Trauma Rehabilitation After War and Conflict

Erin Martz
Editor
Trauma
Rehabilitation After
War and Conﬂict
Community and
Individual Perspectives
123
Trauma Rehabilitation After War and Conflict
Erin Martz
Editor
Trauma Rehabilitation After

War and Conflict
Community and Individual Perspectives
123
Editor
Erin Martz
Rehability
Portland, OR
USA
martzerin@gmail.com
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
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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 indi-
viduals 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 early-
life 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.
vii
Contents
1 Introduction to Trauma Rehabilitation After War

and Conflict . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Erin Martz
2 Exploring the Trauma Membrane Concept . . . . . . . . . . . . . 27
Erin Martz and Jacob Lindy
3 Forgiveness and Reconciliation in Social Reconstruction
After Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Everett L. Worthington and Jamie D. Aten
4 A Public-Health View on the Prevention of War
and Its Consequences . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Joop T. de Jong
5 Community-Based Rehabilitation in Post-conflict
and Emergency Situations . . . . . . . . . . . . . . . . . . . . . . . 97
Arne H. Eide
6 A Systems Approach to Post-conflict Rehabilitation . . . . . . . . . 111
Steve Zanskas
7 Human Physical Rehabilitation . . . . . . . . . . . . . . . . . . . . 133
Pia Rockhold
8 Psychological Rehabilitation for US Veterans . . . . . . . . . . . . 159
Thomas A. Campbell, Treven C. Pickett, and
Ruth E. Yoash-Gantz
9 Psychological Rehabilitation of Ex-combatants
in Non-Western, Post-conflict Settings . . . . . . . . . . . . . . . . 177
Anna Maedl, Elisabeth Schauer, Michael Odenwald,
and Thomas Elbert
10 Psychosocial Rehabilitation of Civilians
in Conflict-Affected Settings . . . . . . . . . . . . . . . . . . . . . . 215
Laura McDonald
ix
x Contents
11 Shame and Avoidance in Trauma . . . . . . . . . . . . . . . . . . . 247

K. Jessica Van Vliet
12 Psychosocial Adjustment and Coping
in the Post-conflict Setting . . . . . . . . . . . . . . . . . . . . . . . 265
Erica K. Johnson and Julie Chronister
13 Helping Individuals Heal from Rape Connected to Conflict
and/or War . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
Meghan E. McDevitt-Murphy, Laura B. Casey, and Pam Cogdal
14 The Psychological Impact of Child Soldiering . . . . . . . . . . . . 311
Elisabeth Schauer and Thomas Elbert
15 The Toll of War Captivity: Vulnerability, Resilience,
and Premature Aging . . . . . . . . . . . . . . . . . . . . . . . . . . 361
Zahava Solomon and Avi Ohry
16 Trauma-Focused Public Mental-Health Interventions:
A Paradigm Shift in Humanitarian Assistance and Aid Work . . . 389
Maggie Schauer and Elisabeth Schauer
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 429
Contributors
Jamie D. Aten University of Southern Mississippi, Hattiesburg, MS, USA,

atenjamie@gmail.com
Thomas A. Campbell VA Medical Center, Richmond, VA, USA,
thomas.campbell4@va.gov
Laura B. Casey University of Memphis, Memphis, TN, USA,
lpcasey@memphis.edu
Julie Chronister Department of Counseling, San Francisco State University, San
Francisco, CA, USA, jchronis@sfsu.edu
Pam Cogdal University of Memphis, Memphis, TN, USA,
pcogdal@memphis.edu
Joop T. de Jong VU University Medical Center & Boston University School of
Medicine, Amsterdam, The Netherlands, jtvmdejong@gmail.com
Arne H. Eide SINTEF Health Research, Oslo, Norway, arne.h.eide@sintef.no
Thomas Elbert University of Konstanz, Konstanz, Germany; vivo International,
Konstanz, Germany, thomas.elbert@uni-konstanz.de
Erica K. Johnson Western Washington University, Bellingham, WA, USA;
University of Washington, Seattle, WA, USA, ericajohnsonphd@uwalumni.com
Jacob Lindy University of Cincinnati, Cincinnati, OH, USA, jdlindymd@3001.us
Anna Maedl University of Konstanz, Konstanz, Germany, anna.maedl@vivo.org
Erin Martz Rehability, Portland, OR, USA, martzerin@gmail.com
Meghan E. McDevitt-Murphy University of Memphis, Memphis, TN, USA,
mmcdvttm@memphis.edu
Laura McDonald Psychiatric Epidemiology, Johns Hopkins University
Bloomberg School of Public Health in the Mental Health, Baltimore, MD, USA,
lmcdonal@jhsph.edu
xi
xii Contributors
Michael Odenwald University of Konstanz, Konstanz, Germany,

michael.odenwald@uni-konstanz.de
Avi Ohry Tel Aviv University, Tel Aviv, Israel, aohry@bezeqint.net
Treven C. Pickett VA Medical Center, Richmond, VA, USA,
treven.pickett@va.gov
Pia Rockhold Consultant to World Bank and EU; Chair of the North South Group
for Poverty Reduction, Ashton, MD, USA, piaroc@hotmail.com
Elisabeth Schauer Department of Psychology, University of Konstanz, Konstanz,
Germany; vivo International, Konstanz, Germany,
elisabeth.schauer@uni-konstanz.de
Maggie Schauer Center for Psychiatry Reichenau, University Konstanz,
Konstanz, Germany, margarete.schauer@uni-konstanz.de
Zahava Solomon Tel-Aviv University, Ramat-Aviv, Israel,
solomon@post.tau.ac.il
K. Jessica Van Vliet University of Alberta, Edmonton, AB, Canada,
jvanvliet@ualberta.ca
Everett L. Worthington, Jr. Virginia Commonwealth University, Richmond, VA,
USA, eworth@vcu.edu
Ruth E. Yoash-Gantz VA Medical Center, Salisbury, NC, USA,
ruth.yoash-gantz@va.gov
Steve Zanskas The University of Memphis, Memphis, TN, USA,
szanskas@memphis.edu
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 repre-
sentative 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 direc-
tors 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 reha-
bilitation 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
xiii
xiv About the Contributors
Evidence-Based Practitioners in Rehabilitation. She received the CSU Vice-

Presidential Scholarship award in 2009 and was awarded the 2009 research award
by American Rehabilitation Counseling Association. Her primary research inter-
est 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 coun-
seling 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 pro-
fessor 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 devel-
oped 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 Norwegian-
based 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 psychopathol-
ogy. 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, tor-
ture, 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.
About the Contributors xv
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 psy-
chology. 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 clin-
ical 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 posttrau-
matic 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
xvi About the Contributors
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 cogni-
tive 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 popula-
tions 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, his-
tory 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 com-
pleted 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 involve-
ments 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 inter-
ests 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
About the Contributors xvii
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 conceptu-
alize 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 sub-
committee 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.
xviii About the Contributors
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 teach-
ing 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 for-
giveness 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 board-
certified 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 coun-
seling 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 rehabilita-
tion on a psychological and physical level. In this chapter, the multidimensional
concept of rehabilitation is explored and the definitions of disability and the mul-
tidimensional trauma membrane (intrapsychic, interpersonal, and communal) are
described. In addition, the topics of the psychosocial effects of war on individu-
als 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 individ-
ual level and the community level. Because rehabilitation interventions consist of
processes to facilitate healing on multiple aspects of human life, human rehabilita-
tion 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 dis-
aster” (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: martzerin@gmail.com
E. Martz (ed.), Trauma Rehabilitation After War and Conflict, 1

DOI 10.1007/978-1-4419-5722-1_1, C Springer Science+Business Media, LLC 2010
2 E. Martz
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 physiolog-
ical, 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 multidi-
mensional 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 success-
ful 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 commu-
nal 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 rele-
vant 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 inter-
ventions that can be implemented after war or armed conflict. The coping resources
1 Introduction to Trauma Rehabilitation After War and Conflict 3
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 com-
munal 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 hor-
rific 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 post-
conflict 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 post-
conflict environments “do not necessarily imply a completely peaceful atmosphere”
(Isturiz, 2005, p. 75) or complete cessation of all violence. The term “conflict-
affected” 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 post-

trauma 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), orig-
inally 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 infrastruc-
tures may be destroyed or damaged, consequently decreasing the naturally occurring
process of a protective, interpersonal “trauma membrane” to individuals. Martz and
4 E. Martz
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 mem-
branes 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 orga-
nizations (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 cre-
ating 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 encour-
age 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 influ-
ence 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 pro-
cess; one example is the situation in which interpersonal violence is not reduced to
manageable levels or violence restarts between warring parties after conflict, caus-
ing 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 sus-
tenance 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 invest-
ment, 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.
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 indi-
vidual 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 com-
munity 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 cre-
ating 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 commu-
nity 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 expe-
rience 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, experi-
encing 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.
6 E. Martz
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 dis-
abilities 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 dis-
aster 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., hur-
ricanes, rapes) and type 2 traumatic reactions to long-term, repeated traumatic
exposure (e.g., childhood sexual abuse, political torture). Terr also noted the exis-
tence 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 conse-
quences. 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 depen-
dent 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
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 disas-
ter. 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 ramifica-
tions 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 con-
sequences 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 under-
standing 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);
8 E. Martz
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 physi-

cal 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 stress-
ful 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 instru-
ment 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 sit-
uation, 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 psycho-
logical 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
assessed in some traumatized populations demonstrate that PTSD is not necessar-

ily 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 trau-
matic reactions is discerned when the presence of the symptoms persists and exerts
an adverse effect on adaptive functioning” (p. 19). Lifton (1988) viewed posttrau-
matic 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 over-
whelming 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 con-
trollable; (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 possi-
ble 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 find-
ing 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 conse-
quences 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, inter-
group 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 psycho-
logical 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
10 E. Martz
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) com-
mented 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 con-
sidered 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 (community-
level 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 facil-

itate 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
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 mul-
tidimensional; 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 fac-
tors 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., interper-
sonal) 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 inter-
ventions 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 addi-
tion to vocational and social rehabilitation (OSCE, 2005). The International Labor
Organization (ILO) also has worked for many years to improve the rights and treat-
ment 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
12 E. Martz
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 individu-
als 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 disabil-
ities may be viewed as a lower priority group for assistance and humanitarian aid.
This may occur because individuals with disabilities might be perceived as requir-
ing 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 reha-
bilitation is an intervention with the community as its focus. This form of rehabili-
tation should be distinguished from community-based rehabilitation (CBR), which
is a form of rehabilitation that is practiced with individuals in developing coun-
tries (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
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 non-
governmental 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 assis-
tance for emergency situations and the developmental planning. This contin-
uum of community-level interventions can be simply described as “emergency-
rehabilitation-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 devel-
opmental 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 rehabili-
tation 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 restora-
tion 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).
14 E. Martz
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., govern-
mental functioning and physical resources, such as roads). Reconstruction can be
viewed as part of development. Rehabilitation, on the other hand, refers to the heal-
ing 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 mul-
tifaceted 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 non-
governmental 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 disarma-
ment, demobilization, rehabilitation, and reconstruction (DDRR) programs. The
United Nations agencies coordinate a program called the “4R’s”: repatriation, rein-
tegration, 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).
Vocational Rehabilitation As an Intervention

From the point of view of psychiatry, it is important that these individuals [who have trau-
matic 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 indi-
viduals with physical or psychiatric disabilities to obtain competitive employment
as a means for greater independence and economic stability. While vocational reha-
bilitation 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 indepen-
dent, 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 com-
munity. 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 situ-
ations. 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 demo-
graphics 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 voca-
tional 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 con-
flict. 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 rehabil-
itation) 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).
16 E. Martz
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, cus-
toms, 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 exter-
nal 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 interact-
ing 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 community-
level 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 com-
munity 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 expe-
rience 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 commu-
nity 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
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 community-
wide loss (e.g., the destruction of buildings) typically has more powerful ramifica-
tions 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 cau-
tiously. 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 inter-
vention 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 interven-
tion as maintenance (e.g., reduce long-term effects, complications, or chronicity).
The prevention phase is divided into universal and selective interventions: univer-
sal interventions apply to the general public and selective interventions apply to
certain individuals or subgroups, who are at an elevated risk for psychosocial prob-
lems. 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.
18 E. Martz
In their chapter on psychosocial rehabilitation of refugees and asylum seekers,

Ekblad and Jaranson (2004) created detailed chart (see pp. 618–619) that lists sug-
gested, 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: attach-
ment, 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 inter-
ventions 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 com-
munity 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 activ-
ities (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 inter-
national 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 infrastruc-
ture 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).
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 becom-
ing 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 orienta-
tion/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 stand-
still 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 compres-
sion 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 “tem-
poral continuity” (p. 430), as manifested primarily by intrusive flashbacks of the
20 E. Martz
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 unem-
ployed 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, pur-
poseless, without an identity, had low self-esteem, and were bored. According
to Feather and Bond (1983), unemployment may lead to a greater risk of “tem-
poral 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 individ-
uals 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 immedi-
ate, 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 resid-
ual skills and abilities after the onset of disability or other forms of major trauma
and loss.
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 devel-
opmental 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 mul-
tidimensional. 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., communi-
ties/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 adapta-
tion and healing. The trauma membrane acts as an intrapsychic and interpersonal
mediator, interfacing between the person and the traumatic memories and every-
day 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 multi-
level 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 cov-

ering 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: martzerin@gmail.com

28 E. Martz and J. Lindy
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 lev-
els: 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 dys-
functional. On the interpersonal level, wars and armed conflicts create animosity
between groups or individuals as a consequence of personal loss or injury, witness-
ing 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 trau-
matic 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 individ-
uals 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, psychoso-
cial 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
2 Exploring the Trauma Membrane Concept 29
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 spe-
cific interpersonal and community dynamics (Lindy, Grace, & Green, 1981). The
trauma membrane can be considered as interfacing closely with the recovery envi-
ronment – 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 mem-
brane 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 heal-
ing 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, politi-
cal 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).
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 exacer-
bating 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, neu-
tral 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 config-
uration. 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 lay-
ers 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 speak-
ing) 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
arising specifically from trauma exposure until 1980, when posttraumatic stress dis-
order (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 disor-
der, 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 con-
sultants 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 com-
munities 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 com-
munity. 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 mem-
brane 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 imper-
sonal 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),
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 inves-
tigators 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 down-
town 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 clin-
icians, 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
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 mental-
health 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 phe-
nomenon 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 mem-
brane. 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 sit-
uation, “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
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, develop-
ing 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 expe-
riences” (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
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 gen-
erating 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 heal-
ing 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 con-
trolled 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 memo-
ries into their consciousness, which can include flashbacks or intrusive, non-verbal
memories (e.g., smells, sights, sounds). Because intrusive memories are a repeti-
tion 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 physio-
logic 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 neu-
rosis because “the whole ego structure has been altered in these chronic cases”
(p. 216, emphasis added), making abreaction “irrelevant” for curing traumatic
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 non-
verbal 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 dis-
tressing 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 inves-
tigators. 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 psy-
chological 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 defen-
sive 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 mas-
tering 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.
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 non-
functional. 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 post-
traumatic 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 indi-
viduals, 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 fix-
ations. 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 acci-
dent/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 mat-
ter 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 bar-
rier is not a simple concept, because of the evidence that the stimulus threshold
can be lowered (i.e., sensitization) or raised (i.e., adaptation) with traumatic stim-
uli. Further, several researchers have proposed that the stimulus barrier can be both
passive and active by the receptive and protective functions respectively. For exam-
ple, 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 dur-
ing 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 stimu-
lus 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”;
p. 136). Instead of using the Freudian viewpoint on traumatic neurosis and sex-
ual 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 individ-

ual’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 psy-
chological 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 annihi-
lates 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.
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” psy-
chological 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 dur-
ing 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 integrat-
ing 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 mem-
ories, 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 mem-
brane, 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 con-
tains the sensory and emotional imprints of events (Van der Kolk, 2004). While
the autobiographical memory may be altered over time, the implicit memory
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 trauma-
tized 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 trau-
matic 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, “posttrau-
matic hysteria” was a process in which there was an increasing lack of integration,
creating even a broader range of problems in personality functioning and synthe-
sis. 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
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 con-
ceptualizations 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 mod-
erated 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 rec-
ognizable” (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 repet-
itive 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 alter-
nation 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 tech-
niques by which this is achieved will vary according to clients and the phases of
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’ theo-
ries, 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 “crip-
pling” 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 men-
tal framework that contains past experiences, beliefs, and expectancies (Creamer,
Burgess, & Pattison, 1992). When traumatic events occur, individuals have to inte-
grate 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 intru-
sion precedes avoidance symptoms, because intrusion occurs when a trauma or fear
network is formed. This fear network includes stimuli cues about the trauma, cogni-
tive, affective, physiological, and behavioral responses, and interpretive information
about the trauma. These researchers found that scores on the intrusion and avoid-
ance subscales (as measured by the Impact of Event scale) mediated the severity
of exposure to trauma (measured as a dichotomous score) and the resulting symp-
tom levels (as measured by the Global Severity Index), which they interpreted as a
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 dys-
function, 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 indi-
cation 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 con-
text of a well-functioning trauma membrane, according to Lindy (1986), involved
three tasks: (a) pinpointing affect-laden memories of the trauma, (b) ascribing mean-
ing 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
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 con-
tinuing 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 pro-
cesses, 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 “cog-
nitive 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 emo-
tions 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 mem-
ories 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), person-
ality 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 after-
math. 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
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 dam-
aged 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 pro-
cessing 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 permit-
ted 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 accom-
plished. 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 rein-
forces 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 ther-
apist 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 aggres-
sively tries to penetrate the trauma membrane, harm may occur. If the therapist is
guided by a strategy of digging out the trauma content, he or she is at risk of plung-
ing 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 oppor-
tunity 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 titra-
tion 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 posi-
tion 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 treat-
ment, 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 aux-
iliary 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)
In the pressure to have answers to the above questions, the therapist may over-
react 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 over-
whelmed 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 coun-
selor/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 mem-
brane to regulate the impact of these client narratives, in order to protect against
absorbing the un-metabolized trauma and consequently experiencing secondary vic-
timization. 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 action-
oriented 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 sur-
vivors, 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
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 non-
caring behaviors to which survivors are exposed. Ideally, these two structures – the
trauma membrane and recovery environment – work in concert with each other facil-
itating healing of the survivor and the community. However, following particular
disasters, tension at the interface between these two structures can be consider-
able. 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 recov-
ery 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 contam-
ination, 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 circumfer-
ence, 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 sur-
vivors, 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 com-
mandments 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 spe-
cial reason for their being spared. For example, the African-American population
at Buffalo Creek experienced a particularly rapid recovery. One factor, accord-
ing 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
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 mem-
brane 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 symp-
toms, 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 pos-
sibility 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 pro-
cess 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 under-
standably, 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, mem-
bers 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 exploita-
tion, 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.
Attending to potential discrepancies – between the interpersonal trauma mem-

brane on the one hand and the recovery environment on the other – provides a
rational guide for discovering new roles for mental-health professionals in post-
disaster 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 expo-
sure 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 com-
ponent to the necessary, acute interventions, such as those related to food, housing,
and medical needs. The innovation of combining mental-health efforts with emerg-
ing, 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 holis-
tically 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 sur-
vivors 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 mem-
ories 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 multi-
level trauma membrane can help researchers and clinicians explain trauma-related
processes and their clinical applications.
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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 aggres-
sion 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 rec-
onciliation 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 differ-
ent country. In the present chapter, we are concerned with social reconstruction
E.L. Worthington (B)

Virginia Commonwealth University, Richmond, VA, USA
e-mail: eworth@vcu.edu
Chapter submitted for Erin Martz (Ed.), Post-conflict Rehabilitation: Creating a Trauma
Membrane for Individuals and Communities and Restructuring Lives After Trauma.

56 E.L. Worthington and J.D. Aten
after human-caused trauma – with a focus on warfare, civil disquiet, or conflict.

Specifically, we examine the roles of forgiveness and reconciliation in social recon-
struction. 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 psy-
chological 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 gov-
ernment 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 coun-
tries 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 defen-
sive 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 experi-
enced 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 jus-
tified 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, for-
giveness 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.
3 Forgiveness and Reconciliation in Social Reconstruction After Trauma 57
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
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 unfor-
giving emotions (Worthington, 1998). The person, thus, may experience a second
type of forgiveness called emotional forgiveness. Emotional forgiveness is the emo-
tional 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 individ-
ual (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 forgive-
ness” 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 try-
ing 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 phe-
nomenon. It is a social or societal phenomenon. Reconciliation cannot be granted
to someone else. Rather, both people, through mutually trustworthy behaviors, con-
tribute 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 dur-

ing 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 exam-
ple, a forthright accusation of wrongdoing typically elicits defensiveness from the
transgressor.
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 men-
tally 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 rel-
ative 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 work-
ing 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
(Worthington, 2009). For example, some psychological structures include memo-

ries, 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 cur-
rently 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 success-
fully (Worthington, 2009). It would also appear that strong situations (e.g., Milgram
obedience experiments) – instead of eliminating personal beliefs and values – trig-
ger 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 recon-

ciliation, several crucial propositions that undergird understanding societal trauma
are identified. These assumptions have evolved out of or our own personal observa-
tions, 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 individu-
als, should likewise be expected to fluctuate widely in societal reactions to trauma.
Second, civil conflicts spur diverse and varying opinions among groups. From those
opinions a variety of advocates will evolve. Advocates for unequivocal peace, vio-
lence, 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 transgres-
sions 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 pro-
vided. 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 bene-
ficial reconciliative structures, (b) make the reconciliative structures more attractive
and rewarding than are the structures that maintain animosity, (c) build new reconcil-
iative 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, con-
flictual structures will persist, ready for a trigger to activate them in the future. The
practical problems with establishing the awareness of valuable relationships, care-
worthiness, 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)
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 abso-
lutely 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 spiri-
tual 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
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 repres-
sion 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 wrong-
doing, 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 accommo-
dated. Typically, this will require receiving information by other in-group members.
Though there may already be an exchange of information between in-group mem-
bers, 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 forgive-
ness 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 help-
ful 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.
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 suf-
fering. People respond to this threat by suppressing weakness and by masking this
fear through expressions of anger and shows of strength. Though this defensive-
ness 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 suffer-
ing 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
Cycle of Aggression Aggression
Suppress Aggressive Acts

• Turn other cheek
• Legal
• International Appeal
Strengthen Reconceptualize
Coping: Enacting Communities Cycle of Suffering
Suffering
Strength • Build New Peacemaking • Anything good
Structures • Redemptive
Weakness Turned to
Strength
• Solidarity
• Turn to God
Defensive Coping:
Suppress Weakness
Fig. 3.1 Cycles of aggression and peacemaking

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 peacemak-
ing 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 peacemak-
ing, 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 embrac-
ing 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 inter-
vention is not usually necessary (still, this falls within track-one diplomacy). For
most intrastate conflicts, the warring parties have little capability to regulate vio-
lence 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)
Troops might effectively suppress military activities and reduce (but not usu-
ally 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 peo-
ple 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 lucra-
tive positions. To change their stance is highly unlikely unless pressure is applied.
Peacekeepers can apply pressure, but if a leader knuckles under to foreign peace-
keepers, 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 diplo-
macy 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 repre-
sent. Because they have local credibility, they can influence people toward more
positive, accepting, and healing attitudes and behaviors. As Botcharova (2001) sum-
marized, “When a critical mass of medium-level and top grassroots enthusiasts
manages to heal its traumas, process its sense of victimhood, and come to for-
giveness, 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 commu-
nities. 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 experi-
ences 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 informa-
tion. Non-threatening approaches are therefore needed, such as psycho-educational
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 mem-
brane to be permeated by new interpersonal experiences instead of hardened by
defensiveness.
Skillful group facilitation is necessary to productive inter-group empathy build-
ing 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 pro-
vide either direct or indirect avenues for healing within communities. Once opinion
leaders are on board for promoting societal rehabilitation, then programs and per-
suasion 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 vio-
lence and aggression. Truth commissions are charged with seeking testimony that
brings out a truthful narrative. Truth, however, is dependent on different percep-
tions 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 super-
vised by parties’ representative of both sides, the findings will often be seen as more
balanced than a partisan view.
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 peo-
ple 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 hear-
ings 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 impor-
tant 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 educa-
tion 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
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 rec-
onciliation 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.
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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 rela-
tive 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, multi-
modal, 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 aggra-
vation or continuation of violence. A major increase in understanding is needed of
the relations between risk and protective factors and of the developmental path-
ways 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: jtvmdejong@gmail.com

74 J.T. de Jong
Introduction
Population growth, technological advancement, economic interdependence, and
ecological vulnerability, combined with the availability of weapons and the con-
tagion of hatred and incitement to violence, make it urgent to find ways to prevent
disputes from turning massively violent. Armed conflicts have significantly dam-
aged 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 conven-
tional 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 pro-
tective 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 main-
tain 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) defini-
tion 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 vio-
lence includes war and violent conflicts, state violence, terrorist acts, and mob
violence. Economic violence includes attacks by larger groups motivated by eco-
nomic 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
4 A Public-Health View on the Prevention of War and Its Consequences 75
to increasing poverty, hunger, and malnutrition (Farmer, 2003; Kleinman, Das &
Lock, 1997). A local conflict can spill over into national conflicts, which some-
times 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 antago-
nism (Staub, 1993). A progression of mutual retaliation may start with small acts
that escalate, resulting in a “malignant social process” (Deutsch, 1983). The esca-
lation 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 combina-
tion, 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 West-
Pakistan, 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-WW-
II 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 coun-
tries 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 eco-
nomic 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,
76 J.T. de Jong
and thus may have a higher predisposition to conflict. Health and nutritional indica-
tors 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 allevia-
tion, 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 institu-
tions (e.g., Organization of Security and Cooperation of Europe), whose purpose
is to restrain hostile acts against another nation. Although some of these insti-
tutions 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 combin-
ing 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 indi-
cated preventive interventions. Preventive interventions were classified to fit in the
appropriate cell of a nine-cell matrix.
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 identi-
fied 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 ethnic-
religious 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 sol-
diers 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 cumula-
tive 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, commu-
nities, 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
Table 4.1 Indicators of states at risk of collapse and internal conflict with examples and sequelae
78
Indicators Signs Examples Consequences
Inequality Widening social and economic inequalities, Former USSR and Yugoslavia The state is unable to manage political
both between and within population challenges and to maintain control over the
groups. Globalization, failed states, use of force
privatization, decline of social safety Increased mortality and physical disability,
nets, deprivation, competition for high death rates among civilians
resources, increased availability of National army and rebel/guerilla forces
weapons and landmines engage in armed conflicts to secure access
Struggle over access to resources such as Angola, Congo, S Leone, Chad, Nigeria, to the resources. Manipulation of resource
oil, diamonds, gems, timber, and rivers Sudan, Cambodia, Indonesia shortages for hostile purposes (e.g., using
Struggle over access to illicit drugs Afghanistan, Columbia, Myanmar water as a weapon).
Competition for income from narco-traffic
Rapidly Rapid changes in population structures Darfur
changing including large-scale movements of Pre/post-conflict massive population
demographic refugees and IDPs movements (e.g., refugees, IDPs) and
characteristics competition for resources in areas into
High rates of (infant) mortality Uganda, Angola, Mozambique, Zepa which people move. Environmental
(Balkan) degradation
Excessively high population densities Rwanda, Burundi Decline vaccination coverage, increase
High levels of unemployment, especially Liberia, S Leone, S Lanka, Sudan, Tigray infectious diseases, reduced access to
among youth health services
Insufficient supply of food or access to safe Eritrea Overcrowding, resource depletion,
water environmental degradation, high exposure
Disputes over territory or environmental Ethiopia, Eritrea to vectors, high risk of HIV infection, poor
resources claimed by distinct ethnic nutrition, increased risk diseases
groups or governments Discontent, recruitment into rebel forces
Conscription or looting of farmers,
destruction water and sanitation
infrastructure
Create a climate of warfare and involve
civilian populations
J.T. de Jong
Table 4.1 (continued)
4
Indicators Signs Examples Consequences
Lack of Violations of human rights Bhutan, Cambodia, Iran Yugoslavia, Torture, imprisonment, mutilation
democratic Criminalization or de-legitimization of the Guatemala, Iraq, Mozambique, S Leone, High military expenditures
processes state Ethiopia Use of violence to survive or to achieve their
Corrupt governments, faulty leaders aims
Political Rapid changes in regimes Somalia, East Congo, Liberia, S Leone, Failed states
instability Ethnic composition of the ruling elite Angola, Mozambique Protracted cycles of violence and eruptions of
differing from the majority Rwanda, Burundi ethic clashes
A legacy of vengeance –seeking group Balkan (Bulgaria, Hungary, Romania,
grievance Slovakia)
Ethnic Political and economic power exercised – Rwanda, Burundi, S Lanka, Balkan, Inter-ethnic strife
composition of and differentially applied – according to Caucasus,
ruling ethnic ethnic or religious identity Nagorno-Karabakh/ Azerbaijan,
group different Desecration of ethnic or religious symbols Afghanistan
from the Tibet
population at
large or ethnic
groups
straddling
interstate
boundaries
Deterioration of A decline in the scope and effectiveness of Poverty, deprivation, discontent, and
public services social safety nets designed to ensure subsequent involvement in armed struggle
A Public-Health View on the Prevention of War and Its Consequences
minimum universal standards of service

Severe economic Uneven economic development West Africa, Great Lakes Region of Africa Reduced public expenditure on, e.g., health
decline Grossly unequal gains or losses between and education
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 Great Lakes region of Africa Rise of complex humanitarian emergencies
79
revenge groups
80
Table 4.2 Matrix showing the relation between Universal, Selective, and Indicated Preventive Interventions, and Primary, Secondary, and Tertiary
Preventiona
Society-at-large/(inter)national Community Family and individual
Primary Universal preventive interventions Universal and selective preventive Universal and selective interventions
prevention: Economy, governance, and early warning interventions Include women and children in the
eliminate a conflict Free media and press Rural development and food production distribution of economic growth
or problem before Resolve underlying root causes of violence Community empowerment Family reunion/family tracing
it can occur (Inter)national laws Decreasing dependency and learned Family/network building
Defining and condemning human-rights helplessness Improvement of physical aspects
violations Public health and education Public health and education
Research into events and their Peace education and conflict resolution in
consequences schools
Setting standards for intervention and Public education
training Security measures
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
J.T. de Jong
4
Society-at-large/(inter)national Community Family and individual
Secondary Humanitarian relief operations Conflict prevention & resolution Prevention of recruitment of child soldiers
prevention: Reparation and compensation Crisis intervention Reparation and compensation for afflicted
shorten the Voluntary repatriation Vocational skills training families
course of a (Co-occurring) Natural disasters: quality Public (mental) health and disease control
conflict or standards Crisis intervention
problem
Tertiary Peacekeeping and peace-enforcing troops. Reconciliation and mediation skills Involve the family in rehabilitation and
prevention: Peace agreements between groups reconstruction
prevent a conflict
from becoming
chronic, to recur,
and to contribute
to rehabilitation
and
reconstruction
A Public-Health View on the Prevention of War and Its Consequences
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
81
82 J.T. de Jong
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 pop-
ulation 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 inter-
ventions 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 fore-
shadows 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 (cri-
sis) intervention and case identification, and refer the conflict to relevant authorities,
such as the United Nations or governments. Tertiary prevention includes interven-
tions 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).
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 reconstruc-
tion aims at integrating external and internal efforts to restore essential services and
restart economic activity.
Governance goals include addressing corruption, weak and unaccountable gov-
ernment, 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 resolu-
tion. 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, politi-
cal 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., link-
ing 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
84 J.T. de Jong
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 edu-
cation 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 anthro-
pologist 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 abduc-
tions, gender-based violence (GBV), the destruction of homes, mass killings, or
ethnic cleansing. The result is mistrust, mutual hatred, and extreme stress, neces-
sitating 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 vio-
lence (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 unemploy-
ment, 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 bar-
riers 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 environ-
ment. 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.
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 pro-
tecting 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 non-
violent 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 pre-
venting 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, dia-
logue, 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
86 J.T. de Jong
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 over-
come 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, eco-
nomic, 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).
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., set-
ting 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), on-
going 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 liveli-
hood 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 agri-
cultural 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 pop-
ulations and IDPs or refugees. Rural development is one aspect of empowering a
community.
2. Community empowerment aims at revitalizing helping skills that are not uti-
lized by the local people, due to demoralization, collective apathy, or a lack of
appropriate knowledge. Empowerment activities involve community members to
88 J.T. de Jong
help themselves, their families, and their neighbors. These interventions lead to
communal pride – a psychological sense of community (Sarason, 1974), and stimu-
late “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 sto-
rytellers 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 edu-
cation 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 edu-
cation 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 educa-
tional 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 surveil-
lance 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 organiza-
tions, 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 accom-
plish is similar to what parents can do – employ positive discipline practices, teach
the capacity for responsible decision making, foster cooperative-learning proce-
dures, 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.
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 vio-
lence 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 re-
traumatized 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 popula-
tion 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 lead-
ers, 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 demo-
bilized 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.
90 J.T. de Jong
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 vulner-
able 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 accommo-
dated 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 cer-
tain 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 impor-
tant that they are involved in the development of their life-world, including the
physical aspects of their habitat or refugee camp. This includes discussing accept-
able 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 agen-
cies 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 sub-
primary 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 gov-
ernment armies and rebel forces. This type of prevention includes (1) ensuring
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 peo-
ple 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 sol-
diers, 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 sit-
uations of collective violence, para-professional counselors are recruited among
the target population. They provide problem-solving and supportive counsel-
ing 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 psy-
chotherapy or counseling (e.g., tricyclic antidepressants or selective sero-
tonin reuptake inhibitors [SRRIs], inhibitors of adrenergic activity, and mood
stabilizers).
5. Crisis intervention. A crisis team can intervene when health emergencies, sui-
cide, 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.
92 J.T. de Jong
Tertiary Prevention at the Level of the Family and the Individual

The goal of tertiary prevention is to reduce anomia, apathy, and chronicity of dis-
abling 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 occur-
rence. 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 devel-
opment 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, ran-
domized 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 random-
ized community designs are not feasible for ethical and political reasons. However,
quasi-experimental studies, such as using matching techniques to reach compa-
rability or time-series designs, offer an alternative. We certainly need to better
comprehend the micro-, meso-, and macro-levels of political, economic, social, cul-
tural, 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 fac-
tors, 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
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 exam-
ple, when the international court decides to prosecute a president – such as Bashir
of Sudan – this may be regarded as a secondary and tertiary preventive interven-
tion (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 vio-
lence, 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 organiz-
ing 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.
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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 deliv-
ering 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 devel-
opment, which also incorporates human rights, democracy, and a gender-based
perspective within its ambitions. Such core values are under strong pressure in post-
conflict 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, uti-
lizing 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 individu-
als 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 post-
conflict 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 situa-
tions following human or natural disasters. According to the International Disability
A.H. Eide (B)

SINTEF Health Research, Oslo, Norway
e-mail: arne.h.eide@sintef.no

98 A.H. Eide
and Development Consortium ([IDDC], 2000, p. 5), “. . .. in conflict situations, dis-

ability 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 sit-
uations 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 strat-
egy 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 pre-
ferred 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 com-
munities, and the appropriate health, education, vocational, and social services”
(p. 2). CBR has developed from an extension of primary health care (PHC) and reha-
bilitation services for disadvantaged communities to a comprehensive strategy for
community development and change (Thomas & Thomas, 2003). At this stage, how-
ever, 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
5 Community-Based Rehabilitation in Post-conflict and Emergency Situations 99
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 com-
prises many aspects or strategies, including medical or therapy, educational, voca-
tional, 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 con-
textual 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 primar-
ily 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
100 A.H. Eide
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, ensur-
ing 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 dis-
abilities 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 dis-
proportionately 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 sup-
port 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 relation-
ship 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
Table 5.1 Different types of

chronic conflict situations 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 situa-
tions 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 peo-
ples 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 sit-
uations, 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 incorpo-
rating 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 devel-
oping 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
102 A.H. Eide
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 dissemina-
tion, 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 struc-
tures 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 par-
ticularly 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 struc-
ture, 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 pop-
ulation has experienced 30 years of war, followed by ongoing conflict with Ethiopia
and thus permanent mobilization for war. The state machinery in Eritrea is function-
ing 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 implemen-
tation 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 exam-
ple 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 flex-
ibility 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
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 infras-
tructure. 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 fam-
ilies 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 invis-
ible 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 manage-
ment 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 them-
selves 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.
104 A.H. Eide
– 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 exam-
ple, 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 peo-
ple 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 aware-
ness 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 peo-
ple with disabilities. This may reduce the danger of people with disabilities being
excluded or deliberately neglected to the advantage of individuals without disabili-
ties 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
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 every-
one 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 partici-
pation. 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 ser-
vice 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 sit-
uation 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 individ-
ual 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 pop-
ulations (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
106 A.H. Eide
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 fam-
ilies 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 sit-
uation, 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 possi-
ble reasons, such as a breakdown of services, increased mobility problems due to
destruction and security problems, mental stress on the person with a disability him-
self/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 cul-
tural, 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.
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 impor-
tant 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 establish-
ing environments conducive for participation of people with disabilities. At this
level, access to education, health services, social arrangements, and decision mak-
ing 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 engage-
ment 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 consid-
eration 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,
108 A.H. Eide
clothing, water and sanitation, shelter, and medicines. Not only will it be prob-
lematic to focus on the long-term core CBR activities within the chaotic con-
text 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 dif-
ferentiation – 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 with-
out 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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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 post-
traumatic 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: szanskas@memphis.edu

112 S. Zanskas
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, dis-
ruption 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 fac-
tors 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, psycholog-
ical, 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 the-
ory, 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 sys-

tems theory is reflected by the early writings of Lewin (1951) and Bertalanffy
6 A Systems Approach to Post-conflict Rehabilitation 113
(1952). Lewin (1951) considered the person and their environment as interdepen-
dent regions of life space with a permeable boundary between the psychological
and physical world. Bertalanffy (1952) conceptualized systems as mutually interact-
ing components that were connected through relationships. Relationships between
members of a system increase exponentially faster than the actual number of mem-
bers 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 under-
standing 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 sys-
tems 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).
114 S. Zanskas
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 clini-
cian’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 dif-
ferent 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 sur-
vivors 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 circum-
stances, 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 interven-
tion 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 con-
flict. 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 sub-

systems (Hudson, 2000). A simple system involves fewer members and interactions
among members than complex systems. A system is considered simple if its com-
ponents 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 char-
acterized 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).
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 sur-
vivors of mass violence experience varies with the type and extent of the conflict,
personal and community resilience, socio-cultural factors, and the environmen-
tal 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 conceptu-
alize the recovery environment. Bronfenbrenner (2001) added the chronosystem as
a final layer to his system to represent the reciprocal influence of time on the sur-
vivor and their recovery environment. The first layer, the microsystem, includes the
survivors’ immediate environment, their activities, roles, and interpersonal relation-
ships. 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 con-
sists 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 deliv-
ery 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 com-
plex 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 con-
flicts are viewed as threats to both individual and collective coping and resilience.
Described as a multidimensional approach, this model attributes individual
116 S. Zanskas
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 individu-
als 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 envi-
ronment 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 oper-
ationally defined recovery as improvement in any one of the following domains:
the survivor’s authority over the remembering process; their integration of mem-
ory 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 gener-
ally 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 disabil-
ity, the provider, and the context are brought together by the traumatic event. Each
client subsystem consists of the interaction among each client’s unique personal-
ity, competencies, and goals. Prior to implementing services, Hershenson (1998)
recommended that the characteristics of each client’s system and subsystem be ana-
lyzed 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).
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 inter-
ventions 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 Reintegrate Counsel

Personality
Goals Reformulate Counsel
Competencies Resolve or replace Coordinate
Environment
Family Restructure Consult
Learning Restructure Consult
Peer group Restructure Consult
Independent living Restructure Consult
Work Restructure Consult
Conception of disability Restructure Consult
Cultural–political–economic context Restructure Consult
Provider
Rehabilitation services delivery Realize Case manage
Rehabilitation counselor Revise 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 per-
sonality or during their reformulation of goals. As the counselor attempts to assist
survivors to restore or replace pre-conflict services, coordination becomes the pri-
mary 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 ser-
vice integration, and facilitate organizational effectiveness. Finally, humanitarian
workers need to continuously monitor and critique the effectiveness of their inter-
ventions as a provider, revising their functions and interventions as needed, in order
to meet the survivors’ needs.
118 S. Zanskas
Although a broad range of social and mental-health interventions have been sup-
ported by research, the value of mental-health-care services in resource-poor coun-
tries 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 assis-
tance, 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 con-
ceptualized 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 con-
text 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 devel-
opment, 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 coun-
try’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 profes-
sionals 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 sur-
vivors 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
initially occurs through conversation with survivors, emphasizing information rel-

evant 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 fac-
tors 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 exam-
ples 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 fol-
lowing 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 partic-
ipants attended a weekly group session that addressed abreaction, normalization
of their feelings, coping with symptoms, and cognitive restructuring. The partici-
pants’ 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 mea-
sure 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 debrief-
ing, was provided to 42 British soldiers, who were responsible for identifying and
120 S. Zanskas
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 differ-
ence 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. Follow-
up 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 par-
ticipated 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 fol-
lowing 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 con-
trast, 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 debrief-
ing intervention and the control group that was composed of 59 officers. However,
18 months following the crash, those officers who did participate in the debrief-
ing showed significantly more disaster-related symptoms than officers that did not
participate in the debriefing intervention.
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 com-
prehensive 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 cognitive-
behavioral approaches that involve exposure therapy, cognitive processing therapy
(CPT), and stress inoculation training (SIT) have sufficient research to be rec-
ommended as primary treatments for chronic PTSD. However, early intervention
focusing on the forced recall of events or associated emotions appears inconsis-
tently 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), psy-
chotherapy 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 psy-
chotropic 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
122 S. Zanskas
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 iso-
lation, 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, sug-
gest 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 enter-
ing 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 anti-
psychotic 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 post-
traumatic 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 experienc-
ing 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 oth-
ers 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
devices (in the chaos of a war zone), have increased difficulty accessing basic life-
survival needs, and are affected by the loss of the infrastructure that previously pro-
vided rehabilitation services. According to the World Health Organization (2005),
an appropriate response to post-conflict rehabilitation includes institute-based reha-
bilitation (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 dis-
abilities, 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 estab-
lishing multi-disciplinary task forces that consider available resources, in order to
prepare a long-term rehabilitation program. During the reconstruction phase, long-
term responses include the identification and assessment of the immediate and future
needs of people with newly acquired and pre-existing disabilities; resource map-
ping to determine community abilities for addressing basic existence, health care,
and rehabilitation needs; infrastructure development to provide medical rehabili-
tation 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; col-
laboration; 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 humani-
tarian 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 account-
ability. 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
124 S. Zanskas
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 par-
ticularly important during the acute-response phase to disaster. Emphasis is placed
on reuniting and keeping intact families, as well as communities. Community par-
ticipation 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 com-
munity. 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 psy-
chological and psychiatric intervention indicators (Sphere, 2004). Any intervention
should be based on an assessment of the existing resources and socio-cultural con-
text, 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 assess-
ment results can be used to develop recommendations for a community-based,
appropriately timed, mental-health program. Consistent with Hobfoll’s (1989) con-
servation of resources model of stress, the RAMH results provide a description of
the available individual, family, community, human, financial, political, and mate-
rial resources. A particular strength of the instrument is its evaluation of the cultural,
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 coordinat-
ing 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 pro-
tecting 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 work-
ers 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 guid-
ance 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 achieve-
ment 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 sys-
tems, 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 sup-
ports, 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 con-
ditions. Interventions designed to restore community and family supports include
family tracing and reunification, mourning and healing ceremonies, outreach
126 S. Zanskas
communication regarding effective methods of coping, restoration of educational

and employment activities, and initiation of social networks. Focused, non-
specialized 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 psy-
chological 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 psy-
chosocial support. Each intervention is organized by the category of response: emer-
gency 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 devel-
opment of human resources. Core mental health and psychosocial support domains
include community mobilization and support, capacity building in the areas of edu-
cation, 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 popu-
lation’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 psy-
chosocial 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
(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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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 econom-
ically 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 nec-
essary continued access to rehabilitation for people affected by conflict and others
living with disabilities, but further address the more long-term needs for rehabilita-
tion 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: piaroc@hotmail.com

134 P. Rockhold
this chapter will describe current knowledge of the impact of conflict-related, com-
plex emergencies on human physical health, focusing primarily on conflict-related,
intentional injuries. Second, it will emphasize the importance of human rehabil-
itation 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 con-
siderable breakdown of authority resulting from internal or external conflict and
which requires an international response that goes beyond the mandate or capac-
ity 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
7 Human Physical Rehabilitation 135
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 con-
flict on public health have provided more precise and accurate evidence suggesting
that conflict-related deaths are on the increase. Modern conflict is, in an increas-
ing 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 cov-
ered 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 indi-
rect 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 con-
flict 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).
136 P. Rockhold
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 non-
combat-related (indirect) mortality in conflict-affected zones, estimated the war-
related 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 ser-
vices (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 infras-
tructure 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).
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 essen-
tial medical supplies and medicines, are often greatly reduced in conflict-affected
settings, as the security situation worsens. Further, health prevention and interven-
tion 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 exacerbat-
ing 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 short-
age 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 humani-
tarian 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 provi-
sion of clean water and sanitation (Liberia, 2006). This type of destruction threatens
public health long after the conflict ends. Essential services, such as immuniza-
tion and maternal and child health, are often jeopardized (Neumayer & Plumper,
2006), increasing infant, child, and maternal morbidity, disability, and mortal-
ity, 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
138 P. Rockhold
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 under-
mine 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 special-
ized 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 per-
cent) (Loretti, 1997). Most conflict-affected countries suffer when scarce national
resources are diverted away from the promotion and protection of health and pro-
ductive 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.
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 opportu-
nity, 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 gender-
based violence, including forced prostitution (e.g., in military brothels) and sex-
trafficking (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, accord-
ing 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, espe-
cially 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).
140 P. Rockhold
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 commer-
cial 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 anti-
tank 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, includ-
ing 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 interna-
tional 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)
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 bot-
tom 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, dispropor-
tionately 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 produc-
tivity 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 exploita-
tion 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 experi-
enced 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 con-
founded 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 clas-
sified 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 one-
self 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,
142 P. Rockhold
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 disor-
ders 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 long-
term 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 ade-
quate secondary and tertiary prevention (e.g., emergency services, trauma care,
and rehabilitation to reduce the impact of injury or illness). Early access to emer-
gency 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 ter-
rain; 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 hin-
dering them from gaining access to relief, distributions, and development decisions for themselves
and their families (Oosters, 2005).
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 chil-
dren 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 devel-
ops 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 stabiliza-
tion 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 limita-
tions, 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
144 P. Rockhold
of a wheelchair, prosthetic, or orthotic devices) and (2) addressing environmental

barriers (e.g., by preventing or removing physical barriers in buildings and trans-
portation, 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 spe-
cial 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 out-
side 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 compo-
nent 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).
Beyond the emergency phase, there seems to be little global and national aware-
ness of the importance of rehabilitation as a continuous, essential strategy and tool
to prevent the development of disability in individuals with injuries, chronic con-
ditions, 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 conse-
quence 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 rehabili-

tation 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 multidisci-
plinary 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 profession-
als 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 exclu-
sively 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.
146 P. Rockhold
Rehabilitation activities aim to (1) minimize the impact of impairments (e.g., by

muscle strengthening and fine-motor coordination improvement); (2) prevent sec-
ondary consequences of the condition (e.g., pressure sores or contractions); and
(3) provide adaptations designed to compensate for impairments (e.g., use of pros-
thesis, 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 pre-
vent 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 pro-
vided 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 middle-
income 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 coun-
tries (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).
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 essen-
tial 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 opti-
mize 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 pre-
vent 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 limita-
tions 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 parapro-
fessionals may be trained to provide some of this service), is typically needed
after trauma or serious illness, which many people surviving conflict have expe-
rienced (Bhuvaneswar, Epstein, & Stern, 2007). Some clients will also need speech,
vocational, neuropsychology, or occupational therapy to address cognitive and per-
ceptual 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 ser-
vices 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
148 P. Rockhold
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 dif-
ficult 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 activi-
ties, 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 correspond-
ing 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 eco-
nomic 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 sys-
tems and services to ensure sustainable peace and development.
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 pro-
duction 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 lim-
ited. 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 recog-
nized by the international community and large amounts of resources are used to
strengthen the temporary provision of rehabilitation services, especially to land-
mine 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 ser-
vices, 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 emer-
gency 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 long-
term, post-conflict phase in the transition from conflict toward more long-term,
150 P. Rockhold
sustainable development. This most likely occurs, due not only to limited coor-
dination 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 invest-
ment made by humanitarian agencies during the immediate post-conflict phase into
the more long-term post-conflict phase towards sustainable development is essen-
tial 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 acci-
dents 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 under-
estimation 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 imme-
diate 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 long-
term-sustainable health systems and development planning was recognized and
recommended by the United Nations already in 1991:
There is a clear relationship between emergency, [overall] rehabilitation and development.

In order to ensure a smooth transition from relief to [overall] rehabilitation and develop-
ment, 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 objec-
tive 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 ensur-
ing “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 reha-
bilitation 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 sys-
tems, 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 coun-
tries, especially in countries affected by conflict. Less than five percent of these
people presently have access to rehabilitation services (WHO, 1999). The funda-
mental 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 pro-
portion (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 con-
tinuously. 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-conflict-
related disabilities, it is necessary to think multi-dimensionally (Vanleit, 2008). The
attention to social and environmental barriers is important, but may have eclipsed
152 P. Rockhold
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 func-
tional 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 reha-
bilitation 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 gen-
eral 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 con-
sequence, 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 identifi-
cation 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 alle-
viation. 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 ser-
vices 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 strengthen-
ing of human physical rehabilitation services and systems during the post-conflict
emergency response phase, and adequately responding to health needs in the
short-and long-term period following conflict need to be retained and institution-

alized 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 coordi-
nation 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 devel-
opment of today. We, therefore, need to enhance our efforts in addressing the
fundamental challenge of quantifying the actual direct and indirect impacts of con-
flict on health. Increased global awareness of the importance of conflict prevention
and management is best achieved through improved access to evidence-based infor-
mation, Meanwhile, rehabilitation, as a holistic approach to assisting those injured
by war or conflict, facilitates reintegration of individuals with impairments or dis-
abilities 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
154 P. Rockhold
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 pre-
deployment 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 mil-
itary 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: thomas.campbell4@va.gov
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.

160 T.A. Campbell et al.
Kavanagh, & Miller, 2006). The following chapter outlines the cycles of deployment
as described by Logan (1987) and presents information regarding the specific stres-
sors 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 descrip-
tions 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 pre-
ceding 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 pre-
deployment 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 pre-
deployment 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 pre-
deployment 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
8 Psychological Rehabilitation for US Veterans 161
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 emo-
tional 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 posttrau-
matic stress disorder (PTSD) or a host of other psychiatric disorders (Weins & Boss,
2006).
In the pre-deployment phase, families prepare for separation and increased inde-
pendence. 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 parent-
ing 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 fam-
ilies 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 deploy-
ment 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 pre-
deployment 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 mental-
health condition that does not preclude deployment, it is generally expected that
the service member should be free of “significant” mental-health symptoms asso-
ciated 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
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 seri-
ously 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 ser-
vice 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 charac-
ter 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 dur-
ing) 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 train-
ing reported fewer mental-health problems than those who did not (Mental-Health
Advisory Team V, 2008).
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 mental-
health 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 exam-
ple, 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, com-
prehensive 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 pre-
vent, 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,
psychiatric nurses, social workers, occupational therapists, and mental-health tech-

nicians (Moore & McGrath, 2007). The primary goals of mental-health profes-
sionals 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 psychol-
ogists 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 sepa-
rate 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 pur-
pose 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 pro-
vide 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 spiri-
tual 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 deploy-
ment 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 ser-

vice members have shown differing rates of mental-health diagnoses for different
deployments and eras. In OEF–OIF conflicts, depression, PTSD, and TBI (a physi-
cal 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 return-
ing 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
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 vet-
erans 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 stres-
sors 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 contex-
tual 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 sta-
tus occurs secondary to becoming wounded in combat or combat-related activity.
“Polytraumatic injuries” are traumas to one or more physical region or organ sys-
tem 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 evac-
uated 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 hospi-
tals 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 polytrau-
matic 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 rehabil-
itation 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).
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 mental-
health services in the post-deployment cycle. In part as an initiative to assess
and track medical and mental-health problems that are associated with deploy-
ment 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 psycho-
logical 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 mental-
health 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 rec-
ognized 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 con-
fusion 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 assess-
ment and referral system in place, some service members and veterans may not be
inclined to pursue mental-health assessment or intervention services. Perceived soci-
etal 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
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 striv-
ing 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 mental-
health 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 treat-
ment (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 per-
sonnel, 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 reac-
tions 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 encoun-
tered 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 histori-
cal biological, psychological, and sociological precursors (i.e., “biopsychosocial”;
Kiesler, 1999) that are aggravated by or even present before the stresses of deploy-
ment. 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.
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 classifica-
tions: mild, moderate, and severe. These classifications are based on indicators, such
as the duration of loss of consciousness and posttraumatic amnesia, or on-site mea-
sures 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 co-
occurrence (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 stres-
sors, 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 sub-
stance abusers without PTSD are more likely to report using substances in response
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 preva-
lence 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 spec-
trum 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 epidemiologi-
cal 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 diag-
nosis 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,
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 net-
work, 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, in-
patient 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 iden-
tify and treat a particular cluster of symptoms common to many combat veterans.
These veterans were reporting dramatic and unwanted re-experiencing of memo-
ries and nightmares that were associated with particularly traumatic experiences,
hypervigilance, increased anxiety, and avoidance of environmental cues of the trau-
matic experience. This disorder was classified as PTSD in the DSM-III (American
Psychiatric Association, 1980), and knowledge of it largely grew from work con-
ducted 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 dissemina-
tion 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 inter-
disciplinary treatment teams at these centers provide specific treatments and care
for the service member, but also work to provide support for family of the veter-
ans 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 veter-
ans 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
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 psycholog-
ical 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 train-
ing 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 under-
way 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 psycholog-
ical 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 mem-
brane 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 con-
duct 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
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 preven-
tion 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 compo-
nent embedded or attached to them, in order to manage the mental-health needs of
those deployed. Upon returning home from deployment, military personnel and vet-
erans 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 pro-
fessionals 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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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 soci-
ety, 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 combat-
ants 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 suffi-
ciently 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 inter-
ventions and dissemination methods have been successfully evaluated, including
Narrative Exposure Therapy and Interpersonal Therapy. It suggests a comprehen-
sive, 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: anna.maedl@vivo.org

178 A. Maedl et al.
Introduction: Violent Conflicts on a Worldwide Scale

Currently 34 large-scale armed conflicts and 3 wars are being fought world-
wide (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 con-
flicts 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 popu-
lation 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 delib-
erate 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 phe-
nomena, 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 eco-
nomic 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 politi-
cal perspective of stabilizing a country or region. The metaphor of the ‘trauma
membrane’ (Lindy, 1985; Lindy & Wilson, 2001) helps us to understand how com-
munities 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.
9 Psychological Rehabilitation of Ex-combatants, Post-conflict Settings 179
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 irreg-
ular 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 num-
ber 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 mem-
bers 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 for-
mer 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 train-
ing, 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
180 A. Maedl et al.
interventions in developing countries, in order to support war-to-peace transition

processes (Kingma, 2000a). DDR is also referred to as DDRR (disarmament, demo-
bilization, 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 sev-
eral 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 demobiliza-
tion commission) and NGOs. The typical first steps are to collect the combatants’
weapons (disarmament), to gather the combatants in encampment areas and for-
mally 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 (reinte-
gration). 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., rein-
sertion), 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 dur-
ing 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 civil-
ian 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 reconcil-
iation, 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 pro-
cesses 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
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 post-
conflict 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, trauma-
related 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 ran-
domly 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 suffer-
ing, mostly severe psychotic disorders intermingled with drug abuse, trauma-related
disorders, and emotional problems (Odenwald et al., 2005). In most cases, uncon-
trollable 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 con-
fronted 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 sub-
stance 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
182 A. Maedl et al.
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 combat-
ants 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 spe-
cially 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 stres-
sors. 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, sui-
cidal 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 investi-
gated (Boscarino, 2006; Johnson et al., 2008; Odenwald, Lingenfelder et al., 2007).
Although not fully understood, there is some evidence that the development of
9
Table 9.1 PTSD and depression rates in different samples of (ex-)combatants in non-Western post-conflict countries
Country Conflicta Study Group Representative? N % PTSD % MDD
Nigeria ECOMOG missions Okulae & Jones Veterans with No 878 22% Not
1990–1994 (2006) traumatic assessed
experiences in
in-patient
treatment
Northern Uganda Internal violence Ertl et al. (2007) Former child No 40 12.5% 2.5%
since 1986 combatants
Eastern DRC, Internal and Bayer et al. (2007) Former child No 169 35% Not
Uganda, and cross-border combatants assessed
Rwanda war/violence since
1997
South Africa Ongoing Seedat, le Roux, & Active soldiers of the No 198 26% 17%
peacekeeping duty Stein (2003) South African
National Defense
Force
Somalia Internal War Odenwald, Veterans on No 62 16% Not
1988–1991 Lingenfelder et al. government assessed
(2007) payroll
Mozambique Internal and Boothby (2006) Child soldiers No 39 Widespread
cross-border war psychological distress
Psychological Rehabilitation of Ex-combatants, Post-conflict Settings
1976–1992 reported, no DSM

diagnosis
Liberia 1989–2004 internal Johnson et al. (2008) Former combatants Yes 549 57% 52%
violence and (40.4% DDR
cross-border war participants)
a Conflict to which study relates
183
184 A. Maedl et al.
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 emo-
tional 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 for-
get 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 dis-
orders, 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.
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 thou-
sands 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 ex-
combatants’ 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, psy-
chological 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 inti-
mate 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 physi-
cal violence (Savarese, Suvak, King, & King, 2001). Findings on the relationship
between alcohol abuse and inter-family violence among civilians in Sri Lanka indi-
cate 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 ele-
vated 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 fam-
ily, 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 impor-
tance 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 nega-
tive. Psychiatric distress and malfunctioning, especially when expressed as outward
aggression, irritation, or acting out of intrusions (e.g., flashbacks, dissociation), fur-
ther 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
186 A. Maedl et al.
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 indi-
cate 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 sub-
group are consequences of the combined effects of factors, which include host
communities’ negative attitudes toward ex-combatants and the ex-combatants’ psy-
chological 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 spe-
cial 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 neg-
ative 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 sta-
bility 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
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 dis-
torted 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 shat-
tered 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 individ-
uals’ 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 recon-
ciliation 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 per-
ceived 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 chil-
dren’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 indi-
vidual 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 geno-
cide in the early 1900s, the impact of traumatization was evident even in the second
and third generations (Rowland-Klein & Dunlop, 1998; Shmotkin, Blumstein, &
188 A. Maedl et al.
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 influ-
ence 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 trans-
generational transmission of trauma-related psychological disorders requires further
research.
The bodily and cerebral alterations caused by repeated frightening and life-
threatening 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 stress-
ful 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 sol-
diers, 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 ex-
combatants’ 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 ex-
combatants with disabilities are typically not sufficient to provide for sheer survival.
9
Table 9.2 Examples of current demobilization programs in sub-Saharan Africa
Conflict Number of Economic Examples of

(latest) DDR beneficiaries reintegration Psychosocial follow-up studies on
Country from – to Conflict parties from–to targeted modules modules reintegration success
Angola 1975– União Nacional para 04/2002– 138,000 Single payment, Trauma counseling, Porto, Parsons, &
2002 a Independência present From which: micro-credit psychosocial care, Alden (2007)
total de Angola 105,000 UNITA, support, traditional n = 603 (574 male,
(UNITA) 33,000 employment in ceremonies 29 female, UNITA
Government forces government forces infrastructure For children: DDR participants
rehabilitation, recreational and
vocational activities, non-participants)
training, business community-based Self-report
training and support network, instrument and
business advisory family tracing and focus groups
services, job reunification No assessment of
placement, mental-health
agricultural status
support to gain
self-sufficiency
189
190

Burundi 1996– Conseil National 12/2004– 85,000 Integration in armed Community Uvin (2007)
2002 pour la Défense present From which: 21,500 forces, cash sensitization, n = 63 (60 male, 3
de le Démocratie/ paramilitary payments in fostering female, DDR
Force pour la installments, reconciliation participants and
Défense de le in-kind support, with community non-participants)
Démocratie, on-the-job and For children: Qualitative
Forces Nationales professional community interviews
de Libération – training, support preparation, No assessment of
Parti pour la to self- support to mental-health
Libération du employment, vulnerable status
Peuple Hutu and access to national biological
other rebel groups reconstruction and families, support
Government forces employment to community-
creation based care
programs, access arrangements,
to land, formal provision of
education community-based
For children: formal psychosocial
education support
A. Maedl et al.
9

DR Ongoing Maï-Maï, Forces 07/2004– 150,000 Integration into Psycho-social Molina (2007)
Congo Démocratiques de present Congolese government support, n = 364 (362 male,
la Libération du nationals forces, single community 2 female, all DDR
Rwanda (FDLR), (combatants on payment, starter sensitization participants)
Rally for foreign soil and shelter kit, For children: Questionnaire
Congolese managed by production kit, recreational No assessment of
Democracy- separate vocational activities, mental-health
Kingsangani- programs) training, income religious status
Movement for generating activities, family
Liberation activities, access tracing,
(RCD-K/ML; to micro-projects, community
including all employment in building,
splinter groups) infrastructure sensitization and
Government and UN rehabilitation, training, family
forces humanitarian aid tracing
to host
communities
For children:
minimal
education,
skills-oriented
training
191
192

Eritrea 1998– Eritrean and 10/2002– 200,000 Monthly payment Counseling ?

2000 Ethiopian present government forces for 1 year, grants,
government forces and paramilitaries on-the-job
training, job
placement,
agricultural
settlement
projects, business
startups
Liberia 1999– National Patriotic 12/2003– 107,000 Payment in two Counseling, Pugel (2007)
2003 Front of Liberia, present From which: 15,600 installments, reconciliation, n = 590 (471 male
Liberation pro-government micro-loans, traditional rituals, and 119 female,
Movement for paramilitary formal education, community DDR participants
Democracy in vocational and sensitization, and
Liberia professional For children: family non-participants)
Liberians United for training, reunification Questionnaire
Reconciliation agricultural No assessment of
and Democracy training, work in mental-health
(LURD), public sector status, attempt to
Movement for measure
Democracy in self-esteem as
Liberia (MODEL) proxy for
Government forces psychological
(& ECOMOG?) reintegration
A. Maedl et al.
9

Sierra 1991– Revolutionary 10/1999 72,500 Reintegration into Social and trauma Humphreys &
Leone 1999 United Front, – armed forces, cash counseling Weinstein (2005,
Civil Defense 01/2002 payments, rural 2007)
Force (Kamajor) (01/2005) integration support, n = 1043 (935 male,
Government forces vocational training/ 108 female, DDR
apprenticeship, participants and
formal education, non-participants)
agricultural support, Questionnaire
job placement No assessment of
mental-health
status
193
194 A. Maedl et al.
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 counsel-
ing 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 pro-
grams: former child combatants and abductees2 (Kingma, 2000b; Verhey, 2001),
female ex-combatants (De Watteville, 2002), as well as ex-combatants with disabi-
lities, 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 institu-
tions – 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 long-
term 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.’
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 devel-
opment will be impaired and a multitude of physical, psychological, and mental
problems will result. Furthermore, early recruitment prevents the young from regu-
lar schooling and training, learning social rules and norms, building peer networks,
and acquiring the skills for healthy, intimate relationships. Although the UN princi-
ples 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, how-
ever, 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 esti-
mated 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 develop-
mental 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 preva-
lence 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 inter-
viewed 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 com-
munity. Therefore, a trauma-focused treatment, namely narrative exposure
therapy (NET), was initiated for formerly abducted children with PTSD diag-
nosis, 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
196 A. Maedl et al.
even capable of reducing sub-syndromal PTSD symptom load, suggesting a

preventative effect. These results confirm that thorough, high-quality screen-
ing 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 slav-
ery. 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 fami-
lies 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 reinte-
gration 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 fund-

ing a business training and micro-finance project for 400 widows and female
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 set-
tled. 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 gov-
ernment 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 suc-

cessfully implementing a reintegration project for former combatants from
198 A. Maedl et al.
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 per-
sonnel, 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 ther-
apy (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 par-
ticipate 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 usu-
ally ill-defined and there is very little evidence of their impact and efficacy. The
overall hypothesis is twofold: that DDR programs improve the reintegration suc-
cess 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
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 speech-
less, 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 fragmen-
tation 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 post-
conflict 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.
200 A. Maedl et al.
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 con-
trolled 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 com-
munities 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 psy-
chologists were trained to deliver the therapy; they also managed to achieve clear
symptom improvement, reducing the PTSD rate by about 60%. The Rwandan psy-
chologists 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
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 func-
tional 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 treat-
ment 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 psychol-
ogists 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) trauma-
focused 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 function-
ing 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 tradi-

tional 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
202 A. Maedl et al.
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 ex-
combatant, 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 tra-
ditional 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 psychia-
trists 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 viola-
tions 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 for-
merly ‘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 out-
bursts 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 mod-
els, 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-and-
now 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 reac-
tions 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
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 prison-
ers 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 per-
sons (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 psychologi-
cal 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 post-
treatment, 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 intru-
sions 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 eval-
uation 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 col-
lectively 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
204 A. Maedl et al.
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 soci-
ety 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, coun-
seling 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 chil-
dren, 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 cen-
ter 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
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 collabo-
rate 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 organiza-
tion 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 proto-
cols 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 mech-
anisms; these societies are expected to modify the existing collective explanations
and guard against the establishment of unbalanced and one-sided views and inter-
pretations 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 develop-
ing 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 fam-
ily 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 suc-
cessful. 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 ex-
combatants suffer from severe psychological distress, including PTSD, depression,
substance dependence, and psychotic conditions. These ex-combatants are heavily
206 A. Maedl et al.
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 peace-
building 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 pro-
visions for psychologically affected ex-combatants, these are often not sufficient
and not specific or professional enough. Even more important, psychosocial inter-
ventions 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 interven-
tions. 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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160.
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 char-
acterized 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 under-
standing 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 conse-
quences 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 chap-
ter, 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: lmcdonal@jhsph.edu

216 L. McDonald
Introduction
Civilians in every region of the world are affected by armed conflict. Fear, dis-
placement, 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 approxi-
mately 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 recov-
ery 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 trauma-
tized 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 indi-
viduals surviving conflict in an effort to promote sustainable psychosocial rehabili-
tation. 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 experi-
ence 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
10 Psychosocial Rehabilitation of Civilians in Conflict-Affected Settings 217
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 coun-
tries, 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 orga-
nizations, 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 individu-
als, 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 fam-
ily, 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 substance-
abuse 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
218 L. McDonald
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 cul-
ture. 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 neces-
sary 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 anni-
hilation” (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 pop-
ulations, 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
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 scien-
tists were the first to conduct large-scale studies on the mental-health response to
conflict (Lopes Cardozo & Fricchione, 2005). Veterans returning from war suf-
fered posttraumatic stress symptoms, which were called by various terms, including
“wounded heart” and “battle fatigue.” Indeed, research shows that PTSD is preva-
lent 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 popula-
tions, 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 prob-
lems 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 numer-
ous 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”
220 L. McDonald
(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 per-
spective 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, per-
ceived 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 relation-
ships 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 liveli-
hoods 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 humilia-
tion (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 indi-
vidual’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
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 disor-
ders 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 speci-
fically, Disability Adjusted Life Years (DALYs). The GBD study explored the impact
of major diseases in terms of disability, using the newly defined DALYs measure-
ment 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 Yearslived 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).
222 L. McDonald
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 well-
being 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 stipu-
lated 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 cir-
cumstances 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 psychologi-
cal 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. Conflict-
affected 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 vari-
ety of environments where recovery efforts will be needed. For example,
populations might cross national or international borders temporarily and/or
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 individu-
als, 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 pre-
cise 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 environ-
ments, that feasible strategies and approaches can be designed, implemented, and
evaluated.
It should be emphasized that difficult settings that constrict research and lim-
itations in resources do not absolve the mental health, relief, and/or development
communities from taking an appropriate response – in the same way that the loca-
tion 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 popula-
tions, 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 cap-
ital, 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 cen-
tral 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
224 L. McDonald
social support; and hope (Hobfoll et al., 2007). Herman (1997) asserts that recov-
ery from trauma occurs in three stages, each which has its own central task: (a)
establishing safety, (b) remembrance and mourning, and (c) reconnecting to ordi-
nary life. Besides these key domains of recovery, individuals who have survived
traumatic events as a result of armed conflict live within settings that are character-
ized 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 understand-
ing 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 understand-
ing 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 opti-
mal, 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 provi-
sion 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 “for-
eign clinicians often arrive to promote PTSD case-finding and trauma-focused
treatment in the absence of a system-wide public health approach that con-
siders 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 perspec-
tive. 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
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 inter-
nal 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 approach-
ing 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 influ-
encing mental health, health and mental-health professionals should work in close
partnership with colleagues from other disciplines (e.g., communication, educa-
tion, community development, and disaster coordination) to ensure that relevant
social interventions are fully implemented.” Mental-health professionals and para-
professionals 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 communica-
tion, coordination, and clear assignment of responsibilities – but optimal treatment
may require nothing less. As Watters suggests, treatment specifically for conflict-
affected 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.
226 L. McDonald
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 appro-
priate 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 inter-
ventions. 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 dis-
orders (see Hyman et al., 2006; Stanley et al., 2009). Studies have found evidence
showing that improvement can be the greatest when such therapies are com-
bined 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 re-
experience 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 com-
bined with the provision of psychotropic medicine, may be perceived by govern-
ments 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 pharmaco-
logical 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 men-
tal 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 recov-
ery 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.
228 L. McDonald
Ensuring Physical Safety, Promoting Psychological and Social Safety

According to Herman (1997), the most important step in trauma recovery is ensur-
ing 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 annihila-
tion. 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 non-
threatening 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 enjoy-
ment. 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 psy-
chological 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 com-
mon 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 partic-
ipation in income-generating activities (IGA). Their safety was promoted not only
through both counseling and care but also through efforts to change their envi-
ronment 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 pro-
gram 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 psycho-
logical safety, individuals will undertake the difficult work of remembrance and
mourning. As an individual feels safer, he/she may then feel comfortable in recon-
structing 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 “working-
through 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 “acknowledge-
ment, 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
230 L. McDonald
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 compo-
nent 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 cer-
emonies. This had a major impact on the bereavement process, preventing it from
taking its natural course (Hagengimana, 2001). A large body of literature docu-
ments 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 pro-
moted 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 return-
ing 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 pro-
moting 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 popula-
tions 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.
Herein, actors concerned with community health and well-being can assist in pro-
moting sustainable change and growth, while achieving the recovery of previous
positive outcomes.
The following activities are reliant on cross-sector collaboration and are sug-
gested 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 com-
prehensive, but provides insight into some possible interventions to achieve these
objectives.
Educational and Vocational Activities. In resource-poor settings, such as dis-
placement camps and among resettled refugees, the (re-)establishment of educa-
tional activities, including but not limited to literacy, vocational, and skills training,
can play an important role in restoring empowerment and hope. It provides an oppor-
tunity 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. Self-
actualization, 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 strength-
ening 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 psychi-
atric 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 devel-
opment 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
232 L. McDonald
to ensure that beneficiaries are made aware of repayment requirements and potential
difficulties. The psychological distress, for example, associated with debt and diffi-
culties 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, cre-
ating 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 con-
tributing to the world and those individuals around them. Indeed, existing research
has found an association between altruistic social interest behaviors and better men-
tal 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 commu-
nities 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 possi-
ble, 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 vari-
ous programs to identify and to address psychological distress among war-affected
populations. Two organizations which have emphasized the importance of includ-

ing 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 recov-
ery 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 exam-
ple, WHO (2003a) describes the potential beneficial functions of self-help support
groups that are community based. They can function as a source for sharing prob-
lems, 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 founda-
tion 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 popula-
tions. 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 creative-
socialization 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 par-
ticipate 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 collab-
oration 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 depres-
sion 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.
234 L. McDonald
Examples of Effective Interventions

The following provides an overview of two interventions in this field, which incor-
porate 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 individ-
ual 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 min-
istries 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 statisti-
cally 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 eco-
nomic 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 disempow-
ering experiences, the organization believed “they must gain the power to control
their personal situation and address and reduce social injustice” (Ibid.). In addi-
tion 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
and participant. These plans would be used in deciding, for example, what activ-
ities and trainings a woman might participate in, rather than giving everyone the
same training or course. The group continued to meet, regardless of their indi-
vidual 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 coop-
eration 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 “emancipa-
tion, 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 psychoso-

cial rehabilitation of conflict-affected populations need to consider the significant
resources that the community can provide and to emphasize the community’s abil-
ity 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 main-
tains 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 ben-
efit 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 men-
tal health must also work within and address the realities in which these individuals
236 L. McDonald
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 sug-
gested “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 interven-
tions, which are viewed as a prerequisite for health and recovery in industrialized
settings, as feasible and critical in conflict-affected settings (e.g., supported employ-
ment). 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 effec-
tive change, the following areas must be addressed: policy/legislation, financing,
science-based mental-health services, multidisciplinary education, role of interna-
tional agencies, linkage to economic development and human rights (Mollica &
McDonald, 2003); McDonald, Bhasin, & Mollica, 2005).
Promoting Culturally Appropriate and Informed Care. Given the cultural fea-
tures 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 cul-
turally 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 collabo-
rating closely with the local community – both the general population and those
with healing roles (e.g., the health and mental-health practitioners, religious lead-
ers, 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 conflict-
affected 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
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 diffi-
cult 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 empow-
erment. 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 lim-
ited 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, “dis-
abling” 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 necessar-
ily 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
238 L. McDonald
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 human-
itarian 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 organi-
zations, 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 suffer-
ing 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, espe-
cially 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 inter-
ventions alone are not enough to address the needs of individuals with severe psy-
chiatric disorders. Various types of interventions, including productive and/or social
activities, as have been described in this chapter, can provide important mental-
health 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, cul-
turally 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 strength-
ened and included in the toolkit for humanitarian and development assistance to
conflict-affected populations.
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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 adap-
tive 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 stim-
uli 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 under-
standing 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 alert-
ing 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 res-
olution 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: jvanvliet@ualberta.ca

248 K.J. Van Vliet
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 exter-
nal 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; Lindsay-
Hartz 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 emo-
tional 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 self-
consciousness along with negative self-appraisals, an understanding of the differ-
ences 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 dif-
ference 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, posttrau-
matic 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 oth-
ers 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
11 Shame and Avoidance in Trauma 249
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 judg-
ments 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, with-
out the self necessarily being judged as bad, unjust, or blameworthy (Gilbert, 1998).
Importantly, humiliation often leads to feelings of shame. For example, torture vic-
tims 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 veter-
ans (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 vio-
lent 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 situa-
tions 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 sit-
uation 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 self-
ideals, can generate intense feelings of internal shame. Individuals may also suffer
external shame in response to other people’s negative judgments about their actions,
250 K.J. Van Vliet
regardless of whether these judgments are real or imagined. Furthermore, posttrau-

matic 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 pow-
erlessness to prevent the injury or to restore the body to its previous, non-disabled
state (Wright, 1983). Moreover, after suffering a permanently disabling injury, peo-
ple 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 pow-
erlessness 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 consid-
ered 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, &
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 neg-
ative 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 sub-
stance 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 with-
drawal, 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 cog-
nitive avoidance strategies, such as emotional detachment and thought suppression,
252 K.J. Van Vliet
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 situa-
tions. 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 vulner-
ability 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 threaten-
ing 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 nega-
tive 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
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 cop-
ing. 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 orien-
tation. 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 envi-
ronment (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 them-
selves 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 stres-
sors 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 recov-
ery 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 self-
worth. 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 strate-
gies, 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 posi-
tive self-image in the face of CID. Moreover, by downplaying the seriousness and
254 K.J. Van Vliet
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 “pos-
itive 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 cop-
ing) was positively related to PTSD symptoms among survivors of sexual assault.
These findings were consistent with other studies that linked denial, behavioral dis-
engagement, 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 trau-
matic 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 per-
petuated in part by idiosyncratic negative interpretations of intrusive recollections.
These interpretations are thoughts related to the self, others, or the world that con-
flict with existing assumptions and beliefs and are deemed unacceptable (see also
Janoff-Bulman, 1992). For example, intrusive memories may be interpreted as neg-
ative 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 threat-
ening 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
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 nega-
tive 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 particu-
larly 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 non-
adaptive 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 psy-
chodynamic 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 attach-
ment system. In her theory, shame occurs in response to perceived rejection from
important attachment figures, beginning with the primary caregiver. This percep-
tion 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 perfec-
tionism, excessive striving for power or achievement, and excessive pre-occupation
256 K.J. Van Vliet
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 trans-
ferring 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 judg-
ments 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 associ-
ated 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 rejec-
tion, 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 peo-
ple respond to these disclosures—can exacerbate shame and prompt further social
withdrawal. Ullman et al. (2007) found that rape victims who received negative reac-
tions 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 disclo-
sure 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 men-
tioned 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
rationalization often allows individuals to refocus their attention on actions, per-

sonal strengths, and interpersonal relationships that enhance the self. In other words,
avoidance can serve the important function of providing a buffer behind which indi-
viduals 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 indi-
viduals 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 individ-
ual 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 distress-
ing material helps ensure that emotional arousal and intrusion do not overwhelm
the capacity to cope. In cases where avoidance is chronic or non-adaptive, gen-
tle 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 envi-
ronment. 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 val-
ued 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
258 K.J. Van Vliet
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 condi-
tions 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 perpet-
uate 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 particu-
larly 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 work-
ing 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 dehu-
manization 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
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 self-
compassion (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 trau-

matic 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 interven-
tions. 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. Stress-
coping concepts are integral to the manner in which individuals and communities
cope with trauma in post-conflict societies. The salience of social support and psy-
chological resilience, as additional concepts through which work with survivors can
be approached, offer opportunities for facilitative intervention. This chapter pro-
vides a review of the literature addressing individual and collective responses to
trauma, and non-adaptive responses to trauma such as stress, anxiety, and mood dis-
orders. 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 post-
conflict 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 peo-
ple 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: ericajohnsonphd@uwalumni.com

266 E.K. Johnson and J. Chronister
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 mem-
brane 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 stres-
sors, both in terms of their scope and severity. The research literature on civilian
post-traumatic stress in conflict zones indicates prevalent stressors include experi-
enced 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 psycho-
logical 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 nat-
urally engages in a physically and mentally reflexive “fight or flight” response,
which prepares the individual to either escape (flight) or ward off (fight) the stres-
sor. 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
12 Psychosocial Adjustment and Coping in the Post-conflict Setting 267
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 environ-
ments characterized by sustained, prolonged violence (Yehuda, Bryant, Marmar, &
Zohar, 2005).
The socio-cultural level of stress warrants particular mention in an exam-
ination of war and post-conflict rehabilitation to the degree that social con-
flict 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 observa-
tions of medically unexplained symptoms that may be conceptualized as phys-
ical 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 demoraliza-
tion (Lacy & Benedek, 2003; Ursano, Fullerton, & Norwood, 1995). Research
in the traumatic stress literature indicates that the majority of people and com-
munities 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 vet-
erans of war (Boscarino, Galea, Ahern, Resnick, & Vlahov, 2002; Rosenheck &
Fontana, 2003; Vazquez & Perez-Sales, 2007). At the community level, collec-
tive action is most commonly effective, adaptive, and cooperative, and groups of
people tend to be resourceful in the face of post-disaster response (Glass & Schoch-
Spana, 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 phy-
sical and health conditions are viewed as stable characteristics between cultures and
societies in conflict, the psychological responses to stressors associated with con-
flict 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 ter-
rorism, although generally speaking, the most frequent disorders include PTSD,
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 reac-
tion 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, avoid-
ance, 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 DSM-
IV-TR, are categorized into three primary domains: hyperarousal (e.g., hyper-
vigilance; irritability), numbing/avoidance (e.g., inability to recall important aspects
of the trauma; feeling emotionally distant; avoiding cues or reminders), and re-
experiencing (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 clus-
ters 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 partic-
ular interest are the clinical implications of the symptom-cluster debate with respect
to coping, in that numbing and avoidance have been shown to correlate differ-
ently with depression, suicidal ideation, and suicidal behavior (Asmundson, Coons,
Taylor, & Katz, 2002; Cox et al., 2008). As such, assessment and intervention deci-
sions 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 compara-
tive 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 post-
traumatic 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 differ-
ent 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 fea-
tures 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); percep-
tion 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 conflict-
related 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
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 post-
conflict 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 dis-
order 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 devel-
opment 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 psychi-
atric 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 stud-
ies 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 indi-
cate 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
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 individu-
als 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 impli-
cations 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 dif-
ferently 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 trau-
matic 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 spe-
cific 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 expe-
riencing 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
psychotic symptoms, recurrent thoughts of death, suicidal ideation, and make sui-
cide 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 indi-
cate 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 fac-
tors 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 dis-
orders, 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 co-
occurrence 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 dis-
orders. 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 ten-
sion, and trembling, somatic symptoms, such as sweating and nausea, autonomic
hyperarousal, and an exaggerated startle response (APA; Kessler et al.). These fea-
tures 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 preva-
lence 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 predic-
tion 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,
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 pre-
dicted 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 indi-
cate 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 sub-
stance 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 experi-
encing 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 vet-
erans, 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 rela-
tionship 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
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 non-
adaptive 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 anxi-
ety 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 commu-
nity has been conducted, available research suggests that communities may be at
risk of experiencing a stress response (Lacy & Benedek, 2003). As with individu-
als, 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 subse-
quent 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 interper-
sonal assets, such as coping ability and social support (Sheridan & Ramacher, 1992;
Wright, 1983). The application of interventions aimed at creating a trauma mem-
brane 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
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 cognitive-
behavioral 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, habit-
ual 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 dis-
positional style that involves a psychological orientation either toward (approach)
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 rep-
resentations 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 mate-
rial 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 facilitat-
ing 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 stres-
sor (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 con-
ceptualizations of coping are those models based on cognitive theory and the work
of Lazarus and Folkman (1984). In these models, cognitive and behavioral strate-
gies are employed based on the interaction between the individual, context, and
stressor (Lazarus & Folkman). Coping is typically hypothesized to include thoughts,
feelings, and behaviors that serve as mediators between the stressor and the
stress-response (Folkman & Lazarus, 1988). The most commonly cited cognitive-
behavioral 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 engag-
ing 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 vent-
ing 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) pro-
posed 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 cognitive-
behavioral 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 Al-
Aqsa 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 situa-
tions 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 indi-
vidual 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 circum-
venting the threat or mitigating its potential harm to property or life by taking protective
measures against the potentially devastating consequences of attack. Unfortunately, the var-
ious strategies do not remove the threat itself by any means and are essentially “safety
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 strate-

gies 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 emotion-
focused 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 con-
ceptualized 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, reli-
gion, 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, includ-
ing 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
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 rela-
tionship between higher levels of stress and higher usage of coping strategies
(Meisenhelder, 2002; Schuster et al., 2001), which is consistent with the trend indi-
cating that higher levels of stress are linked to more coping. In addition, studies
suggest that the probability of experiencing posttraumatic stress symptoms follow-
ing the September 11th attacks were significantly higher for individuals who used
emotion- or avoidant-focused strategies, such as denial, self-distraction, disengage-
ment, 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 indi-
viduals 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 understand-

ing 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 estab-
lished (Chronister, 2009). Social support is thought to interact with the stressor to
reduce the deleterious effects of stress and promote physical and emotional well-
being. 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 inter-
connections 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 con-
ceptualized 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
involves such provisions as financial aid, physical assistance, and providing trans-
portation, whereas emotional support involves such provisions as expressing affec-
tion, concern, empathy, caring and reassurance, and provides opportunities for
emotional expression and venting (Cohen, 2004). It is believed that these func-
tions 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 con-
ceptually similar to the role of the trauma membrane on an interpersonal level.
Specifically, the interpersonal trauma membrane serves as a socially supportive net-
work 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, envi-
ronmental 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 net-
work 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, pre-
dictability, and security” (Miller, Omidian, Rasmussen, Yaqubi, & Daudzai, 2009,
p. 612). Studies with refugee populations provide an explanation of the relation-
ship 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 inves-
tigated 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).
Restoring and facilitating an individual’s social support system is critical to

the adjustment process of individuals and communities who experienced conflict-
related 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 conflict-
related 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 meaning-
making 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 psy-
chological 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 individu-
als 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 por-
tion 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 com-
pelling 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 dis-
positions in terms of an approach-avoidance paradigm. The styles that Horowitz
(1976, 1979) described in the denial-intrusion coping model map onto descrip-
tions 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 intru-
sion 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 indi-
viduals’ attempts to cope with the physical and emotional aftermath of the trauma.
Because such styles are purported to be reflective of enduring characteristics, facil-
itators 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, inter-
ventionists 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 articu-
lating 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 com-
munity 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 com-
munity response and community coping in post-conflict settings (Yaswi & Haque,
2008), further discussion of social support as a form of coping may provide addi-
tional 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 multi-
dimensional 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
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 devel-
opment 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 sup-
port, 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 consid-
eration, 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 tra-
jectory 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 dis-
abilities 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 commu-
nity 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
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 mem-
ber 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 life-
time (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, accord-
ing 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: mmcdvttm@memphis.edu

292 M.E. McDevitt-Murphy et al.
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 dis-
order, 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 cul-
tural 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 track-
ing 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, non-
governmental 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
13 Helping Individuals Heal from Rape Connected to Conflict and/or War 293
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 preva-
lence 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 perpetra-
tors 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 interna-
tional 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 sup-
ports this assertion by calling sexual violence during wartime a tactic or a means
to terrorize the opposition. Another explanation suggests that rape follows natu-
rally 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 after-
math 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 character-
ized 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 the-
ories 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
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 cul-
tural 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 conse-
quence, 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
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 prospec-
tive 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 hyper-
arousal, 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 sup-
port 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 relation-
ships, 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 expe-
riences 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 sex-
ual 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 dis-
closed more readily than assaults by known assailants (Golding, Siegel, Sorenson,
Burnam, & Stein, 1989; Starzynski, Ullman, Filipas, & Townsend, 2005). One study
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 insti-
tutions (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 help-
ful 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 sup-
port 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 expe-
rience 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 cul-
tures 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 impreg-
nating 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
(Coomaraswamy, 1999). Similarly, in some cultures, women suspected of premar-

ital 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 under-
standing. 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 psy-
chological 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 present-
ing 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 multi-
ple methods. Generally, a combination of self-report (paper–pencil) measures and
structured interviews conducted by a trained clinician will yield the most reliable
information. Weathers and colleagues recently provided recommendations for con-
ducting 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 seek-
ing 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 par-
ticularly 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 experi-
ences (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 clin-
ical 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 DSM-
IV symptoms of PTSD. The PTSD Checklist (Weathers, Litz, Herman, Huska, &
Keane, 1993) is a 17-item self-report questionnaire that includes one item per DSM-
IV 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 mul-
titude 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) pub-
lished 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
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 under-
addressed 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 dis-
cussion only to treatments of PTSD, because PTSD will likely be the most
frequent disorder encountered in this population. For an overview of evidence-
based 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 psychoso-
cial 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 lim-
ited 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 ther-
apy 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 combi-
nation 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,
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 situ-
ations that would be relevant to improving the client’s quality of life. The client
receives weekly homework assignments that involve engaging with the feared activ-
ity. In session, the client discusses progress along the hierarchy and troubleshoots
difficulties in completing homework with the therapist. In vivo exercises will neces-
sarily 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 encour-
ages 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 expo-
sure (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 partic-
ular: 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 popu-
lations (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
focus is on the cognitions related to the trauma. CPT is aimed at (1) helping sur-
vivors 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 ther-
apy 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 mal-
nutrition (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 demon-
strated 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 set-
tings (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, normaliza-
tion, 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.
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 success-
fully applied to appropriate candidates within the early weeks following trauma
exposure, resulting in significant amelioration of symptoms. Generally, early inter-
ventions 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 symp-
toms 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 cognitive-
behavioral 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 sug-
gest 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 cur-
rent symptoms of PTSD, depression, and other anxiety disorders to develop an
appropriate treatment plan. An appropriate treatment plan will include interventions
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 consider-
ations 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 psy-
chological 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 com-
mitted 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 sur-
vivors, 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 infrastruc-
ture may result in little means for supporting a family financially and a decimated
social support system. Subsequently, parenting a child conceived in rape and pro-
viding for the child in a war-torn locale may create overwhelming stressors for the
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 non-
victimized 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 con-
tracted 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 sur-
vivors. 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 seek-
ing services in one facility after rape by uniformed military personnel. The specific
psychological intervention that was offered included (a) provision of safe and empa-
thetic environment; (b) active listening; (c) allowing expression of personal views
about events and distress; (d) assessing familial and social consequences; (e) nor-
malizing 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 disor-
ders (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 meet-
ing 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
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 fol-
lowed 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 follow-
up 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 symp-
toms, larger proportions endorsed items such as “heightened awareness of potential
dangers to themselves” (43.8%), “irritability or outbursts of anger” (37.5%), or “dif-
ficulty 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 gen-
erally (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 disin-
clined 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 mental-
health 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 mis-
trustful of professionals who are affiliated with formal institutions, given fear of
reprisal. In locales in which the socio-political structure has been severely disrupted
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 differ-
ences, 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 pre-
requisite 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 per-
spective, becoming a fighter may seem an attractive possibility for children and
adolescents who are facing poverty, starvation, unemployment, and ethnic or polit-
ical 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: elisabeth.schauer@uni-konstanz.de
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.

312 E. Schauer and T. Elbert
changes. Such exposure also deprives the child from a normal and healthy develop-
ment 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 inter-
action. The risk of re-recruitment is high when ex-combatants fail to reintegrate
economically and socially into their civil host communities, which may cause sub-
stantial economic development issues, and a new turn in the cycle of violence
becomes inevitable. We therefore conclude that the provision of extensive mental-
health 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 reac-
tions, 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 expe-
riences, 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 world-
wide, 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 war-
ring 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 out-
lined 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
14 The Psychological Impact of Child Soldiering 313
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 continu-
ously 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 disabil-
ity, 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 chil-
dren 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, peace-
keeping, or medical workers; leaving landmines or unexploded ordnance; destroying infrastructure
essential for civilian survival (e.g., food, water sources, hospitals).
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 conse-
quences 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 tor-
ture 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, displace-
ment, 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 contrac-
tion 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 bor-
ders. 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 vulnera-
bility 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).
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 govern-
ment 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, por-
tering, 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 possi-
ble 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 inter-
national 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 west-
ern 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).
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 dis-
crimination, 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 (espe-
cially 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 invulnera-
bility, 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 eth-
nic 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 com-
manders 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
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 strate-
gies. 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 investiga-
tions 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 experi-
enced 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
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:
• 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 poten-
tial 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, guid-
ance, 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 struc-
ture, 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 vol-
untary 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 emo-
tional 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
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 polit-
ical 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 hor-
rifying 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.
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 cumula-
tively 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 intercon-
nected, 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
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%), experi-
enced 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
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 dis-
obeying, 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.
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 indi-
viduals 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 psycholog-
ical 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 dan-
ger. 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 trau-
matic 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 disor-
ders 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 orga-
nized 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 acci-
dents 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 con-
dition that emerges among a range of possible trauma-spectrum disorders including
depression, suicidality, and substance abuse. The considerable similarities and con-
sistencies in the clinical manifestations of psychological disorders across diverse,
affected groups globally tend to outweigh cultural and ethnic differences (Garcia-
Peltoniemi, 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 trauma-
specific re-enactments); recurrent and distressing dreams (e.g. for children,
nightmares with scary content of any nature); acting or feeling as if the
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), fore-
shortened sense of future (e.g. even small children can express hopelessness
in relation to ever growing up), recklessness and risk-taking behaviour, hyper-
activity, 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 suf-
fering 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,
1.0 9
8
Probability for PTSD .8
depressive symptoms
7
.6
6
.4 5
.2 4
3
.0
1 2 3 4 5 2
traumatic event load 1
1 2 3 4 5
12 5
11
functional impairment
physical complaints
10
4
9
8
3
7
5 2
1 2 3 4 5 1 2 3 4 5
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
associated with similar elements of a hot memory (i.e. physiological, like heart beat-
ing, 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 post-
traumatic 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 transi-
tory 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 long-
term 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 every-
thing 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 sis-
ter 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 for-
get 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
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
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
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% post-
traumatic 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 witness-
ing abusive violence and enormous cruelty was of especially high-traumatic valence
(Hiley-Young, Blake, Abueg, Rozynko, & Gusman, 1995; Nader et al., 1993).
The Impact of Trauma on the Body

Beyond psychological suffering from the symptoms of PTSD, traumatized popu-
lations 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, fre-
quently report high rates of physical illness, involving a variety of physiological
systems. In a recent study (Sommershof et al., 2009), we observed a substan-
tial 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 torture-
related PTSD. Thus, there seems to be a positive correlation not just between
developed psychiatric illnesses and prior trauma, but also a significant relation-
ship 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 hyperten-
sion 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).
Further Psychological Consequences of Trauma Exposure

There are a multitude of further psychological consequences of experiencing trau-
matic 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 peri-
ods. 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 develop-
ing 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 exten-
sively 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 anx-
iety 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 expe-
riences 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:
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 sub-
stance 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 sam-
ples 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 ‘self-
medicate,’ 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 stud-
ies, 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 para-
noia. 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 psycho-
logical 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 popula-
tion, 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, dys-
functional 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 symp-
tom 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
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 captiv-
ity 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 cor-
relation 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 hav-
ing killed members of the family, friends, or community members emerged as a key
predictor of suicidal ideation (Pfeiffer et al., submitted). Authors suggest that suici-
dal 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 physi-
cally unable to defend themselves or escape. The most readily accessible response
to the pain of trauma may be to activate dissociative mechanisms, involving dis-
engagement 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
(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 non-
adaptive, 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 micro-
psychotic episodes, including auditory command hallucinations. It is not uncommon
for severely traumatized children to hear voices commanding them to harm them-
selves 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 aggres-
siveness 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 develop-
ment in captivity, under the constant threat of abuse and manipulation by their
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 world-
view 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 col-
lective identification might occur post hoc after return to their home communities.
Gloeckner explained that questions and discussions of family and community mem-
bers 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, identifica-
tion 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 cog-
nitive 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 sol-

diers 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 individu-
als 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 acceler-
ated the healing process (Servan-Schreiber, Le Lin, & Birmaher, 1998). Cognitive
appraisals of experiences seem to matter in symptom development in various forms
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 occu-
pational 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 concen-
trate 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, stom-
achaches, 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 abil-
ity. 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 North-
Eastern 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
in the sample reported lasting interference of experiences with their daily life. The
neuropsychological testing and the investigation of school grades validated mental-
health 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 resear-
chers 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 dis-
order, have clear-cut difficulties on the job, suffer increased concentration problems,
and are more likely to act out aggressively in difficult situations, which eventu-
ally 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 fam-
ilies, 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 moth-
ers 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 emo-
tional and cognitive impairments (Sapolsky, Krey, & McEwen, 1985; Sapolsky,
Uno, Rebert, & Finch, 1990). While the genome, the DNA sequence, remains unaf-
fected 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, epi-
genetic 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 environ-
ment, 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
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 behav-
ior against women, children are maltreated as well (Edleson, 1999; Levendosky &
Graham-Bermann, 2001). In fact, domestic violence against the child’s mother dur-
ing 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 moth-
ers, 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 sys-
tem (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 moth-
ers 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 cer-
tain 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, fearful-
ness 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,
might make it even more challenging to regulate babies and their own affect ade-
quately. Parental sensitivity in pre-empting a child’s need might be impaired, and
‘high expressed emotions’ without sufficient verbalization of the context can ren-
der a small child helpless in understanding parental motivation and intention. It has
been shown that if children live in such unpredictable reward–punishment environ-
ments, 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 sur-
vivors, 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 fam-
ily members (Al-Turkait & Ohaeri, 2008; MacDonald, Chamberlain, Long, & Flett,
1999). On the other hand, children of survivors can be equally affected by their par-
ents’ symptoms of numbing and avoidance, which are associated with substantial
decrements in parent–child relationship quality and which prevent normal emo-
tional 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 satis-
faction. 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 (govern-
ment 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 work-
ing 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
activities, girls’ participation is central to sustaining a force because of their pro-

ductive 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 partici-
pation 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.
Key gender-based experiences of both women and girls during armed con-
flicts consist of sexual violence, including torture, rape, mass rape, sexual slavery,
enforced prostitution, forced sterilization, forced termination of pregnancies, giv-
ing 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 fight-
ing 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 sol-
diers 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, tuber-
culosis, anaemia, diarrhea, malnutrition, disabilities, scars, and burns (McKay &
Mazurana, 2004; Stavrou, 2005).
Returning women, who are perceived to have had sexual relations with combat-
ants, 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 sup-
portive partnership, within which to bring up their children in civilian life. The
environments into which girls reintegrate are also problematic. Domestic violence
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 demobiliza-
tion 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 insuf-
ficiently 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 demo-
bilized 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, reproduc-
tive 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
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 cross-
ing 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 hin-
drances 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 atroci-
ties they have committed (Bayer et al., 2007). In many cases child soldiers are forced
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 ex-
combatants is a reciprocal process that happens within the host communities where
the former fighters are settled. The attitudes of the host communities towards the ex-
combatants 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 sup-
portive element for affected communities, who have lost children to abduction and
child soldiering; yet, this is possible only when a sufficient number of adult com-
munity 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 caretak-
ers, providers, and role models. Neither local healers nor religious leaders, who
have traditionally offered health-related services, or carried out re-integration mea-
sures 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 return-
ing 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,
especially when suffering from clinical symptoms of the post-traumatic stress syn-
drome 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 espe-
cially 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 mecha-
nisms 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 reconcilia-
tion. 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 sig-
nificantly 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 dis-
played 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 sur-
vivors’ 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 symp-
toms 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, aggres-
sion, and perceived stigmatization in returning, former child soldiers (Allen &
Schomerus, 2006; Annan & Blattman, 2006; Corbin, 2008; Pfeiffer et al., submit-
ted). 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.
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 bizarre-
looking 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 height-
ened aggressiveness. Aggression was associated with having a history of abduction,
an increased level of perceived stigmatization, heightened symptoms of psycholog-
ical 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 abduc-
tion 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 sub-
group 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 combat-
ants and of civilians are affected by war-related psychological problems, and remain
without assistance for psychological rehabilitation, the opportunity to initiate self-
sustained 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.
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 impor-
tantly, 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 expe-
riencing 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 crit-
ical 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 individ-
ual’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 con-
trol 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 ade-
quately 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 reintegra-
tion 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 mal-
functioning, 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
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 expe-
rience 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 col-
lapses 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, com-
batants 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 partici-
pants ordered to partake in violent actions by their superiors. Mental and physical
fatigues stemming from continuous combat, alongside loneliness, lack of social sup-
port, and denial of privacy profoundly affect the combatants’ psyche and mental
Z. Solomon (B)
Tel-Aviv University, Ramat-Aviv, Israel
e-mail: solomon@post.tau.ac.il

362 Z. Solomon and A. Ohry
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 sol-
diers 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 con-
tinuously 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 con-
tinuous 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 “spe-
cial” 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 dur-
ing 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.
15 The Toll of War Captivity: Vulnerability, Resilience, and Premature Aging 363
Captors use various brutal means to deliberately break the captives’ spirit. In
fact, during the Yom Kippur War, Israeli POWs were repeatedly exposed to anti-
Israeli 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 “main-
tain 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 ex-
POWs 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 some-
what 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
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 malfunc-
tions 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 post-
traumatic stress disorder (PTSD). PTSD includes three major symptom clusters
(APA, 2000): (a) re-experiencing of the traumatic event, (b) avoidance of stim-
uli 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).
In the wake of war captivity, posttraumatic stress disorder (PTSD) rates approxi-
mately 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 disor-
der, 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 per-
spectives. 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 anx-
iety 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 retrospec-
tively (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 phys-
ical 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 rela-
tively 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.
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 self-
reports. 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 DSM-
IV criteria.
Prevalence of PTSD in Israeli Ex-POWs

Our study shows that three decades after their release from captivity, 23% of for-
mer 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 hard-
ships 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 them-
selves, 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 inten-
tionally 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 dif-
ferences 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 com-
passion 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 sur-
vivors, 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).
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 fol-
lowed 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 psy-
chological 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%
1.9% 0.9% 18.20%

3%
Controls Ex-POWs
95.3% 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 exacer-
bates 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
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 activ-
ity 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 dor-
mant 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 dura-
tion 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
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 sex-
ual 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 dis-
tress 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 trauma-
specific 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 symptoma-
tology 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 trau-
matic 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 depres-
sion, anxiety, and substance abuse, in addition to PTSD (Boudenwyns, Woods,
Hyer, & Albrecht, 1991). Finally, the findings of multiple problems are consis-
tent with the varied clinical picture of survivors of other traumatic events (Herman,
1992).
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 nar-
row 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 dis-
orders 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 deter-
mine whether coexisting disorders are complications of PTSD or share the same risk
factors.
The ex-POWs suffered from higher rates of general psychiatric symptomatol-
ogy 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 con-
trol 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 disor-
der 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
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 reac-
tions. 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 ex-
POWs 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, per-
vasive, and widespread distress (Herman, 1992). Previous studies of Israeli veterans
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 dif-
ference 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 after-
math of war captivity has emanated primarily from a pathogenic perspective and
focused on negative or pathological outcomes such as posttraumatic stress disor-
der (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 exten-
sive psychological testing prior to their captivity. Ursano (1985) concluded that
the alterations in personality style caused by captivity “are neither pathologi-
cal 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.
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 question-
naire 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 vet-
erans 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 fre-
quently 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 num-
ber 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 pos-
itive 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 pre-
vious 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
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 psycho-
logical 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 emo-
tional 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 contain-
ment 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 nega-
tive. These findings support previous studies of American (Elder & Clipp, 1989)
and Israeli (Yarom, 1983) war veterans, showing that positive changes are dis-
cernible in “existential” spheres, and negative changes manifest mostly in the form
of symptoms.
Collins and colleagues (1990) suggest that negative changes directly reflect pas-
sive responses to victimization, whereas positive changes result from active attempts
to cope with the trauma. Symptoms are less subject to change via cognitive or behav-
ioral 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.
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 interper-
sonal 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 atten-
tion. Three perspectives for the relationships between PTSD and PTG are offered.
The first clearly suggests that not disregarding the extreme and long-lasting nega-
tive 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, includ-
ing 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, indepen-
dent 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, pos-
itive and negative changes emerge as two separate, unrelated outcomes that can
both occur in one person, though not necessarily within the same areas. This two-
dimensional stress response perspective posits that most people will respond to even
extreme stress with some mixture of both resilience and vulnerability. Lending sup-
port 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 posi-
tively 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 corre-
lations between growth and distress were also found in Pargament, Smith, Koenig,
and Perez’s (1998) study of residents of Oklahoma City following the 1995 bomb-
ing. 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 emo-
tions and behaviors used in coping with captivity and the ex-POWs’ subjective
assessment of the severity of captivity. Experimental and empirical studies on ex-
POWs’ 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 cap-
tivity (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 inter-
active 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 cop-
ing 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 con-
trols 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
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 func-
tioning, 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 pos-
itive effects and severe trauma. The first approach views the perceived benefits of
trauma as signifying healthy adjustment, that is, either a real strengthening of per-
sonality 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
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 post-
traumatic 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 lev-
els 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 find-
ings (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 stud-
ies 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, post-
traumatic 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 con-
sequences 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
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 health-
related 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 appear-
ance 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 generalizabil-
ity 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 dis-
eases, 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 pre-
vious findings. First, the consistency may be related to differences in the length
and severity of the captivity experience. The POWs in Far East were exposed to
prolonged captivity, torture, continuous interrogation, isolation, extreme environ-
mental 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 psy-
chiatric 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 ill-
nesses. 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 impos-
sible 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.
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 con-
tribution. 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 con-
comitant 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 psychologi-
cal problems, are more likely to interpret their physical sensations or discomforts
as more problematic than are their emotionally uninjured counterparts. To over-
come 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 captiv-
ity, and our findings clearly attest to captivity’s detrimental psycho-physiological
effects. Pathology stemming from war trauma is not restricted to psychiatric symp-
toms 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 captiv-
ity 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 decision-
makers 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 alle-
viating 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 “eco-
nomic,” 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 inten-
tional 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 peo-
ple 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: margarete.schauer@uni-konstanz.de
The authors declare that they have no competing interests. Both authors have made substantial con-
tributions 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.

390 M. Schauer and E. Schauer
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 asy-
lum 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 pub-
lic 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, develop-
ment 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 disas-
ters 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 indi-
viduals. 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 vio-
lence 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 after-
shocks 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
16 Trauma-Focused Public Mental-Health Interventions 391
over public mental-health interventions is more divided than ever. Arguments are
fought over topics, like “Western versus local approaches,” the possible “medi-
calization 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 guide-
lines 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 resource-
poor, 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 community-
based 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 trauma-
focused 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 adversi-
ties before and during current crisis and to identify populations at risk. Include
individuals’ experiences, sociodemographic indicators, trauma and loss expo-
sure (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 assess-
ment 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, psy-
chosocial 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 individu-
als and groups deal with traumatic stress-related symptoms (PTSD, depression,
suicidality, substance abuse, bereavement), which is able to be applied by locally
trained paraprofessionals.
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 acknowl-
edge 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, educa-
tion, 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, par-
ents, 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 awareness-
raising 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, testimo-
nial 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 coher-
ent 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.
proximity to danger (Schauer & Elbert, 2008). These reaction patterns provide opti-
mal 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 contex-
tual cues, such as time and location of the danger. A characteristic post-experience
feature of traumatic stress is the persistent involuntary reexperiencing of the horrify-
ing 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 acti-
vation (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 avoid-
ing 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
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 impair-
ments 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 volun-
tarily 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 com-
prehension 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 inter-
ventions, 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 mecha-
nism 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
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 accom-
pany 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 commu-
nities 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 income-
generating 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 men-
tal 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 trans-
mitting 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 victimi-
zation. 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 prerequi-
sites 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-
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 psy-
chological 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 mor-
tality (Boscarino, 2004; Kolassa et al., 2007; Neuner, Onyut et al., 2008; Ouimette,
Goodwin, & Brown, 2006; Schnurr & Jankowski, 1999). As outlined above, evi-
dence 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 alter-
ation of bodily processes, due to a state of persistent readiness for an alarm
response. Psychobiological abnormalities in PTSD are observed as psychophysio-
logical, 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 vari-
ety 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 psy-
chiatric 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 dis-
orders, 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; vul-
nerability 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,
2000), but interestingly enough, not psychological service utilization. Clinical

observation suggests that the symptoms of PTSD or associated psychosocial prob-
lems can interfere with offered healthcare, causing difficulty in provider–patient
communication; reducing patients’ active collaboration in evaluation and treat-
ment; 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 com-
munities 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 pop-
ulations 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 otherwise-
caused 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 ser-
vices, 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 col-
laborated 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 psy-
chophysiological imprint not just in their children’s, but in their grandchildren’s
generation, such as non-adaptive changes in the offspring’s stress responsive sys-

tem (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 dur-
ing 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 cog-
nitive 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 alter-
ations 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 preg-
nant 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 devel-
opment 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 challeng-
ing 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
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 “nega-
tive 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 distur-
bance, 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 moth-
ers 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 sub-
stances, may be at twice the risk of experiencing physical or sexual abuse, compared
to children with nonsubstance-abusing parents. An extensive body of research fur-
ther 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 behav-
ior (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
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 stud-
ies 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 non-
traumatized 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 con-
tribute 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 recov-
ery. 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 experi-
ences. 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 psy-
chological trauma. Authors report that systematic torture or child soldiering, for
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 disor-
ders. 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 socioe-
conomic 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 commu-
nity 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 mecha-
nisms 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 simi-
lar 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
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’ symp-
toms 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 experi-
ences. 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 post-
conflict/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 follow-
up assessments. Currently implemented, non-specific “psychosocial” interventions,
which are almost always “social” rather than “psychological” in nature, have, as
of yet, not shown evidence in reinstating functioning and healing psychiatric disor-
ders 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 psychotrauma-
tization, 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 trau-
matic stress-related conditions. With the intention of ameliorating psychological
trauma, NET also intends to contribute directly to the fight against torture, per-
secution, 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 vio-
lence 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 eco-
nomic 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,
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 recon-
struction, 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, narra-
tive 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 with-
out taking the entire biographical context of the person into account. Each personal
experience is purposefully anchored at its correct “time” and “place” in the individ-
ual’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 person-
centered 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 for-
ward 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 per-
sonal 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 sur-
vivor’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 therapeu-
tic approach are based on theories of habituation, as well as cognitive theories of
autobiographical, language-based memory recovery, the assessment and restructur-
ing 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;
• 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 affec-
tive interconnections and separating the memory about the traumatic event from
conditioned emotional reactivity;
• Construction of a conscious, semantic connection between physiological reactiv-
ity 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 “sur-
vivor 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 psy-
chotherapeutic 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
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 dissem-
inated 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, refer-
ral 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 for-
merly 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 disas-
ter and war settings always includes the healing of the collective. We hypothesize
that the collective rewriting of the past, based on diverse individual autobiograph-
ical 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 trau-
matic events legitimize private memories, help memorialize them, and contribute
to the healing process. In a currently implemented, controlled trial, we have there-
fore added a “NET Truth” component, where the efficacy of providing peers with
read-out parts of NET testimonies, in order to remedy trauma symptoms in class-

mates, 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 experi-
ences 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/post-
violence 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 suscep-
tibility 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 sys-
tem, 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 collec-
tive 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
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 imple-
mentation 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 clin-
ical psychology. There has been very little, if any, break-through knowledge that
has been directed at the most urgently needed intervention-research areas, espe-
cially 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 mor-
tality. Mental health-related conditions, including depressive and anxiety disorders, alcohol
and drug abuse, and schizophrenia, contribute to a significant proportion of disability-
adjusted life years and years lived with disability. . .Apart from causing suffering, mental
illness is closely associated with social determinants, notably poverty and gender disadvan-
tage, 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 orga-
nized violence on the minds and lives of the civilian population, little scientific gains
have been made in finding evidence-based, public mental-health and population-
based solutions. The multidimensional relationships especially between the abuse of
human rights, impaired mental health, perpetuation of the cycle of conflict, and fail-
ure to rebuild peaceful communities post-conflict remain scientifically unexplored.
Until recently, the evidence base for the efficacy of non-specific psychosocial inter-
ventions 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”
activities are often restricted to “educational” or “social” interventions, such as cre-

ative 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 the-
oretical background and the efficacy of these methods is doubtful (Bolton et al.,
2007). Despite this lack of scientific foundation, resources are lobbied for such non-
specific 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 men-
tal 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 rec-
ommendations 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 co-
existing 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. Garcia-
Peltioniemi, 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 dif-
ferences. She claims that knowledge of this should lead us away from treating the
mental-health difficulties of refugees as something new and unusual, while allow-

ing 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 simi-
larly 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 inter-
ventions globally (U.N. and international NGOs alike) adopted a new policy in
respect to psychosocial programming, based on the overwhelming experiences dur-
ing 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, neigh-
borhood, 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 com-
pares the investment in individual trauma treatment for severely affected children
and their parents by specifically trained, lay counselors to the impact and compar-
ative 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 mental-
health 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
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 por-
trayal 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 majo-

rity” 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 tri-
angle 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 mental-
health 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 epidemiologi-
cal 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 inter-
ventions 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 com-
monly 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 sen-
sitive approaches in the context of PTSD treatment can certainly be found among
modern, research-based psychotherapies. Thus, we argue, the decision for “relief
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 tradition-
ally 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 diag-
nostic 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 “trauma-
focused 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, commu-
nity, 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 psychoeco-
logical 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 emo-
tional 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 func-
tioning 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 scien-
tific 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
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 any-
thing. 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 close-
ness 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, mag-
nitude, 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 symp-
toms (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 posttrau-
matic problem of victims carries the risk of perpetuating trauma-related behavior.
A strategy of social support can be an additional element for affected communi-
ties only where a sufficient number of adult community members remain at least
partly protected from the psychological impact of armed conflict, organized vio-
lence, 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 ser-
vices, remain 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 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 indi-
viduals 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 pur-
suits. As international agents, however, we cannot desire to reinforce traditional and
religious structures, norms, and values, unless research proves their efficacy or bene-
fits. 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 knowl-
edge 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:
Article 39: state parties shall take appropriate measures to promote physical and psycholog-
ical 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 encour-
aged, 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 ser-
vice interventions, or any humanitarian interventions, have the duty to address key
problematic issues such as traditional, as well as current gender inequality, and age-
old 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 slav-
ery 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 vulner-
able 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 sol-
idarity 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 pro-
grams 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).
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 project-
related, 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 interven-
tion 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 vio-
lence, specific abuse and stigmatization, drug-taking behaviors, among many others,
all of which are of key importance for consideration when developing an appro-
priate intervention program. Most often, however, there is a complete absence of
empirical data collection at start, looking at characteristics of the beneficiaries (indi-
viduals, 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 psychother-
apy). Regardless of whether the data are collected initially, mid- to long-term
follow-up of beneficiaries is blatantly absent, thereby missing out on the oppor-
tunity 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 resolu-
tion. 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
directly touches on issues of human rights and equality. The possibility of provid-
ing 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 mental-
health 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 mental-

health 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 human-
itarian best practices lessens, while trauma-focused, public mental-health service
implementation emerges as a key priority. The possibility of the build-up of large-
scale, 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 mental-
health 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 trauma-
focused, 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.
A paradigm shift toward human rights and evidence-based service in the pro-
vision 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 297–299, 302, 305, 337–338, 366,

Abduction, 141, 179, 187, 314, 316, 321–322, 368–369, 377, 391, 396, 400, 404,
325–326, 328, 336–337, 341, 345, 348, 410, 417
402, 407 Attitudinal barrier, 100, 116
Acculturation, 319 Autobiographic memory, 393
Acute-care, 147 Avoidance, 5, 9, 31, 40–45, 48, 50, 57–58, 121,
Acute stress disorder (ASD), 121, 217, 226, 170, 181–182, 202, 247–259, 268–270,
268, 271–274, 302 276, 280–282
Adaptation, 8, 38–40, 42–43, 45, 102, 276, Avoidance coping, 251–252, 256, 277
283, 305, 319, 324, 364, 393 Azerbaijan, 79, 292, 304
Adaptive coping, 266, 276, 282, 284
Adjustment, 11, 83, 161, 202, 265–284, 332,
B
345, 375, 378–379
Bangladesh, 144, 147–148, 150
Affect regulation, 269, 339–340, 398–399
Bosnia, 75, 98, 102–103, 120, 135, 219, 223,
Affect tolerance, 44–45, 116
293, 301
Afghanistan, 78–79, 98, 103, 142, 160,
Burundi, 78–79, 93, 135, 137, 190,
163–164, 168, 170, 182, 185, 229, 231,
229–230, 315
296–297, 315, 390, 400, 411, 416
Aggression cycle, 64–65
Algeria, 112, 142, 182, 270 C
Allostasis, 362 Cambodia, 15, 78–79, 86, 88, 93, 112, 142,
Amputation, 136, 141, 152, 227 144, 147–148, 150, 182, 219, 237–238,
Angola, 78–79, 93, 135, 137–138, 189, 197, 270, 371
315, 342, 348, 414 Case management, 117, 165, 167
Anxiety, 7, 20, 40, 63, 112, 120, 124, 170, Central nervous system, 334, 337
182–183, 188, 217–218, 220–222, 226, Centrifugal disasters, 33, 114
229, 234, 254, 256, 266–274, 280, Centripetal disasters, 33, 49, 114
293–294, 297–298, 300, 302–304, Child soldier, 3, 81, 89–91, 178–179, 187–188,
331–332, 338, 365, 370–371, 373, 377, 194, 196, 203, 311–349
381, 395–399, 403, 408–409 China, 56, 75, 141
Armed conflict, 2–3, 5–6, 8–10, 13–15, 20–21, Chronic illness, 10–11, 151, 253–254
74–76, 85, 87, 93, 98, 103, 112, 126, Civilians, 74–75, 78, 100, 135, 140, 163,
137–139, 141, 181, 197, 216–217, 222, 179, 185–186, 204–205, 215–239,
224, 257, 271, 301, 312–315, 319, 340, 277, 292–294, 312–313, 322, 341,
345, 390, 407, 413–414 344–347, 390
Armenia, 75, 187, 221 Civil war, 58, 76, 83, 101, 167, 178–179, 185,
Assessment, 17, 106, 116, 119–120, 123–124, 270, 312, 319, 326, 337–338, 346
126, 145, 150, 161–163, 166–167, Clinical intervention, 116, 216, 226–227,
189–193, 199, 218–219, 269, 292, 238–239

DOI 10.1007/978-1-4419-5722-1, C Springer Science+Business Media, LLC 2010
430 Index
Cognitive-behavioral therapy (CBT), 91, 121, Democratic Republic of Congo (DRC),

226–227, 299 135, 138, 183, 196, 204, 304, 315,
Cognitive-processing model, 43 317–318, 320, 323, 342, 348–349, 390,
Cognitive processing therapy (CPT), 91, 121, 406, 416
171, 300–301 Denial, 35, 42, 48–49, 59, 251–257, 276,
Collective action, 267 278–279, 282, 295, 361–362, 377, 379,
Collective identification, 336 394, 413
Collective violence, 74–77, 82–83, 85–86, Department of Defense (DoD), 161–166
91–92, 139 Department of Veterans Affairs,
Collectivistic, 92 165, 169–172
Combatants, 14–16, 18, 91, 139, 149–150, Depression, 7, 15, 41, 105, 120–122, 125,
177–206 142, 164, 167–169, 171–172, 181–184,
Combat captivity, 367 188, 198, 200–201, 203, 205, 218–219,
Combat exposure, 163, 167, 184 221–222, 227, 233–234, 268–269,
Communal coping, 16–17 271–274, 279–280, 292, 294, 297, 324,
Communal psychological wounds, 9–10 332–334, 338–339, 346–347, 391, 399,
Communal trauma membrane, 124, 283–284 401–402, 409
Community-based rehabilitation (CBR), 12, Development, 7, 10, 12–14, 16–17, 20–21,
18, 97–108, 123, 148, 151 35, 40–41, 49, 74, 76, 79–80,
Community-level rehabilitation, 12–14, 21 82–83, 85, 87–90, 92, 98–102, 105,
Comorbid disorder, 182 107–108, 123–126, 137, 139, 142,
Complex emergency, 5, 134, 407 144–145, 148–153, 178, 184–186,
Complex system, 93, 114–115 194–195, 205–206, 222–223, 225,
Conflict-affected, 5, 136–138, 142, 148–151, 229–231, 236–239, 274–275, 283–284,
215–239, 305, 390, 400, 408, 418 293, 295, 301–303, 332–333,
Conflict resolution, 80, 83, 85, 88–89, 92, 395, 335–339
402, 409, 416 Diagnostic and Statistical Manual (DSM),
Conservation of Resources, 17, 124–125 31, 57, 163, 165, 168, 170, 183,
Convention of the Rights of the Child, 317, 415 200–201, 217, 221, 251, 268, 298, 324,
Convention on the Rights of Persons with 366–367, 371
Disabilities (CRPD), 100, 145 Diplomacy, 61, 65–69, 83, 92
Co-occurring disorder, 7, 121, 221, 272, Direct effect of war, 16, 136
297, 305 Disabilities, 5–7, 10–12, 14–15, 18, 89, 91,
Coping, 2–3, 7, 16–17, 20, 30, 42, 44, 60, 98–108, 111, 115, 122–123, 126–127,
62, 64, 88, 115–116, 119, 126, 169, 140–147, 150–153, 180–181, 188, 194,
172, 183, 186, 219–220, 228, 233–234, 198, 237
248–255, 263–282, 292–294 Disarmament, Demobilization, Reintegration
Counseling, 11, 31, 91, 116–117, 119, 121, (DDR), 14, 178–180, 183–184,
147–148, 164, 170, 189, 192–194, 196, 188–199, 204, 206, 338
198–199, 202–203, 229–230, 232–234 Disclosure, 256, 295–296, 363
Crimes against humanity, 62, 178, 237–238, Disorders of Extreme Stress Not Otherwise
313, 316–317, 403 Specified (DES-NOS), 269
Crisis intervention, 81–82, 89, 91 Dissociative mechanism, 334
Cross-cultural, 267–268, 391, 417 Donor community, 4, 84, 180
Cultural context, 92, 124, 267–268 Drug abuse, 181–182, 194, 201, 254, 314,
Cultural destruction, 294 332–333, 381, 408
Cycle of violence, 79, 186–188, 312, 347–348,
396, 399, 407, 416
E
D Ecological approach, 216
Debriefing, 119–120, 302 Ecological framework, 18
Defense mechanisms, 30, 35, 46, 393 Economic cost, 1
Demobilization, 14, 149, 178–181, 189, Economic development, 74, 76, 79, 118, 142,
196–197, 204, 312, 343–347 186, 194, 231, 236, 312, 347
Index 431
Education, 17, 68–69, 76–77, 79–80, 84, Guilt, 44, 58, 63, 229, 248, 266, 271, 294, 298,
88–92, 98, 104, 107, 116, 118–119, 332, 334, 337, 364, 405
124, 126, 136–138, 142–146, 148, 164,
171, 179, 190–193, 205, 217, 225, 229, H
231, 233, 236–237, 267, 272, 314, 320 Handicap International (HI), 12, 103, 149
Ego defenses, 34, 36 Health, definition of, 85, 239
Egypt, 297, 363, 366, 381 Health outcomes, 138, 217–219, 221, 331,
Emotional distress, 104, 142, 161, 230, 252, 338, 396
267, 278, 375, 410 Helplessness, 38–39, 41, 47, 80, 88, 185, 187,
Emotion-focused coping, 252, 255, 218, 228, 237, 250, 268, 324, 329, 338,
277–278, 377 346, 362, 369, 393–394, 401, 403
Employment, 5, 11, 15, 20, 29, 91, 122–124, Help-seeking, 256, 372–373, 412
126, 142, 144–146, 184, 189–191, Herzegovina, 98, 223, 293
231–232, 236, 281, 320, 338 Homeostasis, 38, 253, 336, 361–362
Empowerment, 80, 87–88, 90, 220, 228–231, Human Development Indices, 137
234–235, 237–238 Human dimension, 4, 14
Environmental barriers, 144–145, 148, Human factor, 4
151–152 Human healing, 4
Epidemiological study, 169, 334, 381 Humanitarian assistance, 4, 134, 150, 238,
Eritrea, 75, 78, 102, 108, 137, 188, 192, 230 389–418
Ethiopia, 75, 78–79, 102, 112, 137–138, 192, Humanitarian work, 4, 84, 115, 117–119, 125,
270, 390, 416 127, 408
European Union, 4, 13, 101, 180 Human rehabilitation, 1–2, 21, 134, 145, 153
Evidence-based, 10, 74, 153, 171, 199, Human rights, 11, 18, 68, 77, 79–80, 84–86,
202–206, 216, 238, 299, 391–408, 90, 92, 98–103, 106–108, 125–126,
412–417 136–139, 202, 222, 236–237, 321, 345,
Ex-combatant, 18, 91, 149–150, 177–206, 312, 373, 390, 395–396, 403–404, 407–408,
333–334, 338, 344, 346–349 413–417
Existential despair, 47–48 Human shield, 48, 218, 313
Exploded remnants of war (ERW), 136,
139–140 I
Imaginal exposure, 35, 299–300
Imprisonment, 79, 380–381, 403
F Improvised explosive devices (IED), 139–140
Fear network, 43–44, 254, 321, 324, 326, 334, Inclusive community, 33
393, 401, 403 Income-generating activities (IGA), 89, 228,
Flashbacks, 8, 19, 35, 45, 181, 185, 250, 268, 231–233
276, 282, 407 India, 148, 150, 315
Foreshortened sense of the future, 19–20 Indirect effect of war, 136
Forgiveness, 55–69, 229 Individual-level rehabilitation, 10–12
Functional limitation, 5, 11, 140–143, 147, Indonesia, 75, 78, 235
150, 152–153, 274 Information processing, 40–43
Future time orientation, 19–20 Injuries, 2, 6–7, 10, 14, 18, 74, 91, 112, 123,
133, 136, 140, 142, 144–147, 150–153,
G 163, 165, 168, 170–172, 216, 250,
Gaza, 98, 101–104, 106–108, 154, 182, 234 292, 313
Gender-based violence (GBV), 84, 86, 136, Inter-Agency Standing Committee (IASC),
196, 220 105, 124–126, 134, 137, 224–226, 232,
Genocide, 57, 62, 65–67, 75, 93, 139, 187, 238, 409, 415
199–201, 203–204, 293, 326, 346, 401, Internally displaced persons (IDPs), 77–78, 82,
403, 405 86–87, 138–139, 200, 331, 390
Germany, 56, 75, 84, 165, 187, 203, 293 International Classification for Functioning,
Global Burden of Disease (GBD), 134, 221 Disability and Health (ICF), 100,
Guatemala, 79, 270 141, 143
432 Index
International Disability and Development Mental disorders, 17, 111–112, 202, 216,
Consortium, 14 220–222, 224–225, 235, 251, 324, 381,
International humanitarian relief, 4 402, 408, 412
International Labor Organization (ILO), 11, Mental-health professional, 3, 28–31, 33, 48,
15, 98–100, 106, 316 50–51, 85, 91, 112, 118, 127, 164, 172,
International Rescue Committee (IRC), 135 204, 225, 232, 296, 395, 410
International Society for Traumatic Stress Mental-Health Screenings, 161–162
Studies, 410 Meta-analysis, 2, 7
International tribunals, 86 Metaphor, 29–30, 47–48, 51, 67, 178
Interpersonal sensitivity, 119, 372 Military deployment, 159–160, 165, 167, 169
Interpersonal therapy (IPT), 200, 203–204 Military forces, 18, 89, 91
Interpersonal trauma membrane, 35, 44, 48, Millennium Development Goals, 76, 408
51, 113, 125, 257, 280, 282–283, Mobility problems, 104, 106
296, 303 Models of rehabilitation, 11
Intervention, 2, 10–12, 15–19, 27, 33, 63, 65, Mortality, 76–78, 91, 133–138, 152, 221,
77, 80–82, 84–85, 89, 91, 93, 106, 313–314, 331, 369, 379–381,
114–127, 137, 163–164, 166–167, 171, 396–397, 408
194, 197–198, 202, 227, 229–230 Mozambique, 75, 78–79, 88, 137–138, 183,
Intrapsychic trauma membrane, 34–36, 40, 44, 230, 315, 342
47–48, 119, 257, 259, 281–283 Multidimensional approach, 2, 10–14, 29,
Intrusion, 8, 41–44, 51, 181, 185, 202–203, 115–116
252, 254, 257, 276, 282, 344, 368, 393 Multidimensional concept, 51
Intrusive memories, 9, 35, 254 Multidimensional model, 10
Invisible wound, 7, 216, 219, 238 Multi-level, 2, 29, 92
In vivo exposure, 299–300 Multi-level model, 16
Iraq, 75, 79, 142, 149, 160, 163–164, 168, 170, Mutilation, 79, 141, 178, 293, 313, 322,
229, 315, 413 324, 415
Israel, 56, 102, 119, 363, 369, 372, 381
N
Narrative exposure therapy (NET), 198–206,
J 227, 301, 303, 305, 312, 403–407, 417
Japan, 56, 84, 144 Natural disaster, 2, 81, 87, 97–98, 201, 253,
Justice, 56, 59, 61, 63, 65, 67–69, 84, 86–87, 278, 320, 324, 376, 405
92, 237, 346, 395, 401, 415 Negative attitudes, 15, 108, 144, 186, 312,
346–347
K Negative reciprocity, 339, 399
Kenya, 137, 144, 148, 150, 224 Neuro-endocrine system, 337
Korean War, 378 Nicaragua, 237, 409
Kosovo, 410, 416 Nigeria, 75, 78, 183
Non-adaptive cognition, 45, 171
Non-adaptive response, 8–9, 264–274, 283
L
Non-governmental organization (NGO), 4, 10,
Land mines, 85–86, 89, 136, 139–142, 153
18, 65, 77, 85, 101–102, 108, 202, 227,
Laws of War, 317
234–235, 394
Liberia, 78–79, 135, 137–139, 188, 192, 220,
Non-verbal memories, 35
228, 236, 315
Longitudinal study, 43–44, 364, 366, 368 O
Loss cycles, 17 Open system, 113–115
Organization of Security and Cooperation of
M Europe, 76
Mass rape, 178, 294, 313, 342 Organized violence, 181, 187–188, 196, 199,
Mastery, 9, 38, 44, 47, 116, 237, 254 312, 324, 338, 345, 390, 394, 401, 403,
Medical rehabilitation, 16, 123, 143–145, 405, 408, 413
147–152 Orphans, 200, 319–320
Index 433
P Prisoners of war (POW), 361–364, 367,

Paradigm, 74, 76, 224, 277, 281, 296 370, 380
Paradigm shift, 389–418 Problem-focused coping, 252, 255,
Peace-building, 4, 18, 84, 148, 178–179, 187, 277–279, 377
199, 204–205, 412 Prolonged exposure (PE), 112, 171, 299–300,
Peacekeeping, 65–66, 80–81, 86–87, 89, 332, 364
183, 313 Protective barrier, 29–30, 282
Perceptual apparatus, 34, 45–46 Protective factors, 74, 217, 294–295, 401
Peritraumatic, 334–335 Psychiatric disability, 270, 272–274, 283, 370
Pharmacological treatment, 121, 227, 235 Psychiatric symptomatology, 365,
Pharmacotherapy, 91, 205 370–371, 381
Physical infrastructure, 2, 222 Psychobiological consequences of trauma, 412
Physical injury, 5–7, 57, 164–165, 249, Psycho-education, 66–67, 119–120, 229,
266, 293 283, 302
Physical rehabilitation, 11, 133–154 Psychological rehabilitation, 10–11, 159–172,
Physiological reactivity, 405 177–206, 225, 347–348, 390, 396,
Polytraumatic injuries, 165 403, 416
Post-conflict context, 99, 275 Psychological shock, 5, 44
Post-conflict environments, 10, 15, 271, 306 Psychological stress, 2–3, 5, 29, 105, 159, 187,
200–201, 206, 266, 280–281
Post-conflict rehabilitation, 4, 7, 10, 13,
Psychological trauma, 5, 9, 14, 30, 40, 44, 115,
111–127, 178, 253, 267
216, 228, 328, 397, 400, 403
Post-conflict situation, 14–15, 28, 99–108,
Psycho-physiological complaint, 380–381
124, 281
Psycho-physiological impairment, 380
Posttraumatic growth, 8, 373–380
Psychosocial assistance, 222, 226, 228, 231,
Posttraumatic hysteria, 41
238, 408, 412
Posttraumatic stress disorder (PTSD), 7–9,
Psychosocial intervention, 16–17, 126, 199,
19–20, 30–31, 37–38, 40–43, 45–46,
206, 402, 408, 410
105, 111–112, 119–122, 142, 161–165,
Psychosocial trauma, 112, 127
167–172, 181–184, 187–188, 194,
Psychosocial treatment, 299–300
200–201, 203, 205, 217–219, 221–222,
Psychotherapy, 34, 91, 121–122, 201, 227,
224, 226–228, 248–249, 251–252, 254,
298, 300, 306, 312, 372, 403, 405, 416
256, 267–274, 276, 278, 280–283,
Psychotraumatology, 394, 417
291, 294–306, 311, 321–328, 330–331,
Psychotropic medication, 121, 162
345–347, 364–373, 375–379, 381, 391,
Public health, 17, 73–93, 135, 137, 143–144,
393–394, 396–397, 399–402, 404–406,
150, 199, 224, 381, 390, 402
407–409, 411, 417
Public-health perspective, 143
Poverty, 5, 12, 74–76, 79, 83–84, 99–100, 102, Public mental-health approach, 391
105, 107, 137, 152, 178, 184, 194, 196,
217, 219, 223, 230, 301, 314, 316, 320, R
331, 333, 391, 397, 408 Randomized controlled trial, 92, 171, 200, 392
Premature aging, 361–382 Rape, 5–6, 29, 77, 91, 141, 178, 196, 227,
Prevalence, 8, 85, 135, 138, 142, 153, 163–164, 249, 254, 256, 258, 270, 291–306,
169, 182, 195, 201, 216, 218–219, 313–314, 319, 321, 324–326, 328,
267–270, 272, 292–293, 313, 315–316, 341–342, 415
326, 330, 346, 364–365, 367, 381, Rape as weapon of war, 293
401–402 Reconciliation, 10, 55–69, 81, 84–86, 88–89,
Prevention 91, 180, 187–188, 190, 192, 206, 229,
primary, 76–77, 80, 82–93, 142, 144, 225 237–238, 345–346, 348–349, 395,
secondary, 76–77, 80, 82–93, 142, 144, 152 401–403
tertiary, 76–77, 80, 82–93, 142, 144, 152 Reconstruction, 4, 12–15, 18, 55–69, 81–83,
Preventive intervention, 74, 76, 80, 82–86, 85, 87, 92–93, 103, 108, 123–124,
92–93 126, 142, 148, 151, 180, 190,
Primitive defense, 37, 44–45 348, 404
434 Index
Recovery, 2, 4, 15, 17, 28–29, 33–34, 40, Sexual crime, 292–293

48–51, 55, 60–61, 115–116, 124–125, Sexual and gender-based violence (SGBV),
147, 151, 171, 180, 188, 216, 218–220, 136, 142, 220, 228–229, 236–237
222–233, 235–239, 250, 253, 256, 259, Sexually transmitted infection, 304
274–275, 283, 299, 302, 327, 366, 370, Shame, 229, 247–259, 266, 294, 296–298, 332,
372–373, 379, 391, 395, 397, 400, 342, 364, 405
403–404, 406–408, 414–417 Sierra Leone, 93, 137, 149, 185, 193, 292, 315,
Recovery environment, 29, 48–51, 115, 332, 342, 346–347
124–125, 223, 250, 253, 274, 299 Small arms, 136, 140–142, 162, 316
Refugee, 15, 18, 77–78, 82, 86–88, 90, 100, Social context, 113, 141, 225, 367
104–105, 111–112, 118, 124–125, Social dysfunction, 401
138–139, 179, 182, 199–201, 202–203, Social infrastructure, 3, 142, 303
219–220, 222–225, 228, 231, 233, Social intervention, 16–18, 123–124, 126,
235–237, 269, 280, 298, 301, 305, 314, 199, 201, 6, 224–225, 234, 402–403,
319–320, 325, 331, 336, 390, 395, 408–412
405–406, 408–410 Social isolation, 107, 122, 186, 267, 280, 292,
Rehabilitation counseling, 116–117 294, 312, 347
Rehabilitation definition, 11–14, 143–146 Social participation, 105, 107
Rehabilitation international (RI), 102 Social reconstruction, 55–69, 85, 348
Rehabilitation intervention, 2, 4, 10–11, 14–15, Social stigma, 6, 250, 256, 340–343
18–21, 348 Social support, 6, 44, 106, 114, 125–126,
Rehabilitation philosophy, 11 149–150, 152, 190–191, 224, 232–233,
Rehabilitation psychology, 7 238, 255–256, 270, 274, 279–284,
Reintegration, 9, 14–15, 18, 143, 149, 151, 295–296, 303, 345, 361–362, 367, 401,
153, 178–186, 188–197, 204–205, 235, 412–414
319, 343–348, 407, 415 Social trauma, 56–57, 69, 112, 127
Religious coping, 278 Societal trauma, 55–57, 60–62, 65, 118
Religious leader, 88–89, 236, 345, 413
Socio-ecological theory, 16
Repatriation, 14, 81, 87, 100, 180, 380
Socioeconomic status, 75–76
Repetition compulsion, 8, 38
Somaliland, 181, 198, 333
Repression barrier, 34
South Africa, 56, 61, 63, 67–68, 75, 183,
Resiliency, 87, 118, 162–163, 172, 274
296, 338
Ripple effect, 2, 5, 10, 29, 137, 292, 303
Speechless terror, 393, 395
Risk factors, 7, 74, 77, 82, 92, 112, 119, 163,
Sri Lanka, 93, 98, 185, 200–201, 203, 315,
217, 270–272, 274, 283, 320, 371
317, 320, 326, 334, 337, 390–392, 400,
Romania, 79, 390, 394, 416
406, 412, 416
Rwanda, 66–68, 78–79, 84, 89, 93, 135, 137,
183, 187, 191, 200, 203–205, 230, 236, Stimulus barrier, 8, 29, 36–39, 45–46, 48, 51
293, 304, 315, 320, 326, 346, 390–391, Stress inoculation training, 91, 121
401–402, 406, 416 Stress load, 5, 7, 331
Stressor, 2, 10, 16–17, 34, 57, 112, 125,
S 159–163, 165, 167–172, 178, 182,
Safe space, 228–229, 253 251–253, 255, 266–268, 271, 275–277,
Salutogenic outcome, 373 279–282, 297–298, 303–304, 321, 324,
Screening, 160–163, 166–167, 172, 200, 227, 326–327, 331–332, 335, 345, 361–362,
274, 298, 391–392, 397, 417 364–365, 372–373, 381, 391, 398,
Secondary complication, 146 400–401, 409–410, 413–414
Secondary victimization, 48 Stress-regulating system, 339, 398–399
Sensitivity to stress, 339 Stress response, 6, 29, 188, 266–267, 271–274,
Service system, 99 277, 283–284, 338, 376, 398
Sexual abuse, 6, 29, 104, 196, 249, Structural prevention, 84
323–324, 399 Sub-Saharan Africa, 134, 139, 149, 180, 189
Sexual assault, 254, 266, 270, 273, 291–306, Substance-use disorder (SUD), 168–169,
322, 324 270, 332
Index 435
Sudan, 75, 78, 93, 138, 182, 200, 229, 237, 370–372, 374, 376–377, 379, 390,
315, 321 393–394, 401, 405–406, 412
Suicidal ideation, 169, 182, 250–251, 269, 272, Traumatic memories, 4, 8–9, 15, 20, 27,
332, 334 29–30, 33–37, 40–48, 51, 56, 111–112,
Suicide, 3, 74, 91, 140, 163–164, 169, 252–253, 259, 282, 306, 369, 395
195–196, 232, 250–251, 269, 272, 297, Traumatic neurosis, 31, 35–42, 45
313, 316, 334, 338, 340, 369, 398 Traumatic stress, 2, 6–7, 16, 29, 31–32, 50,
Survival, 8, 10, 12, 20, 37, 40, 56–57, 106, 105, 111–112, 119, 122, 126, 142, 170,
108, 179, 188, 255, 313, 316, 319, 332, 182, 186, 188, 219, 265–269, 283, 311,
338, 367, 397–398 313–314, 321–330, 333, 337, 346, 348,
Survivor network, 27–28, 31, 49, 267, 281, 283 364, 371, 378, 381, 392–393, 397, 400,
Sustainable peace, 15, 148, 150–151 402–403, 410–411
Sustainable recovery, 4 responses, 6, 29
Syria, 75, 297, 363–364, 366, 381 Treatment, 4, 6, 10–11, 17, 20, 35, 42, 46–47,
Systemic rape, 292 88, 91, 112, 115–116, 119–122, 125,
Systems theory, 112–115, 127 127, 142–144, 161–162, 165–172, 177,
181, 185, 198–205, 216, 224–227,
232–233, 235, 237, 267, 272, 289,
T
292–295, 297–301, 303–306, 313, 318,
Tanzania, 84, 304
372, 379, 382, 389–390, 391, 396–397,
Terrorism, 84–85, 139, 267, 274, 324
402–403, 405–407, 410–412, 415–417
Terrorist, 74, 119, 278, 313
Trigger, 6, 16, 35, 41–43, 46, 56, 60–61,
Time distortion, 19 64, 67, 74, 87, 230, 247, 306, 324,
Torture, 6, 29, 79, 85–86, 91, 139, 178, 188, 334–335, 365, 393, 405
202, 218, 220, 228, 234, 249–250, 293, Truth commission, 67
301, 313–314, 321, 324–325, 328, 331, Truth and reconciliation, 63, 68, 86
336, 342, 362–363, 367, 370, 372, 377, Turkey, 75, 297
380–381, 394, 400, 403, 405, 415 Type of trauma, 29, 31, 33, 218, 227, 299, 328
Traditional healer, 202, 230, 232–233,
236, 414 U
Transgenerational, 188, 338–340, 389–390, Uganda, 78, 88, 105, 186–187, 203–204, 233,
397–400, 403 292, 311, 315, 318, 321–323, 327–330,
Transgression, 58–61, 63, 249 333, 335, 341–345, 347–348, 390–392,
Trauma 401, 406, 414–415
care, 123, 142, 146–147, 149–150, 152 Unemployment, 20, 78, 84, 184–185, 222, 316,
membrane, 3–4, 27–51, 55, 61–62, 64, 333, 338
67, 113–114, 118–119, 124–125, 127, Unexploded ordnance (UXO), 86, 89, 313
166–167, 170–171, 178, 253, 257, 259, United Nations, 4–5, 10–14, 76–77, 82–83, 85,
265–267, 271, 273–276, 280–284, 296, 98, 101, 134, 145, 150–151, 191, 219,
303, 305–306 293, 305, 315, 342, 348, 394, 410, 414
rehabilitation, 1–21, 112–113, 115–118, United Nations Children’s Fund (UNICEF),
127, 165, 170 82, 102, 138, 141, 178, 233, 313–316,
researcher, 8–9, 220, 227, 280, 366 336, 413
-spectrum disorder, 184, 201, 205, 324, United Nations Educational, Scientific and
331, 338, 391, 396–397, 402, 411 Cultural Organization (UNESCO),
Traumatic brain injury (TBI), 7, 161, 164–165, 98–100, 106
167–170 United Nations Fund for Women (UNIFEM),
Traumatic event, 3–9, 17–18, 20, 28–29, 31, 82, 291, 293, 297, 304–305
35–37, 42–44, 46–49, 51, 67, 113–114, United Nations High Commissioner for
116, 118–119, 171, 182, 184, 202–203, Refugees (UNHCR), 82, 126–127, 134,
216–218, 220, 222, 224, 228, 247, 178, 219, 222–224, 316, 345, 408,
249–250, 252–254, 258–259, 267, 414–415
269–271, 273, 275, 281–282, 294, United Nations Relief and Rehabilitation
299–302, 323–327, 334, 338, 364, 366, Administration (UNRRA), 13
436 Index
United States, 13, 56, 84, 121, 162, 185, 250, Vocational rehabilitation, 11, 15–16, 144
346, 371, 381 Vocational skills, 81, 89–91
United States Department of State, 13
W
V
War
Verbal memory, 40, 202
captivity, 323, 330, 334–336, 339, 361–382
Veterans, 7, 20, 33–34, 37, 49, 122, 159–172,
neurosis, 38
182–185, 219, 249–250, 252, 267, 273,
327, 330, 334, 366, 369, 371–378, 381 -related injury, 313
Victimization, 9, 18, 48, 249, 295–296, 375, -related rape, 297, 299, 303–305
378, 394–395, 403, 407 West Bank/Palestine, 98, 101–104, 106–108,
Vietnam, 20, 33–34, 47, 49, 122, 142, 164, 112, 142, 144, 149, 270
168, 170, 250, 271, 334, 364, 373, 376 Withdrawal, 40, 251, 254–256, 269, 325, 332,
Violence, 1–5, 9–10, 43, 60–62, 65–69, 74–77, 364, 377
79–80, 82–89, 91–93, 104, 111–112, World Bank, 1, 3, 5, 21, 82–83, 101, 105, 142,
115–116, 118–120, 133–137, 139, 144, 146–147, 149–150, 180, 204, 223,
141–142, 150, 178, 181, 183–188, 196, 313
198, 201, 206, 216–220, 222–223, 226, World Health Organization (WHO), 11, 18, 74,
228, 230, 234, 238, 249, 267, 270, 274, 98, 111, 123, 134, 219, 271, 298
276–278, 280–281, 291–294, 297–298, World War, 13, 49, 56, 74, 135, 144, 170, 178,
303–305, 311–314, 316, 319–320, 324, 216, 271, 293, 369, 378
327, 330–332, 335–336, 338–340,
342–349, 362, 371, 389–391, 394, 397, Y
399, 401–403, 405–408, 413–416 Yugoslavia, 78–79, 137, 187, 293–294,
Violent behavior, 83, 248, 399 346, 415

Trauma Rehabilitation After War and Conflict

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Trauma Rehabilitation After War and Conflict

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Erin Martz

Trauma Rehabilitation After

Community and Individual Perspectives

ISBN 978-1-4419-5721-4 e-ISBN 978-1-4419-5722-1

Library of Congress Control Number: 2010923780

© Springer Science+Business Media, LLC 2010

Printed on acid-free paper

Springer is part of Springer Science+Business Media (www.springer.com)

How people survive

How they trust

How they can

How they let the

How they learn

1 Introduction to Trauma Rehabilitation After War

11 Shame and Avoidance in Trauma . . . . . . . . . . . . . . . . . . . 247

Jamie D. Aten University of Southern Mississippi, Hattiesburg, MS, USA,

Michael Odenwald University of Konstanz, Konstanz, Germany,

Jamie D. Aten, Ph.D., is an assistant professor of counseling psychology in

Evidence-Based Practitioners in Rehabilitation. She received the CSU Vice-

Erica K. Johnson, Ph.D., is an instructor and clinical director of the graduate

worked in conflict-affected countries in sub-Saharan Africa for over 20 years.

K. Jessica Van Vliet, Ph.D., R.Psych., is an assistant professor in counseling

If a meaning is to be assigned to life after trauma. . .the meaning

Abstract This book investigates the topic of individual-level and community-level

E. Martz (ed.), Trauma Rehabilitation After War and Conflict, 1

Boundaries of This Book

of an individual or a community are often exceeded after widespread violence;

Creating a Trauma Membrane

The concept of a multidimensional trauma membrane, which acts as a type of post-

Lindy described in more detail the description of the concept of an intrapsychic

War and Disability

Referring to the treatment of disability in war, the International Federation of

Posttraumatic Reactions and Disability

Psychological Reactions After War or Armed Conflict

As previously mentioned, even if individuals do not experience the direct physi-

assessed in some traumatized populations demonstrate that PTSD is not necessar-

experiments, Solomon, Greenberg, and Pyszczynski asserted that ultimately the

A Multidimensional Approach to Rehabilitation Interventions

Rehabilitation interventions can be discussed on two levels: responses to the

Definition of Individual-Level Rehabilitation

Generally speaking, rehabilitation is viewed as a time-limited intervention to facil-

of an individual’s life (e.g., vocational, social, familial, economic, recreational). The

Definition of Community-Level Rehabilitation

The Commission of the European Communities (1996) defined rehabilitation on

participation, and helping to address the environmental impact of armed conflicts.

Reconstruction is a term that should be distinguished from rehabilitation. On the

Frameworks for Individual-Level Interventions

Vocational Rehabilitation As an Intervention

Frameworks for Community-Level Interventions

In their chapter on psychosocial rehabilitation of refugees and asylum seekers,

Other Forms of Interventions

Future Time Orientation of Rehabilitation Interventions

Isturiz, F. (2005). Military forces’ training for post-conflict peacebuilding operations. In A.

Erin Martz and Jacob Lindy

The trauma membrane is a temporary psychosocial structure, a buffer zone or cov-

E. Martz (ed.), Trauma Rehabilitation After War and Conflict, 27

The Concept of the Trauma Membrane

A Brief History of the Concept

The Trauma Membrane at the Level of the Intrapsychic

Typically, an individual cannot process the traumatic memory related to a trauma

The Formation of an Intrapsychic Trauma Membrane

We could summarize the development of the trauma membrane: After a traumatic

neurosis. Kardiner’s quote reflects an understanding of the power of trauma to cause

Freud’s Ideas on Trauma Neurosis