Therapy

Broadening perspectives on trauma and recovery:

a socio-interpersonal view of PTSD$

Andreas Maercker* and Tobias Hecker

Division of Psychopathology and Clinical Intervention, Department of Psychology, University of

Zurich, Zurich, Switzerland

Posttraumatic stress disorder (PTSD) is one of the very few mental disorders that requires by definition an

environmental context*a traumatic event or events*as a precondition for diagnosis. Both trauma sequelae

and recovery always occur in the context of socialinterpersonal contexts, for example, in interaction with

a partner, family, the community, and the society. The present paper elaborates and extends the social

interpersonal framework model of PTSD. This was developed to complement other intrapersonally focused

models of PTSD, which emphasize alterations in an individual's memory, cognitions, or neurobiology. Four

primary reasons for broadening the perspective from the individual to the interpersonalsocietal contexts are

discussed. The three layers of the model (social affects, close relationships, and culture and society) are outlined.

We further discuss additional insights and benefits of the socialinterpersonal perspective for the growing

field of research regarding resilience after traumatic experiences. The paper closes with an outlook on therapy

approaches and interventions considering this broader socialinterpersonal perspective on PTSD.

Keywords: Post-traumatic stress disorder; interpersonal processes; social context; disclosure; social sharing

Responsible Editor: Marit Sijbrandij, VU University, Netherlands.

*Correspondence to: Andreas Maercker, Division of Psychopathology and Clinical Intervention, Department

of Psychology, University of Zurich, Binzmuehlestr, 14/17, CH-8050 Zurich, Switzerland, Email: maercker@

psychologie.uzh.ch

This paper is part of the Special Issue: Trauma occurs in social contexts. More papers from this issue can

be found at www.ejpt.net

For the abstract or full text in other languages, please see Supplementary files under 'Article Tools'

Received: 30 July 2015; Revised: 29 October 2015; Accepted: 13 November 2015; Published: 18 March 2016

Within the traditional professional perspective of

clinical psychology and psychiatry, posttrau-

matic stress disorder (PTSD) is usually con-

sidered solely in terms of the individual. Approaches that

aim to describe, explain, or treat PTSD or other stress-

and trauma-related disorders center on the patient and do

not consider the social context in which they are situated

(e.g., families, partners, close friends, communities, or even

societies). This focus on the individual perspective has

its value and benefits. This is particularly evident when we

consider the progress in evidence-based treatments for

PTSD over the last 20 years. However, this individual-

centered perspective also leaves out a host of potential

influential factors external to the individual. The influence

of family members, peers, and the society at large all have

an impact on the development and maintenance of the

individual's PTSD symptoms. Thus, focusing only on the

individual when treating PTSD may not be enough to

******ensure an optimal chance of recovery****. In reaction to this,

some prominent researchers have sought to question

or broaden the individual-centered approach to explain

and treat PTSD (Ajdukovic ́ & Ajdukovic ́, 2003;

Somasundaram, 2014; Summerfield, 1999). In a previous

theoretical and review paper, our group (Maercker &

Horn, 2013) developed a framework model on social

interpersonal processes in PTSD to complement the other

existing models of memory or neurobiological dysfunc-

tions in PTSD. The present paper will further elaborate the

theory of our socialinterpersonal model, with the addition

of new findings, and present some applications for both

clinical and psychosocial work with survivors of trauma.

Broadening the focus on trauma survivors

There are several reasons to expand the study of trauma*

both theoretical and clinical: 1) the philosophical view

that humans are social beings; 2) the well-articulated

$

The present paper is a slightly modified version of a paper presented at the XIV European Conference on Traumatic Stress (ECOTS), Vilnius/Lithuania, June 2015.

PSYCHOTRAUMATOLOGY

EUROPEAN JOURNAL OF

European Journal of Psychotraumatology 2016. # 2016 Andreas Maercker and Tobias Hecker. This is an Open Access article distributed under the terms of the Creative

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1

Citation: European Journal of Psychotraumatology 2016, 7: 29303 - http://dx.doi.org/10.3402/ejpt.v7.29303

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view that often entire societies rather than individuals are

traumatized; 3) the occurrence of traumatic stress on a

global scale; and 4) the improved but still limited effec-

tiveness of individualized psychotherapies for PTSD.

Many diverse philosophical theories converge upon the

same fundamental insight that the social, or interpersonal

realm, is a central element of human nature (Aristotle,

1999; Ricoeur, 2005). This is implicit in any considera-

tion of mental disorders, mental health, and psychologi-

cal well-being. As human beings, we can be individual

agents, acting independently as well as group members

(e.g., family, neighborhood, society), acting interdepen-

dently. Whether we act independently or interdepen-

dently varies depending on different factors, for example,

historical era, culture, and individual life-span phase.

Interdependent psychological functioning, defined as

the degree to which members of the group are mutually

dependent on the others, has recently gained increased

attention in social psychology and psychiatry, indicating

a broad range of neurobiological and psychological

covariation of this distinction (Han & Ma, 2014). Even

in individualistic European or Westernized societies,

the degree of sociality or interdependence should not

be neglected*and this is particularly true for PTSD.

A landmark meta-analysis demonstrated this finding

that ''(perceived) social support'' as the most important

variable was negatively related to PTSD symptom severity

(Brewin et al., 2000). This relation was replicated for both

perceived and received social support in another meta-

analysis (Prati & Pietrantoni, 2010).

The term ''traumatized societies'' has received more

attention in recent research. It is defined as a large social

group sharing the same geographical territory and do-

minant cultural values that have experienced genocide,

war, or other extensive violence, so that the majority of

the society's members experienced exposure to extremely

threatening or horrific events. An incomplete list of such

societies includes the territory or at least larger parts

of Afghanistan, Bosnia-Herzegovina, Chechnya, Demo-

cratic Republic of Congo, Eastern Ukraine, Eritrea, etc.

This term has also been used for populations that have

either survived historical trauma, or are descended from

those who have, for example, Jewish Holocaust survivors,

Native Americans, and Apartheid witnesses. Several

authors, however, questioned the usefulness of the term

''traumatized societies'', for example, because it is often

used too unspecifically, without giving detailed descrip-

tions of its characteristics (Bruner, 2014). Large-scale

trauma may also lead to disruption of the very fabric of

a society (e.g., dismantling of institutions, displacement

of potential support networks). Therefore, a cautious

consideration of broad- or long-lasting effects of trauma

should include the societal context as well.

Data from international aid organizations [related to

United Nations (UN) or non-governmental organizations]

indicate that traumatic events are ubiquitous. Every

minute approximately 10 children die due to hunger

and malnutrition, which sums up to 6 million deceased

children per year (UNICEF, 2012); the daily death toll due

to violent conflict around the world sums up to around 500

persons (www.crisisgroup.org); and in the first 6 months

of 2015, around 2,500 individuals died by drowning in the

Mediterranean Sea while trying to reach Europe from

the North African coast (Amnesty International, 2015).

All these deceased have close family and friends who most

probably mourn their deaths and may have simultaneously

experienced what the trauma criterion in DSM-5 and

ICD-10 define as traumatization by witnessing. Altogether,

this would entail there being millions of traumatized

individuals, particularly in war-torn countries and regions.

A growing amount of research has highlighted a sub-

stantial gap, particularly in resource-poor countries,

between the burden caused by mental disorders and

the resources devoted to prevent and treat them (Collins,

Insel, Chockalingam, Daar, & Maddox, 2013). The con-

sequence is that more than 75% of people with trauma-

related and other mental health disorders do not receive

any official mental health care at all in these countries. It

is unlikely that individual trauma-focused therapy could

be mobilized to deal with this great number of trauma

survivors for a number of reasons, for example, lack of

trained therapists, lack of resources, and lack of a mental

health care infrastructure. Therefore, the World Health

Organization (WHO) increasingly advocates for larger

scale programs in post-conflict regions, targeting whole

communities or whole societies (Epping-Jordan et al.,

2015; Tol et al., 2014).

In the developed countries, with their contemporary

standards of mental health sciences and service oppor-

tunities, PTSD and related disorders can be treated in

the majority of patients suffering from these conditions.

An enthusiastic and tremendously inventive community

of scientists and practitioners has developed effective

treatment approaches for PTSD, as indicated, for exam-

ple, by prominent publications by the International and

the European Society for Traumatic Stress Studies (Foa,

Keane, Friedman, & Cohen, 2008; Olff et al., 2015;

Schnyder et al., 2015). However, we also know that up to

40% of our traumatized patients nevertheless do not reap

all the benefits from our individualized PTSD therapies

(Bradley, Greene, Russ, Dutra, & Westen, 2014). Current

treatment guidelines only adhere to treatments targeted

to modify individual dysfunctions in memory, cognition,

or affect. However, there are few new approaches aimed

at facilitating social support or restructuring commu-

nities or societies (see closing section of this article for

more detail).

Andreas Maercker and Tobias Hecker

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The socialinterpersonal framework model

of PTSD

It is vital to understand how all the various interpersonal

and social factors relevant for the development and main-

tenance of PTSD fit together. To achieve this, Maercker

and Horn (2013) developed a model as an explanatory

framework. It consists of factors that determine how

traumatic stress is mitigated or intensified by different

layers of personenvironment interactions. The simplified

structure is shown in Fig. 1 (a more detailed version of

this figure is given in Maercker & Horn, 2013). The model

describes three layers: 1) social affects comprising shame,

guilt, anger, revenge, etc.; 2) close relationships including

trauma disclosure, social support or negative exchange,

empathy, etc.; and 3) culture and society, comprising

aspects like the collective experience of trauma, social

acknowledgment as victim or survivor, cultural value

orientation, etc.

Social affects

The first level of social affects comprises well-described

modes of action tendencies and interactive styles of

traumatized persons. Affective reactions that relate to

other persons, groups, or communities are termed ''social

affects'' (Hareli & Parkinson, 2008). For example, guilt is

generally considered to function for its own immediate

relief. However, chronic guilty feelings contribute to

the maintenance of psychopathology in the long run

(Rachman, 1993). The functionality of shame in the

context of PTSD is still unclear. Shame has been demon-

strated to be strongly related to intrapersonal avoidance

(Street, Gibson, & Holohan, 2005). Furthermore, it is

plausible that shame is related to social withdrawal (for

more details, see Maercker & Horn, 2013). Whereas

posttraumatic shame and guilt have been investigated

frequently, other social affects, such as anger or aggres-

sion, have received little attention despite their common

manifestation in trauma survivors. In continuation of

Maercker and Horn's (2013) descriptions, we focus here

on recent findings on anger and aggression in trauma

survivors. The association between PTSD and interperso-

nal aggression is a robust finding in the literature. When

a person experiences repeated and constant threats to

their life, this person may develop cognitive networks

that guide cognitions, emotions, and actions in order to

increase chances of survival (Elbert & Schauer, 2002).

Although being highly alert and aroused in dangerous

situations has survival advantages, in situations where

threat to life is low, it can produce inappropriate and

aggressive behavior. High PTSD symptom severity was,

for example, associated with reactive aggression*an

aggressive reaction to some perceived provocation or

threat*in survivors of hurricane Katrina (Marsee, 2008)

or in veterans (Byrne & Riggs, 1996). A meta-analysis of

31 studies on the association between PTSD and intimate

relationship discord found medium-size associations

between PTSD and interpersonal physical and psycholo-

gical aggression, with trait anger mediating this relation-

ship (Taft, Watkins, Stafford, Street, & Monson, 2011).

Furthermore, it has been repeatedly shown that a

person's own experiences of childhood maltreatment and

their own victimization through intimate partner violence

predict aggressive parenting behavior (Saile, Ertl, Neuner,

& Catani, 2014). These findings provide further evidence

that exposure to trauma and violence in the past is

associated with the display of aggressive behavior and

violence. Correspondingly, former child soldiers who

have been frequently exposed to severe violence also

perpetrated more types of violence (Weierstall, Schalinski,

Crombach, Hecker, & Elbert, 2012). These findings,

however, were not limited simply to reactively aggressive

acts that grew out of trauma-related suffering. Instead,

Traumatic

experiences

Culture & society

Close relationships

Social

affects

Outcomes

Individual recovery

Relationship quality

Community integration

Fig. 1. The socialinterpersonal framework model for trauma sequelae. (From Maercker & Horn, 2013.)

Socialinterpersonal perspective on PTSD

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they reported that exposure to violence fostered appeti-

tive aggression. For this subtype of aggression, the

infliction of harm upon an individual is itself reward-

ing, fascinating, and a source of enjoyment *above and

beyond secondary rewards like status or material benefits

(Hecker, Hermenau, Maedl, Elbert, & Schauer, 2012). In

environments dominated by violence, exposure to violence

and other traumatic stressors have been linked to appeti-

tive aggression and encouraged violent behavior, thereby

creating a cycle of violence (Hecker, Fetz, Ainamani, &

Elbert, 2015). Developing appetitive aggression seems to

be an adaptive survival strategy for children growing up

in such violent environments (Hermenau, Hecker, Maedl,

Schauer, & Elbert, 2013). Appetitive aggression has

been shown to be a major risk factor for future violent

behavior. Therefore, both reactive and appetitive aggres-

sion may hinder successful treatment and integration into

civil society (Annan, Brier, & Aryemo, 2009). Thus, social

affects such as anger, aggression, and revenge need to be

addressed to enable trauma survivors to fully reintegrate

into their society.

Close relationships

The second layer comprises trauma-relevant processes in

close relationships of the survivors. Disclosure of trau-

matic experiences is a phenomenon that deserves parti-

cular attention. If a trauma survivor is able to share

parts or even central elements of his or her horrible

experience with family and friends, he or she reports better

psychological well-being. This basic relationship has been

described by clinicians (Briere & Scott, 2013; Gray et al.,

2012) as well as in so-called analog research designs,

that is, with non-traumatized students who were studied

after experimental manipulation as if they were trauma-

tized (Pennebaker, 1995). Disclosure prevents ''oppressive

silence'', which may extend from close relationships

into broader societal contexts*as already described by

several pioneering traumatic stress studies (e.g., Boston

Women's Health Book Collective, 2011; Shay, 1994).

Recent research on disclosure in PTSD incorporated

methodological advancements of longitudinal as well as

dyadic assessments. Pielmaier, Milek, Nussbeck, Walder,

and Maercker (2013) studied patients and their significant

others after severe traumatic brain injury at 3, 6, and 12

months post-injury. They measured three aspects of

dysfunctional disclosure tendencies (reluctance to talk,

urge to talk, emotional overreactions) based on previous

research (Mueller, Mo ̈rgeli, & Maercker, 2008). As hy-

pothesized, the extent of PTSD symptom severity in

patients was related both with their own dysfunctional

disclosure, that of their significant other, and additionally

with the interaction between the two disclosure styles.

If both were frank to each other (low dysfunctional

disclosure), they reported low PTSD symptom severity

and vice versa with high dysfunctional disclosure and high

PTSD symptom severity. If the significant others showed

highly dysfunctional disclosure while the patient showed

low levels of dysfunctional disclosure, medium levels

of PTSD were reported, indicating the crucial role of

the significant others in fostering healing through verbal

exchange.

Regarding social support or negative social exchange,

important lines of research originate from PTSD research

on the consequences of natural disaster. Kaniasty and

Norris (2004) describe how initial positively received

social support shortly after the traumatic event*in a

phase they call ''honeymoon stage''*often transfers into

a negative state of social support deterioration for various

reasons, for example, interpersonal weariness (''pressure

cooker effect''), need for actual support surpasses the

availability, potential for interpersonal conflicts, lack

of consensus in appraisal of the event, etc. In a 2-year

longitudinal study on severe flood victims, they showed

by means of elaborated cross-lagged analysis that social

support is the most prominent cause of a decrease in symp-

toms during the earlier phase after a trauma (Kaniasty

& Norris, 2008). However, the causal relationship appears

to switch directions 18 months after the trauma, when an

increase in trauma-related symptoms leads to less reported

social support. This finding strongly indicates the need

for sequentially ordered social interactions and avoids

regarding social support as a self-revolving inexhaustible

positive resource.

Culture and society

The third level of the socialinterpersonal model repre-

sents the societal and cultural sphere. Thus far, trau-

matic stress responses have predominantly been studied

in individualistic contexts. Yet, whether collectivistic or in-

terdependent orientations may lead to different symptom-

society dynamics remains unclear. In addition to the

clinical and research specifications in the Maercker and

Horn (2013) article, we focus subsequently on new results

on the issues of social acknowledgment as a victim or

survivor as well as on human value orientation changes.

Social or societal acknowledgment as a victim is assumed

to be particularly relevant for survivors of man-made

trauma; it is close to the restorative justice perception of

persons trying to overcome the traumatic disruption

of their lives (Sullivan & Tifft, 2007). Maercker and

Mu ̈ller (2004) have developed a 16-item questionnaire

measuring the three independent subscales of recognition,

family disapproval, and general disapproval. Studies

with this questionnaire were conducted, for example, with

war victims in Poland, Germany, Indonesia, and the

USA (e.g., Lis-Turlejska, Szumial, & Okuniewska, 2012;

Schumm, Koucky, & Bartel, 2014), refugees (Maercker,

Povilonyte, Lianova, & Po ̈hlmann, 2009); former political

prisoners from East Germany or Lithuania (e.g., Kazlauskas

& Zˇ elviene ̇, 2015); and traumatized street gang members

Andreas Maercker and Tobias Hecker

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Citation: European Journal of Psychotraumatology 2016, 7: 29303 - http://dx.doi.org/10.3402/ejpt.v7.29303

in South Africa (Sommer et al., submitted). Across the

various cross-sectional studies, the correlation between the

total score of self-perceived social acknowledgment and

PTSD ranged between r0.25 and 0.45. In long-

itudinal studies, the score predicted a regression Beta

coefficient of up to 0.33, indicating a large effect of

social acknowledgment*or its lack, that is, disapproval*

on trauma sequelae (e.g., Mueller et al., 2008).

Human value orientations are rarely considered in

clinical psychology or psychiatry as a relevant phenomen-

on, probably because they are regarded as impersonal

and abstract dimensions. This disregard is unfortunate,

because value orientations span a variety of important

social and psychological phenomena, from intrapersonal

concerns to regulatory matters of the whole society and

culture (Boer & Fischer, 2013). Intrapersonally, values

guide individual motivation by setting goals or proscrip-

tions for managing one's life. Regarding societies or

cultures, value orientations regulate, for example, morality,

ideas of progress or endeavor, and social order (Schwartz,

1994). Very few studies have been conducted on value

orientations in trauma- and stress-disorder victims. Those

that have been carried out indicate that modern (e.g.,

self-direction, stimulation, hedonism) and traditional

values (e.g., power, achievement, conformity) differentially

mediate the relationship between trauma exposure,

social support process, and the extent of PTSD symptom

severity, with*non-trivially*stronger traditional values

worsening, and higher modern values ameliorating the

health outcomes (Maercker, Forstmeier, Wagner, Glaesmer,

& Bra ̈hler, 2008; Mueller, Orth, Wang, & Maercker,

2009). Zimmermann et al. (2014) confirmed this pattern

for German soldiers after recent NATO deployment in

Afghanistan. This is in contrast to conventionally held beliefs

that personal orientations towards traditional values have

in general a positive impact on health (cf. Kleinman &

Kleinman, 1985).

A systematic survey of European studies on mental

health and PTSD (Wittchen et al., 2011) together with

the data from the European Social Survey (www.

europeansocialsurvey.org, round 1, 2002) allowed an

exciting exploratory data analysis on probable value change

after war exposure. In this study, Burri and Maercker

(2014) analyzed national PTSD prevalence rates in

European countries and examined the complex interrela-

tions between this and countries' pattern of value orienta-

tions, rates of war death (in WWII and the Yugoslavian

wars), and the interaction between values and war death

rates. The results indicate a strong interaction between

these variables and the temporal sequence of association

between war deaths and subsequent value orientations

(measured around the year 2000). The findings suggest

a value change from modern to traditional values in

countries with higher war death tolls (Burri & Maercker,

2014). If this result can be confirmed by other data,

it would explain the decrease of societal support for indi-

vidual rights observed by various scholars for post-conflict

regions (Ajdukovic ́ & Ajdukovic ́, 2003; Somasundaram,

2014). This would be one of the most far-reaching con-

sequences of traumatization.

Resilience as application of the

socialinterpersonal model

Yet, many survivors of traumatic experiences do not

develop PTSD or other trauma-related disorders. Further-

more, the spontaneous remission rate in this group is high.

Therefore, many clinicians and researchers in the field of

traumatic stress studies are fascinated by recent deve-

lopments concerning human resilience. Resilience as the

capacity to bounce back from a negative experience can

be formulated on both an individual (biological, psycho-

logical, etc.) and socialinterpersonal level. In recent

research, the former has been more popular, whereas the

latter is often disregarded. However, at least one promi-

nent paper on resilience, written for a broader audience,

the American Psychological Association's ''10 ways to

build resilience'' lists a socialinterpersonal feature as no.

1 in its outline: ''Make connections. Good relationships

with close family members, friends or others are impor-

tant. Accepting help and support from those who care

about you and will listen to you strengthens resilience.

Some people find that being active in civic groups, faith-

based organizations, or other local groups provides social

support and can help with reclaiming hope. Assisting

others in their time of need also can benefit the helper''

(American Psychological Association, 2012). Yet, face

validity is not always supported by empirical evidence.

Therefore, further research is highly required to gain a

better understanding of resilience factors on a social

interpersonal level.

In resilience research, a leading author in particular

promotes what he calls the ''socio-ecological model of

resilience'' (Ungar, 2011). This model highlights crucial

aspects of resilience, like facilitative environments, which

enable the individual access to resources, the interaction

of protective mechanisms with exterior risk factors, and a

longitudinal period of record as well as cultural relativity.

Ungar's research is primarily concerned with resilience

in children confronted with challenging environments. He

argues, for example, that for children from conflict areas,

exposure to violence during war was less debilitating for

their well-being than the separation from their caregivers

(e.g., Solomon & Laufer, 2005). Research on community-

level resilience factors in adults, however, is still sparse.

Maercker, Hilpert, and Burri (2015) applied the socio-

ecological resilience model to a group of Swiss elderly

people with a long-term history of childhood trauma and

adversity. They confirmed the potential of these extended

approaches by showing, for example, socialinterpersonal

Socialinterpersonal perspective on PTSD

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factors outperforming the well-established individual re-

source of high self-esteem in predicting resilience.

Outlook for therapy and interventions

The present paper should not end without a short over-

view on the efforts to overcome trauma sequelae on an

interpersonal and societal level. In brief, the main goals of

such interventions, apart from the reduction of PTSD

symptoms, are improvements of relationship and commu-

nity functioning. In the logic of the presented social

interpersonal model (see Fig. 1), social affect focused

therapies are necessary for its first layer, couple and family

therapies, for its second layer, and community interven-

tions for the third layer.

Social affects

Trauma-related guilt and shame is thoroughly addressed

in evidenced-based individual-level PTSD interventions

(Schnyder et al., 2015). Anger and aggression, however,

have been a particular focus in traumatized soldiers and

veterans, although other populations also deserve atten-

tion. Yet, research on aggression and anger even within

military populations is sparse. For example, in their review

of treatment approaches in military populations focusing

on anger and aggression, Morland, Love, Mackintosh,

Greene, and Rosen, (2012) identified only two formal

anger treatment protocols that have been studied in

military samples, both of which used multicomponent

cognitive behavioral therapybased protocols to address

anger. One study found significant decreases in anger

symptoms; whereas the other found significant decreases

in both state and trait anger symptoms, as well as reports

of physical aggression (see Morland et al., 2012).

Furthermore, Narrative Exposure Therapy for Forensic

Offender Rehabilitation (FORNET) aims at reducing

both symptoms of traumatic stress and controlling read-

iness for aggressive behavior (Hecker, Hermenau,

Crombach, & Elbert, 2015). FORNET follows the logic of

the evidence-based trauma-focused Narrative Exposure

Therapy (Schauer, Neuner, & Elbert, 2011) with special

emphasis on aggressive behavior and violent acts in the

past and future. The first randomized-controlled trials

with veterans and violence-affected youths have proven

the feasibility of FORNET and found first evidence of a

positive outcome, for example, recovered mental health

(PTSD, depression), fewer offenses committed, less

drug intake, and improved integration into civil society

(Crombach & Elbert, 2015; Hermenau, Hecker, Schaal,

Maedl, & Elbert, 2013; Ko ̈bach, Schaal, Hecker, & Elbert,

in press).

Close relationships

Monson, Wagner, Macdonald, and Brown-Bowers (2015)

give an overview on evidence-based couple and family

interventions for traumatized family members. In ascend-

ing order of focusing trauma or PTSD, they distinguish

four classes of interventions: programs on education and

family-facilitated engagement, generic couple therapy,

partner-assisted intervention, and disorder-specific cou-

ple therapy. The class of disorder-specific couple therapy

for PTSD has the strongest empirical support in terms

of achieving multiple outcomes (i.e., reductions in PTSD,

improvements in relational functioning, improvements in

partners' psychological functioning). If both the client

and the partner are willing to participate in a dyadic

intervention for PTSD, disorder-specific couple therapy

is recommended, regardless of level of relationship distress,

because these interventions have been tested with couples

across the spectrum of relationship satisfaction. The

authors acknowledge that these interventions are in their

infancy, and additional research is warranted to further

establish the effectiveness of the interventions, as the vast

majority of the work thus far has been done within the

veteran populations (Monson et al., 2015).

Culture and society

For community-level trauma interventions, it is more

difficult to get a comprehensive overview of available

services and programs that are developed around the

globe. Many of these programs have been developed

by local or regional stakeholders that are not as well

connected as the communities of clinicians or researchers

working on individual trauma sequelae. The WHO more

recently tried to integrate and evaluate such posttrauma

or post-disasters services to avoid uncoordinated and

disproportional aid activities that sometimes sponta-

neously develop after international emergency situations

and to collect systematic knowledge on previous missions

(Epping-Jordan et al., 2015; Tol et al., 2014).

Interventions that aim at improving the community

situation after traumatic events*and that not only apply

large-scale individual treatment*give people a voice

(e.g., against local officials, their government); encourage

action against deterioration of social support over time;

fight embitterment or defeatism; and facilitate identity,

value, and meaning reconstruction (Linden & Maercker,

2011; Somasundaram, 2014). The following five classes of

programs or services have been developed and applied:

. Post-disaster mental health programs: Developed

primarily after natural catastrophes, for example,

floods, hurricanes, and volcanic eruptions (Norris,

Friedman, & Watson, 2002)

. Community training in critical contexts: Developed

for communities with ongoing high levels of vio-

lence, for example, in US Black local communities

(Laborde, Magruder, Caye, & Parrish, 2013)

. Reconciliation and trauma-healing approaches in

post-war settings: For example, applied in post-war

Burundi and Rwanda after the genocide (Staub,

Andreas Maercker and Tobias Hecker

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Pearlman, Gubin, & Hagengimana, 2005; Yeomans,

Forman, Herbert, & Yuen, 2010)

. Post-war community-based rehabilitation programs:

Developed in various regions of the world, for example,

in the Balkans (Ajdukovic ́ & Ajdukovic ́, 2003) and

in Sri Lanka (Somasundaram & Sivayokan, 2013)

. Mental health reforms advocated by international

agencies like the UN and WHO to raise the

awareness of psychosocial needs and improve sus-

tainable services for community members in need

(Epping-Jordan et al., 2015)

So far little is yet known about the effectiveness of

these community-based approaches. Though they are

frequently implemented in war and crisis regions, they

still lack support from studies using scientifically rigorous

methods (Tol et al., 2011). Future research is needed to

empirically test their effectiveness.

It is our conviction that the best care for traumatized

human beings combines services for the individual, his or

her core social group, and the society. The field of trau-

matic stress studies has been very successful in assisting

the individual*but needs to be broadened to encompass

family, community, or societal means and measures for

recovery or restoration. The individual-centered focus on

the individual survivor may not be enough, particularly

in regions of war and conflict or after mass disasters.

Conflict of interest and funding

The authors declare that they have no competing

interests.

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