Social contexts of trauma and healing

Mental health during and after protests, riots and revolutions: A systematic review

OBJECTIVES

Protests, riots and revolutions have long been a part of human history and are increasing globally, yet their impact on mental health remains largely unknown. We therefore systematically reviewed studies on collective actions and mental health.

METHOD

We searched PubMed, Web of Science, PsycINFO and CINAHL Plus for published studies from their inception until 1 January 2018. Study quality was rated using the Newcastle-Ottawa Scale.

RESULTS

We identified 52 studies (n = 57,487 participants) from 20 countries/regions. The prevalence of post-traumatic stress disorder ranged from 4% to 41% in riot-affected areas. Following a major protest, the prevalence of probable major depression increased by 7%, regardless of personal involvement in the protests, suggestive of community spillover effects. Risk factors for poorer mental health included female sex, lower socioeconomic status, exposure to violence, interpersonal conflicts, frequent social media use and lower resilience and social support. Nevertheless, two studies suggested that collective actions may reduce depression and suicide, possibly due to a collective cathartic experience and greater social cohesion within subpopulations.

CONCLUSION

We present the first systematic review of collective actions and mental health, showing compelling evidence that protests even when nonviolent can be associated with adverse mental health outcomes. Health care professionals therefore need to be vigilant to the mental and psychological sequelae of protests, riots and revolutions. Further research on this emerging sociopolitical determinant of mental health is warranted.

"We are children like others": Pathways to mental health and healing for children born of genocidal rape in Rwanda

Despite the well-documented prevalence of rape as a strategy of war, little is known about the specific psychological consequences to children born of conflict-related sexual violence. The results of data analysis of 7 focus groups and 60 in-depth interviews with children born of genocidal rape in Rwanda indicated that they are carrying the trauma of their own stigmatization and marginalization, are burdened with their mothers' trauma, and, we conclude, symbolize unresolved collective trauma for the society. Analysis also reveals that healing for these young adults requires interpersonal and intrapersonal compassion and acceptance, a meaningful connection with a peer group, societal recognition, and empowerment to help contribute to and transform their lives and societies. Each of these pathways to healing-intrapersonal, interpersonal, and social-is contingent upon the other, and none can be considered in isolation. To support this largely invisible population striving to fulfill their potential, opportunities need to be created for self-acceptance and acceptance by mothers, families, and communities; sharing and building emotional and social bonds with their cohort group; formal recognition; official social rituals to validate their experiences and those of the mother-child dyad in the context of culture and community; and for socioeconomic opportunities to enable them to fully participate in building the future of Rwanda.

Loss of Trust May Never Heal. Institutional Trust in Disaster Victims in a Long-Term Perspective: Associations With Social Support and Mental Health

Natural disasters, technological disasters, and terrorist attacks have an extensive aftermath, often involving society’s institutions such as the legal system and the police. Victims’ perceptions of institutional trustworthiness may impact their potential for healing. This cross-sectional study investigates institutional trust, health, and social support in victims of a disaster that occurred in 1990. We conducted face-to-face interviews with 184 survivors and bereaved, with a 60% response rate 26 years after the disaster. Levels of trust in the police and in the justice system were compared with general population data. We assessed the relationships between institutional trust and current psychological distress, social support, and life satisfaction. The levels of trust in the police and in the justice system were notably lower in survivors and bereaved than in the general population. Among the victims, low institutional trust was associated with more mental health problems, poorer social support, more barriers to seeking social support, and a lower life satisfaction. Lost trust in the aftermath of a disaster may perhaps never be restored and the lack of trust may act to strengthen or maintain health problems. An exclusively individualistic approach to trauma and disaster may miss out on the opportunities for promoting health and well-being that lies within the larger societal structures. Decision-makers should take this information into account, and acknowledge the potential long-term consequences of institutional performance in the aftermath of a disaster.

Needs assessment with elder Syrian refugees in Lebanon: Implications for services and interventions

Currently, over 1 million Syrian and Palestinian refugees have fled Syria to take refuge in Lebanon. Among this vulnerable population, elder refugees warrant particular concern, as they shoulder a host of additional health and safety issues that require additional resources. However, the specific needs of elder refugees are often overlooked, especially during times of crisis. Our study used a semi-structured interview to survey the needs of elder refugees and understand their perceived support from Lebanese fieldworkers. Results indicate a high prevalence of depression and cognitive deficits in elder refugees, who expressed concerns surrounding illness, loneliness, war, and instability. Elders highlighted the importance of family connectedness in fostering security and normalcy and in building resilience during times of conflict. Elders spoke of their role akin that of the social workers with whom they interacted, in that they acted as a source of emotional support for their communities. Overall, this study clarifies steps to be taken to increase well-being in elder refugee populations and urges the response of humanitarian organisations to strengthen psychological support structures within refugee encampments.

Association between posttraumatic stress and acceptance of social changes: Findings from a general population study and proposal of a new concept

BACKGROUND

There is a growing understanding of the importance of the social factors of posttraumatic stress disorder.

AIMS

This study expands research on association between posttraumatic stress and social factors by introducing the measure of the acceptance of social changes and evaluating possible links between posttraumatic stress disorder symptoms and acceptance of social changes.

METHODS

A general population sample ( n = 778) aged from 18 to 89 years ( M = 40.2) from Lithuania participated in our study, of whom 68% reported exposure to traumatic events. Posttraumatic stress reactions were measured with the Impact of Event Scale - Revised (IES-R), and acceptance of social changes was measured with the Acceptance of Social Changes Instrument (SOCHI) developed by the authors of this study.

RESULTS

About 8% of the participants had a potential posttraumatic stress disorder (PTSD) diagnosis. Acceptance of social changes was negatively associated with posttraumatic stress. PTSD was related to lower acceptance of social changes ( d = .61). Structural equation model (SEM) revealed the mediating role of PTSD for acceptance of social changes following trauma exposure.

CONCLUSION

Findings of our study indicate that the acceptance of social changes might be an important psychosocial factor of PTSD.

Predictive factors of depression symptoms among adolescents in the 18-month follow-up after Wenchuan earthquake in China

BACKGROUND

It is unclear about the change and risk factors of depression among adolescent survivors after earthquake.

AIMS

This study aimed to explore the change of depression, and identify the predictive factors of depression among adolescent survivors after the 2008 Wenchuan earthquake in China.

METHODS

The depression among high school students at 6, 12 and 18 months after the Wenchuan earthquake were investigated. The Beck Depression Inventory (BDI) was used in this study to assess the severity of depression.

RESULTS

Subjects included 548 student survivors in an affected high school. The rates of depression among the adolescent survivors at 6-, 12- and 18-month after the earthquake were 27.3%, 42.9% and 33.3%, respectively, for males, and 42.9%, 61.9% and 53.4%, respectively, for females. Depression symptoms, trauma-related self-injury, suicidal ideation and PTSD symptoms at the 6-month follow-up were significant predictive factors for depression at the 18-month time interval following the earthquake.

CONCLUSIONS

This study highlights the need for considering disaster-related psychological sequela and risk factors of depression symptoms in the planning and implementation of mental health services. Long-term mental and psychological supports for victims of natural disasters are imperative.

Messages of Hope: Using Positive Stories of Survival to Assist Recovery in Rwanda

For the past twenty years, the overriding story of Rwanda has been centred around the events and consequences of the genocide. In Rwanda, public expressions of that story have occurred in the gacaca courts, where survivors and perpetrators testified about their experiences and actions, during ongoing annual remembrance and mourning commemorations, and in memorial sites across the country that act as physical reminders of the genocide. While important as mechanisms for justice, testimony, and commemoration, on their own such events and installations also have the potential to re-traumatise. Accordingly, Rwandan agencies have encouraged a focus on the future as the overarching theme of recent national commemorations. Yet, opportunities for Rwandans to recount and disseminate positive, future-oriented stories of survival and healing remain sparse. Creation and awareness of positive stories have the potential to assist in recovery by increasing feelings of hope and efficacy; and recent research has demonstrated the value of hopefulness, well-being, and social support for vulnerable people. The Messages of Hope program seeks to leverage those ideas into a framework for generating positive messages by Rwandan survivors, providing an opportunity for everyday Rwandans to record and transmit their own positive stories of survival to demonstrate recovery and growth after the genocide, and to reinforce connectedness by sharing their challenges and aspirations. We describe the development and early implementation of this initiative and its potential longer-term application in other contexts of vulnerability.

When the world collapses: changed worldview and social reconstruction in a traumatized community

BACKGROUND

Traumatic experience can affect the individual's basic beliefs about the world as a predictable and safe place. One of the cornerstones in recovery from trauma is reestablishment of safety, connectedness, and the shattered schema of a worldview.

OBJECTIVE

This study explored the role of negatively changed worldview in the relationship between war-related traumatization and readiness for social reconstruction of intergroup relations in a post-conflict community measured by three processes: intergroup rapprochement, rebuilding trust, and need for apology. It was hypothesized that more traumatized people are less supportive of social reconstruction and that this relationship is mediated by the changed worldview.

METHOD

The study included a community random sample of 333 adults in the city of Vukovar, Croatia, that was most devastated during the 1991-1995 war. Six instruments were administered: Stressful Events Scale, Impact of Event Scale-Revised, Changed Worldview Scale, and three scales measuring the post-conflict social reconstruction processes: Intergroup Rapprochement, Intergroup Trust and Need for Apology.

RESULTS

Mediation analyses showed that the worldview change fully mediated between traumatization and all three aspects of social reconstruction.

CONCLUSIONS

In a population exposed to war traumatization the worldview change mediates post-conflict social recovery of community relations.

Lessons learned about psychosocial responses to disaster and mass trauma: an international perspective

At the 13th meeting of the European Society for Traumatic Stress Studies in 2013, a symposium was held that brought together international researchers and clinicians who were involved in psychosocial responses to disaster. A total of six disasters that occurred in five countries were presented and discussed. Lessons learned from these disasters included the need to: (1) tailor the psychosocial response to the specific disaster, (2) provide multi-dimensional psychosocial care, (3) target at-risk population groups, (4) proactively address barriers in access to care, (5) recognise the social dimensions and sources of resilience, (6) extend the roles for mental health professionals, (7) efficiently coordinate and integrate disaster response services, and (8) integrate research and evaluation into disaster response planning.

Displacement, county social cohesion, and depression after a large-scale traumatic event

BACKGROUND

Depression is a common and potentially debilitating consequence of traumatic events. Mass traumatic events cause wide-ranging disruptions to community characteristics, influencing the population risk of depression. In the aftermath of such events, population displacement is common. Stressors associated with displacement may increase risk of depression directly. Indirectly, persons who are displaced may experience erosion in social cohesion, further exacerbating their risk for depression.

METHODS

Using data from a population-based cross-sectional survey of adults living in the 23 southernmost counties of Mississippi (N = 708), we modeled the independent and joint relations of displacement and county-level social cohesion with depression 18-24 months after Hurricane Katrina.

RESULTS

After adjustment for individual- and county-level socio-demographic characteristics and county-level hurricane exposure, joint exposure to both displacement and low social cohesion was associated with substantially higher log-odds of depression (b = 1.34 [0.86-1.83]). Associations were much weaker for exposure only to low social cohesion (b = 0.28 [-0.35-0.90]) or only to displacement (b = 0.04 [-0.80-0.88]). The associations were robust to additional adjustment for individually perceived social cohesion and social support.

CONCLUSION

Addressing the multiple, simultaneous disruptions that are a hallmark of mass traumatic events is important to identify vulnerable populations and understand the psychological ramifications of these events.

Recovery from posttraumatic stress symptoms: a qualitative study of attributions in survivors of war

Objective

The study explored factors to which people traumatized by war attribute their recovery from posttraumatic symptoms and from war experiences.

Methods

: In-depth interviews were conducted with two groups of participants with mental sequelae of the war in the former Yugoslavia: 26 people who had recovered from posttraumatic stress disorder (PTSD) and 17 people with ongoing symptoms of PTSD. Participants could attribute their recovery to any event, person or process in their life. The material was subjected to thematic analysis.

Results

Eight themes covered all factors to which participants attributed their recovery. Six themes described healing factors relevant for both groups of participants: social attachment and support, various strategies of coping with symptoms, personality hardiness, mental health treatment, received material support, and normalization of everyday life. In addition to the common factors, recovered participants reported community involvement as healing, and recovered refugees identified also feeling safe after resolving their civil status as helpful. Unique to the recovered group was that they maintained reciprocal relations in social attachment and support, employed future-oriented coping and emphasised their resilient personality style.

Conclusions

The reported factors of recovery are largely consistent with models of mental health protection, models of resilience and recommended interventions in the aftermath of massive trauma. Yet, they add the importance of a strong orientation towards the future, a reciprocity in receiving and giving social support and involvement in meaningful activities that ensure social recognition as a productive and valued individual. The findings can inform psychosocial interventions to facilitate recovery from posttraumatic symptoms of people affected by war and upheaval.

Subjective quality of life in war-affected populations

Background

Exposure to traumatic war events may lead to a reduction in quality of life for many years. Research suggests that these impairments may be associated with posttraumatic stress symptoms; however, wars also have a profound impact on social conditions. Systematic studies utilising subjective quality of life (SQOL) measures are particularly rare and research in post-conflict settings is scarce. Whether social factors independently affect SQOL after war in addition to symptoms has not been explored in large scale studies.

Method

War-affected community samples were recruited through a random-walk technique in five Balkan countries and through registers and networking in three Western European countries. The interviews were carried out on average 8 years after the war in the Balkans. SQOL was assessed on Manchester Short Assessment of Quality of Life - MANSA. We explored the impact of war events, posttraumatic stress symptoms and post-war environment on SQOL.

Results

We interviewed 3313 Balkan residents and 854 refugees in Western Europe. The MANSA mean score was 4.8 (SD = 0.9) for the Balkan sample and 4.7 (SD = 0.9) for refugees. In both samples participants were explicitly dissatisfied with their employment and financial situation. Posttraumatic stress symptoms had a strong negative impact on SQOL. Traumatic war events were directly linked with lower SQOL in Balkan residents. The post-war environment influenced SQOL in both groups: unemployment was associated with lower SQOL and recent contacts with friends with higher SQOL. Experiencing more migration-related stressors was linked to poorer SQOL in refugees.

Conclusion

Both posttraumatic stress symptoms and aspects of the post-war environment independently influence SQOL in war-affected populations. Aid programmes to improve wellbeing following the traumatic war events should include both treatment of posttraumatic symptoms and social interventions.

Introducing the notion of social context of collective trauma to ESTSS

Living amidst war and mass suffering while grasping the opportunity for professional growth, intertwined into my life perspective. Along the years, ESTSS provided a backdrop for my contacts with mental health colleagues from whom I learned, and among whom many became my friends. These rich experiences guided me towards promoting awareness within ESTSS of the importance of social context in which healing of traumatized populations is expected to progress. Each incident of organized violence leaves behind new scores of traumatized individuals and family members, among whom many will need support that may stretch their resources beyond reasonable limits. We need to acknowledge the hindering effects of living in such a social context and that many people that we meet as professionals may carry the burden of unresolved trauma, which should not go by unattended.

Holding harm: narrative methods in mental health research on refugee trauma

In this article, we question narrative inquiry's predominant ethics of benefit when engaging in narrative research on trauma and social suffering. Through a particular focus on the use of a narrative methodology in a refugee health study, we explore the potential risk and protective function of narrative trauma research with vulnerable respondents. A review of ethical questions emerging during the course of a multiple-case study with refugee families documents how narrative methods' characteristics clearly revisit the impact of traumatization on autonomy, narrativity, and relationship building in participants and, thus, evoke the replay of traumatic experience within the research relationship itself. Blurring a straightforward ethics of benefit, this reactivation of trauma accounts for the research relationship's balancing movement between reiterating and transforming traumatic distress, and urges for the need to contain coexisting aspects of both harm and benefit in developing narrative research with traumatized participants.

The experience of collective trauma in Australian Indigenous communities

OBJECTIVE

The concept of collective trauma has predominantly been applied in the context of natural and human disasters. This paper seeks to explore whether collective trauma offers a respectful way in which to explore and respond to mental health and wellbeing issues for Aboriginal families and communities.

METHOD

A review of the international literature was undertaken in order to determine the elements of collective and mass trauma studies which may have relevance for Indigenous communities in Australia.

RESULTS

Findings support the proposition that the patterns of human responses to disasters, particularly in protracted traumas such as war-zones, shows strong parallels to the contemporary patterns of experience and responses articulated by Aboriginal people affected by colonization and its sequelae in Australia.

CONCLUSION

Adopting evidence-informed principles of family and community healing developed internationally in disaster situations may provide helpful ways of conceptualizing and responding in a coordinated way to mental health and wellbeing issues for Indigenous people within Australia.

Caught between the ethnic sides: Children growing up in a divided post-war community

The war-related process of disintegration of a highly integrated and multi-ethnic community is described using a series of studies done in the city of Vukovar (Croatia) as a case example. After analyzing the key points of the community social breakdown , the three roots of ongoing ethnic division are explored: the feelings of being betrayed by important others at life-important situations; massive suffering and traumatization; and lack of compassion and acknowledgment of the victimhood. These also influence the inner dynamic of the divided community in which the strong social norm is not to cross the ethnic lines in public. When the schools became divided after the war so that the Serb and Croat children started going to separate schools, opportunity to meet each other across the ethnic lines became and remained severely limited. The implications for children that grow up in an ethnically divided community are documented in a study of children's and parental inter-ethnic attitudes and behaviors. The study included 1,671 students aged 12 to 16 and their parents. It showed that the children had more out-group biases and negative attitudes, and were more likely to choose discriminative behaviors towards their peers from the ether ethnic group. Consequences for the future community inter-ethnic relations in the post-war societies and life limitations the children face are discussed.

Social context and depression after a disaster: the role of income inequality

STUDY OBJECTIVE

To examine the association between neighbourhood income inequality and depression, both overall and among those with different levels of income, in the post-disaster context.

DESIGN

A representative cross sectional random digit dial telephone survey was conducted.

SETTING

New York City (NYC) six months after September 11, 2001.

PARTICIPANTS

1570 respondents were interviewed, of whom 1355 provided residence information permitting their inclusion in this analysis. Past six month depression was assessed using a lay administered instrument consistent with DSM-IV criteria. Income inequality was measured with the Gini coefficient.

MAIN RESULTS

The sample was demographically representative of NYC (56.2% female, 35.7% white, 6.3% Asian 24.2% African American, 29.7% Hispanic, and 4.2% other race or ethnicity) and the prevalence of past six month depression was 12.4%. In a final adjusted model, neighbourhood level income inequality was positively associated with depression but this association was not significant (beta = 7.58, p = 0.1). However, among those with low individual income (< 20,000 US dollars) there was a strong significant association between income inequality and depression (beta = 35.02, p<0.01), while there was no association among those with higher income.

CONCLUSIONS

In the post-disaster context, neighbourhood level income inequality was associated with depression among persons with lower income; this group may be more socially or economically marginalized and dependent on local resources. Future research should examine potential mechanisms through which income inequality and other features of the social context may affect mental health in the post-disaster context.