The impact of trauma on communities and societies ravaged by conflict and war – Part Three in a series on Trauma and Conflict

How trauma and reconciliation are linked needs to be examined from the perspective of an individual, a community, and a society. Reconciling⁠1 means to restore to friendship or harmony, or to settle or solve conflicts. Thus, an individual may heal from consequences of a traumatic event by restoring inner harmony, integrating memory and behavioral impact of trauma into a healthy form of living. In that sense an individual reconciles his/her memory as a condition for a path to learn healthier forms of behavior than those which he/she suffered from through trauma. Psychotherapy is based on that, and so are all, very successful, self-help groups following the 12-Step-principles⁠2.

But what happens if trauma, triggered by the same events, essentially affects all members of a community, or a majority? What happens if these events last for a long time, when those who suffer have no way to escape? Recent history is filled with so many examples, whether Syria, Yemen, or so many more. 

However, let me introduce a country in which I spent four years of my life: I lived in Sarajevo, the capital of Bosnia & Herzegovina, between 2008 and 2012, arriving twelve years after the end of an all-out war.

When Bosnia&Herzegovina declared it’s independence from Yugoslavia, the Yugoslav People’s Army laid siege to the town between April 1992 and February 1996. For 1425 days⁠3, Sarajevo’s citizens had to move under sniper fire and mortar shelling raining down on them from hilltops overlooking the city. They had to flee from violence along frontlines moving backward and forward multiple times. Frontlines where ground forces of the Yugoslav People’s Army and the Bosnian government defense forces clashed for years. Every surviving Sarajevan who came out of that with severe trauma. Bosniaks, Croats, and remaining Serbs.

Bosnia & Herzegovina is home to a multi-ethnic society in which individuals mainly identify themselves as members of either the Bosniak, the Croat, or the Serb nation. For centuries they had lived together in peace. Sarajevo was the glaring example for a multi-ethnic and multi-religious society, Muslims, Catholics, and Orthodox Christians lived together, the rate of inter-marriages was high. Sarajevo’s hospitality and friendliness during the Olympic Winter Games of 1984 are unforgotten. 

The brutal atrocities between 1992 and 1996, carried out under General Ratko Mladic and under political control of Radovan Karadzic and Slobodan Milosevic changed that, forever. Between 2008 and 2012 I was the Head of a European Union Mission assisting in restoring police and the rule of law. In this Mission hundreds of local Bosnian staff members served alongside their international colleagues. Thus, I had ample opportunity to listen to members from all walks of life of today’s Bosnian society. The memories of the war, the impact of traumatic memories, they run deep in every individual I met. Bosniaks, Serbs, Croats have slowly restored a way of living peacefully together. However, the fearful memories of the past impact on them in every aspect of today’s life.

What struck me most was the seeming inability of these three nations living in one State to move on into reconciling with the past. The historical narrative has become very different: Bosniaks in Bosnia will tell a different history opposed to, say the Bosnian Serbs. Nowhere is this more visible than in acknowledging the Srebrenica genocide. There is simply no joint narrative, and I have not seen successful efforts to find a path towards reconciliation. The efforts of all sides are frozen. Until today, the annual commemoration at the Potocari memorial and graveyard site happens without participation of political representatives of the Republica Srpska, the Serb part of the Federation of Bosnia & Herzegovina. As another example, Bosnia & Herzegovina knows the concept of “Two Schools Under One Roof⁠4”. An unknowing passer-by would see Bosniak and Croat school children use the same school. But in reality, they are enlisted into two distinctly different schools. Why else than for the purpose of establishing a different history, and maintaining a different identity?

Years earlier, between 2000 and 2004, I lived in Kosovo. The violent conflict between Milosevic’s Serbian Forces and the Kosovo-Albanian Kosovo Liberation Army had just ended less than a year earlier, through a military campaign carried out against Milosevic by NATO. Very early at the beginning of the post-conflict period in Kosovo, I saw the same like later in Bosnia: Ethnic Albanian and ethnic Serb children did not receive any joint education⁠5. The memory of communities in Kosovo is altered forever. I lived both in Albanian neighborhoods and Serb enclaves. Especially in Serb enclaves, depression and fear ran high. 

These are just two illuminating examples of a more comprehensive personal experience which I made in post-conflict societies all over the World. I share this experience with hundreds of thousands of people in the peace and humanitarian community. One has to get out of the “international bubble”, out of the walled compounds and protected hotels and out of heavily armored vehicles. By living with and within ravaged communities, the heuristic knowledge about the depth of impact of trauma is gained. But what is it that academic research tells us?

The PubMed Central (PMC)⁠6 is a free full-text archive of biomedical and life sciences journal literature at the U.S. National Institutes of Health’s National Library of Medicine (NIH/NLM). As of this writing, it offers access to 4.9 Million articles from 2138 journals that participate fully, 330 NIH portfolio journals, and 4692 selective deposit journals.

 A research of it’s database with the search term “PTSD” offers 33.829 articles. The search term “PTSD conflict war” leads to 3273 references. “PTSD reconciliation” leads to 362 offerings.  “PTSD reconciliation war” references 219 articles. Amongst these, I have undertaken an initial scoping which is not complete. I selected articles that could give some answers to the questions above. To document this, all examined literature can be found in the footnote section⁠7. 

I find the following statements being supported by the selection of scientific research that I have examined:

  • Communities and societies that have come out of conflict include an extraordinary high percentage of individuals with health conditions including PTSD, and other forms of trauma impact, including depression. The impact of war on the mental health of members of communities is most significant.
  • Women are more affected than men, other significant groups with high numbers of trauma survivors include children, elderly, and the disabled.
  • Some studies find very high percentages of trauma survivors in children in refugee camps and displaced populations, and almost as high amongst their caregivers.
  • Among war-affected youth, the association between war exposure and psychological distress is mediated by daily stressors. The breakdown of societal structures in conflict directly affects the impact of trauma on mental health. Within childhood, experiences of family violence and external violence were significantly related to increased mental health symptoms.
  • The availability (or not) of physical and emotional support affects the consequences of traumatization. The use of cultural and religious coping strategies is frequent in developing countries. Where such traditional spiritual and religious support structure break down, coping strategies are severely hampered.
  • Physical disability and depression and PTSD correlate. 
  • Mental disturbances and feeling upset correlate.
  • Trauma effects from conflict, such as somatization, PTSD, anxiety disorder, major depression, alcohol and drug misuse, and functional disability are trans-cultural.
  • Studies support that the above symptoms are the same for victims of rape and forms of conflict-related sexual exploitation and abuse. 
  • Effective public mental health services are needed to address large scale effects of traumatization.
  • The impact of trauma in such societies can be traced for decades, there is also supporting evidence for intergenerational consequences.
  • The trauma impacting on victims and perpetrators of violence leads to different coping strategies. Perpetrators of violence against civilian populations might display less symptoms. The impact of trauma on former child-soldiers can be mediated through family- and community-based care. Conversely, where this is not the case, severe traumatization persists.
  • Some studies mention that there is no established consensus on how war- and conflict-related traumatization should be addressed from a public health perspective.
  • One study (South Sudan) finds that most participants thought reconciliation was not possible without prosecuting perpetrators or compensating victims and did not support amnesty. Participants with probable PTSD were more likely to endorse confessions, apologies, and amnesty, and to report that compensation and prosecution were not necessary for reconciliation. The more traumatic events people experienced, the more they endorsed criminal punishment for perpetrators and the less they endorsed confessions.
  • One study, based on 160 reports, finds that the five most commonly reported activities were basic counseling for individuals; facilitation of community support of vulnerable individuals; provision of child-friendly spaces; support of community-initiated social support; and basic counseling for groups and families. Most interventions took place and were funded outside national mental health and protection systems.

To reduce the findings and my own conclusions even more: 

(1) Conflict- and war-related trauma affects communities and societies significantly and this impact spans over generations.

(2) The most vulnerable suffer most.

(3) Large scale coping strategies depend on the availability of culture-specific services and functions that often have broken down in conflict.

(4) There is little analysis of the effects of traumatization on post-conflict reconciliation.

(5) There is, however, a dire need to look into how the international community factors this context into work assisting in peacekeeping, peacebuilding, and conflict prevention processes.

August 26, 2002, the General Assembly of the World Psychiatric Organization approved a statement on mental health implications of disasters. It begins as follows⁠8: 

 

“The World Psychiatric Association would like to draw the attention of psychiatrists and other mental health professionals, health authorities, decision-makers and the general public to the serious and potentially catastrophic psychological and psychopathological effects of disasters. These effects can be diverse in character, intensity and potential for chronicity, but acute stress reactions, post-traumatic stress disorder (PTSD), mood, anxiety and psychotic disorders, and permanent changes in the personality are the ones that, if left untreated, may have the most serious consequences. Disasters can result from a variety of causes such as earthquakes, floods, hurricanes, fires, naval and plane accidents and terrorist attacks, but also from acts and consequences of war and negative conditions affecting important groups of population like famine, sanctions, forced migrations and similar deprivations. All of them produce very serious effects on the population and particularly on children, having a negative impact on the social structure and systems, which increases the effect of the disaster on individuals and population.”

  

So, whilst it appears that a context between trauma and reconciliation can be established, these findings are a first indicator for that the context with reconciliation, and thus the context with efforts to sustain peace, requires more attention.

Do policy of the United Nations and political decision-making processes such as by the Security Council take the above impact into account? What do we know about systematic or non-systematic efforts of peace operations to factor this into their mandated work. What do we know to which extent peace building efforts take this into account? Are there practices and best-practices?

1 https://www.merriam-webster.com/dictionary/reconciled

2 A twelve-step program is a set of guiding principles outlining a course of action for recovery from addiction, compulsion, or other behavioral problems.

https://en.wikipedia.org/wiki/Twelve-step_program; retrieved June 19, 2018

3 For many more comprehensive documentaries, here a brief video:

4 https://en.wikipedia.org/wiki/Two_schools_under_one_roof

5 At least for ten years preceding the Kosovo-Albanian insurgency, Milosevic maintained rigid control over the previous largely autonomous province of the former Yugoslavia, surely leading to the same effect, but with the curricular written under Belgrade’s control. After the war, the Kosovo-Albanian leadership in Pristina wrote the curriculae for the Albanian schools, and Belgrade maintained as much control as possible over the northern parts of Kosovo and Kosovo-Serb enclaves south of the river Ibar.

6 https://www.ncbi.nlm.nih.gov/pmc/

7 (1) Mental health consequences of war: a brief review of research findings; R. SRINIVASA MURTHY, RASHMI LAKSHMINARAYANA; in World Psychiatry 5:1, February 2006; 

retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1472271/pdf/wpa050025.pdf, June 20, 2018

(2) Post-traumatic stress symptoms among former child soldiers in Sierra Leone: follow-up study, Theresa S. Betancourt, Elizabeth A. Newnham, Ryan McBain, and Robert T. Brennan;  THE BRITISH JOURNAL OF PSYCHIATRY, 2013 Sep; 203(3): 196–202; 

Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3759030/, June 20, 2018

(3) Psychological Consequences of Rape on Women in 1991-1995 War in Croatia and Bosnia and Herzegovina; Mladen Lončar, Vesna Medved, Nikolina Jovanović, and Ljubomir Hotujac; in Croat Med J. 2006 Feb; 47(1): 67–75.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2080379/, retrieved June 20, 2018

(4) Mental health of victims of sexual violence in eastern Congo: associations with daily stressors, stigma, and labeling; An Verelst, 1 Maarten De Schryver,2 Eric Broekaert,3 and Ilse Derluyn; BMC Womens Health. 2014; 14: 106; Published online 2014 Sep 6. doi: 10.1186/1472-6874-14-106

Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4237834/, June 20, 2018

(5) The structure of post-traumatic stress disorder and complex post-traumatic stress disorder amongst West Papuan refugees; Alvin Kuowei Tay, Susan Rees, Jack Chen, Moses Kareth, and Derrick Silove; in: BMC Psychiatry. 2015; 15: 111; Published online 2015 May 7. doi: 10.1186/s12888-015-0480-3;

Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4459680/, June 20, 2018

(6) Youth mental health after civil war: the importance of daily stressors; Elizabeth A. Newnham, Rebecca M. Pearson, Alan Stein, and Theresa S. Betancourt; in: Br J Psychiatry. 2015 Feb; 206(2): 116–121; doi: 10.1192/bjp.bp.114.146324

Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4312966/, June 20, 2018

(7) Prevalence and factors associated with Posttraumatic Stress Disorder seven years after the conflict in three districts in northern Uganda (The Wayo-Nero Study); James Mugisha, Herbert Muyinda, Peter Wandiembe, and Eugene Kinyanda; in BMC Psychiatry. 2015; 15: 170. PMCID: PMC4513792; Published online 2015 Jul 24. doi: 10.1186/s12888-015-0551-5

Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4513792/, June 20, 2018

(8) Relationships of Childhood Adverse Experiences With Mental Health and Quality of Life at Treatment Start for Adult Refugees Traumatized by Pre- Flight Experiences of War and Human Rights Violations; Marianne Opaas, and Sverre Varvin, Dr.Philos, MD; in J Nerv Ment Dis. 2015 Sep; 203(9): 684–695. PMCID: PMC4554230; Published online 2015 Aug 31. doi: 10.1097/NMD.0000000000000330

Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4554230/, June 20, 2018

(9) Cognitive-Behavioral Therapy versus Other PTSD Psychotherapies as Treatment for Women Victims of War-Related Violence: A Systematic Review; N. Inès Dossa and Marie Hatem; in ScientificWorldJournal. 2012; 2012: 181847. PMCID: PMC3345529; Published online 2012 Apr 19. doi: 10.1100/2012/181847

Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3345529/, June 20, 2018

(10) Trauma and posttraumatic stress disorder in South Africa: analysis from the South African Stress and Health Study; Lukoye Atwoli, Dan J Stein, David R Williams, Katie A Mclaughlin, Maria Petukhova, Ronald C Kessler, and Karestan C Koenen; in BMC Psychiatry. 2013; 13: 182; Published online 2013 Jul 3. doi: 10.1186/1471-244X-13-182 

Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3716970/, June 20, 2018

(11) Pathways from Victimization to Substance Use: Post Traumatic Stress Disorder as a Mediator; Jung Yeon Lee, Judith S. Brook, Stephen J. Finch, and David W. Brook; in Psychiatry Res. 2016 Mar 30; 237: 153–158; Published online 2016 Jan 22. doi: 10.1016/j.psychres.2016.01.049

Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4769948/, June 20, 2018

(12) Posttraumatic stress disorder, trauma, and reconciliation in South Sudan; Lauren C. Ng, Belkys López, Matthew Pritchard, and David Deng; in Soc Psychiatry Psychiatr Epidemiol. 2017 Jun; 52(6): 705–714; Published online 2017 Apr 11. doi: 10.1007/s00127-017-1376-y;

Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5510537/, June 20, 2018

(13) From War to Classroom: PTSD and Depression in Formerly Abducted Youth in Uganda; Nina Winkler, Martina Ruf-Leuschner, Verena Ertl, Anett Pfeiffer, Inga Schalinski, Emilio Ovuga, Frank Neuner and Thomas Elbert; in Front Psychiatry. 2015; 6: 2. PMCID: PMC4348469;  Published online 2015 Mar 3. doi: 10.3389/fpsyt.2015.00002

Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4348469/, June 20, 2018

(14) Mental health and psychosocial support in humanitarian settings: linking practice and research; Wietse A Tol, Corrado Barbui, Ananda Galappatti, Derrick Silove, Theresa S Betancourt, Renato Souza, Anne Golaz, and Mark van Ommeren; in Lancet. 2011 Oct 29; 378(9802): 1581–1591; Published online 2011 Oct 16. doi: 10.1016/S0140-6736(11)61094-5

Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3985411/, June 20, 2018

(15) The enduring mental health impact of mass violence: A community comparison study of Cambodian civilians living in Cambodia and Thailand; Richard F Mollica, Robert Brooks, Svang Tor, Barbara Lopes-Cardozo, and Derrick Silove; in Int J Soc Psychiatry. 2014 Feb; 60(1): 6–20; Published online 2013 Feb 7. doi: 10.1177/0020764012471597

PMCID: PMC4737641 NIHMSID: NIHMS753770 PMID: 23396287

Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4737641/, June 20, 2018

(16) Transgenerational consequences of PTSD: risk factors for the mental health of children whose mothers have been exposed to the Rwandan genocide; Maria Roth, Frank Neuner, and Thomas Elbert; in Int J Ment Health Syst. 2014; 8: 12. PMCID: PMC3978019 Published online 2014 Apr 1. doi: 10.1186/1752-4458-8-12

Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3978019/, June 20, 2018

(17) Traumatic episodes and mental health effects in young men and women in Rwanda, 17 years after the genocide; Lawrence Rugema, Ingrid Mogren, Joseph Ntaganira, and Gunilla Krantz; in BMJ Open. 2015; 5(6): e006778. PMCID: PMC4480039; Published online 2015 Jun 24. doi: 10.1136/bmjopen-2014-006778

Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4480039/ Jun 20, 2018

(18) Aggression inoculates against PTSD symptom severity—insights from armed groups in the eastern DR Congo; Tobias Hecker, Katharin Hermenau, Anna Maedl, Maggie Schauer, and Thomas Elbert; in Eur J Psychotraumatol. 2013; 4: 10.3402/ejpt.v4i0.20070. PMCID: PMC3651955; Published online 2013 May 13. doi: 10.3402/ejpt.v4i0.20070

Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3651955/ June 20, 2018

8 Disasters and Mental Health (World Psychiatric Association) (Kindle Locations 3385-3390). Kindle Edition.  Emphasis (bold text) added by me.

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