Political violence, collective functioning and health: A review of the literature

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  • This article was downloaded by: [University of Tasmania]On: 29 November 2014, At: 14:13Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH,UK

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    Political violence, collectivefunctioning and health: A reviewof the literatureCindy A. Sousa aa Bryn Mawr College Graduate School of Social Workand Social Research, Bryn Mawr , PA , USAPublished online: 22 Aug 2013.

    To cite this article: Cindy A. Sousa (2013) Political violence, collective functioning andhealth: A review of the literature, Medicine, Conflict and Survival, 29:3, 169-197, DOI:10.1080/13623699.2013.813109

    To link to this article: http://dx.doi.org/10.1080/13623699.2013.813109

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  • Political violence, collective functioning and health: A reviewof the literature

    Cindy A. Sousa*

    Bryn Mawr College Graduate School of Social Work and Social Research, Bryn Mawr,PA, USA

    (Accepted 4 June 2013)

    Political violence is implicated in a range of mental health outcomes,including PTSD, depression, and anxiety. The social and political contextsof peoples lives, however, offer considerable protection from the mentalhealth effects of political violence. In spite of the importance of peoplessocial and political environments for health, there is limited scholarship onhow political violence compromises necessary social and political systemsand inhibits individuals from participating in social and political life.Drawing on literature from multiple disciplines, including public health,anthropology, and psychology, this narrative review uses a multi-level,social ecological framework to enhance current knowledge about the waysthat political violence affects health. Findings from over 50 studies wereanalysed and used to build a conceptual model demonstrating how politicalviolence threatens three inter-related domains of functioning: individualfunctioning in relationship to their environment; community functioningand social fabric; and governmental functioning and delivery of services topopulations. Results illustrate the need for multilevel frameworks thatmove beyond individual pathology towards more nuanced conceptualiza-tions about how political violence affects health; findings contribute to thedevelopment of prevention programmes addressing political violence.

    Keywords: political violence; war; health; collective functioning

    Introduction

    Political violence is the deliberate use of power and force to achieve politicalgoals (World Health Organisation (WHO) 2002). As outlined by the WorldHealth Organisation (2002), political violence is characterized by both physicaland psychological acts aimed at injuring or intimidating populations. Examplesinclude shootings or aerial bombardments; detentions; arrests and torture; andhome demolitions (Basoglu, Livanou, and Crnobaric 2005a; Clark et al. 2010;de Jong et al. 2002; Dubow et al. 2010; Farmer 2004; Giacaman et al. 2007c;Hobfoll, Hall, and Canetti 2012). The WHO definition of political violence

    *Email: csousa@brynmawr.edu

    Medicine, Conflict and Survival, 2013Vol. 29, No. 3, 169197, http://dx.doi.org/10.1080/13623699.2013.813109

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  • also includes deprivation, the deliberate denial of basic needs and humanrights. Examples include obstruction related to freedom of speech (e.g., activ-ists who speak out against a regime being subject to torture (see, for instance,Robben 2005)), and denial of access to food, education, sanitation, and health-care (for instance, see International Committee of the Red Cross (ICRC) 1949;UNESCO 2006; UNESCO: International Programme for the Development ofCommunication (IPDC) 2012; United Nations Population Fund 2007).

    Particularly when we look at dimensions of deprivation within politicalviolence, it is clear that political violence is intimately related to structuralviolence: the ways that structures of society (e.g., educational, legal, cultural,healthcare) insidiously act as social machinery of oppression (Farmer andLaurie 2006, 307) to regularly, systematically, and intentionally prohibit therealization of full human potential through unequal arrangements of social,economic, and political power (Farmer 2004; Farmer et al. 2006; Galtung1969). Indeed, it is overwhelmingly clear that structural violence often precipi-tates, coexists with, and is deployed as a regular tool within political violence.Structural inequalities based, for instance, on class, nationalities, or ethnicgroups often lead to political uprisings and rebellions and then to the yieldingof power through violent repressions that characterize political violence (Cairnset al. 1998; de Jong 2010). In addition, it is usually the poorest and most dis-enfranchised that suffer the most within wars and conflicts as they are particu-larly targeted and/or face oppression and violence within a multitude ofoverlapping experiences (see, for instance, Al Gasseer et al. 2004; Berg 2009;Lykes et al. 2007; UNRISD (United Nations Research Institute for SocialDevelopment) 2005). Furthermore, political violence in the forms of repression,torture, and forced exile is often levelled specifically towards those who posethe most threat to the prevailing and oppressive social order (see, for instance:Blum 2005; Esparza 2005; Robben 2005). Despite their mutual influence,authors, including Galtung (1969), who is widely credited with developing theinitial framework for structural violence (Farmer 2004), have proposed a fewkey points of differentiation between structural and political violence: whereasstructural, indirect violence is covert, static, and lacks a clear aggressor,direct violence (what Galtung terms personal violence, but would alsoinclude political violence) is overt, dynamic, and connects a discernableaggressor with the victim (Galtung 1969; Vorobej 2008; Winter and Leighton2001). Although its relationship to structural violence will be clear as findingsare presented below (and, in fact, the uncovering of this dynamic is one of thecontributions of this overview), the research presented here centres on politicalviolence, as defined above.

    A considerable amount of research has examined how political violence isimplicated in a variety of poor outcomes related to mental health, includingPTSD, depression, and anxiety (Barber 2008; de Jong et al. 2003; de Jonget al. 2008; Haj-Yahia 2008; Punamki 1990; Summerfield 2000). The WHO,for example, estimates that between one-third to one-half of people exposed to

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  • political violence will endure some type of mental distress, including PTSD,depression or anxiety (World Health Organisation (WHO) 2001). In spite ofthese risks, however, we know that individuals and communities regularlymanage the traumas of political violence as they demonstrate considerableresilience (Summerfield 1999). Resilience the successful recovery from oradaptation to hardship (Agaibi 2005; Masten et al. 1990) is not an anomaly,but rather, is a predictable reaction to stress for both individuals and collectives(Bonanno 2004; Norris et al. 2008). While some individual traits may buildresilience in the face of political violence (for reviews of these, see Betancourtand Khan 2008; Masten et al. 2012; Sousa et al. 2013), resilience ultimatelydepends on the relationship between people and their social and politicalenvironments (Masten et al. 2008; Shinn and Toohey 2003; Ungar 2011b).Individuals involvement in collectives, cohesive community networks, anddemocratic, responsive governmental systems are each central to health andwell-being (Garbarino 2011; Hobfoll et al. 2007; Katz 2001; Nowell and Boyd2010; Pfeiffer et al. 2008; Ungar 2011a; CSDH 2008).

    For populations affected by political violence, resources within the environ-ment (e.g., schools, community institutions, opportunities for social andpolitical engagement, responsive public systems, and governmental account-ability for atrocities committed against civilian populations) appear to offerprotection against the deleterious impacts of political violence on health (Berk1998; Farwell and Cole 2001; Lykes et al. 2007; Betancourt et al. 2010;Melton and Sianko 2010). In spite of what we know, however, about thepotential for social and political contexts to build resilience, there is limitedhealth scholarship on how political violence threatens the individual-environ-ment relationship, which we know is core to well-being (Kemp et al. 1997;Melton and Sianko 2010). While it is increasingly recognized that politicalviolence is a collective experience (Martn-Bar et al. 1994; Summerfield2000; Nelson 2003; Robben 2005; Giacaman et al. 2007c), we know moreabout its influence on individuals than we do about the ways it affects thelarger groups, organizations, and government structures that underpin healthand well-being.

    However, particularly when we look across disciplines, there does existsome evidence about how political violence affects the dynamic relationshipsbetween individuals and the collective. This scholarship coincides with anincreased attention to multilevel perspectives that transcend individual pathol-ogy through emphasizing social and political determinants of health (Krieger2001, 2008; Williams 2002). Social ecological frameworks are particularlyimportant for examinations of political violence because the violence simulta-neously affects multiple domains related to individual and collective well-being(Hoffman and Kruczek 2011; Martinez and Eiroa-Orosa 2010), as it causeswhat Edelman et al. (2003) refer to as the sociopolitical effects of politicalviolence. Due to their comprehensive scope, multi-level frameworks enrichboth scholarship on and intervention planning for political violence (Dubow

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  • et al. 2009; Tol et al. 2010). Accordingly, this review aims to enhance the liter-ature on political violence by examining and synthesizing literature from acrossmultiple disciplines to improve our understandings about the implications ofpolitical violence for collective well-being.

    The term collective in this review refers to three inter-related domains offunctioning: individuals ability to participate in social and political life;community functioning and social fabric; and governmental functioning anddelivery of services to populations (see Figure 1). These three domains, whichwere built and clarified through the process of synthesizing the literature forthe review, represent the central organizing framework for this paper. In linewith Bronfenbrenners theories (1986), which referred to bidirectional relation-ships between domains of functioning as mesosystems, this review alsoconsiders how political violence harms the relationship between areas ofcollective functioning. For instance, it considers how political violence mightaffect governmental functioning, which then weakens individuals willingnessto engage in political life.

    Figure 1. Domains of collective functioning.

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  • Methods

    For both local and outside researchers alike, within political violence there islittle assurance for the safety or the stability and infrastructure needed forextended fieldwork, or for in-depth, large-scale, and/or longitudinal studies.Furthermore, as Krieger (2008) asserts, as a whole, social ecologicalexaminations of health are still new, and accordingly, there are still ongoingdeliberations regarding some of the core constructs like proximal, distal, andlevel. Although political violence, with its multi-level repercussions, demon-strates the need for social ecological perspectives, its complex nature,variations in its expression across locations and time points, and the range ofevidence required for sound evaluation of its effects across levels (particularlyat the collective level) all present special challenges for research. With theseissues in mind, this review deliberately utilizes an integrated design to draw onfindings from across disciplines (including public health, anthropology,geography, sociology, and psychology) and methodologies (for more on theadvantages and disadvantags of integrated review studies, see Sandelowski,Voils, and Barroso 2006; Voils et al. 2008). The variety of disciplines andmethods represented in this review illustrate the importance of scholarship thatis qualitative in nature, that is the product of reflections from professionalswith extended time in the field, and/or that are overviews resulting fromauthors analyses of official reports or statistics, architecture, policies orprogrammes, or historical events. Although aspects of systemic reviewprocesses were employed (evident in the explanation of the search strategydescribed below), this is a narrative review. A narrative format was chosen duethe advantages it offers in terms of drawing on a wide array of disciplines andmethods of inquiry, and its consequent fit with integrated approaches toreviews of literature (for more on the importance of narrative reviews, see forinstance, Murphy 2012).

    To meet inclusion criteria, articles must be peer reviewed, published inEnglish, and address the research question of how political violence directlyaffects individuals abilities to interact with collective structures or the collec-tive structures themselves (e.g., community and governmental functioning).Psychinfo and PubMed databases were searched in 2011 using the key termpolitical violence, resulting in 323 and 617 articles, respectively. Pubmed wassearched using war + infrastructure, resulting in 309 articles (politicalviolence + infrastructure only resulted in 17 articles so the search was donewith the key term war instead of political violence). To further ensure represen-tation of social science disciplines (and to provide a more updated searchtimeframe), an additional search was done in ProQuest in 2013 (limited topeer-reviewed sources), using the key words political violence; this resultedin 739 papers (many of which were duplicates on the original searches) thatwere searched, again first at the level of the title and the brief view of theabstract (where the search terms are highlighted in their context) and then at

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  • the level of the abstract. Excluding repeated articles, more than 1200 titleswere initially reviewed, first based on their titles and then their abstracts.

    Specific searches were also done within journals closely related to politicalviolence (e.g., Conflict and Health, Disasters) or those with special issues orconsiderable space dedicated to political violence (e.g., Social Science andMedicine, Qualitative Sociology, Human Geography). Grey literature, authorsdatabases, and reference lists of published literature on related topics were alsoused; in this way, literature from relevant books were included and the searchreached more deeply into the fields of geography and anthropology. Literaturewas not selected if it did not either address how political violence affects indi-viduals involvement in the collective or reflect findings about how politicalviolence affects collective structures (e.g., schools, healthcare, governmentsystems, community well-being); for example, literature was rejected if itfocused on the causes, rather than effects, of political violence; on the individ-ual mental health implications of political violence; or solely on interventionsrelated to political violence. In the end, 53 articles and 9 books or booksections were retained for review and analysis.

    Results

    Investigation and synthesis of the literature resulted in the establishment ofthree broad categories of collective functioning (each containing severalsub-themes): (1) individuals ability to participate in social and political life;(2) community functioning and social fabric; and (3) governmental functioning.The review is organized according to these three domains. The discussionprovides an analysis of the effects of political violence across these threedomains. Table 1 illustrates the central organizing framework for the findings,and shows the number, methods, and locations of studies with respect to thethree domains of collective functioning investigated. Table 2 provides the loca-tions and descriptions of political violence provided by authors included in thisreview.

    Influence of political violence on individual functioning in relationship totheir envirornment

    Participation in civil society and political processes is essential for the healthand well-being of individuals (CSDH 2008). It engenders a sense of responsi-bility for collective functioning, enhancing individual well-being (Nowell andBoyd 2010). Political violence undermines individuals ability to engage with,and have confidence in, social and political life by: contributing to individualsisolation and withdrawal from society; deteriorating individuals trust in others,justice, and government entities and democracy itself; and lessening individu-als abilities or willingness to engage in political activities.

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  • Table

    1.Pheno

    mena,

    metho

    dology,nu

    mber,andlocatio

    nsof

    stud

    ies.

    Pheno

    menon

    Survey

    research

    Narrativ

    eresearch

    (e.g.,

    interviews,

    focusgrou

    ps)

    Ethno

    graphy,

    prolon

    ged

    fieldw

    ork,

    participant

    observation

    Overview

    basedon

    analysisof

    existin

    gevidence

    total#of

    stud

    ies(#

    empirical,#

    overview

    )Locations

    Influenceon

    individu

    als

    ability

    toparticipatein

    social

    and

    political

    life

    Isolation,

    mistrust,

    suspicion,

    with

    draw

    al

    34

    31

    10(9,1)

    Argentin

    a,ElSalvado

    r,NorthernIreland,

    Peru,

    Guatemala,

    Burma,

    Kosov

    o,Indian

    Kashm

    irValley

    Deterioratio

    nof

    trustin

    moral

    order,justice,

    government

    entities,democracy

    13

    22

    7(5,2)

    Guatemala,

    Nicaragua,Former

    Yug

    oslavia,

    NorthernIreland

    Weakenedability

    ofindividu

    alsto

    organize

    andwork

    collectively

    14

    31

    8(7,1)

    Argentin

    a,Guatemala,

    Bosnia,

    Burma

    Influenceon

    commun

    ityfunctio

    ning

    /social

    fabric

    Masskilling

    sor

    disapp

    earances

    24

    42

    9(7,2)

    Peru,

    Guatemala,

    Croatia,

    Colom

    bia,

    ElSalvado

    r,Argentin

    a,Nicaragua

    Displacem

    entand

    migratio

    n4

    51

    512

    (7,5)

    NorthernIreland,

    Zim

    babw

    e,Peru,

    SriLanka,Bosnia,

    El

    Salvado

    r,North

    America

    (Con

    tinued)

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  • Table

    1.(Con

    tinued). Pheno

    menon

    Survey

    research

    Narrativ

    eresearch

    (e.g.,

    interviews,

    focusgrou

    ps)

    Ethno

    graphy,

    prolon

    ged

    fieldw

    ork,

    participant

    observation

    Overview

    basedon

    analysisof

    existin

    gevidence

    total#of

    stud

    ies(#

    empirical,#

    overview

    )Locations

    Wide-scale

    physical

    destructionof

    places,including

    thoseof

    special

    meaning

    11

    46(2,4)

    Croatia,Guatemala,

    Palestin

    e,Iraq,Bosnia

    Con

    trol

    ofspace

    andmov

    ement

    13

    56

    13(7,6)

    Iraq,Argentin

    a,Northern

    Ireland,

    Palestin

    e,Burma,

    Sou

    thAfrica,

    North

    America,

    Peru,

    ElSalvado

    r,Guatemala,

    Nepal

    Instillationof

    collectivefear

    &terror

    33

    37(5,3)

    Nicaragua,Colom

    bia,

    Guatemala,

    Burma,

    El

    Salvado

    r,Israel

    Destructio

    nof

    social

    networks

    24

    41

    9(8,1)

    Burma,

    Guatemala,

    Peru

    Dim

    inishm

    entof

    thenu

    mberand

    streng

    thof

    commun

    ityorganizing

    activ

    ities

    24

    42

    9(7,2)

    Guatemala,

    Burma,

    Zim

    babw

    e,Peru,

    ElSalvado

    r

    (Con

    tinued)

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  • Table

    1.(Con

    tinued). Pheno

    menon

    Survey

    research

    Narrativ

    eresearch

    (e.g.,

    interviews,

    focusgrou

    ps)

    Ethno

    graphy,

    prolon

    ged

    fieldw

    ork,

    participant

    observation

    Overview

    basedon

    analysisof

    existin

    gevidence

    total#of

    stud

    ies(#

    empirical,#

    overview

    )Locations

    Influenceon

    governmental

    functio

    ning

    and

    deliv

    eryof

    services

    topo

    pulatio

    ns

    Deterioratio

    nof

    public

    utilities

    21

    58(3,5)

    Iraq,Afghanistan,Lebanon,

    SriLanka,Sou

    thAfrica,

    Gaza,

    WestBank

    Deterioratio

    nof

    medical

    system

    s2

    1214

    (2,12)

    ThroughoutAfrica,

    Haiti,

    Pakistan,

    Iraq,Mozam

    biqu

    e,Nicaragua,Peru,

    Afghanistan,

    Guatemala,

    Zim

    babw

    e,the

    Philip

    pines,ElSalvado

    r,Croatia,Bosnia,

    Palestin

    e,Kashm

    irDeterioratio

    nof

    scho

    olsystem

    s1

    12

    13(2,1)

    Mozam

    biqu

    e,Palestin

    e,Burma

    Deterioratio

    nof

    public

    sector

    and

    governments

    ability

    toprov

    ide

    forits

    citizenry

    1010

    (10)

    ThroughoutAfrica,

    El

    Salvado

    r,Haiti,

    Palestin

    e,Lebanon

    ,Iraq,Bosniaand

    Herzego

    vina,Som

    alia

    Destructio

    nof

    governance

    processes

    11

    14

    7(3,4)

    Guatemala,

    ElSalvado

    r,Som

    ali,glob

    alevaluatio

    ns,

    Nicaragua

    Notes: C

    ategoriesareno

    tmutually

    exclusive;

    stud

    iesoftenhadmultip

    leph

    enom

    enon,metho

    d,andlocatio

    n,andthey

    arecoun

    tedin

    each

    ofthesethat

    they

    repo

    rt.Overviewsincluded

    historical,policy,

    orprogrammeanalyses

    usingofficial

    governmentreports,

    newsreports,

    orbudgets;

    spatialdata

    (e.g.,maps,

    architecture);andexistin

    gliterature.

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  • Table 2. List of locations and short explanation of political violence, as reported bystudy authors.

    Location Authors

    Timeline, if given, &characterization of politicalviolence by authors

    Africa (Ityavyar and Ogba 1989) 19601987: violence andpolitical conflicts

    Afghanistan (Salvage 2007; Acerra et al.2009)

    19791989: invasion and warwith Soviet Union; internalfactional fighting, 2001: USinvasion

    Argentina (Robben 2005) 19551979: armed violence,1976: start of state terror anddirty war against citizens

    Bosnia (Jones 2002; Carballo et al.2004; Coward 2004; Jones andKafetsios 2005; Simunovic2007)

    19921995; war

    Burma (Skidmore 2003) Beginning 1998; totalitarian statecontrol

    Colombia (Oslender 2007) Beginning 1980s: internal crises,armed struggles for power

    Croatia (Duli 2006) 19411945; war(Violich 1998) 19911995: war

    El Salvador (Jenkins 1991; Martn-Bar et al.1994; Ugalde et al. 2000)

    19791892 civil war,culmination of militarization andpolitical repression

    Guatemala (Lykes 1997; Preti 2002; Esparza2005; Lykes et al. 2007; Floreset al. 2009; Pedersen, Kienzler,and Gamarra 2010)

    Long history of conflict andviolence, dating back to BC;written records of violence,torture, massacres from invasionof conquistadores in 1533 andthroughout colonization from16th19th century; 19601996;civil war between army and left-wing guerillas, amidst non-violent leftist organizing for landreform, civil rights, democracy

    Haiti (Farmer 2004) 1991: violent coupIraq (Basu 2004; Graham 2004;

    Hamid and Everett 2007;Salvage 2007; Gregory 2008)

    Beginning 2003: invasion andwar

    Ireland (Feldman 2003; Dillenburgeret al. 2008)

    Beginning 1969: sectarianviolence and political conflict

    Israel (Bar-Tal 2001) Protracted conflictKashmir Valley (de Jong et al. 2008) Beginning 1947: disputed

    ownership of region, liberationstruggle between India andKashmiri militants

    (Continued)

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  • Table 2. (Continued).

    Location Authors

    Timeline, if given, &characterization of politicalviolence by authors

    Kosovo (Jones et al. 2003; Morina andFord 2008; Wang et al. 2010)

    19981999: war and inter-ethnicviolence

    Lebanon (Graham 2004; Hamieh andGinty 2010)

    2006: war between Hezbollahand Israel in Lebanon

    Mozambique (Garbarino et al. 1992) WarNepal (Tol et al. 2010) Beginning 1740: armed

    rebellions against autocratic rule,1950: armed insurrection, 1971:uprising, 19962006: armedinsurgency

    Nicaragua (Garfield et al. 1987; Tully1995)

    19361990: brutal dictatorshipfollowed by US financed civilwar

    North Americaindigenous lands

    (Evans-Campbell 2008) Community massacres, genocidalpolicies

    Pakistan (Yusufzai 2008) 2005: US-led war on terrorPalestine (Barghouthi and Giacaman 1990;

    Giacaman et al. 2003; Segalet al. 2003, Giacaman et al.2004; Graham 2004; Shalhoub-Kevorkian 2006; Giacaman et al.2007a; Weizman 2007; Barber2008)

    Most of last century, continuinginto twenty-first century;ongoing political conflictcombined with invasion in 2002

    Peru (Snider et al. 2004; Pedersenet al. 2008)

    1980s, early 1990s; civil war;aggression by both radicalMaoist group and Peruvianmilitary, including torture,murder and forced displacement

    Somalia (Menkhaus 2010) 19911992: state collapse, civilwar; 19931995: armed conflict,20072008: external intervention

    South Africa (Turshen 1986; Yach 1988) 19601984: apartheid policies,stripping of citizenship, 19851986: outbreak of violencerelated to apartheid policies

    Sri Lanka (de Jong et al. 2002; Reilleyet al. 2002)

    19832002; civil war, armedethnic conflict

    Yugoslavia (Basoglu et al. 2005b) WarZimbabwe (Keller et al. 2008) Beginning 2007; state-sanctioned

    torture and political repression

    Note: On locations reported on by multiple authors: If authors studied different time periods/con-flicts in same place, separate lines are used. Otherwise, dates and characterization of conflicts usecombined information.

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  • Distrust, isolation, and withdrawal are consequences of political violence.Robben (2005) reported that political violence in Argentina inhibited individualsfrom interacting with others for collective purposes. Withdrawal, suspicion,mistrust and isolation of members from larger community and social life due topolitical violence were reported by Esparza (2005), Lykes et al. (2007) and Floreset al. (2009), who each examined political violence in Guatemala. Withdrawal,distrust and isolation were also reported from an array of research locations,including Dillenburger et al. in Ireland (2008), Snider et al. in Peru (2004), Skid-more in Burma (2003), and Jenkins (1991) research among refugees from ElSalvador. Morina and Fords research in Kosovo found 34.3% of participantsreported symptoms of damaged relationships, including distrust and withdrawal(2008). De Jong et al.s research in the Indian Kashmir Valley (2008) found isola-tion, aggressive behaviour, and ceasing to speak to people were the mostcommonly reported mechanisms used by respondents to cope with politicalviolence (64.1%, 46.1%, and 36.9%, respectively), far above seeking supportfrom family (12.4%) or talking to others (22.9%). Findings of isolation, mistrustand withdrawal resulting from political violence is consistent with scholars con-clusions that mental health problems resulting from political violence rupturepeoples ability to access help from their social environments (de Zulueta 2007).

    Political violence diminishes individuals trust in the moral organization ofsociety, government entities and processes of democracy. Lykes et al.s studyin Guatemala found the complicity of peoples own governments in politicalviolence decreased individuals trust towards community and organizationalprocesses (2007). This was also found by Flores et al. (2009) in Guatemalaand Tully (1995) in Nicaragua, who reported distrust in institutions and sys-tems of justice arose from political violence. Basoglu et al. (2005c) found thetrauma of war in Former Yugoslavia was compounded by participants percep-tions that those responsible were not brought to justice. This conviction wasassociated with a drop in survivors belief in the basic goodness of people anda just order. Dillenburger et al.s (2008) study of political violence in Irelandfound lasting bitterness among people towards larger society fueled byviolence and the perception that perpetrators were not held accountable. Thisdiminished belief in goodness of people and a just order, in turn, reducedpeoples belief in democracy.

    Political violence lessens the willingness of individuals to engage in politi-cal activities, including community organizing. Lykes et al. (2007) foundMayan peasants in Guatemala targeted with violence due to their political orga-nizing reported a preoccupation with defeatist and negative thoughts aboutcommunity organizing as a result of political violence. Robben (2005) foundthat in Argentina torture was used against individuals to deter them frompolitical engagement. Individuals may curtail social action to try to protectthemselves from political violence, as reported by Skidmore in Burma (2003)and Esparza in Guatemala (2005). And, this disengagement may indeed offerpsychological protection against the traumas of political violence, as found in

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  • Jones (2002) examination of political violence and engagement in politicalprocesses in Bosnia Herzegovina.

    Influence of political violence on community functioning

    Community is usually defined as a network of connexions, often centred in aphysical location, that encompass shared beliefs, circumstances, concerns andrelationships (Chaskin, 2001). Community strength and connectedness is essen-tial for the health and well-being of individuals, particularly when they areexposed to massive human tragedies (Hobfoll et al. 2007; Ungar 2011a). Schol-ars propose communities function well due to collective efficacy, a combinationof social cohesion, and the ability of the collective to operate as a unit that canaffect change for the common good (Sampson 2003, 2006). Political violencenot only lessens individuals abilities to act within their communities, it alsoundermines the social foundations of a society (Summerfield 2000), rupturingsocial fabric (collective histories, identities and values (Pedersen 2002)) andoften engendering collective senses of fear (Bar-Tal et al. 2007). Studies revealpolitical violence deteriorates community functioning and social fabric by: (1)damaging community as a shared physical location of people, culture and iden-tity through mass killings and displacement, destruction of meaningful places,and control of space and movement; and (2) changing the overall climate andfunctioning of communities through instillation of collective fear and terror,destruction of networks, and diminishment of community organizing activities.

    Mass killings were reported by Oslender in Colombia (2007), Duli inCroatia (2006), and Jenkins in El Salvador (1991). Lykes et al. (2007) reportthat in Guatemala, more than half of those killed were murdered in groupmassacres aimed at destroying the whole community. Pedersen et al. (2008)and Snider (2004) each conclude that in Peru, mass graves serve as visualreminders the target was not an individual but masses of people. Disappear-ances were reported by Robben (2005), Tully (1995) and Jenkins (1991) inArgentina, Nicaragua, and El Salvador, respectively. Massive displacement andmigration due to political violence diminishes local and national networks,with scholars estimating the majority of the worlds 12 million refugees and 22to 25 million internally displaced persons are fleeing political violence(Pedersen 2002; Sidel and Levy 2008). Massive displacement, internal andoutward migration were reported as consequences of political violence byDillenburger et al. (2008), Carballo et al. (2004), de Jong et al. (2002),Pedersen et al. (2008), Ugalde et al. (2000), and Jones and Kafetsios (2005) intheir studies in Ireland, Bosnia, Sri Lanka, Peru, El Salvador and Zimbabwe.Evans-Campbell (2008) concluded forced displacement of American Indianchildren into boarding schools, adoptions and foster care has lasting conse-quences for communities, including loss of language, traditional practices andpotential future leaders, ultimately jeopardizing the ability of a community toenvision or plan its collective future.

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  • Physical environments nurture communities by facilitating and rootingrelationships and fulfilling needs for safety, comfort, and collective identity,history, and pride (Low and Altman 1992; Fullilove 1996). These are centralto the dynamic relationship between person and environment, mutually consti-tuting entities (Kemp 2010). Violich (1998) concluded physical destructioncaused by political violence in Croatia diminished the sense of unity and col-lectivity. Coward, who examined the destruction of urban spaces (or urbicide)in Bosnia within political violence, concluded there is a certain kinshipbetween urbicide and genocide; physical destruction is intimately related tocultural destruction of peoples (Coward 2004). Acts of political violenceinclude the demolition of homes and businesses and the destruction of entirevillages. Giacaman et al. (2004) reported 31% to 87% of homes or businesseswithin the five villages studied in Palestine were destroyed due to Israeli inva-sions. Lykes et al. (2007) reported that in Guatemala, acts of political violenceincluded destruction of more than 400 villages.

    Destruction of meaningful places representing community, culture andreligion is an assault against collective identity. Sacred sites include places ofcommunal space or land with shared historical and religious meaning; closures,take-overs and bombings represent particular, deliberate wounds to the culturaland spiritual lives of the community, as Coward (2004), Gregory (2008) andViolich (1998) found in Bosnia, Iraq and Croatia. Trauma to sacred sites mayinclude denigration of the land itself through dumping of hazardous materials,as noted by Evans-Campbell research with American Indian and AlaskaNative populations (2008). Destruction of collective land may be particularlyharmful for indigenous populations whose attachment to the land may repre-sent particular sets of social relations, as Lykes (1997) found in Guatemala.

    Control of physical space and the populations therein is a primary objectiveof political violence (Graham 2004; Gregory 2008). In Feldmans (2003) studyof urban geography in Ireland, findings showed one-way streets and cul-de-sacs,roads with no escape where fighting parties are easily trapped, are fundamental tothe militarization of space. Segal et al. (2003), Weizman (2007), Gregory (2008),Skidmore (2003) and Turshen (1986) found in Palestine, Iraq, Burma, and SouthAfrica that military roads, checkpoints, barricades, and networks symbolize andactualize control over territories where populations were previously free to movethrough space. This included the forced movement of communities into enclaves,Bantustans, and reservations in Palestine, South Africa and North America (Tur-shen 1986; Shalhoub-Kevorkian 2006; Evans-Campbell 2008). In Skidmores(2003) research in Burma, control over space, beyond practical and immediateconsequences, is also described as symbolic violence and aggression with theintent to disorient a population and engender fear and terror. Giacaman et al.(2007b), Shalhoub-Kevorkian (2006), Pedersen et al. (2008), Jenkins (1991),Gregory (2008), and Tol et al. (2010) found in Palestine, Peru, El Salvador, Iraqand Nepal, constant control and surveillance of space through blockades, check-points, and roadblocks not only curtailed physical activities (access to health care

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  • and education, economic trade) but activities of community (interactions andcreations of ease, comfort, familiarity, ownership).

    Political violence changes the overall climate and functioning of communi-ties through instilling a collective sense and generalized climate of fear, asreported in studies of political violence from Nicaragua, Colombia, Guatemala,Burma and El Salvador (Tully 1995; Skidmore 2003; Lykes et al. 2007; Oslen-der 2007; Flores et al. 2009). Work on intergroup conflict makes clear that polit-ical violence affects collective emotional orientations, or cultural frameworks,such as collective fear or collective hope. The collective sense of hope is clo-sely linked to resilience and the potential for peace in the face of political vio-lence; in contrast, collective fear and collective hatred further entrench conflictand violence (Bar-Tal 2001; Bar-Tal et al. 2007). In addition to fostering theconflict, collective terror is also deliberately deployed to control populationswithin political violence, as research by Jenkins (1991) in El Salvador and Skid-more (2003) in Burma each concluded.

    The destruction of networks that are central to the well-being of bothindividuals and collectives is another way in which the overall functioning ofcommunities is threatened. Scholars of political violence in El Salvador andArgentina concluded political violence deliberately destroys relationships, socialties and networks (Martn-Bar et al. 1994; Robben 2005). While other authorsdo not characterize the destruction of networks as an overt act of political vio-lence, studies by Pedersen et al. (2008), Jones et al. (2003), and Dillenburgeret al. (2008) in Peru, Kosovo and Ireland found destruction of networks was theultimate result.

    Finally, political violence diminishes the number, and strength, of commu-nity organizations and organizing activity, as reported in research by Skidmorein Burma (2003) and Esparza (2005), Flores et al. (2009), and Lykes et al.(2007) in Guatemala. Increased collective resignation and passivity, defeatistthoughts about moving forward, and failure to speak out against furtherrepression were reported by Pedersen, Kienzler, and Gamarra in Peru (2010).In Lykes et al.s research in Guatemala, more than half of respondents indi-cated unity and social mobilization existed only a little bit or not at all (Lykeset al. 2007). Diminished organizing activity is often accomplished throughtargeted killings, surveillance and repression aimed at individuals or geographicareas suspected of community organizing, particularly university students andprofessors and community leaders, as reported by Keller et al. (2008), Floreset al. (2009), Skidmore (2003), Snider (2004), and Wang et al. (2010) ofpolitical violence in Zimbabwe, Guatemala, Burma, Peru and Kosovo.

    Political violence & governmental functioning

    The freedom, pluralism, accountability and trust inherent within functioningdemocracies support individual development and well-being, particularly withincases of mass disasters such as political violence (Melton and Sianko 2010;

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  • Garbarino 2011). In a more practical sense, individuals depend on governmen-tal structures to provide opportunities for meaningful participation and to fulfilbasic requirements of health and well-being, such as systems for emergencyresponse, water, sanitation, health and schooling (Flores et al. 2009; Meltonand Sianko 2010). Political violence is intimately related to several areas ofgovernance, including leadership, freedom of the press, and accountability bygovernments for atrocities (de Jong 2010). The literature suggests that politicalviolence deteriorates the functioning of governments and its consequent abilityto support the populace in three ways: (1) by deteriorating government systemsnecessary for daily living; (2) by weakening the public sector; and (3) bydestroying democratic processes.

    Well functioning public utility systems ensure public health. Studies donein El Salvador, Iraq, Afghanistan, Lebanon, Sri Lanka and South Africa foundeffects of political violence include the destruction or neglect of public utilitysystems (sewage, electric and water) and infrastructure like roads and bridges(Yach 1988; Ugalde et al. 2000; Reilley et al. 2002; Coward 2004; Salvage2007; Gregory 2008; Hamieh and Ginty 2010). Graham (2010) concludedattacks on physical infrastructure needed for water and electricity networks inGaza, the West Bank, Lebanon and Iraq represent an underlying aim tode-modernize whole societies. The damage to medical systems due to politi-cal violence has a host of consequences, including increased infectious disease(Beyrer 1998; Reilley et al. 2002; Gayer et al. 2007) and problems in vaccina-tion services (Centres for Disease Control and Prevention (CDC) 2003; Herpet al. 2003). Damage is incurred through deliberate targeting of or collateraldamage to health centres, as reported by Ityavyar and Ogba (1989), Farmer(2004) and Yusufzai (2008) in Africa, Haiti, and Pakistan, respectively. Peder-sen (2002) reported this damage in Mozambique, Nicaragua, and Peru. Salvage(2007) reported deterioration of health systems resulting from political violencein Iraq through material destruction of clinics and a reduction in supplies,equipment and drugs necessary for healthcare provision. Medical personnelhave also been explicit targets of political violence in Afghanistan, Guatemala,Pakistan, Zimbabwe, the Philippines, Iraq, El Salvador, Nicaragua, Croatia,Bosnia, Palestine and Kashmir (Garfield et al. 1987; Pedersen 2002; Kelleret al. 2008; Yusufzai 2008; Acerra et al. 2009; Flores et al. 2009). Basu(2004), Farmer (2004) and Simunovic (2007) correlate political violence to theshortage of healthcare workers in Haiti, Iraq and Bosnia and Herzegovina.

    In addition to physical infrastructure for healthcare, strong and responsivegovernmental systems are needed for health and well-being of populations(Katz 2001; Farmer 2004; Pfeiffer et al. 2008). However, political violencecontributes to the deterioration of public sector and governments ability toprovide for citizenry, creating governance voids (Cliffe and Luckham 2000).It draws funds away from health and social services (Sidel and Levy 2008),and diminishes resources for health sectors, as reported by Ityavyar and Ogba(1989) in research throughout Africa, by Ugalde et al. (2000) in El Salvador,

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  • where the healthcare budget was reduced by 50%, and by Farmer (2004) inHaiti, where in 2004, the newest medical school was turned into a militarybase for foreign troops. De-investment in the public sector as a part of politicalviolence has been reported by Barghouthi and Giacaman (1990) in Palestineand Hamieh and Ginty in Lebanon (2010). Iraq is an example of a countrywith strong investment in the public mental health system prior to the invasionthat now has virtually no plan for a government system of control or regulation(Hamid and Everett 2007). Cliffe and Luckham (2000) and Pedersen (2002)report tensions are common with outside experts who have little understand-ing of the historical and political context of the area yet take control ofrecovery. This usurpation of control threatens government power as itdecreases coordination and increases inefficiency and corruption, as reportedby Simunovic (2007), Menkhaus (2010), Giacaman et al. (2003), Ugalde et al.(2000), and Salvage (2007) in Bosnia and Herzegovina, Somalia, Palestine, ElSalvador and Iraq. Some reports charge the politics of outside aid within situa-tions of political violence go beyond tensions over turf; rather that aid isdeliberately used within political violence to manipulate and control govern-ments or populations and to threaten sovereignty (Giacaman et al. 2003;Jacoby and James 2010; Menkhaus 2010).

    Representation and inclusion of populations in decision-making processesof government are essential for well-being (CSDH 2008). Governmental sys-tems that uphold the principles of democracy and accountability foster individ-ual development and nurture well-being (Melton and Sianko 2010; Garbarino2011). However, political violence undermines participation, as governmentsare weakened due to external targeting or turn against their own citizens. Theaim of political violence perpetrated by peoples own governments is often toweaken political opposition, as reported in Guatemala, Argentina and Burma(Preti 2002; Skidmore 2003; Robben 2005). Political violence often leaves astate void of institutions to protect its populace. There are also numerous exam-ples of political violence wherein state institutions are the aggressors, asreported by Lykes et al. (2007), Menkhaus (2010) and Farwell and Cole (2001).Literature from Peru, former Yugoslavia, El Salvador and Guatemala reveals thehigh prevalence and effects of governments denial of atrocities and lack ofaccountability for the wrong-doings during political violence in these locations(Martn-Bar et al. 1994; Preti 2002; Basoglu, Livanou, and Crnobaric 2005a;Lykes et al. 2007).

    Discussion

    This review summarized literature on the effects of political violence, empha-sizing the ways in which it impairs and dismantles collective functioning,which in turn threatens individual well-being. Findings were discussed withrespect to how political violence affects an individuals ability to participate insocial and political life; how community functioning is lessened; and how the

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  • functioning of government and its official bodies is undermined. Figure 2illustrates the effects of political violence in each domain of inquiry, followingthe findings detailed in the review and seen in Table 1.

    Findings of various studies suggest well-being across domains isinterdependent; often the weakening of one area (for instance, governmentalfunctioning) affects another in turn (for instance, individuals willingness toengage in political life) (Figure 2). Studies by Robben (2005) and Skidmore(2003) found that, as individuals are less able to act as part of a collective dueto mistrust and isolation stemming from political violence, community func-tioning suffers. Individuals are less able to take part in community activitieslike organizing. Lykes et al. (2007) found that, as community functioningdeteriorates (due to displacement, fear and terror, and destruction of socialnetworks), isolation and mistrust increases. Additionally, Esparza (2005) foundthat, as individuals become less willing to hold governments accountable andare less trusting of governments and processes of democracy, government func-tioning deteriorates. Governments are also less accountable to individuals andhave inadequate physical and organizational infrastructure to ensure well-beingof society (Ugalde et al. 2000).

    Figure 2. Effects of political violence on domains of collective functioning.

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  • While most of these studies detailed the negative effects of politicalviolence, one alternative hypothesis that should be presented is the notion thatpolitical violence might actually incite positive growth to the benefit of thecollective, as it encourages what has been referred to on the individual level aspost-traumatic growth (Linley and Joseph 2004). For instance, scholars havenoted that political violence inspires communities to come together for thepurposes of resistance and collective demands for justice and accountability;thus, particularly in the responses, political violence may increase politicalinvolvement and build both individual and collective empowerment (Lykeset al. 2007; Punamki 1990; Stewart 2008). In addition, as noted in the intro-duction, political violence and structural violence are quite intertwined, usuallyco-occurring and sometimes co-precipitating. Further research is needed todetermine how they interact and which might be the driving force of thecollective injury within the context of political violence, and therefore perhapsthe most salient point of intervention (see, for instance, Miller et al. 2010).

    Implications for Further Research

    Findings of this review provide implications for research. Specifically, there is aneed to (1) examine health effects of political violence across multiple, interde-pendent areas of influence; (2) collect and refine indicators of collective func-tioning, especially those that may be effected by political violence; and (3)continue to develop and improve multilevel conceptual models that representthe diverse effects of political violence on health across and within levels. Theseare discussed below and then implications for policy and practice are explored.

    First, the notion that areas of influence interact with one another is in linewith theories that assert well-being rests on the mutual exchange between aperson and his or her environment (Brofenbrenner and Morris 1998, in(Bronfenbrenner and Evans 2000)). This theory of mutual exchange betweenperson and their environment also resonates with scholars of political violencewho assert it acts on multiple areas simultaneously (Martinez and Eiroa-Orosa2010). Thus, research frameworks that examine simultaneous consequences ofviolence within multiple areas of influence will provide more nuanced under-standings of political violence (for expanded discussions and examples of this,see Evans-Campbell 2008; Cummings et al. 2009; Dubow et al. 2010;Panter-Brick 2010; Tol et al. 2010, as well as the 2010 special issue of SocialScience and Medicine on conflict and health).

    Second, future studies should seek to develop or refine indicators of collec-tive functioning. Findings from this literature review suggest indicators offunctioning relevant to understanding the problem of political violence onlevels beyond the individual (de Jong 2010). Creating, testing and refiningmeasures of the areas of collective functioning on which political violencewould be a useful next step in understanding the problem. Table 3 providessuggestions to this end.

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  • Third, this paper provides a preliminary conceptual model for identifyingsome of the effects of political violence on relationships between domains ofcollective functioning that underlie health. Future research might investigatethis further and refine conceptual models that examine the effects of politicalviolence on mutually created domains of collective functioning. It would be ofparticular use if these models or future research on political violence examinedthe relationship between community functioning/social fabric and governmentalfunctioning, as this review of the literature did not find studies that proposedor explored this relationship. Research might also add domains, such as familyfunctioning, to models of collective effects of political violence (Garbarino andKostelny 1996; Qouta et al. 2006; Haj-Yahia 2007). Future models might alsotake a more positive focus and attend to resiliency or protective factors withinpolitical violence across multiple levels of functioning, as socioculturalprocesses, community resilience, and civic and political engagement all appearto build endurance in the face of political violence (Jenkins 1991; Qouta et al.1995; Khamis 1998; Barber 2001; Norris et al. 2008; Nguyen-Gillham et al.2008; Nuwayhid et al. 2011; Sousa et al. 2013; Zraly and Nyirazinyoye 2010).

    Findings from this review suggest a few implications for policy andpractice. In light of the far-reaching effects of political violence demonstratedin this review and elsewhere, prevention of political violence itself should be

    Table 3. Conceptualizing indicators of collective functioning.

    Participation in social &political life

    Community functioning &social fabric Governmental functioning

    Involvement incommunity activities,political activities

    Willingness to aid incommunity & politicalactivities

    Confidence in ability toaffect change incommunity & politicalsphere (efficacy)

    Level of trust incommunity &government

    Physical safety ofcommunity

    Physical stability ofcommunity

    Freedom of movement Community Develop-

    ment Initiatives (led bycommunity, notoutsiders)

    The number of and trustwithin communityinstitutions (healthcenters, cultural groups,etc)

    Collective space &place as locations ofgrowth, safety andcommunity

    Individuals perceptionsof community cohesion

    Non-violent government Democratic government

    (existence of civil,political and social rights)

    Strong systems foreducation, healthcare andsocial security ingovernment hands;decreasing amount ofoutside control

    Legitimate modes ofholding perpetratorsaccountable andmemorializing the trauma

    Individuals perceptionsof government function-ing and accountability

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  • prioritized, as pointed out by other health scholars (Hagopian, Ratevosian, andDeriel 2009; de Jong 2010). In terms of secondary or tertiary prevention, orrecovery from or management of effects of political violence, an increase inknowledge of the collective effects of political violence is particularly salientfor mental health professionals focusing on conflict zones. Researchers havesuggested sound collective social and political functioning plays a positive,protective role in the mental health of those who have experienced politicalviolence (Farwell and Cole 2001; de Zulueta 2007). Equally important is theability of individuals to aid in the rebuilding of social and political arenas oftheir societies after political violence through active participation, whichnecessitates trust and the ability to work collectively (Hernndez 2002).Understanding, then, how political violence affects both individuals and thesocial and political systems on which their health and well-being depend willhelp us to identify potential targets for multilevel policy and practiceinterventions (for examples of this, see Robben 2005; Laplante and Holguin2006; Hoffman and Kruczek 2011).

    Recovery from the effects of political violence happens not only in theworld of the individual, but also in their social and political worlds (Almedomand Summerfield 2004). By focusing on political violence and collective well-being, this review illustrates the potential for multilevel frameworks that movebeyond individual pathology to develop more nuanced conceptualizations ofthe health problems resulting from political violence. This increasedunderstanding holds the potential to help to develop and implement treatment,intervention and prevention programmes and policies that address the influenceof political violence on health across multiple levels of functioning.

    Note on contributor

    Cindy A. Sousa is an assistant professor at the Bryn Mawr College GraduateSchool of Social Work and Social Research, where she leads and teaches inthe Community Practice, Policy, and Advocacy concentration and teachescourses in health and global social work. Cindys research centres on the healtheffects of violence, stress, and trauma-particularly collective forms of traumaas with disasters, war, and political/state violence. She is especially interestedin models that reflect dynamic and cumulative processes of trauma andresiliency wherein individual, family, community, and structural experiencesintersect. Cindy has a number of publications based on her work, includingarticles in the journals Trauma, Violence and Abuse, The Journal of Interper-sonal Violence, and Global Public Health. Cindy is currently researching onpolitical violence, health, and resilience among Palestinian women, usingoriginal quantitative and qualitative data collected in collaboration with thePalestinian Medical Relief Society.

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  • AcknowledgementsThe author wishes to acknowledge Todd Herrenkohl, Susan Kemp, Taryn Lindhorst,David Takeuchi, Tracy Harachi and Amy Hagopian for their thorough edits andthoughtful assistance with the preparation of this manuscript. This research was fundedin part by NIMH Grant T32MH20010.

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    14:

    13 2

    9 N

    ovem

    ber

    2014