Chapter 6

A Systems Approach to Post-conict 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 ve million of these displaced individuals have chronic pre-existing mental disorders and another ve million experience psychosocial problems that are either personally disruptive or disturb the 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 posttraumatic stress (de Jong, 2000; Harvey, 1996; Lindy et al., 1981), among other psychiatric issues. The incidence of post-traumatic stress disorder (PTSD), which
S. Zanskas (B) The University of Memphis, Memphis, TN, USA e-mail: szanskas@memphis.edu

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is a diagnosis indicating difculties 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-conict 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-conict countries of Algeria, Cambodia, Ethiopia, and Palestine indicated that common mental disorders were prevalent and exposure to armed conict 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 conict (de Jong et al., 2003). PTSD has also been associated with an array of other life stressors, including deprivation, disruption of support networks, uncertainty, and general conditions in refugee camps (WHO, 1999). Mental-health services that focus exclusively on violence associated with armed conict 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 conict. These factors include exposure to chronic communicable diseases; poor health and nutrition; inadequate peri-natal care; birth injuries; separation from caregivers or other support systems; risk of traumatic epilepsy; and prolonged exposure to stress. On average, half of all refugees present with some form of trauma, distress, or mental-health disorder (WHO, 1999). Considering the extent of the problem and resource limitations, mental-health professionals who are working with survivors need to develop a multidimensional perspective that includes an understanding of the survivors physical, psychological, social, historical, and cultural environments. Adopting a systems approach allows mental-health professionals to develop a comprehensive understanding of the impact war has upon survivors and facilitate a holistic approach to treatment by targeting multiple domains of relevance (de Jong, 2002; Fairbank, Friedman, de Jong, Green, & Solomon, 2003; Hershenson, 1998; van Der Veer, 1998). The purpose of this chapter is to introduce the basic concepts of systems theory, discuss how this epistemological framework transcends the separation between mental health and psychosocial trauma rehabilitation, review the pertinent research regarding collective trauma rehabilitation, and outline the recommendations and model interventions that have evolved as a result of the implementation of this meta-theoretical framework.

Systems Conceptualizations General Systems Theory

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

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(1952). Lewin (1951) considered the person and their environment as interdependent regions of life space with a permeable boundary between the psychological and physical world. Bertalanffy (1952) conceptualized systems as mutually interacting components that were connected through relationships. Relationships between members of a system increase exponentially faster than the actual number of members in the system. From this perspective, cause becomes a reciprocal concept that can be found at the intersection of the interaction between the individual and their system (Cottone, Handelsman, & Walters, 1986). Even in the smallest system, a system that consists of two members, a third factor exists: the relationship between the two members (Cottone, et al., 1986). Understanding the importance of relationships is fundamental to our understanding of the intrapsychic, interpersonal, and psychosocial aftermath of war. Conceptualized as a holistic process, rehabilitation theory in its application has often been implemented as a clinicalmedical 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 conict 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-conict trauma rehabilitation (Cottone, 1986; Harrison, 2006; Hudson, 2000). Cottone (1987, p. 169) identied 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 reect rules and roles. 6. Social system rules can be explicit and implicit. 7. Social systems are driven by communication and information. 8. Systems are either open or closed. Although they vary by extent, all social systems are open systems, importing and exporting information external to their boundaries. Open systems involve permeable boundaries. Closed social systems have reduced communication and serve to minimize the formation of new relationships. However, as a social system, even the most repressive totalitarian regimes are not true closed systems. Conceptually, the interpersonal trauma membrane, which forms around survivors of trauma, can model either open or closed systems, in that sometimes professionals can gain clinical access to survivors, while in other circumstances, they cannot obtain access (Lindy, 1985).

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Although all social systems are open, the extent that they are permeable can be viewed on a continuum. This continuum is evident in Lindys (1985) description of the trauma membrane. The survivor communitys receptiveness to the clinicians therapeutic intervention and research following the Buffalo Creek disaster exemplies an open system (Lindy, Green, Grace, Titchener, 1983). In contrast to the therapeutic teams acceptance following the Buffalo Creek disaster, community leaders were reluctant to allow therapeutic intervention or research following a different disaster the Beverly Hills Supper Club re (Lindy, 1985). Despite the fact that a few leaders in the community allowed the therapeutic team access to the survivors of the Beverly Hills re, the trauma membrane functioned as a closed system and clinical access to survivors was often precluded. Lindy (1985) observed that therapeutic access following mass trauma is a result of a complex array of circumstances, including the approval of community leaders, who often function at the boundary of the trauma membrane (Lindy, 1985). Lindy et al. (1981) classied disasters by their location and their impact upon the survivors support networks. A survivors receptiveness to therapeutic intervention was hypothesized as being contingent upon whether the disaster was classied 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 conict. 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 conict become receptive to the assistance of mental-health practitioners. Centripetal disasters produce open systems. The complex web of cultural, environmental, historical, and interpersonal relationships produced by war can involve either centrifugal or centripetal disasters.

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

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

Ecological Perspective: A Pragmatic Approach

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

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differences in post-traumatic response and recovery to the interactions among the person, event, and environment. Emphasis is placed on the social, cultural, and political context of the survivor with the community as a source of resilience. The effectiveness of treatment interventions can be evaluated within the context of how well they improve the relationship between the individual, their environment, and to the extent that they achieve an ecological t. Harveys model assumes that individuals experience trauma in a unique manner, that treatment access is variable, and that clinical interventions will not always afford recovery. Further, according to Harvey (1996), resilient individuals in a supportive environment may recover from trauma without any form of intervention. However, the timing and type of intervention matter, because clinical interventions interact with other aspects of a clients system to promote or obstruct recovery. Harvey operationally dened recovery as improvement in any one of the following domains: the survivors authority over the remembering process; their integration of memory 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 conict, establishing a safe environment and nding shelter are essential foundations for the survivors mental health. Several weeks after the outbreak of violence, interventions generally focus on community education, in order to develop community awareness of the potential effects of the event, to foster community resilience, and to promote methods of coping. Approximately 4 months after the event, which is during the restoration phase of trauma rehabilitation, more traditional mental-health services are employed (NIMH, 2002; Young et al., 1998; Young et al., 1999). Hershenson (1998) developed a systemic ecological model for rehabilitation counseling practice. In his model, the client, the functional aspects of ones disability, the provider, and the context are brought together by the traumatic event. Each client subsystem consists of the interaction among each clients unique personality, competencies, and goals. Prior to implementing services, Hershenson (1998) recommended that the characteristics of each clients system and subsystem be analyzed 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 ve core functions that can be applied to post-conict trauma rehabilitation: counseling, coordinating, consulting, case management, and critiquing (Hershenson, 1998). Rehabilitation counselor functions and interventions are described according to their targeted domain of relevance in Table 6.1 (Hershenson, 1998). The rehabilitation process is iterative, rather than static, and the role of the rehabilitation worker includes determining which function will be the most effective with their client at any point in the process (Hershenson, 1998). It is important to note that each of the core functions and broad service interventions can be provided separately or combined depending on a clients needs.

Table 6.1 Rehabilitation counseling process Target for intervention Client Personality Goals Competencies Environment Family Learning Peer group Independent living Work Conception of disability Culturalpoliticaleconomic context Provider Rehabilitation services delivery Rehabilitation counselor Nature of intervention Reintegrate Reformulate Resolve or replace Restructure Restructure Restructure Restructure Restructure Restructure Restructure Realize Revise Primary counselor function Counsel Counsel Coordinate Consult Consult Consult Consult Consult Consult Consult Case manage Critique

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

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

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Although a broad range of social and mental-health interventions have been supported by research, the value of mental-health-care services in resource-poor countries has been controversial (Ager, 1997; Fairbank, et al., 2003; Summereld, 1999a; Summereld, 1999b; Summereld, 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 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 assistance, and policy development (Balagna, 2003; Green et al., 2003; Hershenson, 1990; Maki & Riggar, 2004; NIMH, 2002; White, Fox, & Rooney, 2007). Further, the reallocation of resources through policies and programs that promote social development in the community can prevent a source of traumatic events. As conceptualized by Hershenson (1998), humanitarian workers during this preparatory phase are engaged in advocacy and consultation. By interventions such as restructuring the cultural, economic, and political context through capacity building, humanitarian workers can establish a societal trauma membrane that facilitates the development of resiliency. Baker and Ausink (1996) have developed a predictive model that humanitarian workers and NGOs can use to identify failed states, compare and analyze conicts at various stages of development, identify potential outcomes, and to suggest the necessity of intervention. Monitoring demographic pressures, refugee movements, economic development, historical violence, government corruption, economic distress, exodus of a countrys middle class, deterioration of public services, the legal system, and protective services can provide an early warning about the outbreak of potential violence. As one form of post-trauma intervention, training can be provided for professionals and paraprofessionals, who are engaged in early intervention. This training may include response structures and processes, disaster mental-health resources, intervention considerations, vulnerable populations, cultural concerns, outreach and how to deal with the media. A case study of New 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 condence in the application of skills (Norris, et al., 2005). As another form of post-trauma intervention, education can be provided to survivors of disaster; yet, the effectiveness of this has not been empirically established (Ehlers et al., 2003; Eisenman et al., 2006). Education, however, can contribute to the normalization of the trauma experience for survivors of mass violence (Young, 2006). The majority of post-disaster education is informal (Young, 2006). It

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

The Intrapsychic Trauma Membrane

While the humanitarian worker is working, counseling and coordination are examples of humanitarian-worker functions that can be emphasized, in order to address the survivors intrapsychic trauma membrane. Yet, limited controlled, randomized research has been available to support any particular psychological intervention for collective trauma, which is operationally dened 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 dened target symptoms, treatment adherence, blind evaluators, random assignment, and the absence of specic treatment programs that are manualized and replicable (NIMH, 2002). The research that has been conducted on psychological intervention following collective trauma can be organized into the following sections delineating studies on debrieng, individual or group therapy, and the use of medications.

Debrieng Interventions
There have been mixed ndings regarding the impact of psychological debrieng within 1 month of the collective traumatic event. Amir, Weil, Kaplan, Tocker, and Witzman (1998) studied the collective traumatic experience of 15 women, who were not physically injured, within 1 month after a terrorist attack in Israel. The participants attended a weekly group session that addressed abreaction, normalization of their feelings, coping with symptoms, and cognitive restructuring. The participants full-scale scores on the Impact of Event Scale (IES) were signicantly higher in the 2 days post-trauma assessment than at their 2- and 6-month assessments. Despite the passage of time, increased interpersonal sensitivity, which is a measure of 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 debriefing, was provided to 42 British soldiers, who were responsible for identifying and

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the handling of bodies during the Gulf War (Deahl, Gillham, Thomas, Searle, & Srinivasan, 1994). Twenty soldiers, who were unable to participate in the session, were used as a control group. Nine months following the intervention, 42% of the control group and half of the treatment group reported symptoms of anxiety related to life threat and a history of psychological problems. However, there was no difference between those participating in the debrieng and the control group on the IES or the General Health Questionnaire28 (GHQ-28). In a study of formal psychological debrieng, 106 British soldiers serving in Bosnia were randomly assigned by their commanding ofcers to either an assessment-only control group or a single, 2-hour, formal group-debrieng session (Deahl et al., 2000). When comparing the intervention group with the control group, the assessment-only control group was found to have higher anxiety scores and total scores on the Hospital Anxiety and Depression Scale (HADS) and the IES. Followup assessment 1 year later revealed that those assigned to the control group had more overall symptoms reported on the Symptom Checklist-90 (SCL-90) and higher alcohol consumption ratings on the CAGE Questionnaire than the soldiers who participated in one, 2-hour, formal debrieng session. This suggests that the debrieng intervention was effective and maintained its efcacy over 1 year. Response to immediate or delayed debrieng was also studied among bank employees, who had been working at the time of a bank robbery (Campeld & Hills, 2001). Employees were randomly assigned to groups that received either an immediate debrieng (< 10 hours) or delayed debrieng (> 48 hours). Although the number and severity of PTSD symptoms did not differ signicantly immediately following debrieng, those individuals receiving immediate debrieng reported fewer symptoms 2 days, 4 days, and 2 weeks post-robbery than those who participated in delayed debrieng. Several studies suggest that debrieng shortly following exposure to mass violence can abate symptoms. Jenkins (1996) offered Critical Incident Stress Debrieng (CISD) to 36 emergency medical personnel, who worked at the site of a mass shooting. Participation in the debrieng 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 debrieng by Shalev, Peri, Rogel-Fuchs, Ursano, and Marlowe (1998). The participants were evaluated before and after the debrieng. The prepost debrieng scores reected that debrieng was correlated with the reduction of anxiety symptoms on the State-Trait Anxiety Inventory (STAI) and improved self-efcacy on the Self-Efcacy Questionnaire (SELF-C). In contrast, police ofcers 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 ofcers who participated in the group debriefing intervention and the control group that was composed of 59 ofcers. However, 18 months following the crash, those ofcers who did participate in the debriefing showed signicantly more disaster-related symptoms than ofcers that did not participate in the debrieng 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 are also promising to reduce the duration, incidence, and intensity of stress disorders and depression experienced by trauma survivors (Watson, 2004; Young, 2006). A complete review of the various individual and group counseling interventions for survivors of trauma is beyond the scope of this chapter. Readers interested in comprehensive coverage of these therapeutic topics are referred to the works of Foa, Hembree, and Rothbaum (2007), Follette and Ruzick (2006), Schauer, Neuner, and Elbert (2005), Scott and Stradling (2006), and Taylor (2006). Reviewing the ISTSS (2008) treatment guidelines regarding cognitive-behavioral therapy for adults with PTSD reects that effective therapies generally consisted of individual sessions held once or twice weekly, 6090 minutes duration per session over the course of 812 sessions. According to the ISTSS, those cognitivebehavioral approaches that involve exposure therapy, cognitive processing therapy (CPT), and stress inoculation training (SIT) have sufcient research to be recommended as primary treatments for chronic PTSD. However, early intervention focusing on the forced recall of events or associated emotions appears inconsistently effective at reducing future symptoms and may even increase the potential for their development (Chemtob, Tomas, Law, & Crieniter, 1997; NIMH, 2002; Rose & Bisson, 1998).

Pharmacology
According to the National Collaborating Centre for Mental Health (2005), psychotherapy is the current treatment of choice for PTSD. However, medications are often used in conjunction with therapy to reduce the symptom features of PTSD and co-occurring disorders (Cukor, Spitlanick, Difede, Rizzo, & Rothbaum, 2009). Although no specic drug or combination of drugs has been found to prevent the emergence of an acute stress disorder or prevent PTSD, almost every class of psychotropic medication has been prescribed for those experiencing PTSD (Vieweg et al., 2006; ISTSS, 2008). The majority of the literature regarding the pharmacological treatment for PTSD involves the class of anti-depressants known as selective serotonin reuptake inhibitors (SSRIs) (Ravindran & Stein, 2009). SSRIs are the only medications in the United States to have Food and Drug Administration approval for the treatment of PTSD (ISTSS, 2008; Ravindran & Stein, 2009; Vieweg et al., 2006). This class of anti-depressants has been demonstrated to reduce or eliminate the clinical symptoms of re-experiencing, avoidance/numbness, and hyper-arousal (Albucher & Libergon, 2002; APA, 2004; ISTSS, 2008; Stein, Ipser, & Seedat, 2006; Vieweg et al., 2006). In addition to reducing the symptom complex of PTSD, SSRIs, such as sertraline, paroxetine, and uoxetine, 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 rst-line treatment for PTSD (Ravindran & Stein, 2009). Venlafaxine, an SNRI, has been found as effective as the SSRIs in the treatment of PTSD and when targeting co-occurring depression (ISTSS, 2008; Ravindran & Stein, 2009). Individuals with PTSD, who are being treated with SSRIs or SNRIs for PTSD and who are also experiencing hypervigilance, paranoia, aggressiveness, social isolation, or other trauma-related symptoms, have also beneted from augmentative therapy using atypical anti-psychotics such as risperidone or olzanapine (Bartzokis, Turner, Mintz, & Saunders, 2005; Hamner et al., 2003; ISTSS, 2008; Stein, Kline, & Matloff, 2002; Vieweg et al., 2006). The relatively few, controlled, randomized clinical-trial studies, which have been conducted on the effectiveness of medication following combat-related PTSD, suggest medication represents a later form of treatment and has yielded equivocal results (NIMH, 2002). Petty et al. (2001) studied the response of 30 Vietnam and Gulf War veterans with combat-related PTSD to olanzapine that was prescribed for a period of 8 weeks. The mean duration of PTSD was 6 years prior to entering the study with a range of 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 antipsychotic medications, and the control group did not reveal any signicant changes between the two groups on reported PTSD symptoms, the number of psychiatric symptoms, alcohol or drug use, employment, or subjective distress. Another pharmacologic treatment that has shown promise includes the use of antiandrenergics (ISTSS, 2008). Prazosin has been effectively used to reduce posttraumatic nightmares, as well as the overall symptoms of PTSD (Raskind et al., 2007; Taylor, Freeman, & Cates, 2008; Taylor, Martin, et al., 2008; Thompson, Taylor, McFall, & Raskind, 2008). Large, controlled, clinical trials are necessary to address its role in prevention of acute or post-traumatic stress disorder, alone or as an adjunct to psychotherapy (Ravindran & Stein, 2009). The Sphere Standards for Health Services (2004) provide informational guidance for the prescription of medications. In general, health-care workers are advised to refrain from the extensive administration of benzodiazepines to survivors experiencing acute post-conict distress, due to their addictive potential. However, individuals with pre-existing psychiatric disorders or those requiring urgent psychiatric care for bipolar disorders, depression, psychoses, or dangerousness to oneself or others should have access to essential psychiatric medications through primary-care providers (Sphere, 2004).

Model Systems Approaches to Intervention

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

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devices (in the chaos of a war zone), have increased difculty accessing basic lifesurvival needs, and are affected by the loss of the infrastructure that previously provided rehabilitation services. According to the World Health Organization (2005), an appropriate response to post-conict rehabilitation includes institute-based rehabilitation (IBR) and community-based rehabilitation (CBR). IBR involves the provision of medical rehabilitation services following immediate trauma care. The emphasis of CBR is on community development and inclusion for people with disabilities (see Chapter 5). The post-conict response to prevent new disabilities and support people with existing disabilities can be classied into acute and reconstruction phases (WHO, 2005). The acute response involves the identication of people with existing disabilities, responding to their specic health needs, identication of those requiring and providing appropriate trauma care to mitigate disability, transferring people with severe injuries to centers with specialists for medical rehabilitation, and establishing multi-disciplinary task forces that consider available resources, in order to prepare a long-term rehabilitation program. During the reconstruction phase, longterm responses include the identication and assessment of the immediate and future needs of people with newly acquired and pre-existing disabilities; resource mapping to determine community abilities for addressing basic existence, health care, and rehabilitation needs; infrastructure development to provide medical rehabilitation services; development of community-based rehabilitation services to ensure equal access to services; ensuring the integration of people with disabilities into the community and the opportunity for employment; and implementation of universal design during the reconstruction of the 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; collaboration; integrating of services into primary health care; ensuring access to all; training and supervision of community paraprofessional and professional service providers; adopting a long-term perspective; establishing indicators; and monitoring the efcacy of services. Recognizing the broad, systemic implications of conict, a group of humanitarian 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 conict and that those affected by disaster have a right to life with dignity and assistance. Sphere (2004) describes itself as being comprised of three things: a handbook, a process of collaboration, and a statement of commitment to quality and accountability. Acknowledging their reciprocal relationship, Sphere distinguishes between social and psychological intervention (Sphere, 2004). Sphere acknowledges the reciprocity of the two interventions that social intervention can have secondary psychological effects and that psychological interventions have secondary social effects, as the term psychosocial suggests. Signicant social problems can be

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pre-existing, conict-induced, or a result of humanitarian aid efforts (IASC, 2007). Examples of pre-conict 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 conicts. At times, culturally insensitive humanitarian aid efforts have compromised traditional community-support systems. Social interventions refer to those activities that primarily have effects on the development of the survivors interpersonal and communal trauma membrane. Access to activities that facilitate inclusion in social networks is fundamental to the development of a recovery environment. Sphere considers social interventions particularly important during the acute-response phase to disaster. Emphasis is placed on reuniting and keeping intact families, as well as communities. Community participation in the decisions, design, and activities directed toward the reconstruction of the devastated community is essential to long-term success of the reconstruction process. Survivor access to credible information related to the relief efforts is considered a fundamental human right and a primary method of mitigating anxiety (Sphere, 2004; IASC, 2007). The information provided should include the depth and breadth of the disaster and the efforts taken to reestablish a safe environment for the community. Restoration of cultural and religious activities is also considered vital to the development of a recovery environment. Culturally appropriate opportunities for grieving and bereavement promote closure and are more benecial 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 Spheres standards for disaster response. The Sphere Humanitarian Charter and Minimum Standards describe key psychological and psychiatric intervention indicators (Sphere, 2004). Any intervention should be based on an assessment of the existing resources and socio-cultural context, in collaboration with the 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 conict and in post-conict situations (WHO, 2001). The instrument can be used during the emergency intervention phase and post-conict situations. The assessment results can be used to develop recommendations for a community-based, appropriately timed, mental-health program. Consistent with Hobfolls (1989) conservation of resources model of stress, the RAMH results provide a description of the available individual, family, community, human, nancial, political, and material resources. A particular strength of the instrument is its evaluation of the cultural,

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

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

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

Conclusions
The trauma membrane represents a protective system for survivors of post-conict 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-conict trauma rehabilitation. It is anticipated that humanitarian workers and mental-health professionals who adopt an ecological systems approach to post-conict 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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