Anna Maedl

Appetitive aggression in former combatants - Derived from the ongoing conflict in DR Congo

Soldiers and combatants often report that committing violence can be appealing, fascinating and exciting (Elbert, Weierstall, & Schauer, 2010). This appetite for aggression was investigated in a sample of 224 former combatants from different armed groups and forces in eastern DRC. In a semistructured interview they were questioned about their military history, exposure to violence and perpetrated violence. Appetitive aggression was assessed with a 15-item-scale (Weierstall & Elbert, 2011), which was successfully implemented in comparable samples (Weierstall, Schalinski, Crombach, Hecker, & Elbert, submitted for publication). A sequential multiple regression was conducted to determine possible predictors of appetitive aggression. Perpetrated violence types, recruitment type, and joining as a child were significant predictors and explained 26% of the variability in appetitive aggression. Duration or military rank within the armed group and exposure to violence did not play a significant role. Thus, combatants reporting high levels of appetitive aggression are characterized by perpetrating a high number of violent acts, joining armed groups on their own accord and as children. Joining an armed group on ones own accord indicates pre-existing appetitive aggression. However, joining young and perpetrating violence on a regular basis seem to intensify the appetite for aggression.

Does perpetrating violence damage mental health? Differences between forcibly recruited and voluntary combatants in DR Congo.

As a consequence of the ongoing conflict in the Democratic Republic of the Congo (DRC), combatants are constantly involved in various forms of violence. Findings concerning the impact of perpetrating violence on mental health are contradictory, ranging from increasing to buffering the risk for mental ill health. The present study investigated the impact of perpetrating violence on mental health. In total, 204 forcibly recruited and voluntary male combatants (mean age = 24.61 years) from different armed groups in the eastern DRC took part in the study. In a semistructured interview, respondents were questioned about appetitive aggression and posttraumatic stress disorder (PTSD) as well as self-experienced violence and self-perpetrated violent offending. A multivariate analysis of variance (η(2) = .23) revealed that voluntary combatants perpetrated more violent acts (η(2) = .06) and showed higher appetitive aggression η(2) = .03). A moderated multiple regression analysis (R(2) = .20) showed that perpetrating violence was positively related to PTSD in forcibly recruited combatants, but not in voluntary combatants. Thus, perpetrating violence may not necessarily qualify as a traumatic stressor. Further studies might consider assessing the combatants perception of committing violent acts.

Addressing Post-traumatic Stress and Aggression by Means of Narrative Exposure: A Randomized Controlled Trial with Ex-Combatants in the Eastern DRC

Former child soldiers and ex-combatants are at high risk of developing trauma-related disorders and appetitive aggression, which reduce successful integration into peaceful societies. In a randomized controlled clinical trial, we offered Narrative Exposure Therapy for Forensic Offender Rehabilitation (FORNET) to 15 ex-combatants with the goal of reducing traumatic stress and appetitive aggression compared to “treatment as usual.” Measures included the PTSD Symptom Scale-Interview and the Appetitive Aggression Scale assessed prior to treatment and 2 weeks and 6 months after the treatment. We also assessed closeness to combatants as an index of reintegration. The treatment group reported reduced PTSD symptoms and less contact with combatants. Appetitive aggression decreased substantially in both groups. The results indicate that it is feasible to add psychological treatment to facilitate the reintegration process. We wish to thank the former combatants and former child soldiers who participated in this study and the Congolese translators. We also want to thank the very motivated and reliable staff of the reintegration center, especially Pascal Badibanga Zagabe, Leonce Kyakimwa, Lydie Mirimo Ajua, David Ngufu, and Matata Banyene. Furthermore, we want to thank Charlotte Salmen for conducting the follow-up interviews and James Moran for conducting the follow-up interviews as well as proofreading the manuscript. Sources of support: Deutsche Forschungsgemeinschaft (DFG), vivo international. Trial registration clinicaltrials.gov Identifier: NCT01625117

Rape as Weapon of War in the Eastern DRC?: The Victims' Perspective

Rampant sexual violence is one of the most horrendous human rights abuses taking place within Democratic Republic of the Congo’s (DRC) armed conflict. The UN has called these abuses “strategic” and a “weapon of war.” Both labels carry specific implications within the human rights discourse. However, there is a lack of structured data exploring these concepts in the context of the DRC. To address this empirical gap, twenty-five rape survivors were interviewed. In the eyes of the victims the rapes served a multitude of different purposes and appear to be both endemic and indiscriminate. The rapes are the modus operandi of the war.

Dissemination of psychotherapy for trauma spectrum disorders in postconflict settings: a randomized controlled trial in Rwanda

Background: Dissemination of psychotherapeutic modules to local counselors seems a key requirement for coping with mental health disasters in conflict regions. We tested a train-the-trainer (TTT) dissemination model for the treatment of posttraumatic stress disorder (PTSD). Methods: We randomly assigned widowed or orphaned survivors of the 1994 Rwandan genocide with a PTSD diagnosis to narrative exposure therapy (NET) treatment (NET-1, n = 38) or to a 6-month waiting list (WL) condition to be followed by treatment (WL/NET-2, n = 38). Expert therapists trained a first dissemination generation of local Rwandan psychologists in NET complemented by 2 sessions of interpersonal psychotherapy modules. Under the supervision of the experts, these Rwandan psychologists (a) provided NET to the NET-1 participants and (b) subsequently trained and supervised a second generation of local psychologists. This second dissemination generation provided treatment to the WL/NET-2 group. The primary outcome measure was the Clinician-Administered PTSD Scale total score before therapy and at 3- and 12-month follow-ups. Results: At the 3-month follow-up, the NET-1 participants suffered significantly and substantially less from PTSD symptoms than the participants in the WL group. The treatment gains of NET-1 were maintained and increased at follow-up, with a within-group effect size of Cohens d = 1.47 at the 12-month follow-up. After treatment by the second dissemination generation of therapists, the WL/NET-2 participants improved to an extent similar to that of the NET-1 group at follow-ups, with an effect size of Cohens d = 1.37 at the 12-month follow-up. Conclusions: A TTT model of PTSD treatment dissemination can be effective in resource-poor postconflict societies.

Growing up in armed groups: trauma and aggression among child soldiers in DR Congo

Background Child soldiers are often both victims and perpetrators of horrendous acts of violence. Research with former child soldiers has consistently shown that exposure to violence is linked to trauma-related disorders and that living in a violent environment is correlated with enhanced levels of aggression. Objective To gain more insight into the experiences and the mental health status of former child soldiers, we conducted a survey with N=200 former child soldiers and adult combatants in the DR Congo. Methods We conducted semi-structured interviews concerning military experiences, experienced and perpetrated violence, and mental health. Results Former child soldiers reported more experienced and perpetrated violence, a greater severity of trauma-related suffering, as well as higher appetitive aggression than adult ex-combatants. Appetitive aggression was related to more perpetrated violence, higher military ranks, voluntary recruitment and higher rates of reenlistments in former child soldiers. Conclusions Our results indicate that growing up in an armed group is related to higher levels of trauma-related disorders and aggressive behavior. This may explain the challenge of reintegrating former child soldiers. It is thus important to consider mental health problems, particularly trauma-related disorders and aggressive behavior, of former child soldiers for designing adequate reintegration programs.

Aggression inoculates against PTSD symptom severity* insights from armed groups in the eastern DR Congo

Background In the ongoing conflict in the Democratic Republic of the Congo (DRC), combatants are exposed to massive forms of violence and other traumatic stressors. Nevertheless, many combatants do not suffer from trauma-related disorders, although they have experienced numerous traumatizing events. Perceiving aggressive behavior as fascinating and arousing might be a defense against trauma-related disorders in the violent environment of war and conflict. Objective Thus, in this study we investigated the relationship between the exposure to traumatic stressors, appetitive aggression, and posttraumatic stress disorder (PTSD) symptom severity. We hypothesized that cumulative traumatic experiences correlated positively and appetitive aggression negatively with PTSD symptom severity. Method In total, 105 voluntary male combatants from different armed groups in the eastern DRC took part in this study. In a semistructured interview, respondents were questioned about their exposure to traumatic stressors, the extent of appetitive aggression (Appetitive Aggression Scale) and their PTSD symptom severity (PTSD Symptom Scale - Interview). Results A multiple sequential regression analysis showed that traumatic events were positively related to PTSD symptom severity. For participants with low to medium PTSD symptom severity, appetitive aggression correlated negatively with PTSD symptom severity. Conclusions The results of this study provide further support for earlier findings that repeated exposure to traumatic stressors cumulatively heightens the risk of PTSD and revealed that appetitive aggression buffers the risk of developing PTSD symptoms under certain circumstances. Thus, the perception of aggressive behavior as fascinating and arousing seem to help combatants to adapt to violent environments but may also be one reason for recurrent failure of reintegration programs for excombatants.

Psychological Rehabilitation of Ex-combatants in Non-Western, Post-conflict Settings

Disarmament, demobilization, and reintegration (DDR) programs are part of most international peace-building efforts and post-conflict interventions in developing countries. Well over a million former combatants have participated in DDR programs in more than 20 countries, the vast majority of them in sub-Saharan Africa. The impact, however, has remained disappointing.

A pilot study on community-based outpatient treatment for patients with chronic psychotic disorders in Somalia: Change in symptoms, functioning and co-morbid khat use.

BackgroundIn Low and Middle Income Countries, mental health services are often poorly developed due to the lack of resources and trained personnel. In order to overcome these challenges, new ways of care have been suggested such as a focus on community-based services. In Somalia, the consumption of the natural stimulant khat is highly prevalent, aggravating mental illness. At the same time, mental health care is largely unavailable to the vast majority of the population. In a pilot project, we tested possibilities for effective measures in community-based out-patient mental health care.MethodsThirty-five male patients with chronic psychotic disorders and their carers were involved in a 10-months follow-up study. All of them abused khat. Seventeen outpatients experiencing acute psychotic episodes were recruited from the community and received an intensive six week home-based treatment package. Additionally eighteen patients with chronic psychotic disorders in remission were recruited either following hospital discharge or from the community. In a second phase of the study, both groups received community-based relapse prevention that differed in the degree of the family’s responsibility for the treatment. The treatment package was comprised of psycho-education, low-dose neuroleptic treatment, monthly home visits and counseling. The Brief Psychiatric Rating Scale (BPRS) was applied three times. Additionally, we assessed functioning, khat use and other outcomes.ResultsOf the 35 patients enrolled in the study, 33 participated in the 10-month follow-up. Outpatients improved significantly in the first six weeks of treatment and did not differ from remitted patients at the start of the second treatment phase. In the preventive treatment phase, we find heterogeneous outcomes that diverge between symptom and functioning domains. With the exception of depressive symptoms, symptoms in all patients tended to worsen. The outpatient group had higher BPRS positive and negative symptom scores compared to the remitted group. Levels of functioning in 20 out of 33 patients significantly improved, with small differences between groups. Most patients experienced improvements in basic functioning, such as communication, self-care etc. Khat use could only be reduced in the group of outpatients.ConclusionsCommunity-based out-patient mental health treatment for chronic psychotic disorders has demonstrated positive effects in Somalia and is both feasible and practical, despite facing formidable challenges, e.g. controlling khat intake.

Using Micro-Level Data to Map State Failure: The Example of Somalia

In the study of state failure, scholars and practitioners have mostly focused on macro-level indicators to determine which state is failed and which is not. This focus overlooks crucial local and regional variation that has to be taken into account when designing interventions. In this article, we develop a new approach to examine state failure on this microlevel. Using a unique data-set on Somalia, we identify micro-level indicators for state failure. The analysis shows that micro-level data are crucial for detecting variation in state failure.