Recovery from Posttraumatic Stress Symptoms: A Qualitative Study of Attributions in Survivors of War Dean Ajdukovic 1 *, Dea Ajdukovic 2 , Marija Bogic 3 , Tanja Franciskovic 4 , Gian Maria Galeazzi 5 , Abdulah Kucukalic 6 , Dusica Lecic-Tosevski 7 , Matthias Schu ¨ tzwohl 8 , Stefan Priebe 3 1 Department of Psychology, Faculty of Humanities and Social Sciences, University of Zagreb, Zagreb, Croatia, 2 Unit for Psychological Medicine, Merkur Teaching Hospital, University of Zagreb, Zagreb, Croatia, 3 Unit for Social and Community Psychiatry, Queen Mary University of London, London, United Kingdom, 4 School of Medicine, University of Rijeka, Rijeka, Croatia, 5 East London National Health Service Foundation Trust, London, United Kingdom, 6 School of Medicine, University of Sarajevo, Sarajevo, Bosnia and Herzegovina, 7 University School of Medicine, Belgrade, Serbia, 8 Department of Psychiatry and Psychotherapy, Technische Universitat Dresden, Dresden, Germany Abstract Objective: The study explored factors to which people traumatized by war attribute their recovery from posttraumatic symptoms and from war experiences. Methods: : In-depth interviews were conducted with two groups of participants with mental sequelae of the war in the former Yugoslavia: 26 people who had recovered from posttraumatic stress disorder (PTSD) and 17 people with ongoing symptoms of PTSD. Participants could attribute their recovery to any event, person or process in their life. The material was subjected to thematic analysis. Results: Eight themes covered all factors to which participants attributed their recovery. Six themes described healing factors relevant for both groups of participants: social attachment and support, various strategies of coping with symptoms, personality hardiness, mental health treatment, received material support, and normalization of everyday life. In addition to the common factors, recovered participants reported community involvement as healing, and recovered refugees identified also feeling safe after resolving their civil status as helpful. Unique to the recovered group was that they maintained reciprocal relations in social attachment and support, employed future-oriented coping and emphasised their resilient personality style. Conclusions: The reported factors of recovery are largely consistent with models of mental health protection, models of resilience and recommended interventions in the aftermath of massive trauma. Yet, they add the importance of a strong orientation towards the future, a reciprocity in receiving and giving social support and involvement in meaningful activities that ensure social recognition as a productive and valued individual. The findings can inform psychosocial interventions to facilitate recovery from posttraumatic symptoms of people affected by war and upheaval. Citation: Ajdukovic D, Ajdukovic D, Bogic M, Franciskovic T, Galeazzi GM, et al. (2013) Recovery from Posttraumatic Stress Symptoms: A Qualitative Study of Attributions in Survivors of War. PLoS ONE 8(8): e70579. doi:10.1371/journal.pone.0070579 Editor: Andrew H. Kemp, University of Sydney, Australia Received February 11, 2013; Accepted June 19, 2013; Published August 7, 2013 Copyright: ß 2013 Ajdukovic et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: This study was funded by a grant from the European Commission, contract number INCO-CT-2004-509175. The views expressed are those of the authors and not necessarily those of the European Commission. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist. * E-mail: dean.ajdukovic@ffzg.hr Introduction War and disaster related mental health consequences have been well documented, in particular posttraumatic stress disorder (PTSD) and depression [1]. Most research on correlates of war- related posttraumatic sequelae has focused on characteristics of the survivors (e.g. age, gender, education, employment status, prior experience with trauma, pre-traumatization mental health) [2,3,4,5,6,7,8,9] and characteristics of the traumatizing experi- ences (e.g. severity, proximity, number of events experienced) [10,11]. Such information can help to identify people at risk for developing severe mental health problems and for providing treatment and other forms of assistance to the survivors. War is the prototypical case of organized violence that challenges the basic human and moral categories, and questions the existential meaning of the self and others [12,13]. Consequently, war-related trauma typically involves a complex set of interpretations of the reasons for the distress and the consequences for their health. People attribute their recovery - or lack of it - by constructing the meaning of events based on their understanding of the cause of their distress and on their perception of the environment [14,15]. Mental health consequences of war can last several years after the ending of the conflict [16,17]. The post-war environment is typically unstable, often unsafe and lacks supportive mechanisms to help recovery from posttraumatic symptoms. This applies to both forced migrants [18,19] and people who stayed in the area of conflict [20]. Most people recover from trauma and, after some time, continue with their productive life [21]. Some receive PLOS ONE | www.plosone.org 1 August 2013 | Volume 8 | Issue 8 | e70579