War exposure, daily stressors, and mental health in conflict and post-conflict settings: Bridging the divide between trauma- focused and psychosocial frameworks - Miller & Rasmussen - 2010 - Article

What is the difference between trauma-focused and psychosocial approaches?

Over the past 25 years, interest in the psychological effects of organized violence has grown. This also leads to some discussions, such as whether there should be a trauma-focused or a psychosocial approach to understand and address the mental health needs of communities who are affected by armed conflicts. These approaches have different assumptions regarding the factors that most influence mental health in conflict and post-conflict settings. For the advocates of a trauma-focused approach, the critical factor is direct exposure to the violence and the destruction of war. For psychosocial advocates, the attention is focused mainly on the stressful social and material conditions that are caused or worsened by armed conflict. Think of poverty, malnutrition, destruction of social networks, etcetera.

According to trauma-focused advocates, war-related trauma should be treated using a specialized clinical treatment. They also believe that by ameliorating symptoms of war-related trauma, this will improve mental health and also enable people to cope more effectively with ongoing environmental stressors. The advocates for a psychosocial approach see the distress of the clients rooted in the conditions of everyday life. Altering these stressful conditions would, according to them, lead to improvements in mental health, and it would also foster the inherent capacity to recover from the effects of exposure to war-related violence and loss.

What is this article about?

According to the authors of this article state that armed conflict does have an effect on those who experience it directly. However, they also argue that organized violence generates high stressful conditions and daily stressors, such as poverty. Some studies have looked at the role of daily stressors in helping to explain the high rates of psychological distress which is often found among survivors of armed conflict. These studies have shown that adding daily stressors to the model induced by the trauma-focused advocates, does increase the predictive power of the model. Therefore, the model as proposed by the trauma-focused advocates is an overly simplistic model, which leads these advocates to overestimate the strength of the direct effects of direct war exposure in explaining psychological distress within communities. This, in turn, lead to an emphasis on trauma-focused interventions that are aimed at alleviating war-related PTSD, when there should be more attention to daily stressors.

The authors state that a narrow psychosocial focus is also not correct. This would lead to underestimation of the impact that exposure to armed conflict can have on mental health and psychosocial functioning.

Therefore, the authors are advocates of a new, more complex model. This model includes both war exposure and daily stressors as predictors of mental health status. In this model, armed conflict results in exposure to violence and loss, which in turn directly affects mental health and psychosocial functioning. Exposure to armed conflict also gives rise to daily stressors, which in turn affect psychological wellbeing. The model also includes daily stressors that are not related to armed conflict. The authors examine the pathways through which organized violence appears to exert its effects on psychological wellbeing.  

How do war exposure and daily stressors contribute to mental health?

The research that looks at in which ways war exposure and daily stressors contribute to mental health can be divided into three sets:

The consistently large amount of unexplained variance in mental health outcomes when war exposure is used as the only predictor of psychological distress.

Research with refugees in developed countries shows that post-migration or exile-related stressors such as social isolation, unemployment, and discrimination consistently predict levels of psychiatric symptoms as well as, or better than, pre-migration exposure to organized violence.

Studies of non-war affected populations in which so-called ‘daily hassles’ are often more highly associated with mental health symptom severity than major life events.

What are the origins of the direct effects model?

Studies onto the mental health effects of organized violence began in the 1980s. It followed two distinct tracks. Researchers in South Africa and Latin America adopted a broad view of the pathways by which organized violence influences mental health. Researchers in North America, Europe, and Australia viewed the mental health needs of refugees through the lens of Western psychiatry. They often classified the mental health status of refugees, based on PTSD (post-traumatic stress disorder). War exposure was linked to PTSD symptoms, and greater exposure was predictive of greater PTSD symptoms. So, this combination of PTSD-focused research and clinical work with refugees was critical in launching a worldwide interest in the mental health of war-affected population.

So, even though war exposure does predict PTSD symptom levels, this prediction is not perfect. It accounts for less than 25% of the variance in PTSD symptoms. Therefore, this lead researchers to think about what other factors might contribute to levels of distress.

As researchers began to add post-migration or exile-related stressors to their models, they found that these stressors accounted for equal or greater variance. This lead to two questions:

1. To what extent do daily stressors help account for high levels of unexplained variance in levels of distress? That is, to what extent does the addition of daily stressors strengthen the explanatory power of the direct effects model?
2. To what extent do daily stressors function to mediate or explain the relationship between war exposure and distress?

What makes daily stressors so stressful?

The authors suggest four reasons. First, daily stressors represent close or immediate stressors. War exposure is often more of a distal experience. Things such as poverty, social isolation, and overcrowding affect people day by day. Second, daily stressors are stressful because they are noxious stimuli that are not under the control of people. Such lack of control contributes to the perception of those events as stressful. Third, daily stressors are pervasive within conflict-affected populations, whereas direct war exposure is highly variable. Finally, the term itself includes a wide range of stressful phenomena. Some of these may be traumatic.