand, involves negative evaluations of one’s behaviors, with the sense of self typically left intact (Tangney & Dearing, 2002; Tracy & Robins, 2004). This difference is essentially the shame-based belief, “I am bad (or inadequate)” versus the guilt-based belief, “What I did was bad (or wrong).” Perhaps not surprisingly, shame is associated with greater psychological symptoms than guilt. Depression, posttraumatic stress, addictions, eating disorders, personality disorders, and violent behavior are among the many psychosocial problems linked to shame (Andrews et al., 2002; Brown, 2004; Lee, Scragg, & Turner, 2001; Leskala, Dieperink, & Thuras, 2002; O’Connor, Berry, & Weiss, 1999). Moreover, shame prompts a distancing from others and appears to interfere with the ability to experience empathy (Lewis, 1992; Lindsay-Hartz et al., 1995; Tangney & Dearing, 2002). Guilt, on the other hand, is rooted in empathy and sympathy toward others and motivates approach behaviors that are aimed at redressing the harm caused to other people through one’s actions (Gilbert, 2005; Tangney & Dearing, 2002). Shame must also be differentiated from its close cousin, humiliation. In the emotions literature, shame and humiliation have sometimes been conceptualized

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as existing on the same continuum, with humiliation representing an extreme form of shame (Nathanson, 1992; Tomkins, 1962). However, a number of theorists have pointed out crucial phenomenological distinctions between the two emotions (e.g., see Gilbert, 1998; Klein, 1991; and Miller, 1988). With shame, harsh negative judgments are levied against the self, and there is usually considerable self-blame for one’s perceived loss of social status. In contrast, humiliation involves the experience of feeling disrespected and disempowered by others (Klein, 1991; Miller, 1988). The humiliated person’s focus is on the perceived wrongful actions of other people, without the self necessarily being judged as bad, unjust, or blameworthy (Gilbert, 1998). Importantly, humiliation often leads to feelings of shame. For example, torture victims may feel shame for being unable to defend themselves against the humiliation suffered at the hands of their tormentors (Wilson, Droždek, & Turkovic, 2006).

Shame and Posttraumatic Stress Increasingly, shame has been recognized for its role in the phenomenology and perpetuation of posttraumatic stress. A number of researchers have found positive correlations between shame and posttraumatic stress symptoms in combat veterans (Leskala et al., 2002; Wong & Cook, 1992), violent crime and rape victims (Andrews, Brewin, Rose, & Kirk, 2000; Vidal & Petrak, 2007), and survivors of childhood sexual abuse (Feiring, Taska, & Lewis, 2002). Shame-proneness, which is the characterological propensity to experience shame, has been found to predict PTSD symptoms in trauma victims (Andrews et al., 2000; Feiring et al., 2002). For example, Andrews et al. (2000) found that in a sample of 157 victims of violent crime, shame-proneness independently predicted PTSD symptoms 6 months following victimization. At the same time, trauma can generate debilitating shame reactions in individuals who are not highly prone to shame (Leskala et al., 2002). Furthermore, shame can impede the emotional processing of the trauma and prolong the course of PTSD (Brewin, Dalgleish, & Joseph, 1996; Feiring et al., 2002). Lee et al. (2001) distinguished between peri-traumatic shame, which arises as a primary emotion during a traumatic experience, and posttraumatic shame, which occurs as a secondary emotion following a traumatic event. Traumatic situations associated with social threat and disempowerment may activate peri-traumatic shame. For instance, shame may be elicited as a primary emotion during incidents of interpersonal violence, physical injury, and personal boundary violations. After the event, posttraumatic shame may result from the attributions that occur as part of the individual’s meaning-making process. In particular, individuals commonly blame themselves for their perceived failures or transgressions in the trauma situation and regard their shortcomings as global and stable characterological flaws (Van Vliet, 2009). Intrusive and recurrent images of their own inadequacy during the event, combined with the perception that their actual selves fell short of their selfideals, can generate intense feelings of internal shame. Individuals may also suffer external shame in response to other people’s negative judgments about their actions,

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regardless of whether these judgments are real or imagined. Furthermore, posttraumatic symptoms, such as flashbacks, dissociation, and depressive states, can become painful sources of shame, as individuals berate themselves for their difficulties with coping (Ehlers & Steil, 1995; Stone, 1992). Where the traumatic event resulted in injuries or disabilities, shame can be that much worse. Wright (1983) has written poignantly about how people with various types of disabilities often feel “set apart” from others and struggle with acute feelings of shame and diminished self-worth. Similarly, Phemister and Crewe (2004) noted how visible disabilities often carry social stigma, where social stigma is defined as “a socially constructed phenomenon that may serve as a constant reminder to persons with disabilities that society views them as ‘different’ and devalues them as a result” (p. 33). Shame may be heightened by the sense of powerlessness to prevent the injury or to restore the body to its previous, non-disabled state (Wright, 1983). Moreover, after suffering a permanently disabling injury, people may be riddled with shame and self-blame about choices they made immediately before the injury (Lohne, 2009). With post-conflict trauma survivors who were victims of wartime crime, terror, and dislocation, significant shame can result from the realization of their own powerlessness to defend themselves against attack or to help other victims (Stone, 1992; Wilson et al., 2006). In his reflections on the nature of the shame in response to wartime torture, Shapiro (2003) noted that torture victims’ lack of blameworthiness for the actions carried out against them might be expected to prevent or eliminate their shame. However, according to Shapiro, the opposite is more likely: It is the victim’s helplessness to resist the torture that itself becomes the source of shame. As an example, one need only look at the extreme shame that so many Holocaust victims experienced from being stripped of their basic human dignity (Rabkin, 1976). Ironically, for the perpetrators, actions that in peaceful times would be considered repugnant and shameful often do not elicit shame during combat situations. As some theorists have noted, the conditions of war may instill a set of values and morals that justify, and in some cases, condone acts of brutality (Shapiro, 2003; Wilson et al., 2006). Rather than engendering shame, such acts may be seen as signs of military toughness and become sources of pride (Shapiro, 2003). On the other hand, soldiers’ failure to live up to expectations of their fellow military personnel, even if those expectations involve committing atrocities, may cause shame (Singer, 2004). Upon returning home, combat veterans may be met with shame and confusion in the clash between wartime values and the values of home (Singer, 2004; Wilson et al., 2006). This could be seen in the aftermath of the Vietnam War, when public opinion had turned against the war, and many veterans returning to the United States were met with derision for having contravened societal values and standards (Singer, 2004). As Lindy and Titchener (1983) have noted, these people were thus alienated from the recovery environment so necessary for healing. The high rates of suicide among Vietnam war veterans, when considered in light of research suggesting that shame may be a factor in suicidal ideation and completion (Hastings, Northman, &

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Tangney, 2000; Lester, 1998; Mokros, 1995), point to a possible role that shame may have played in this tragic loss of life. More research is needed to better understand the relationship between shame and suicide in survivors of war and conflict.

Definition and Conceptualization of Avoidance Closely related to shame, avoidance is a defensive response often elicited in the face of trauma and negative affect. While avoidance is recognized as a means of coping with stressors, definitions of avoidance vary widely. Avoidance has sometimes been described as involving conscious efforts to direct attention away from thoughts and feelings related to a distressing event (e.g., see Horowitz, 1986; Livneh, 2009a). This is in contrast to denial, which is seen as more unconscious in nature. Yet, others have regarded avoidance as involving the unconscious disavowal or minimization of negative experiences, and the terms avoidance and denial have been used synonymously in this sense (e.g., see Nathanson, 1992). Conceptualizations of avoidance also differ in the extent to which behavioral, cognitive, and emotional processes are emphasized. Some theorists have viewed avoidance as consisting primarily of overt behaviors, such as distraction or substance use/abuse, to defend against threatening stimuli (e.g., see Endler & Parker, 1990). More commonly, avoidance is viewed in broader terms to additionally encompass cognitive and emotional avoidance processes, such as numbing and thought suppression (e.g., see Carver, Scheier, & Weintraub, 1989; Ehlers & Steil, 1995; Holahan, Moos, Holahan, Brennan, & Schutte, 2005; Zeidner & Saklofske, 1996). In the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) criteria for PTSD, avoidance is one of three major symptoms clusters that includes the persistent avoidance of stimuli (i.e., thoughts, feelings, conversations, people, activities, and places) associated with the trauma, as well as numbing, emotional distancing, and estrangement from others (APA, 2000). In this chapter, the terms avoidance and avoidance coping are used broadly and interchangeably to refer to cognitive, emotional, and behavioral coping strategies for diverting one’s attention away from painful stimuli. Denial, distraction, social withdrawal, fantasy, substance use or abuse, numbing, dissociation, thought suppression, minimization, emotional detachment, and behavioral disengagement or distancing from a stressor are among the most common forms of avoidance (Carver et al., 1989; Ehlers & Steil, 1995; Kenardy & Tan, 2006). These strategies differ in the degree to which they are conscious or unconscious. What unites them are the function and motivation, whether conscious or not, to escape distress. Moreover, as with coping in general, avoidance strategies are dynamic processes that fluctuate over time (Lazarus & Folkman, 1984; Livneh, 2009a; Zeidner & Saklofske, 1996). Temporary avoidance responses, if used repeatedly or sustained over a prolonged period, can become characterological traits (Honig, Grace, Lindy, Newman, & Titchener, 1999). Paunovic (1998), for example, pointed out how cognitive avoidance strategies, such as emotional detachment and thought suppression,

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which were instilled during combat training, can solidify into perpetual habits in combat veterans. Temporary avoidance strategies during combat can also develop into the avoidance cluster of PTSD symptoms. Avoidance coping can co-exist with other forms of coping in particular situations. Lazarus and Folkman’s (1984) distinction between problem-focused coping and emotion-focused coping is relevant here. Problem-focused coping involves responses aimed at changing the source of the stressor or the person’s relationship to the environment, while emotion-focused coping consists of attempts to reduce the emotional distress associated with a problematic situation rather than solving the problem itself. From this perspective, avoidance coping can be seen as a form of emotion-focused coping (Carver et al., 1989; Kenardy & Tan, 2006) and can co-exist with problem-focused coping. Additionally, avoidance strategies can be thought of as multi-faceted processes that vary in appearance, meaning, and degree, depending upon the particular person and situation. For example, denial, an avoidance strategy that has been researched extensively in the literature on coping, presents as a complex and multi-faceted construct in Breznitz’s (1983) well-known model of denial and stress. Breznitz identified seven types of denial that, in general, progress from relatively mild to extreme distortions of reality. These include: (a) the denial of personal relevance of the threat, (b) denial of the threat’s urgency or danger, (c) denial of personal vulnerability or responsibility, (d) denial of negative affect related to the threat, (e) denial of the relevance of any negative affect that is acknowledged, (f) denial of threatening information through selective inattention, and (g) complete and indiscriminate disavowal of threatening information. Breznitz’s model underscores the importance of considering the idiosyncratic meanings and manifestations of denial, as a form of avoidance, in specific contexts.

Avoidance and Trauma Adaptive Functions of Avoidance As a defensive response to trauma, avoidance serves several adaptive functions. A key function is to protect against emotional flooding or intolerable levels of negative affect. Avoidance can provide temporary relief from emotional pain, whereby those who have experienced trauma can regroup and shore up their coping resources (Lindy & Wilson, 2004; Zeidner & Saklofske, 1996). The buffering effects of two forms of avoidance, namely denial and numbing, figure prominently in Horowitz’s (1986) seminal theory on posttraumatic response processes, which maintains that trauma is resolved through a process of oscillation between emotional numbing and denial of the traumatic event on the one hand and intrusion of traumatic memories on the other. Alternation between these polarities is believed to be a normal aspect of “working through” and an eventual “completion” of the trauma. Stated in another way, denial allows trauma to be processed in manageable “doses” over time. Based

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on Horowitz’s theory, it is thus possible to regard some manifestations of avoidance not as an indication of psychological disorders, but rather as a signal that further processing of a traumatic event is needed (Joseph & Linley, 2008). The notion of dosing has appeared in other theories on how people cope with distressing life events. For example, in their dual-process model of coping with bereavement, Stroebe and Schut (1999) explained how the loss of a loved one is followed by oscillation between loss-oriented coping and restoration-oriented coping. With loss-oriented coping, the bereaved person’s attention is focused primarily on the grief and other negative affect associated with the loss. Confrontation of the loss is a necessary and adaptive part of the grieving process. If pursued relentlessly, however, confrontation can impair well-being and interfere with other necessary tasks related to bereavement. Therefore, loss-oriented coping needs to occur in doses, in conjunction with distancing from the grief through a restoration orientation. Restoration-orientated coping involves attending to life changes, engaging in new activities, distracting oneself from grief, denying and ignoring the grief, and developing new roles, identities, and relationships. Two additional concepts, those of the trauma membrane and the recovery environment (Lindy, 1985; Lindy, Grace, & Green, 1981) help to illuminate the role of avoidance in coping with trauma. Lindy and his colleagues observed how, in the aftermath of man-made or natural disasters, trauma survivors commonly find themselves surrounded by groups of family members, partners/spouses, close friends, and other trusted people from the survivor’s social network. These groups, which can develop at an individual or communal level, shield traumatized people from stressors that could interfere with healing. Metaphorically, the trauma membrane serves as a protective layer encapsulating a recovery environment or “safe space” (Lindy & Wilson, 2004, p. 442), in which healing processes—including the avoidance of intrusive stimuli and traumatic memories that could potentially overwhelm coping resources—can occur without major disruption. Moreover, an individual’s trauma membrane may also include avoiding “outsiders,” who could pose a potential threat to the homeostasis developing beneath the surface of the membrane (Lindy et al., 1981). One result of this phenomenon is that, during post-conflict rehabilitation, helping professionals may often struggle with gaining admission into the recovery environment. This may be particularly frustrating for helpers who, though well intentioned in their offers of assistance, may lack an understanding of the adaptive role of avoidance and the trauma membrane in recovery from trauma. Another important function of avoidance is the preservation of self-esteem. As discussed above, trauma can take a serious toll on people’s beliefs in their selfworth. Threats to self-concept can be neutralized through denial, minimization, distraction, and other avoidance strategies (Elison, Lennon, & Pulos, 2006; Yelsma, Brown, & Elison, 2002). Where trauma has resulted in disability, avoidance strategies, such as the use of denial, can protect against a perceived loss of social desirability and value (Wright, 1983). Based on an extensive review of literature on the role of denial in people with chronic illness and disability (CID), Livneh (2009a) concluded that denial can be instrumental in preserving self-esteem and a positive self-image in the face of CID. Moreover, by downplaying the seriousness and

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implications of an unacceptable reality, denial can bolster motivation and hope and help combat the sense of powerlessness that typically accompanies disability. This relates to the pioneering work of Taylor and Brown (1988), who argued that “positive illusions,” defined as “unrealistically positive self-evaluations, exaggerated perceptions of control or mastery, and unrealistic optimism” (p. 193), which often occur as part of normal thinking, are positively related to psychological well-being.

Costs of Avoidance Although avoidance may be of significant benefit to survivors of trauma, it has also been associated with a range of psychological costs, including depression, stress, addictions, and the maintenance of posttraumatic symptoms (Ehlers & Steil, 1995; Elison et al., 2006; Holahan et al., 2005; Kenardy & Tan, 2006). Ullman, Townsend, Filipas, and Starzynski (2007) found that reliance on avoidance strategies, including distraction, denial, and behavioral disengagement (e.g., giving up attempts at coping) was positively related to PTSD symptoms among survivors of sexual assault. These findings were consistent with other studies that linked denial, behavioral disengagement, and social withdrawal to poorer outcomes for rape victims (Frazier, Mortensen, & Steward, 2005; Ullman, 1996). The specific processes involved in the perpetuation of PTSD symptoms through avoidance have been the subject of considerable interest. Foa and her colleagues (Foa & Kozak, 1986; Foa, Steketee, & Rothbaum, 1989) have argued that in order for trauma to be resolved, fear networks associated with trauma need to be activated so that the meaning of trauma-related memories can be reinterpreted, and the traumatic event can be integrated into conscious experience. By interfering with fear activation, avoidance may block the emotional processing of trauma (Foa & Kozak, 1986; Rachman, 2001). Ehlers and Steil (1995) have suggested that PTSD is perpetuated in part by idiosyncratic negative interpretations of intrusive recollections. These interpretations are thoughts related to the self, others, or the world that conflict with existing assumptions and beliefs and are deemed unacceptable (see also Janoff-Bulman, 1992). For example, intrusive memories may be interpreted as negative thoughts, such as that the self has been permanently damaged or that the world is an unjust place. Behavioral and cognitive avoidance are then generated as a way of controlling intrusion and, by extension, diverting attention away from catastrophic possibilities. Although avoidance strategies may help ward off anxiety in the short term, they can block out corrective information necessary for changing the meaning of traumatic events over time. In the context of CID, avoidance may have several other negative consequences. As Livneh (2009a) has pointed out, denial can be non-adaptive or even life threatening if it (a) keeps a person from taking necessary action such as seeking medical attention; (b) takes the form of dangerous or destructive behaviors, such as drug abuse or operating heavy equipment in an incapacitated state; (c) keeps a person from mastering skills needed for effective functioning; and (d) disconnects the

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person from sources of social support over an extended period of time. Various forms of avoidance can also be non-adaptive if used to the exclusion of active problem solving (Zeidner & Saklofske, 1996). A conclusion that can be reached from the foregoing discussion is that the value of avoidance depends upon the specific duration and context in which it occurs. In the short term, some avoidant strategies, such as distraction and the denial of negative affect, can be highly effective in restoring normal functioning (Livneh, 2009a; Ullman et al., 2007; Zeidner & Saklofske, 1996). As Lazarus and Folkman (1984) have indicated in their theory of emotion-focused coping, avoidance may be particularly helpful in situations where the stressor is uncontrollable or cannot be changed. However, the same strategy that is adaptive in the short term can become nonadaptive if sustained over an extended period of time, especially in situations where action or problem-focused coping is necessary to change the person’s relationship to the environment.

Shame Avoidance Given its extensive threat to identity, shame automatically activates an arsenal of defensive processes and strategies aimed at preserving the integrity of the self. Denial, as a form of avoidance that protects the self from being overwhelmed, plays a key defensive function in response to shame (Kaufman, 1989; Nathanson, 1992). With denial, a person unconsciously disavows feelings of shame. Among some psychodynamic thinkers, bypassed shame refers to denial and repression as a means of avoiding the aggressive tendencies that emerge in response to shame (Lewis, 1971). The concept of bypassed shame was first introduced by H. B. Lewis, who regarded all emotions, including shame, as being embedded in the life-long attachment system. In her theory, shame occurs in response to perceived rejection from important attachment figures, beginning with the primary caregiver. This perception prompts narcissistic rage and aggression, as a protest against the severance of attachment ties. If left unchecked, these aggressive impulses further damage the valued relationship. Shame is therefore bypassed or denied as a means of keeping the relationship intact. Coming from a biopsychoevolutionary perspective, Gilbert and Procter (2006) stated that the need to feel loved and accepted is wired into our brains, as our very survival in the past may have depended on social acceptance. Shame, as a signal of rejection, registers as a basic survival threat in the nervous system. As a result, humans automatically develop strategies, such as dissociation, denial, and anger, to protect the self. Nathanson (1992) identified four major strategies that comprise the “compass of shame,” which is invoked to defend against shame. These include avoidance, attack other, attack self, and withdrawal. Avoidance, as Nathanson used the term, includes strategies through which humans “attempt to avoid, disguise, prevent, elude, or circumvent” shame (p. 339). Common manifestations of avoidance include perfectionism, excessive striving for power or achievement, and excessive pre-occupation

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with managing one’s image. Other theorists have pointed out how avoidance can manifest itself in shamelessness and extreme forms of narcissism (Broucek, 1991; Lewis, 1987; Morrison, 1989). Shame avoidance may also prolong the course of PTSD and impede emotional healing of the trauma (Feiring et al., 2002). The response of attacking others, similar to Lewis’s (1971) notion of narcissistic rage, is an attempt to defend against shame-induced powerlessness through actions, such as blaming, belittling, and harming, all aimed at disempowering others. As Kaufman (1985) stated, blaming and humiliating other people are means of transferring shame onto others to avoid one’s own feelings of shame. With the strategy of attacking the self, a person exhibits anger, contempt, disgust, and derision against the self. In essence, this strategy is a means of forestalling the punishing judgments of others by judging oneself first. Paradoxically, attacking the self sometimes serves the defensive function of increasing a sense of hope and control (Gilbert & Irons, 2005). For example, there may be the largely unconscious belief that “If I beat myself up enough, I’ll make fewer mistakes and have less cause for shame.” Moreover, a sense of control can be increased by attacking the self before others do (Driscoll, 1988). Withdrawal, the fourth major defense in Nathanson’s (1992) compass of shame, involves leaving the social arena and retreating into the privacy of one’s inner world so that “the wounds of shame. . .can be licked until the pain has decreased enough to permit re-entry into the ever-dangerous social milieu” (p. 318). If shame involves the sense of having one’s inadequacy exposed to the outside world, then withdrawal provides an escape from public view. However, temporary relief from exposure can come at a high cost. Withdrawal can exacerbate the painful sense of isolation associated with shame, thus increasing the risk of depression (Scheff, 2001; Thompson & Berenbaum, 2006). Furthermore, the tendency to avoid social contact, prompted by the fear of rejection, can severely impede help-seeking behaviors (Crossley & Rockett, 2005; Lee et al., 2001; Moor, 2007; Van Vliet, 2008). Moor (2007), for example, explored how self-blame, victim-blaming, and the social stigma associated with rape often prevent rape victims from disclosing their trauma and seeking the social support that could help in their recovery. Disclosures of trauma—or more specifically, how other people respond to these disclosures—can exacerbate shame and prompt further social withdrawal. Ullman et al. (2007) found that rape victims who received negative reactions from others in response to disclosure of the rape were more likely to engage in avoidance coping and self-blame. The potential negative consequences of disclosure are borne out in a review by Kelly and McKillop (1996), who concluded that disclosures of a traumatic or deeply embarrassing nature often increase anxiety and stress in the listener, resulting in avoidance, rejection, or negative judgment toward the discloser. Despite the potentially harmful consequences of avoidance, these defensive strategies can also be highly adaptive ways of coping with shame. As mentioned above, avoidance can help mitigate damage to the self. In research on how adults bounce back from significant experiences of shame, Van Vliet (2008) found that avoidance of shame feelings through denial, minimization, repression, and

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rationalization often allows individuals to refocus their attention on actions, personal strengths, and interpersonal relationships that enhance the self. In other words, avoidance can serve the important function of providing a buffer behind which individuals may bolster their internal and external resources until they are ready to process the shame experience. This echoes the adaptive function of avoidance and the intrapsychic trauma membrane in response to trauma. In the context of shame, the interpersonal trauma membrane can be seen as a way of protecting those people suffering from shame by surrounding them with understanding and compassion.

Guidelines and Implications for Helping Professionals For helping professionals working with the survivors of war and armed conflict, the functions of avoidance need to be understood, and defenses should be approached with caution and care. As Lindy and Wilson (2004) have stated, helpers need to “do no harm” by “respecting the trauma membrane” (p. 432). Considerable sensitivity is needed to avoid perforating the interpersonal protective layer that forms around individuals or groups of people to ward off further harm. In the aftermath of shame and trauma, avoidance can be taken as a possible signal of the need to strengthen individual or collective resources before processing the distressing experience. Moreover, helpers must attend to the place of avoidance, as part of an intrapsychic trauma membrane, in the overall processes of healing. For example, a person may be in the process of oscillating between denial and intrusion as part of “working through” trauma to completion (Horowitz, 1986). Dosing (Horowitz, 1986) or titrating (Levine, 1997) the exposure to distressing material helps ensure that emotional arousal and intrusion do not overwhelm the capacity to cope. In cases where avoidance is chronic or non-adaptive, gentle confrontation may be necessary in order to promote healthy functioning. For instance, a person may need to face the existence and implications of a disability, in order to effectively adjust to a changed relationship with themselves and the environment. However, considerable care must be taken in the timing and intensity of confrontation. The individual must have adequate coping resources to tolerate the confrontation, and a stable and secure therapeutic alliance must be in place (Livneh, 2009b). Moreover, confrontation should help increase awareness and insight without stripping the individual of hope (Breznitz, 1983; Livneh, 2009b). Where shame is present, therapeutic interventions should help counter the sense of alienation that comes with this emotion and help restore the severed connection to the human community. In large part, this is accomplished through caring and accepting relationships. Van Vliet (2008) identified connecting as a core process in overcoming shame. By connecting to sources of support within one’s existing social network and forming new affiliations, people can rebuild their sense of being valued members of society. Of course, this may be easier said than done, as it may be difficult to counteract the tendency for people to withdraw in response to shame and thus avoid others. Given how shame intensifies sensitivity to judgment and fear of

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rejection, therapists and others involved in rehabilitation efforts must be take great care to communicate non-judgment and compassion at all times. This echoes the therapeutic conditions of acceptance, understanding, and unconditional positive regard at the heart of Rogers’ (1961) person-centered therapy. Together, the conditions create a sense of safety that soften the individual’s defenses and allow natural healing processes to emerge. In addition, helpers should honor clients’ choices to disclose or not disclose shame-laden events, without placing pressure on them to move beyond their own pace. Because trauma victims often blame themselves for key aspects of their trauma experience, it is essential to explore the causal attributions and beliefs that perpetuate posttraumatic shame. Victims can be helped to identify external factors that caused or contributed to the traumatic event, and individuals may need to hear the words, “It’s not your fault.” Van Vliet (2008) suggested that therapists help their clients resist social practices and attitudes, such as prejudice and stereotyping, that have been internalized and have contributed to their shame. Victim-blaming can also lead to shame and self-blame. Moor (2007), for example, has described how victim-blaming and rape myths perpetuate shame in rape victims. At the same time, one needs to recognize that self-blame, however unfounded it may seem from the outside, may serve the protective function of increasing a victim’s sense of control, particularly if the perceived causes are seen as being temporary and changeable (Dalenberg & Jacobs, 1994; Janoff-Bulman, 1979; Moor, 2007). In such cases, a useful distinction can be made between judgments of responsibility for causes and judgments of responsibility for solutions (Brickman et al., 1982). Victims can be reminded that although they were not responsible for the traumatic event and were powerless to stop it from occurring, they have the responsibility and means to exercise greater control over their future safety and well-being. Where shame resulted from harm caused to others, helpers may feel particularly challenged in avoiding the judgments that perpetuate shame. Acceptance and understanding may be particularly difficult when working with individuals whose past actions would be judged as “bad” or “evil” by most moral standards. However, acceptance, as conceptualized here, in no way means moral relativism or failure to hold people responsible and accountable for their actions. Rather, when working with shame, one must separate out the person from the person’s actions and help the client do the same. Ideally, shame-distressed clients will shift from “I am bad” to “What I did was bad, but that doesn’t mean I am a bad person” (Van Vliet, 2008). Taking responsibility for one’s actions, as well as the harm caused by one’s actions, can be a crucial step toward shame reparation. In helping individuals cope with self-blame, emphasis should be shifted from the global and immutable aspects of the self to specific behaviors that can be changed. As with trauma, it can also be helpful to discuss social and cultural beliefs that contributed to the perpetrator’s actions. For example, an understanding of how war encourages dehumanization of “the enemy” and sets into motion forces that can lead people to commit “evil” actions can help reduce shame (see Zimbardo, 2007). Furthermore, in working with perpetrators, compassion can be increased through recognizing that all

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human beings—including helping professionals—have the potential for moral and immoral actions. Indeed, recognition of the universality of the human experience is considered by some researchers to be one of the central elements of compassion (e.g., see Neff, 2003). Compassion-focused therapy, an approach that has recently emerged to help counter shame and self-criticism through the development of selfcompassion (Gilbert & Irons, 2005; Gilbert & Procter, 2006), may be particularly helpful here. Finally, shame can be normalized as a basic human emotion with an essential purpose. By sensitizing individuals to others’ opinions, shame promotes moral and pro-social behaviors and helps preserve the fabric of society, as well as the individual’s place and relationships within society (Gilbert, 1998; Izard, 1977; Kaufman, 1989; Van Vliet, 2008). From this perspective, shame can be reframed as an opportunity to revisit and recommit to core values.

Summary Shame is a painful, self-conscious emotion often experienced in response to traumatic events. In the days, weeks, and years following violent conflict, survivors of trauma may feel intense shame for the events that occurred during the upheaval. While shame is important for alerting people to threats to their relationships and social place, it can also interfere with recovery from trauma. Avoidance, as a means of coping with the emotional pain of shame and trauma, can be highly adaptive in the short term and when the source of distress is unchangeable. As part of an intrapsychic trauma membrane that provides a protective buffer against shame and traumatic memories, avoidance can help create a healing space in which resources can be strengthened and intrusive stimuli can be slowly processed. Helping professionals, who are working with trauma survivors, need to be aware of the presence of shame and avoidance in their clients. An understanding of the nature and functions of avoidance is essential in facilitating therapeutic interventions. Interventions should be aimed at restoring the individual’s and community’s connection to the outside world, while at the same time honoring avoidant defenses. To prevent further harm, exposure to shame-invoking and traumatic stimuli should be gently titrated over time. In an environment of compassion and acceptance, trauma survivors can begin the delicate work of restoring themselves to wholeness.

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Chapter 12

Psychosocial Adjustment and Coping in the Post-conflict Setting Erica K. Johnson and Julie Chronister

Abstract Individual and collective responses to trauma influence the way scholars and clinicians think about the stress response and the survivor network. Stresscoping concepts are integral to the manner in which individuals and communities cope with trauma in post-conflict societies. The salience of social support and psychological resilience, as additional concepts through which work with survivors can be approached, offer opportunities for facilitative intervention. This chapter provides a review of the literature addressing individual and collective responses to trauma, and non-adaptive responses to trauma such as stress, anxiety, and mood disorders. This chapter also provides a review of current concepts related to coping and social support and the manner in which these concepts have been characterized in post-conflict settings. Finally, this chapter concludes with considerations of the manner in which the concepts of individual and communal resilience relate to the trauma membrane and encourage thinking about capacity building that supports a healing environment for those in post-conflict societies.

Introduction Coping behavior can provide powerful insights into the ways in which a trauma membrane can be facilitated and supported for individuals and communities in postconflict situations. In order to appreciate the complexity of the relationship between coping and the trauma membrane or coping and supporting individuals as they recover from conflict-based trauma, an appreciation of the manner in which people respond to traumatic stress is needed. This range of responses, both typical and atypical, can stimulate thinking about the manner in which a trauma membrane can be developed and sustained for individuals recovering from trauma. To that end, this E.K. Johnson (B) Western Washington University, Bellingham, WA, USA; University of Washington, Seattle, WA, USA e-mail: [email protected]


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chapter will first review the literature addressing individual and collective responses to trauma and non-adaptive responses to trauma such as stress, anxiety, and mood disorders. Subsequently, a review of critical concepts related to coping with stress and the manner in which these concepts can inform thinking about the trauma membrane will be presented. Finally, this chapter will conclude with a discussion of the ways that the trauma membrane can support adaptive coping by considering both stress and resilience in individuals and communities.

Normative Responses to Stress and Trauma People living in conflict or war zones are subject to a variety of unusual stressors, both in terms of their scope and severity. The research literature on civilian post-traumatic stress in conflict zones indicates prevalent stressors include experienced or witnessed physical and sexual assault; experience of severe physical injury and threat of death; witnessing unnatural death of family or friends; loss of family members, as well as possessions and property; being confined to home or forced to hide because of danger; forced evacuation under dangerous circumstances; and combat experience (Farhood, Dimassi, & Lehtinen, 2006; Obilom & Thacher, 2008; Thapa & Hauff, 2005).

The Stress Response Stress, regardless of cause, is commonly conceptualized as involving related and interactive types or levels, namely systemic or physiological, psychological, or social/communal (Monat, Lazarus, & Reevy, 2007; Selye, 1976; Smelser, 1963). Systemic/physiological stress refers to the body’s stress response, whereas psychological stress refers to the cognitive and emotional variables that contribute to the appraisal of threat. Social/communal stress places an emphasis on the disruption of social systems or units in the context of a stressor. The physiological and psychological domains uniquely interact and influence each other during the stress response. In the presence of a stressor, the body naturally engages in a physically and mentally reflexive “fight or flight” response, which prepares the individual to either escape (flight) or ward off (fight) the stressor. This response is characterized by arousal of the autonomic nervous system, whereby heart rate, respiratory rate, and blood pressure increase; stress hormone levels (i.e., adrenaline) increase; sensory systems alter; attention is concentrated to the immediate threat at hand; typical perceptions of pain, fatigue, and hunger are altered, such that the individual is able to disregard them; and intense emotions are evoked (Selye, 1976). Commonly, emotional states associated with the stress response include fear and anger, although envy, jealousy, anxiety, guilt, shame, and sadness are proximally related to the stress response as well. Distal emotional states include an array of positive emotions such as happiness, pride, love, and gratitude

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and are commonly associated with coping efforts (Lazarus, 2007). These systemic changes in arousal, attention, perception, and emotion are normal and adaptive to the degree that they facilitate the individual’s ability to terminate an immediate threat or danger (Herman, 1997). These stress reactions strongly persist in the presence of the actual threat and as such this stress response may be sustained in conflict environments characterized by sustained, prolonged violence (Yehuda, Bryant, Marmar, & Zohar, 2005). The socio-cultural level of stress warrants particular mention in an examination of war and post-conflict rehabilitation to the degree that social conflict and war engender stress reactions in both individuals and social groups. Within the socio-cultural context, war contributes to social strains, which produce stress in both individuals and groups (Lazarus, 2007; Smelser, 1963). Collective responses to traumatic events include emotional distress and increased observations of medically unexplained symptoms that may be conceptualized as physical manifestations of stress (e.g., hyperventilation, dyspnea, dizziness, nausea, headache, syncope, gastrointestinal distress, and agitation) (Lacy & Benedek, 2003). Social symptoms include diminished confidence in government; anger with government leaders and people of authority; social isolation; and demoralization (Lacy & Benedek, 2003; Ursano, Fullerton, & Norwood, 1995). Research in the traumatic stress literature indicates that the majority of people and communities show symptoms of arousal, which are considered normal reactions to unusual events, which resolve fairly rapidly without complication, and which are helped by rest, reassurance, support, education, and information. Further, in the context of collective traumatic events, an epidemic of post-traumatic stress disorder (PTSD) is improbable, even within vulnerable populations, such as veterans of war (Boscarino, Galea, Ahern, Resnick, & Vlahov, 2002; Rosenheck & Fontana, 2003; Vazquez & Perez-Sales, 2007). At the community level, collective action is most commonly effective, adaptive, and cooperative, and groups of people tend to be resourceful in the face of post-disaster response (Glass & SchochSpana, 2002; Lacy & Benedek, 2003; Norris, Stevens, Pfefferbaum, Wyche, & Pfefferbaum, 2008). To draw a parallel to the concept of the trauma membrane, the community may become the post-conflict survivor network, where the experience of trauma is arguably universal and healing is possible through collective action.

Non-adaptive Responses to Stress and Trauma Conflict and trauma occur cross-culturally in a cultural context. Although the physical and health conditions are viewed as stable characteristics between cultures and societies in conflict, the psychological responses to stressors associated with conflict and loss tend to differ between cultures (Doherty, 1999; Lechat, 1990). This poses certain challenges to characterizing the typical psychological responses and the prevalence of psychiatric disorders that occur in the context of war and terrorism, although generally speaking, the most frequent disorders include PTSD,

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depression, and anxiety (de Jong, Komproe, & Van Ommeren, 2003; Golier, Yehuda, Schmeidler, & Siever, 2001; Murthy, 2007; Roberts, Damundu, Lomoro, & Sondorp, 2009; Thapa & Hauff, 2005; Yaswi & Haque, 2008).

Stress Disorders The Diagnostic and Statistical Manual-IV-TR (DSM-IV-TR; American Psychiatric Association [APA], 2000) delineates extreme responses to trauma based on expert consensus. Acute stress disorder (ASD) and PTSD are the diagnostic labels applied to a constellation of symptoms that are representative of an anxiety-based reaction to exposure to an extreme stressor that provokes fear, helplessness, or terror in response to the threat of injury or death. From a clinical and diagnostic standpoint, ASD develops within 1 month of exposure to the traumatic stressor. During and/or after the event, the individual experiences a number of dissociative symptoms, such as numbing, detachment, and depersonalization, as well as re-experiencing, avoidance, anxiety/increased arousal, and impairment in role functioning. Symptoms occur for up to 4 weeks after the event. The DSM-IV-TR indicates prevalence rates between 14 and 33% for ASD (APA, 2000). Available research with post-conflict survivors reported rates from 4.3 to 20.3% (Cohen, 2008; Cohen & Yahav, 2008; Yahav & Cohen, 2007), varying based on age (e.g., higher prevalence estimates in younger adults) and ethnicity (e.g., higher rates in Arab versus Jewish citizens after the second Lebanese war in 2006). One of the primary distinguishing characteristics between ASD and PTSD is temporal, where the diagnosis of PTSD is applied to individuals who experience persisting symptoms over 4 weeks (APA). While not every person with ASD goes on to develop PTSD, research indicates ASD is a risk factor for later development of PTSD (APA, 2000; Yehuda, 2002). Specifically, the severity of acute symptoms or a diagnosis of ASD has some positive predictive power in relation to a chronic PTSD diagnosis (Bryant, Creamer, O’Donnell, Silove, & McFarlane, 2008; Denson, Marshall, Schell, & Jaycox, 2007). Broadly, PTSD symptoms, as outlined by professional consensus in the DSMIV-TR, are categorized into three primary domains: hyperarousal (e.g., hypervigilance; irritability), numbing/avoidance (e.g., inability to recall important aspects of the trauma; feeling emotionally distant; avoiding cues or reminders), and reexperiencing (e.g., recurrent and distressing recollections of the event; dreams and flashbacks). Debate exists in the research literature as to whether numbing and avoidance represent intercorrelated, yet distinct, dimensions of PTSD. Specifically, several researchers have conducted factor analytic studies to address symptom clusters in PTSD, although consensus in the field has yet to be reached. This lack of consensus is chiefly due to methodological issues related to sample population and goodness-of-fit standards, as well as a paucity of consistent replication of findings supporting a four-factor model (Cox, Mota, Clara, & Asmundson, 2008). Of particular interest are the clinical implications of the symptom-cluster debate with respect

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to coping, in that numbing and avoidance have been shown to correlate differently with depression, suicidal ideation, and suicidal behavior (Asmundson, Coons, Taylor, & Katz, 2002; Cox et al., 2008). As such, assessment and intervention decisions are likely to vary based on the presence of stronger symptoms of avoidance versus numbing. The interested reader is referred to Asmundson, Stapleton, and Taylor (2004) for a conceptual review of the distinction between avoidance and numbing; Asmundson and colleagues (2000) for a factor analysis and comparative study of symptoms models; and King, Leskin, King, and Weathers (1998), McWilliams, Cox, and Asmundson (2005), and Taylor, Kuch, Koch, Crockett, and Passey (1998) for studies examining the symptom structure seen in individuals diagnosed with PTSD. Considering the psychological sequelae of prolonged war and conflict as well as repeated trauma, Herman (1997) advocates for the consideration of a complex posttraumatic stress disorder, which also has been called Disorders of Extreme Stress Not Otherwise Specified (DES-NOS) by other researchers (Taylor, Asmundson, & Carleton, 2006). Current diagnostic criteria for PTSD were not developed to account for the myriad of extreme stresses and traumatic events that people in war zones experience. Citing the experiences of Holocaust survivors and Southeast Asian Refugees, Herman makes the case that the anxiety, phobias, panic, depression, and somatic symptoms experienced by these individuals are qualitatively different than the “ordinary” disorders capitulated in the PTSD diagnosis as studied epidemiologically in community populations, which are subject to heterogeneous trauma. Specifically, Herman indicates that in addition to the characteristic features described in the DSM-IV-TR, post-conflict survivors may demonstrate severe personality disorganization, as well as altered affect regulation (e.g., persistent dysphoria, chronic pre-occupation with suicide, self-injurious behavior); perception of the perpetrator(s) (e.g., preoccupation with revenge); and relationships with others (e.g., isolation and withdrawal; persistent distrust; and disrupted intimate relationships). The primary caveats to take from this overview of stress conditions are that these phenomena are distinctly different from a normative reaction to traumatic stress, which typically resolves after a relatively brief period of time; that acute symptoms of stress disorder have some predictive utility with respect to the future development of PTSD, and as such may indicate a window for facilitative intervention; and that empirical and clinical literature among post-conflict survivors find some difference with the characterization of PTSD relative to the DSM-IV-TR criteria, which has assessment and treatment implications.

PTSD Estimates Related to War/Conflict The psychiatric condition most commonly associated with exposure to conflictrelated traumatic events is PTSD. In the National Co-morbidity Survey, the lifetime prevalence of PTSD (i.e., the occurrence of PTSD for individuals at any point

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in their lifetime, in contrast with point-prevalence estimates, which indicate the occurrence of PTSD only at the time measured) in the general population of the USA was estimated at 10.4% for women and 5.0% for men (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). However, rates tend to be higher in post-conflict and conflict-ridden societies (Eytan et al., 2004). For example, in a study that examined lifetime prevalence of PTSD, mood, and other anxiety disorders in four postconflict societies (Algeria, Cambodia, Ethiopia, and Palestine), researchers found PTSD prevalence ranged from 15.8% (Ethiopia) to 37.4% (Algeria). In a study of Guatemalans subsequent to civil war, 44% met criteria for lifetime psychiatric disorder and 34% of the total sample met criteria for lifetime PTSD (Rivera, Mari, Andreoli, Quintana, & Ferraz, 2008). Obilom and Thacher (2008) examined PTSD in civilian Nigerians 7–9 months after cessation of ethno-religious rioting and found that 89.7% met re-experiencing criteria for PTSD diagnosis; 49.1% met avoidance criteria for PTSD diagnosis; and 84.0% met arousal criteria for PTSD diagnosis. In conceptualizing preventative interventions, such as those utilized in the development of the trauma membrane, clinicians and researchers should be aware of those characteristics which serve as risk factors for the development of PTSD. Numerous investigations have confirmed a dose–response curve to exposure and PTSD rates, such that as the level of exposure to traumatic events (i.e., number or intensity of events) increases, so does the prevalence rate of PTSD (Breslau, Chilcoat, Kessler, & Davis, 1999; Cao, McFarlane, & Klimidis, 2002; Frans, Rimmo, Aberg, & Fredrikson, 2005; Neuner et al., 2004). Thus, individuals with a prior history of trauma exposure, either in terms of multiple exposures or in terms of one (or more) severe exposure(s), represent a group at risk of developing PTSD. Additional risk factors for the development of post-conflict psychiatric conditions include psychiatric disability or substance-use disorders that existed before experiencing conflict situations (Breslau, 2007; Breslau, Davis, & Schultz, 2003; Brewin, Andrews, & Valentine, 2000). Biological markers, such as atypical neuroendocrine changes (e.g., lower cortisol levels) and increased heart rate, have been identified as risk factors in retrospective studies (Yehuda, 2004). Socio-demographic factors such as gender, race/ethnicity, and age have also been identified as risk factors in retrospective studies of PTSD, with researchers currently hypothesizing that the relationship is due to the higher occurrence of violence in communities where young male minorities are more likely to reside (Breslau, 2007). Additionally, epidemiological data indicate sex differences in risk for development of PTSD. Women are more likely than men to develop the condition, even when type of event (e.g., rape, sexual assault) is removed or controlled; there is evidence to suggest that the relationship is due to a gender-specific vulnerability to the PTSD-inducing effects of assault-related violence (Breslau, 2007; Breslau et al., 1999; Breslau et al., 2003). Finally, a lack of social support post-trauma influences the development of PTSD (Brewin et al., 2000; Yehuda, 2004). Taken on the whole, these findings indicate the need to screen for history and risk factors when considering post-conflict intervention strategies. At the communal level, non-adaptive responses are often feared and are rarely observed (Foa et al., 2005; Glass & Schoch-Spana, 2002; Norris et al., 2008). Mass panic is one example of a non-adaptive response, which results in a loss of social

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organization and social roles, along with community chaos (Glass & Schoch-Spana; Lacy & Benedek, 2003). Another type of response is the mass reporting of medically unexplained symptoms, which may be construed as somatoform disorders. Such symptoms have been observed in groups of people after World War I, Vietnam, and the Persian Gulf War (Lacy & Benedek, 2003). Risk factors for non-adaptive stress reactions in groups include a belief that there is a small chance for escape from the traumatic stressor, perceived high personal risk in relation to the traumatic stressor, limited resource availability, no perceived effective response, and loss of credibility of authorities (Lacy & Benedek, 2003). In summary, PTSD is a common psychiatric condition observed in individuals in post-conflict environments, although rates of this disorder vary considerably between countries, samples, and conflict events. Measurement issues are relevant in epidemiological research, such as when and how PTSD is assessed (Breslau, 2007). The limitations observed in epidemiological research have important implications for the manner in which trauma and the trauma membrane is addressed in post-conflict societies. It is crucial to consider severity of symptomatology when addressing intervention needs, as research supports a dose–response relationship between exposure to trauma and PTSD. Additionally, PTSD symptom clusters differently relate to other psychological problems, such as depression. In thinking about post-conflict communities, we must also be aware of a collective response to trauma, which is more commonly associated with broad increases in medically unexplained symptoms that could be misattributed as somatoform disorders, rather than indicative of a stress response.

Mood and Anxiety Disorders Although ASD and PTSD are considered primary complications of exposure to traumatic events, the World Health Organization (2001) estimates that in situations involving armed conflict, conditions that are more common include depression, anxiety, and somatic problems, such as sleep disturbance and pain. Studies specific to post-conflict settings indicate that anxiety and mood disorders are the most common co-occurring psychiatric difficulties experienced by civilian populations (de Jong, et al., 2003). Recent estimates indicate that nearly 50% of individuals in the general population with PTSD also meet criteria for major depressive disorder (Golier, et al., 2001; Orsillo et al., 1996). Depression is a mood disorder characterized by both cognitive and behavioral features. Specifically, individuals with depression experience sadness, hopelessness, and/or discouraged mood and loss of interest or pleasure in nearly all daily activities for a period of 2 weeks or greater (APA, 2000). Additionally, individuals experiencing this condition sustain a combination of symptoms that includes changes in vegetative states (sleep, appetite, energy), altered psychomotor activity, feelings of worthlessness or guilt, and difficulty with cognitive activities, such as thinking, concentration, and decision-making. In more severe cases, individuals experience

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psychotic symptoms, recurrent thoughts of death, suicidal ideation, and make suicide plans and attempts (APA, 2000). Symptoms occur in number and severity, such that they are present more often than not, and are disruptive to daily functioning. Epidemiological estimates from large community samples in the USA indicate a lifetime prevalence of major depressive disorder (MDD) of 16.2% and a 12-month prevalence of 6.6% (Kessler et al., 2005; Kessler et al., 2008). Risk factors include female gender and White ethnicity (Kessler et al., 2008). In relation to PTSD, it is unclear whether MDD represents a separate, co-occurring disorder, or whether it represents associated features of PTSD (Golier et al., 2001). To that end, community-based research has indicated that 72.1% of lifetime and 78.5% of 12-month cases of MDD also met criteria for co-occurring DSM-IV-TR disorders, including PTSD (Kessler et al.). In terms of etiology, it appears that the presence of PTSD, rather than trauma exposure itself, increases the risk for cooccurrence of psychiatric disability. That is, PTSD and major depression appear to share biological, and perhaps also psychosocial, diatheses that act upon vulnerability to psychiatric disability (Breslau et al., 2003; Scherrer et al., 2008). In diagnostic terms, ASD and PTSD are included in the family of anxiety disorders. Thus, in exploring the co-occurrence of PTSD with other anxiety-based conditions, it is important to explicate that a co-occurrence of PTSD may be observed with generalized anxiety, panic, agoraphobia, or specific phobia. While the majority of studies that examine anxiety in relation to major trauma focus specifically on the measurement of PTSD symptoms, there is some evidence that some individuals with PTSD experience additional anxiety disorders (de Jong et al., 2003). While a detailed examination of the family of anxiety disorders is beyond the scope of this work, an illustration of generalized anxiety disorder (GAD) can aid in the understanding of the salient issues relevant to post-conflict settings. Features of GAD include excessive and uncontrollable diffuse worry, which is unrealistic in relation to objective circumstances and persists for 1 month or longer (APA, 2000; Kessler et al., 2008). Additionally, people with anxiety report vigilance, muscle tension, and trembling, somatic symptoms, such as sweating and nausea, autonomic hyperarousal, and an exaggerated startle response (APA; Kessler et al.). These features of anxiety-related arousal mirror characteristics common to post-traumatic experience as alluded in the previous discussion of the stress response. To that end, distinguishing a normative response to threat from persistent anxiety symptoms is relevant to understanding and treating individuals in post-conflict settings. Epidemiological data from samples in North America indicate the lifetime prevalence of GAD is 5.7%, and 12-month prevalence estimates are slightly lower, at 2.5–3.0%. Risk factors include female gender, White ethnicity, and low education (Grant et al., 2005; Kessler et al., 2008). Anxiety disorders commonly co-occur (i.e., an individual may have both generalized anxiety, as well as panic attacks), and anxiety and mood disorders, most commonly depression, also frequently co-occur. The lifetime prevalence of any anxiety disorder is estimated at 28.8%. In prediction models estimating lifetime prevalence of MDD and GAD, odds ratio estimates of 7.5 and 6.6 have been reported in large studies, indicating a strong relationship between the two conditions. A history of GAD predicts the persistence of MDD,

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although the reverse has not been found to be true (Kessler, et al., 2005; Kessler et al., 2008). Interestingly, although anxiety has been found to have familial patterns (i.e., is heritable), a question remains as to whether a history of GAD predicts onset of PTSD after trauma. There is some limited research that indicates a history of psychiatric disability predicts onset of PTSD and that the relationship between PTSD severity and the severity of other psychiatric disability is reciprocal (Macias, Young, & Barreira, 2000). While both depression and substance abuse have been shown as positive predictors, symptoms of anxiety (e.g., worry, fear) have not predicted onset of PTSD and a weaker relationship between GAD and PTSD has been reported (odds ratio of 2.2) (Macias et al., 2000; Ruscio et al., 2007). Finally, in thinking about other mental health issues that arise in the context of PTSD, substance abuse must be considered. There is some limited evidence to indicate that people increase their substance use after experiencing a traumatic event and that those diagnosed with PTSD are more likely to also be diagnosed with a substance use disorder when compared to those that either were exposed to a trauma and did not develop PTSD, or to those who had not been exposed to trauma at all (Breslau, 2007). Both MDD and GAD are associated with substance-use problems. More specifically, there is some evidence to indicate that between 25 and 50% of people with substance-abuse disorders also experience depression (Davis, Uezato, Newell, & Frazier, 2008; Wohl & Ades, 2009). Further, epidemiological research with North American populations indicates that GAD is more strongly associated with substance dependence than abuse. Twelve-month odds ratios of GAD and alcohol dependence were 3.1 and GAD and any drug dependence were 9.8 (Grant et al., 2005). Taken on the whole, these data suggest risk for individuals experiencing PTSD to also experience a substance-abuse disorder; however, it is unclear how strong this risk is when we examine specific subgroups of people who have experienced trauma, such as post-conflict community-dwelling survivors, war veterans, police and other first responders, and survivors of sexual assault. This is an issue because there are research findings that support the strength of relationship between PTSD and substance abuse in veterans, police, and other first responders (Scherrer et al., 2008; Steindl, Young, Creamer, & Crompton, 2003). Yet, this relationship is not explored, supported, or vetted in studies of community survivors with PTSD (Blight, Persson, Ekblad, & Ekberg, 2008; Roberts et al., 2009; Thapa & Hauff, 2005; Vlahov et al., 2002; Yaswi & Haque, 2008), such that we are able to understand clearly whether substance-use issues develop, persist, and moderate the relationship between other co-occurring conditions or psychiatric and health states. Several points can be gleaned from this review to guide thinking of the trauma membrane in post-conflict communities. For one, a normative acute stress response is likely to be common, if not universal, within post-conflict community dwellers (Eytan et al., 2004). However, for the majority, that response is not necessarily non-adaptive, as reported rates of ASD in post-conflict settings are on the order of 4–20%. In some instances, the acute response may occur in the context of prolonged or multiple trauma exposures. That is, the duration of the trauma may exceed that time frame which is typically utilized to define the acute versus chronic period of post-traumatic response. As such, a more realistic approach to serving

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people in post-conflict settings may be one that conceptualizes normal responses to terrorism and other acts of violence for longer than 30 days post-trauma (Yehuda, et al., 2005). This point is relevant to the degree that prescribed time frames are used to make diagnoses and presumably inform treatment interventions, including those that contribute to the trauma membrane. While the acute response frequently abates without intervention in most studied groups, the ASD and PTSD literature specific to conflict settings alludes to the fact that relatively higher proportions (upward of 84–90%) of individuals experience persisting symptoms such as re-experiencing and arousal (Murthy, 2007; Rivera et al., 2008). This discrepancy in rates of nonadaptive responses to stress may be attributable to the difficulty of studying acute stress disorders amid ongoing exposure to trauma, such as in conflict zones. Another consideration is the role of screening in identifying subgroups that may be particularly vulnerable to the development of PTSD, depression, and/or anxiety conditions subsequent to trauma exposure. Post-conflict interventions aimed at facilitating a trauma membrane may need to be specifically formulated to detect and treat those at highest risk for developing further problems, such as women who have experienced assault-related violence, people with a childhood or prior history of trauma, history of psychiatric disability, a family history of psychiatric illness, and/or substance abuse disorder (Breslau, 2007). Another issue is that although less systematic study of the post-conflict community has been conducted, available research suggests that communities may be at risk of experiencing a stress response (Lacy & Benedek, 2003). As with individuals, attending to the risk factors suggestive of community-wide stress is important in conceptualizing the trauma membrane. Broadly, important themes include the ability to escape, perceived social and personal threat, and effective action, in terms of resource dissemination and protection on the part of the authorities. Last, one way to approach prevention, particularly in relation to psychiatric concerns, such as mood and anxiety disorders, can be gleaned from the fields of rehabilitation and health psychology. Rehabilitation and health perspectives recognize the subjective experience of individuals who experience disability and chronic health conditions, both in terms of subjective loss, trauma, and subsequent psychosocial and functional limitations. The two perspectives also emphasize the individual’s, and by extension the community’s, ability to adapt and mobilize resources, such as psychological resilience, and social, psychological, and interpersonal assets, such as coping ability and social support (Sheridan & Ramacher, 1992; Wright, 1983). The application of interventions aimed at creating a trauma membrane may thus need to detect specific risk and resiliency factors and address each as they relate to individual and community adjustment in the context of socio-political instability.

Coping and the Trauma Membrane The trauma membrane was first conceptualized by Lindy, Grace, and Green in 1981 as a characterization of the recovery environment of individuals who had been

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severely traumatized. On a fundamental level, the membrane can be conceptualized as a stress buffer that protects the individual from further psychological distress and provides psychological space for the individual to begin to cope with the traumatic event and resulting distress. In contrast, coping is viewed as “the efforts we take to manage situations we have appraised as being potentially harmful or stressful” (Kleinke, 2007, p. 291), and coping has long been conceptualized as the first line of defense in mitigating the mentally and physically deleterious effects of stress. There is a large body of research supporting the role of coping as a mediator between stress and well-being with various populations in diverse contexts (Chronister, Johnson, & Lin, 2009). As such, coping is an important personal resource to consider within the context of post-conflict stress and to the development and sustenance of the trauma membrane.

Coping Theory and Research There are numerous conceptualizations and theoretical models of coping that range from those rooted in psychodynamic theories to those comprised of cognitivebehavioral strategies that are based on the work of Lazarus and Folkman (1984). As such, coping encompasses a broad range of styles, strategies, and efforts that can be viewed as personal dispositions, including stable and enduring traits, habitual styles, or behavioral patterns (Byrne, 1964; Krohne, 1996; McGlashan, Levy, & Carpenter, 1975; Miller, 1987; Mullen & Suls, 1982; Roth & Cohen, 1986; Shontz, 1975), as well as situation-specific cognitive and behavioral strategies and efforts (Billings & Moos, 1981, 1982; Carver, Scheier, & Weintraub, 1989; Endler & Parker, 1990; Lazarus & Folkman, 1984; McCrae, 1984; Pearlin, Menaghan, Lieberman, & Mullan, 1981; Pearlin & Schooler, 1978; Stone & Neale, 1984), which are applied in a given circumstance to reduce life stress, regulate distressing emotions, and gain control of one’s immediate environment (Chronister & Chan, 2007; Moos & Schaefer, 1984, 1993). For a detailed review of coping models and research, including disability-specific conceptualizations related to coping and adjustment, see Chronister and Chan (2007) and Chronister et al. (2009). In addition, there is a large body of research investigating the role of coping styles in mitigating stress with various populations in diverse contexts. To date, there is no consensus as to whether one strategy is more adaptive than another; in fact, in a lengthy literature review of reactions to stressful life events, Silver and Wortman (1980) concluded that there were no coping strategies that were uniformly effective. The effectiveness of coping depends on many factors such as the context, temporality, and the type of stressor. In addition, it can be difficult to determine the effectiveness of coping, because it is often confounded by the stressor itself. Nonetheless, there is general consensus among scholars that coping strategies are widely used personal resources to manage stress, and thus, the investigation of them within a post-conflict context is highly warranted. From a personality or trait-based perspective, coping may be viewed as a dispositional style that involves a psychological orientation either toward (approach)

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or away from (avoidance) stress that is consistently accessed across stressors and contexts (Chronister & Chan, 2007; Roth & Cohen, 1986). Horowitz’s (1976, 1979) model of denial–intrusion is an example of a dispositional coping model based on approach–avoidance constructs. In this model, denial (e.g., numbness, removal of material from consciousness, and avoidance of reminders of the stressor) is driven by the need to protect the ego from the impact of the stressful event, whereas, intrusions (e.g., nightmares, flashbacks, and being reminded of the stressor from numerous external stimuli) involve an “intrinsic tendency toward repetition of representations of contents” (Roth & Cohen, 1986, p. 93). In Horowitz’s model, there can be vacillating periods of denial and intrusion, which ultimately become less salient over time. Adaptation involves “working through” the stressful event, which allows for a complete integration of the stressor (Horowitz; Roth & Cohen).

Coping in Post-conflict Settings Horowitz’s model provides a framework to understand coping within the context of post-conflict violence. Specifically, the styles that Horowitz (1976, 1979) describes closely resemble descriptions of PTSD symptoms: numbness, removal of material from consciousness, and avoidance of reminders of the stressor on the denial side, and nightmares, flashbacks, and being reminded of the stressor from numerous external stimuli on the intrusion side. To that end, individuals involved in facilitating a trauma membrane for traumatized persons may think about stress symptoms as the individuals’ attempts to cope with the physical and emotional aftermath of the trauma (Yaswi & Haque, 2008). Because such styles are purported to be reflective of enduring characteristics, facilitators of the trauma membrane would also need to consider individual differences or individual coping styles, when approaching work with survivors. If we base our understanding of coping with trauma on a model such as Horowitz’s, interventionists would accommodate the need for a flexible membrane to allow for (a) individual approaches to coping that are variable in keeping with dispositional style; (b) support of variation in specific strategies, as no one style is considered to be uniformly effective; and (c) support of changing needs over time and according to duration, proximity of the trauma, and controllability of the stressor (Zeidner, 2005, 2007). Due to the role of time since trauma and controllability of stressors in the efficacy of coping responses, interventionists would want to consider each of the current and historical traumas or stressors present for an individual in a post-conflict setting and consider whether distinct approaches for different stressors would advance adaptive coping. From a state-based perspective, the most widely researched and popular conceptualizations of coping are those models based on cognitive theory and the work of Lazarus and Folkman (1984). In these models, cognitive and behavioral strategies are employed based on the interaction between the individual, context, and stressor (Lazarus & Folkman). Coping is typically hypothesized to include thoughts,

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feelings, and behaviors that serve as mediators between the stressor and the stress-response (Folkman & Lazarus, 1988). The most commonly cited cognitivebehavioral coping dimensions include emotion-focused and problem-focused coping (e.g., Billings & Moos, 1981, 1984; Carver et al., 1989; Folkman & Lazarus, 1980, 1985; Pearlin & Schooler, 1978). Problem-focused coping involves responses that address the problem which is causing distress, such as making a plan of action or concentrating on the next step, whereas, emotion-focused coping involves responses that ameliorate the negative emotions associated with the problem, such as engaging in distracting activities, acceptance, using alcohol or drugs, or seeking emotional support (Folkman & Moskowitz, 2004). Additional cognitive-behavioral coping dimensions include avoidance coping and meaning-focused coping. Avoidance coping has a long research history that dates back to the traditional trait-based paradigms. The construct emerged as a result of the finding that avoidance coping can include either problem-focused or emotion-focused coping strategies (Endler & Parker, 1990). Specifically, individuals may avoid a stressful situation by obtaining support from other people or by venting emotions (emotion-focused responses), or by engaging in another task rather than directly addressing the stressor-involved situation at hand (problem-focused). In regard to appraisal or meaning-making coping, Park and Folkman (1997) proposed that people draw on values, beliefs, and goals to modify the meaning of a stressful transaction. This may be true, especially in cases of chronic stress, which may not be amenable to problem-focused efforts (Folkman & Moskowitz, 2004). There is a growing body of literature investigating the role of cognitivebehavioral coping within the context of post-conflict trauma. For example, Zeidner (2007) investigated the salience of problem- versus emotion-focused coping among Israeli adults experiencing community disaster in two different situations: the AlAqsa Intifada and ballistic missile attacks targeting Israeli civilians during the Persian Gulf War. Zeidner found that problem-focused coping was the most salient coping strategy used during the Gulf War, which is consistent with the theory that problem-focused coping is more adaptive and accessed more often in situations in which the individual has some control over the outcome of the stressor. In Zeidner’s study, it was suggested that “protective action” was feasible, and thus, problem-focused coping was used more frequently than emotion-focused coping. Indeed, there has been much debate in the broader coping literature as to whether problem-focused coping strategies are more effective in situations in which the individual has some control over the outcome, and emotion-focused strategies are more adaptive in situations in which the outcome is unchangeable. Zeidner (2006) made a poignant statement about the effectiveness of all types of coping with respect to the uncontrollable nature of conflict-related violence, stating that [E]ven the most efficient type of problem-focused coping would merely involve circumventing the threat or mitigating its potential harm to property or life by taking protective measures against the potentially devastating consequences of attack. Unfortunately, the various strategies do not remove the threat itself by any means and are essentially “safety

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measures” at best. Thus, emotion-focused and avoidant coping (e.g., denial, behavioral disengagement) might be adaptive under conditions of minimal environmental control (p. 298-299).

According to Zeidner and Saklofske (1996), a broad repertoire of coping strategies may be the most effective approach to coping in situations that are highly traumatic. In support of this, Zeidner and Hammer (1992) found that individuals used a mixture of emotion- and problem-focused coping strategies in negotiating crisis situations. Conversely, studies have suggested that the utilization of both problem- and emotion-focused coping strategies were linked to higher levels of emotional distress (Zeidner, 2006). These findings are not surprising; similar to findings in the broader coping literature, it is not uncommon to find higher levels of coping linked to higher levels of emotional distress, as distress increases the need to employ more coping strategies (Zeidner). Finally, Zeidner found that women use coping strategies more frequently than men, including both problem- and emotionfocused strategies, under conflict-related violent circumstances. These findings are consistent with prior research (Tamres, Janicki, & Helgeson, 2002), and supportive of the general hypothesis that women use coping more often and access more types of coping than men. Research based on the September 11, 2001, terrorist attacks have also informed scholarly notions of coping within the context of violence. For example, studies based on nationally representative samples of adults about their reactions to the terrorist attacks suggest a predominant theme of religious coping – typically conceptualized as a type of emotion-focused coping strategy – following the September 11th attacks (Biema, 2001; Schuster et al., 2001; Wagner, 2001). Specifically, Biema reported increased and elevated church/synagogue attendance following the attacks; Schuster and colleagues reported that 90% of a sample surveyed utilized prayer, religion, or connection to spiritual feelings to cope with emotional distress; and Wagner (2001) reported that nearly 50% of the community-dwelling respondents surveyed stated their faith was stronger following the September 11th attacks. Importantly, these studies were based on samples of the population not directly present at the September 11, 2001, attacks, and therefore, the types of coping strategies employed may not accurately parallel those strategies drawn upon when faced directly with trauma or violence. Studies investigating coping within the context of a natural disaster (earthquake) also point to the salience of emotion-focused strategies, such as giving meaning to the experience and religious coping (Perez-Sales, Cervellon, Vazquez, Vidales, & Gabroit, 2005). These findings align with the perspective that religious coping affects well-being by providing a feeling of comfort, sense of control, and connectedness to self and others (Meisenhelder, 2002). Research indicates that religious coping is linked to lower levels of depression and other forms of psychological distress, including PTSD (Pargament, Smith, Koenig, & Perez., 1998; Pargament, Tarakeshwar, Ellison, & Wulff, 2001; Sigmund, 2003; Sowell et al., 2000; Tix & Frazier, 1998), and better physical health (Pargament et al., 1990). Notably, negative religious coping, which involves the perception that God has abandoned or punished an

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individual (Meisenhelder, 2002), has been found to be associated with higher depression and poorer mental health (Fitchett, Rybarczyk, DeMarco, & Nicolas, 1999; Pargament et al., 1998; Pargament et al., 2001). Other findings based on studies from the September 11th attacks report a relationship between higher levels of stress and higher usage of coping strategies (Meisenhelder, 2002; Schuster et al., 2001), which is consistent with the trend indicating that higher levels of stress are linked to more coping. In addition, studies suggest that the probability of experiencing posttraumatic stress symptoms following the September 11th attacks were significantly higher for individuals who used emotion- or avoidant-focused strategies, such as denial, self-distraction, disengagement, self-blame, and seeking social support (Schuster, et al.). Finally, Schuster, et al. reported that in addition to the 90% of individuals who reported coping through religion, 98% of individuals endorsed coping by talking to others, 60% of individuals endorsed coping by participating in group activities, and 36% of individuals endorsed coping by making charitable donations, which can be categorized as problem-focused coping efforts because they involve taking direct action toward improving the situation.

Social Support and Trauma Social support is another critical psychosocial resource to consider in understanding adjustment to post-conflict trauma. Social support is one of the most widely researched psychosocial constructs in behavioral health disciplines today, and the inverse relationship between social support and psychological distress is well established (Chronister, 2009). Social support is thought to interact with the stressor to reduce the deleterious effects of stress and promote physical and emotional wellbeing. Accordingly, social support is theoretically considered to be a moderator of stress, acting as a stress-buffer, with increased levels of social support believed to reduce the effects of stress by contributing to fewer negative cognitive appraisals (Cohen & Hoberman, 1983). Conceptually, social support refers to both the provision of psychological and material resources by another person intended to benefit an individual’s ability to cope with stress (Cohen, 2004) and to the quantity and characteristics of interconnections between social ties. The latter is considered the structural aspect of a support network and is generally assessed by the presence or absence of certain indices, as well as the number and frequency of contacts with specified social ties (Cohen). The former is by far the most popular way in which social support is conceptualized and measured today, and the inverse relationship between the functional aspect of social support and psychological distress is well documented (Chronister, 2009). Functional support involves the type of supportive exchange believed to be available or actually received, such as tangible and emotional support (Chak, 1996; Cohen, Mermelstein, Kamarck, & Hoberman, 1983; Cohen & Wills, 1985; Schumaker & Brownell, 1984; Schwarzer & Leppin, 1992). Tangible support

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involves such provisions as financial aid, physical assistance, and providing transportation, whereas emotional support involves such provisions as expressing affection, concern, empathy, caring and reassurance, and provides opportunities for emotional expression and venting (Cohen, 2004). It is believed that these functions are differentially useful for various types of problems or stressors (Cutrona & Russell, 1990). Placed within the context of the post-conflict setting, social support is conceptually similar to the role of the trauma membrane on an interpersonal level. Specifically, the interpersonal trauma membrane serves as a socially supportive network that protects the individual against further psychological stress and attends to and monitors the person’s psychological and instrumental needs (Martz & Lindy, 2010). This social support system is an important, yet minimally researched, environmental resource for persons facing post-conflict violence. According to North and Hong’s (2000) research that was specific to disaster situations, survivors more frequently seek emotional support from community resources, or natural support networks, than from relief workers. Similarly, Lindy and colleagues (1981) found that traumatized individuals were frequently found to be enveloped by a small network of trusted individuals, such as a spouse, close friend, professional, or adult child. Conversely, prolonged violence may indirectly affect psychological health by “weakening or destroying social networks, thereby reducing the availability of social support and increasing social isolation, and by weakening the social bonds and norms that underlie civil society and that create a sense of normality, predictability, and security” (Miller, Omidian, Rasmussen, Yaqubi, & Daudzai, 2009, p. 612). Studies with refugee populations provide an explanation of the relationship between psychological distress and social support. Specifically, in samples of refugees who have been exposed to high levels of violent political conflict, social factors may explain a significant amount of unexplained variance in levels psychological distress, with social isolation, lack of social support, and lack of family contact factors identified as important moderators of stress that influence outcomes such as PTSD, depression, and anxiety (Gorst-Unsworth & Goldenberg, 1998; Kinzie, Sack, Angell, Manson, & Rath, 1986; Lavik, Hauff, Skrondal, & Solberg, 1996; Miller et al., 2009; Pernice & Brook, 1996; Silove, Sinnerbring, Field, Manicavasagar, & Steele, 1997). Social networking within a post-conflict environment allows for individuals to share the effects of trauma in such a way that a “person’s problem becomes the community’s problem” (Yaswi & Haque, 2008, p. 478), which in turn dilutes or reduces the negative effects on the individual. For example, in a study that investigated coping, social support, and PTSD among individuals who experienced either direct or indirect trauma, researchers found that those who experienced direct trauma exhibited higher levels of PTSD relative to those who experienced indirect trauma. Additionally, social avoidance and an inability to connect with others were variables that differentiated the two groups. Thus, a decrease in, or inability to access social support may be related to symptoms associated with PTSD, which appears to contribute to negative outcomes (Yaswi & Haque, 2008).

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Restoring and facilitating an individual’s social support system is critical to the adjustment process of individuals and communities who experienced conflictrelated trauma (Antonovsky & Sagy, 1986). Social support networks can serve as a buffer against the enduring and daily stressors that occur in post-conflict settings, such as lack of employment, roadblocks, financial problems, illness/disability, and loss of family and friends by the provision of daily tangible and emotional support from one’s natural network. According to Yaswi and Haque (2008), “it is because of this societal networking that the Kashmiris have found ways to cope with taxing psychological problems” (p. 478). In fact, according to Kubiak (2005), the effects of social support on stress outcomes are likely to have a stronger long-term influence than the initial exposure to violence. In sum, in applying coping and social support within the context of conflictrelated violence, it is important to consider the ways in which the trauma membrane invites opportunity for the use of a wide array of coping strategies and social support networks. For example, drawing on adaptive problem, emotion, and meaningmaking focused coping strategies such as taking direct action, using prayer and acceptance, or finding positive meaning in the traumatic event (i.e., feeling drawn more closely to family) may mediate the impact of trauma on the individual’s psychological health. Indeed, the types of strategies employed depend upon the context in which violence is experienced, the individual, and the community in which the individual exists. In addition, accessing social support networks such as aligning with community groups and/or a survivor network to address rebuilding or allowing family and friends to serve as a holding environment that assists the individual in waiting before acting can be more useful that formal support services.

Coping and Social Support: Understanding the Trauma Membrane In their research, Lindy and colleagues (1981) found that traumatized individuals were frequently enveloped by a small network of trusted individuals, such as a spouse, close friend, professional, or adult child.. The interpersonal function of the trauma membrane was to buffer the traumatized individual from further psychological stress and attend to and monitor the person’s psychological and instrumental needs. This psychodynamic concept was meant to characterize a portion of the healing process wherein the person is protected from further injury – practically or psychologically. Further, the parallels between post-trauma stress reactions, coping, social support, and the intrapsychic trauma membrane are compelling and suggest possibilities for conceptualizing ideal therapeutic techniques to utilize and healing environments to create in post-conflict situations for individuals and communities. The macro-analytic coping approach considers stable, individual coping dispositions in terms of an approach-avoidance paradigm. The styles that Horowitz (1976, 1979) described in the denial-intrusion coping model map onto descriptions of PTSD symptoms: numbness, removal of material from consciousness, and

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avoidance of reminders of the stressor on the denial side and nightmares, flashbacks, and being reminded of the stressor from numerous external stimuli on the intrusion side. To that end, individuals involved in facilitating an interpersonal trauma membrane for traumatized persons may think about what kind of social support can help to alleviate some of the post-conflict needs, in addition to considering individuals’ stress symptoms and their intrapsychic trauma membrane, as the individuals’ attempts to cope with the physical and emotional aftermath of the trauma. Because such styles are purported to be reflective of enduring characteristics, facilitators of the trauma membrane would also need to consider individual differences, or individual coping styles, when approaching work with survivors. More specifically, if we base our understanding of coping with trauma on a model such as Horowitz’s, interventionists would accommodate the need for a flexible intrapsychic trauma membrane to allow for (a) individual approaches to coping that are variable in keeping with dispositional style; (b) support of variation in specific strategies as no one style is considered to be uniformly effective; and (c) support of changing needs over time and according to duration, proximity of the trauma, and controllability of the stressor (Zeidner, 2005, 2007). Due to the role of time since trauma and controllability of stressors in efficacy of coping responses, interventionists would want to consider each of the traumas or stressors present for an individual in a post-conflict setting and consider whether distinct approaches for different stressors would advance adaptive coping. Considering the micro-analytic coping model, we might also think about the ways in which the intrapsychic trauma membrane invites opportunity for the use of specific cognitive, behavioral, and meaning-making strategies, such as articulating positive sequelae of the traumatic event (i.e., feeling drawn more closely to family); seeking out social support; taking direct action (i.e., aligning with community groups to address rebuilding); and/or allowing the trauma membrane to serve as a holding environment that assists the individual in waiting before acting. Given the universal experience or war and conflict and the important role of community response and community coping in post-conflict settings (Yaswi & Haque, 2008), further discussion of social support as a form of coping may provide additional insights into the relationship between coping and both the interpersonal (e.g., providing a healing environment) and the intrapsychic (e.g., processing traumatic memories) trauma membrane.

Resilience and the Trauma Membrane This analysis of psychosocial adjustment, coping, and trauma in post-conflict settings may be further understood in relation to concepts of resilience. The multidimensional trauma membrane has been conceptualized as a protective barrier that prevents further psychological breakdown, as well as a conserving edge that contains that which is healing (Martz & Lindy, 2010). Originally used in the physical sciences, the term “resilience” describes the capacity of a material or system to resume equilibrium after displacement (Norris

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et al., 2008). Foa and colleagues (2005) conceptualized individual resilience as “one end of a continuum of vulnerability to emotional dysfunction and psychopathology when exposed to a stressful experience” (p. 1808) and as such, resilience can be conceptualized as biological, psychological, and social factors, which are protected and facilitated in the trauma membrane, and which contribute to adaptive recovery. As indicated in this review, some individuals will be clearly vulnerable to the development of psychiatric disability in the context of the severe traumas that arise from a conflict environment, and these individuals are likely to present with identifiable risk factors that can inform intervention decisions. Specifically, coping behaviors can be explored and addressed in a supportive therapeutic context and social support, particularly the formation of a survivor network, can be fostered. On the other end of the spectrum, some individuals will experience a stress reaction, but will not develop PTSD or another psychiatric disability. These individuals also need consideration, although probably a different level and intensity of therapeutic intervention (e.g., encouraging an interpersonal trauma membrane, instead of focusing on the state of the intrapsychic trauma membrane). The community as a whole can also be considered in terms of the communal trauma membrane. As Norris and colleagues (2008) indicate, community resilience represents a “process linking a set of networked adaptive capacities to a positive trajectory of functioning and adaptation in constituent populations after a disturbance” (p. 131). This idea of linking networked capacities conceptually matches the idea of the formation and strengthening of cellular layers in the trauma membrane. As such, the idea of community-based outreach to prevent the development of psychiatric disabilities in people at risk (Lindy et al., 1981) is consistent with the concept of linking adaptive capacities to a specific constituency. As has been suggested by researchers, a focus on the non-adaptive response belies facilitating adaptive community coping and resilience (Foa et al., 2005; Norris et al., 2008; Vazquez & Perez-Sales, 2007). Thus, facilitators of the communal trauma membrane may be considered both as sources for intervention and sources of resilience. Sources of individual and community resilience may be found in spiritual and religious organizations or practices that are aimed at promoting safety and a sense of hope, addressing existential conflicts (Sigmund, 2003), meaning making, or providing physical space and resources for community organizations, and available media outlets that are able to produce and disseminate effective psycho-educational materials to address mental-health needs.

Conclusion In conclusion, the relationship between traumatic stress, coping, social support, and the multi-dimensional trauma membrane is interesting and complex. On the whole, the intrapsychic trauma membrane functions to create a holding space for stress responses, to protect adaptive responses, and to prevent the development of non-adaptive psychiatric conditions. Integral to the intrapsychic space is an attention to the manner in which individuals cope with stress and flexible interventions that

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support individually based, adaptive coping responses. Integral to the interpersonal and communal trauma membranes is the concept of the social network, considered here as a more global concept of social support as a critical element for facilitating adaptive coping, which contributes to resilience in the post-conflict environment.

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Chapter 13

Helping Individuals Heal from Rape Connected to Conflict and/or War Meghan E. McDevitt-Murphy, Laura B. Casey, and Pam Cogdal

Abstract Rape and sexual assault have been employed as weapons of war in recent conflicts. The effects on individuals, communities, and cultures can be devastating. Sexual assault is associated with high risk for posttraumatic stress disorder and other adverse outcomes. Some of the contextual factors (i.e., displacement, widespread fear and terror, multiple other forms of trauma, disrupted social support networks) related to war can only expound those effects. This chapter offers some guidance for clinicians working with survivors of war-related rape. Clinicians are advised to be sensitive to cultural and socio-political factors that will vary based on locale. The chapter includes information about assessment and treatment and describes one treatment approach (narrative exposure therapy) that has been successfully used in a chaotic war-torn environment.

Introduction Rape and sexual assault are acts of violence used to exert power, and the terms denote any unwanted and involuntary sexual acts committed against men, women, or children. The assailant can be anyone from an acquaintance to a family member to a stranger (National Center for Victims of Crime, 1995). In the USA, it is estimated that 683,000 adult women are forcibly raped each year, according to the National Center for Victims of Crime and Crime Victims Research and Treatment Center (1992), and the United Nations Fund for Women (UNIFEM) estimates that one in five women worldwide will be a victim of rape or attempted rape in her lifetime (2007). In terms of men in the USA, it is estimated that one in every ten rape victims is a male (National Center for Victims of Crime, 1995); however, according to the Rape, Abuse, Incest National Network (RAINN), this number may be an underestimation, due to the fact that males are the least likely to report a sexual M.E. McDevitt-Murphy (B) University of Memphis, Memphis, TN, USA e-mail: [email protected]


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assault. Regardless of the gender of the victim, time, and/or place, there are some well-documented psychological side effects of rape (e.g., posttraumatic stress disorder, depression, social isolation), in addition to the physical injuries experienced at the time of the assault. Rape is a powerfully destructive trauma. It results in behavioral, emotional, and cognitive dysfunction that may be persistent. In the context of war, rape has been used as a weapon to engender widespread terror and disrupt the social and cultural infrastructure. Intervening with survivors of war-related sexual assault requires awareness of these intrapersonal responses, as well as the interpersonal impact that widespread rape has inflicted on societies. Due to the ripple effects of systemic rapes on the social fabric of communities, working with sexual assault survivors in the wake of war or civil unrest requires not only awareness of cultural beliefs about rape, but also an awareness of the current socio-political climate. This chapter describes the incidence and impact of rape during wartime, recommends assessment and intervention tools for clinicians working with survivors of war-related sexual assault, and touches upon some of the relevant cultural issues.

Rape During Wartime Rape is unfortunately common during wartime and is not a new phenomenon, with historical evidence suggesting wartime rape is an ancient human practice (Gottschall, 2004). In fact, wartime rates of sexual violence reflect an increase as compared to peacetime levels and some evidence suggests that rape and other forms of sexual violence are being used explicitly as weapons of war (Gottschall, 2004; Seifert, 1996). It is difficult, however, to ascertain the full extent to which it occurs, because of the challenges in collecting such data and the reluctance of the victims to come forward. Additionally, in many war-torn locales, the infrastructure for tracking the prevalence of rape may simply not exist as a consequence of war, and thus there may be no formal mechanism for reporting rape. Despite these factors, nongovernmental organizations (NGOs) have made attempts to document estimates of sexual violence across war zones, and this information is summarized by Farr (2009) for 27 recent conflicts. Rates of sexual violence seem to vary across countries and within each country; typically, there is a wide range of prevalence estimates. Some specific examples include 52.3% of women in Sierra Leone during the conflict that raged in the 1990s, 74% of women from one region of Somalia having been raped in 1993, and 70% of women in one region of Uganda having been raped by soldiers in 1991. Another publication investigated the rate of rape among internally displaced women in Azerbaijan and found that 30% of their sample of 457 women reported a lifetime history of rape, and 21% of the sample reported a past year rape (Kerimova et al., 2003). Sexual crimes during war have been documented to affect women, children, men, civilians, and military personnel as it does not discriminate against its victims. It also varies in terms of the degree of violence and the form of abuse perpetrated onto the victim or victims. Some evidence suggests that the rates of rape during conflict have

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increased and that today’s phenomena may be best conceptualized as “extreme war rape.” Farr (2009) described extreme war rape as “regularized, war-normative acts of sexual violence accompanied by intentional serious harm, including physical injury, physical and psychological torture, and sometimes murder” (p. 6). Also implied by this term is that this kind of rape is characterized by multiple rapists (or “gang rape”), sequential rape or sexual slavery, and intentional injury and mutilation by the rapist (Farr, 2009). Recent scholars have examined patterns of sexual assault during conflict. Farr (2009) described four patterns of wartime rape, based on a review of recent wars in 27 countries. The patterns were characterized based on five dimensions: the prevalence of rape, the nature of the perpetrators (i.e., state agents or armed opposition groups), the locations of the rapes (e.g., homes, detention facilities, checkpoints), primary victim demographics (ethnicity, behavior, politics), and primary perpetrators of forced labor (e.g., state agents, rebels). Examples of patterns of sexual assault during conflict include the following. The sexual violence of Bosnian Muslim women by Bosnian Serbs was at such a magnitude and large scale during the conflict in Bosnia-Herzegovina that it was deemed a crime against humanity under international law. The rape of Tutsi women in Rwanda was so widespread that it was later termed a form of genocide by the International Criminal Tribunal (Wood, 2006). Yet, sexual crimes may be present in forms other than rape, such as prostitution of civilians, with estimates around 50,000 serving in brothels throughout Germany’s Reich during World War II, or as sexual slavery, as evident in Yugoslavia in the 1990s, with approximately 20,000 female victims (Wood, 2006).

Why Does Sexual Violence Occur During Conflict? Different theories have been offered to explain the increased rates, although most frequently invoked is the “strategic rape theory,” which characterizes rape as a weapon of war, exacting its effect through the spread of terror (Gottschall, 2004). The United Nations Development Fund for Women (UNIFEM, 2009) further supports this assertion by calling sexual violence during wartime a tactic or a means to terrorize the opposition. Another explanation suggests that rape follows naturally from the violent tendencies unleashed in warriors, and once they transgress the nearly universal code “do not kill,” other forms of violence (including rape) and destruction follow. An alternative explanation casts rape in the psycho-physiological context of the high-stress combat environment. Pointing to evidence that in the aftermath of extreme anxiety, people exhibit diminished inhibition, Littlewood (1997) noted that rape may result from the increased physiological arousal (the fight response) experienced by soldiers in combat. While military leaders have characterized rape as a side effect or by-product of war, attributing responsibility to individual soldiers who are undisciplined, some scholars have rejected this idea, favoring theories that characterize rape as a deliberate military action (Seifert, 1996). Seifert pointed out that rape is often used to destroy cultures. Because of women’s role

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in maintaining family and community cohesion, mass sexual assault destroys the social fabric. Seifert pointed to specific instances where mass rape has been used as part of a larger strategy of cultural destruction. In the former Yugoslavia, the aggression conducted by the Serbs included deliberate attacks on people and objects of cultural importance. Upon invading a town, the Serbs destroyed objects of cultural importance, and then went after the intellectuals, taking them captive and in some instances, killing them. Finally, they established camps for the purpose of mass rape of women with the goal of impregnating them (Neill, 2000; Seifert, 1996). In that conflict, rape was an explicit tool in the goal of ethnic cleansing, and as a consequence, approximately 20,000 women were raped (Salzman, 1998). Several sources review evidence supporting the idea that rape was a deliberate strategy; one quote, cited by Neill (2000), was from a Serbian soldier, who purportedly said, “We have orders to rape the girls,” words which were relayed by a young female victim. It is noteworthy that in addition to the rates of sexual violence against enemy civilians that occurs during conflict, some evidence suggests that the rate of sexual violence against US military women, committed by their comrades, increases during wartime (Wolfe et al., 1998). Three quarters of those victimized did not report the incidents to an authority. One-third of victims reported that they did not know how to go about reporting the incidents. One study suggested that military women who experienced sexual assault in the military were more likely to have posttraumatic stress disorder (PTSD) than women whose sexual assault occurred in a civilian or pre-military context (Suris, Lind, Kashner, Borman, & Petty, 2004).

Psychological Factors of Rape and Sexual Trauma The psychological consequences of rape and sexual assault may include mood or anxiety disorders, such as depression or PTSD. According to the National Center for Victims of Crime and Crime Victims Research and Treatment Center (1992), nearly one-third of all rape victims develop PTSD sometime during their lifetimes. In addition, sexual-assault survivors may blame themselves, or feel as though others blame them for their fate. Further, the stigma of sexual assault compounds the social isolation, guilt, and shame that many rape survivors experience (Ullman, Townsend, Filipas, & Starzynski, 2007). The consequences of sexual assault may also involve substance abuse, suicidality, and substantially increased health-care use (Resick, Calhoun, Atkeson, & Ellis, 1981; Roth & Lebowitz, 1988).

Coping and Resilience Although sexual assault is among the traumatic events most likely to result in PTSD (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995), many survivors respond to this trauma with few symptoms. Understanding the protective factors that reduce

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risk for PTSD and other adverse outcomes may help prevention of PTSD and other mental-health consequences and the treatment efforts. Much work has been devoted to describing the coping patterns of trauma survivors that seem to be particularly adaptive or non-adaptive. One large study of sexual-assault survivors suggested that greater use of non-adaptive coping responses, such as self-distraction, denial, or behavioral disengagement, was predictive of higher levels of PTSD symptoms (Najdowski & Ullman, 2009). Another study of both physical- and sexual-assault survivors used a prospective design to identify cognitive factors that contributed to an increase in PTSD symptoms. Specifically, they examined emotional appraisal, reflecting participants’ judgments about their own emotional responses to the event. Examples include, “If I can react like that, I must be very unstable”, “I cannot accept the emotions which I had,” or “my reactions since the assault mean I must be losing my mind.” They found that an individual’s appraisal of emotional responses both during and after the assault was predictive of the severity of PTSD symptoms such as physical hyperarousal, intrusive thoughts or memories, and avoidance (Dunmore, Clark, & Ehlers, 2001). Ullman et al. (2007) listed some factors that contributed to development of PTSD for rape victims. These factors included disengagement by not talking about the assault, withdrawing from others to avoid blame, a focus on self as the cause for the rape, or denial. While a large number of studies have highlighted the importance of social support as a protective factor against the development of PTSD among trauma survivors (e.g., Brewin, Andrews, & Valentine, 2000), few studies have examined this in detail (i.e., the mechanism by which social support is protective against PTSD). Presumably, one way that social support may be helpful is through close relationships, in which the assault survivor may feel safe disclosing his or her experience to trusted others, and in which the disclosure is met with empathy and validation. While some research has supported the efficacy of disclosure of traumatic experiences for therapeutic benefit (e.g., Lepore, Ragan, & Jones, 2000; Pennybaker, 1993), those findings should be understood in context. Studies that have examined the effects of survivor-initiated disclosure of sexual trauma have reported mixed results with regard to the perceived helpfulness of disclosure. Ullman and others have noted that the potential therapeutic benefit of disclosure is likely contingent on the response by the person receiving the disclosure (Ullman, 2007). A recent study suggests that disclosure itself does not automatically lead to symptom reduction, but the response of the social environment is critical. A recent survey of sexual-assault survivors found that negative responses by informal support-givers were associated with higher levels of posttraumatic stress symptoms (Borja, Callahan, & Long, 2006). Several studies have investigated predictors and consequences of disclosure about sexual victimization and have found that most sexual-assault survivors tend to disclose the assault to someone eventually, but that a number of factors influence the likelihood of survivors disclosing the event. Assaults by strangers tend to be disclosed more readily than assaults by known assailants (Golding, Siegel, Sorenson, Burnam, & Stein, 1989; Starzynski, Ullman, Filipas, & Townsend, 2005). One study

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noted that survivors were more likely to disclose their sexual assault when it met a cultural stereotype of rape (i.e., perpetrated by a stranger, use of force, presence of a weapon, assailant is a member of a minority group, and victim is Caucasian) (Starzynski et al., 2005). Survivors are far more likely to report their victimization to informal supporters (family, friends), rather than to members of formal institutions (clergy, police, medical/mental-health professionals), and they may have different motivations for disclosure to formal versus informal sources (Starzynski et al., 2005). Overall, studies report that disclosing the trauma seems to be viewed as helpful by survivors (Golding et al., 1989) and that telling others generally results in positive responses (Starzynski et al., 2005). Some evidence suggests, however, that the receipt of self-rated negative responses from others were related to both the level of the survivor’s PTSD symptoms and to behavioral self-blame (Starzynski et al., 2005). Negative responses characterized by insensitivity, blaming, or doubt may have the effect of silencing survivors, and arresting the healing process that may have otherwise resulted from disclosure (Ahrens, 2006). This is related to the concept of the interpersonal trauma membrane, such that an intact social support network comprised of compassionate, nurturing individuals may provide the environment needed for healing to occur.

Cultural Aspects of Treating Sexual Assault Paramount to the appropriate treatment intervention for a survivor of sexual assault is the correct conceptualization of a survivor’s experience. This would include understanding the client’s cultural definition of what has happened to them. Every culture organizes societal behavior around norms and customs. These norms include topics ranging from child care to sexual behavior. It is in the culture’s explanation of gender roles that may best portray a survivor’s definition of sexual assault or rape. Some of these norms may seem inappropriate to a Western caregiver, and yet the paradigm needs to be understood. From a place of cultural understanding, the advocate may work more effectively to alleviate symptoms. Hensley (2002) notes the Latina culture as an example wherein a female’s experience of rape may be colored by the more patriarchal system of the culture. Given such a schemata, one might better understand a survivor’s reluctance to report an incident of sexual assault, while blaming oneself and isolating out of fear and shame. Even more challenging for therapists, caregivers, or advocates may be cultures which define sexual conquests as a rite of manhood. One such example was a description of a South African Township in which “jackrolling” was defined as “gang rape” and part of the “youth culture” (Stuijt, 2009). The “jackrolling” was defined as young males organizing in “hunting packs” with the goal of impregnating young women. Further, in Afghanistan under Taliban rule, a rape victim needed the testimony of four witnesses to prove she was raped, otherwise it was decided that she committed adultery or fornication, which were punishable crimes

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(Coomaraswamy, 1999). Similarly, in some cultures, women suspected of premarital sex are subjected to “honor killings,” and this happens even in cases of rape. Honor killings have been documented in Pakistan, Jordan, Lebanon, Turkey, Syria, Yemen, Morocco, and Egypt (UNIFEM, 2007). An awareness of the weight of the taboo surrounding premarital sex and of the way this would likely compound the shame associated with rape is critical for clinicians to keep in mind. Sexual assault survivors may be far less likely to disclose their experiences in these contexts. It is evident that some level of cultural awareness is critical for clinicians and advocates working with sexual violence survivors; although it is impossible to gain competence in every culture’s background, it is important for clinicians to assess accordingly and to take into consideration the client’s worldview and level of understanding. Clinicians are also advised to be mindful of local attitudes toward seeking assistance from agencies or outsiders. Castillo (1997) recommends working within the culture’s system of “shamans”, priests, or other classifications of caregiver types when reaching out to survivors of sexual assault. This would be especially relevant if there also are language-related barriers to work through.

Assessment Careful assessment of posttraumatic reactions is a critical first step to developing a treatment plan. This assessment should include gathering information about psychological disorders like PTSD, depression, anxiety, as well as an evaluation of current stressors and current risk level. In some cultures, the stigma surrounding rape may result in overwhelming shame, increasing the risk of suicide. Therefore, a full assessment is important for understanding the range and severity of presenting symptoms. It is advisable to assess all potential sexual assault victims, to the extent that this is feasible. Given the brutal nature of war-related rape, survivors are at risk to experience adverse psychological responses. In this section we review some relevant constructs as well as assessment measures that may be useful in this context. PTSD is a complex and serious disorder that may occur in the aftermath of trauma, but there are several reasons why mental-health practitioners should also assess for other disorders. First, distress reactions following trauma may be better described by a diagnosis other than PTSD, such as a depressive disorder or anxiety disorder. Second, PTSD is associated with a high degree of co-occurring disorders, with some studies suggesting that more than half of people diagnosed with PTSD may also meet criteria for another DSM-IV diagnosis (Breslau, Davis, Andreski, & Peterson, 1991; Kessler et al., 1995). These diagnostic findings may have important implications for the treatment planning process. A comprehensive assessment of psychological disorders should include data from multiple sources when possible, and should be gathered by using multiple methods. Generally, a combination of self-report (paper–pencil) measures and

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structured interviews conducted by a trained clinician will yield the most reliable information. Weathers and colleagues recently provided recommendations for conducting assessments with trauma survivors, which reflect contextual considerations, such as the goal of the assessment and the available resources (Weathers, Keane, & Foa, 2008). Brief screening measures may be favored in environments where the goal is to identify “at risk” cases and to provide general psychological care. More detailed measures may be preferred before survivors engage in psychotherapy. Given the stigma associated with experiencing psychological distress and with seeking help from professionals, as well as the guilt and shame typically associated with sexual assault, the clinician should be cognizant of creating a warm and validating environment, in which individuals will feel free to report accurately the trauma that they experienced without concern about negative consequences. This may be a particularly important factor to keep in mind when working with individuals who have lived in environments with histories of political violence and oppressive regimes, as they may be unduly concerned with the consequences of reporting their experiences (e.g., having been raped by individuals representing the official government). In these settings, it will be important for clinicians to provide reassurance about confidentiality policies and to work closely with agencies that may help survivors find safe living environments. Assessment of psychological disorders may include interview-based measures, as well as self-report instruments. Instruments assessing a wide range of potential symptoms, including but not limited to the PTSD syndrome, may be particularly useful. Structured interviews are regarded as the “gold standard” for assigning clinical diagnoses. One broad-based instrument, the Structured Clinical Interview for DSM-IV Axis I diagnoses (First, Gibbon, Spitzer, & Williams, 1996), may be used to assess the full spectrum of DSM-IV diagnoses, including mood, anxiety, and psychotic disorders. The Clinician-Administered PTSD Scale (Blake et al., 1995; Weathers et al., 2004) is the most widely used, interview-based measure specifically for assessing PTSD (Weathers et al., 2008). A number of questionnaire measures have been developed to assess PTSD. Experts advise using self-report measures that directly correspond to the DSMIV symptoms of PTSD. The PTSD Checklist (Weathers, Litz, Herman, Huska, & Keane, 1993) is a 17-item self-report questionnaire that includes one item per DSMIV criterion, each of which is rated on a five-point Likert scale. The PCL has shown strong psychometric characteristics across a variety of trauma populations. The PCL may be administered quickly and thus can serve as a screen for identifying probable PTSD cases. The Posttraumatic Stress Diagnostic Scale (PDS; Foa, 1995) is also DSM correspondent and includes 49 items that assess all of the DSM criteria. The PDS has also demonstrated excellent psychometric characteristics. There are a multitude of assessment instruments available for PTSD—the aforementioned are just a sample; a recent text provides a wealth of information about the contexts in which different instruments may be most beneficial (Wilson & Keane, 2004). For work in post-conflict settings, the World Health Organization (2001) published a tool for the rapid assessment of mental-health needs for refugees and displaced populations, which can provide an overview of the extent of the stressors

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facing a given community. This tool may be particularly helpful for assessing the extent to which survivors may establish and/or be able to access a positive recovery environment within their community.

Treatment Considerations Providers of psychological treatment of survivors of war-related rape should operate as part of a team of care providers. Mental-health needs of survivors are often underaddressed in conflict settings and clinicians working in these settings may have limited resources. Additionally, clients may have considerable hardship in reaching care providers, due to factors such as distance, transportation difficulty, and child care concerns. Regarding treatment approaches for the sequelae of trauma, we limit this discussion only to treatments of PTSD, because PTSD will likely be the most frequent disorder encountered in this population. For an overview of evidencebased approaches to other mental-health conditions, a comprehensive clinical guide book to evidence-based practice for a wide range of disorders, such as Fisher and O’Donohue (2006) may be useful for practitioners. Further, the reader is directed to a website sponsored by the American Psychological Association which maintains a list of evidence-based practices for a range of disorders: http://www.psychology.sunysb.edu/eklonsky-/division12/. A number of psychosocial treatment approaches have been developed in recent years for PTSD. Most of these treatments have been empirically validated in samples of survivors of a single type of trauma (e.g., combat trauma, sexual assault). The evidence has most strongly supported the efficacy of cognitive-behavioral approaches (Bradley, Greene, Russ, Dutra & Westen, 2005). Cognitive-behavioral therapy (CBT) typically focuses on the contribution of thought and behavior patterns to current distress. The client is engaged in a process of skill acquisition and practice, in order to change non-adaptive patterns. Generally, CBT is time limited and focused on specific goals. Cognitive-behavioral approaches typically involve “homework” designed to enhance skill acquisition by ensuring practice outside the therapy session. Several treatment guides for cognitive-behavioral therapy for PTSD are available (the following references denote treatment manuals: Follette & Ruzek, 2006; Foy, 1992; Taylor, 2006; Zayfert & Becker, 2007), and two have been written specifically for survivors of sexual assault (Foa & Rothbaum, 2001; Resick & Schnicke, 1993). Successful psychosocial treatments for PTSD generally include some combination of the key elements of exposure and cognitive restructuring. Therapeutic exposure refers to deliberate attempts to expose the survivor to reminders of the traumatic event, and this may take the form of “imaginal” exposure or “in vivo” exposure. Imaginal exposure focuses on reducing cognitive avoidance or internal efforts to avoid thinking about the trauma. Imaginal exposure is a key component of prolonged exposure therapy (Foa et al., 2007). The key activity of imaginal exposure therapy is the repeated retelling of the trauma narrative by the client,

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with effort devoted to clearly remembering the events and to feeling the associated emotions. In vivo exposure involves systematically confronting situations that the client has identified as evoking significant distress reaction or behavioral avoidance (e.g., reminders of the rape and its context). In vivo work typically begins with the therapist soliciting a list of feared/avoided situations from the client. These situations are organized into a hierarchy from most feared/avoided to least feared/avoided. Generally, items on the hierarchy are situations that would be relevant to improving the client’s quality of life. The client receives weekly homework assignments that involve engaging with the feared activity. In session, the client discusses progress along the hierarchy and troubleshoots difficulties in completing homework with the therapist. In vivo exercises will necessarily place clients in settings that will elicit anxiety, and the technique works due to the phenomenon of habituation. The client must remain in the situation long enough for the anxiety response to begin to decline. When using imaginal exposure treatment, the majority of the session time is devoted to the client retelling the story of the trauma. The therapist typically encourages the client to feel the associated emotions, so that extinction of the aversive emotional response is eventually achieved. Sessions are typically scheduled for 90 minutes and occur weekly for 12 weeks. The therapist guides the client’s retelling, encouraging more repetitions of “hot spots” or particularly traumatic aspects of the event (Foa, Hembree, & Rothbaum, 2007). For both imaginal and in vivo exposure work, the therapeutic tasks generally involve the evocation of distress. The mechanism of action for both in vivo and imaginal exposure is the extinction of the intense emotional response. The client is encouraged to tolerate the distressing emotional reaction until the magnitude of the response (based on the client’s self-report) begins to diminish, signaling that extinction is occurring. Psychosocial treatment using imaginal and in vivo exposure (and other techniques) for PTSD may be administered in a group or individual format.

Individual Approaches Two individual approaches have been studied with sexual-assault survivors in particular: prolonged exposure therapy (Foa et al., 2007) and cognitive processing therapy (Resick & Schnicke, 1993). Prolonged exposure (PE) therapy uses both in vivo and imaginal exposure techniques to combat the behavioral and cognitive avoidance that contribute to the maintenance of PTSD symptoms; PE is one of the best supported psychotherapy approaches (Nemeroff et al., 2006). PE was originally developed with sexual assault survivors and has been tested extensively among other populations (Foa et al., 2005; Marks, Lovell, Noshirvani, Livanou, & Thrasher, 1998; Schnurr et al., 2007). Cognitive processing therapy (CPT) also was originally developed with a sample of sexual-assault survivors. Although CPT involves aspects of exposure, its primary

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focus is on the cognitions related to the trauma. CPT is aimed at (1) helping survivors understand the relationship between thoughts and emotions, (2) accepting that the assault happened, (3) experiencing the emotions related to the sexual assault, (4) analyzing and confronting non-adaptive beliefs about the sexual assault, and (5) understanding how the survivor’s prior experiences impacted his/her reaction to the sexual assault (Resick & Schnicke, 1993). There have been few published studies describing the efficacy of established interventions with individuals traumatized in the context of war. Schulz, Resick, Huber, and Griffin (2006) adapted cognitive processing therapy for use with Bosnian refugees. Their article describes cultural considerations, as well as the implications of working with an interpreter. Exposure therapy has been adapted for use in the field with survivors of war and torture, referred to as “Narrative Exposure Therapy” (NET; Neuner, Schauer, Elbert, & Roth, 2002). The developers were mindful of the many phenomena that raised questions about whether traditional exposure therapy could be applied directly to survivors of war-related trauma, noting that these survivors typically will have reported multiple traumatic events, and may live in unstable and unsafe conditions, characterized by ongoing threat, poverty, and malnutrition (Neuner et al., 2008). NET is a short-term standardized therapy, based on cognitive-behavioral principles. However, rather than focus on a specific traumatic event, clients are guided through the development of a narrative of their entire lives, with a focus on traumatic events that occurred over time. A recent study demonstrated that the treatment may be successfully administered by lay counselors in the field (Neuner et al., 2008).

Group Approaches Several group-therapy approaches have been developed and tested with survivors of various forms of trauma. Overall, the data suggest that group therapy may be helpful for symptoms of PTSD. Given the limited resources that often are experienced after an armed conflict or war ends, group therapy for the trauma of rape may be the most efficacious and practical way of providing psychological treatment to a large number of survivors. Cognitive processing therapy has been successfully administered in group settings (Resick & Schnicke, 1993). Several other group approaches have been developed and tested in samples of sexual trauma survivors. Generally, there is empirical support for group therapy using an interpersonal or a cognitive-behavioral approach (Shea, McDevitt-Murphy, Schnurr, & Ready, 2008). Group therapy is often offered to clients with PTSD in clinical settings and is frequently thought to be preferable to individual therapy, due to the benefits of peer support, normalization, and validation by virtue of developing relationships with other group members. However, no controlled studies have examined the question of whether group or individual therapy is superior for the treatment of PTSD symptoms.

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Timing of Intervention Data on posttraumatic reactions suggest that for many trauma survivors, there is a natural recovery over the first 3 months following exposure (e.g., Riggs, Rothbaum, & Foa, 1995). While PTSD is linked to events that involve a range of horrific traumatic events, the trend in published research suggests that most trauma survivors, in general, will not meet criteria for PTSD 3 months post-event. However, a prospective study of a sample of sexual assault survivors indicated that rape-related PTSD may be more severe and persistent than PTSD following other traumatic events. Specifically, 90% of sexual assault survivors were found to be symptomatic in the first few weeks following the assault, and by 3 months, approximately 47% met the full criteria for PTSD. This proportion persisted through 9 months. Thus, although many people experience “natural recovery” of PTSD symptoms, a large proportion of rape survivors remain symptomatic without intervention (Rothbaum, Foa, Riggs, Murdock, & Walsh, 1992). Although many individuals recover from PTSD symptoms within a few months, there is some evidence suggesting that well-designed interventions may be successfully applied to appropriate candidates within the early weeks following trauma exposure, resulting in significant amelioration of symptoms. Generally, early interventions are best applied following the “immediate impact” phase (the first 10 days posttrauma). Two cognitive-behavioral techniques have been developed for early intervention. Both were delivered to trauma survivors who showed significant symptoms of posttraumatic disorders and who were referred for services. In one study, the four-session, cognitive-behavioral intervention was substantially better than an assessment-only control condition for reducing symptoms of PTSD in a sample of female survivors of rape or aggravated assault (Foa, Hearst-Ikeda, & Perry, 1995). A second study by an independent group of investigators tested this intervention in a more rigorous design, comparing it to a supportive intervention, which was described as including psycho-education about trauma and problem solving, with the therapist adopting an “unconditionally supportive” role (Bryant, Harvey, Dang, Sackville, & Basten, 1998). In this second study, participants met criteria for Acute Stress Disorder, which is a term used to denote a specific syndrome of symptoms occurring within the first month posttrauma and a disorder that is associated with increased risk for the development of PTSD. Participants receiving the cognitivebehavioral intervention were significantly less likely to meet criteria for PTSD at post-treatment and at the 6-month follow-up point (Bryant et al., 1998). Debriefing interventions are often conducted within hours following a trauma, to large groups of people, irrespective of differences in individual emotional reactions. While mass “debriefing” interventions have gained some popularity, some data suggest that the use of Critical Incident Stress Debriefing in the aftermath of trauma may actually have iatrogenic effects (Bisson, Jenkins, Alexander, & Bannister, 1997). One general guideline to avoid the administration of unnecessary (or even iatrogenic) interventions is to conduct a careful individual assessment of current symptoms of PTSD, depression, and other anxiety disorders to develop an appropriate treatment plan. An appropriate treatment plan will include interventions

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aimed at the syndromes that best reflect a client’s reported symptoms. The treatment plan will also need to be appropriate to the context, with respect to cultural considerations and current environmental conditions. While some well-established therapies exist for distress that is related to sexual assault, little work has investigated the use of these therapies in a conflict-ridden areas. Work by Neuner and colleagues (2002, 2008) offers promising data about the applicability of narrative exposure therapy in such environments.

Providing Psychological Care in a Post-conflict Environment For clinicians working with survivors of sexual assault that was committed in the context of war, there are several factors that may be important to keep in mind, in addition to guidelines for working with sexual assault survivors in other contexts. First, rape in the context of modern warfare has been characterized as “extreme,” suggesting that survivors of war-related sexual assault are at risk for severe psychological outcomes. Survivors of war-related rape may have experienced multiple instances of sexual assault and/or been assaulted by multiple persons in a gang-rape situation. This severe form of trauma should be understood as more likely to result in PTSD or other adverse reactions. Additionally, rape in this context is often committed as a tool to engender terror in the population. Thus, it is likely that survivors were subjected to protracted periods of fear of rape and other violence, aside from the specific instances of rape. While non-combat rape survivors benefit from social support networks, which in most instances were not also traumatized personally in the same event (e.g., a rape victim in the USA), this important protective factor may not be available to survivors, because of additional trauma to the social network that may be widespread. When isolated, non-combat rape occurs, survivors may confide in trusted others, who likely can devote attention to providing instrumental and emotional support, forming a “trauma membrane” around the survivor. In contrast, for war-related rape survivors, members of the social support network may have been killed, injured, or raped themselves. Thus, the multitude of traumata that occur in the context of war will exacerbate the impact of any single event by a ripple effect, which may cause a tear in the social fabric and a possible failure in the development of an interpersonal trauma membrane around rape survivors in war zones. An additional consideration when working with survivors of war-related rape is the medical sequelae of rape in this context. First, in many underdeveloped nations, birth control may not be widely used and the risk of pregnancy resulting from rape is likely higher. The physical and psychological burden of pregnancy in a conflict zone may be substantial, given that the destruction of social infrastructure may result in little means for supporting a family financially and a decimated social support system. Subsequently, parenting a child conceived in rape and providing for the child in a war-torn locale may create overwhelming stressors for the

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survivor. Additionally, the risk of sexually transmitted diseases and HIV infection is likely higher in survivors of war-related rape, compared to the general population in Westernized countries. Among victims of sexual violence, generally (including rape outside of the context of war), the incidence of HIV infection is higher than nonvictimized samples (UNIFEM, 2007). Results from one study in Tanzania suggest that women who were HIV positive were 2.5 times more likely to have experienced violence from their partners (Maman et al., 2001). But in wartime, the impact is likely higher, given that in at least one instance (Rwanda), the deliberate spread of HIV infection was used as a tool of war (Rehn & Sirleaf, 2002) . In a sample of internally displaced women in Azerbaijan, women who experienced a recent rape were significantly more likely to have genital ulcers and lower abdominal pain than other women (Kerimova et al., 2003). Thus, survivors who seek psychological care should also be referred to medical care if they are not already receiving it. In the context where the rape occurred, medical care was likely scarce, and survivors may not have been treated immediately following the assault; thus, they may have contracted sexually transmitted infections that remain untreated, some of which can lead to medical complications or even death. An additional consideration when working with survivors of war-related rape is the impact of displacement. Residents of war-torn regions are often displaced from their homes for extended periods. This displacement may lead to disrupted social relationships and loss of possessions. Living conditions for displaced persons are often characterized by a lack of privacy, and vulnerability to interpersonal violence (Farr, 2009). The conditions of displacement are also associated with risk for sexual assault (Roberts, Ocaka, Browne, Oyok, & Sondorp, 2008). Few studies have investigated specific interventions for war-related rape survivors. One study, however, described an intervention employed by psychologists in the Democratic Republic of Congo (DRC) in the time period following a coup d’etat and massive civil unrest (Hustache et al., 2009). The investigators described the services provided by psychologists to a sample of 178 women, who were seeking services in one facility after rape by uniformed military personnel. The specific psychological intervention that was offered included (a) provision of safe and empathetic environment; (b) active listening; (c) allowing expression of personal views about events and distress; (d) assessing familial and social consequences; (e) normalizing women’s reactions; (f) encouraging appropriate coping strategies, and (g) working on acceptance and developing future plans. The women in Hustache and colleagues’ (2009) study had arrived at the facility within 4–6 weeks of their rape, and on average the women had been raped by two attackers; yet, the rate of PTSD was surprisingly low in the sample, estimated to be approximately 3%. However, all participants in the sample met criteria for at least one psychological disorder, the most frequent of which being other anxiety disorders (54.1% of the sample). The low rate of PTSD reported by this study is puzzling, given the relatively high degree of psychological distress (with all participants meeting criteria for at least one disorder), in the sample. The authors point out that this rate is drastically lower than other highly traumatized samples from war-torn regions of Africa, so it is unlikely that the PTSD concept lacks cultural relevance. While no

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obvious reason for the low rate emerged, it is possible that the particular measure, technique (e.g., not acknowledging co-occurring disorders), or interviewers utilized by the investigators contributed to underestimating the rate. The researchers followed up a subset of 70 women 2 years later, in order to investigate the long-term impact of the intervention (note: most of the remaining sample was lost to followup due to change in residence). At the 2-year follow-up, the rate of PTSD was again approximately 3%; although when analyzed at the level of individual symptoms, larger proportions endorsed items such as “heightened awareness of potential dangers to themselves” (43.8%), “irritability or outbursts of anger” (37.5%), or “difficulty falling or staying asleep” (26.6%). The authors reported that overall Global Assessment of Functioning ratings improved over the 2-year follow-up period. Although not specific to rape-related PTSD, narrative exposure therapy (described earlier) has been developed for survivors of war-related PTSD more generally (Neuner et al., 2008). The treatment was successfully conducted in refugee camps in Uganda, with trained lay counselors. The content of the treatment reflects an adaptation of typical cognitive-behavioral exposure therapy and may be useful in treating the trauma of rape in conflict-affected areas. Clinicians working in these environments are also advised to consult the work of the United Nations. The United Nations Fund for Women (UNIFEM) is dedicated to understanding, documenting, and preventing violence against women worldwide. They have contributed significantly to the understanding of the extent of wartime rape. The UN also sponsors a website, www.stoprapenow.org dedicated to the topic of war-related rape. The website offers “advocacy resources,” which consolidates documents from international meetings dedicated to the topic, as well as web links and videos about the extent of the problem of war-related rape. The website also includes narrative descriptions of survivors’ experiences and details about what the UN is doing to intervene in this worldwide problem.

Summary and Conclusions The research reviewed in this chapter suggests that survivors of rape or other sexual assault committed in the context of war are a population at high risk for adverse psychological outcomes, such as PTSD. Sexual assault survivors may be disinclined to disclose their experiences, particularly if they have previously disclosed and received a negative response from their support network or from others in their environment. Thus, it is critically important that crisis management and mentalhealth providers display empathy and validation for the survivor’s experience, thus, helping to create a trauma membrane around rape survivors. Careful assessment is critical to understanding the extent of symptoms, as well as the survivor’s coping behaviors and cultural background. In the context of war or conflict, sexual-assault victims may be particularly mistrustful of professionals who are affiliated with formal institutions, given fear of reprisal. In locales in which the socio-political structure has been severely disrupted

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and in which heinous acts were committed by those in authority, survivors may feel confused about whom to trust. Thus, as professionals seek to collaborate within survivors’ trauma membrane, they must be sensitive to the political climate and to assumptions survivors may make about them. Survivors suffering from symptoms of PTSD may need psychotherapy to overcome their traumatic memories and anxieties triggered by trauma-related stimuli. Repeated contacts with mental-health providers may not be possible for internally displaced persons, but once the health systems of a community are restored, there are multiple empirically supported treatments that can be administered. Much of the research on treatment for sexual-assault survivors has been conducted among survivors of civilian sexual assault in Western societies. There is a pressing need to conduct extensive field research about the effects of rape in post-conflict environments not only understand the clinical and cultural differences, compared to existing rape research, but also to provide therapeutic assistance and to facilitate healing of the psychological wounds created by rape.

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Chapter 14

The Psychological Impact of Child Soldiering Elisabeth Schauer and Thomas Elbert

Abstract With almost 80% of the fighting forces composed of child soldiers, this is one characterization of the ‘new wars,’ which constitute the dominant form of violent conflict that has emerged only over the last few decades. The development of light weapons, such as automatic guns suitable for children, was an obvious prerequisite for the involvement of children in modern conflicts that typically involve irregular forces, that target mostly civilians, and that are justified by identities, although the economic interests of foreign countries and exiled communities are usually the driving force. Motivations for child recruitment include children’s limited ability to assess risks, feelings of invulnerability, and shortsightedness. Child soldiers are more often killed or injured than adult soldiers on the front line. They are less costly for the respective group or organization than adult recruits, because they receive fewer resources, including less and smaller weapons and equipment. From a different perspective, becoming a fighter may seem an attractive possibility for children and adolescents who are facing poverty, starvation, unemployment, and ethnic or political persecution. In our interviews, former child soldiers and commanders alike reported that children are more malleable and adaptable. Thus, they are easier to indoctrinate, as their moral development is not yet completed and they tend to listen to authorities without questioning them. Child soldiers are raised in an environment of severe violence, experience it, and subsequently often commit cruelties and atrocities of the worst kind. This repeated exposure to chronic and traumatic stress during development leaves the children with mental and related physical ill-health, notably PTSD and severe personality

E. Schauer (B) Department of Psychology, University of Konstanz, Konstanz, Germany; vivo International, Konstanz, Germany e-mail: [email protected] Statements quoted in the text originate from the authors’ own work with formerly abducted children and former child soldiers during diagnostic interviews or therapeutic work in Northern Uganda and the Democratic Republic of Congo in the framework of project interventions of the NGO vivo. All clients have personally given written informed consent for publication of their experiences. Some have in fact urged us to tell the world what happened using their own words. E. Martz (ed.), Trauma Rehabilitation After War and Conflict, C Springer Science+Business Media, LLC 2010 DOI 10.1007/978-1-4419-5722-1_14,

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changes. Such exposure also deprives the child from a normal and healthy development and impairs their integration into society as a fully functioning member. This chapter presents in detail the cascade of changes that prove to be non-adaptive in a peaceful society. Further, ex-combatants experience social isolation arising from a number of factors, which include host communities’ negative attitudes towards ex-combatants and their psychological problems causing difficulties in social interaction. The risk of re-recruitment is high when ex-combatants fail to reintegrate economically and socially into their civil host communities, which may cause substantial economic development issues, and a new turn in the cycle of violence becomes inevitable. We therefore conclude that the provision of extensive mentalhealth services needs to be an essential part of demobilization and rehabilitation programs. This will improve the individual’s functioning, it will build capacity within the affected community, and it may be designed to break the cycle of violence. In this chapter, we include formerly abducted children’s description of selected experiences of child soldiering. The reader might be faced with emotional reactions, due to the detailed first-person reports. All narratives originate from either clinical diagnostic interviews or testimony established during psychotherapy with NET (Narrative Exposure Therapy). All children, who are voicing their life experiences, have been part of an already completed or on-going mental-health project, implemented to psychologically rehabilitate the beneficiaries by the NGO vivo.

Child Soldiers Characterize ‘New Wars’ In 2004, political scientists counted more than 42 wars and armed conflicts worldwide, almost all of them in developing countries (Schreiber, 2005). Observers of these current ‘new wars’ (Kaldor, 1999) or ‘complex political emergencies’ (Ramsbotham & Woodhouse, 1999) have noted that the main target of the warring parties is the civilian population, and the systematic atrocities, massacres, and bombings are often applied as rational strategies within current warfare. Never before in history have child soldiers played such a prominent role, constituting 80% of the fighting forces. This is one indication that we are witnessing a qualitative change in the way wars are waged and in the way organized violence is exerted; in other words, a transformation in the ‘culture of violence’ cannot be overlooked. Researchers have noted that the following are new characteristics or trends (Elbert, Rockstroh, Kolassa, Schauer, & Neuner, 2006; Kaldor, 1999): • Fighting is dominated by irregular forces, including paramilitary units, rebel forces, mercenary troops, and foreign armies that intervene in civil wars. As outlined below, a clear separation between civilians and soldiers disappears. Forcibly recruited child soldiers belong to the usual repertoire of most forces in the new wars. Parties to the conflict are frequently led by powerful warlords, with little or no power of the state. • Conflicts are justified by identification with ethnic groups, cultures, or religions, while actually the conflicts are driven by economic factors: warring parties get

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resources from supporting foreign countries and exiled communities, in order to control local resources, like minerals, oil, or drugs. • Warfare strategies include systematic atrocities, like massacres and mass rapes, to frighten civilians and to make regions uninhabitable for the group to be expelled. Another reason for the prevalence of atrocities in current wars is the assumption that they help to unite the group committing the atrocities. Easily available small weapons are sufficient for this type of warfare. Children have increasingly become victims and perpetrators of warfare (Redress, 2006). Crimes against humanity, like hunting humans, mutilations, and mass rape, are not an exception, but may be a characteristic of adolescent gangs that have gotten out of society’s control. Some have argued that the ability to be cruel is a way to exert negotiating power in this context, which may explain why there is little intervention of the ruling groups to prevent atrocities. Internationally agreed upon, undesirable, and prohibited war outcomes, which in fact are a hallmark of today’s conflicts, have been defined (Hicks & Spagat, 2008) and the phenomenon of child soldiering is one of them.1 The proportion of civilian casualties in armed conflicts has increased continuously during the twentieth century and is now estimated at more than 90%. About half of the victims are children (UNICEF, 2002). More than 2 million children have died as a direct result of armed conflict over the last decade. More than three times that number – at least 6 million children – have been seriously injured. Between 8,000 and 10,000 children are killed or maimed by landmines every year (Pearn, 2003; UNICEF, 2005). Of the ten countries with the highest rates of deaths of those under the age of 5 years, seven are affected by armed conflict (UNICEF, 2005). The World Bank reports additionally that the average mortality rate of children under the age of 5 years increased significantly as a consequence of war (Collier, 2003). War-related injury means wounds in the body and the mind. Traumatic stress can also occur from painful and frightening medical treatments and living with disability, especially in resource-poor countries. It is estimated that 4 million children have acquired disabilities after they were wounded in conflict over the last decade. For example, 75% of the injuries incurred from landmines in rural Somalia are to children between the ages of 5 and 15 years (ICRC, 1994). All of these samples include formerly abducted children and child soldiers. The lack of appropriate and timely 1 According to Hicks & Spagat, 2008, others are high mortality to civilians versus combatants; increased injuries to civilians versus combatants; torture of civilians or combatants; rape or sexual humiliation of civilians or combatants; sexual humiliation of civilians or combatants; mutilations of civilians or combatants; kidnapping and hostage taking; disappearances; summary execution of captured prisoners; terrorist attacks; assassination of civilian leaders; attacks on religious and medical personnel and on medical units; use of particularly undesirable or prohibited weapons (e.g., landmines and booby traps); suicide bombers disguised as civilians; child death or injury; female civilian mortality or injury; elderly civilian mortality or injury; violence to non-combatant indigenous groups; use of human shields; initiating weapon fire from among civilians; locating headquarters or weapons storage among civilians; combatants taking civilian appearance during military operations (e.g., not wearing uniforms); combatants disguised as humanitarian, peacekeeping, or medical workers; leaving landmines or unexploded ordnance; destroying infrastructure essential for civilian survival (e.g., food, water sources, hospitals).

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medical assistance during child soldiering is an additional serious humanitarian issue. Among a number of at-risk populations, children of war and child soldiers are a particularly vulnerable group and often suffer from devastating long-term consequences of experienced or witnessed acts of violence. Child war survivors have to cope with repeated and thus cumulative effects of traumatic stress, exposure to combat, shelling and other life-threatening events, acts of abuse, such as torture or rape, violent death of a parent or friend, witnessing family members being tortured or injured, separation from family, being abducted or held in detention, insufficient adult care, lack of safe drinking water and food, inadequate shelter, explosive devices and dangerous building ruins in the proximity, marching or being transported in crowded vehicles over long distances, and spending months in transit camps (Barath, 2002; Boothby, 1994; Elbert et al., 2009; Karunakara et al., 2004; Mollica, Poole, Son, Murray, & Tor, 1997; Schaal & Elbert, 2006; UNICEF, 2005; Yule, 2002). These experiences can hamper children’s healthy development and their ability to function fully, even once the violence has ceased. Furthermore, destruction brought by war is likely to mean that children of war and child soldiers are deprived of key services, such as education and health care. A child’s education can be disrupted by armed conflict, due to abduction, displacement, absence of teachers, long and dangerous walks to school (e.g. landmines, snipers), and parental poverty (e.g. inability to provide school fees and uniforms and the necessity for children to contribute to household income). Schools can be caught up in conflict as part of the fighting between government forces and rebel groups or can be used as centers for propaganda and recruitment. Attacks on and abductions of teachers and students are a frequent phenomenon of global warfare. The same can be observed for hospitals, doctors, and nursing staff. Health centers often become a direct target, the medical supply is cut off during intense periods of fighting, and health personnels are frequently kept from accessing the sick and injured as a political strategy (Cairns, 1996; Sivayokan, 2006; UNICEF, 2005). The social consequences of growing up in shattered, war-torn environments include effects like alcoholism, drug abuse, and early unprotected sexual activity (sex for food and security), which can result in teenage pregnancy and the contraction of HIV/AIDS (Kessler, 2000; Yule, 2002). The increased likelihood of HIV transmission in conflict zones is mostly due to the breakdown of family, school, and health systems, with their regulatory safeguards that could counter these risks (UNICEF, 2005). During 1990 and 2005, an estimated 30 million children were forced by conflict and human right violations to escape their homes and are currently living as refugees in neighbouring countries or as internally displaced within their own national borders. During flight, families may become separated. More than 2.5 million children have been orphaned or separated from their families because of war in the past decade (Pearn, 2003; Southall & Abbasi, 1998; UNICEF, 2005). The poor living conditions, in which fleeing families find themselves, increase children’s vulnerability to malnutrition, diarrheal diseases, and infections (Toole & Waldman, 1993). In Africa, crude mortality rates have been as high as 80 times baseline rates among refugees and internally displaced populations (IDP) (Toole & Waldman, 1997).

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Often the period of exile runs into years and decades, and in such cases, children may spend their whole childhood in camps and displacement. Nowadays, there are entire generations of children who have never lived at home in Africa and Asia (UNICEF, 2005).

The Use of Child Soldiers in Armed Conflicts Prevalence and Phenomenon A child soldier is any person under the age of 18 who is a member of or attached to government armed forces or any other regular or irregular armed force or armed political group, whether or not an armed conflict exists. Child soldiers perform a range of tasks including participation in combat, laying mines and explosives; scouting, spying, acting as decoys, couriers or guards; training, drill or other preparations; logistics and support functions, portering, cooking and domestic labour; and sexual slavery or other recruitment for sexual purposes (Coalition to Stop the Use of Child Soldiers, 2007).

Hundreds of thousands of children are conscripted, kidnapped, or pressured into joining armed groups. The proliferation of lightweight weapons has made it possible for children under the age of 10 years to become effective soldiers. Compared to earlier weapons, which required strong physical force to be an effective fighter, this is a notable change in technology that has allowed recruiting children as a new class of fighters, which is a defining characteristic of the ‘new wars.’ The trend in using children in armed conflict as soldiers is not diminishing. An estimated 300,000 child soldiers – boys and girls under the age of 18 – are involved currently in more than 30 conflicts worldwide (Child Soldier, 2001; Jayawardena, 2001). Some 40% or 120,000 child soldiers are girls, whose plight is often unrecognized because international attention has largely focused on boy soldiers. In general, when people speak of ‘child soldiers,’ the popular image is that of boys, rather than the thousands of girls who comprise the less visible, ‘shadow armies’ in conflicts around the world (McKay & Mazurana, 2004).2 While the use of child soldiers as combatants is a 2 According to the United Nations and Save the Children, key conflict areas where the problem of boy and girl soldiers has been and remains acute today include Colombia, East Timor, Pakistan, Uganda, the Philippines, Sri Lanka, the Democratic Republic of the Congo (DRC), and western and northern Africa. Moreover, in Afghanistan, Chechnya, the West Balkans, Haiti, Liberia, Peru, Rwanda, and Sierra Leone, recruitment and abuse of child soldiers have occurred. Like the boys, typically the majority of girl soldiers are abducted or forcibly recruited into regular and irregular armed groups, ranging from government-backed paramilitaries, militias, and self-defense forces to antigovernment opposition and factional groups, which are often based on ideological, partisan, and ethnic or religious affinity. Children are recruited and used in armed conflict in at least 15 countries and territories at present which are Afghanistan, Burma (Myanmar), Central African Republic, Chad, Colombia, Democratic Republic of Congo (DRC), India, Iraq, Occupied Palestinian Territories, Philippines, Somalia, Sri Lanka, Sudan, Thailand, and Uganda. Countries especially named for sexual exploitation of child soldiers – this includes boys as well as girls – are Afghanistan, Angola, Burundi, Congo, Honduras, Cambodia, Canada, Columbia, Liberia, Mozambique, Myanmar/Burma, Peru, Rwanda, Sierra Leone, Uganda, United Kingdom, and USA (Alfredson, 2001; Human Rights Watch, 2009).

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contemporary development, children have continuously served throughout history as servants, messengers, porters, cooks, and to provide sexual services. Some are forcibly recruited or abducted; others are driven to join by poverty, abuse, and discrimination, or to seek revenge for violence enacted against themselves and their families. When children are recruited into combat and servitude, they experience sexual violence and exploitation and are exposed to explosives, combat situations, and the experience and witnessing of killings (Pearn, 2003). Reports abound from conflict zones of girls and boys being abducted and forced into sexual slavery by militias or rebel groups (Southall & Abbasi, 1998; UNHCR, 2003; UNICEF, 2005).

Reasons for Recruitment of Children The development of light weapons and small arms made it possible, for the first time in history, to recruit children as fighters. Blattman (2007) summarized several reasons why children and young adolescents have become the focus of recruitment, because this possibility arose in the late twentieth century. The following arguments should be interpreted as complementary facets of motivations for child recruitment. First, the current demographic shift in poor countries (in part due to HIV/AIDS) led to the largest population of children and adolescents ever, making this age group most available for recruitment and abduction. Second, commanders (especially African) emphasize stamina, survival, and stealth of child soldiers, as well as their fearlessness and will to fight (International Labor Organization [ILO], 2003). This may be due to children’s limited ability to assess risks, feelings of invulnerability, and short-sightedness (Brett & Specht, 2004). It is a fact that child soldiers are more often killed or injured than adult soldiers, which can be explained by their being deployed at the front line, e.g. to lay or clear mines, or as suicide bombers because they provoke less suspicion (Coalition to Stop the Use of Child Soldiers, 2008). Third, child soldiers are cheaper for the respective group or organization than adult ones, because they receive fewer resources, including fewer and smaller weapons and equipment. From a different perspective, becoming a fighter may be an attractive possibility for children and adolescents facing poverty, starvation, unemployment, and ethnic or political persecution (International Labor Organization [ILO], 2003). Facing these problems, children are ‘soft targets’ as recruits into armed groups and may be more willing to fight for honour or duty, for revenge, or for protection from violence (Brett & Specht, 2004; Redress, 2006). Fourth, children are also easier to retain in the group. In our interviews (see below), child soldiers and child commanders argue that children are more malleable and adaptable, and hence easier to indoctrinate. They stick more to authorities without questioning them. Moral and personality development is not yet completed in children, reducing their inhibition against performing crimes against humanity. Interviews with rebel leaders of the Ugandan Lord’s Resistance Army (LRA) revealed that adults have been the most skilled fighters, but also those who were most likely to desert. Despite being weak

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fighters, young children have been most likely to stay, because they were easiest to indoctrinate, while at the same time, it is more difficult for them to plot escape strategies. Adolescents seemed to offer the best fit between malleability or likelihood to stay and effectiveness as fighters (Blattman, 2007). In addition, Somasundaram (2002) stated that military leaders in Sri Lanka prefer younger children because of their suggestibility and fearlessness or weaker ability to estimate dimensions of danger.

Enlistment and Recruitment Pertinent Laws of War anonymously state that the enlistment, recruitment, use, and/or deployment of child soldiers under the age of 15 are actions that are war crimes according to the 1989 Convention on the Rights of the Child, and the 1998 Rome Statue of the International Criminal Court. These two guiding, international instruments have even been advanced by the Convention of the Rights of the Child, which states a ‘straight 18’ approach to recruitment in the 2002 Optional Protocol to the Convention on the Rights of the Child. The 1990 African Charter on the Rights and Welfare of the Child supports the age of 18 as a minimum entry age of soldiering (more information on related topics can be sought in Redress, 2006). There are hardly any systematic investigations of child soldiers, exploring their views, motives, and identities. We therefore have performed semi-structured interviews in several regions of East Africa.

Forced or Voluntary Recruitment and Remaining? A cautionary note to the reader: the following pages contain interviews with children, some of whom report events that were exceedingly graphic or violent. These children have experienced or observed these horrific events in environments of conflicts or wars, and thus, their first-person accounts, while shocking, are needed to illustrate the nature and depth of the issues. The editor.

K.G., a 16-year-old boy at the time of the interview (South Kivu, Democratic Republic of Congo [DRC], March 2009), was an active recruit for 3 years, i.e. he joined at age 13: I think I joined freely. All my friends were already part of this group, even my uncle and many of my cousins. The Mai-Mai had long been around us; in fact they had built shelters next to our community in the forest. One day a friend of mine told me to come to the football grounds for a game. There we saw the Mai-Mai and they were telling us that today would be their pay-day, that a government official of the Congolese army would come and give them their monthly wages and if we joined, we could all get a share of that money. It didn’t take me long to decide. In those days I was frightened, since our home was attacked almost every night by bandits and other rebel groups as well, what did I have to lose? Also my parents were too poor to send me to school anymore. My mind was made up fast, I joined my friends and from that day I never went home to my parent’s house again. I know you think, how can I not think of home, but I never did. I was totally there in the forest

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with the rebels, I only thought of today and the drugs we got there. One time my parents tried to find me and buy me out with a goat, but I didn’t even look at them. Home did not exist anymore you know, I was always under drugs from that day onwards. Also we had a purpose. You know North Kivu is very rich, many people come and want to rule us, they come and want our riches and we need to fight that, we need to fight for our freedom and to fight for our village. Our commander used to talk to us about this every morning when we met for morning assembly.

O.B. received therapeutic treatment for trauma-related mental health when he was an 18-year-old (May 2006). He had served for nearly 5 years after being abducted by the Lord’s Resistance Army (LRA) in Northern Uganda at age 14: After two days, an assembly took place. Everybody was gathered. They talked about us newly abducted children and they said: “you look like people who plan to escape and we are going to make you rebels now.” They told us to lie down. Now we were surrounded by 40 rebels. They said: “do not raise your head or we will kill all of you.” We had to stretch our hands forward and put our foreheads to the ground. They started beating my back. 350 strokes were given on my back and buttocks. After a while the pain was so big that I felt that it would be better if I was dead. It was just too much to bear. Coldness started creeping into my body. And the trembling started. And then it happened again. I looked at my body from outside. I knew I would die. I saw death. It was in me. Death takes people’s soul. My soul was already outside my body. I could feel pain, deep pain, but it was not from my back, from the strokes, it was everywhere inside me now. Death was trying to take my soul. Pain was everywhere in me. I could see death. You can see it when you are going to die. I couldn’t hear anything. I also didn’t realise when it was that they had stopped beating me. But then I heard a loud voice: “Get up.” I tried, but I couldn’t sit. I kneeled for almost one hour. It felt like a very long time. I realised that all other children around me had died in the beating. I could see them lying still and not breathing. They were lying all around me. Their bodies were swollen and full of blood all over. The rebels dragged their bodies and dumped them into the nearby river.

K.K.G., male, 16 years old at time of diagnostic interview (March 2009), spent 3 years as an active recruit, joining Mai-Mai, in North Kivu, DRC at age 13: When you would not follow the commander’s rule, he could get very angry. People would get beaten terribly for disobedience or if they were trying to escape. When their wounds were open and bleeding, salt was rubbed inside their wound. In that the commander was merciless. You had to follow the rules or you would lose the ‘protection’. When people did something really wrong, they got killed as a punishment. . .I have seen 5 people being killed for severe disobedience during my time with the group. They were crucified in the forest. The commander would order them being nailed to trees at their hands and feet higher up on tall trees. The nails were thick ones, like those you would use to nail big logs for the roof of a house. You would first nail through the palms of the hand and later through the feet, just below the ankle and then turn the nail around so as to fix the foot to the tree stem. Sometimes the commander then ordered for people to be burnt with hot plastic again and again until they had real holes in their bodies.

Even if it might appear so to the individual child, from a psychological and social point of view, children’s choices to join and remain in armed groups cannot be considered ‘voluntary’. In summary we propose the following reasons:

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• Children have no or limited access to information concerning the consequences of their choice; they neither control nor fully comprehend the structures and forces that they are dealing with. • Children have little knowledge and understanding of the mid- and long-term consequences of their actions. • Children might be told and believe that they have to ‘stand up’ against an enemy, who would otherwise kill them or hurt their families; they tend to trust and obey caretakers’ and families’ or key community leaders’ judgement on this. • Children might believe that they have to take the place of a family member, who would otherwise be enlisted, or to avenge a family member, who has been killed by the ‘enemy,’ which might constitute a emotionally perceived life-threat for the child. • Conditions of civil war and armed conflict undermine the ability of families and communities to protect the young of both sexes (Druba, 2002); parents might then be driven to give in to the powerful influence of militia leaders of their own ethnic group. Enlistment on the part of the parents or caretakers can never be considered ‘voluntary’ on part of the child. • A large number of child victims of social chaos and violence become orphans, refugees, or are only partly protected by adult care, as a result being left alone in their struggle to survive social, emotional, and economic hardship, a potential push factor into recruitment. Interestingly, it is extremely rare for wealthier children from urban areas to be recruited. • With systematic indoctrination and acculturation, a commander can, over time, replace the position of a caretaker/parent and serve as an adult role model, which children will naturally accept, and in fact, need to attach to for mentorship, guidance, and survival; fellow child combatants can take the place of siblings and/or replace the community peer group; this ‘surrogate family’ phenomenon does not imply a voluntary choice by the child, but a forced adaptation and might, in fact, be a sign of healthy development in the absence of other choices. • Children might feel that they have to protect themselves, if the official state structure, community, or family cannot; by perceiving to have no choice, they might try to escape the violence and abuse around them – and enlisting might become a perceived means of survival. • Girls might think that joining an army might protect them from being raped or harmed by free-roaming ‘militia groups’. • During the initial period, children who have joined armed groups, whether voluntary or forced, are almost always subjected to harsh, life-threatening initiation procedures, such as severe beatings, forced killings, magic-spiritual rituals (e.g. tattooing, scarring, spraying with blood or ‘holy’ water), and forced drug intake, in order to make them ‘proper soldiers’ and fear the repercussions of escape; such practices tend to be forced on the new recruit and put children’s lives in danger. • Rarely do demobilized children share with their parents or communities the emotional context of what they have experienced or how they were treated; as a result of the lack of emotional communication, reintegration into local communities is hampered by perceptions of the community’s view of the particular armed group

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with which the child was associated. The individual needs and unique case of the returning child are rarely considered. Stigmatization levels are high at the time of re-entry into the community of origin and constitute a potential push factor for re-recruitment.

Risk Factors for Recruitment Known risk factors for becoming a child soldier are poverty, less or no access to education, living in a war-torn region, displacement, and separation from one’s family, with orphans and refugees being particularly vulnerable (Beth, 2001). Somasundaram (2002) lists the following factors as catalysts for children to become Liberation Tigers of Tamil Eelam (LTTE) child soldiers in North-Eastern Sri Lanka: death of one or both parents or relatives, family separation, destruction of home or belongings, displacement, lack of food, ill health, economic difficulties, poverty, lack of access to education, no avenues for future employment, social and political oppression, harassment from government soldiers, abductions, and detention. He also describes an emerging pattern of youth violence in the general population after two decades of war in the affected communities. After growing up in a war environment, male youth in displaced camps seemed to drift into anti-social groups and activities when a natural disaster hit the coastal regions. Unemployed and left out of school-based programs, some left to join militant groups, while other started abusing alcohol and formed into violent groups and criminal gangs. Having grown up immersed in an atmosphere of extreme war violence, many had witnessed horrifying deaths of relatives, the destruction of their homes and social institutions, experienced bombings, shelling, and extrajudicial killings (Somasundaram, 2007). A similar pattern of ‘saturation’ can be assumed in children who grow up in conflict-stricken communities, which later become recruitment targets of rebel movements. This could constitute a pull factor for joining the movement. Further reasons might be hearing false promises or relatives taking part in the movement. As P.A.N., who was male, 29 years at time of diagnostic interview (March 2009), served 1 year as an active recruit, and joined Mai-Mai in North Kivu, DRC at the age of 15 years, described: The whole village was overtaken by Hutu’s and even our houses and shambas (fields) were occupied by them. The population of the villagers was living in displacement. My whole family and all my relatives and friends were displaced. So we decided to protect ourselves and our ‘earth’ and to fight. All young men were in this, family members, friends, the whole community. You see our parents could not support us, there were no more school fees and no more home. When I was 16 years old, I joined the Mai-Mai. We fought to eliminate the Hutus, and there were two groups of them, the old Hutus who had come earlier and those who came during the genocide of Rwanda in 1994. So I joined to help create a resistance movement and to protect our home. During my time in the group, things changed of course and later I stayed on also because I was afraid to be killed if I fled. But there was also the other voice in me, which wanted to stay and learn as best I could to be a good combatant and especially learn how to have enough inner discipline to be strong for the rest of my life, so as to never be helpless again.

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The Consequences for Children Who Have Been Combatants Exposure to Traumatic Stress Severe and traumatic stress and its deteriorating effects for mental health, such as the development of post-traumatic stress disorder (PTSD), a debilitating psychiatric condition, gain more and more importance in the description of societies affected by the new wars’ human rights violations. Our research has highlighted the role of a ‘building block effect’: traumatic experiences build upon each other and cumulatively increase the chance of developing PTSD and depression (Karunakara et al., 2004; Kolassa & Elbert, 2007; Kolassa et al., in press; Onyut et al., 2009; Schaal & Elbert, 2006; Schauer & Elbert, 2010; Schauer, Neuner, & Elbert, 2005; Schauer et al., 2003). PTSD patients have developed a ‘fear network,’ composed of interconnected, trauma-related memories, in which even only peripherally related trauma stimuli can cause a cascading fear response with flash-back properties. Therefore, the cumulative exposure to traumatic stress constitutes a predictor of endemic mental-health issues. We begin our discussion about traumatic stress with an exemplary outline of the type and frequency of traumatic stressors in crisis regions: V.A., a 20-year-old woman who, at time of therapy (May 2006), had spent 10 years in abduction with the LRA, Northern Uganda, reported: I remember my life from around the time when I was 5 years old. I lived with my parents in the hills around Gulu and we had a good time. When I was 7 years old, my mother got poisoned and died. From then on, my step-mother took over the household and I suffered a lot, she used to beat me badly. When I was 9 years old, a boy raped me while I was on the way to the well to fetch water. When I was 10 years old, I got abducted by the LRA. I witnessed how many other children got abducted and we were made to walk towards Sudan. On the way, I saw how he beat many people to death, probably those who could not keep up with the walking and the heavy loads. When we arrived at Kony’s place in Sudan, I witnessed the torture and killing of a wizard. I was given to one of the elder women of a commander as a helper. She was nice, but she died soon and from then on I was mistreated by the co-wives. At age 11, I remember the commander coming home to the house early and I had not cleaned-up yet; he beat me severely for that. From that day onwards he would do it regularly. Sometimes so much that I had to go to hospital, but the rebels always took me out again forcefully and brought me back before my wounds were healed. One day when I was 12 years old, we saw how children in a school were forced to eat their own teacher by the LRA; apparently the man had resisted giving food to the rebels. At age 14 years, the commander started raping me and told me that I am now his wife. A few months later I had my first baby. It was a beautiful child, but I did not know how to look after him, so he died soon. In the same year, there was a fierce battle with the UPDF [Uganda People’s Defense Force], an air attack, where many of our people in the settlement died. At age 16, I gave birth to another baby. The next morning when I woke up, also he had died. He had been tiny and weak and he probably died from the cold night air, since I had nothing to cover him. One day soon after this we saw how the Lutugu people got hold of enemies and poured boiling water over their bodies until they died. At age 18, I had to take part in a raid on Lira IDP camp. We were trying to get new abductees and food, but people resisted, so 18 of them were killed by our group. At age 20, I gave birth to George in the bush. He is weak, but he is still alive, I so much hope that he will grow up. That same year during an attack by government soldiers, the rebels, including my husband, left me behind. I guess I was a burden to them, since we women with small children were not able to run fast. He never

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explained to me what he was thinking, he just left me behind and the soldiers brought me to this reception center. In the future I hope to do small business. I am a bit worried, since I can’t read and write. They want me to go back to my relatives’ place, but it is insecure and rebel attacks are frequent. If I could choose, I would choose a safe place to live.

F.O., a 13-year-old boy at time of therapy (April 2006), who had spent 3 years in abduction with the LRA in Northern Uganda, described his experiences: I was born in 1994 in a small village in Uganda. My mother used to cook beans so well for me and my father. When I was 6 years old, my parents had a fight and my mother got wounded by my father with a knife. He would always start acting in a funny way when he was drunk, he would act as if he was still a soldier in the bush. At age 7, I finally started going to school, that was a good day. At age 11, I was abducted and that same day they made me kill 3 of my uncles. A few days later, they ‘initiated’ me to be a soldier and gave me 100 strokes of beating. One year later, I was forced to cut off both hands of a hunter with a hapanga. In the same year, we fought a big battle with the UPDF, where my friend was killed. When I started crying, the commander forced me to lie in his blood. Many battles followed that one in the same year, also air attacks. We were often starving, since there was no time to find food. Once we had to ambush a bus with civilians on the road towards Atiok to get hold of food; many people died and got burnt. Two days later we were asked to attack a camp. We were told to bring food and girls; we found three, but I was forced to kill two since they couldn’t manage to carry the heavy loads and keep up. It wasn’t long after that incident in the same year that I got a chance to escape during a battle with the UPDF. I was 13 when I reached this center.

In a study by our group (Pfeiffer et al., submitted), which was carried out in a representative selection of IDP camps of Northern Uganda during 2007 and 2008, it was found that of the interviewed sample of 1114 children and young adults, 43% were formerly abducted children and many of them were recruited temporarily as child soldiers. The most common traumatic life events of those who had been abducted were forced to skin, chop, or cook dead bodies (8%), forced to eat human flesh (8%), forced to loot property and burn houses (48%), forced to abduct other children (30%), forced to kill someone (36%), forced to beat, injure, or mutilate someone (38%), caused serious injury or death to somebody else (44%), experienced severe human suffering, such as carrying heavy loads or being deprived of food (100%), gave birth to a child in captivity (33% of women), were threatened to be killed (93%), saw people with mutilations and dead bodies (78%), experienced sexual assault (45%), experienced assault with a weapon (77%), and experienced physical assault including being kicked, beaten, or burnt (90%). The PTSD rate of the children, who were never abducted, was found to be 8.4%; of those who had ever been abducted, 33%, and those who had spent more than 1 month in captivity, the PTSD rate was measured at 48%. In this large, representative study, the children’s mental-health impairment had remained chronic, because in a majority of cases, the interviews had taken place years after they had come back from captivity. One out of four former child soldiers reported to be still currently disturbed by different intensities of self-perceived ‘spirit possession,’ which as our data shows is a way to express and attribute symptoms of trauma-related illness and which in the studied population correlates well with a PTSD diagnosis. In another large study by Vinck and colleagues (Vinck, Pham, Stover, & Weinstein, 2007), again in Northern Uganda, it was found that 82% of formerly

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abducted children presented with PTSD symptoms. A follow-up review of Pham and colleagues (Pham, Vinck, & Stover, 2009) with former abductees showed that 67% met the symptom criteria for PTSD; in those abducted for 6 months or more, this rate rose to 80%. In 2007, Bayer and colleagues (Bayer, Klasen, & Adam, 2007) carried out a study among former child soldiers in Uganda and Congo. The interviewed 169 children had a mean age of 15 years at the time of being interviewed. All children reported that they had been violently recruited by armed forces at a mean age of 12 years. They had served an average of 38 months in captivity. The most commonly reported traumatic experiences were having witnessed shooting (92.9%), having witnessed somebody being wounded (89.9%), and having been seriously beaten (84%). A total of 54% of the children reported having killed someone, and 28% reported that they were forced to engage in sexual contact. Further, 35% of the interviewed children had exhibited a fully developed post-traumatic stress disorder. The 2004 Derluyn et al. (Derluyn, Broekaert, Schuyten, & De Temmerman, 2004) findings are the highest symptom scores so far reported in formerly abducted children. The study interviewed 301 former child soldiers who had been abducted. All children were abducted at a young age (mean 12.9 years) and for a long time (mean 25 months). Almost all the children experienced several traumatic events (a mean of six traumatic events): 77% saw someone being killed and 39% had to kill someone themselves. Amone-P’Olak (2005) examined experiences of war, physical abuse, sexual abuse, and related psychological disorders in formerly abducted girls in 2005. The results demonstrated that 98% of girls had been threatened to be killed when disobeying, 98% had thought that they would be killed, 99% only narrowly escaped from death, 72% had been sexually abused by the rebels (in most cases forcefully ‘being given as a wife’ from the age of 13 years), 65% witnessed people being killed, 44% of the girls witnessed people being mutilated, 18% of the girls participated in killings, and 7% were forced to participate in killing own relatives. On average, the girls experienced 24 traumatic events during captivity. The large ‘Survey of War Affected Youth – SWAY’ study (Annan & Blattman, 2006) found very similar rates and types of traumatic experiences as all of the above mentioned. As an additional item, this study found that 23% of the children had been forced to abuse dead bodies (see Coalition to Stop the Use of Child Soldiers, 2004, 2008 for a more comprehensive description of child soldiers’ experiences).

Post-traumatic Stress Disorder K.K.G., male, 16 years, who, at time of diagnostic interview (March 2009), had spent 3 years as an active recruit and had joined the Mai-Mai, in North Kivu, DRC at age 13 years, reported: When I was out in the forest, I was feeling nothing, I was drugged all the time. But after I had come out and now since I stay in this transit center, I get these terrible nightmares.

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They are always about the children we killed, especially their crashed skulls and I hear the voice of my commander telling me to do things. I wake up and get so frightened. My heart is beating strong these days and something in my head is so wrong. On one hand, I have a new life and I have left the forest behind and also all the hardship of those days, on the other, I think of the times and especially the drugs we had. Sometimes at night I walk out of the building, especially when I get the dreams and stare at the sky. I would just wish that my head gets normal again.

According to the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2000), a PTSD diagnosis is restricted to individuals who have experienced or witnessed at least one traumatic event in their life, i.e. a stressor that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or other, and the subjective perception of intense fear, helplessness, and/or horror. Victims, as well as eyewitnesses, can enter a psychological alarm state during the traumatic event and a cascade of responses in the body and mind is triggered which can damage both the mind and the body (Schauer et al., 2005). During life-threat, the defense cascade is activated as a coherent sequence of fear responses that escalate as a function of defense possibilities and proximity to danger. These reaction patterns provide optimal adaptation for particular stages of the imminence of threat. The actual sequence of trauma-related response dispositions acted out in an extremely dangerous situation depends on the appraisal of the threat by the victim in relation to his/her own power to act (e.g. age, gender), as well as the perceived characteristics of the threat or perpetrator (Schauer & Schauer, 2010 this volume; Schauer & Elbert, 2010 this book). Repeated experience of traumatic stress forms a fear network that can become detached from contextual cues, such as time and location of the danger, and thus may lead to psychological disorders or non-adaptation (Schauer et al., 2005). Traumatic events can be man-made or caused by natural disasters. The former may involve state-sanctioned or organized violence (e.g. being in a situation of war and combat, torture riots, terrorism, and mass killing) or interpersonal violence (e.g. experienced or witnessed killing or mutilation, severe physical or sexual assault, sexual abuse, rape, and domestic violence), as well as catastrophes (e.g. car accidents, airplane crashes, and accidents involving poisonous substances). Traumatic natural disasters may be severe floods, hurricanes, earthquakes, or volcanic eruptions. After repeated exposure to traumatic stressors, post-traumatic stress disorder is the most likely psychiatric condition that emerges among a range of possible trauma-spectrum disorders including depression, suicidality, and substance abuse. The considerable similarities and consistencies in the clinical manifestations of psychological disorders across diverse, affected groups globally tend to outweigh cultural and ethnic differences (GarciaPeltoniemi, 1998; Schauer & Schauer, 2010). Across cultures, defining symptoms of PTSD are reported as follows (APA, 1994; Joshi & O’Donnell, 2003): (1) Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions (e.g. observable in children’s repetitive play or traumaspecific re-enactments); recurrent and distressing dreams (e.g. for children, nightmares with scary content of any nature); acting or feeling as if the

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traumatic event was recurring; intense psychological and physiological distress at exposure to internal or external cues (e.g. observable in constriction of affect); (2) Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness; (3) Persistent symptoms of heightened arousal and constant alertness. Children often experience this as eating and sleeping problems, increased autonomic arousal (e.g. sweating, raised heartbeat, and concentration difficulties), foreshortened sense of future (e.g. even small children can express hopelessness in relation to ever growing up), recklessness and risk-taking behaviour, hyperactivity, withdrawal, defiance, aggression, and also numerous psychosomatic complaints (e.g. common are stomachaches and headaches) which result from frequent alarm responses, easily elicited by trauma-related cues that may appear in everyday life. (4) In its most extreme forms, phenomena like derealization, depersonalization, or symptoms that resemble psychosis have been noted. In order to qualify as a psychiatric disorder, the disturbance must cause clinically significant distress or impairment in emotional, social, occupational, scholastic, or otherwise important areas of functioning. In children, this is also observable as loss of acquired skills (e.g. an impact on the child’s developmental functioning, such as the ability to speak), as well as its persistence for a certain amount of time. Age at traumatization is not a consistent predictor nor a protector from traumatic stress reactions and the expression of symptomatology (Berman, 2001; Elbedour, ten Bensel, & Bastien, 1993). The age of the individual at the time of exposure does not seem to mediate symptom expression over time for a majority of suffering survivors. There are also no significant differences found in PTSD rates across different developmental stages (Fletcher, 1996). Numerous studies suggest that regardless of the passage of time, affected children and adolescents continue to suffer from distressing symptoms, with PTSD being most persistent (Almqvist & Brandell-Forsberg, 1997; Bichescu et al., 2005; Bremner & Narayan, 1998; Dyregrov, Gjestad, & Raundalen, 2002; Elbedour et al., 1993; Goenjian et al., 1999; Hubbard, Realmuto, Northwood, & Masten, 1995; Kinzie, Sack, Angell, Clarke, & Ben, 1989; Kinzie, Sack, Angell, Manson, & Rath, 1986; Marshall, Schell, Elliott, Berthold, & Chun, 2005; McFarlane, Policansky, & Irwin, 1987; Morgan, Scourfield, Williams, Jasper, & Lewis, 2003; Perry & Pollard, 1998; Ruf, Neuner, Gotthardt, Schauer, & Elbert, 2005; Sack, Him, & Dickason, 1999; Schaal & Elbert, 2006; E. Schauer, Catani, Mahendran, Schauer, & Elbert, 2005; M. E. Smith, 2005; P. A. Smith, Perrin, Yule, Hacam, & Stuvland, 2002; Thabet & Vostanis, 2000; Yule et al., 2000).

Post-traumatic Stress Disorder Investigating more than 3,000 war refugees, we (Neuner et al., 2004; Schauer et al., 2003) found that the greater the number of different types of traumatic events experienced by an individual (e.g. torture, fighting, shelling, abduction, abuse/rape,

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Fig. 14.1 The probability to develop a PTSD increases with cumulative experience of types of traumatic events experienced (upper left). Units on the abscissa correspond to classes of cumulative experiences of traumatic stressors. The full range is about 25 different types experienced. Circles indicate the observed average for PTSD for a particular event load. For those who have developed a PTSD, depressive symptoms, functional impairment, and physical diseases also become more likely with increasing exposure to traumatic stressors). Graph upper left: Data from survivors of the Rwandan genocide, Kolassa et al., (in press). Other graphs: data from a survey in Sri Lankan school children with PTSD due to the civil war, Schauer, E. (2008)

forcible female circumcision, car accident), the more likely the individual was to have PTSD, with more pronounced symptoms. In our studies, PTSD prevalence rates reached 100% for individuals having experienced a sufficiently large number of different traumatic-event types (see Fig. 14.1). This building-block effect may be a result of the development of a neural fear network, which is strengthened and extended in response to each new traumatic event (Elbert et al., 2006). During a traumatic event, perceptual and emotional features of the situation are ‘burnt’ into memory (Elbert & Schauer, 2002), forming the nucleus of a neural network that is associated with the traumatic event. Subsequent traumatic events are

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associated with similar elements of a hot memory (i.e. physiological, like heart beating, sweating, as well as an emotional-like feeling, such as helpless and horrified, cognitive, such as I cannot do anything, and even sensory, such as man in uniform, weapon). Network connections are strengthened through synchronous activation, so that activity in one of the memory representations facilitates activity in the other. Thus, memories of specific traumatic events will merge into an indistinct whole and a fragmentation of autobiographic context-memory results (Elbert et al., 2006; Kolassa & Elbert, 2007). Research repeatedly has demonstrated the significant relationship between the number of traumatic-event types experienced and the likelihood of developing posttraumatic stress disorder and other disorders of the trauma spectrum: the more exposure to trauma, the more likely the development of psychological disorders (Allwood, Bell-Dolan, & Husain, 2002; Catani, Jacob, Schauer, Mahendran, & Neuner, 2008; Catani et al., 2005; Elbert et al., 2009; Kolassa & Elbert, 2007; Kolassa et al., in press; Macksoud & Aber, 1996; Neuner et al., 2004; Schaal & Elbert, 2006; Schauer et al., 2003; Steel, Silove, Phan, & Bauman, 2002). This effect of cumulative exposure makes ex-combatants a highly vulnerable group, as they are exposed to a great number and outstanding diversity of traumatic stressors.

Living with Post-traumatic Stress Disorder and Trauma Symptoms Literature consistently shows that post-traumatic stress reactions are not transitory entities, but rather persist over time. Studies from Western countries, e.g. with Second World War veterans or political prisoners, found that PTSD has a high longterm stability, up to 40 years after the trauma (Bichescu et al., 2005; Lee, Vaillant, Torrey, & Elder, 1995). Even when a decline in symptoms is observed, it does not equate complete recovery. Presently, we know that the suffering felt by survivors of violence will last a few months, but a countless number of severely traumatized individuals, especially those who have gone through cumulative traumatic events, could suffer for the rest of their lives. V.O., male, who was 18 years at time of therapy (October 2008), was abducted twice (first time age 4 for 7 years, second time age 13 for 2 years) by the LRA, Northern Uganda. He explained: My younger sister Aciro doesn’t get those problems that I have, when I forget everything and act in strange ways when the memories from the bush come back. We are alone, since my parents have been killed and living in a small hut in the camp makes life difficult when this thing comes over me. When my mind goes away, then my sister runs out and locks me up in the hut. Later, when I have stopped acting out and lie down to sleep and stay quiet, she comes back. It can happen twice a day that I forget time and wake up in a strange place where I don’t know how I got there. . .but this didn’t just start when I had reached home. Even out in the bush, when I would sit somewhere, I started to see the film of how I had killed in front of my eyes and I also started thinking of how my father and mother were killed by the rebels, especially how they were cut. The memories came back so much and it is all mixed in my mind. Sometimes I would sit and a cold feeling would creep into my body and I would start

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shivering and from a distance pictures of the killings came to appear in front of my eyes. I used to cry so much and a great sadness had come into me. Problem now is that people in the community think I am crazy and they want to take away our ancestral land from us, but digging and harvesting is the only source of income we have.

In terms of magnitude, some research suggests that a critical mass of survivors never recover from PTSD, but that figure can be much higher after exposure to extreme, multiple, or deliberately inflicted psychological trauma. Systematic torture or child soldiering, for example, can result in much higher rates of PTSD; some authors report rates of up to 90% of survivors being affected (Basoglu et al., 1994; Derluyn et al., 2004; Moisander & Edston, 2003; Mollica, McInnes, Poole, & Tor, 1998; Neuner et al., 2009). There is emerging clarity to the question of what type of traumatic experiences will lead most likely to the development of trauma-spectrum disorders. Perpetrator events, as well as surviving rape and cruel torture, seem to have a predictive power in terms of likelihood of development of psychological disorders. One example is given by O.B., a male, 18 years at time of therapy (May 2006), whose time as an active recruit was 5 years, and who was abducted by LRA, Northern Uganda, at age 14: Around 5 pm, we found more people. It was a man and his wife. In the distance, I saw two children playing, boys of school-going age. I cannot say whether they had seen us coming. The parents, however, looked so frightened when they saw us. People know that rebels do bad things. The commander “A. Smart” said, come here and sit down. He asked them: “what were you doing?” The people said: “we were just at home.” He replied: “we are going to kill you.” The people looked frozen. Smart said: “look down.” Then he recruited two people, Okello and me and he said: “Cut off their necks or I will kill you.” I was trembling with fear. I knew that those who don’t kill will be killed themselves. These rebels had spent a long time in the bush and had grown beards. I hadn’t even been in the bush for 1 year. I was still considered newly recruited. Everybody had a gun, except me. I felt different to them. I didn’t have a friend in the group. I also had different thoughts. Many of them had no fear and no mercy. They liked killing. The commander gave me the hapanga and told me to kill the man. Okello was given the woman. Rebels don’t kill people twice, they do it in one stroke. So I knew it had to be one stroke. They had shown us at other times when they killed how to do this. I cut hard and through the bones in the back. The head did not come off completely, but the man was sinking forward. I was trembling. I looked around and I saw that Okello had killed the woman. Then I saw the children. They had come closer and they saw their parents now. They started crying. I still held the hapanga in my hand. All the rebels noticed the children. Nobody spoke. I started thinking of my mother and became sad. The memories of the day of my abduction and how the rebels had killed my mother came back. Then the command for movement was given. I moved with the hapanga in my hand as we went away. If you show how you feel you will be killed.

Another example is provided by F.O., a male, who was 13 years at time of therapy (April 2006), and who had spent 3 years in abduction, with the LRA, Northern Uganda: One day, when I was 10 years old, I had gone to collect firewood outside in the bush with my 3 uncles. As we were just tying up the logs, the rebels came. We had not heard them coming. They told us to sit down. There were 5 of them. In fact, they were younger than my uncles, all between 12 and 15 years. They were wearing dark green uniforms and had dread locks and gum boots. They had guns and they were pointing them at us. They said: “who are you?” And we tried to tell them that we are village people trying to collect firewood. They

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tied my uncles’ arms on their back and seated us apart. Since they did not tie me up, I was sure they would kill me first. My heart was racing, I had such fear. I started shaking all over my body. They told me to bend forward to the ground while being seated. That way I could not see a lot anymore what was going on around me. I could not hear anything anymore; there was this high tone in my ear. A gun was pressing into the back of my neck. Next, we were told to get up and carry the luggage, which they fixed on my uncle’s head. . .When morning came, we stopped near a river. We were told to sit down. I looked at my uncles and felt such pity for them. They looked as if they knew that they are going to die. . .now two rebels got up and we were all told to get up. We walked some distance to a clearing under a tree. They told my uncles to lie down on their stomachs face down about three meters apart. They gave me a big stick and told me to kill them: “hit them on the back of their heads”. I was starting to shake. I threw the stick away and said: “I cannot do that. I have never killed anybody.” I was so frightened my body was gripped by fear. They picked the stick back up and handed it to me: “You hit or you will be killed first.” There was no escape. The gun was pointed at me. I aimed and closed my eyes. I started hitting the back of my uncles’ heads. I hit three times on my first uncle. He kept so quiet. No sound from him. The rebels stood behind me: “if you hit slow we will stab you from behind.” Again, three times on the back of the head of my next uncle. I was shaking with helplessness. Great sadness came over me. The rebels said: “if you cry now we will kill you.” I hit my third uncle on the head. Again complete quietness. There was blood and a cracking noise every time I hit. Finally the rebels pulled me away. I prayed for the dead, as I was sitting there in sadness. I thought of my mum, I was sure she could have helped me if she would have been here. I feel so frightened that the spirit of the dead will come and haunt me. I have seen children in our tent here in the center at night getting haunted by the spirits. They shout and scream and get possessed. But then I remembered my uncles well. There was Opio, the oldest, he was a nice man; he would even wash my clothes for me and cook for me. Then there was Okumu, he was a clever and kind man; he taught me how to read and write. Then there was Robert, a good man; he would bathe with me in the river and treat me like a brother. I know they would never mean to harm to me. I know they would never send a bad spirit for me.

Another example is given by M.O., a male, who was 19 years at time of therapy (May 2006), and whose time as an active recruit was 8 years, having been abducted by LRA at age 7 in Northern Uganda: My sister was crying hard and she said: “I cannot walk anymore. See my feet, see how they are swollen. Carry me, please carry me.” Our commander Bosco heard this. He was angry now and said to me: “tell her to walk.” I was trying to pull my sister up, to make her stand on her feet. I was so helpless and fearful. We were both crying now. I was a small boy, I was eight years at the time and I could do nothing. My sister was six and she was tired, she could not stand anymore. Then I saw Bosco bringing a hapanga. My mind was racing, I thought he will kill both of us now. I had such fear in my chest. My heart was racing. He gave the hapanga to me. Now I realized what would happen. Bosco said: “Cut your sister or you both will die.” I didn’t move. Bosco slapped me with the blade of the hapanga on my back. I just stood still. I didn’t move. Then he got the gun. He pointed it at me, “cut her and do it fast,” was what he said. I saw three other rebels coming now. They all had guns and they all pointed at me. I thought: “let me die as well.” I was not ready to move. Then I heard them firing the guns just above my head. My heart dropped. I was full of fear, I started trembling. They would not wait long now. I raised my hand and in this moment my sister cried. She shouted: “Don’t cut me. We are one.” I was crying and shaking and I replied: “Forgive me, I am forced to do this.” Bosco gave me a kick again. I raised my hand and now the hapanga came down on the back of my sister’s neck. She lay there flat on her stomach with her arms stretched out widely to both sides. Blood was coming out. She was still alive, the hapanga had not killed her. Now the others took over and killed her. They had big wooden logs and also took the hapanga and hit her hard on her head and she died. I looked at my little sister

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how she laid there, arms stretched out, quiet now. My heart was racing. And her voice was still with me, the way she had pleaded for her life. Such sadness settled now in me. My sister was left on the ground and her voice was with me for a long time. Then it got dark. I sat under a tree next to a mountain. There was food, but I could not eat. I also could not sleep. I was thinking and thinking. The pictures were there and the voice of my sister in my ear. I cried. In the morning, they gathered the group and the commander said: “if you don’t walk, we will kill you just like we killed a person yesterday.” I could not get out of this confused state for almost one week.

Yet, another example is given by A.A., a female, who was 15 years at time of therapy (May 2006), and who was abducted at age 13 by the LRA in Northern Uganda: The commander looked around and saw me and my friend sitting in some distance and he said: “call those two seated over there.” He called us to come in front. And he told us: “A girl should be killed by a girl. Get the sticks and beat her to death.” I got so frightened and started to shake. I said: “I don’t want to kill, I don’t know how to do this, I have never harmed a person.” And he replied: “if you keep talking like this, then it will be Doris beating you to death and not the other way around.” I feared so much now and they saw me shaking and crying. They told us to lie down on the floor on our stomach and we received 10 canings each from a boy, so as to make the fear and the crying stop. In my heart, I did not want to kill. I knew I did not want this. Doris was lying on the ground next to us on her stomach. We got up and lifted the sticks. They were about as thick as my hand wide and as long as my arm. We started beating her. On her buttock, on her shoulders, on her back. I heard her crying and shouting for help. Everybody was watching us. The commander sat right next to us. We hit her again and again. I was shaking. It was such hard work, I was so helpless. Doris cried and pleaded for help. The commander said: “if you don’t stop crying now, then you have to kill a boy as soon as you are finished with her.” I felt so helpless. Then Doris cried out my name. She shouted: “You are killing me, we are such good friends and now you are killing me.” I slowed down the beating as much as I could and I answered her: “I did not want to do this, I am forced to do this. If it was me, I wish I would not have to do this.” After that she kept quiet. She was not crying anymore. We did not know when to stop the beating, but the commander said: “Now she is dead, take her by the arms on each side and pull her over to that place in the bush, then leave her there.“ Finally we were allowed to leave the place. I went to where people were seated. I sat next to an older woman. Girls who have freshly killed are not allowed to sit next to the boys. But there are older women, who have killed often and know what to do, so you sit next to them. She consoled me and she took me by the arm and told me not to cry. She said to me: “stop crying or else they will kill you.” She sat near me and held my hand. After you kill you shouldn’t cry.

A study by Gloeckner (2007) found that the more violence children had been forced to commit against others, the more PTSD symptoms could be expected. Nader and colleagues (Nader, Pynoos, Fairbanks, al-Ajeel, & al-Asfour, 1993) found that children who reported ‘hurting another human being’ scored highest in terms of development of PTSD symptoms in war-exposed children in Kuwait. Derluyn and colleagues (Derluyn et al., 2004) reported a prevalence of 97% posttraumatic stress reactions of clinical importance in former child soldiers, among who 39% had to kill a person themselves and 77% of the children had witnessed killings while in captivity. Other studies in veterans have furthermore shown that witnessing abusive violence and enormous cruelty was of especially high-traumatic valence (Hiley-Young, Blake, Abueg, Rozynko, & Gusman, 1995; Nader et al., 1993).

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The Impact of Trauma on the Body Beyond psychological suffering from the symptoms of PTSD, traumatized populations show significantly elevated levels of physical morbidity and mortality. As outlined above, in recent years, evidence has mounted that severe anxiety states – stress at a traumatic level – lead to a functional and structural alteration of the brain (Eckart et al., submitted; Kolassa & Elbert, 2007). The co-occurrence of several pathogenic processes includes a permanent alteration of bodily processes, due to a state of persistent readiness for an alarm response. Psychobiological abnormalities in PTSD are observed as psychophysiological, neurohormonal, neuroanatomical, and immunological effects (Boscarino, 2004; Kolassa et al., 2007; Neuner et al., 2008; Schnurr & Jankowski, 1999). Trauma survivors, including child soldiers, frequently report high rates of physical illness, involving a variety of physiological systems. In a recent study (Sommershof et al., 2009), we observed a substantial and clinically relevant change in immune function, based on a 34% reduction of naïve and a 54% reduction of regulatory T cells following war and torturerelated PTSD. Thus, there seems to be a positive correlation not just between developed psychiatric illnesses and prior trauma, but also a significant relationship between the amount of traumatic exposure and poor physical health outcomes. An emerging body of literature is successfully exploring the relationship between trauma-spectrum disorders, foremost PTSD and increased somatic complaints, such as cardiovascular, pulmonary, neurological, and gastrointestinal complaints; various types of somatic pain; susceptibility to infectious diseases; vulnerability to hypertension and atherosclerotic heart disease; abnormalities in thyroid and other hormone function; increased risk of cancer and susceptibility to infections and autoimmune disorders; and problems with pain perception, pain tolerance, and chronic pain (Altemus, Dhabhar, & Yang, 2006; Boscarino, 2004; Dyregrov & Yule, 2006; Elbert et al., 2009; Escalona, Achilles, Waitzkin, & Yager, 2004; Ford et al., 2001; Ironson et al., 1997; Joshi & O’Donnell, 2003; Karunakara et al., 2004; Kessler, 2000; McEwen, 2000; Neuner et al., 2008; S. J. Roberts, 1996; Rohleder & Karl, 2006; Schnurr & Jankowski, 1999; Seng, Graham-Bermann, Clark, McCarthy, & Ronis, 2005; Somasundaram, 2001; van der Veer, Somasundaram, & Damian, 2003). It is important to keep in mind that in post-disaster/conflict regions, children and their parents, who remain in the area or are forced to migrate (asylum seekers, refugees, IDPs), have not only survived an unusual number and types of traumatic stressors, but also had to endure poverty related or other social stressors and adversities, such as domestic violence, family separation, and child labor (Catani et al., 2008; Catani et al., 2009). Child soldiering additionally contributes to the already heightened stress load due to adversity. Taking into account the absence of health services in this context, high child, adolescent, and adult mortality, epidemic rates of disease transmission, as well as low life expectancy rates in many of today’s (post-)conflict settings come as no surprise (AACAP, 1998; Dyregrov & Yule, 2006; Ehntholt & Yule, 2006; Elbert et al., 2009; Karunakara et al., 2004; Miranda & Patel, 2005; Neuner et al., 2008; Neuner, Schauer, Catani, Ruf, & Elbert, 2006; Odenwald et al., 2007).

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Further Psychological Consequences of Trauma Exposure There are a multitude of further psychological consequences of experiencing traumatic life-threat. In sum, the response to war-related trauma by ex-combatants and former child soldiers in countries directly affected by war and violence is complex and renders the survivors vulnerable to various forms of psychological disorders, whereby stressors may have a different impact during different developmental periods. During childhood and adolescence, the mind and brain are particularly plastic and hence, stress has a great potential to affect cognitive and affective development. Exposure to significant stressors during sensitive developmental periods causes the brain to develop along a stress-responsive pathway. As a consequence, the brain and mind become organized in a way to facilitate survival in a world of deprivation and danger, enhancing an individual’s capacity to rapidly and dramatically shift into an intense angry, aggressive, or fearful fleeing/avoiding state when threatened. This pathway, however, is costly because it is associated with increased risk of developing serious medical and psychiatric disorders, like the aforementioned PTSD, and is unnecessary and non-adaptive in peaceful environments (Elbert et al., 2006; Teicher, Andersen, Polcari, Anderson, & Navalta, 2002). Chronic danger or exposure to extreme stress requires costly developmental adjustment in children. Though the core symptoms of PTSD are the most extensively studied psychological consequences of war, they are clearly not the only ones. In addition to associated features like survivor’s guilt or shame and changes in personality, survivors may also suffer from substance-use disorders, affective disorders, including major depression, suicidal ideation, and various forms of anxiety disorders (Bichescu et al., 2005; Boscarino, 2004, 2006; Catani et al., 2009; Johnson & Thompson, 2008; Keane & Kaloupek, 1997; Lapierre, Schwegler, & Labauve, 2007; Odenwald et al., 2007; Schauer, 2008). Surviving traumatic experiences might be followed by social withdrawal, loss of trust, major changes in patterns of behaviour or ideological interpretations of the world, and feelings of guilt and shame (Dickson-Gomez, 2002; Janoff-Bulman, 1992).

Drug Abuse Parallel to the trafficking of light weapons, the global commerce of illicit pharmacological stimuli served as an effective catalyst of war. (Maclure & Denov, 2006), p. 127

Systematic drug taking is especially reported among West African-based militia movements. In fact, some authors consider hallucinatory drug intake a critical factor that has contributed to the desensitization of boy soldiers during their prolonged exposure to violent aggression and to prepare them for combat. Utas and Jorgel (2008) described, in their account of the ‘West Side Boys’ child soldiers of Sierra Leone, how most fighters used drugs in abundance: crack cocaine, smoked heroin, ephedrine, benzodiazepines, and marijuana:

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Drugs were used in military navigation both to enable soldiers to act courageously and ultra-violently, and also to make fighters relax in extreme settings of fear. (Utas & Jorgel, 2008, p. 502)

Drug abuse may also develop as a means of coping with PTSD (Chilcoat & Breslau, 1998; Shipherd, Stafford, & Tanner, 2005). Gear (2002) notes that substance abuse can be seen as a way to escape the emotional burden associated with extreme poverty and unemployment, at the same time being an attempt to cope with trauma-related symptoms, and thus, is a form of self-medication. In several samples of Somali (ex-)combatants, our group (Odenwald, Hinkel, & Schauer, 2007; Odenwald et al., 2007) found that those with PTSD used more drugs in order to ‘selfmedicate,’ especially those who indicated that drug use helped them forget stressful war experiences (Odenwald et al., 2005). The main drug (ab)used in Somalia are the leaves of the khat shrub that contain the amphetamine-like cathinone. In these studies, we could clearly demonstrate that PTSD leads to higher khat intake and this, in turn, leads to a higher risk for the development of psychotic symptoms, such as paranoia. In a large cross-sectional household survey, involving 4854 randomly selected persons of the general population of Hargeisa, Somaliland, we (Odenwald et al., 2005) observed that 12 years after the end of the liberation war and 6 years after the last fighting, 16% of the ex-combatants were severely impaired by complex psychological suffering, mostly severe psychotic disorders intermingled with drug abuse, trauma-related disorders, and emotional problems. In most cases, uncontrollable behaviour, like aggressive outbreaks, had led to the situation that helpless family members had chained them for years to concrete blocks or trees in the backyard of their compounds or that they had ended up in prison. Among the male adult population, former combatants with civilian war survivors and persons who never had been confronted with war (i.e. those who managed to flee abroad before the war) were compared. The rate of 8% of PTSD, depression, and drug abuse disorder in the civilian war survivors doubled among the group of ex-combatants, and reached less than 3% in those without direct war exposure. In a city like Hargeisa the Capital of Somaliland, every fourth household had to care for one severely affected, dysfunctional young man in the household, drawing resources from all members of the household and forcing the household to lose out on the support and capacity of one male family member.

Depression and Suicidality The significant correlation between post-traumatic stress disorder and clinical depression is scientifically well known. In a large study by Vinck and colleagues (Vinck et al., 2007) in Northern Uganda, it was found that 52% of formerly abducted children suffered from depression symptoms. A follow-up review of Pham et al. (Pham et al., 2009) with former abductees showed that 40% fulfilled the symptom criteria for major depression. In our study (Pfeiffer et al., submitted), using a child soldier sample again from Northern Uganda, 16% of children who were ever

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abducted had a fully developed major depression, with this rate increasing to 24% in those who had stayed in captivity 1 month or longer. The most disturbing finding is the risk of suicidality in the former child soldier sample of Pfeiffer and colleagues (Pfeiffer et al., submitted). In this group, 34% of children showed a risk of suicidality (17% of children at high risk), with this rate rising to 37% (25% at high risk) in those who were forced to stay in captivity for 1 month and longer. Post-Vietnam studies showed highly elevated risks of suicide among ex-combatants and veterans of war (Hendin & Haas, 1991; Kang & Bullman, 2008; Lester, 2005). Having been an agent of killing and having been a failure at preventing death and injury of others are especially related more strongly to general psychiatric distress and suicide attempts (Fontana, Rosenheck, & Brett, 1992). The few investigations that there are among children indicate a significant correlation between a childhood diagnosis of PTSD and suicidal ideation. Guilt might play an important mediating factor. In the case of child soldiers, the guilt about having killed members of the family, friends, or community members emerged as a key predictor of suicidal ideation (Pfeiffer et al., submitted). Authors suggest that suicidal ideation may be increased additionally when the child’s functioning is impaired (Famularo, Fenton, Kinscherff, & Augustyn, 1996). In an epidemiological study in the LTTE-controlled areas of North-Eastern Sri Lanka (Elbert et al., 2009), we observed a highly significant relationship between PTSD and risk for suicide, which was diagnosed for 26% of the children with PTSD, but only for 7% of children without PTSD. The reasons for these epidemic proportions are unclear. Researchers suggest that for some youngsters, self-poisoning seemed to be the preferred or only method of dealing with difficult situations (Eddleston, Sheriff, & Hawton, 1998). Child soldiers might simply lack adequate coping or interpersonal skills, such as the ability to communicate anger and sadness, or might not be able to place trust in supportive and positively guiding relationships with adults.

Dissociation and Derealization Another, so-called associative feature of severe child traumatization, often seen in former child soldiers, is the phenomenon of ‘dissociation.’ During times of trauma, fight or flight responses are rarely options for children, as they are often physically unable to defend themselves or escape. The most readily accessible response to the pain of trauma may be to activate dissociative mechanisms, involving disengagement from the external world. Biological defense mechanisms are activated by the central nervous system, such as depersonalization, derealization, numbing, and in extreme cases, catatonia and ‘tonic immobility’ (Perry & Pollard, 1998). The individual cascade of defense mechanisms that a survivor has gone through during the traumatic event can replay itself whenever the fear network, which has evolved peritraumatically, is activated again by internal or external triggers. Whereby some survivors have experienced mainly peritraumatic sympathetic activation

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(fleeing-feeling anxious; fighting-feeling angry and acting out), others went through the whole defense cascade, with parasympathetic dominance as an end point (e.g. tonic immobility, no more voluntary movement, sensory de-afferentation, loss of muscle tonus, fainting) (Schauer & Elbert, 2008). Thus, peritraumatic dissociation might be allowing the child to psychologically and physically survive the trauma. Over time, however, it often becomes nonadaptive, emerging at inappropriate times during, for example, situations that may trigger verbal or nonverbal/bodily memories of earlier trauma or at any other time of perceived emotional threat. Children who have learned to cope with trauma by dissociating are vulnerable to continuing to do so in response to minor stresses. The continued use of dissociation as a way of coping with stress interferes with the capacity to fully attend to life’s ongoing challenges. During dissociative episodes, the child may stare off and appear as if he or she is daydreaming (Sack, Angell, Kinzie, & Rath, 1986). Such children may be misdiagnosed, e.g. as suffering from ADHD, inattentive type (Joshi & O’Donnell, 2003). Other children may freeze in response to certain activating stimuli. Caregivers or teachers may misinterpret this reaction as an act of defiance. If confronted, more anxious children can quickly escalate to feeling threatened, ‘frozen,’ and ultimately resort to a classic fight or flight response by becoming aggressive or combative over relatively minor events (Joshi & O’Donnell, 2003; Schauer & Elbert, 2010). Other children may react to stressors by dissolving into regressed, dissociative states that may contain micropsychotic episodes, including auditory command hallucinations. It is not uncommon for severely traumatized children to hear voices commanding them to harm themselves or others, which is a dangerous, unpredictable condition. Consequently, such adolescents can be erroneously misdiagnosed as suffering from a primary psychotic disorder, such as schizophrenia.

Anti-social and Disruptive Behavior PTSD is also significantly associated with negative behavior against an individual’s own family, the expression of anger and hostility to others, and self-harm (Burton, Foy, Bwanausi, Johnson, & Moore, 1994; Deykin, 1999; Deykin & Buka, 1997; Dodge, 1993; Dutton et al., 2006; Friedman & Schnurr, 1995; Golding, 1999; Joshi & O’Donnell, 2003; Lewis, 1992; Perry & Pollard, 1998). Research shows that former child soldiers have difficulties in controlling aggressive impulses and have little skills for handling life without violence. These children show on-going aggressiveness within their families and communities, even after relocation to their home villages (Wessels, 2006). In a qualitative study, Magambo and Lett (2004) reported that former child soldiers in northern Uganda mainly applied physical violence to resolve conflicts. Although the children sympathized with victims of violence, they could not even think of non-violent alternatives, reflecting an absence of adequate social skills. Most former child soldiers have spent several critical years of their development in captivity, under the constant threat of abuse and manipulation by their

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commanders. Most probably, this period affects the development of a personal and collective identity (Kanagaratnam, Raundalen, & Asbjornsen, 2005). In general, children exposed to war and child soldiering show a strong identification with their own group (Gloeckner, 2007; Jensen & Shaw, 1993) and develop a worldview dominated by political and nationalistic categories (Punamaki & Suleiman, 1990), which often includes pro-war attitudes (Feshbach, 1994). In the Gloeckner (2007) study, it emerged that the longer children had stayed in abduction, the stronger was their rebel-related collective identity. But it may be that their collective identification might occur post hoc after return to their home communities. Gloeckner explained that questions and discussions of family and community members about the cruelty of the LRA’s actions may activate a process of reasoning about what had happened. Former beliefs about ‘right’ and ‘wrong’ actions might clash with current ones, and in order to regain cognitive homeostasis, identification with the rebel group is aspired. Interestingly, this study showed a positive correlation between collective identification and reactive aggression (physical and verbal aggression and anger). In addition, Gloeckner ( 2007) reported that formerly abducted children with PTSD might be especially vulnerable to accepting simplistic models of ‘good versus bad’ – a black and white worldview, which is a known cognitive distortion. Although a rigid political view might be protective during exposure to war events, it might facilitate violent behavior after returning from the fighting to individuals’ home communities. Children living in conditions of political violence and war have been described as ‘growing up too soon’ and ‘losing their childhood’ (Boothby & Knudsen, 2000; UNICEF, 2005, 2006). Levels of conscience seemed to be significantly related to the severity of PTSD symptomatology, but also with negative schematizations of self and others and lower self-efficacy ratings (Goenjian et al., 1999; Joseph, Brewin, Yule, & Williams, 1993; Saigh, Mroueh, Zimmerman, & Fairbanks, 1995).

Ideological Commitment There is also the discussion on ideological commitment of former child soldiers to a cause and its influence on mental health. Some studies (Muldoon & Wilson, 2001; Punamaki, 1996) indicate a protective mechanism, associating strong ideology with good mental health in adolescents, however, mainly in individuals who were exposed to low levels of political violence. A recent study among Tamil child soldiers shows that this protective mechanism only worked in the group of those who were not among the highest exposure intensity group, e.g. length of exposure, being wounded, having killed, having tortured, direct combat (Kanagaratnam et al., 2005). Tibetan refugee children also reported that the sense of participating in their nation’s struggle against an oppressor and their strong Buddhist beliefs would have protected them against mental-health difficulties and accelerated the healing process (Servan-Schreiber, Le Lin, & Birmaher, 1998). Cognitive appraisals of experiences seem to matter in symptom development in various forms

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and strong feelings of guilt and responsibility might increase trauma symptoms. In Kanagaratnam’s study (Kanagaratnam et al., 2005) personal achievement in combat, popularity, knowledge and experience acquired by being a combatant, friendship, and the support of the community were considered as the best of combat life by the youngsters; death of friends, killings of their own people, guilt of being responsible for unnecessary killings, and being confronted with morally conflicting situations were the worst experiences for most of them.

Cognitive, Educational, and Occupational Impairment When comparing abductees with non-abductees, Blattman (2006) came to the conclusion that especially traumatic experiences during abduction had an adverse impact on education, less years of schooling, greater reading problems, lower occupational functioning, and lower work quality later in life. What research has shown is that exposure to trauma in formative years may affect the maturation of the central nervous system and the regulatory neuro-endocrine systems, as outlined above. Resulting from exposure to traumatic stress and PTSD, the inability to concentrate and learn often translates into a refusal to attend school and eventual drop-out (Dodge, 1993). In a study by Duncan (2000), college enrollment rates continued to drop at each subsequent semester until, by their senior year, only 35% of students who had suffered multiple abuses were in attendance. In addition, adolescents with PTSD, compared to adolescents who have suffered a stressful experience but did not develop PTSD, were shown to have significantly lower scores on a standardized achievement test compared to their controls (Saigh, Mroueh, & Bremner, 1997). A study by McFarlane and colleagues (McFarlane et al., 1987) showed that 18% of surveyed children after a disaster were underachieving educationally after 8 months; this figure had a statistically significant increase to 25% at 26 months. The underachieving children were also those with the highest trauma symptom scores and with the most days absent from school, reporting headaches, stomachaches, and feeling miserable and worried as their reasons for absenteeism. Perez & Widom (1994) asserted that child abuse represents a significant risk factor for poor long-term intellectual and academic outcomes, e.g. lower IQ and reading ability. Findings of low IQ in traumatized children were also described by Mannarino and Cohen (1986). In his book ‘Scarred minds,’ Somasundaram (1998) presented a list of psychosocial problems in adolescents, sampled from six different schools and colleagues across the war-affected North-Eastern educational zones of Sri Lanka. Within that study, 28–65% of children reported loss of memory, 33–60% loss of concentration, and 35–60% loss of motivation to achieve in education. Besides psychometric testing for psychiatric disorders, our group (Elbert et al., 2009) undertook cognitive and memory tests in a sub-sample validation group of Tamil school children, residing at the time in the LTTE-controlled areas of NorthEastern Sri Lanka. This region had been affected by two decades of civil war at the time of assessment in 2002. All traumatized children with a diagnosis of PTSD

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in the sample reported lasting interference of experiences with their daily life. The neuropsychological testing and the investigation of school grades validated mentalhealth outcomes further and accentuated some specific cognitive problems that were associated with PTSD, especially the deficiency in memory functions. In fact, the affected children’s performance decreased with the number of traumatic events experienced. The children’s grades in school, when averaged separately for the two groups and across disciplines, reflected that the problems in functioning were mental in nature, with a focus on deficits in the verbal abilities. Employment possibilities are already scarce in post-war societies, and researchers observe that finding a job is even more difficult for ex-combatants (Gear, 2002; Heinemann-Gruder, Pietz, & Duffy, 2003). Mogapi (2004) reported from the South African DDR program that ex-combatants, who suffer from a trauma-spectrum disorder, have clear-cut difficulties on the job, suffer increased concentration problems, and are more likely to act out aggressively in difficult situations, which eventually leads to job loss. In turn, the situation of unemployment causes feelings of helplessness and thus aggravates symptoms of depression in a downward-spiral effect.

Transgenerational Effects Psychological exposure and suffering from trauma can cripple individuals and families, even into the next generations. After having experienced organized violence, affected parents can leave an imprint in their grandchildren’s generation (Yehuda, Halligan, & Bierer, 2001). Concern about consequences for offspring, whose mothers were stressed during pregnancy, derives from evidence gained in experimental biology, as intrauterine stress shows to affect neurodevelopment in animals, which are thought to be relevant to cognition, aggression, anxiety, and depression in humans (Seckl & Holmes, 2007). Chronic maternal stress during pregnancy, for example, interrupts healthy regulation of hormonal activity including cortisol, which easily crosses the placenta during the first two trimesters (Phillips, 2007; Sandman, Wadhwa, Chicz-DeMet, Porto, & Garite, 1999; Sandman et al., 1999; Weinstock, 1997, 2005). Changed hormonal regulation then can promote a range of emotional and cognitive impairments (Sapolsky, Krey, & McEwen, 1985; Sapolsky, Uno, Rebert, & Finch, 1990). While the genome, the DNA sequence, remains unaffected by acute stress responses, its readability (i.e. epigenetic alterations) may be manipulated by a variety of conditions, notably stress hormones (Meaney, Szyf, & Seckl, 2007). If a pregnant mother is affected by severe and chronic stress, epigenetic modifications in the child may act as a molecular or cellular memory that tune the offspring for one or several generations for survival in a hostile environment, making generations more vulnerable for mental illnesses, including suicide (Szyf, McGowan, & Meaney, 2008). The quality of how a mother is able to attach to and care for her child alters the expression of genes in the child that regulate behavioral and endocrine responses to stress, as well as hippocampal plasticity and

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development. These effects may contribute to the development of differences in stress reactivity and certain forms of pathologic cognition. Literature shows that boys and men with war and combat experiences are more likely to exhibit violent behavior (Begic & Jokic-Begic, 2001; Bryne & Riggs, 1996; Catani et al., 2008; Glenn et al., 2002). The same can be expected for men who have a history of child soldiering. In families where men show violent behavior against women, children are maltreated as well (Edleson, 1999; Levendosky & Graham-Bermann, 2001). In fact, domestic violence against the child’s mother during the first 6 months of life elevates the risk of physical child abuse three times, while doubling the risk of emotional abuse and neglect of the child (McGuigan & Pratt, 2001). Additionally, babies born to traumatized and socially stressed mothers, which certainly can include formerly abducted child-mothers (i.e. women who gave birth to babies in captivity), are born with a deformed stress regulating system (HPA-a), which translates into babies’ higher and faster arousal peaks, longer intervals of crying and irritability, and impaired affect regulation (Sondergaard et al., 2003). Such behavior by infants is a challenge for any new parent, but is a major challenge for a parent who her/himself suffers from a disorder of the trauma spectrum, has little or no social support and lives in poverty. Parents of ‘highly stressed’ babies report less confidence and joy in their role as caregivers and the phenomenon of ‘negative reciprocity’ starts to develop (Papousek & von Hofacker, 1998). In fact, research shows that behaviourally inhibited children, who are fearful and have a tendency to withdraw, were regarded by their mothers as hard to soothe and received less care and less maternal sensitivity as a result. This, in turn, heightened the children’s sensitivity to stress and changed their internal stress-diathesis system towards a biased attention to threat (Fox, Hane, & Pine, 2007). A child with reduced abilities for affect regulation, in combination with one or two traumatized primary caregivers, is a very great potential risk constellation. Internalized affects of violent and neglectful caretaker models deform the psyche and can also imprint on the next generation. As a result, the family suffers from heightened levels of stress, and psychiatric symptoms can be evoked in people who live with an individual who suffers from PTSD. Violence and trauma at the time of parents’ childhood may result in problematic attachment relationships that have long-term consequences for mental health and interpersonal relationships for their children. An intergenerational cycle of dysfunction is set in motion (Bowlby, 2004; Grossmann, Grossmann, & Waters, 2005; Lewis, 1992; Qouta, Punamaki, & Sarraj, 2003; Smith, Perrin, Yule, & Rabe-Hesketh, 2001; Solomon, 1988; Zuravin, McMillen, DePanfilis, & Risley-Curtiss, 1996). The amount of stress encountered in early life sensitizes an organism to a certain level of adversity; high levels of early-life stress may result in hypersensitivity to stress later, as well as to adult depression. Beyond epigenetic factors, fearfulness and nurturance are transmitted from generation to generation through maternal behaviour (Parent et al., 2005). Traumatized parents are challenged in providing secure attachment, because post-traumatic symptoms of emotional numbing might be hindering emotional closeness. Symptoms of hyperarousal, such as irritability,

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might make it even more challenging to regulate babies and their own affect adequately. Parental sensitivity in pre-empting a child’s need might be impaired, and ‘high expressed emotions’ without sufficient verbalization of the context can render a small child helpless in understanding parental motivation and intention. It has been shown that if children live in such unpredictable reward–punishment environments, their psycho-physiological arousal is significantly heightened and will over time lead to a changed hypothalamic–pituitary–adrenal axis. Beyond coincidence, researchers clearly note higher rates of psychiatric morbidity in children of survivors, compared with non-traumatized comparison groups (Ben Arzi, Solomon, & Dekel, 2000; Bramsen, van der Ploeg, & Twisk, 2002; Dekel & Solomon, 2006; Dirkzwager, Bramsen, Ader, & van der Ploeg, 2005; Franciskovic et al., 2007; Solomon et al., 1992; Weinstock, 1997). A partner, father, or grandmother suffering from traumatization can behave like a distant, fearful stranger, who cannot tolerate closeness or emotional expression, even within the family unit. Survivor’s intense and bizarre way of self-expression in form of irritability, jumpiness, or hypervigilance may be so extreme as to appear like paranoia and can engender fear, confusion, and a sense of powerlessness in family members (Al-Turkait & Ohaeri, 2008; MacDonald, Chamberlain, Long, & Flett, 1999). On the other hand, children of survivors can be equally affected by their parents’ symptoms of numbing and avoidance, which are associated with substantial decrements in parent–child relationship quality and which prevent normal emotional expression and closeness (Lauterbach et al., 2007). Consequently, children are forced to operate within a domestic context in which intimacy, as well as affect regulation, is severely impaired (Almqvist & Broberg, 2003). Avoidance symptoms seem to have an additional deleterious effect on the parent–child relationship satisfaction. Studies on fathers, who have experienced numerous war events, show that feelings of detachment and numbing can carry over to their children, leading to behavioural problems in the child (Ruscio, Weathers, King, & King, 2002; Samper, Taft, King, & King, 2004). Based on the vulnerability of surviving a war or growing up in a post-conflict setting, children, in turn, might also become more vulnerable to forces that incite violence (Somasundaram, 2002; Uppard, 2003).

Social Stigma of Returning Girls and Women Between the years 1990 and 2003, girls were present in fighting forces (government forces, paramilitary/militia, and armed opposition groups) in 55 countries, and in 38 of these countries they were involved in situations of armed conflict (McKay & Mazurana, 2004). Girls’ roles typically overlap and include working as spies and informants, in intelligence and communications, and as military trainers and combatants. They are health workers and minesweepers, and they may conduct suicide missions. Other support roles include raising crops, selling goods, preparing food, carrying loot and weapons, and stealing food, livestock, and seed stock. It is important to understand that underlying these various roles and

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activities, girls’ participation is central to sustaining a force because of their productive and reproductive labor. As such, they replicate traditional societal gender roles and patriarchal privilege, whereby girls (and women) serve men and boys. Honing their labor is a foundation, upon which fighting forces throughout the world rely (McKay & Mazurana, 2004). The following are three examples of the participation of girls. The first is described by V.A., a female, 20 years at time of therapy (May 2006), who had spent 10 years in abduction with the LRA, Northern Uganda: There were many other battles, but this had been the worst one I had been in. This time they had sent us out to do work in Atiak at night. We separated in smaller groups and were told to loot the IDP camp there. We were just about to enter when the dogs barked. I squatted down with others and waited in some distance. The boys went ahead. The idea for us girls was to shoot and scare soldiers and make the group seem larger. I had a newly abducted girl with me. A bomb came so fast that I didn’t realise it even detonating. My body was paralyzed and the bomb particles entered my body. My left arm, the inside of my left leg and my right leg got wounded. We tried to flee, but I could just move a small distance. The aeroplane came back to attack us, I ran, taking the newly abducted with me. . .

J.A. is a female, 15 years at time of therapy (May 2006), who spent 1 year in abduction with the LRA, Northern Uganda: It was evening and we were waiting along the roadside. We were many. Most of the rebels had guns, just like government soldiers. We were in Anaka, hiding in the grass. We had formed two groups on either side of the road. The rebels with guns were in the front line, then the other children were seated further behind in the bush. I was in the back. The men are the ones who do the shooting. Us girls were told to wait and ambush. The command for the boys was to look out for army vehicles and shoot those. Then we heard the sound. It was a lorry. It was noisy and colored like an army car. There were people seated in the cabin, but also many on the back of the truck. My heart was bumping. I feared that these were government soldiers and that they would attack us. But I saw civilians and calmed down. The command for shooting was given. Then we saw the truck burning. There was a big fire and people burnt. We took the loads and ran. . .

A.A. is a female, 15 years at time of therapy (May 2006), who spent 3 years in abduction with the LRA in Northern Uganda: They untied me and I was told to sit with a man. He was a lot older than me, he looked mature, like a grown-up. I was 13 years at the time. I didn’t like him at first sight, but I had to sit down next to him. He told me that he had sent the boys to go and get him a girl to be his wife and that I am the one. Then he asked my name only. He spoke no more. My heart was beating much. I was scared, since I was not sure what he meant. Some people were cooking greens and I ate some food. After a while the man asked me to come with him. We went to a clearing under a tree. First, I thought that he takes me aside from the others, because he wants to kill me. He told me to lie and said that we would sleep there. I lied down on my side, like going to sleep. He was upset about this and started to beat me. I was surprised. He slapped my face and head. He said: “Don’t act stupid. You know what I want from you.” Then he pushed me unto the ground and laid on me. My heart was beating really fast now. He had a bad body smell. Then he forced himself into me. He said: “if you cry, I will kill you.” When I heard his words, I got so scared that I actually started crying. This made him put a gun to my head. He warned me. I could feel the gun. I stopped crying. He continued raping me and when he was finished he left me alone. He told me to get up. I was not able to. Everything in my body pained. From then on, he raped me every night. I realised that this is how it would be for me. Every night we went to that tree.

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Key gender-based experiences of both women and girls during armed conflicts consist of sexual violence, including torture, rape, mass rape, sexual slavery, enforced prostitution, forced sterilization, forced termination of pregnancies, giving birth without assistance, and being mutilated (United Nations, 2002). Girls in fighting forces in Mozambique, Northern Uganda, and Sierra Leone reported sexual violence, and abducted girls were almost universally raped (McKay & Mazurana, 2004). As was the situation in Sierra Leone, sex labor in Angola was integral to the function of girl soldiers (Stavrou, 2005). Again, depending on the context, when they reach puberty, girls may supply reproductive labor through giving birth to and rearing children, who become members of the force. For example, in the LRA fighting force in Northern Uganda, the leader Joseph Kony has been prolific in fathering large numbers of children, who have grown up in his force. Physically, girl soldiers are challenged to survive as they cope with illnesses, exhaustion, wounds, menstrual difficulties, complications from pregnancy and birth, sexually transmitted diseases, and a host of other maladies, such as malaria, intestinal parasites, tuberculosis, anaemia, diarrhea, malnutrition, disabilities, scars, and burns (McKay & Mazurana, 2004; Stavrou, 2005). Returning women, who are perceived to have had sexual relations with combatants, whether forced or voluntarily and/or bring back children from such encounters, belong to the most stigmatized group of survivors. An example is given by M.K., who is a female, 22 years at time of diagnostic interview (January 2009), and who had been abducted for 6 months by Interahamwe groups, North Kivu, DRC: Since I was able to run from the Interahamwe and have managed to survive the time in the forest, my husband does not talk to me anymore. They found me in a village and brought me to this hospital. Now I am pregnant from the many weeks of rape in the forest and I am infected, there is a white liquid running from my vagina and great pain in my abdomen. One of the nurses gave me a mobile phone the other day and I called my husband in Goma, but he hung the phone up on me when he heard my voice; even though he was there the night I was raped and abducted by the rebels from our own house. The worst thing is that I had to leave my two small children behind that night. How are they doing without me? My son was only 9 months old at the time and I was still breastfeeding him. Sometimes I miss him so much that I have visions of him lying in a corner of the room here in the hospital all naked and hungry and crying and I go there and take him into my arms and console him until one of the women wakes me up from this day dream, I notice that I have tears running from my eyes.

Most communities regard the illegitimate children as a shame, not only on the child and mother, but also on the family and the community as a whole, sometimes forcing mothers to choose either between their child or their community (Redress, 2006). Schalinski and research team (Schalinski et al., submitted) found that a great number of returning women in Eastern Congo are living in forced separation from their husbands and experience homelessness after they are back from captivity. This is especially the case when they are feared infected with STDs and HIV and if they bring back a child from the time in the forest. In many cultural settings, girls are unable to get married or re-married and find it difficult to enter a new supportive partnership, within which to bring up their children in civilian life. The environments into which girls reintegrate are also problematic. Domestic violence

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and sexual violence are more common in IDP camps and communities of war-torn areas, as men can be traumatized, depressed, alcoholic, or otherwise aggravated, due to the strain of war, which can contribute to violent behaviour (Redress, 2006). Demobilization and reintegration services are still a novelty for formerly abducted girls and women. Gender disparities that privilege boy soldiers over girls mean that few girls enter or benefit from formal demilitarization and demobilization or from rehabilitation and reintegration programs where the re-adjustment process can be fostered. These programs are mainly designed to restore security, and as female combatants are not seen as a major security threat, they are insufficiently targeted (Bouta, 2005). In a study conducted in five provinces of Eastern Democratic Republic of Congo, 23 girls, as compared with 1,718 boys, were demobilized by four international NGOs, despite girls being recruited or abducted as extensively as boys; it was estimated that girls comprise 30–40% of children in fighting units (Verhey, 2004). Girls’ and women’s full reintegration most likely encompasses a much more holistic approach, including mental health, reproductive health and vocational training interventions, because it can not be assumed that traditional socioeconomic support within marriage is an option for most female returnees.

The Challenges of Demobilization and Reintegration of Child Soldiers Most children get freed from captivity or from armed groups during combat. A significant number has stayed out in the bush for several years during key phases of their development, making them feel unfamiliar and at times afraid of civilian life. Three examples follow. The first is K.K.G.’s experience, who is a male, 16 years at time of diagnostic interview (March 2009), and who spent 3 years as an active recruit, joining at age 13 years: How did I get out? The MONUC freed me together with many others. It was a fierce battle that day, but they won over us. My commander was freed too and he could go his way. I think he lives in Kinshasa today. Those over 18 years could just take off after a few days, they were given amnesty and some got offers by the Congolese army to join them. But we children were taken to different child rehabilitation centers in the province. That is how I ended up in Bukavu. When I was taken away the commander said to the UN people: “You know that you are taking my son. I will get him back that is for sure. You just wait for me”. Since that day I am afraid. I know he has made his way to Bukavu. He has already once waited for me outside the gates of the children’s center, telling me to come back to the bush with him. I don’t know what I should do? I fear him greatly, but I also fear this new life.

B.O. is a male, 15 years at time of therapy (May 2006), who spent 4 years as an active recruit, abducted by the LRA at age 12 in Northern Uganda: On the 25th of December, Christmas day, we had gone out to get sugar cane. It was 6 pm in the evening, just before it was getting dark. As we were already in the fields and harvesting, the UPDF started firing. There were 7 of us rebels, but the soldiers were many. They were all hiding in the ground. The firing started and I tried to escape. Suddenly a bullet hit me on

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my back and it came out in the front, just above my heart. I started vomiting blood. There was this piercing, sharp pain. When I was breathing, it felt like air was coming through the hole. I was sure that now the time had come, I would die. I kept bleeding, I just let the blood. I knew I must run, so I made it up to the end of this garden. I was so afraid that the soldiers would come and get me. I had been left alone. The others had left me. I laid down again with my face down on the ground and fell unconscious. Soldiers saw me and caught me the next day. I was so frightened of them, you never knew whether they would kill you now. They brought me to the nearest IDP camp, where they had a small military post. They asked: “Where is your gun?”, “Where is your commander?” “Where are the other rebels?” I told them how we got separated, that I had been alone. . .I slept in the barracks for two more nights together with the soldiers. Finally they brought me to Gulu. . .Tomorrow I will go back home. First my father has told me to see him in Kitgum, but he is a man who likes alcohol much, he drinks a lot and is poor. I finally hope to live with my dear mother. The thing that is most important for me is my education. I think I can make it, I want to go back to school so much. I just have to find the necessary money. I am sure I will. And one day I will be a tailor.

A. A. is a female, 15 years at time of therapy (May 2006), who was abducted at age 13 by the LRA in Northern Uganda: We were cooking as the intelligence boy came and told us that soldiers were moving towards our settlement. We abandoned everything and UPDF started to chase us. We had been crossing a swamp when we found the soldiers hiding. We were running on one side and soldiers on the other. I could see them and at some point we just scattered. The UPDF saw me also, but they did not aim at me. They saw that I was a girl. I saw many rebel children falling and dying that day though. Ojok was also there. I liked him a lot. He had been the one who abducted me. Ojok never got used to killing. He even refused to do it. I liked him for that. He had a rank in the rebel group. Whenever Ojok saw me being sad, he came over to me and told me that he will think of a plan to take me home. He was like a brother to me. I saw him running and ran behind him. I got so frightened. Ojok told me that we are safe and that I should not worry, but I knew it was not true. I knew we might die any moment. We kept running. After some time I was hiding under a tree. Ojok saw that, he looked at me and said: “Get up, we will go home now.” As we started off, we met another girl. We took her along as well. In a way, both of us were afraid of Ojok. We could not be sure that he would deliver us. Would he trick us? He reassured us that he would release us. We were so far from a place of release. We had to walk another night and day to get there. On the way we passed an old military camp. The soldiers called us and we went to them. They said: “don’t fear, you are home now.”

Psychiatric distress and malfunctioning, especially when expressed as outward aggression, irritation, an acting out of intrusions (e.g. flash-backs) and dissociation, exacerbates ex-combatants’ difficulties in reintegrating into communities and the wider society (Pfeiffer et al., submitted). Ex-combatants suffering from psychiatric distress might face double stigmatization for having engaged in combat and for being noticeably psychologically affected. Beyond the multitude of psychological problems that former child soldiers might be struggling with, there are other hindrances that can adversely affect the successful reintegration. Child soldiers carry a special burden of simultaneously being the recipient and perpetrator of violence (Boothby & Knudsen, 2000); they are, therefore, a distinct group among children and adolescents in war regions. They are victimized twofold, because they first are exposed to traumatic experiences and later are blamed and stigmatized for the atrocities they have committed (Bayer et al., 2007). In many cases child soldiers are forced

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to commit atrocities against civilians, at times against own family and community members, which they are required to do so as to cut-off return routes and to inflict increased terror and psychological harm on home communities. These practices may force the recruited soldiers to violate their own moral principles and to break from any social attachment (Amone-P’Olak, 2007), ultimately resulting in a pull factor for re-recruitment. This fact alone challenges their integration and re-acceptance. However, after such traumatizations, not just the formerly abducted child, but also the community has changed. On the communal level, the reintegration of excombatants is a reciprocal process that happens within the host communities where the former fighters are settled. The attitudes of the host communities towards the excombatants are of particular importance for reintegration success (Kingma, 2000). In some cases, because of assumed or actual abusive violence that combatants have perpetrated against civilians during war times, the attitudes of host communities towards former combatants are negative. There is no doubt, and there is empirical evidence, that adequate social support and other supportive community practices are truly important mediators of the expression of trauma-related symptoms (Ahern et al., 2004; Basoglu et al., 1994; Brewin, Andrews, & Valentine, 2000; Coker et al., 2002; Johnson & Thompson, 2008; Kovacev & Shute, 2004; Mollica, Cui, McInnes, & Massagli, 2002). A strategy of social support can be an additional supportive element for affected communities, who have lost children to abduction and child soldiering; yet, this is possible only when a sufficient number of adult community members remain at least partly protected from the psychological impact of armed conflict, organized violence, and forced displacement. However, many key community members, such as parents, teachers, elders, counselors, nurses, lawyers, and doctors in post-conflict settings suffer from physical, as well as mental impairment, incapacitating their normal, healthy ability to function as caretakers, providers, and role models. Neither local healers nor religious leaders, who have traditionally offered health-related services, or carried out re-integration measures for individuals who had committed harm in the community, nowadays have remained unaffected by the stressors of war and violence (Glenn et al., 2002; Human Rights Watch, 2000; Kenyon Lischer, 2006; Pittaway, 2004; Solomon, 1988; UNHCR, 2003; van de Put, Somasundaram, Kall, Eisenbruch, & Thomassen, 1998; Widom, 1989). As members of the Children and War Foundation (Dyregrov, Gupta, Gjestad, & Raundalen, 2002, p. 138) state: There are some war situations that are so unprecedented, i.e. massacres in the community, that no cultures have societal healing or coping mechanisms to apply.

Thus, the culturally indigenous mechanisms of healing and reconciliation at the family and community level, which might have served in the rehabilitation of returning child soldiers, are in most settings not available anymore. It is not surprising that former abductees report difficulties when coming home to their community after abduction, especially those who met criteria for symptoms of PTSD. Researchers (MacMullin & Loughry, 2004; Pham et al., 2009) have found that formerly abducted children in Northern Uganda do experience difficulties in psychosocial adjustment,

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especially when suffering from clinical symptoms of the post-traumatic stress syndrome and depression. Affected youngsters not only experience more feelings of hopelessness and fear, but also more difficulties with regard to peer interaction, family interaction, and community activities, when compared with less clinically impaired non-abductees. In reintegration programs, ex-combatants with PTSD are considered an especially problematic group. Recent studies, which have examined the prevalence of psychological effects after conflict, suggest that traumatic exposure and resultant symptoms of PTSD and depression can influence how individuals perceive mechanisms aimed at promoting justice and reconciliation. In 2004, Pham and colleagues (Pham, Weinstein, & Longman, 2004) investigated this association in 2074 adult survivors of the Rwandan genocide. The findings indicated that traumatic exposure and PTSD symptoms were associated with negative attitudes towards reconciliation. Bayer’s group (Bayer et al., 2007) undertook a similar research, in that they tried to understand the association of trauma and PTSD symptoms with openness to reconciliation and feelings of revenge among former Ugandan and Congolese child soldiers. The results indicated that those among the group of former child soldiers (girls and boys alike), who showed clinically relevant symptoms of PTSD, had significantly less openness to reconciliation and significantly more feelings of revenge than those with fewer symptoms. Likewise, the children with PTSD symptoms might regard acts of retaliation as an appropriate way to recover personal integrity and to overcome their traumatic experience. In the former Yugoslavia, Basoglu and team (Basoglu et al., 2005) similarly found that PTSD severely impedes processes of reconciliation and reintegration: war survivors exposed to war-related traumata displayed stronger emotional responses to perceived impunity, including anger, rage, distress, and desire for revenge, than those who did not experience war. Moreover traumatized survivors showed less belief in the benevolence of people and reported demoralization, helplessness, pessimism, fear, and loss of meaning in and control over life. Vinck et al.’s (2007) study found a very similar association between survivors’ symptoms of PTSD and depression and their attitude toward peace. Those who met the PTSD symptom criteria were more likely to favor violent means to end the conflict, while those with depression symptoms were less likely to identify non-violence means to achieve peace. In these populations, psychological symptoms associated with the trauma may be closely related to a desire for retribution, rather than restorative ways to deal with past violence. There seems to be also a link between symptoms of traumatization, aggression, and perceived stigmatization in returning, former child soldiers (Allen & Schomerus, 2006; Annan & Blattman, 2006; Corbin, 2008; Pfeiffer et al., submitted). In the United States, attitudes of the home environment were found to have a high impact on adult ex-combatants’ ability to cope with war and trauma and the subsequent psychopathological development. This effect has been conceptualized as the ‘home-coming reception’ (Fontana & Rosenheck, 1994). Having belonged to a faction that was very abusive towards civilians during the civil war in Sierra Leone had a significant negative effect on reintegration (Humphreys & Wienstein, 2005). Our study (Pfeiffer et al., submitted) showed that stigmatization of any kind (e.g.

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being called names, such as ‘killer,’ being accused by community members to have an ‘evil rebel mind’ or ‘disturbed mind,’ or being forcefully pushed away from the well while fetching water) is reported by 73% of the formerly abducted youths. In this study, stigmatization was also found to be associated with symptoms of PTSD and clinical depression, as well as with elevated levels of aggression. Stigmatization was connected more closely to heightened levels of psychopathology than to the mere fact of having been abducted. The authors’ assumption is that children, who have a mental illness as a result of their time in the bush and show symptoms of the trauma spectrum, are the ones who are stigmatized, primarily because they behave ‘different’, e.g. experience nightmares, behavioural acting out, are prone to bizarrelooking forms of dissociation, and choose to stay alone and distant from others. In the same sample, increased levels of aggression (e.g. verbal, physical, anger, and hostility) were found in the group of former abductees, with 31.6% showing heightened aggressiveness. Aggression was associated with having a history of abduction, an increased level of perceived stigmatization, heightened symptoms of psychological disorders, and having survived a higher number of traumatic experiences. The score on aggression additionally showed a connection to higher identification with the rebel group. Interestingly, having been forced to kill and the duration of abduction did not predict heightened aggression, suggesting that it is the overall score of psychological symptoms, resulting from traumatic experiences during abduction, which drives levels of aggression and stigmatization, as well as identification with the rebel group. There were no gender differences in these findings. Social isolation and the formation of ex-combatants as a distinct civilian subgroup area consequence of the combined effects of factors, which include host communities’ negative attitudes towards ex-combatants and their psychological problems causing difficulties in social interactions. The risk of re-recruitment heightens when ex-combatants fail to reintegrate economically and socially into their civil host communities. When a sufficiently large number of former combatants and of civilians are affected by war-related psychological problems, and remain without assistance for psychological rehabilitation, the opportunity to initiate selfsustained ways of living and with it, substantial economic development, will be considerably reduced. Another round in the cycle of violence seems inevitable if psychological wounds are not addressed. Children know that hidden weapons and former comrades are always waiting somewhere out there.

Recommendations I often think of all these children out there who still suffer and try to survive. So many people out there went through the same thing as I did. When I go through town here, there are so many children I recognize from the bush and they recognize me. Those who know me from the bush when we meet say, “we came back, and now you are also back, who would have thought?” If they can manage, I can also survive. When you ask me about 5 years from now where I would like to be in life, then I say, if all goes very well I will survive and be alive.” V.O., male, 18 years at time of therapy (October 2008), who was abducted twice (first time at age 4 for 7 years, second time at age 13 for 2 years) by the LRA, Northern Uganda.

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Social and traumatic stress, caused by multiple experiences of violence, has a severe negative impact for the reintegration of ex-combatants and child soldiers on several levels. Rehabilitative efforts on all related levels are needed to increase the successful reintegration of former combatants into civil society; most importantly, their mental-health needs must be attended to. A most likely, but largely unstudied, driver of the cycle of violence might be the detrimental impact of experiencing massive violence and abuse on individuals’ psychological functioning, and the related social dynamics and consequences for communities. Reconciliation and peace building might be impeded by the psychological problems of a critical mass of individuals. In particular, large-scale violence may cause patterns of emotional and cognitive processing, which might feed into further violence (Schauer & Schauer, 2010 this volume). War-related severe stress, even though transient, indelibly changes an individual on various levels. On a cognitive level, traumatic experiences shatter the most fundamental beliefs about safety, trust, and self-esteem, which lend instability and psychological incoherence to the individual’s internal and external worlds (Janoff-Bulman, Berg, & Harvey, 1998). As a consequence of a shattered belief system, the world is perceived as basically unsafe, frightening, and evil. Victims feel weak, dependent, and without the control and competence that is vital for the psychological and cognitive coping with the environment. Severely psychologically affected, formerly abducted children need more clinical, therapeutic attention, rather than unspecific psychosocial or social approaches. In reality, current rehabilitation interventions for former child soldiers focus on brief vocational training, family tracing, and reunification. The latter two are done with the assumption being that once a child lives with his or her family again, the psychological wounds will automatically heal. It must be clearly understood that as of today, no structures are in place to adequately address the psychological rehabilitation needs of formerly abducted children and child soldiers in the Great Lakes region of Africa or any other resource-poor, conflict-stricken region of the world. In fact, child combatants have a particularly high risk of being left out or marginalized by international programs in the reintegration process (Colletta, Boutwell, & Clare, 2001). They are especially vulnerable for reintegration failure. Only in recent years, the fact that both these vulnerable groups and ex-combatants in post-conflict countries suffer from psychological problems has been recognized. The acknowledgement that many of them are unable to profit from standard reintegration tools, due to severe psychological distress, daily malfunctioning, and gender-based discrimination, is slowly leading to the inclusion of special program steps for this group. The lack of programs is a clear neglect of the international community’s obligation to psychologically rehabilitate former child soldiers, according to Article 39 of the United Nations Convention on the Rights of the Child (United Nations, 1987). In the absence of psychological rehabilitation services, efforts to promote social reconstruction may be undermined, because rates of abduction are near 50% of the overall population in war-affected regions, such as Northern Uganda, Angola, and parts of the Democratic Republic of Congo (Pfeiffer et al., submitted; Roberts, Ocaka, Browne, Oyok, & Sondorp, 2008; Vinck et al., 2007). A critical mass of

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affected persons in a given society can, therefore, be assumed lost as potential pro-active, mediating community agents for change and development (Schauer & Schauer, 2010 this volume). These child ex-combatants are, to a great extent, impaired in their daily functioning. This outcome of traumatization has far-reaching consequences for the process of reconciliation, peace building and development within their communities and post-war areas at large. It might even fuel cycles of violence, reaching into following generations. Providing them with specific, trauma-focused, public mental-health services (see Chapters 9, 16) might be a key component for breaking this vicious circle. Acknowledgements We highly appreciate the hard work and dedication of our team members at the NGO vivo (www.vivo.org), as well as the adjunct Department of Clinical Psychology at the University of Konstanz, Germany (www.clinical-psychology.uni-konstanz.de). Most importantly, our respect and thanks goes to our local counselors and collaborating colleagues in the various places of (post-)conflict, but especially to all the boys and girls who have experienced abduction and child soldiering and who persevere so bravely in their struggle for a better tomorrow. Research for this chapter was supported by the NGO vivo, the Deutsche Forschungsgemeinschaft (DFG), the University of Konstanz, Germany, the European Refugee Funds (EFF and ERF), as well as the ‘Herz fuer Kinder Fund’, Hamburg, Germany.

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Chapter 15

The Toll of War Captivity: Vulnerability, Resilience, and Premature Aging Zahava Solomon and Avi Ohry

Philosophical and Historical Introduction And after that? How did men cope with all the cultural and social changes that had taken place while they were there? How did their stomachs readjust to a ‘civilized’ diet; and how their wives and children relate to the prematurely aged figure that arrived home, instead of the mantelpiece snapshot? (Shephard, 2002, P. 320).

It is apparent from clinical experience and the literature that persons, who experience severe physical or mental trauma, are susceptible to premature aging (or psychological symptomatology). Long-term follow-up of repatriated prisoners of war also confirm this observation. Coping with physical and mental sequelae of captivity means a constant struggle to maintain some kind of “homeostasis.” Often, this delicate equilibrium fails. Claude Bernard stated that “To have a free life, independent of the external environment, requires a constant internal environment” (Bernard, 1957, P. 8). This is the underlying principle of homeostasis. When it collapses due to “wear and tear” processes, premature aging/morbidity process takes place.

The Stressors of War Participation in active combat has been known to expose combatants to extreme physical and mental stress. Alongside the continuous threat of annihilation, combatants often face deprivation of food, water, and sleep and are liable to sustain injury and witness it befall their fellow combatants. Soldiers often face grotesque images of destruction and abuse, in which they might function as reluctant participants ordered to partake in violent actions by their superiors. Mental and physical fatigues stemming from continuous combat, alongside loneliness, lack of social support, and denial of privacy profoundly affect the combatants’ psyche and mental Z. Solomon (B) Tel-Aviv University, Ramat-Aviv, Israel e-mail: [email protected]


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strength (Solomon, 2001). These stressors have been known to take a significant mental toll; most soldiers experience intense fear and even helplessness. For one group of soldiers, combat is but the first step in a traumatic journey. For these soldiers who fall in enemy captivity, the war continues though the shooting has stopped. These prisoners of war (POWs) continue to be exposed to prolonged and often even more extreme traumatic experiences.

Stressors of War Captivity Falling into enemy hands and being held in captivity are periods marred by intense exposure to recurrent harrowing stressors. At the time of the actual physical capture, the combatant is engaged directly and at short range with his enemies, and brutal force typically deprives him of his autonomy (e.g., Avnery, 1982). During captivity, the prisoner is usually held in poor conditions of sanitation and climate and is continuously deprived of sufficient amounts of food and water (e.g., Hunter, 1993). The POW is subjected to brutal torture and interrogations and is subjected to humiliation and violence. Mock executions are often carried out; the use of solitary confinement is pervasive. Deprivation of a benevolent human interaction enhances the captive’s dependency upon his captors. The lack of social support, denial of privacy, and continuous torture and humiliation may cripple one’s self-identity and potentially pave the way for a breakdown of the defensive mental system. Allostasis is a concept which deals with the ability to maintain stability through changes; it is a fundamental process through which organisms actively adjust to both predictable and unpredictable events. This concept enables a differentiation of the needs for keeping homeostasis during “normal” life history versus a “special” life situation, such as chronic disability. Hence, allostatic overload acts first as an adaptive defense mechanism (biological as well as psychological), but in the long run, engenders non-adaptive patterns that may lead to the acceleration of aging processes. The physical, mental, and social burdens among ex-POWs may lead to severe disruption of this fragile equilibrium.

The Symptoms of War Captivity The trauma of captivity is unique in the sense that it entails recurrent exposure (repeated trauma) to physical and mental torture. These stressors pile up on top of the extreme conditions and hazards that the POWs have already experienced during combat. In addition, while the experience of war may be impersonal, captivity is characterized by continuous personal interaction between captive and captures and as such generates a unique form of a controlling and coercive relationship (Herman, 1992). Various methods of control and coercion are employed in order to deprive the prisoners of war of their sense of autonomy and replace it with a sense of horror and helplessness.

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The Toll of War Captivity: Vulnerability, Resilience, and Premature Aging

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Captors use various brutal means to deliberately break the captives’ spirit. In fact, during the Yom Kippur War, Israeli POWs were repeatedly exposed to antiIsraeli propaganda, misinformed of the death of Israel’s leaders, the triumph of Arab states over Israel and its occupation. At times, captives were informed that their homes were destroyed and their family members and relatives were killed. These acts were deliberate efforts aimed at harming captives by exacerbating their feelings of loneliness and desertion. The trauma of captivity was often further exacerbated when the prisoners felt that they failed to meet the heroic ethos deeply rooted in the Israeli culture. This ethos requires that prisoners of war not disclose any information, endure the unbearable pain of interrogation without disclosing military information, and, even if need be, sacrifice or take their own lives. This code of conduct is intertwined with the ideal image of the Israeli combatant who is expected to “fight until the end” and “maintain his honor” through interrogation (Gavriely, 2006). Thus, many Israeli POWs were regarded not only as soldiers who failed in the important role of defending their homeland but also as a threat to national security, because they may have disclosed potentially sensitive information. This public notion is mirrored by the Israeli military law, which defines surrender to the enemy, when not ordered to do so, as a severe offense – a betrayal – that may entail a death penalty. Furthermore, the disclosure of secrets while in captivity is defined as “treason” and “despicable behavior.” This rigid outlook of the Israeli establishment and society toward captivity clearly runs at the heart of the “captive’s dilemma”: staying alive and sustaining criticism and condemnation or obeying the norm at the cost of jeopardizing one’s life. Among many ex-POWs, this dilemma has induced feelings of utter failure and unbearable weakness. This mental fault has been further nourished by past stories of former exPOWs who did not disclose any information, at the cost of their own lives. For the surviving POWs, clearly, these former captives were a role model not easily lived up to.

Israeli POWs of the Yom Kippur War During the 1973 Yom Kippur War, 240 land force Israeli soldiers fell into captivity in both the Syrian and the Egyptian fronts. POWs held in Egypt were released after a relatively short period of time (i.e., a month or 6 weeks). POWs in Syria were held for 8 months. During captivity in Egypt, the prisoners were held at separate cells, while in Syria, after a rigorous interrogation period, POWs were held in two groups, each in a large common room. In both states of captivity, Israeli soldiers were subjected to interrogation and torture designed to mentally break them down. As noted, in Syria, by the end of the interrogation period, the POWs were held in a common cell. While this transformation in their condition might have somewhat alleviated their loneliness, it was also reported to be a source of new stress due to lack of privacy and intense, unregulated contact with other POWs. These

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experiences gave rise to feelings of humiliation, guilt, frustration, and shame – all significant stressors. It has been repeatedly observed that intense and prolonged exposure to traumatic stressors, that war captivity entails, is highly pathogenic and likely to be followed by increased psychiatric and somatic symptomatology and considerable malfunctions and disability. The following sections will systematically review the relevant literature on the aftermath of captivity and present some highlights of an ongoing 35-year longitudinal study of Israeli ex-POWs of the Yom Kippur War.

Psychiatric Sequelae of Captivity – Posttraumatic Stress Disorder Traumatic stress is highly pathogenic and its detrimental effects may take many forms. The most common and conspicuous psychiatric sequela of captivity is posttraumatic stress disorder (PTSD). PTSD includes three major symptom clusters (APA, 2000): (a) re-experiencing of the traumatic event, (b) avoidance of stimuli that are reminiscent of the traumatic event, and (c) increased physical arousal. PTSD is characterized by considerable distress and malfunctioning. While PTSD has become the most conspicuous diagnosis for traumatized individuals, it does not take into account the full complexity of adaptation to trauma. It has been suggested that following repeated abuse in captivity, victims tend to develop a unique form of posttraumatic sequela that penetrates and consumes their personality, often referred to as “complex PTSD” (Herman, 1992; Van der Kolk, 2002). According to Herman (1992), “prolonged captivity disrupts all human relationships and. . . the survivor oscillates between intense attachment and terrified withdrawal” (p. 93). This type of posttraumatic reaction is less likely to occur following a single event, but rather characterizes ongoing exposure to traumatic events of an interpersonal nature, such as captivity that involves forced dependency (e.g., for food). Research on the adaptation of ex-prisoners of war (POWs) has consistently found them to be a high-risk group for psychological distress and especially for PTSD. The pathogenic effects of war captivity continue to be documented years after World War II (Kluznik, Speed, Van Valkenburg, & Magraw, 1986; Sutker, Allain, & Winstead, 1993); the Korean War (Sutker, Winstead, Galina, & Allain, 1991); the Vietnam War (Ursano, Boydstun, & Wheatley, 1981); and the Yom Kippur War (Solomon, Neria, Ohry, Waysman, & Ginzburg, 1994).

Prevalence of PTSD Among Ex-POWs Studies of the psychosocial impact of war captivity have identified it as a highly pathogenic experience, with posttraumatic stress disorder (PTSD) being the most common and widely documented psychological sequel (e.g., Solomon et al., 1994).

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In the wake of war captivity, posttraumatic stress disorder (PTSD) rates approximately two to five decades after captivity range along a wide spectrum, from 5 to 88%. Most studies have found that substantial proportions of former POWs carry their wounds with them for a very long time (Engdahl, Dikel, Eberly, & Blank, 1997; Port, Engdahl, & Frazier, 2001). In addition, POWs may also suffer from a wide range of psychiatric coexisting disorders, especially anxiety and depression (Ursano & Rundell, 1990). In a sample of Israeli ex-POWs of the 1973 Yom Kippur War, PTSD rates were 13 and 23.2% assessed 18 and 30 years after the war, respectively, and ex-POWS showed heightened levels of psychiatric symptomatology (Neria, Solomon, & Dekel, 1998; Solomon & Dekel, 2005). This significant variance in reported PTSD rates may be attributed to the fact that POWs experienced different forms of trauma and were assessed by different methods at different points in time following their release from captivity. It is a well-known fact that PTSD is a dynamic disorder, which follows a highly complex course over time. Little, however, is known about the course of the PTSD over those years, and consequently the long-term psychological consequences of war captivity are poorly understood.

Trajectories of Captivity-Induced PTSD The literature on the longitudinal effects of war captivity offers three alternative perspectives. One is that time is a healer: as the years pass, any detrimental impact of captivity will weaken, and more ex-POWs will recover partly or in full. This view is supported by previous findings of declines in the levels of depression and anxiety among former POWs after approximately a decade (Tennant, Fairley, Dent, Sulway, & Broe, 1997), as well as findings of fewer PTSD symptoms some 50 years after captivity than in the first year post-captivity, as reported retrospectively (Engdahl, Speed, Eberly, & Schwartz, 1991; Potts, 1994). The second view is that PTSD is a chronic ailment, in which symptoms will intensify with the passage of time, with the natural decline in the individual’s physical and mental condition over the years. This view gained some support from a recent study that found increased PTSD over a 4-year period among former American POWs (Port et al., 2001). The third view is that, other than an initial decline in psychological distress relatively soon after the captivity, no clear pattern is discernible. This view stresses the labile quality of PTSD and the ability of events in the individual’s outer and inner life to trigger its recurrence or intensification after periods of latency or remission (Zeiss & Dickman, 1989). Like the previous view, this perspective also expects a rise in distress over time, when age-related stressors like retirement, deteriorating health, and loneliness make the individual vulnerable (Buffum & Wolfe, 1995); but this view expects more idiosyncratic changes, depending on events in the individual’s environment and personal life.

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Trauma researchers have not yet established which of these three views best describes the long-term implications of war captivity. Too few studies tracing the longitudinal effects of captivity have been carried out, most of which have assessed recovery and other changes in PTSD symptomatology through retrospective selfreports. In addition, the observed variability in the aftermath of captivity, both between and within groups, is not as well understood as we would like.

Longitudinal Study Among Israeli Ex-POWs In light of the aforementioned distinct perspectives about the effects of war captivity, we set out to prospectively examine the long-term mental and physical health effects of war captivity among Israeli ex-POWs. We assessed the rates of PTSD among former POWs and comparable controls and studied changes in their PTSD over time. The study targeted all land forces soldiers, who had been captured by Syria and Egypt in the 1973 Yom Kippur War. The study was based on a prospective, longitudinal follow-up of two groups of veterans over a 35-year period: (a) ex-POWs from the Israeli Army land forces, who were taken captive in either the Egyptian or the Syrian fronts during the Yom Kippur War; (b) a control group consisting of combat veterans, who fought in the same fronts as the ex-POWs during the Yom Kippur War, but were not taken captive. Controls were matched with the ex-POWs in personal and military background. Participants were assessed at two points in time – 18 and 30 years after the war and consisted of 164 ex-POWs in the first wave, followed by 103 in the second wave, respectively, and 185 controls in the first wave, followed by 106 in the second wave.

Criteria of PTSD Our study covers a time period of 30 years, during which the diagnostic criteria for PTSD have significantly changed. In fact, the DSM edition used at the time of our first assessment (DSM-III-R; APA, 1987) was different from the one used during our second assessment (DSM-IV; APA, 1994), the most significant change being the addition of the F criteria for PTSD to the latter edition. According to this criterion, the disturbance caused by the traumatic event should cause significant psychological distress or impairment in functioning. Thus, as years passed, DSM criteria for the diagnosis of PTSD have become more stringent. In a previous study based on the same sample used here (Solomon & Horesh, 2007), it was shown that the application of DSM-III–R criteria upon the sample resulted in higher PTSD rates compared to when DSM-IV criteria were used. This difference stemmed mainly from the addition of the F criterion. Therefore, in order to allow standardization across time, we chose to conform to the updated definition of PTSD and analyzed data from all three assessments according to DSMIV criteria.

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Prevalence of PTSD in Israeli Ex-POWs Our study shows that three decades after their release from captivity, 23% of former Israeli POWs still met DSM-IV symptom criteria for PTSD, in comparison to 4.8% of non-POW controls (Solomon & Dekel, 2005). This figure points to both the resilience of 77% of the former POWs who did not meet PTSD criteria and to the long-lasting psychological damage of captivity to the remaining 23%. The question is why the psychological damage of captivity should be so much more enduring than that of combat, which is itself pathogenic (Solomon, 1993). Several explanations may be offered. The simplest is perhaps the special hardships of captivity: the torture, humiliation, and isolation that are part and parcel of war captivity (Molica et al., 1990), but not of combat. Beyond the hardships themselves, however, is the fact that they are personal (Herman, 1992). That is, the threat of combat to the life and physical integrity of the soldier is a relatively impersonal threat, in that it is directed toward whomever is in the line of fire and not at any particular soldier. Thus, there is no affront to the soldier’s personhood, even if he or she is injured. The trauma of captivity, however, occurs within the relationship between the captives and their captors. The special torments of captivity are part of a planned and concerted effort to “break” the particular individuals and are intentionally inflicted on them by persons, whom they get to know and may relate to on a daily basis and on whom they are dependent for physical survival. Another explanation for higher PTSD levels among POWs has to do with differences in the social context of combat captivity. Combatants are equipped with weapons and protective devices and fight alongside commanders and comrades. The powerful stress-mediating effect of unit cohesion and social support, derived from comrades and commanders, is well documented as a sustaining force for combatants (Solomon, Mikulincer, & Hobfoll, 1987; Steiner & Neumann, 1978). On the other hand, captivity renders the POW totally isolated and deprived of any human compassion and support. The severity of captivity may thus be compounded by isolation and loneliness, leaving a more profound and enduring traumatic imprint. Another possible explanation is that POWs internalized the behaviors that were useful in captivity, such as suspiciousness and hyper-alertness, and generalized them to their lives afterward, where these behaviors were often counterproductive. Eberly, Harkness, and Engdahl (1991) suggest that traumatized POWs can be seen as survivors, who continue to exhibit patterns of affect, behaviors, and cognitions that were adaptive during the traumatic phase. A fourth possible explanation is the doubling of the traumatic experience with captivity. For most POWs, the trauma of captivity follows on the heels of the trauma of combat. Captivity thus extends the duration of the traumatic experience, further drawing on the soldier’s already depleted coping resources (Ursano et al., 1996). As is well known, the longer a traumatic experience lasts, the more severe the ensuing psychiatric disorders are likely to be (Hunter, 1993). Beyond this, however, captivity is a distinct, separate traumatic exposure, in addition to the trauma of combat. The cumulative damage of multiple traumas is known to be more severe than the damage of a single trauma (Herman, 1992).

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Trajectories of PTSD: Changes over Time In our longitudinal study, two waves of measurement took place, the first in 1991 and the second in 2003 (Solomon & Dekel, 2005). The findings show that PTSD followed a different course among the ex-POWs and combat controls. The ex-POWS were 10 times more likely than the controls to experience deterioration in their psychological condition in the 12-year interval between the two assessments. Almost 20% of ex-POWs, who did not meet PTSD criteria 18 years after their release, met it at the 30-year mark, in comparison to less than 1% of the controls (Fig. 15.1). 1.9% 1.9%

1% 0.9%

Controls 95.3%

3%

18.20%

Ex-POWs 77.80%

PTSD in 2003 but not in 1991 (delayed) No PTSD at neither times PTSD in 1991 but not in 2003 (recovered) PTSD at both times

Fig. 15.1 Rates of PTSD in study groups in 1991, 2003

The ex-POWs also showed a statistically significant increase in the endorsement of each of the PTSD symptom clusters (intrusion, avoidance, and hyperarousal), as well as a statistically significant increase in their endorsement of 11 of the 17 symptoms queried and a non-significant rise in all but one of the others. Among the non-POW controls, in contrast, there was no change in the endorsement of the three symptom clusters, along with a downward trend in their endorsement of most of the individual symptoms, which reached statistical significance with regard to recurrent and intrusive recollections. These findings clearly show that time exacerbates the detrimental effects of war captivity. The increase in PTSD in the ex-POWs is consistent with the findings of increased PTSD rates and symptom levels over a 4-year measurement interval among older American ex-POWs (Port et al., 2001), but differs from findings of reports of decreased PTSD symptoms over time among American ex-POWs (Engdahl et al., 1991). The differences are probably related to the times of measurement in the research studies. A previous study (Port et al., 2001) found a U-curve pattern, with high PTSD rates immediately after captivity, followed by a gradual decline and then, from midlife onward, a rise in rates. It may be conjectured that our first assessment, taken

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18 years after the prisoners’ release, fell within the lower part of the curve, and our second assessment, 12 years later, reflected the rising rates as the men aged. The ex-POWs’ heightened PTSD, in terms of both rate and intensity 30 years after their release, may be related to either or both the aging process and the unremitting threat of war and terror in Israel. At our second assessment, the men were in their late fifties through early sixties. This is a high-risk time of life for both delayed onset and reactivation of PTSD. Midlife generally entails some reduction in activity and a shift from planning to reminiscence and from occupation with current events to the review and rethinking of one’s life. The altered perspective may bring forgotten or suppressed traumatic memories to the foreground (Buffum & Wolfe, 1995). Aging also inevitably entails many losses and exit events, from retirement through illness. Such losses may be particularly distressing for former POWs and may remind them of their misery and helplessness in captivity. Moreover, aging clearly heightens one’s awareness of mortality as one is nearing the end of life. With regard to the second explanation, the second assessment took place at the height of the second Intifada (the Palestinian uprising), when suicide bombings and drive-by shootings created tremendous insecurity and fear among most Israelis. These events, regularly reported on television, may also have reawakened the dormant traumatic contents among the ex-POWs by reminding them of their misery and helplessness in captivity. Given the study design, it is impossible to know whether the 20% rise in the ex-POWs’ PTSD reflects reactivation or delayed onset. Previous studies report delayed onset PTSD in 11% (Green et al., 1990) to 20% (McFarlane, 1988; Wolfe, Erickson, Sharkansky, King, & King, 1999) of various traumatized groups. Along with the psychiatric disorders found in this study, we should also note the resilience of the study participants. The non-POW veterans had very low rates of PTSD both 18 and 30 years after the war (3.8 and 4.8%, respectively). Even though all of them had seen combat, most continued to serve in active reserve duty through age 45, and all, like the rest of the Israeli population, were exposed to the ongoing threat of terror, which has the capacity to reawaken earlier traumas. Among the ex-POWs, the PTSD rates were considerably higher, but the vast majority did not meet PTSD criteria at either time of assessment. The high level of resilience in both groups lends further support to Bonanno’s (2004) conclusions from his review of the literature that resilience in the face of trauma is more common than is often believed. Finally, it should be noted that ex-POWs’ PTSD rates found in our study 30 years after the war are lower than those found in most previous studies of ex-POWs. The rates are higher than the PTSD rates of 5% (Tennant et al., 1997) and 15% (Potts, 1994) that were found among American POWs in World War II several decades postwar, but those rates are on the low end. Most reports of World War II POWs note rates of 30–76% 40–50 years postwar (Speed, Engdahl, Schwartz, & Eberly, 1989; Sutker & Allain, 1996; Zeiss & Dickman, 1989). And studies of POWs of the Korean conflict report rates over 80% 40 and 50 years postwar (Sutker & Allain, 1996). The lower rates in the present study may be attributed to the shorter duration and lesser severity of the Israeli soldiers’ captivity. The Israeli prisoners were held for between 6 weeks and 8 months; the American POWs were held in the

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Far East for several years, during which time they were subjected to prolonged and repeated torture and exposed to extremely harsh physical conditions and deprivation (Sutker & Allain, 1996).

Coexisting Psychological Disorders The effects of traumatic experiences are not limited to PTSD. In fact, consistent observations revealed that a wide array of psychological difficulties and psychiatric disorders follow war captivity. Studies that examined the long-term effects of war captivity found wide and substantial emotional (Solomon et al., 1994; Ursano et al., 1996), cognitive (Sutker et al., 1991), and functional impairments (Van Vranken, 1989), which continue to disturb ex-prisoners of war (ex-POWs) and seriously impair their quality of life for many years. Among the emotional disorders, in addition to PTSD, ex-POWs were found to exhibit a wide range of psychiatric symptomatology; anxiety and depression have been found to be the most common long-term disorders (Ursano, 1981), as well as the most commonly noted coexisting disorders of PTSD among ex-POWs (Engdahl et al., 1991). The literature also points to elevated levels of schizophrenia (Beebe, 1975), and paranoid tendencies, as well as higher rates of hypochondria (Sutker & Allain, 1991) and alcoholism (Beebe, 1975; Sutker, Winstead, Galina, & Allain, 1990) among ex-POWs. Moreover, many ex-POWs experience severe long-term impairment of interpersonal (Solomon et al., 1994; Sutker & Allain, 1991) and sexual functioning (Ursano, 1981), and their divorce rates are high (Nice, McDonald, & McMillian, 1981; Van Vranken, 1978). As part of our study, we set out also to assess psychiatric symptoms. Almost two decades after the Yom Kippur War, ex-POWs reported significantly greater distress than non-POW combat controls. The residual effects were not only deep, but as hypothesized, they also extended over a wide range of measures, from traumaspecific emotional disorders through general psychiatric disorders and problems in functioning. In addition to experiencing significantly higher rates of PTSD and slower recovery, the ex-POWs had more severe, general psychiatric symptomatology manifested by somatization, obsessiveness, anxiety, hostility, and phobic anxiety; more impairment in functioning (in family, work, and the military); higher rates of recognized war-related psychiatric disability; and a greater sense of need for and utilization of psychological assistance. These findings are consistent with former studies that showed long-term traumatic sequelae, ranging from specific trauma-related reactions to general psychiatric disorders among prisoners of war (Sutker et al., 1991; Ursano, 1981). They are also consistent with both clinical and empirical findings on war-induced psychiatric disorders, which similarly show elevated levels of other disorders, including depression, anxiety, and substance abuse, in addition to PTSD (Boudenwyns, Woods, Hyer, & Albrecht, 1991). Finally, the findings of multiple problems are consistent with the varied clinical picture of survivors of other traumatic events (Herman, 1992).

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According to DSM-IV (APA, 1994), PTSD is the only psychiatric disorder that is clearly the direct result of traumatic exposure. Yet our findings clearly indicate that PTSD is not the only psychiatric disorder that follows traumatic stress. By and large, these results are consistent with studies of various populations conducted in other parts of the world that followed different traumatic events, including the Lockerbie plane crash (Brooks & McKinlay, 1992), the Buffalo Creek dam collapse (Green, Lindy, Grace, & Leonard, 1992), civil violence in Northern Ireland (Loughrey, Bell, Kee, Roddy, & Curran, 1988), the civilian war in Cambodia (Kinzie & Boehnleen, 1989), the general population in the United States (Breslau, Davis, Anderski, & Peterson, 1991), and other studies. These studies revealed that PTSD is often accompanied by other coexisting disorders. Both previous research and our findings cast doubt on the ability of the narrow formulation of PTSD to grasp the wide-ranging emotional, interpersonal, and functional damage caused by traumatic exposure, including captivity.

PTSD and Coexisting Disorders To explain the high occurrence of a coexisting disorder with PTSD, four alternative explanations may be suggested: (a) preexisting disorders constitute a vulnerability to PTSD, (b) the other disorders are subsequent complications of PTSD, (c) the disorders occur because of shared risk factors, and (d) a coexisting disorder is a result of a measurement artifact (i.e., symptoms of PTSD artificially increase the chances of other disorders). Close inspection of the most prevalent coexisting disorders in this study (i.e., obsessiveness, somatization, anxiety, paranoid ideation) reveals that symptom overlap is minimal. If coexisting disorders constitute a predisposing or a vulnerability factor for PTSD, we would expect an elevated level of other disorders prior to combat. This possibility is unsubstantiated for Israeli combatants, who were all screened and found to be healthy before the war. Both PTSD and other coexisting disorders emerge after war; but based on our design, we cannot unequivocally determine whether coexisting disorders are complications of PTSD or share the same risk factors. The ex-POWs suffered from higher rates of general psychiatric symptomatology than the controls, a fact which suggests that even the veterans without PTSD among the ex-POWs suffer more distress than their peers without PTSD in the control group. This finding may raise questions about the exclusivity of PTSD as the only direct result of traumatic exposure, such as whether PTSD should in fact be regarded as the most common conspicuous and even as the only psychiatric disorder stemming from traumatic events. Alternative views would hold that traumatic sequelae are multifaceted and not limited to PTSD symptomatology (Solomon, 1993). Furthermore, the complex, long-term course of both PTSD and its coexisting disorders should be carefully assessed, because one possible speculation based on current findings is that general symptomatology may persist even when PTSD is in remission. This may be a result of complex PTSD symptoms, which may have

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long-lasting effects on the individual’s personality and his interpersonal relations, long after the common PTSD symptoms have abated. From a somewhat different perspective, it has been suggested that the existing diagnostic criteria for PTSD may be appropriate for a circumscribed traumatic event. Yet, after prolonged, repeated trauma, the clinical picture may be more diffuse, comprehensive, and complex (e.g., Niederland, 1968). Contrary to our expectations that the ex-POW PTSD veterans would experience greater coexisting disorders than the PTSD casualties in the control group, no such difference was found. The expectation was based on the assumption that the degree of a coexisting disorder would be related to the severity of the posttraumatic reactions. The finding may mean that while a coexisting disorder of PTSD is prevalent among trauma casualties, it is not related to severity of PTSD. Alternatively, this finding may be an artifact of the small number of veterans with PTSD in the two groups. Further research employing longitudinal designs and careful assessments of various traumatic events of various populations is required to cast light on the complex interplay between PTSD and a coexisting disorder. The significantly lower level of interpersonal sensitivity among the ex-POW PTSD veterans is also surprising. It may have to do with the more personal nature of their trauma, which may have caused greater erosion of trust in them than the more impersonal trauma of the non-POW combat veteran casualties. Furthermore, Israeli ex-POWs, much like ex-POWs in other countries, were met with suspicion and even accusations of succumbing to the enemy and being traitors upon homecoming. The interrogation of the men that we studied, in a military installation in Israel upon their release, was described by some of them as worse than what they were subjected to by the enemy. It may be that the ex-POW PTSD veterans, who suffered personal torture and humiliation at the hands of their captors, have so little faith and so few expectations of other human beings that they can no longer feel hurt by them.

Need of Professional Help and Help-Seeking Lastly, the findings show that about twice as many ex-POWs as combat controls felt that they needed psychotherapy, and about five times as many ex-POWs as combat controls actually sought and obtained it. The rates of psychotherapy-seeking and readiness to admit the need for help were high relative to norms in Israel (Solomon, 1993), even in the control group. They are testimony to the intensity of the distress from which men in both groups suffer, as well as the increasing acceptance in Israeli society in recent years of seeking help following traumatic military experiences. The higher rates of both reported need and actual help-seeking among the exPOWs may be explained by their greater trauma-related and general distress and their lower recovery rates. Even those who received treatment were less prone to recover than the combat controls that were treated. The complex and prolonged stressors to which they were exposed may have contributed to their intensive, pervasive, and widespread distress (Herman, 1992). Previous studies of Israeli veterans

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clearly demonstrated the link between level of distress and help-seeking. The most distressed veterans were more inclined to apply for help (Solomon, 1993). The difference may also be explained by the public awareness, which developed in the wake of the research that ex-POWs are a particularly high-risk group for severe and long-term disorders. Filtering down to the society at large, this awareness may have reduced the stigma of help-seeking by ex-POWs. The fact that the rate of recovery among treated POWs was lower than among treated controls is yet further evidence not only of the difficulties in treating trauma but also of the fact that the more massive the trauma, the more damage it causes, and the more difficult it is to ameliorate with professional intervention.

Salutogenic Aspects: Posttraumatic Growth As with other traumas (Antonovsky & Bernstein, 1986), research on the aftermath of war captivity has emanated primarily from a pathogenic perspective and focused on negative or pathological outcomes such as posttraumatic stress disorder (Solomon et al., 1994; Zeiss & Dickman, 1989), depression (Engdahl, Page, & Miller, 1991), and anxiety (Sutker et al., 1990). The investigation of any possible salutary or positive effects is extremely rare. As noted, captivity entails the infliction of severe and deliberate trauma by one person onto another. The notion that this severe and sadistic violation of one’s basic human rights may yield a salutogenic outcome has deterred potential researchers for many years. Thus, not surprisingly, when we commenced our study in 1991, we found only three studies that even considered positive outcomes of captivity. One study by Sledge, Boydstun, and Rabe (1980) assessed the consequences of war captivity 4 years after the release of ex-U.S. Air Force officers who were held prisoner in Vietnam. Results showed that 92% of POWs felt that they had benefited from their captivity. These people saw themselves as more optimistic, believed they had more insight, and felt better able to distinguish between the important and the trivial. They also reported positive changes in the interpersonal realm, claiming that they developed good interpersonal skills, patience, understanding of others, and an increased awareness of the importance of communicating with others. In a study of Israeli Air Force pilots taken prisoner in the 1973 Yom Kippur War, the author (Barnea, 1981) suggested that compared to non-POWs combatants, POWs developed a richer inner life, more creativity and flexibility, more freedom in expression of affect, more balance in their need for achievement, and greater actualization of their potential. Finally, Ursano (1981, 1985) conducted a unique study of a small group of repatriated U.S. Air Force POWs, who had coincidentally undergone extensive psychological testing prior to their captivity. Ursano (1985) concluded that the alterations in personality style caused by captivity “are neither pathological nor beneficial in and of themselves, but depend on the starting point of the personality structure” (p. 351) and that along with its pathological and destructive effects, exposure to war captivity may also evoke certain positive changes.

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In the first wave our study in 1991, alongside pathogenic outcomes, positive and negative changes were also examined. Sledge et al.’s (1980) self-report questionnaire was used, which covered changes in 53 traits, attitudes, and behaviors. Each item consisted of one area (e.g., “optimism” or “aggressiveness”), in which the participant is asked to make comparison of the self now and before the war. The questionnaire contains both desirable and undesirable features, so that the response on each item can indicate either a positive change (increase in a desirable trait or decrease in an undesirable one), a negative change (increase in an undesirable trait or decrease in a desirable one), or no change. The results of the study reveal two major findings. Both positive and negative changes were reported by men in both groups. However, ex-POWs differed from controls only in the amount of negative changes that they reported. Thus, although ex-POWs reported both positive and negative changes, the war-captivity experience was uniquely associated with an increase in negative changes. Yet, along with the well-documented pathogenic effects, survivors of traumatic events also reported positive experiences. When asked to compare their current selves with how they were before the war, a considerable percentage of veterans reported increased insight, maturity, self-esteem, and self-confidence, a more optimistic view of life, greater satisfaction with their families, and enhanced ability to differentiate the important from the trivial. This finding is congruent with results of earlier studies. Of a sample of American POWs captured by the Vietnamese, 92% reported that they had some psychological gains from their captivity (Sledge et al., 1980). Of Israeli combat veterans of the Yom Kippur War, 94% believed that they had derived at least some benefit from their war experiences (Yarom, 1983). An intriguing finding in our study was that positive changes were more frequently endorsed than negative ones. In fact, positive changes were 1.6 times more prevalent than negative changes. Similar results were reported by Yarom (1983) in her study of Israeli combatants, and by Collins, Taylor, and Skokan (1990) in a study of survivors of breast cancer. These findings suggest that trauma victims do not lose the capacity for psychological growth, despite their harrowing traumatic experiences. On the other hand, ex-POWs did not differ from controls in either the number or the intensity of positive changes, nor in the domain of these changes. We thus concluded that war captivity neither impaired nor improved ex-POWs’ ability to experience positive change or growth. This finding is inconsistent with claims that survivors of trauma are enriched by their traumatic experience. The trauma of captivity does not seem to entail any benefits for survivors. It might be that the positive changes reported by both groups simply reflect normative maturation that is unaffected by traumatic experiences. An alternative explanation is that positive changes following trauma are short lived. The current study was conducted 18 years after captivity, whereas the previous studies (e.g., Sledge et al., 1980) were conducted a short time after the traumatic event. Alternatively, one may speculate that traumatization does promote positive changes, but that non-victims also mature over time and “catch up” with the

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victims, so that any difference between the two eventually disappears. The current design can neither support nor reject any of these explanations. Only prospective studies with multiple assessments can shed light on this matter. The most striking difference between the groups was observed with regard to negative changes, as ex-POWs reported significantly more negative changes than controls. They endorsed greater exacerbation in symptomatology, impairment of self-concept, deterioration in social relations, decline in work functioning, and reduction in capacity for pleasure and relaxation. This was also evident in elevated PTSD rates among these POWs (see Solomon et al., 1994). These changes have been consistently demonstrated to characterize survivors of trauma (e.g., Kluznik et al., 1986; Solomon, 1993; Sutker, Thomason, & Allain., 1989). We concluded that, in fact, our findings suggest that the imbalance in the trauma literature, which is focused on the negative outcomes of exposure to trauma and neglects the positive consequences, reflecting the state of the present mode of trauma research, instead of some kind of bias. The results also indicate that the same person may experience both positive and negative changes following trauma. A high degree of distress coexisted with psychological growth and maturation. These findings are congruent with results reported by Elder and Clipp (1989), who examined the relationship between resilience and psychological symptoms in American war veterans. They conclude that “the more resilient veterans at mid-life are not necessarily symptom-free in terms of emotional distress and impairment” (p. 337). These findings clearly demonstrate the multidimensionality of human response to trauma. It may be argued that the ability of some trauma victims to compartmentalize their reactions enables the containment of their distress, so that it does not undermine subsequent psychological growth. A related question addressed in this study was whether positive and negative changes occur in different or in the same areas. Results clearly point to the area contiguity of changes. In four out of the five areas examined – life satisfaction, view of self, social relations, and family orientation – changes were found to be mostly positive. However, in the area of symptomatology, most of the changes were negative. These findings support previous studies of American (Elder & Clipp, 1989) and Israeli (Yarom, 1983) war veterans, showing that positive changes are discernible in “existential” spheres, and negative changes manifest mostly in the form of symptoms. Collins and colleagues (1990) suggest that negative changes directly reflect passive responses to victimization, whereas positive changes result from active attempts to cope with the trauma. Symptoms are less subject to change via cognitive or behavioral coping strategies. Changes in priorities and seeking the company of others, on the other hand, may be active attempts to cope with victimization. According to Taylor (1983), the attempt to find positive meaning in a trauma produces more optimal psychological adjustment. In the same vein, Frankl (1962) claims that in an extreme traumatic experience, such as in the Holocaust, the ability to regain meaning enables the victims to survive.

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Posttraumatic Growth More recently, within the realm of the salutogenic approach, a similar yet distinct approach was defined and a new term was coined. Posttraumatic growth (PTG) marks significant, covert positive changes in self-image, world-view, and interpersonal relations, in the wake of exposure to a highly stressful or traumatic experience (Tedeschi & Calhoun, 1996). PTG has been much less studied than PTSD, yet a rapidly growing body of research assessed PTG. Many studies among adults (Tedeschi & Calhoun, 1996; Weiss, 2002) as well as adolescents (e.g., Cryder, Kilmer, Tedeschi & Calhoun, 2006; Milam, Ritt-Olson, & Unger, 2004). Among the traumatic events that were associated with posttraumatic growth are medical problems (e.g., Weiss, 2002), natural disasters (McMillen, Smith, & Fisher, 1997), and man-made disasters (Ai, Cascio, Santangelo, & Evans- Campbell, 2005). Many of the studies of PTG also assessed PTSD, and the relationship between these two outcomes has received considerable theoretical and some empirical attention. Three perspectives for the relationships between PTSD and PTG are offered. The first clearly suggests that not disregarding the extreme and long-lasting negative consequences of war, there is sufficient evidence supporting the existence of salutary outcomes of both combat (Aldwin, Levenson, & Spiro, 1994; Schnurr, Rosenberg, & Friedman, 1993) and war captivity (Sledge et al., 1980). As noted by Sledge et al. (1980), 90% of American former Air Force officers, who were held prisoner in Vietnam, viewed their changes following captivity as favorable, including greater understanding of self and others and a clearer concept of priorities in life. Similarly, our own study cited above (Solomon, Waysman, & Neria, 1999) found that positive changes were more frequently endorsed than negative ones by Israeli ex-POWs and war veterans. An alternative view suggests that growth and distress are two separate, independent dimensions of the traumatic experience, such that high scores on one dimension do not necessarily entail low scores on the other. According to this perspective, positive and negative changes emerge as two separate, unrelated outcomes that can both occur in one person, though not necessarily within the same areas. This twodimensional stress response perspective posits that most people will respond to even extreme stress with some mixture of both resilience and vulnerability. Lending support to this view are studies that found no correlations between growth and distress (Ursano, Wheatley, Sledge, Rabe, & Carlson, 1986). In line with this perspective, our above cited study (Solomon et al., 1999) found no correlation between PTSD measures and positive changes among Israeli POWs, yet showed that they can both occur in the same individual simultaneously. The third perspective claims that salutary and pathological outcomes are positively correlated – hence, the most highly distressed persons are also likely to show the highest psychological growth. Lending support to this claim are Tedeschi and Calhoun’s (1996) findings that people who experienced traumatic events report more positive changes than persons who have not experienced such events. Positive correlations between growth and distress were also found in Pargament, Smith, Koenig,

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and Perez’s (1998) study of residents of Oklahoma City following the 1995 bombing. In some cases, however, a curvilinear relationship has been noted, for which higher levels of growth are reported by those with intermediate levels of exposure (Fontana & Rosenheck, 1998) or symptoms (Butler et al., 2005). Another unanswered question is whether the pathological and salutary outcomes of trauma share similar predictors. In ex-POWs, these predictors include the emotions and behaviors used in coping with captivity and the ex-POWs’ subjective assessment of the severity of captivity. Experimental and empirical studies on exPOWs’ coping mechanisms have shown that sense of control, faith, reality testing, denial, rationalization, humor, and active problem-focused coping promote better mental health after release. Yet, apathy, withdrawal, emotional constriction, and emotion-focused coping have been found to decrease anxiety and stress during captivity (Nardini, 1952; Strentz & Auerbach, 1988). Appraisal findings suggest that the more the subjective suffering, the greater the post-captivity psychological distress (e.g., Sledge et al., 1980; Solomon, Ginzburg, Neria & Ohry, 1995). Regarding predictors of growth, the literature suggests that growth is an interactive function of pre-event resources, event appraisals, and coping strategies (Holahan, Moos, & Schaefer, 1996). Studies dealing with the determinants of growth, and specifically with the relationships between appraisals and coping, have found that high levels of perceived threat and harm (Armeli, Gunthert, & Cohen, 2001; Fontana & Rosenheck, 1998), as well as problem-focused coping, are related to high levels of growth (Armeli et al., 2001). These findings support the notion that growth stems, to a certain degree, from coping with the event (Tedeschi, Park, & Calhoun, 1998). Although the contribution of appraisal has been examined among combatants (Fontana & Rosenheck, 1998), it has not been examined among POWs.

Posttraumatic Growth in POWs of the Yom Kippur War In our second wave in 2003, we aimed (a) to assess PTSD and posttraumatic growth among former POWs and combat veterans, (b) to assess the relationship between PTSD and posttraumatic growth, and (c) to assess the relationships between coping and appraisal, on the one hand, and PTSD and posttraumatic growth, on the other hand. Therefore, in our second wave of measurements (2003), we assessed both PTSD and PTG and the relationship between PTSD and PTG in ex-POWs and controls (for details, see Solomon & Dekel, 2007). Our findings showed that traumatic events were associated with both pathological and salutary outcomes. As noted above, 23% of the former Israeli POWs and almost 4% of the combat controls met criteria for PTSD. At the same time, both groups reported considerable posttraumatic growth on all five posttraumatic growth subscales. These findings are consistent with the co-occurrence of negative and positive effects following a wide range of catastrophic events such as torture and terror, solitary confinement, and systematic deprivation of basic needs. They are also consistent with Maercker and Zoellner’s (2004) finding that 72% of East German former political prisoners

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spontaneously provided at least one example of posttraumatic growth when asked whether they got anything positive from their incarceration. Furthermore, they are consistent with the findings of our previous study’s findings (Solomon et al., 1999), which was based on the same Israeli former prisoners of the Yom Kippur War as the current study, but used Sledge et al.’s (1980) measure of positive and negative consequences of war captivity. How can we reconcile the apparently contradictory findings of positive changes following war captivity, on the one hand, and negative changes in the form of PTSD, on the other? Several attempts at synthesizing the literature were made. Masten, Best, and Garmezy (1990) stated that the hallmark of resilience is adaptive functioning, despite feelings of distress and negative affect. In other words, a person may experience considerable distress, yet at the same time continue to function and grow. The current findings confirm this view: Positive and negative changes clearly emerge as two separate yet related outcomes. Posttraumatic distress is not necessarily indicative of an absence of psychological growth and maturation. These two different types of outcome cannot, therefore, be conceptualized as two ends of the same continuum; they are not necessarily characteristic of two different types of individuals (e.g., resilient vs. vulnerable) and are not mutually exclusive. The results of the present study thus highlight the complexity of the human response to traumatic stress, as well as the multidimensionality of psychological well-being. Negative posttraumatic effects occur, but in many cases they are contained and do not interfere with subsequent psychological development and growth. Conversely, the findings also indicate that even when a person is able to grow and experience positive changes following trauma, this does not undo the ongoing suffering that the event has created. The findings also suggest that the posttraumatic growth is associated with the severity of the traumatic experience. The ex-POWs in this study endorsed more growth than the combat veterans on all the posttraumatic growth subscales. This finding is consistent with several empirical studies that have similarly shown that the positive consequences of trauma are directly proportional to the severity of the traumatic exposure (Aldwin et al., 1994; Tedeschi & Calhoun, 1996). In particular, they are consistent with Elder and Clipp’s (1989) findings on American soldiers in World War II and the Korean War, which show that those who had been exposed to severe combat were more likely to report distress in midlife and showed more resilience and resourcefulness in coping during later life than did those who had less exposure. Two very different interpretations have been offered for the coexistence of positive effects and severe trauma. The first approach views the perceived benefits of trauma as signifying healthy adjustment, that is, either a real strengthening of personality stemming from the experience (e.g., enhanced self-efficacy or acquisition of unique coping skills) or the adoption of a unique set of cognitions or “positive illusions,” which help a person cope with victimization (Taylor, 1989). Fontana and Rosenheck (1998) suggest that this paradoxical relationship stems from the fact that coping with or even surviving trauma strengthens beliefs in one’s abilities and

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bolsters self-esteem. Traumatic events also bring people face to face with their own mortality, which may help them to live their lives to the fullest (Frankl, 1962). The alternative explanation suggests that positive changes may not be positive at all. According to this perspective, the insistence that one has benefited from a traumatic experience reflects pathological adjustment to trauma. Thus, perceived benefits are seen as compensating defenses, which protect victims from gaining awareness of the psychological damage caused by their experiences. In this vein, it has been argued that because these perceived benefits are based on denial rather than on accurate reality testing, the adoption of such a “Pollyanna” type of response will inhibit recovery and contribute to chronicity of problems (Andersen, 1975). Similarly, Sledge et al. (1980) maintained that the sense of having been changed favorably by captivity is a defensive maneuver, aimed at denying a deeper sense of having been impaired by captivity. The findings also revealed a significant relationship between the extent of posttraumatic growth and severity of PTSD. This result suggests that posttraumatic growth is a function not only of the severity of the traumatic experience but also of the suffering that a person experiences because of it. This finding supports our third perspective, i.e., that salutary and pathological outcomes correlated positively with each other. Additionally, the curvilinear (inverted U) relationship between PTSD symptoms and growth, i.e., the finding that participants reporting intermediate levels of symptoms experienced the highest levels of growth, suggests that although distress and PTG can be experienced simultaneously, there may be an optimal level of distress that promotes growth. These findings are consistent with previous findings (Schnurr et al., 1993). At the same time, however, there may also be a point at which a person is overwhelmed by distress and growth is impeded (Butler et al., 2005). Even though our findings do not support the hypothesis that distress and growth are two opposite poles of the same dimension (the first perspective), some studies have found negative correlations between pathological and salutary outcomes (Zoellner & Maercker, 2006), which are consistent with the hypothesis. Because the study of positive effects is still in its early stages, it is worth considering some of the reasons for these distinctions. In this connection, it should be noted that salutary outcomes have been defined differently in different studies. In fact, in our own two studies, different measures were used (e.g., benefit-finding, posttraumatic growth), and although the definitions may overlap, they are not identical. For example, Sears, Stanton, and Danoff-Burg (2003) found that benefit-finding, positive-reappraisal coping, and posttraumatic growth among women with breast cancer were not necessarily concurrent and had different predictors. Overall, the present study contributes to our knowledge regarding the consequences of war captivity and has practical implications for the treatment of ex-POWs. The findings reveal high levels of resilience and posttraumatic growth, along with serious emotional impairment. They also indicate that ex-POWs are more likely than are non-POW combat soldiers to exhibit PTSD, positive changes, and posttraumatic growth. In practical terms, the study suggests some potentially useful

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ways to encourage posttraumatic growth among trauma survivors. Reframing the traumatic experience in terms of positive outcomes, while not ignoring the negative ones, may help ex-POWs experience themselves as survivors rather than victims.

Health Problems in Ex-POWs As noted above, the detrimental effects of war captivity are not limited to psychiatric and psychological problems but are also manifested in somatic health and healthrelated habits. Literature documenting the detrimental effects of war captivity on health covers malnutrition (Cohen & Cooper, 1954, hearing loss (Reid & Strong, 1988), hemorrhoid (Reid & Strong, 1988), peripheral neuropathy (Beebe, 1975), broken limbs (Reid & Strong, 1988), and head injury (Beebe, 1975). Some effects appear during captivity (Berg & Richlin, 1977a, 1977b), whereas others may appear after a long latency periods (e.g., Cohen & Cooper, 1954; Reid & Strong, 1988) following repatriation. In addition, premature aging, shown by the early appearance of such illnesses generally associated with old age (e.g., rheumatism, cardiac and vascular disease, and deterioration of mental functioning), has also been noted among former prisoners of war (Beebe, 1975; Nefzger, 1970; Spaulding, 1977). In the literature, two hypotheses regarding the association between war captivity and psycho-physiological illness are presented. The first hypothesis states that the physical conditions of imprisonment, such as torture and malnutrition, have direct medical implications. The second hypothesis proposes that the extreme stress of captivity creates psychological distress that, in turn, reduces the body’s resistance to physical illness (Engel, 1968). Although the literature on POWs is fairly consistent, close scrutiny of previous studies reveals considerable variability in the type of sample assessed, which is not always a representative sample; in the amount of time passed since repatriation; and in the duration and severity of the captivity experience itself. In addition, because nearly all prior studies have been of American POWs, questions about generalizability exist. We examined psycho-physiological complaints and illness among former Israeli POWs of the Yom Kippur War and contrasted them with a comparable group of controls. We assessed three types of outcomes: psycho-physiological complaints, diagnosable illnesses, and illness-related behavior. The same trend was evident in all three areas, with ex-POWs reporting more psycho-physiological impairment than did controls. This finding suggests that ex-POWs, as a group, are at high risk for physical symptomatology. It should be noted, however, that differences between the POWs and non-POW controls reached statistical significance primarily in the area of psycho-physiological complaints. By contrast, World War II POWs, for example, suffered more from infectious diseases, cardiopulmonary, hepatic, and ocular diseases, as well as premature mortality and proneness to accidents. Our findings are, therefore, only partially consistent with previous studies. We suggest a number of possible explanations for lack of consistency with previous findings. First, the consistency may be related to differences in the length

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and severity of the captivity experience. The POWs in Far East were exposed to prolonged captivity, torture, continuous interrogation, isolation, extreme environmental conditions, nutritional deprivation, and a lack of medical care. All these factors led to avitaminoses, fatigue, cardiac and neurological diseases, as well as psychiatric sequelae. Nefzger (1970) added the perspective that the existence of a high mortality rate among the ex-POWs from the Far East is a result of accidents, tuberculosis, and alcoholic cirrhosis, and Beebe (1975) noted the excessive psychiatric symptomatology among the repatriated POWs. The 1973 Syrian-Egyptian captivity was characterized initially by brutal interrogation, isolation, humiliation, hygienic and nutritional deprivation, and so forth, but it differed substantially from the Far East experience (Japanese, Vietnamese, Korean) in a number of ways. The period of imprisonment was shorter (8 months in Syria, 1 month in Egypt); the length and intensity of noxious stressors were relatively shorter; and medical, hygienic, and environmental conditions improved over time. Second, the relatively low rate of diagnosable illness may be related to the fact that most subjects had not yet reached the characteristic age of onset for many illnesses. Only 15% of our subjects were 44 years of age or older. Studies of U.S. ex-POWs usually involved older subjects. For example, in Beebe’s (1975) study, 40% of ex-POWs were 47 years old or older. It is thus possible that we may observe higher rates of illness as the men in our sample grow older. Third, at least some of the illnesses, which were noted in previous studies but not observed in this sample (e.g., cirrhosis of the liver), may be mediated by alcohol or drug abuse. Our finding that substance abuse was relatively uncommon in the Israeli POWs may explain why the prevalence of illnesses caused by abuse was low. Alcohol abuse has consistently been observed among traumatized American war veterans (Hendin & Pollinger-Hass, 1984); among Israeli war veterans, however, it is much less prevalent. This difference may be accounted for by cultural norms. Social drinking is common in the United States but, until recently, not in Israel; alcohol abuse was not a public health problem in Israel at that time. An extensive epidemiological study on mental disorders in Israel indicated that alcoholism was extremely rare among Israelis (Solomon, 1993), a fact that epidemiologists noted was strikingly different from other countries. Most of the psycho-physiological complaints reported uniquely by POWs in our study are recognized anxiety symptoms. This finding is consistent with findings in previous studies that the pathogenic effects of traumatic stress are not limited to PTSD. Moreover, our analyses indicated a high correlation between the number of psycho-physiological complaints and the number of PTSD symptoms reported. It is possible that the psychological distress associated with PTSD may have increased the POWs’ vulnerability to physical problems. But the more likely explanation is that the psycho-physiological complaints and the PTSD symptoms both result directly from the POW experience. As Hunter (1993) has noted, it is virtually impossible to differentiate between the psychological and physiological sequel of war captivity, because the stresses associated with physical torture or trauma have many concomitant psychological effects.

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In addition to finding that the ex-POWs as a group were vulnerable to increased symptomatology, we found that the extent of health impairment was associated with specific aspects of the captivity experience. Two subjective factors representing thoughts and feelings on being captured and while in prison made the principal contribution. We suggest these possible explanations: ex-POWs who tend to complain more, to report more symptoms, and to perceive life as difficult may also be more likely to remember themselves as having suffered in prison. On the other hand, it is also possible that those who suffered more while in prison may have sustained greater impairment to their psycho-physiological health. It is unfortunate that the health data in this study were collected without concomitant medical examinations. This leaves open the possibility that psychiatrically affected subjects may have over-reported their health problems. It is possible that ex-POWs, who regard themselves as sick or weak in light of their psychological problems, are more likely to interpret their physical sensations or discomforts as more problematic than are their emotionally uninjured counterparts. To overcome the possibility that self-reporting may have undermined the reliability of our findings, we also obtained medical records from the Rehabilitation Branch of the Ministry of Defense. We found high concordance between the two sources. This high concordance supports the use of self-report measures in the current sample and adds to our confidence in our findings. The absence of physiological confirmation, however, by no means obviates the negative health consequences of war captivity, and our findings clearly attest to captivity’s detrimental psycho-physiological effects. Pathology stemming from war trauma is not restricted to psychiatric symptoms per se, but may also be manifested in physiological and psycho-physiological symptoms.

Conclusion The studies presented above were conducted among Israeli ex-POWs from the 1973 Yom Kippur War. They were based on a prospective longitudinal design, with assessments both 18 and 30 years after the war. The findings showed war captivity to be implicated in a series of psychological and physical symptoms. While the doors of prison may have opened years ago, many ex-POWs are still faced on a daily basis with the pathogenic effects of captivity. Further, for many of these ex-POWs, the picture has become even bleaker with time, as their mental and physical state has deteriorated more rapidly than their fellow non-captured combatants. Although these studies shed light on the enduring toll of captivity, it was also made evident that resilience among those captured is much more prevalent than previously expected. These findings call for further research as to what differentiates between resilient and non-resilient casualties. Identifying these factors is clearly an ongoing challenge – one which should direct researchers, clinicians, and decisionmakers in the formulation of future treatments and preventive measures.

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Chapter 16

Trauma-Focused Public Mental-Health Interventions: A Paradigm Shift in Humanitarian Assistance and Aid Work Maggie Schauer and Elisabeth Schauer

Abstract At present, the mission in development and humanitarian aid, crisis assistance, and emergency interventions undertaken by governments, the United Nations, and non-governmental organizations is to support suffering populations medically, economically, socially, and politically. As humanitarians, we aim at alleviating the plight of war and danger, of natural disasters, and of poverty, as well as assisting human beings who experience human-rights violations and persecution. However, the basic postulate of “helping” has rarely been scientifically challenged when it comes to the interplay of aid and mental health. Much of currently extended humanitarian assistance is offered as “social,” “scholastic,” or “economic,” rather than as evidence-based psychological rehabilitation. Issues of the “medicalization” of political problems, “cultural and traditional wisdom” versus “empirically based scientific approaches,” and/or “non-interference” or even intentional policies of exploitation keep blocking the design of efficacious, mental-health interventions for severely affected survivors in resource-poor countries, who may, at times, make up nearly 50 percent of a given population. This chapter makes the case that restoring mental health with trauma-focused interventions is a key feature in and a necessity for effective development and humanitarian assistance. Healing from trauma reduces emotional pain, enables people to live productive lives, decreases the likelihood of aggression by survivors against themselves and others, stops the transgenerational transmission, and thus may help to interrupt the prevalent cycle of violence and under-development. Recent field-based studies have shown the efficacy of short-term, evidence-based, trauma treatment methods, which can be successfully built into large-scale service provision and applied by locally trained lay counselors. The authors’ and their organization

M. Schauer (B) Center for Psychiatry Reichenau, University of Konstanz, Konstanz, Germany e-mail: [email protected] The authors declare that they have no competing interests. Both authors have made substantial contributions to conception and design of the chapter, have been involved in drafting the manuscript, and have given final approval of the version to be published.


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vivo’s perspectives are based on research interventions in places such as Sri Lanka, Rwanda, Uganda, Democratic Republic of Congo, Ethiopia, Romania, Somalia, Afghanistan and by working with conflict-affected populations as diverse as asylum seekers, refugees, and internally displaced persons (IDPs) in Western countries, the Balkans, the African continent, as well as Central and Southern Asia. Most specifically, a set of empirically valid, trauma-focused guiding principles for public mental-health interventions after war, violence, and disaster are presented. This research is intended to bring awareness and action into a nearly neglected field of public health, human-rights implementation, humanitarian intervention, development aid, policy-making, and funding. The perspectives presented in this chapter substantiate that a programmatic innovation is needed, rendering a paradigm shift inevitable.

Background The Case for Trauma-Focused Guiding Principles Over the past two decades, the world has witnessed the eruption, reignition, or intensification of armed conflict. Wars, fought overwhelmingly within rather than between states, have had a devastating impact on civilians. These man-made disasters shatter the assumptions of humans to live in a predictable and safe environment. The consequences of grief and loss are overwhelming for the majority of individuals. Many victims suffer from an impaired capacity to translate their intense emotions and perceptions related to trauma into a communicable language. The psychological and physical toll that trauma commonly takes on victims’ minds very often creates transgenerational scars. Solutions to this kind of psychiatric emergency of pandemic proportions have become increasingly urgent in an atmosphere of terror and organized violence. The need to act in the face of massive human-rights and humanitarian-law violations is felt globally. However, due to the paucity of rigorous scientific investigation, there is little clarity about ways to address survivors’ psychological rehabilitation against large-scale violence. Presently, we know that the suffering felt by survivors of violence will last a few months for a countless majority of the severely traumatized; especially in those who have gone through cumulative traumatic events, suffering can last for the rest of their lives. A single horrific experience with painful aftershocks can sear the psyche for decades; even worse is the second and third traumatic event in sequel, acting like a “building block.” Our own implementation research, as well as work by other groups, has shown that efficacious, methodologically sound, culturally accepted trauma treatment approaches can be disseminated and can be applied successfully by locally trained persons. However, the reality of humanitarian intervention is a different one. The controversy around prioritizing “social,” “educational,” and “economic” support

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over public mental-health interventions is more divided than ever. Arguments are fought over topics, like “Western versus local approaches,” the possible “medicalization of a political problem” by diagnosing trauma-spectrum disorders, and “non-intervention” for the benefit of cultural integrity. Until recently, the global mental-health community has not come to formulate common mental-health guidelines for implementing best practices. And even though these guidelines have finally emerged, they lack a focus on trauma-related psychological rehabilitation. In fact, even the research discourse itself is hampered at times by the polarity of argumentation. The build-up of large-scale, population-based, service structures in resourcepoor, post-war settings is possible, as our work in Sri Lanka, Uganda, and Rwanda has demonstrated; in fact, it demonstrates the cross-cultural applicability and successful integration of clinical psychotherapeutic approaches within communitybased local service structures. Therefore, we suggest that evidence-based, public mental-health assistance is a humanitarian and ethical first-order imperative within comprehensive disaster and war-recovery programs. The issues of how intervention can be implemented successfully are presented in the following discussion traumafocused guiding principles for implementation research in the context of war and disaster: 1. Begin project planning with sound epidemiologic data collection and community-wide screening to understand particularities of local circumstances, like e.g. drug types abused, types of traumatic and other stressors and adversities before and during current crisis and to identify populations at risk. Include individuals’ experiences, sociodemographic indicators, trauma and loss exposure (also pre-disaster), and social stressors. Beyond current levels of traumatic stress-related symptoms (e.g., PTSD, depression, grief, suicidality), be aware of conflict-related and local adversity factors, such as forced migration, severe human suffering, poverty-related sexual exploitation, child labor, female genital mutilation, heightened family violence, and self-medication substance abuse. In planning disaster and war-relief efforts, population-based mental-health assessment and research procedures should be introduced as an integrated component of recovery efforts. 2. If numbers of persons in need are high, aim for a community-based, multi-tiered, public mental-health approach to service delivery (hierarchical, cascade-model structures). This means layered training for lower level experts (screening, psychosocial and psycho-educational activities, counseling, community linking, awareness raising, and referral) and higher level experts (psycho-diagnostics, psychological treatment/therapy, supervision, and training facilitation) within a referral system (also for other mental health disorders, such as schizophrenia and epilepsy), as well as engaging complementary psychosocial domains. 3. Include a trauma-focused treatment module that is focused on helping individuals and groups deal with traumatic stress-related symptoms (PTSD, depression, suicidality, substance abuse, bereavement), which is able to be applied by locally trained paraprofessionals.

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4. Ensure that training develops the capacities of local service providers and builds local support structures, so that people within the communities served ultimately can sustain an intervention program. For this, it seems beneficial to acknowledge trainees’ personal experiences and local knowledge, but at the same time, introduce scientific global mental health standards. This includes the partnering of local expert practitioners from academia, mental health, medicine, education, counseling, and law, collaborating with international expert practitioners of the same ranks, thereby ensuring that scientific-based knowledge and skills are available to the trainees and accessible to the beneficiaries. 5. Base the implementation structure on “natural communities,” such as the school system for children or self-help associations.1 These “natural communities” are often also a vehicle to support victims’ social environments, such as peers, parents, teachers, and partners who might have been affected by the violent events themselves. 6. Design appropriate “mental-health and psychoeducational” resource, screening, and training packages for the various tiers, as well as a public awarenessraising strategies, so as to psycho-educate the population, especially caretakers, officials, and decision-makers on mental-health issues. Such education should increase the understanding of the long-term effects of trauma exposure and loss, introduce skills for coping at various levels, and give information on support and therapeutic/rehabilitative activities. 7. Base counseling and therapy on a human/child/woman’s rights-based, testimonial approach, which acknowledges past injustice and favors social change toward the implementation of those rights. 8. Ensure a rigid form of evidence-based project evaluation, which is best in the form of randomized, controlled trials (RCT) with variation protocols and longer term follow-up of beneficiaries. 9. And finally, challenge the nihilism of global health planners regarding the role of mental health, especially as it relates to a global commitment to the provision of adequate funds for mental-health implementation research.

Why Do We Need Evidence-Based, Public Mental-Health Interventions? Impact of Traumatization on the Mind of the Individual and the Community During life threat, the cascade of “Freeze-Flight-Fight-Fright-Flag-Faint” is a coherent sequence of fear responses that escalate as a function of defense possibilities and 1 E.g. the “Concerned Parents Association”, a community-based organization, run by siblings, returnees, parents and family members of formerly rebel-abducted children in Northern Uganda or “Aruthal” a teacher counselor organization, which has formed in the North-Eastern war- and tsunami affected Sri Lankan provinces.

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proximity to danger (Schauer & Elbert, 2008). These reaction patterns provide optimal adaptation for particular stages of the imminence of danger. The actual sequence of trauma-related response dispositions that are acted out in an extremely dangerous situation depends on the appraisal of the threat by the victim, in relation to his/her own power to act (e.g., age, gender), as well as the perceived characteristics of the threat or perpetrator (Schauer & Elbert, in press). Repeated experience of traumatic stress forms a fear network that can become pathologically detached from contextual cues, such as time and location of the danger. A characteristic post-experience feature of traumatic stress is the persistent involuntary reexperiencing of the horrifying events of the past, psychophysiological hyperarousal, as well as the avoidance of thinking and/or talking about what has happened. This constellation of symptoms in severely traumatized individuals is called posttraumatic stress disorder (PTSD) (APA, 2000). The individual cascade of defense mechanisms that a survivor has gone through during the traumatic event can replay itself whenever the fear network, which has evolved peri-traumatically, is activated again by internal or external triggers. Whereby some survivors have experienced mainly peri-traumatic sympathetic activation (fighting, fleeing, feeling angry, and acting out), others went through the whole defense cascade, with parasympathetic dominance as an end point (e.g., tonic immobility, no more voluntary movement, sensory deafferentation, loss of muscle tonus, fainting) (Schauer & Elbert, in press). Intrusions can be understood as repetitive displays of parts or fragments of the traumatic event, which elicit a corresponding combination of hyperarousal and dissociation, depending on the dominant physiological response that was present during life threat. We see PTSD patients live through immense suffering due to involuntary sensory, visual, or other recall of the most horrific moments of their lives, whereby their autobiographic memory is often fragmented and their ability to willingly focus their mind and to concentrate is greatly reduced. Much of the daily and nightly energy is spent avoiding reminders, because remembering the traumatic experience brings up painful emotions, panic-like physical arousal, and distress. The severity of trauma symptoms and the distress of talking about the event are tightly linked to each other. We have observed that, with mounting severity of symptoms, people’s distress increases when asked to disclose their traumatic scenes. Paradoxically, the urge to talk about the experiences also increases. This condition is known as “speechless terror.” Survivors are seemingly unable to fully verbalize their experience or give consistent testimonies. This phenomenon is caused by a form of memory pathology, which has its origin in moments of great fear or helplessness (Schauer, Neuner, & Elbert, 2005). Research has begun to show that traumatic events are not properly coded by the brain’s episodic memory system, due to their overwhelming, terrorizing quality. In fact, it is the hallmark of a traumatic memory in its original state that it presents itself in a dissociated form from autobiographic memory and semantic access (Kolassa & Elbert, 2007; Kolassa et al., 2007). Consequently, survivors will be limited in their capacity to verbally express in detail and chronology. The person loses access to his/her own autobiographical story and is left with sensory fragments

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on a non-verbal level that has few linguistic components. This failure to process information linked to a context in time and place – which is essential for the proper categorization and integration with other experiences – is commonly seen in survivors of multiple traumas, such as after a disaster, organized violence, or ongoing abuse. Brain changes occur in the form of structural and functional impairments of core areas of memory (Elbert et al., 2005; Elbert, Rockstroh, Kolassa, Schauer, & Neuner, 2006; Kolassa & Elbert, 2007; Schauer & Elbert, in press). In contrast, a healthy memory is reliable, social, and adaptable to the needs of both the narrator and the listener. It can also be expanded, contracted, and voluntarily recalled according to social demands. The memory of individuals suffering from PTSD, however, intrudes as terrifying perceptions and in the form of somatic reexperiencing. Not being able to give a coherent account of the trauma to others or even to oneself, without subjectively feeling as if being traumatized all over again, makes it difficult for victims to articulate their needs. Past victimization shatters basic human hope and assumptions like personal safety, positive identity, a sense of effectiveness, positive relationships with others, and a useable, meaningful comprehension of reality, of community, and the purpose of one’s life (Herman, 1992). The following account of an ex-prisoner and survivor of the Romanian communist regime which was documented by our organization “vivo” (www.vivo.org), gives M.G.’s (male, age 83) testimony reflecting deeply shattered self-esteem: The Nazis were after me, telling me that I am worthless. They tortured me and they tried to massacre all of us. Because I survived this, the communists thought that I must have collaborated. So they incarcerated me, beat me, insulted me, and I was subject to endless, degrading interrogations. I know that I am a victim, that we all were victims. But still, there is this devastating seed of doubt deep down. There is this voice I cannot fight, and it tells me that the offenders acted right in punishing and eliminating our kind. Something must be wrong with us. Somehow I must be bad, evil, worthless. . .if I weren’t, why would I get persecuted and treated like this? And afterwards, I was broken, ill in mind and body, not useful for the society. . .like spoilage. . .There is no human to listen to this. . .who would believe my account, if I can’t trust myself anymore? Even I turned away from myself. . .

Without adequate support from society and with no one to talk to, survivors, especially those most severely affected, are rarely able to break the “conspiracy of silence” in society. Denial, or the will not to believe, is a common reaction to accounts of human cruelty and emotional suffering, and it certainly adds to the explanation of why political leaders, the global community, humanitarian-aid interventions, donors, and even psychiatrists have so far failed to support the conducting of empirical, in-depth research in the field of psychotraumatology as it relates to adequate interventions for people living in places of conflict or post-conflict. This is truer for children and young people in war: Besides parental denial, we have come across another form of denial of trauma. This takes place within United Nations (U.N.) agencies and non-governmental organizations. It can have a disguised form or be more outright. We believe that this denial is a mechanism that protects international aid workers, politicians, and the international community at large. When the international community is unable and helpless preventing atrocities and massacres in war situations, it becomes important to reduce the feelings of helplessness, impotency, and guilt that such situations create. Societies lack the capacity to deal with

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the ramifications of the traumatic events they produce. Collective guilt may be intensified among politicians and the world community at large if we all were to acknowledge the pain and suffering we are unable to protect children from (Dyregrov, Gupta, Gjestad, & Raundalen, 2002, p. 136).

Not wanting to be disturbed by the raw emotions of psychologically injured people, combined with the inability of victims to fully articulate what they feel and need, can have a consummate silencing effect. The outside world’s understanding is that physical wounds or bodily disability can linger, but anxiety and fear that accompany life-threatening events should disappear once the danger passes. Mental-health effects of mass violence are essentially invisible, and victims are advised to “just get over it, go on with life, and best to bury the past.” Ironically, when traumatic memories remain unprocessed, they start leading a life of their own as disturbing symptoms, and we observe that victims, perpetrators, witnesses, and their communities become dysfunctional in the course of time. A psychiatrist retells an account of Hiroshima survivors: There is a general sense of resignation to fate. People have developed dependence on help from outside sources. . .this dependence hampers all rehabilitation and development efforts. People no longer feel motivated to work, or better their lots. . .Even within refugee camps, people did not show interest in self-help programs like vocational training and incomegenerating projects. Outside camps, people appear to have resigned themselves to just surviving. . .They seemed to live a half life, as though they were ‘walking corpses’ or the living dead (Somasundaram, 2007).

Due to immense silent suffering, avoidance, and the stigma associated with mental illness, traumatized people typically avoid seeking help. However, there is one reason that we have observed as to why survivors are ready to respond to offers of mental-health services despite avoidance: if they are not just ensured of their own recovery, but are given an opportunity to document their life-story including war, disaster, or any other human-rights violation, which has happened to them for the benefit of the wider community. Mental-health professionals can provide advocacy for survivors by serving as a voice beyond “speechless terror.” Moreover, mental-health professionals can become advocates of human rights beyond cultural values and norms. In addition, they carry the important task of transmitting injustice to the world outside, in order to facilitate public acknowledgement of people’s suffering. This level of advocacy, along with psychological education, can help victims to overcome the self-devaluation that is a common result of victimization. Narrations, eyewitness testimonies, shared remembering, and rituals (e.g., memorials, documentation archives, museums), which bring suffering to light, are important elements. Truth, retelling, and remembrance are recognized as prerequisites for justice and healing. As renowned peace and reconciliation researcher Ervin Staub says, healing deep-seated antagonism or changing ideologies of antagonism through various types of interactive conflict-resolution procedures can contribute to reconciliation. Members of each group can describe the pain and suffering of their group at the hands of the other, they can grieve for themselves, and they can begin to grieve for the other as well. Members of each group can acknowledge the role of their own group in harming the other. Mutual acknowledgement of responsibi-

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lity can lead to mutual forgiving. Healing from trauma, which reduces pain, enables people to live constructive lives and reduces the likelihood of violence by victims and thus a continuing cycle of violence (Staub, 1998). Therefore, in our guiding principles, we consider it important to ensure that psychological rehabilitation should be based on proper assessment, in order to identify those individuals who are in need of assistance. Further, it is important to include a narrative component that will help modify abnormal neural architecture in the form of language production around one’s own autobiographical memory and, most importantly, to provide psychological treatment based on a human rights-based testimony approach. Impact of Traumatization on the Body Traumatized populations show significantly elevated levels of morbidity and mortality (Boscarino, 2004; Kolassa et al., 2007; Neuner, Onyut et al., 2008; Ouimette, Goodwin, & Brown, 2006; Schnurr & Jankowski, 1999). As outlined above, evidence has mounted in recent years indicating that severe anxiety states – stress at the traumatic level – lead to a functional and structural alteration of the brain. The co-occurrence of several pathogenic processes includes a permanent alteration of bodily processes, due to a state of persistent readiness for an alarm response. Psychobiological abnormalities in PTSD are observed as psychophysiological, neurohormonal, neuroanatomical, and immunological effects (Boscarino, 2004; Kolassa et al., 2007; Neuner, Onyut et al., 2008; Ouimette et al., 2006; Schnurr & Jankowski, 1999). Trauma survivors frequently report high rates of physical illness, involving a variety of physiological systems (Boscarino & Chang, 1999; Kolassa & Elbert, 2007; Schnurr & Jankowski, 1999; Sommershof et al., 2009; Szyf, McGowan, & Meaney, 2008). There seems to be not only a positive correlation between developed psychiatric illnesses and prior trauma but also a significant relationship between the amount of traumatic exposure and poor health outcomes. An emerging body of literature is successfully exploring the relationship between trauma-spectrum disorders, foremost PTSD and increased somatic complaints, as well as decreased immune functioning; cardiovascular, pulmonary, neurological, and gastrointestinal complaints; various types of somatic pain; susceptibility to infectious diseases; vulnerability to hypertension and atherosclerotic heart disease; abnormalities in thyroid and other hormone function; increased risk of cancer and susceptibility to infections and immunologic disorders; and problems with pain perception, pain tolerance, and chronic pain (Boscarino, 2004; Davidson et al., 2003; Felitti et al., 1998; Friedman & Schnurr, 1995; Kolassa et al., 2007; Neuner, Onyut et al., 2008; Ouimette et al., 2006; Schnurr & Jankowski, 1999). It is not surprising, therefore, that trauma-spectrum disorders are directly related to excessive rates of health-care service utilization, where such service is available. Studies document high medical utilization rates for both male and female survivors of violence and disasters (Calhoun, Bosworth, Grambow, Dudley, & Beckham, 2002; Deykin et al., 2001; Schnurr, Friedman, Sengupta, Jankowski, & Holmes,

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2000), but interestingly enough, not psychological service utilization. Clinical observation suggests that the symptoms of PTSD or associated psychosocial problems can interfere with offered healthcare, causing difficulty in provider–patient communication; reducing patients’ active collaboration in evaluation and treatment; increasing the likelihood of somatization (i.e., psychological symptoms that are expressed somatically); and reducing patients’ adherence to medical regimes (Boscarino, 1997; Calhoun et al., 2002; Eisenman et al., 2006). Furthermore, it shows that survivors with PTSD have an increased number of disability days, longer sick leaves, and more frequent and longer-lasting hospitalization periods than control groups, suggesting that experienced problems might affect occupational, scholastic, and social functioning (Ford et al., 2001; Marx et al., 2008; Schnurr & Jankowski, 1999; Walker et al., 2003). To correctly understand, diagnose, and treat trauma-spectrum disorders that are masked as bodily complaints might, in fact, be a determining factor for the survival of populations in circumstances of complex emergencies and humanitarian crisis in resource-poor countries. So far, a significant amount of resources for recovery tends to be channeled into medical-service provision, but almost none of it funds mental-health care. As some researchers have noted: Too often, humanitarian organizations neglect the psychosocial needs of war-affected communities because of limited resources or because they regards such programs as beyond their purview. Our study suggests that psychological trauma is a key health indicator in populations exposed to high levels of personal violence in protracted armed conflicts (Vinck, Pham, Stover, & Weinstein, 2007, p. 553).

A weakened immune status, due to traumatic stress under circumstances of exposure to dysfunctional behaviors and trauma-related ill-health, such as impaired occupational functioning, concentration problems, substance abuse, and otherwisecaused poverty, as well as the exposure to a wide range of infectious diseases, such as TB, HIV/AIDS, malaria, in the context of absent or inadequate health services, might partly explain current high child mortality, epidemic rates of disease transmission, as well as low life-expectancy rates in (post-)conflict settings. A psychometrically sound and representative mental-health, population-based screening at the start of intervention planning after war and disaster can ensure that provided services will meet actual needs. Scarce health resources can then be maximized, due to the synergetic effects of physical and psychological health rehabilitation efforts. Also, community staff training can be coordinated in a collaborated fashion that ensures the build-up of a multi-tiered referral and treatment system, as suggested in our guidelines.

Transgenerational Impact of Trauma at the Individual and Family Level Psychological exposure and suffering from trauma can cripple individuals and families and wreck the social fabric for decades. Affected parents can leave a psychophysiological imprint not just in their children’s, but in their grandchildren’s

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generation, such as non-adaptive changes in the offspring’s stress responsive system (Yehuda, Halligan, & Bierer, 2001). Concern about consequences for offspring, whose mothers were stressed during pregnancy, derives from evidence gained in experimental biology, as intrauterine stress shows to affect neurodevelopment in animals, which are thought relevant to models of cognition, aggression, anxiety, and depression in humans (Seckl & Holmes, 2007). Chronic maternal stress during pregnancy, for example, interrupts healthy regulation of hormonal activity and increases free-circulating CRH (corticotrophin-releasing hormone) (Phillips, 2007; Sandman, Wadhwa, Chicz-DeMet, Porto, & Garite, 1999; Sandman et al., 1999; Weinstock, 1997, 2005). We only now are beginning to realize the consequences of the “life in the womb” for the offspring. As Nathanielsz puts it, that everyone needs to understand that improving the condition of the fetus will have personal, social, and economic benefits and that the time has come to realize that, in a sense, it is not just women who are pregnant, but it is the family and the whole of society (Nathanielsz, 1999). Changed neurotransmitter activity can promote a range of emotional and cognitive impairments. While the genome, the DNA sequence, remains unaffected by acute stress responses, epigenetic alterations may be manipulated by a variety of conditions, including stress hormones (Meaney, Szyf, & Seckl, 2007; Yehuda, Bell, Bierer, & Schmeidler, 2008). With regard to the nervous system, epigenetic alterations play a role in a diverse set of processes and have been implicated in a variety of disorders, including vulnerability to anxiety- and trauma-related illness. If a pregnant mother is affected by severe and chronic stress, epigenetic modifications in the child may act as a molecular or cellular memory that prepare the offspring for one or several generations to survive in a hostile environment, making generations more vulnerable for mental illnesses, including suicide (Szyf et al., 2008). The quality of how a mother is able to attach to and care for her child alters the expression of genes in the child that regulate behavioral and endocrine responses to stress, as well as hippocampal synaptic development. These effects form the basis for the development of stable, individual differences in stress reactivity and certain forms of cognition. Exposure to significant stressors during sensitive developmental periods causes the brain to develop along a stress-responsive pathway. The brain and mind become organized in a way to facilitate survival in a world of deprivation and danger, enhancing an individual’s capacity to rapidly and dramatically shift into an intense, angry, aggressive, fearful, or avoiding state when threatened. This pathway is costly and non-adaptive in peaceful environments. Babies born with a deformed stress-regulating system (HPA-a) experience higher and faster arousal peaks, longer intervals of crying and irritability, and impaired affect regulation (Sondergaard et al., 2003). These behaviors are a challenge for any new parent, but pose a major challenge for a parent who her/himself suffers from a disorder of the trauma spectrum. Symptoms of hyperarousal, such as irritability, might make it challenging to regulate babies and their own affect adequately, in turn, making “high expressed emotional” behavior and punitive or aggressive disciplinary parenting styles more likely. A survivor’s intense and bizarre way of self-expression in the form of irritability, jumpiness, or hypervigilance may be so extreme as to appear like

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paranoia and can engender fear, confusion, and a sense of powerlessness in family members. Furthermore, parental sensitivity in pre-empting a child’s need might be impaired. Symptoms of emotional numbing might hinder emotional closeness and intimacy and cause increased parent-child aggression (Lauterbach et al., 2007). A father or mother suffering from traumatization can behave like a distant, fearful stranger, who cannot tolerate closeness or emotional expression, even within the family unit. Consequently, children are forced to operate within a domestic context, in which intimacy as well as affect regulation is severely impaired (Almqvist & Broberg, 2003; Clarke et al., 2007). Studies on fathers, who have experienced numerous war events, show that feelings of detachment and numbing can carry over to their children, leading to behavioral problems in the child. Also, parents report less confidence and joy in their role as caregivers and the phenomenon of “negative reciprocity” (e.g., a child’s negative response to a parent’s demand increases the likelihood of the parent’s coercion, which in turn might make the child act out more aggressively and so on) starts to develop. A child with reduced abilities for affect regulation, in combination with a traumatized primary caregiver, is a very great potential risk constellation for the perpetuation of the cycle of violence with all its negative consequences. There are a multitude of other psychological consequences of experiencing trauma. Up to 80 percent of all men and women survivors of abuse, violence, and terror, who develop PTSD, suffer from a minimum of one other co-existing disturbance, mainly affective and substance-abuse disorders, like major depression (48 percent), dysthymia (22 percent), general anxiety disorder (16 percent), phobias (30 percent), social phobia (28 percent), panic disorder (7–13 percent), agoraphobia (16–22 percent), alcohol abuse, and dependency disorder (28–52 percent) (Kessler, Sonnega, Hughes, & Nelson, 1995). Not only fathers and substance-abusing mothers are likely to be more punitive, authoritarian, and aggressive toward their children (Miller, Smyth, & Mudar, 1999) but also their parenting practices more severe and threatening (Bauman & Dougherty, 1983). Children, whose parents abuse substances, may be at twice the risk of experiencing physical or sexual abuse, compared to children with nonsubstance-abusing parents. An extensive body of research further found an association between depression and decreased parenting efficacy, including poorer quality of mother–infant attachment, higher maternal hostility, coercion, and less positive parent–child interactions. Internalized affects resulting from violent and neglectful caretaker models deform the psyche and can be manifested in the next generation. Literature shows that men with war and combat experiences are more likely to exhibit violent behavior (Begic & Jokic-Begic, 2001; Catani, Jacob, Schauer, Mahendran, & Neuner, 2008; Glenn et al., 2002). Violent acts reported include property destruction, threats with and without a weapon, and physical fighting (McFall, Fontana, Raskind, & Rosenheck, 1999). During pregnancy, violent behavior and the battering of women seem to increase and tend to continue into the post-partum period (Mezey & Bewley, 1997). In families where men show violent behavior against women, children are maltreated as well (Edleson, 1999; Levendosky & Graham-Bermann, 2001). In fact, domestic violence against the child’s mother during the first 6 months of life elevates

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the risk of physical child-abuse three times and doubles the risk of emotional abuse and neglect (McGuigan & Pratt, 2001). Trauma caused by war and disaster can set an intergenerational cycle of dysfunction and violence in motion at the level of the family (Bowlby, 2004; Catani, Schauer, & Neuner, 2008; Grossmann, Grossmann, & Waters, 2005; Qouta, Punamaki, & Sarraj, 2003; Smith, Perrin, Yule, & Rabe-Hesketh, 2001; Solomon, 1988; Zuravin, McMillen, DePanfilis, & Risley-Curtiss, 1996). Our latest studies with conflict-affected populations of North-Eastern Sri Lanka and Afghanistan could show a clear relationship between on-going war, disaster, and heightened domestic violence (Catani et al., 2008; Catani, Schauer et al., 2009; Catani et al., 2008). Beyond coincidence, researchers clearly note higher rates of psychiatric disorders and intellectual impairment in children of survivors, compared with nontraumatized comparison groups (Ben Arzi, Solomon, & Dekel, 2000; Bramsen, van der Ploeg, & Twisk, 2002; Daud, af-Klinteberg, & Rydelius, 2008; Dekel & Goldblatt, 2008; Dekel & Solomon, 2006; Dirkzwager, Bramsen, Ader, & van der Ploeg, 2005; Franciskovic et al., 2007; Solomon et al., 1992; Weinstock, 1997). As agents of public mental health, we need to acknowledge these factors that contribute to such large-scale psychological family dysfunction and find entry points to intervene via sound assessment and trauma-focused work. Impact of Psychological Dysfunction at the Collective Level Posttraumatic stress reactions are not transitory entities, but rather persist over time. Even when a decline in symptoms is observed, it does not equate to complete recovery. In addition, the age of the individual at the time of exposure does not seem to mediate symptom expression over time for a majority of suffering survivors. Numerous studies suggest that regardless of the passage of time, many survivors, including children and young adults, continue to suffer from distressing symptoms, with PTSD being most persistent throughout life (Almqvist & Brandell-Forsberg, 1997; Bichescu et al., 2005; Bremner & Narayan, 1998; Dyregrov, Gjestad, & Raundalen, 2002; Elbedour, ten Bensel, & Bastien, 1993; Goenjian et al., 1999; Hubbard, Realmuto, Northwood, & Masten, 1995; Kinzie, Sack, Angell, Clarke, & Ben, 1989; Kinzie, Sack, Angell, Manson, & Rath, 1986; Marshall, Schell, Elliott, Berthold, & Chun, 2005; McFarlane, Policansky, & Irwin, 1987; Morgan, Scourfield, Williams, Jasper, & Lewis, 2003; Perry & Pollard, 1998; Ruf, Neuner, Gotthardt, Schauer, & Elbert, 2005; Sack, Him, & Dickason, 1999; Schaal & Elbert, 2006; Schauer, Catani, Mahendran, Schauer, & Elbert, 2005; Smith, 2005; Smith, Perrin, Yule, Hacam, & Stuvland, 2002; Thabet & Vostanis, 2000; Yule et al., 2000). Children and adults, who remain in the area of (post-)conflict or are forced to migrate, have survived an unusual number, types, and severity of traumatic experiences. Additionally, other social stressors and adversities tend to be affecting these populations, such as family separation and the necessity of child labor. In terms of magnitude, we know that a significant percentage of survivors never recover from PTSD, especially after exposure to extreme, multiple, or deliberately inflicted psychological trauma. Authors report that systematic torture or child soldiering, for

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example, can result in over 90 percent of survivors developing PTSD (Basoglu et al., 1994; Derluyn, Broekaert, Schuyten, & De Temmerman, 2004; Moisander & Edston, 2003; Mollica, McInnes, Poole, & Tor, 1998; Neuner, Kurreck et al., in press; Pfeiffer et al., submitted). Traumatic stress has a “building-block” effect and our studies in crisis regions show that surviving an increasing number of different traumatic-event types directly increases the likelihood for mental-health disorders of the trauma spectrum in a linear fashion (Catani et al., 2005; Karunakara et al., 2004; Kolassa & Elbert, 2007; Kolassa et al., in press; Onyut et al., 2009; Schaal & Elbert, 2006; Schauer et al., 2003). As outlined above, repeated life threat leads to the build-up of a fear network, which contains highly arousing, emotional-sensory elements of the survived horror, but lacking relevant contextual information. Exposure to continued experiences enlarges this network and develops psychological disorders. At a high level of exposure to repeated traumatic life threat during war and/or disaster, protective factors, such as social support or personal resilience, are wiped out by the “building-block effect.” The consequences of emotional, social, scholastic, and occupational malfunctioning go unaccounted in children, adolescents, and adult trauma survivors and can greatly aggravate the socioeconomic after effects of war. Victims’ self-perceived condition of helplessness can dissuade them from active participation in post-disaster rebuilding: as much as 25–50 percent of people in a given society can be lost as active community agents for change and development (Catani et al., 2008; Elbert et al., 2009; Karunakara et al., 2004; Mollica et al., 1998; Neuner, Schauer, Catani, Ruf, & Elbert, 2006; Odenwald, Hinkel, & Schauer, 2007; Onyut et al., 2009; Pfeiffer et al., submitted; Schaal & Elbert, 2006; Scholte et al., 2004). Social dysfunction is a consistent consequence in victims of organized violence and their environments. A critical mass of people in crisis regions of this world today is impaired in work, unable to take care of underaged or needy family members, or incapacitated in the ability to participate in socially productive activities or scholastic achievement. Often the ones who would constitute the hopeful leaders of a future new society, with the best education and political insight, are most incapacitated. It is certainly early in research investigations to draw firm conclusions; however, new findings are increasingly pointing to the fact that individuals’ psychological disorders might be an important factor in hindering post-conflict reconciliation and peace building. Studies that have examined the prevalence of psychological effects after conflict suggest that traumatic exposure and resultant symptoms of PTSD and depression can influence social functioning and how individuals perceive mechanisms that are aimed at promoting justice and reconciliation. In 2004, Pham and colleagues (Pham, Weinstein, & Longman, 2004) examined this association among 2074 adult survivors of the Rwandan genocide. The investigators demonstrated that traumatic exposure and PTSD symptoms were associated with attitudes toward reconciliation. Bayer’s group (Bayer, Klasen, & Adam, 2007) undertook a similar research study, in that they tried to understand the association of trauma and PTSD symptoms with openness to reconciliation and feelings of revenge among former Ugandan and Congolese child soldiers. Their study found that those among the group of former child soldiers (girls and boys alike), who showed clinically

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relevant symptoms of PTSD, had significantly less openness to reconciliation and significantly more feelings of revenge than those with fewer symptoms. Likewise, children with PTSD symptoms might regard acts of retaliation as an appropriate way to recover personal integrity and to overcome their traumatic experience. Based on the vulnerability of surviving a war or growing up in a post-conflict setting, children might even become more vulnerable to forces that instigate violence (Somasundaram, 2002; Uppard, 2003). Vinck and colleagues’ (Vinck et al., 2007) study found a very similar association between survivors’ symptoms of PTSD and depression and their attitude toward peace. Those who met PTSD-symptom criteria were more likely to favor violent means to end the conflict, and those with depression symptoms were less likely to identify nonviolence means to achieve peace. In our own study with formerly abducted children in Northern Uganda (Pfeiffer et al., submitted) we confirmed that symptoms of PTSD and clinical depression were interrelated with elevated levels of aggression (verbal, physical, anger, and hostility). Aggression was associated with having a history of abduction, an increased level of perceived stigmatization, heightened symptoms of psychological disorders and having survived a higher number of traumatic experiences. Interestingly, having been forced to kill and the duration of abduction did not predict heightened aggression, suggesting that it is the overall score of symptoms of psychological disorders, resulting from traumatic experiences during abduction that drives levels of aggression and stigmatization in this group, as well as identification with the rebel group. In post-war survivor populations, psychological symptoms associated with the trauma may be closely related to a desire for retribution, rather than restorative ways to deal with past violence. Also, Bayer et al. (2007) found that individuals with severe symptoms of posttraumatic stress are more prone to experience feelings of revenge, are less open to reconciliation, and also that they favor more violent forms of conflict-resolution strategies, e.g., militaristic interventions and the death penalty, when compared to individuals without PTSD. Given the large prevalence rates of trauma-spectrum disorders in postconflict/disaster populations and knowing that the consequences of trauma on individuals’ minds, bodies, and social fabric do not always remedy on their own, our guidelines suggest that the inclusion of trauma-focused treatment modules is a key component of any public health intervention after war and disaster. Trauma therapies might be able to refurbish the experiences of the past, in such a way that they are no longer preventing reconciliation efforts (Ertl, Schauer, Elbert, & Neuner, 2008). Most importantly, trauma-focused interventions are starting to show effects on reversing the established “building-block effect” (Schauer et al., 2006). We furthermore postulate that trauma-focused treatment, beyond remission of symptoms of mental disorders, can decrease feelings of hatred, anger, and revenge. One recent study from Rwanda (Staub, Pearlman, Gubin, & Hagengimana, 2005) was able to add evidence to this assumption. Their study noted that talking about trauma increased the likelihood for more openness to reconciliation in the followup assessments. Currently implemented, non-specific “psychosocial” interventions, which are almost always “social” rather than “psychological” in nature, have, as

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of yet, not shown evidence in reinstating functioning and healing psychiatric disorders for a significant part of society, who have been directly or transgenerationally affected by traumatic stress.

What Can We Do, or Has It Been Empirically Shown That We Can Intervene Based on Evidence? Narrative Exposure Therapy (NET) for the Psychological Rehabilitation of Individuals and the Collective One approach that aims to acknowledge all of the above factors is called “Narrative Exposure Therapy” (NET) (Schauer et al., 2005). NET realizes that psychotraumatization, due to man-made, purposeful, mass violence, is a condition that needs remedy beyond psychological measures. It presents a joint approach of treatment and documentation of human-rights violations. NET achieves release from anxiety, aims to overcome the aforementioned inner imprisonment in states of helplessness and speechlessness, and helps to regain the all-deciding ability to plan and live one’s life, based on healthy social, emotional functioning, and personal choice. The aim of NET from its outset was to conceptualize a form of trauma treatment, which was based on universal, modern, scientific standards of neuroscience and psychology, which can be efficacious in different countries and cultures, which can be taught to local personnel or even local lay people, and which can be administered within a short duration. In addition, the principle behind NET is to also account for human-rights abuses, while having a sociopolitical as well as a therapeutic dimension for treating traumatic stress-related conditions. With the intention of ameliorating psychological trauma, NET also intends to contribute directly to the fight against torture, persecution, and the vicious cycle of victimization and perpetration. While standard practices of psychotherapy, irrespective of its practical issues of applicability, are mostly concerned with the recovery of the individual, survivors of organized violence often decline it, especially those originating from more collectively organized societies. This is partially due to the fact that clients do not want to separate their personal suffering and recovery from the suffering and assistance needed for their people. NET counteracts this concern, because during the course of treatment, it documents organized or state-sponsored violence and war, sociopolitical and economic dimensions that drive a conflict, individual human-rights abuses, crimes against humanity, genocide, victimization, witnessing, as well as perpetration of violence. Our working group has developed Narrative Exposure Therapy as a standardized, short-term approach in recognition of neuroscientific and psychological findings, which assume an inadequate inter-connection of the episodic memory with the implicit fear network. NET is based on a potent theoretical model – its elements have undergone several scientific evaluations and arise from long-standing research collaborations (for an overview please see Elbert et al., 2005; Elbert & Rockstroh,

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2004; Elbert & Schauer, 2002; Foa, 2000; Foa, Keane, & Friedman, 2008; Junghofer et al., 2003; Kolassa & Elbert, 2007; Lang, Bradley, & Cuthbert, 1998; McNally, 1998; NICE, 2005). In its core, NET and the related KIDNET (for traumatized children and adolescents) (Neuner, Catani et al., 2008) are aimed at memory reconstruction, based on effective principles of cognitive–behavioral exposure therapy (Foa & Rothbaum, 1998) and are adapted to meet the needs of multiple and complex, traumatized child and adult survivors by integrating the detailed, narrative documentation of life events, known from Testimony Therapy (Cienfuegos & Monelli, 1983). NET also offers a reliable, profoundly empathic, and transparent therapeutic relationship. In comparison to classic exposure therapy, however, NET does not examine any single traumatic experience or other important life event without taking the entire biographical context of the person into account. Each personal experience is purposefully anchored at its correct “time” and “place” in the individual’s life path. Instead of asking clients to define a single event as a target in therapy, which for survivors of multiple and/or repeated traumatization is almost impossible to do, they are encouraged to construct a narration about their whole life from birth up to the present situation, while focusing on the detailed report of the traumatic experiences. In NET, the client–therapist interaction is consolidated by principles of personcentered therapy (Rogers, 1980), whereby empathic understanding, active listening, congruency, genuineness, and unconditional positive regard are key attitudes of the therapist. Surpassing person-centered therapy, however, the narration is driven forward in a supportive but directly guiding attitude of the therapist, in order to counter avoidance, which is a specific and inherent part of PTSD symptomatology. A view of the “whole” emerges in the process of NET, including realization of the client’s life experiences, patterns of inter-relationships, and corresponding links. The personal biography is acknowledged and the formation of the individual’s identity is (re-)discovered by the client. Step-by-step, the most important moments of the survivor’s life are chronicled by the therapist and the document is handed over in the final session, after a ritual signing process by all witnesses (therapist, translator) and the survivor himself/herself. The assumptions on effectiveness of this therapeutic approach are based on theories of habituation, as well as cognitive theories of autobiographical, language-based memory recovery, the assessment and restructuring of meaning, and the documentation of a full testimony, which is characterized by a deep humanitarian commitment (Brewin, 2001; Conway & Pleydell-Pearce, 2000; Ehlers & Clark, 2000; Foa, 2000; Lang, 1994; Pennebaker & Seagal, 1999; Resick, Nishith, Weaver, Astin, & Feuer, 2002; Staub, 2004). In summary, the following are considered key therapeutic elements of Narrative Exposure Therapy: • Active chronological reconstruction of the autobiographical memory; • Being “held” constantly in the here-and-now in a secure, therapeutic relationship, while exploring and integrating highly emotional, sensory, and bodily memories of the past;

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• Prolonged, “in sensu” exposure of the traumatic experiences (“hot spots”) in the form of full activation of the fear structure with the aim of modifying affective interconnections and separating the memory about the traumatic event from conditioned emotional reactivity; • Construction of a conscious, semantic connection between physiological reactivity and perceptive memory of the experienced event in the context of time and place (when, where, who, what); • Cognitive reevaluation of behavior before, during, and after the traumatic event; the correction of cognitive distortions, especially those which contribute to “survivor guilt,” guilt, and shame; and a final reappraisal of the experienced traumatic events, in application of universal value schemes, e.g., the declaration of human rights; • Preparation of a testimony resulting from the narration, in recognition of the experienced events and with a view of recovering the survivor’s human dignity. Over the course of time, we have put NET to test in a number of countries and settings, for adults as well as children. Beyond PTSD-symptom remission, it could be shown that Narrative Exposure Therapy can reverse the devastating effects that the trauma has left in the brain and memory. First trials show that successful psychotherapeutic intervention with NET normalizes deviant oscillatory brain rhythms that are a signature of cortico-hippocampal interplay (Elbert et al., 2005; Schauer et al., 2006). This short-term treatment is enough to trigger processing stages and a cascade of alterations that lead to a considerable relief for the survivor. It, however, can be combined with an extra session for overcoming PTSD-associated features, such as grief, guilt, and shame, if still necessary at the end. Our key focus in current research trials is on individuals, who suffer from PTSD and other disorders of the posttraumatic disorder spectrum and live in conditions of organized violence, such as internal displacement and/or child soldering (Ertl et al., 2008), as refugees and asylum seekers (Hensel-Dittmann et al., submitted; Neuner et al., in press; Neuner, Onyut et al., 2008; Neuner, Schauer, Klaschik, Karunakara, & Elbert, 2004; Onyut et al., 2005; Ruf et al., 2010; Schauer et al., 2004), suffer from chronic, torture-related PTSD (Bichescu, Neuner, Schauer, & Elbert, 2007; Bichescu et al., 2005; Neuner et al., in press), have survived a genocide (Jacob, Neuner, Schaal, Elbert, & Maedl, submitted-a, submitted-b; Schaal & Elbert, 2006; Schaal, Elbert, & Neuner, 2009), live in situations of post-crisis after natural disaster and war (Catani, Kohiladevy et al., 2009), and live in chronic, on-going conflict (Schauer, 2008; Schauer et al., 2007). In contrast to conventional psychotherapy, Narrative Exposure Therapy (NET) and KIDNET do usually not require more than four to twelve sessions, which can be carried out in any silent place in the community, e.g., at the survivor’s home or the local health center or school. Moreover, both can be easily taught to local lay counselors, with minimum requirement on prior formal education (especially the ability to write), thereby satisfying the urgent need for large-scale dissemination. The procedure of NET is comprehensible for survivors from all cultures, because story-telling, oral tradition, and verbal expression are concepts shared among all

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humankind. In fact, NET proves extremely culturally sensitive, because survivors tell their own stories, in their own fashion and in ways of cultural expression that are related to their own traditional and personal background and setting. Our studies show that the acceptance of NET among people of all ages is high: our youngest subject so far was 6 years of age (an asylum-seeking child in our German outpatient clinic) and our oldest was 82 years (a surviving widow of the genocide in Rwanda), with at times very long chronicity of PTSD symptoms, longest being a mean of 42 years in our NET trial participants in Romania (Bichescu, Neuner, Schauer, & Elbert, 2007). In summary, acceptance is high with dropout rates as much as absence rates. In order to test ability of this trauma-focused treatment module to be disseminated in conflict-torn regions, we added NET as a component to the training of teacher-counselors and as a key element within the build-up of a large-scale, referral structure for the school system of war-torn and tsunami-affected North-Eastern Sri Lanka (Catani, Kohiladevy et al., 2009; Schauer et al., 2007; Schauer et al., 2005). In the course of 3 years (2002–2005), our nonprofit organization, “vivo” in collaboration with local experts from Jaffna University, as well as Shantiham Centre for Health & Counseling in Jaffna, have trained 150 Master Counselors and more than 1300 psychosocially trained teacher-counselors. In Uganda, NET was taught to camp-based refugees from Rwanda and Somalia, who in the course of time successfully gave treatment to 277 of the most severely trauma-affected camp residents (Neuner, Onyut et al., 2008; Onyut et al., 2005). A currently implemented trial in Northern Uganda, where locally trained counselors give treatment to formerly abducted children and child soldiers in IDP camps of the Northern Districts, has shown significantly successful results at a 12-month, final, post-test time point (Ertl et al., 2008). In Rwanda, after successful trials with treatment carried out by our own experts (Schaal et al., 2009), and a subsequent RCT with locally trained B.A. graduates from Butare University (Jacob et al., submitted-a), dissemination has reached a secondary stage, whereby trained, local counselors have independently passed on their therapeutic NET skills to another set of local community aids; first post-test data already show an equally successful trend toward significant recovery of treated beneficiaries (Jacob et al., submitted-b). Currently, NET is also taught to a group of local counselors, nurses, and social assistants in various settings of the Democratic Republic of Congo, who work with survivors of severe and cruel sexual trauma. Beyond individual treatment, the task at hand in large, population-based disaster and war settings always includes the healing of the collective. We hypothesize that the collective rewriting of the past, based on diverse individual autobiographical narratives produced by NET and their translation into education, information, and communication material, might help mediate trauma symptoms in the larger group. That which heals the affected person can at the same time aid the collective to create understanding and eventually acceptance. Public investigations of traumatic events legitimize private memories, help memorialize them, and contribute to the healing process. In a currently implemented, controlled trial, we have therefore added a “NET Truth” component, where the efficacy of providing peers with

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read-out parts of NET testimonies, in order to remedy trauma symptoms in classmates, who have equally been exposed to abduction and forced child soldiering, is systematically observed in Northern Uganda. We understand that refurbishment of important historical events is crucial for the people of a conflict-torn country, as it helps to highlight the underlying conflict mechanisms and might help to defend against the establishment of unbalanced and one-sided views and interpretations and thus ultimately avoid new lines of conflict. As we know, recovery from PTSD involves the reestablishment of a coherent system of basic beliefs that allows the understanding of the traumatic experiences within an adaptive set of basic assumptions about the world and the self; this is true for adults as well as children (Ehlers & Clark, 2000; Resick et al., 2002). The documentation of history through diverse, individual accounts within an affected population-group will produce a comprehensive view of events, based on a mutual understanding of the processes and experiences in the different groups. The victimization of humans by humans not only destroys the victim’s self-respect, pride, strength of will, and belief in personal autonomy but also unravels the person’s meaning-systems in relation to community and social order (Fischer & Lazerson, 1984). From our research and investigations in several post-conflict/postviolence settings, we have observed that when traumatic events occur, which are experienced by a significant number of the members of a society, then the basic social beliefs in society might be shattered and along with it the survivors’ social identity. Lasting conflict and violence disrupt the development of a collective identity; a fragile collective identity, with its associated societal attitudes and susceptibility to belief systems propagating violence, tend to be an amplifier of the cycle of violence. Current models of traumatic memory suggest that a coherent belief system, embedded in a respective collective identity, facilitates the explanation of the traumatic past and thereby possibly ameliorates trauma symptoms, like flashbacks and nightmares. Thus, a process of collective analysis and rewriting of history is assumed to mediate trauma symptoms in the community, increase mental health, improve individual functioning, increase successful reintegration, and consolidate a new and coherent collective identity. Therefore, our guidelines stress the inclusion of a trauma-focused, testimonial approach, such as Narrative Exposure Therapy, to aid individual, as well as collective recovery, and to document past human-rights abuses. Furthermore, individual treatment must be linked to communication, information, and education channels that reach the public, in order to transform and process past injustice. Most of all, treatment approaches must be able to be locally disseminated and short term, in order to satisfy the demand for sustainability and impact. Another key component certainly is the reproducibility of the efficacy of any given treatment approach.

Discussion Despite mounting evidence, field-based, mental-health care interventions from the acute aftermath of a “complex emergency,” such as armed conflict, to the stage

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where so-called re-settlement and development sets in, are still a novelty. As to the authors’ best of knowledge, there currently are only a handful of field-based RCTs that are published for children and adults (Berger, Pat-Horenczyk, & Gelkopf, 2007; Bolton et al., 2007; Layne et al., 2008; Thabet, Vostanis, & Karim, 2005) that aim at the remission of trauma symptoms in circumstances of conflict or post-conflict, apart from our own studies (Bichescu et al., 2007; Catani, Kohiladevy et al., 2009; Ertl et al., 2008; Jacob et al., submitted-a, submitted-b; Neuner, Onyut et al., 2008; Neuner et al., 2004; Onyut et al., 2005; Schaal et al., 2009; Schauer, 2008). Psychosocial assistance in form of skill-based trainings or supportive counseling is offered more frequently in these contexts, but here opinions strongly diverge. The controversy lies in determining the best strategies and practices for implementation of this assistance, and more essentially, its necessity at all. In the past decade, rapid advances in neuroscience, especially research insights about brain plasticity, has had an illuminating effect on advancing treatments in the field of clinical psychology. There has been very little, if any, break-through knowledge that has been directed at the most urgently needed intervention-research areas, especially in resource-poor, conflict-affected regions of the world. The gap of inequality in access to evidence-based, mental-health services is monumental between rich and resource-poor countries. Even the UN’s Millennium Development goals almost entirely ignore mental-health disorders: Yet there is compelling evidence that in developing countries, mental disorders are amongst the most important causes of sickness, disability, and in certain age groups, premature mortality. Mental health-related conditions, including depressive and anxiety disorders, alcohol and drug abuse, and schizophrenia, contribute to a significant proportion of disabilityadjusted life years and years lived with disability. . .Apart from causing suffering, mental illness is closely associated with social determinants, notably poverty and gender disadvantage, including having AIDS and poor maternal and child health (Miranda & Patel, 2005, p. 962).

Issues of prioritization, which have so far played a key role in humanitarian assistance after conflict and disaster and which are common debate themes, have been duly highlighted by experts, raising such questions as “Are psychosocial needs something of a luxury, until basic food, health, shelter and security needs are fully met?” and “Are efforts better directed to support economic recovery of households?” (Ager, 2002; Fernando, 2004; UNHCR, 2000). Despite accumulating evidence of the disastrous, mental-health implications of war, conflict, displacement, and organized violence on the minds and lives of the civilian population, little scientific gains have been made in finding evidence-based, public mental-health and populationbased solutions. The multidimensional relationships especially between the abuse of human rights, impaired mental health, perpetuation of the cycle of conflict, and failure to rebuild peaceful communities post-conflict remain scientifically unexplored. Until recently, the evidence base for the efficacy of non-specific psychosocial interventions in post-disaster settings has been widely lacking (Barenbaum, Ruchkin, & Schwab-Stone, 2004). Despite the fact that regions of crises and refugee camps often attract humanitarian workers from many different countries, “psychosocial”

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activities are often restricted to “educational” or “social” interventions, such as creative play and other non-specific support activities (i.e., capacity-building for “peace and conflict resolution”). Most often, the interventions provided by humanitarian workers and health professionals have been developed ad hoc without a solid theoretical background and the efficacy of these methods is doubtful (Bolton et al., 2007). Despite this lack of scientific foundation, resources are lobbied for such nonspecific interventions, instead of mental-health services. From the point of evidence, we argue that specific mental-health care solutions could be able to provide better results, and therefore, resource investment should no longer be diverted to unspecific interventions. Furthermore, there is not yet a proven unifying framework of best action in mental health that has been endorsed by a majority of leading policy-makers, experts in the field, academia, and U.N. agencies. As a first attempt, the “IASC Guidelines,” focusing on psychosocial rather than mental-health interventions in the immediate aftermath of emergencies, were compiled in February 2007, which presented recommendations from humanitarian work carried out so far (Inter-Agency Standing Committee – IASC, 2007). Without wanting to question its solid interest for better humanitarian practice, unfortunately little of what it suggests is based on scientific evidence. Despite the fact that in post-emergency settings, rates of PTSD and its coexisting disorders, such as depression, anxiety, substance abuse, suicidality, and psychosomatic illnesses, which affect at least every sixth individual, or in some contexts, even every other individual, have been found endemic among adults (de Jong et al., 2001; Karunakara et al., 2004; Mollica et al., 2001; Scholte et al., 2004), and children alike (Catani et al., 2008; Elbert, Schauer et al., 2009; Thabet, Abed, & Vostanis, 2004; Thabet & Vostanis, 2000), critics still doubt the cultural relevance and validity of scientific clinical diagnostic criteria. Experts, mainly based in Europe or the USA continue to express views such as Symptoms [of PTSD] associated with a disorder in one culture are not necessarily indicative of that disorder in another culture (Ager, 2002, p. 43).

This denies the relevancy of psychiatric categorization. Some critics consider PTSD as an inappropriate medicalization of human suffering that is caused by political circumstances. Examples are given, such as a study in Nicaragua, which found that three quarters of those people showing enough symptoms to diagnose them as suffering from PTSD were basically well-adjusted; they were suffering, but apart from that they were functioning well, the authors state (Bracken, Giller, & Summerfield, 1995). Despite such views, for more than a decade now, knowledge and evidence highlight similarities of human suffering, given exposure to war stressors. GarciaPeltioniemi, reiterates that there are considerable similarities and consistencies in the clinical manifestations of psychological disorders across different refugee groups and that these similarities and consistencies outweigh cultural and ethnic differences. She claims that knowledge of this should lead us away from treating the

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mental-health difficulties of refugees as something new and unusual, while allowing us to focus attention on developing culturally sensitive assessment and treatment approaches to meet the special needs (Garcia-Peltoniemi, 1998). Increasing number of studies reinforce the claim that signs of emotional distress are expressed similarly also by children of different cultures and that PTSD resulting from war trauma surmounts the barriers of culture and language (Sack, Seeley, & Clarke, 1997). The persistent dilemma of “right action” in relation to humanitarian response was expressed by senior scientists of the Board of Directors of the Children and War Foundation in Norway state on June 22, 2006: [We need to place] more emphasis on advocating that children in all parts of the world should benefit from the trauma knowledge gained during the last decades. This knowledge has been put to use in the follow-up of children in most Western affluent countries, while debates over the cultural relevance of trauma knowledge used outside of Western countries has blocked this knowledge from reaching many children in less affluent countries (Children and War Foundation, 2006).

Around the turn of the millennium, the largest providers of child-support interventions globally (U.N. and international NGOs alike) adopted a new policy in respect to psychosocial programming, based on the overwhelming experiences during the Kosovo war. The new policy shift informed their intervention methodology: The basic premise of the [organizations’] approach is that practitioners will start at the bottom of the triangle of the war-affected group. They will assume that the majority of the population has the resources to cope with their suffering. . .a base-line survey should identify weaknesses in coping resources [among the most vulnerable] and seek to improve these. Such an approach looks at identifying the positive, understanding and sustaining it, and therefore avoids pathologizing the population (de Berry, 2004, p. 145).

Aligned with this logic, the “conceptual model for psychosocial interventions in social and humanitarian crisis” developed by the United Nations and International Society for Traumatic Stress Studies with the help of senior trauma experts (Fairbank, Friedman, de Jong, Green, & Solomon, 2003) shows an inverted triangle with five interrelated levels of intervention descending: societal, community, neighborhood, family, and individual. Reasoning for such intervention logic is given as follows: Individualized treatments in the post-trauma period are usually not feasible as a first-line strategy, especially considering the shortage of mental-health professionals and greater costs as compared to group interventions. Immediate relief operations can start with non-specific interventions (Barenbaum et al., 2004, p. 56).

As of today, no large-scale, cost-benefit analysis has been carried out that compares the investment in individual trauma treatment for severely affected children and their parents by specifically trained, lay counselors to the impact and comparative resource-consumption of large, general, non-specific psychosocial activities, such as play activities or the reestablishment of traditional healing practices for all. Surely, there are not enough short-term treatment interventions for various mentalhealth problems in existence, which can effectively be applied by local lay people; however, we argue that this should not encourage the trend of finding solutions in

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collective and unspecific interventions instead. No doubt, it would probably be ideal to be able to tackle all levels of this pyramid in terms of beneficial interventions. Today’s reality in post-conflict or crisis settings, however, is characterized by fierce competition over very scarce resources. The need to prioritize action will remain. The policy of “starting psychosocial interventions at the bottom of the triangle” was also responsible for the decision of these large U.N. and international service providers to implement a “resource-based, rather than mental health-based” project in Afghanistan. As a project researcher puts it: We believe that recognizing the capacity that had allowed Afghans to confront, bear, and survive the past quarter decade of loss and destruction would acknowledge the resilience and coping that already existed in Afghan social life. Building on this would prevent the portrayal of Afghans as in desperate need of specialized medical intervention to the detriment of acknowledging their ability to survive and cope (de Berry, 2004, p. 144).

In the psychological research community, the focus on “resilience of the majority” versus the “suffering of the minority” had been challenged in the mid-1990s already (Cairns, 1996). In the humanitarian-aid community, however, statements, such as the above, are still commonly made. This may be due to the fact that it has not been understood by practitioners, that the main assumption of the inverted triangle logic, the projection of only a small minority of severely affected (∼3–5%) in the top part, can scientifically not be upheld. Unfortunately, proponents of the resilience model still underestimate the actual amount of suffering due to mentalhealth disorders, which is not a problem of a minority any more. Mental-health data are mostly underestimated, due to the absence of proper techniques of epidemiological survey data collection prior to the project start. Additionally, health clinics might find themselves confronted with unexpectedly high numbers of somatic complaints, which in fact should be diagnosed as consequences of trauma-spectrum disorders. In the absence of factual empirical data, the clash between “trauma-” and “resilience-” based approaches is fought very much on the grounds claiming that “we know what is right for the populations we serve” and that an expert’s positions are easily detectable by the choice of wording used: The ‘resilience discourse’ often includes a right-oriented approach associated with interventions that respect and protect the rights of the local culture and traditions, whilst the ‘trauma discourse’ is associated with application – and sometimes imposition – of Western, medically-oriented interventions (Agger, 2000, p. 86).

However, what constitutes a rights-based approach? We know that mental-health interventions can be developed in a community-based and resource-oriented way, involving the family and the community. Furthermore, a focus on traumatic stress in programming, in no way, prevents the acknowledgement of resilience and coping. What do authors have in mind when they talk about “intensive medical” solutions? As of today, there is no “medical” treatment of PTSD, which is the most commonly found psychological disorder in children and adults who have survived a war. There is no medication that can cure PTSD. On the other hand, culturally sensitive approaches in the context of PTSD treatment can certainly be found among modern, research-based psychotherapies. Thus, we argue, the decision for “relief

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the mental-health system,” which is in a large part a financial decision, must not fall in favor of a social intervention, especially when the mental-health system itself obviously needs strengthening. Also, if it were to hold true that a large number of people cope well, then from our perspective, there is no need for implementation of non-specific psychosocial assistance, given the resource scarcity – especially as long as empirical evidence of its benefits is lacking. There is another argument, which is used time and again against the scientific clinical-illness model perspective: the “individualistic versus collective society.” In this view, non-Western cultures are defined as “collectivist” and have traditionally been family and community oriented, whereby the individual tends to become submerged in the wider context. It is argued that, because PTSD is based on diagnostic criteria, is assigned to an individual, and afflicts the individual self, with the traumatic event impacting on the individual psyche to produce PTSD, the model might not fit people from a “collectivist” society, because it is understood that the “sick” self extends beyond the individual. What is suggested instead of a “traumafocused approach” is, therefore, a “psycho-social-ecological model” of intervention (de Jong, 2007). The argument is well understood that, in addition to the sum total of individual trauma, there are impacts at the supra-individual family, community, and social levels that produce systemic changes in social dynamics, processes, structures, and functioning (Somasundaram, 2007). However, this argument falls short of justifying the need to tackle the psychoecological level, instead of the individual, psychological first and foremost. Moreover, this position confuses the concept of coping, the construction of meaning, and social support with healing of the individual psychobiological consequences of trauma. From our point of view, only once a minimum amount of cognitive, social, and emotional functioning is reinstalled in an affected individual will the person gain from community rehabilitation programs, such as income-generation activities, survivor support-group meetings, and public awareness-building and peace-building efforts. Sometimes it is the sheer numbers of people who are in need of treatment that dissuade public mental-health interventions. Sri Lankan psychiatrist Somasundaram explains that even though community mental-health programs that do not include the possibility of addressing the problems of those with severe mental disorders would fail in the eyes of the community and cause a breakdown in the smooth functioning of it; it is, in his opinion, not feasible to treat the large numbers of survivors with Western psychiatric treatment (Somasundaram, 2007). The challenge might not be that “science-based” psychiatric treatments do not work in the “collectivist” children or adults suffering from trauma, but that we have not developed adequate evidence-based, trauma-focused, public mental-health models of effective short-term treatment, applicable to large numbers. Another debatable but common focus of humanitarian strategies, related to the provision of social and emotional support, is put on key adult members of the affected group, such as teachers, parents, and community elders. Critics of scientific trauma knowledge that is transferred to traditional cultures frequently assume that “culture has its own frameworks for mental health, and norms for help-seeking at times of crisis” (Summerfield, 1999). Along the same lines of reasoning and

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contrary to current scientific knowledge, advice is given by one of the U.N.’s key psychosocial consultants: Children who suffer from terrible events, if they are cared for and loved, don’t become mentally ill. They do not become psychologically scared. It has an effect, however, on their social world. We have seen changes in social attitudes and inter-relations more than anything. People are incredibly resilient. We have watched children and adults manage to cope after horrific events. We have seen situations around the world that are horrific, and we have watched children and adults managing to cope. It doesn’t mean it doesn’t hurt. It doesn’t mean it doesn’t affect them. However, the consequences are not necessarily severe mental illness. What we have found is that in terrible situations, the parents will suddenly become very strong and loving towards their children. That’s just what the children need. . .what I would be encouraging would not be therapy, not at all. What I would be encouraging would be mothers, fathers, and teachers to talk and love these kids, spend time with them, have activities that promote their feeling safe again (UNICEF, 2004).

We know that maternal distress has an important impact on child reactions. However, having a caring and protective mother or father is not a panacea, and closeness to a responsible parent does not protect children from the traumatic impact of war and persecution, as parents cannot buffer their children from stress (Almqvist & Brandell-Forsberg, 1995; Barenbaum et al., 2004), which is a view that has “blindly been accepted as a truism” (Cairns, 1996). Yule and colleagues have repeatedly pointed out that parents, teachers, and other adults underestimate the intensity, magnitude, and longevity of children’s reactions to adverse events (Yule & Williams, 1990). Dyregrov and colleagues report that reliance on adult reports alone can be questionable. During interviews with children in Iraq following the Gulf war three times in the years following the war, the researchers learned that children had stopped talking with adults about their intrusive images and thoughts, because they felt that adults did not understand them or adults had just told them to forget about their experiences (Dyregrov, Gjestad et al., 2002). There is no doubt that adequate social support and other community-support practices are truly important mediators of the expression of trauma-related symptoms (Ahern, Galea, Fernandez, Koci, Waldman, & Vlahov, 2004; Basoglu et al., 1994; Brewin, Andrews, & Valentine, 2000; Coker et al., 2002; Johnson & Thompson, 2007; Kovacev & Shute, 2004; Mollica, Cui, McInnes, & Massagli, 2002). However, regardless of the level of support offered, the denial of the posttraumatic problem of victims carries the risk of perpetuating trauma-related behavior. A strategy of social support can be an additional element for affected communities only where a sufficient number of adult community members remain at least partly protected from the psychological impact of armed conflict, organized violence, and forced displacement. However, many key community members, such as parents, teachers, elders, counselors, nurses, lawyers, and doctors in post-conflict settings suffer from physical, as well as mental impairment, incapacitating their normal, healthy ability to function as caretakers, providers, and role models. Neither local healers nor religious leaders, who have traditionally offered health-related services, remain unaffected by the stressors of war and violence (Glenn et al., 2002; Human Rights Watch, 2000; Kenyon Lischer, 2006; Pittaway, 2004; Solomon, 1988;

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UNHCR, 2003; van de Put, Somasundaram, Kall, Eisenbruch, & Thomassen, 1998; Widom, 1989). As members of the Children and War Foundations explain: There are some war situations that are so unprecedented, i.e. massacres, that no cultures have societal healing or coping mechanisms to apply (Dyregrov et al., 2002, p. 138).

The eminent Psychosocial Working Group (PWG) further states that the events and circumstances of complex emergencies deplete the resources available to individuals and communities for engaging with the challenges they face at all levels (Ager, 2002). According to PWG, in post-emergency contexts, the individual and the community are in need to deploy those resources, which are depleted, in response to the challenge of experienced events. Clearly, one would argue that a gap of resources, knowledge, and coping has been detected here, which points the way toward development of alternative needs, as well as rights-based, mental-health services structures. A senior PWG member, however, explains further: The people of Angola made extensive use of African traditional medicine and African indigenous church movements in their strategies to address their suffering (Ager, 2002, p. 44).

and This is perhaps the key challenge for psychosocial programs in the coming decade: deploying skills, resources, and knowledge in a manner not only sensitive to, but clearly strengthening of local engagement with suffering (Ager, 2002, p. 44).

Urging the strengthening of local, indigenous practices – without equally urging objective, evidence-based evaluations and the development of human rights-based programs, interventions, and local practices – seems the “best practice” status quo of today. Surely, as organizations trying to provide relief aid, humanitarian assistance, and/or development aid or advice, we must respect local people’s wish to access indigenous venues, such as traditional healers or accept faith-based pursuits. As international agents, however, we cannot desire to reinforce traditional and religious structures, norms, and values, unless research proves their efficacy or benefits. We argue that humanitarian assistance, as well as development aid, must in fact stay away from involving itself in reinstating indigenous practices, but rather put its efforts into helping to build alternative, scientific, and rights-based community services. From a human-rights point of view, even the notion of “non-interference” in cultural traditions, norms, and beliefs is ethically inhumane. Protecting societies that are considered to be traditional from modern progress risks withholding knowledge and skills (also for independent research), leaving communities dependent on the goodwill of the powerful at best (Neuner & Elbert, 2007), but most commonly exploited. The U.N. Convention on the Rights of the Child (CRC) (United Nations, 1987) explicitly states governments’ responsibility to translate articles of the convention into practical action. The 1987 Convention established psychosocial recovery as a right of every child and a duty of providers of assistance to children. Children’s rights remain, no matter how detrimental the life circumstances of children as a result of war are:

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Article 39: state parties shall take appropriate measures to promote physical and psychological recovery and social reintegration of a child victim of any form of neglect, exploitation, or abuse: torture or any other form of cruel, inhuman, or degrading treatment or punishment; or armed conflict. Such recovery and reintegration shall take place in an environment which fosters the health, self-respect, and dignity of the child.

In support, the U.N.’s Graca Machel Report of 1996 (United Nations, 1996) firmly concluded that psychological recovery and social reintegration must be a central feature of all humanitarian assistance programs. According to international agreements, adequate psychosocial and mental-health interventions based on human rights are not a choice, but a necessity. In addition, the implementation of human rights in psychosocial and mental-health intervention work is strongly encouraged, also by newly created committees like the Inter-Agency Standing Committee (IASC) (Inter-Agency Standing Committee – IASC, 2007). Bearing the Convention of the Rights of the Child CRC and the Convention on the Elimination of all Forms of Discrimination against Women CEDAW (Office of the United Nations High Commissioner for Human Rights, 1979) in mind, we realize that in many of today’s conflict regions of the world, human rights are abused, especially within traditional societal settings. In many affected populations, women and children are subjected to a range of traditional and cultural discriminatory-practices and rights’ abuses, such as child labor, female genital mutilation, forced and early marriage, marital rape, unequal inheritance laws, unequal access to education, and domestic violence, to name just a few. For that matter, psychosocial or mental-health service interventions, or any humanitarian interventions, have the duty to address key problematic issues such as traditional, as well as current gender inequality, and ageold and new forms of stigmatization of parts of society, such as formerly abducted children (e.g., child soldiers in Uganda) and women (e.g., survivors of sexual slavery in Congo). Interventions should seek the opportunity of progressive change in society and introduce new awareness and recognition of notions of mental health and well-being, treatment options, women’s and children’s, as well as other vulnerable groups’ rights to safety, health, and equality. Efforts of “non-interference” or “strengthening of indigenous practices and traditional norms,” in the end, might just prove more harmful than evidence- and human rights-based intervention. Reliable mental-health data and evidence-based interventions are powerful political tools. Today’s psychosocial services are often characterized by a consciously chosen, “non-political” approach that seems at odds with the notion of demonstrating solidarity with survivors, favoring their testimony, and affirming their right to justice and social change. An approach of non-intervention could be doing more harm to the vulnerable populations we work with than one of pro-activism (Singh, Orbinski, & Mills, 2007; UNHCR, 2000). How can an organization know that it is adhering to the objective “to do no harm,” if it does not have evidence to substantiate its arguments? The war in Yugoslavia for example has seen the implementation of numerous psychosocial programs but, similar to other crisis regions, these programs rarely underwent rigorous evaluation because the need for action seemingly outweighed the importance of research (Dybdahl, 2001a).

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Some authors cite the daily dangers and harsh circumstances (e.g., no electricity), under which such interventions are implemented, as reasons for not meeting the demands of a scientifically strict evaluation methodology (Mooren, de Jong, Kleber, Kulenovic, & Ruvic, 2003). Even if evaluations take place, they are usually projectrelated, meaning that they focus on whether the project itself was implemented as intended and, thus, are missing the clear identification of factors and predictors, leading to outcomes such as a person’s or community’s mental-health recovery and the ways in which the intervention has contributed to that or has actually aggravated suffering (Fernando, 2004) Again Dybdahl states frankly: The effects of the intervention were impressive. . .how the intervention worked, however, is unknown, and more research is needed to investigate the working factors in this approach (Dybdahl, 2001b, p. 1227).

From our own organization’s work in countries culturally as diverse as Afghanistan, Democratic Republic of Congo, Uganda, Rwanda, Sri Lanka, Ethiopia, Somalia, Kosovo, Romania, we know that unless the planned intervention starts off with a carefully composed, epidemiological, population-based survey, little effective programming can follow. We regularly find social conditions, beyond children’s or adult’s traumatic war experiences, such as child labor, domestic violence, specific abuse and stigmatization, drug-taking behaviors, among many others, all of which are of key importance for consideration when developing an appropriate intervention program. Most often, however, there is a complete absence of empirical data collection at start, looking at characteristics of the beneficiaries (individuals, groups, community), as well as the characteristics of their environment. Less so, we see systematic approaches of variation of psychosocial conditions (e.g., comparison of type of counseling offered or vocational training versus psychotherapy). Regardless of whether the data are collected initially, mid- to long-term follow-up of beneficiaries is blatantly absent, thereby missing out on the opportunity to describe actual impact of the intervention on course of recovery and social change in areas such as remission of symptoms, community coherence, and child development. Because psychosocial programs do not discriminate support, based on categories of mental health, enrollment to programs is usually access-based. The inherent danger of such an approach, however, is that the hypothesis of resilience is derived from such biased population samples, and precious resources are not used in the most effective manner. This brings us to possibly the most significant hindrance in furthering the cause of evidence-based, public mental-health interventions – that is, the absence of funding opportunities. In the current organizational “scramble” for resources to fund mental health and especially, treatment-focused interventions in conflict settings, project proposals, which aim at psychological rehabilitation of the most severely affected and are based on comparative research protocols (i.e., randomized treatment trials, community controlled trials), are not seen as helping the cause of conflict resolution. We argue, however, that this is precisely the method to answer some of the most urgently needed questions on how to break the cycle of violence that has been globally put in motion. The absence of adequate funding for mental health in itself

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directly touches on issues of human rights and equality. The possibility of providing good research evidence, highlighting the needs of war and violence-affected populations, is greatly impaired by current financial policies and vice versa. This condition is not necessarily unintentional. The truth about absent funding might lie even deeper, as Miranda and Patel state: It is surprising that, while the developed world is investing substantial funds into mentalhealth care and mental-health promotion programs for its own populations, the leaders of the Millennium Development Goal project, international donors, and multilateral agencies, all of which are heavily represented by the developed world, have chosen to completely ignore mental health in the agenda for the health of the developing world (Miranda & Patel, 2005, p. 964).

It is for this reason that we lobby a strong commitment to funding of mentalhealth interventions as stated in our guiding principles.

Conclusion In the advent of efficacious, methodologically sound, culturally accepted, and able to be disseminated trauma treatment approaches, the controversy around humanitarian best practices lessens, while trauma-focused, public mental-health service implementation emerges as a key priority. The possibility of the build-up of largescale, population-based service structures in resource-poor, post-war settings has been proven. The cross-cultural applicability and integration of rigorously tested psychotherapeutic approaches have been successfully demonstrated. We postulate that evidence-based, public mental-health assistance is a humanitarian and ethical first-order imperative, given the newly emerging science related to current mentalhealth approaches. This is especially applicable with regard to the involvement of local expert and lay personnel in the systematic screening of affected populations, the stratification of interventions on the basis of assessment, the provision of traumafocused, best-practice interventions, as well as monitoring of the course of recovery within a community-based, comprehensive disaster/war-recovery program. Progress in psychotraumatology and neuroscience provides powerful means to understand, rehabilitate, and empower the survivor and affected communities. Our working group belongs to a hopefully growing pool of researchers, who have shown that programs can be evaluated, which extend the treatment from the individual to the community level and propose that such activities can assist large-scale healing and peace building. Short-term psychological treatment, such as Narrative Exposure Therapy (NET), can prevent or greatly reduce the severity of PTSD and co-existing symptomatology, which in turn enhances survivors’ mental and physical health and their economical and social functioning. This again is likely to relieve the medical system and the society and propel development. It is the ethical and humanitarian obligation of practitioners, researchers, NGOs, U.N., and governments to apply the best practices and to pro-actively engage in furthering this cause.

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A paradigm shift toward human rights and evidence-based service in the provision of mental health is inevitable, given the facts of the case. Evidence-based treatment must not remain the right of a privileged few, but must be available immediately and for all who need it the most: a significant number of people in conflict-affected communities. Acknowledgments For editing, we thank Dr. Uyen Kim Huynh, Program Manager on Mental Health, Millennium Villages Project, The Earth Institute, Columbia University, New York, USA. We would like to highly appreciate the hard work and dedication of our unique team members at the NGO vivo www.vivo.org as well as the adjunct Department of Psychology at the University of Konstanz, Germany www.clinical-psychology.uni-konstanz.de. Most importantly our respect and thanks goes to all our local counselors, collaborating colleagues in academia, and our clients in the various projects, especially those in places of (post-)conflict. Research for this article was supported by vivo international, the Deutsche Forschungsgemeinschaft (DFG), the University of Konstanz, Germany and the European Refugee Funds (EFF and ERF).

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Further Reading See “publications” at www.vivo.org

Index

A Abduction, 141, 179, 187, 314, 316, 321–322, 325–326, 328, 336–337, 341, 345, 348, 402, 407 Acculturation, 319 Acute-care, 147 Acute stress disorder (ASD), 121, 217, 226, 268, 271–274, 302 Adaptation, 8, 38–40, 42–43, 45, 102, 276, 283, 305, 319, 324, 364, 393 Adaptive coping, 266, 276, 282, 284 Adjustment, 11, 83, 161, 202, 265–284, 332, 345, 375, 378–379 Affect regulation, 269, 339–340, 398–399 Affect tolerance, 44–45, 116 Afghanistan, 78–79, 98, 103, 142, 160, 163–164, 168, 170, 182, 185, 229, 231, 296–297, 315, 390, 400, 411, 416 Aggression cycle, 64–65 Algeria, 112, 142, 182, 270 Allostasis, 362 Amputation, 136, 141, 152, 227 Angola, 78–79, 93, 135, 137–138, 189, 197, 315, 342, 348, 414 Anxiety, 7, 20, 40, 63, 112, 120, 124, 170, 182–183, 188, 217–218, 220–222, 226, 229, 234, 254, 256, 266–274, 280, 293–294, 297–298, 300, 302–304, 331–332, 338, 365, 370–371, 373, 377, 381, 395–399, 403, 408–409 Armed conflict, 2–3, 5–6, 8–10, 13–15, 20–21, 74–76, 85, 87, 93, 98, 103, 112, 126, 137–139, 141, 181, 197, 216–217, 222, 224, 257, 271, 301, 312–315, 319, 340, 345, 390, 407, 413–414 Armenia, 75, 187, 221 Assessment, 17, 106, 116, 119–120, 123–124, 126, 145, 150, 161–163, 166–167, 189–193, 199, 218–219, 269, 292,

297–299, 302, 305, 337–338, 366, 368–369, 377, 391, 396, 400, 404, 410, 417 Attitudinal barrier, 100, 116 Autobiographic memory, 393 Avoidance, 5, 9, 31, 40–45, 48, 50, 57–58, 121, 170, 181–182, 202, 247–259, 268–270, 276, 280–282 Avoidance coping, 251–252, 256, 277 Azerbaijan, 79, 292, 304 B Bangladesh, 144, 147–148, 150 Bosnia, 75, 98, 102–103, 120, 135, 219, 223, 293, 301 Burundi, 78–79, 93, 135, 137, 190, 229–230, 315 C Cambodia, 15, 78–79, 86, 88, 93, 112, 142, 144, 147–148, 150, 182, 219, 237–238, 270, 371 Case management, 117, 165, 167 Central nervous system, 334, 337 Centrifugal disasters, 33, 114 Centripetal disasters, 33, 49, 114 Child soldier, 3, 81, 89–91, 178–179, 187–188, 194, 196, 203, 311–349 China, 56, 75, 141 Chronic illness, 10–11, 151, 253–254 Civilians, 74–75, 78, 100, 135, 140, 163, 179, 185–186, 204–205, 215–239, 277, 292–294, 312–313, 322, 341, 344–347, 390 Civil war, 58, 76, 83, 101, 167, 178–179, 185, 270, 312, 319, 326, 337–338, 346 Clinical intervention, 116, 216, 226–227, 238–239

E. Martz (ed.), Trauma Rehabilitation After War and Conflict, C Springer Science+Business Media, LLC 2010 DOI 10.1007/978-1-4419-5722-1,

429

430 Cognitive-behavioral therapy (CBT), 91, 121, 226–227, 299 Cognitive-processing model, 43 Cognitive processing therapy (CPT), 91, 121, 171, 300–301 Collective action, 267 Collective identification, 336 Collective violence, 74–77, 82–83, 85–86, 91–92, 139 Collectivistic, 92 Combatants, 14–16, 18, 91, 139, 149–150, 177–206 Combat captivity, 367 Combat exposure, 163, 167, 184 Communal coping, 16–17 Communal psychological wounds, 9–10 Communal trauma membrane, 124, 283–284 Community-based rehabilitation (CBR), 12, 18, 97–108, 123, 148, 151 Community-level rehabilitation, 12–14, 21 Comorbid disorder, 182 Complex emergency, 5, 134, 407 Complex system, 93, 114–115 Conflict-affected, 5, 136–138, 142, 148–151, 215–239, 305, 390, 400, 408, 418 Conflict resolution, 80, 83, 85, 88–89, 92, 395, 402, 409, 416 Conservation of Resources, 17, 124–125 Convention of the Rights of the Child, 317, 415 Convention on the Rights of Persons with Disabilities (CRPD), 100, 145 Co-occurring disorder, 7, 121, 221, 272, 297, 305 Coping, 2–3, 7, 16–17, 20, 30, 42, 44, 60, 62, 64, 88, 115–116, 119, 126, 169, 172, 183, 186, 219–220, 228, 233–234, 248–255, 263–282, 292–294 Counseling, 11, 31, 91, 116–117, 119, 121, 147–148, 164, 170, 189, 192–194, 196, 198–199, 202–203, 229–230, 232–234 Crimes against humanity, 62, 178, 237–238, 313, 316–317, 403 Crisis intervention, 81–82, 89, 91 Cross-cultural, 267–268, 391, 417 Cultural context, 92, 124, 267–268 Cultural destruction, 294 Cycle of violence, 79, 186–188, 312, 347–348, 396, 399, 407, 416 D Debriefing, 119–120, 302 Defense mechanisms, 30, 35, 46, 393 Demobilization, 14, 149, 178–181, 189, 196–197, 204, 312, 343–347

Index Democratic Republic of Congo (DRC), 135, 138, 183, 196, 204, 304, 315, 317–318, 320, 323, 342, 348–349, 390, 406, 416 Denial, 35, 42, 48–49, 59, 251–257, 276, 278–279, 282, 295, 361–362, 377, 379, 394, 413 Department of Defense (DoD), 161–166 Department of Veterans Affairs, 165, 169–172 Depression, 7, 15, 41, 105, 120–122, 125, 142, 164, 167–169, 171–172, 181–184, 188, 198, 200–201, 203, 205, 218–219, 221–222, 227, 233–234, 268–269, 271–274, 279–280, 292, 294, 297, 324, 332–334, 338–339, 346–347, 391, 399, 401–402, 409 Development, 7, 10, 12–14, 16–17, 20–21, 35, 40–41, 49, 74, 76, 79–80, 82–83, 85, 87–90, 92, 98–102, 105, 107–108, 123–126, 137, 139, 142, 144–145, 148–153, 178, 184–186, 194–195, 205–206, 222–223, 225, 229–231, 236–239, 274–275, 283–284, 293, 295, 301–303, 332–333, 335–339 Diagnostic and Statistical Manual (DSM), 31, 57, 163, 165, 168, 170, 183, 200–201, 217, 221, 251, 268, 298, 324, 366–367, 371 Diplomacy, 61, 65–69, 83, 92 Direct effect of war, 16, 136 Disabilities, 5–7, 10–12, 14–15, 18, 89, 91, 98–108, 111, 115, 122–123, 126–127, 140–147, 150–153, 180–181, 188, 194, 198, 237 Disarmament, Demobilization, Reintegration (DDR), 14, 178–180, 183–184, 188–199, 204, 206, 338 Disclosure, 256, 295–296, 363 Disorders of Extreme Stress Not Otherwise Specified (DES-NOS), 269 Dissociative mechanism, 334 Donor community, 4, 84, 180 Drug abuse, 181–182, 194, 201, 254, 314, 332–333, 381, 408 E Ecological approach, 216 Ecological framework, 18 Economic cost, 1 Economic development, 74, 76, 79, 118, 142, 186, 194, 231, 236, 312, 347

Index Education, 17, 68–69, 76–77, 79–80, 84, 88–92, 98, 104, 107, 116, 118–119, 124, 126, 136–138, 142–146, 148, 164, 171, 179, 190–193, 205, 217, 225, 229, 231, 233, 236–237, 267, 272, 314, 320 Ego defenses, 34, 36 Egypt, 297, 363, 366, 381 Emotional distress, 104, 142, 161, 230, 252, 267, 278, 375, 410 Emotion-focused coping, 252, 255, 277–278, 377 Employment, 5, 11, 15, 20, 29, 91, 122–124, 126, 142, 144–146, 184, 189–191, 231–232, 236, 281, 320, 338 Empowerment, 80, 87–88, 90, 220, 228–231, 234–235, 237–238 Environmental barriers, 144–145, 148, 151–152 Epidemiological study, 169, 334, 381 Eritrea, 75, 78, 102, 108, 137, 188, 192, 230 Ethiopia, 75, 78–79, 102, 112, 137–138, 192, 270, 390, 416 European Union, 4, 13, 101, 180 Evidence-based, 10, 74, 153, 171, 199, 202–206, 216, 238, 299, 391–408, 412–417 Ex-combatant, 18, 91, 149–150, 177–206, 312, 333–334, 338, 344, 346–349 Existential despair, 47–48 Exploded remnants of war (ERW), 136, 139–140 F Fear network, 43–44, 254, 321, 324, 326, 334, 393, 401, 403 Flashbacks, 8, 19, 35, 45, 181, 185, 250, 268, 276, 282, 407 Foreshortened sense of the future, 19–20 Forgiveness, 55–69, 229 Functional limitation, 5, 11, 140–143, 147, 150, 152–153, 274 Future time orientation, 19–20 G Gaza, 98, 101–104, 106–108, 154, 182, 234 Gender-based violence (GBV), 84, 86, 136, 196, 220 Genocide, 57, 62, 65–67, 75, 93, 139, 187, 199–201, 203–204, 293, 326, 346, 401, 403, 405 Germany, 56, 75, 84, 165, 187, 203, 293 Global Burden of Disease (GBD), 134, 221 Guatemala, 79, 270

431 Guilt, 44, 58, 63, 229, 248, 266, 271, 294, 298, 332, 334, 337, 364, 405 H Handicap International (HI), 12, 103, 149 Health, definition of, 85, 239 Health outcomes, 138, 217–219, 221, 331, 338, 396 Helplessness, 38–39, 41, 47, 80, 88, 185, 187, 218, 228, 237, 250, 268, 324, 329, 338, 346, 362, 369, 393–394, 401, 403 Help-seeking, 256, 372–373, 412 Herzegovina, 98, 223, 293 Homeostasis, 38, 253, 336, 361–362 Human Development Indices, 137 Human dimension, 4, 14 Human factor, 4 Human healing, 4 Humanitarian assistance, 4, 134, 150, 238, 389–418 Humanitarian work, 4, 84, 115, 117–119, 125, 127, 408 Human rehabilitation, 1–2, 21, 134, 145, 153 Human rights, 11, 18, 68, 77, 79–80, 84–86, 90, 92, 98–103, 106–108, 125–126, 136–139, 202, 222, 236–237, 321, 345, 373, 390, 395–396, 403–404, 407–408, 413–417 Human shield, 48, 218, 313 I Imaginal exposure, 35, 299–300 Imprisonment, 79, 380–381, 403 Improvised explosive devices (IED), 139–140 Inclusive community, 33 Income-generating activities (IGA), 89, 228, 231–233 India, 148, 150, 315 Indirect effect of war, 136 Individual-level rehabilitation, 10–12 Indonesia, 75, 78, 235 Information processing, 40–43 Injuries, 2, 6–7, 10, 14, 18, 74, 91, 112, 123, 133, 136, 140, 142, 144–147, 150–153, 163, 165, 168, 170–172, 216, 250, 292, 313 Inter-Agency Standing Committee (IASC), 105, 124–126, 134, 137, 224–226, 232, 238, 409, 415 Internally displaced persons (IDPs), 77–78, 82, 86–87, 138–139, 200, 331, 390 International Classification for Functioning, Disability and Health (ICF), 100, 141, 143

432 International Disability and Development Consortium, 14 International humanitarian relief, 4 International Labor Organization (ILO), 11, 15, 98–100, 106, 316 International Rescue Committee (IRC), 135 International Society for Traumatic Stress Studies, 410 International tribunals, 86 Interpersonal sensitivity, 119, 372 Interpersonal therapy (IPT), 200, 203–204 Interpersonal trauma membrane, 35, 44, 48, 51, 113, 125, 257, 280, 282–283, 296, 303 Intervention, 2, 10–12, 15–19, 27, 33, 63, 65, 77, 80–82, 84–85, 89, 91, 93, 106, 114–127, 137, 163–164, 166–167, 171, 194, 197–198, 202, 227, 229–230 Intrapsychic trauma membrane, 34–36, 40, 44, 47–48, 119, 257, 259, 281–283 Intrusion, 8, 41–44, 51, 181, 185, 202–203, 252, 254, 257, 276, 282, 344, 368, 393 Intrusive memories, 9, 35, 254 Invisible wound, 7, 216, 219, 238 In vivo exposure, 299–300 Iraq, 75, 79, 142, 149, 160, 163–164, 168, 170, 229, 315, 413 Israel, 56, 102, 119, 363, 369, 372, 381 J Japan, 56, 84, 144 Justice, 56, 59, 61, 63, 65, 67–69, 84, 86–87, 92, 237, 346, 395, 401, 415 K Kenya, 137, 144, 148, 150, 224 Korean War, 378 Kosovo, 410, 416 L Land mines, 85–86, 89, 136, 139–142, 153 Laws of War, 317 Liberia, 78–79, 135, 137–139, 188, 192, 220, 228, 236, 315 Longitudinal study, 43–44, 364, 366, 368 Loss cycles, 17 M Mass rape, 178, 294, 313, 342 Mastery, 9, 38, 44, 47, 116, 237, 254 Medical rehabilitation, 16, 123, 143–145, 147–152

Index Mental disorders, 17, 111–112, 202, 216, 220–222, 224–225, 235, 251, 324, 381, 402, 408, 412 Mental-health professional, 3, 28–31, 33, 48, 50–51, 85, 91, 112, 118, 127, 164, 172, 204, 225, 232, 296, 395, 410 Mental-Health Screenings, 161–162 Meta-analysis, 2, 7 Metaphor, 29–30, 47–48, 51, 67, 178 Military deployment, 159–160, 165, 167, 169 Military forces, 18, 89, 91 Millennium Development Goals, 76, 408 Mobility problems, 104, 106 Models of rehabilitation, 11 Mortality, 76–78, 91, 133–138, 152, 221, 313–314, 331, 369, 379–381, 396–397, 408 Mozambique, 75, 78–79, 88, 137–138, 183, 230, 315, 342 Multidimensional approach, 2, 10–14, 29, 115–116 Multidimensional concept, 51 Multidimensional model, 10 Multi-level, 2, 29, 92 Multi-level model, 16 Mutilation, 79, 141, 178, 293, 313, 322, 324, 415 N Narrative exposure therapy (NET), 198–206, 227, 301, 303, 305, 312, 403–407, 417 Natural disaster, 2, 81, 87, 97–98, 201, 253, 278, 320, 324, 376, 405 Negative attitudes, 15, 108, 144, 186, 312, 346–347 Negative reciprocity, 339, 399 Neuro-endocrine system, 337 Nicaragua, 237, 409 Nigeria, 75, 78, 183 Non-adaptive cognition, 45, 171 Non-adaptive response, 8–9, 264–274, 283 Non-governmental organization (NGO), 4, 10, 18, 65, 77, 85, 101–102, 108, 202, 227, 234–235, 394 Non-verbal memories, 35 O Open system, 113–115 Organization of Security and Cooperation of Europe, 76 Organized violence, 181, 187–188, 196, 199, 312, 324, 338, 345, 390, 394, 401, 403, 405, 408, 413 Orphans, 200, 319–320

Index P Paradigm, 74, 76, 224, 277, 281, 296 Paradigm shift, 389–418 Peace-building, 4, 18, 84, 148, 178–179, 187, 199, 204–205, 412 Peacekeeping, 65–66, 80–81, 86–87, 89, 183, 313 Perceptual apparatus, 34, 45–46 Peritraumatic, 334–335 Pharmacological treatment, 121, 227, 235 Pharmacotherapy, 91, 205 Physical infrastructure, 2, 222 Physical injury, 5–7, 57, 164–165, 249, 266, 293 Physical rehabilitation, 11, 133–154 Physiological reactivity, 405 Polytraumatic injuries, 165 Post-conflict context, 99, 275 Post-conflict environments, 10, 15, 271, 306 Post-conflict rehabilitation, 4, 7, 10, 13, 111–127, 178, 253, 267 Post-conflict situation, 14–15, 28, 99–108, 124, 281 Posttraumatic growth, 8, 373–380 Posttraumatic hysteria, 41 Posttraumatic stress disorder (PTSD), 7–9, 19–20, 30–31, 37–38, 40–43, 45–46, 105, 111–112, 119–122, 142, 161–165, 167–172, 181–184, 187–188, 194, 200–201, 203, 205, 217–219, 221–222, 224, 226–228, 248–249, 251–252, 254, 256, 267–274, 276, 278, 280–283, 291, 294–306, 311, 321–328, 330–331, 345–347, 364–373, 375–379, 381, 391, 393–394, 396–397, 399–402, 404–406, 407–409, 411, 417 Poverty, 5, 12, 74–76, 79, 83–84, 99–100, 102, 105, 107, 137, 152, 178, 184, 194, 196, 217, 219, 223, 230, 301, 314, 316, 320, 331, 333, 391, 397, 408 Premature aging, 361–382 Prevalence, 8, 85, 135, 138, 142, 153, 163–164, 169, 182, 195, 201, 216, 218–219, 267–270, 272, 292–293, 313, 315–316, 326, 330, 346, 364–365, 367, 381, 401–402 Prevention primary, 76–77, 80, 82–93, 142, 144, 225 secondary, 76–77, 80, 82–93, 142, 144, 152 tertiary, 76–77, 80, 82–93, 142, 144, 152 Preventive intervention, 74, 76, 80, 82–86, 92–93 Primitive defense, 37, 44–45

433 Prisoners of war (POW), 361–364, 367, 370, 380 Problem-focused coping, 252, 255, 277–279, 377 Prolonged exposure (PE), 112, 171, 299–300, 332, 364 Protective barrier, 29–30, 282 Protective factors, 74, 217, 294–295, 401 Psychiatric disability, 270, 272–274, 283, 370 Psychiatric symptomatology, 365, 370–371, 381 Psychobiological consequences of trauma, 412 Psycho-education, 66–67, 119–120, 229, 283, 302 Psychological rehabilitation, 10–11, 159–172, 177–206, 225, 347–348, 390, 396, 403, 416 Psychological shock, 5, 44 Psychological stress, 2–3, 5, 29, 105, 159, 187, 200–201, 206, 266, 280–281 Psychological trauma, 5, 9, 14, 30, 40, 44, 115, 216, 228, 328, 397, 400, 403 Psycho-physiological complaint, 380–381 Psycho-physiological impairment, 380 Psychosocial assistance, 222, 226, 228, 231, 238, 408, 412 Psychosocial intervention, 16–17, 126, 199, 206, 402, 408, 410 Psychosocial trauma, 112, 127 Psychosocial treatment, 299–300 Psychotherapy, 34, 91, 121–122, 201, 227, 298, 300, 306, 312, 372, 403, 405, 416 Psychotraumatology, 394, 417 Psychotropic medication, 121, 162 Public health, 17, 73–93, 135, 137, 143–144, 150, 199, 224, 381, 390, 402 Public-health perspective, 143 Public mental-health approach, 391 R Randomized controlled trial, 92, 171, 200, 392 Rape, 5–6, 29, 77, 91, 141, 178, 196, 227, 249, 254, 256, 258, 270, 291–306, 313–314, 319, 321, 324–326, 328, 341–342, 415 Rape as weapon of war, 293 Reconciliation, 10, 55–69, 81, 84–86, 88–89, 91, 180, 187–188, 190, 192, 206, 229, 237–238, 345–346, 348–349, 395, 401–403 Reconstruction, 4, 12–15, 18, 55–69, 81–83, 85, 87, 92–93, 103, 108, 123–124, 126, 142, 148, 151, 180, 190, 348, 404

434 Recovery, 2, 4, 15, 17, 28–29, 33–34, 40, 48–51, 55, 60–61, 115–116, 124–125, 147, 151, 171, 180, 188, 216, 218–220, 222–233, 235–239, 250, 253, 256, 259, 274–275, 283, 299, 302, 327, 366, 370, 372–373, 379, 391, 395, 397, 400, 403–404, 406–408, 414–417 Recovery environment, 29, 48–51, 115, 124–125, 223, 250, 253, 274, 299 Refugee, 15, 18, 77–78, 82, 86–88, 90, 100, 104–105, 111–112, 118, 124–125, 138–139, 179, 182, 199–201, 202–203, 219–220, 222–225, 228, 231, 233, 235–237, 269, 280, 298, 301, 305, 314, 319–320, 325, 331, 336, 390, 395, 405–406, 408–410 Rehabilitation counseling, 116–117 Rehabilitation definition, 11–14, 143–146 Rehabilitation international (RI), 102 Rehabilitation intervention, 2, 4, 10–11, 14–15, 18–21, 348 Rehabilitation philosophy, 11 Rehabilitation psychology, 7 Reintegration, 9, 14–15, 18, 143, 149, 151, 153, 178–186, 188–197, 204–205, 235, 319, 343–348, 407, 415 Religious coping, 278 Religious leader, 88–89, 236, 345, 413 Repatriation, 14, 81, 87, 100, 180, 380 Repetition compulsion, 8, 38 Repression barrier, 34 Resiliency, 87, 118, 162–163, 172, 274 Ripple effect, 2, 5, 10, 29, 137, 292, 303 Risk factors, 7, 74, 77, 82, 92, 112, 119, 163, 217, 270–272, 274, 283, 320, 371 Romania, 79, 390, 394, 416 Rwanda, 66–68, 78–79, 84, 89, 93, 135, 137, 183, 187, 191, 200, 203–205, 230, 236, 293, 304, 315, 320, 326, 346, 390–391, 401–402, 406, 416 S Safe space, 228–229, 253 Salutogenic outcome, 373 Screening, 160–163, 166–167, 172, 200, 227, 274, 298, 391–392, 397, 417 Secondary complication, 146 Secondary victimization, 48 Sensitivity to stress, 339 Service system, 99 Sexual abuse, 6, 29, 104, 196, 249, 323–324, 399 Sexual assault, 254, 266, 270, 273, 291–306, 322, 324

Index Sexual crime, 292–293 Sexual and gender-based violence (SGBV), 136, 142, 220, 228–229, 236–237 Sexually transmitted infection, 304 Shame, 229, 247–259, 266, 294, 296–298, 332, 342, 364, 405 Sierra Leone, 93, 137, 149, 185, 193, 292, 315, 332, 342, 346–347 Small arms, 136, 140–142, 162, 316 Social context, 113, 141, 225, 367 Social dysfunction, 401 Social infrastructure, 3, 142, 303 Social intervention, 16–18, 123–124, 126, 199, 201, 6, 224–225, 234, 402–403, 408–412 Social isolation, 107, 122, 186, 267, 280, 292, 294, 312, 347 Social participation, 105, 107 Social reconstruction, 55–69, 85, 348 Social stigma, 6, 250, 256, 340–343 Social support, 6, 44, 106, 114, 125–126, 149–150, 152, 190–191, 224, 232–233, 238, 255–256, 270, 274, 279–284, 295–296, 303, 345, 361–362, 367, 401, 412–414 Social trauma, 56–57, 69, 112, 127 Societal trauma, 55–57, 60–62, 65, 118 Socio-ecological theory, 16 Socioeconomic status, 75–76 Somaliland, 181, 198, 333 South Africa, 56, 61, 63, 67–68, 75, 183, 296, 338 Speechless terror, 393, 395 Sri Lanka, 93, 98, 185, 200–201, 203, 315, 317, 320, 326, 334, 337, 390–392, 400, 406, 412, 416 Stimulus barrier, 8, 29, 36–39, 45–46, 48, 51 Stress inoculation training, 91, 121 Stress load, 5, 7, 331 Stressor, 2, 10, 16–17, 34, 57, 112, 125, 159–163, 165, 167–172, 178, 182, 251–253, 255, 266–268, 271, 275–277, 279–282, 297–298, 303–304, 321, 324, 326–327, 331–332, 335, 345, 361–362, 364–365, 372–373, 381, 391, 398, 400–401, 409–410, 413–414 Stress-regulating system, 339, 398–399 Stress response, 6, 29, 188, 266–267, 271–274, 277, 283–284, 338, 376, 398 Structural prevention, 84 Sub-Saharan Africa, 134, 139, 149, 180, 189 Substance-use disorder (SUD), 168–169, 270, 332

Index Sudan, 75, 78, 93, 138, 182, 200, 229, 237, 315, 321 Suicidal ideation, 169, 182, 250–251, 269, 272, 332, 334 Suicide, 3, 74, 91, 140, 163–164, 169, 195–196, 232, 250–251, 269, 272, 297, 313, 316, 334, 338, 340, 369, 398 Survival, 8, 10, 12, 20, 37, 40, 56–57, 106, 108, 179, 188, 255, 313, 316, 319, 332, 338, 367, 397–398 Survivor network, 27–28, 31, 49, 267, 281, 283 Sustainable peace, 15, 148, 150–151 Sustainable recovery, 4 Syria, 75, 297, 363–364, 366, 381 Systemic rape, 292 Systems theory, 112–115, 127 T Tanzania, 84, 304 Terrorism, 84–85, 139, 267, 274, 324 Terrorist, 74, 119, 278, 313 Time distortion, 19 Torture, 6, 29, 79, 85–86, 91, 139, 178, 188, 202, 218, 220, 228, 234, 249–250, 293, 301, 313–314, 321, 324–325, 328, 331, 336, 342, 362–363, 367, 370, 372, 377, 380–381, 394, 400, 403, 405, 415 Traditional healer, 202, 230, 232–233, 236, 414 Transgenerational, 188, 338–340, 389–390, 397–400, 403 Transgression, 58–61, 63, 249 Trauma care, 123, 142, 146–147, 149–150, 152 membrane, 3–4, 27–51, 55, 61–62, 64, 67, 113–114, 118–119, 124–125, 127, 166–167, 170–171, 178, 253, 257, 259, 265–267, 271, 273–276, 280–284, 296, 303, 305–306 rehabilitation, 1–21, 112–113, 115–118, 127, 165, 170 researcher, 8–9, 220, 227, 280, 366 -spectrum disorder, 184, 201, 205, 324, 331, 338, 391, 396–397, 402, 411 Traumatic brain injury (TBI), 7, 161, 164–165, 167–170 Traumatic event, 3–9, 17–18, 20, 28–29, 31, 35–37, 42–44, 46–49, 51, 67, 113–114, 116, 118–119, 171, 182, 184, 202–203, 216–218, 220, 222, 224, 228, 247, 249–250, 252–254, 258–259, 267, 269–271, 273, 275, 281–282, 294, 299–302, 323–327, 334, 338, 364, 366,

435 370–372, 374, 376–377, 379, 390, 393–394, 401, 405–406, 412 Traumatic memories, 4, 8–9, 15, 20, 27, 29–30, 33–37, 40–48, 51, 56, 111–112, 252–253, 259, 282, 306, 369, 395 Traumatic neurosis, 31, 35–42, 45 Traumatic stress, 2, 6–7, 16, 29, 31–32, 50, 105, 111–112, 119, 122, 126, 142, 170, 182, 186, 188, 219, 265–269, 283, 311, 313–314, 321–330, 333, 337, 346, 348, 364, 371, 378, 381, 392–393, 397, 400, 402–403, 410–411 responses, 6, 29 Treatment, 4, 6, 10–11, 17, 20, 35, 42, 46–47, 88, 91, 112, 115–116, 119–122, 125, 127, 142–144, 161–162, 165–172, 177, 181, 185, 198–205, 216, 224–227, 232–233, 235, 237, 267, 272, 289, 292–295, 297–301, 303–306, 313, 318, 372, 379, 382, 389–390, 391, 396–397, 402–403, 405–407, 410–412, 415–417 Trigger, 6, 16, 35, 41–43, 46, 56, 60–61, 64, 67, 74, 87, 230, 247, 306, 324, 334–335, 365, 393, 405 Truth commission, 67 Truth and reconciliation, 63, 68, 86 Turkey, 75, 297 Type of trauma, 29, 31, 33, 218, 227, 299, 328 U Uganda, 78, 88, 105, 186–187, 203–204, 233, 292, 311, 315, 318, 321–323, 327–330, 333, 335, 341–345, 347–348, 390–392, 401, 406, 414–415 Unemployment, 20, 78, 84, 184–185, 222, 316, 333, 338 Unexploded ordnance (UXO), 86, 89, 313 United Nations, 4–5, 10–14, 76–77, 82–83, 85, 98, 101, 134, 145, 150–151, 191, 219, 293, 305, 315, 342, 348, 394, 410, 414 United Nations Children’s Fund (UNICEF), 82, 102, 138, 141, 178, 233, 313–316, 336, 413 United Nations Educational, Scientific and Cultural Organization (UNESCO), 98–100, 106 United Nations Fund for Women (UNIFEM), 82, 291, 293, 297, 304–305 United Nations High Commissioner for Refugees (UNHCR), 82, 126–127, 134, 178, 219, 222–224, 316, 345, 408, 414–415 United Nations Relief and Rehabilitation Administration (UNRRA), 13

436 United States, 13, 56, 84, 121, 162, 185, 250, 346, 371, 381 United States Department of State, 13 V Verbal memory, 40, 202 Veterans, 7, 20, 33–34, 37, 49, 122, 159–172, 182–185, 219, 249–250, 252, 267, 273, 327, 330, 334, 366, 369, 371–378, 381 Victimization, 9, 18, 48, 249, 295–296, 375, 378, 394–395, 403, 407 Vietnam, 20, 33–34, 47, 49, 122, 142, 164, 168, 170, 250, 271, 334, 364, 373, 376 Violence, 1–5, 9–10, 43, 60–62, 65–69, 74–77, 79–80, 82–89, 91–93, 104, 111–112, 115–116, 118–120, 133–137, 139, 141–142, 150, 178, 181, 183–188, 196, 198, 201, 206, 216–220, 222–223, 226, 228, 230, 234, 238, 249, 267, 270, 274, 276–278, 280–281, 291–294, 297–298, 303–305, 311–314, 316, 319–320, 324, 327, 330–332, 335–336, 338–340, 342–349, 362, 371, 389–391, 394, 397, 399, 401–403, 405–408, 413–416 Violent behavior, 83, 248, 399

Index Vocational rehabilitation, 11, 15–16, 144 Vocational skills, 81, 89–91 W War captivity, 323, 330, 334–336, 339, 361–382 neurosis, 38 -related injury, 313 -related rape, 297, 299, 303–305 West Bank/Palestine, 98, 101–104, 106–108, 112, 142, 144, 149, 270 Withdrawal, 40, 251, 254–256, 269, 325, 332, 364, 377 World Bank, 1, 3, 5, 21, 82–83, 101, 105, 142, 144, 146–147, 149–150, 180, 204, 223, 313 World Health Organization (WHO), 11, 18, 74, 98, 111, 123, 134, 219, 271, 298 World War, 13, 49, 56, 74, 135, 144, 170, 178, 216, 271, 293, 369, 378 Y Yugoslavia, 78–79, 137, 187, 293–294, 346, 415

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