Trauma Rehabilitation After War and Conflict (eBook)

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 U.S. 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 disability and trauma, disability and employment, and international rehabilitation.

Acknowledgments 6
Contents 7
Contributors 9
About the Contributors 11
1 Introduction to Trauma Rehabilitation After War and Conflict 17
Introduction 17
Boundaries of This Book 18
Creating a Trauma Membrane 19
War and Disability 21
Posttraumatic Reactions and Disability 22
Psychological Reactions After War or Armed Conflict 24
A Multidimensional Approach to Rehabilitation Interventions 26
Definition of Individual-Level Rehabilitation 26
Definition of Community-Level Rehabilitation 28
Frameworks for Individual-Level Interventions 30
Vocational Rehabilitation As an Intervention 31
Frameworks for Community-Level Interventions 32
Psychosocial Interventions 32
Other Forms of Interventions 34
Future Time Orientation of Rehabilitation Interventions 35
Summary 37
References 37
2 Exploring the Trauma Membrane Concept 42
Definition 42
Domains of Application 43
The Concept of the Trauma Membrane 43
Unpacking a Metaphor 44
A Brief History of the Concept 45
The Trauma Membrane at the Level of the Intrapsychic Structure 49
The Formation of an Intrapsychic Trauma Membrane 49
Freud's Ideas on Trauma Neurosis 51
Kardiner and Traumatic Neurosis 53
Integrating Traumatic Memories 55
Information Processing Views on PTSD 56
Other Models of Processing Traumatic Memories 58
Processing Traumatic Memories and the Trauma Membrane Concept 59
Interpersonal Facilitation of the Trauma Membrane 61
The Recovery Environment Facilitating a Trauma Membrane 63
Reaching Across the Trauma Membrane 65
Conclusions 66
References 67
3 Forgiveness and Reconciliation in Social Reconstruction After Trauma 70
Forgiveness and Reconciliation After Social Trauma 71
Foundational Constructs and Definitions 72
Trauma 72
Forgiveness 72
Reconciliation 73
Transgressions 73
Justice 74
Structures 74
Triggers 75
Assumptions About Societal Recovery from Trauma 75
Societal Recommendations for Facilitating Forgiveness and Reconciliation 76
Examples of Justice-Based Track-Three Diplomacy 82
Truth Commissions 82
South Africa's Truth and Reconciliation Commission (SA TRC) 83
Rwandan Gacaca Hearings 83
Examples of Forgiveness-Based Track-Three Diplomacy 83
Irish Catholic and Protestant Forgiveness Education 83
South American Forgiveness Education 84
Conclusion 84
References 84
4 A Public-Health View on the Prevention of Warand Its Consequences 87
Introduction 88
Methods 90
Risk Factors for Collective Violence 91
Prevention 91
Primary, Secondary, and Tertiary Prevention 96
Primary Prevention in the Society-at-Large 97
Universal Primary Preventive Interventions at the Level of the Society-at-Large 97
Selective Primary Preventive Interventions at the Level of the Society-at-Large 100
Indicated Preventive Interventions at the Level of the Society-at-Large 100
Secondary Prevention in the Society-at-Large 100
Tertiary Prevention in the Society-at-Large 101
Primary Prevention at the Community Level 101
Universal and Selective Primary Prevention at the Community Level 101
Secondary Prevention at the Community Level 103
Tertiary Prevention at the Community Level 103
Primary Prevention at the Level of the Family and the Individual 104
Universal and Selective Primary Prevention at Family Level 104
Secondary Prevention at the Level of the Family and the Individual 104
Tertiary Prevention at the Level of the Family and the Individual 106
Discussion 106
References 107
5 Community-Based Rehabilitation in Post-conflictand Emergency Situations 110
The Evolution of CBR 111
CBR in Conflict Situations 113
Case Studies Involving CBR 115
People with Disabilities During Post-conflict Periods 116
CBR and Mental-Health Services 118
Community Mobilization 119
Discussion 120
References 122
6 A Systems Approach to Post-conflict Rehabilitation 124
The Extent of the Problem 124
Systems Conceptualizations 125
General Systems Theory 125
Complex Systems 127
Ecological Perspective: A Pragmatic Approach 128
Trauma Interventions 129
The Intrapsychic Trauma Membrane 132
Debriefing Interventions 132
Individual and Group Counseling Interventions 134
Pharmacology 134
Model Systems Approaches to Intervention 135
Conclusions 140
References 140
7 Human Physical Rehabilitation 145
Introduction 145
Estimating the Impact of Conflict on Human Health 146
The Direct and Indirect Impact of Conflict on Health 148
Violence, Death, and Injury 151
Land mines, Explosive Remnants of War, and Improvised Explosive Devices 151
Small Arms and Light Weapons 152
Individuals with Disabilities 153
Rehabilitation 155
Rehabilitation from a Health Sector Perspective 158
Human Physical Rehabilitation in Conflict-Affected Settings 160
Summary and Implications 162
Conclusion 164
Recognition 165
References 166
8 Psychological Rehabilitation for US Veterans 171
Introduction 171
Pre-deployment Mental-Health Issues 172
Pre-deployment Mental-Health Screenings 173
Pre-deployment Resiliency Building 174
In-Theater Mental-Health Issues 175
Predictors of Psychological Impairment 175
Post-deployment Mental-Health Issues 176
The Post-deployed Wounded in Action 177
Post-deployment Screening for Mental-Health Conditions and Service-Seeking Among Veterans 178
The Mental-Health Consequences of Deployment 179
Mental-Health Treatment and Rehabilitation 181
Importance of VA Research, Training, and Dissemination to the Non-VA Clinician 183
Summary and Conclusions 184
References 184
9 Psychological Rehabilitation of Ex-combatantsin Non-Western, Post-conflict Settings 189
Introduction: Violent Conflicts on a Worldwide Scale 190
Realities of Ex-combatants in Countries Affected by Civil War 191
Disarmament, Demobilization, and Reintegration Programs 191
Mental Health of Ex-combatants in Post-conflict Settings 193
Psychological Malfunctioning and Reintegration Success 196
Difficulties at the Level of the Individual 196
Difficulties at the Level of the Family and Community 197
War-Related Stress and the Cycle of Violence 198
Attempts to Cope with Psychosocial Problems in DDR 200
Vulnerable Groups 206
Child Combatants and Children Associated with Armed Groups 206
Women 208
People with Disabilities and the Elderly 209
Absence of an Evidence Base 210
What Evidence Exists for the Treatment of Psychological Stress in Post-conflict Regions? 211
Implications from Research with Refugees, Genocide Survivors, and School-Based Approaches 211
Refugees and IDPs 212
Survivors of the Rwandan Genocide 212
School Children in Sri Lanka 212
Traditional Rituals and Healing Methods 213
Evidence-Based Treatment Approaches 214
Narrative Exposure Therapy (NET) 214
Interpersonal Therapy (IPT) 215
An Evidence-Based, Postwar, Peace-Building Initiative for Rwanda A Suggestion 216
Conclusions 217
References 218
10 Psychosocial Rehabilitation of Civilians in Conflict-Affected Settings 226
Introduction 227
Background 227
Responses to Trauma 228
Exploring and Measuring Trauma 229
Mental-Health Outcomes Among Conflict-Affected Populations 229
Resilience and Recovery 230
Far-Reaching Impact of Mental Disorders 231
Environments for Recovery 233
Acknowledging and Identifying Needs and Responding Effectively 234
Possible Options for Responding 237
Clinical Approaches 237
Healing Interventions 238
Ensuring Physical Safety, Promoting Psychological and Social Safety 239
Remembrance and Mourning 240
Reconnecting to Ordinary Life -- A Return to Normal Activities 241
Examples of Effective Interventions 245
Training the Healers: Healing Survivors and Communities 245
Avoiding a Fragmented Approach: Addressing Psychosocial and Economic Needs 245
Care and Rehabilitation of People with Psychiatric Disorders 246
Principles of Assistance 246
Conclusion 249
References 250
11 Shame and Avoidance in Trauma 257
Definition and Conceptualization of Shame 258
Shame and Posttraumatic Stress 259
Definition and Conceptualization of Avoidance 261
Avoidance and Trauma 262
Adaptive Functions of Avoidance 262
Costs of Avoidance 264
Shame Avoidance 265
Guidelines and Implications for Helping Professionals 267
Summary 269
References 269
12 Psychosocial Adjustment and Coping in the Post-conflict Setting 274
Introduction 274
Normative Responses to Stress and Trauma 275
The Stress Response 275
Non-adaptive Responses to Stress and Trauma 276
Stress Disorders 277
PTSD Estimates Related to War/Conflict 278
Mood and Anxiety Disorders 280
Coping and the Trauma Membrane 283
Coping Theory and Research 284
Coping in Post-conflict Settings 285
Social Support and Trauma 288
Coping and Social Support: Understanding the Trauma Membrane 290
Resilience and the Trauma Membrane 291
Conclusion 292
References 293
13 Helping Individuals Heal from Rape Connected to Conflict and/or War 300
Introduction 300
Rape During Wartime 301
Why Does Sexual Violence Occur During Conflict? 302
Psychological Factors of Rape and Sexual Trauma 303
Coping and Resilience 303
Cultural Aspects of Treating Sexual Assault 305
Assessment 306
Treatment Considerations 308
Individual Approaches 309
Group Approaches 310
Timing of Intervention 311
Providing Psychological Care in a Post-conflict Environment 312
Summary and Conclusions 314
References 315
14 The Psychological Impact of Child Soldiering 319
Child Soldiers Characterize New Wars 320
The Use of Child Soldiers in Armed Conflicts 323
Prevalence and Phenomenon 323
Reasons for Recruitment of Children 324
Enlistment and Recruitment 325
Forced or Voluntary Recruitment and Remaining? 325
Risk Factors for Recruitment 328
The Consequences for Children Who Have Been Combatants 329
Exposure to Traumatic Stress 329
Post-traumatic Stress Disorder 331
Post-traumatic Stress Disorder 333
Living with Post-traumatic Stress Disorder and Trauma Symptoms 335
The Impact of Trauma on the Body 339
Further Psychological Consequences of Trauma Exposure 340
Drug Abuse 340
Depression and Suicidality 341
Dissociation and Derealization 342
Anti-social and Disruptive Behavior 343
Ideological Commitment 344
Cognitive, Educational, and Occupational Impairment 345
Transgenerational Effects 346
Social Stigma of Returning Girls and Women 348
The Challenges of Demobilization and Reintegration of Child Soldiers 351
Recommendations 355
References 357
15 The Toll of War Captivity: Vulnerability, Resilience,and Premature Aging 369
Philosophical and Historical Introduction 369
The Stressors of War 369
Stressors of War Captivity 370
The Symptoms of War Captivity 370
Israeli POWs of the Yom Kippur War 371
Psychiatric Sequelae of Captivity Posttraumatic Stress Disorder 372
Prevalence of PTSD Among Ex-POWs 372
Trajectories of Captivity-Induced PTSD 373
Longitudinal Study Among Israeli Ex-POWs 374
Criteria of PTSD 374
Prevalence of PTSD in Israeli Ex-POWs 375
Trajectories of PTSD: Changes over Time 376
Coexisting Psychological Disorders 378
PTSD and Coexisting Disorders 379
Need of Professional Help and Help-Seeking 380
Salutogenic Aspects: Posttraumatic Growth 381
Posttraumatic Growth 384
Posttraumatic Growth in POWs of the Yom Kippur War 385
Health Problems in Ex-POWs 388
Conclusion 390
References 391
16 Trauma-Focused Public Mental-Health Interventions:A Paradigm Shift in Humanitarian Assistance and Aid Work 396
Background 397
The Case for Trauma-Focused Guiding Principles 397
Why Do We Need Evidence-Based, Public Mental-Health Interventions? 399
Impact of Traumatization on the Mind of the Individual and the Community 399
Impact of Traumatization on the Body 403
Transgenerational Impact of Trauma at the Individual and Family Level 404
Impact of Psychological Dysfunction at the Collective Level 407
What Can We Do, or Has It Been Empirically Shown That We Can Intervene Based on Evidence? 410
Narrative Exposure Therapy (NET) for the Psychological Rehabilitation of Individuals and the Collective 410
Discussion 414
Conclusion 424
References 425
Index 436

"Chapter 9 Psychological Rehabilitation of Ex-combatants in Non-Western, Post-conflict Settings (p. 177-178)

Anna Maedl, Elisabeth Schauer, Michael Odenwald, and Thomas Elbert

Abstract Disarmament, demobilization, and reintegration (DDR) programs are part of most international peace-building efforts and post-conflict interventions in developing countries. Well over a million former combatants have participated in DDR programs in more than 20 countries, the vast majority of them in sub-Saharan Africa. The impact, however, has remained disappointing.

A significant portion of ex-combatants suffer from mental-health issues, caused by repeated exposure to severe psychological distress. Individuals with PTSD, depression, substance dependence, or psychotic conditions are heavily impaired in their daily functioning. It is often difficult for them to reintegrate into civilian society, and they are less able to support the process of reconciliation and peace-building within their communities and postwar areas at large. Others, who as child combatants adapted to a culture of violence and aggression, have never been taught the moral attitudes and the behavioral repertoire that are required in peaceful settings.

These failures to adjust fuel cycles of violence that might reach across generations. Psychological components of DDR programs are frequently neither 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 interventions and dissemination methods have been successfully evaluated, including Narrative Exposure Therapy and Interpersonal Therapy.

It suggests a comprehensive, community-based, DDR program, which offers mental-health treatment for affected individuals, as well as community interventions to facilitate reintegration and lasting peace. Introduction: Violent Conflicts on aWorldwide Scale Currently 34 large-scale armed conflicts and 3 wars are being fought worldwide (Harbom, Melander, & Wallensteen, 2008). Most of them can be found in non-Western countries, and 13 major wars were recorded in the last decade in Africa alone (Harbom & Wallensteen, 2008).

The type of warfare has profoundly changed since World War II. The so-called new wars (Kaldor, 2004) or ‘complex political emergencies’ (Ramsbotham &Woodhouse, 1999) mainly take place as internal 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 population and to maintain their power within their own fighting forces. Crimes against humanity, like mass rape, mutilations, and torture, are not an exception, but a deliberate strategy in this context. As a result, the social and economic bases of whole regions are completely destroyed and millions of people are displaced. The UNHCR (2008) estimates that by the end of 2007, about 42 million people had fled their homes from violent conflict."