The April 2010 issue of the American Journal of Orthopsychiatry includes an article comparing the effects of war-related trauma on mental health to effects of the “current stressors” one finds in refugee camps. I’m the first author on this article, and so I’m going to take the privileges afforded by that role and be somewhat critical of the work here.
The article is based around the idea that there are lots of things that happen during wartime that cause emotional and cognitive distress in addition to armed conflict. In order to decide what to do about distress in displacement camps, one should consider these non-conflict stressors. In the paper, we measured war-related traumas (or “potentially traumatic events” to be more precise) separate from other “camp stressors” and examined which was more highly associated with the psychological problems of posttraumatic stress disorder, depression, and two local idioms of distress (local ways of discussing emotional problems). We found that war trauma and camp stressors among Darfur refugees were both related to all four psychological problems, and in several cases the number of camp stressors was actually more strongly associated with these than the number of war traumas. We went on to find that camp stressors partially mediated the effects of war trauma on most psychological problems. We concluded that humanitarian aid agencies interested in addressing general distress in camps thus had empirical support for interventions that target everyday camp stressors, in addition to popular war-related and trauma-focused interventions (which are already empirically-supported for displaced persons with posttraumatic distress).
Since the manuscript was accepted (fall of 2009) I have had a number of opportunities to think about the variability within this category of “current stressors.” Critical to this was the opportunity to co-author an editorial on trauma-focused versus psychosocial perspectives in humanitarian aid with my friend and sometimes collaborator Ken Miller, who is really the pioneer in this work (look up his stuff on Afghanistan and Sri Lanka for examples). Something has always bothered me about the category “current stressors” and a common criticism is that we are throwing a lot of different types of stressors — with different effects — into the same conceptual bag. So, I’d like to propose — really by way of proposing a starting point, not answering the problem outright — a typology of stressors that are critical to consider in studying the psychological consequences of armed conflict and displacement.
1. Direct war exposure potentially traumatic events (PTEs): Direct (both personally experienced and witnessed) exposure to the violence and destruction of war. Examples include (but are in no way limited to) direct attacks by military (or paramilitary) personnel, being pursued by these forces, bombing, and exposure to mines.
2. Collateral PTEs: Direct exposure to trauma collateral to war (i.e., coming about because of war) but not comprising an act of war itself. This may include abuse by non-military persons during flight (e.g., criminals or fellow refugees), attacks by locals in the displacement context, abuse by peacekeeping forces, and motor vehicle accidents occurring during flight.
3. Other PTEs: Non-war-related traumatic events that increase during wartime. It has been noted that all forms of violence increase during wartime (e.g., see the work of James Garbarino for particularly articulate illustrations), whether because of stress on the perpetrators of these events or degraded safety of settings which allow these events to occur more frequently. Examples include domestic violence, child abuse, and attacks by dangerous animals (e.g., poisonous snakes are evidently a big problem in some refugee camps in Sri Lanka).
4. Social ecological stressors: War-related degradation of social institutions (both formal and informal). Examples are destruction of schools and subsequent lack of educational opportunity, diminished health care, loss of social support networks, religious institutions, war-induced poverty, and famine. It may be difficult to distinguish some of these from preexisting conditions (e.g., the difference between war-induced and preexisting poverty may be minimal in some cases).
5. Daily hassles: Daily hassles are those seemingly minor problems of daily life that either come to exist or increase in intensity in wartime. These have shown to be strongly related to mental health problems in non-war contexts, even moreso than stressful major life events. These may include checkpoints along a commute, regular questioning by military or police, mild forms of humiliation (e.g., degradation by authorities, bribes), needing multiple forms of documentation in order to complete simple tasks, long wait times in order to get basic resources (e.g., food distribution at refugee camps), and hearing complaints about such daily hassles from loved ones. All involve some persistent inconvenience or stressor that is not physically abusive or threatening. Some daily hassles may at times come close to collateral trauma (e.g., regular questioning that involves strip searches).
It is important to note that for individuals exposed to the different types of stressors delineated above, differences may seem phenomenologically trivial. Stressors related to direct attacks, harassment and abuse during flight, and loss of social networks may be part and parcel of a single, undelineated narrative of war. Moreover, for many these categories may not be readily distinguishable from non-war-related stressors. War-induced poverty may be seen as an extension of preexisting poverty, increases in domestic abuse may be experienced as an extension of pre-war abusive relationships, and bribes paid to police during wartime may have the same effect as bribes during peacetime. In order to study the effect of conflict, researchers should conduct work that estimates the change in prevalence, incidence, and effect on outcomes of these phenomena over time (i.e., pre-conflict to conflict).
Let me reiterate that these are only a first pass at types of stressors, and I welcome all comments. Next: The sticky problem of stress generation among displaced populations.