Narrative Exposure Therapy - A Short-Term Treatment for Traumatic Stress Disorders

Survivors of Organized Violence

An obvious consequence of organized violence is that many people have to flee from their region of origin because of war or persecution. Figures released by the UN refugee agency for 2009 show that some 43.3 million people were forcibly displaced worldwide – the highest number of people uprooted by conflict and persecution since the mid-1990s. No matter where refugees or internally displaced people flee to after war and persecution, most exiles are not safe or accommodating (Karunakara et al., 2004). Many reports indicate that initial receptions by host government authorities and humanitarian agencies are impersonal and threatening, and that refugees assume roles of dependency and helplessness (Doná & Berry, 1999). While development of social networks, family reunions, and permanent settlements do occur (Castles & Miller, 1993), harsh living conditions, continued anxiety about forced repatriation, and uncertainties regarding resettlement can cause considerable stress for the refugees (Cunningham & Cunningham, 1997). Host country refugee policies are often dictated by domestic concerns, usually of a foreign policy nature, and not necessarily determined by security and protection concerns or by the wishes of host communities in receiving countries (Tandon, 1984). There are many reports that refugee camps and internal displacement camps breed violence, and people are often victims of violent acts perpetrated by the army, militias, humanitarian workers, and by their hosts (Malkki, 1995; Turner, 1999; UNHCR, 2002). For many women and children, the very acts of going to communal latrines (Martin, 1991) or collecting firewood and water can be extremely dangerous. In countries throughout the world, people are being detained and imprisoned arbitrarily without a fair trial. Many face torture or other forms of ill-treatment, as has been frequently documented by Amnesty International. They may be held in inhumane conditions that are cruel and degrading. Cumulative exposure to these stressors piles up and eventually results in PTSD, depression, and related disorders (see next section) (WHO/UNHCR, 1996). Worldwide, millions of children under the age of 18 years have been, and continue to be, affected by armed conflict. They are recruited into government armed forces, paramilitaries, civil militia, and a variety of other armed groups. Often they are abducted at school, on the streets, or at home. Yet international law prohibits the participation in armed conflict of children aged under 18. Children routinely face other violence – at school, in institutions meant for their protection, in juvenile detention centers, and too often in their own homes. There are estimated to be between 100 million and 150 million street children in the world, and this number is growing. Of those, some 5–10% have run away from, or been abandoned by, their families.

Summary What is organized violence?

Organized violence is violence with a systematic strategy. It is put into operation by members of groups with a centrally guided structure or political orientation (police units, rebel organizations, terror organizations, paramilitary, and military formations). It is targeted for continuous use against individuals and groups who have different political attitudes or nationalities, or who come from specific racial, cultural, and ethnic backgrounds. It is characterized by the violation of human rights and disregard of women’s and children’s rights. The consequences reach far into the future of a society.

Survivors of Family Violence

The quality of parent–child interactions predicts the risk for psychopathology over the lifespan Michael J. Meaney (2008)

Family violence, also known as domestic abuse, spousal abuse, child abuse, or intimate partner violence, has many forms including physical aggression (hitting, kicking, biting, shoving, restraining, slapping, throwing objects), sexual violence, or threats thereof. Unemployment, poverty, substance abuse (e.g., excessive alcohol consumption), and mental illness of spouse/ parent are important risk factors for family violence (De Bellis, 2002; Dube, Felitti, Chapman, Giles, & Anda, 2003; Jaffee, 2005; Margolin & Gordis, 2000). Childhood trauma has psychopathological and developmental consequences including adverse emotional, behavioral, and cognitive consequences (De Bellis, 2002). High levels of stress, fear, and anxiety are commonly reported by victims of domestic violence. Depression is also common, as victims are made to feel guilty for “provoking” the abuse, and are constantly subjected to verbal abuse or intense criticism. It is reported that 60% of victims meet the diagnostic criteria for depression, either during or after termination of the relationship, and have a greatly increased risk of suicidality (Barnett, 2001). In addition to depression, victims of domestic violence also commonly experience long-term anxiety and panic, and are likely to meet the diagnostic criteria for a Generalized Anxiety Disorder or Panic Disorder. The most commonly referenced psychological effect of domestic violence is PTSD (Vitanza & Vogel, 1995). Maltreatment of children, defined as neglect, physical abuse, sexual abuse, and emotional abuse (which includes witnessing domestic violence), has always been the most common cause of interpersonal trauma and PTSD in children and adolescents (De Bellis et al., 1999). Among other problems such as severe anxiety, depression, and externalizing behavior, from 10 victims of childhood abuse and neglect, about four develop PTSD (Widom, 1999). In clinically referred samples, the reported incidence rates of PTSD resulting from sexual abuse range from 42% to 90% (McLeer, Callaghan, Henry, & Wallen, 1994; McLeer et al., 1998) and are above 50% when arising from just witnessing domestic violence (Pynoos & Nader, 1989).

Children who grow up in an environment of violence and maltreatment later show severe forms of disorders of the trauma spectrum. Pathological levels of stress are thought to disrupt the normally integrative functions of mental activity, leading some aspects of experience to be segregated from conscious awareness. A number of studies have demonstrated significant associations between childhood physical or sexual abuse and dissociation (Dutra, Bureau, Holmes, Lyubchik, & Lyons-Ruth, 2009). Meta-analyses have confirmed the associations among infant disorganized attachment behavior, parental maltreatment, parental psychopathology, disturbed parent–infant interaction, and childhood behavior problems (Madigan et al., 2006). When intense and persistent stress occurs when the brain is undergoing enormous change, the impact may leave an indelible imprint on its structure and function (Matz et al., 2010; Teicher, et al., 2002). Especially childhood sexual abuse is a risk factor for the emergence of adult psychopathology such as depression (Andersen & Teicher, 2008), borderline personality disorder (Lieb et al., 2004; McLean, & Gallop, 2003), eating disorders (Schaaf & McCanne, 1994; Smolak & Murnen, 2002), somatization disorder (Farley & Keaney, 1997; Kinzl, Traweger, & Biebl, 1995; Morrison, 1989; Walker et al., 1992), and negative effects on physical health (Anda et al., 2005).

A recent prospective study (Widom, Czaja, & Paris, 2009) found that significantly more abused and/or ne glected children overall met the criteria for borderline personality disorder (BPD) as adults, compared with controls, as did physically abused and neglected children. Having a parent with alcohol/drug problems and not being employed full-time, not being a high school graduate, and having a diagnosis of drug abuse, major depressive disorder, and PTSD were predictors of BPD and mediated the relationship between childhood abuse/neglect and adult BPD.

Early stress or maltreatment is an important risk factor for the later development of substance abuse. There are windows of vulnerability for different brain regions when they are exposed to stress (Section 2.2.4). The following modifications in brain structure and function are designed to adapt the individual to cope with continuous adversity and deprivation. Even as an adult, the survivor will maintain a state of vigilance, hyperarousal, sympathetic activation, and suspiciousness to readily detect danger, and the potential to mobilize immediate aggression when threatened with danger or loss. Early childhood abuse and neglect lead individuals into social isolation, hostility, and depression and substance abuse, and foster the emergence of disease processes.

In war zones, children are often victims of both organized and family violence. The combination of these two forms of adversities potentiates the vulnerability for trauma-spectrum disorders (Catani et al., 2009, 2010).

Summary What is familial violence?
Familial and domestic violence have many forms including physical aggression, sexual abuse, emotional neglect, verbal abuse, intimidation, and various forms of deprivation. Domestic and familial violence are common and thus often aggravate effects of other stressful experiences. Hence therapists should assess every client for these forms of violence. Survivors of early maltreatment and abuse often show a range of problems and severe symptoms of complex trauma. Compared with traumatic stressors experienced during adulthood, continuous and developmental trauma during development has even more serious consequences on the brain (see Section 2.2.4) and mind, and thus on the mental and physical well-being of the survivor.