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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 disturbthe persons community. Between 2.5 and 3.5 million displaced people also have

disabilities (Womens 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; Womens 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: [email protected]

111E. Martz (ed.), Trauma Rehabilitation After War and Conflict,

DOI 10.1007/978-1-4419-5722-1_6, C Springer Science+Business Media, LLC 2010


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is a diagnosis indicating difficulties in processing traumatic memories, reportedly

ranges between 4 and 20% of all people exposed to mass violence (Silove, Ekblad, &

Mollica, 2000). Epidemiological studies suggest PTSD is prevalent in post-conflict

settings (de Jong, Komproe, & van Ommermen, 2003; van Ommermen, Saxena, &

Saraceno, 2005). Results of de Jong et al.s (2003) study of 3048 participants fromthe 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 associatedwith 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-healthprofessionals 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 betweenmental 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


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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 clinicalmedical or psychological model that focuses onthe 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 traumarehabilitation (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).


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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 Lindys (1985) description

of the trauma membrane. The survivor communitys receptiveness to the clini-

cians therapeutic intervention and research following the Buffalo Creek disaster

exemplifies an open system (Lindy, Green, Grace, Titchener, 1983). In contrast tothe therapeutic teams 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 survivors 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 destructionof 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 systems members, the range of possible choices, and the rules governing the

choices of individual members. Clearly, centralized decision making simplifies the

complexity of systems (Harrison, 2006).


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Communities, countries, and governments are not closed systems. They are

influenced by cultural, economic, environmental, internal, social, and technological

systems. Rather than possessing a specific identity and predictable interests, they are

dynamic, open systems that are inherently unpredictable (Harrison, 2006; Livneh &

Parker, 2005).

Ecological Perspective: A Pragmatic Approach

The proportion of psychological problems and psychological dysfunction that 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 survivors recovery

environment and the timing and application of potential interventions.

One theory that may be useful is Bronfenbrenners (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 couldnot 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


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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 tothe extent that they achieve an ecological fit. Harveys 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 clients system to promote or obstruct recovery. Harvey oper-

ationally defined recovery as improvement in any one of the following domains:

the survivors authority over the remembering process; their integration of mem-ory and affect, affect tolerance, symptom mastery, self-esteem and cohesion, safe

attachment; and ones ability to develop a sense of meaning from the event. Further,

a persons 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 survivors

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 therestoration 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 ones disabil-

ity, the provider, and the context are brought together by the traumatic event. Each

client subsystem consists of the interaction among each clients unique personal-

ity, competencies, and goals. Prior to implementing services, Hershenson (1998)

recommended that the characteristics of each clients system and subsystem be ana-

lyzed in terms of the clients attitudes and values, behavioral expectations and skills

demands, potential resources and supports, physical and attitudinal barriers, and

opportunities for rewards in order to develop appropriate interventions. Prior to

beginning any intervention, a comprehensive needs assessment is essential (Figley,

1995; Friedman, 2005; Vella, 2002; WHO, 2001).


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Rehabilitation counseling interventions, as one form of counseling that can be

offered in post-trauma situations, involve five core functions that can be applied

to post-conflict trauma rehabilitation: counseling, coordinating, consulting, case

management, and critiquing (Hershenson, 1998). Rehabilitation counselor functions

and interventions are described according to their targeted domain of relevance inTable 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 clients needs.

Table 6.1 Rehabilitation counseling process

Target for intervention Nature of intervention Primary counselor function

Client

Personality

Reintegrate Counsel

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

Culturalpoliticaleconomic 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 Hershensons (1998) model, a humanitarian worker would employ

counseling as a primary function when attempting to reintegrate a survivors 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.


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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 thetheoretical 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 Projects (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 useto 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-

trys 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 Yorks 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


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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 debriefingwithin 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 ones 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


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the handling of bodies during the Gulf War (Deahl, Gillham, Thomas, Searle, &

Srinivasan, 1994). Twenty soldiers, who were unable to participate in the session,

were used as a control group. Nine months following the intervention, 42% of the

control group and half of the treatment group reported symptoms of anxiety related

to life threat and a history of psychological problems. However, there was no differ-ence between those participating in the debriefing and the control group on the IES

or the General Health Questionnaire28 (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 hadmore 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 4872 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 prepost 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.


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Individual and Group Counseling Interventions

The National Institute of Mental Healths (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 arealso 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 consistedof individual sessions held once or twice weekly, 6090 minutes duration per

session over the course of 812 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 theemergence 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


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disorders. Serotonin norepinephrine reuptake inhibitors (SNRIs) are another class

of anti-depressants that are considered a first-line treatment for PTSD (Ravindran

& Stein, 2009). Venlafaxine, an SNRI, has been found as effective as the SSRIs in

the treatment of PTSD and when targeting co-occurring depression (ISTSS, 2008;

Ravindran & Stein, 2009).Individuals with PTSD, who are being treated with SSRIs or SNRIs for PTSD

and who are also experiencing hypervigilance, paranoia, aggressiveness, social 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 equivocalresults (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 117 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 changesbetween 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


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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 theprovision 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 universaldesign during the reconstruction of the communitys 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 projects 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


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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 compromisedtraditional 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 reconstructionprocess.

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 senseof 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

Spheres 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 communitys 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 Hobfolls (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,


15/21


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-careservices 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 survivors 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 becomeprotracted, additional planning is necessary to develop a comprehensive array of

community-based psychological services.

The United Nations 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 peoples mental health and psychosocial con-

ditions. Interventions designed to restore community and family supports include

family tracing and reunification, mourning and healing ceremonies, outreach


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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; theproblems 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, andevaluation; 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 IASCs (2007) guidelines also address areas

that have not been a traditional concern of mental-health providers, such as a popu-lations 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 IASCs 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


17/21


(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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