Ethnocultural Aspects of PTSD

At the outset of this book, I made the point that trauma is a near universal human experience. But as I have just finished saying, psychologists are increasingly questioning the concept of universality. Is trauma a universal experience? Can all human beings be psychologically traumatized? Some researchers argue that the very concept of psychological trauma is culturally constructed and, therefore, might be very different from one ethnocultural context to another. In fact, the very existence of psychological trauma might be called into question. For example, in Israel during its long history of military conflict and turmoil, there was a point in time in which the concept of psychological trauma was considered virtually nonexistent. Amidst the struggle for national survival and growth, the government and military establishment seemed to not have time for the concept of trauma. They were too busy building and defending a country. Israeli Brigadier General, Dr. M. Kordova was quoted as saying, "We do not have this problem and cannot afford this 'American luxury'" (cited in Witzum & Kotler, 2000, p. 106). The point is that the concept of psychological trauma cannot be taken for granted across ethnocultural contexts. Etiology, symptom development, symptom expression, and eventual treatment are all potentially variable across ethnocultural contexts.

However, consideration of ethnocultural variables does not automatically imply that universals do not exist. Stamm and Friedman argue that, "all humans have the capacity to experience and express fear, helplessness, or horror when exposed to traumatic stress" (2000, p. 70). My position for the purpose of the CGPTSD is the same. Despite ethnocultural variation in the etiology, development of, and expression of psychological trauma, all human beings possess the capacity to meet the Criterion A2 in the DSM-IV-TR. Variation might arise when addressing specific stressors or stimuli, of course. Further, Stamm and Friedman (2000) argue that all humans must have or possess an ability to cope with stress. Characteristic responses of stress reactions related to the psychobiological response of fight or flight are also considered universals from their perspective.

Certainly in the United States, psychological trauma is understood primarily from a mental health perspective in the form of PTSD. Posttraumatic Stress Disorder symptoms have been identified in various other ethnocultural contexts, such as Southeast Asia and Central America. But is the American construct of PTSD the best way to conceptualize the psychological impact of traumatic stress for individuals of various other ethnocultural groups?

Remember again from Chapter 1 that acceptance of the PTSD construct into the official nomenclature of modern psychiatry and clinical psychology was dependent on the recognition that PTSD actually existed as a distinct clinical entity. In other words, the mental health community finally acknowledged the reality of psychological trauma. Posttraumatic Stress Disorder was formally recognized as a distinct set of reactions in response to exposure to a traumatic event or events. However, working from an ethnocultural perspective, the reality of PTSD once again comes into question.

Consider this; just as everyone exposed to a traumatic stressor does not develop PTSD symptoms, not everyone exposed to such stressors develops the PTSD symptoms outlined in the DSM-IV-TR. That being said, there is a consensus that exposure to traumatic stressors may result in pathological reactions of both an acute and chronic nature even if there is variation in the expression of posttraumatic reactions and even if they do not map neatly onto the DSM-IV-TR PTSD concept.

Research has consistently documented ethnocultural variations in PTSD in the following areas:

Perceptions of threat and subjective experience of traumatic stressors

Etiology

Expression of symptoms

Comorbidity

Course

Outcome

Treatment

Marsella, Friedman, Gerrity, and Scurfield (2001) focus the ethnocultural study of PTSD on the following questions:

1. Is the PTSD construct valid across cultures?

2. Can PTSD be accurately diagnosed across ethnocultural contexts?

3. Are there ethnocultural variations in the rates and distributions of PTSD?

4. Are certain ethnocultural groups at greater risk for the development of PTSD?

5. Does culture impact interpretations of trauma and responses to it?

6. Is there variation in responses to various forms of treatment, including pharmacological treatment?

7. Is it possible to render successful treatment independently of the patient's cultural construction of their illness experience, or are there alternative therapies that may be more appropriate for particular groups?

If the clinical goal of identifying and treating psychological trauma is to be accomplished, we have to know how to see it (diagnosis of PTSD) and fix it (treatment of PTSD). I often ask my students in my abnormal psychology course, "How do you know a depression when you see it?" After the puzzled looks fade a little, they usually begin to list the perceivable manifestations of depression. The same goes for PTSD, and for the purposes of this chapter, the questions are asked, "When working with clients of varying ethnocultural backgrounds or across ethnocultural backgrounds, how do you know PTSD when you see it?" and "How do you know a posttraumatic reaction of a pathological nature when you see it?" A patient may come to you with a presenting problem and symptom presentation (e.g., somatic complaints) that fails to conform to your DSM-IV-TR conceptual schema. Yet they may describe to you an experience similar to Criterion A2 in the DSM-IV-TR for traumatic stimuli. If you lack the necessary skills or knowledge to work from an ethnocultural perspective, you may very well fail that particular patient.

In this journey to grasp the ethnocultural manifestations of PTSD, keep in mind that it is a process that oscillates between the identification of universals and variations. For instance, research continues to show intense posttraumatic symptoms across a wide range of cultures: Sri Lankans exposed to civil war (Somasundaram, 2004); civilian survivors of the war in Afghanistan (Scurfield et al., 1993); and volcano eruption survivors in Colombia (Lima, Pai, Santacruz, Lozano, & Luna, 1988). These are just a few examples of the universality of posttraumatic reactions. But variations exist nonetheless.

Epidemiological Issues

The International Federation of the Red Cross (IFRC) produces a "World Disaster Report," detailing both human-made and natural disasters across the world. Generally speaking, their data have shown that disaster is a common traumatic stressor across cultures but there are geographic variations as well. The following is the distribution of disasters across global regions:

Asia 42 percent (of global totals)

Americas 22 percent

Africa 15 percent

Europe 15 percent

Oceania 6 percent

Disasters tend to be more frequent in the most economically disadvantaged regions. These regions are also more severely impacted by disaster. The safety net of government protection and nongovernmental organizations is weaker and less developed. From 1967 to 1991, 117 million people in developing countries were affected by disaster compared to 700,000 in developing countries (de Giro-lamo & McFarlane, 1996). Some research has suggested that population density in hazard-prone areas (e.g., housing in flood plains) contributes to this imbalance. These statistics strongly suggest that one's geographic and subsequent national locale can increase one's risk of developing PTSD as a consequence of exposure to disaster.

We've seen that the frequency and impact of disasters vary across the globe, but what about other forms of traumatic stress, for instance, violence? Certainly, by almost any formal measure of violence, there are some ethnocultural contexts or societies that are more violent than others, especially when it comes to war. The IFRC estimates that approximately 40 million people have been killed in wars and conflicts since World War II. Developing countries, again, experience a disproportionate number of wars. There is also the usual consequence of refugees in war-torn regions with its high levels of distress due to displacement. Violent deaths appear to be a more common and prevalent cause of death in developing countries.

Identification and Assessment Issues

The following are some general findings in understanding the relationship between culture and PTSD (de Girolamo & McFarlane, 1996):

Level of acculturation is an issue with respect to diagnosis and symptom manifestation.

The stress of minority status can possibly complicate PTSD and treatment issues such as compliance (e.g., bicultural identity, racism, language issues, mistrust of members of majority culture, stereotypes, etc.).

The degree to which persons identify with their apparent ethnocultural group is an issue.

Researchers addressing the diagnosis and assessment of PTSD across ethno-cultural contexts have concluded that there is a generally accepted biological response to traumatic events of psychophysiological activation and disregulation in adrenergic, opioid, and hypothalamic-pituitary-adrenal axis (HPA-axis) functioning, with a variety of symptoms that cut across cultures. But as this response may not vary, there may be considerable variation in recognizable expression of symptoms. Concepts of self, personhood, social systems, concepts of health, and concepts of disease all mediate the expression of posttraumatic reactions. For example, there appears to be considerable variation in the occurrence of avoidance or numbing and hyperarousal symptoms.

Identification of posttraumatic reactions must take into account the idioms of distress that individuals of different ethnocultural contexts use to discuss problematic aspects of their lives and functioning. These are the words and phrases used to express their problems. They tend to be highly specific and idiosyncratic. It has long been known that non-Westerners use somatic or bodily complaints to discuss all sorts of problems not of a physical nature rather than using a more psychological language, for example.

Treatment Issues

One unmistakable feature of psychological trauma is its powerful push to be known. Judith Herman (1981) states that bearing witness to trauma is a key component in the healing process (for more on Judith Herman's treatment technique, see Chapter 15). People who are traumatized seem compelled to tell the story, as it were. I believe this urge to tell is an ethnocultural universal. As I was buying life insurance one day, the salesman told me he was from Uganda and had witnessed the brutal repression of Idi Amin. His pain was apparent despite his obvious strength and years of learning to cope in virtual silence. This simple gesture of telling me, a psychologist, of his past was an attempt at healing. He went on to talk about how he felt about the political system in the United States and how being from Uganda and witnessing what he had gave him such a different perspective. I believe his story illustrates the point that an individual who finds him- or herself growing up or living as an adult in a society and culture that is not congruent with his or her own cultural identity and experience may exhibit conflicts around issues of belonging, trust, safety, approach-avoidance, and isolation. The patient may find him- or herself thinking, "I'm all alone" or "Nobody understands me." These thoughts are common cognitive sequelae in PTSD and can serve to exacerbate symptoms and interfere with treatment.

Gusman et al. (1996) propose the use of their three-way mirror model as a therapy heuristic. This model purports to help with the interaction of multiple forms of self and social identification and traumatic variables and factors. It helps the clinician explore the connections between pretrauma, trauma, and the accumulation of life experiences both prior to and posttruama.

Pretrauma contexts include cultural practices, control, power, vulnerability, fear, relationships, intimacy, family, gender roles, sexuality, and religion. Trauma contexts and topics include attempts to suppress traumatic recollections in order to escape stress or anxiety, aggression as an attempt to gain control over the experience and emotions, and survival coping mechanisms that can be interpreted as appropriate during the traumatic experience but lead to maladaptive behavior in the long run. The final panel in the mirror refers to how the individual integrates these various components into his or her current functioning and behavioral repertoire.

Ultimately, this model is intended to help patients explore their self-concepts in relation to the trauma with respect to the many ways they identify themselves, be it nationally, ethnically, or religiously, for example.

Based on the work of Catherall (1989), Gusman et al. (1996) proposes that one possible outcome of trauma is a "disorder of the multicultural self." According to Catherall (1989) the two central clinical issues are outlined as (1) conflicts in self-integration and (2) the loss of self-cohesion. With the first issue, a patient does not suffer a loss of his or her sense of self, but the feelings and emotions associated with the trauma cannot be assimilated or tolerated. In the second issue, there is a misalignment between a victim and his or her social environment and his or her ability to assimilate or tolerate traumatic feelings and emotions, which results in additional problems with mistrust, alienation, identity disturbance, and interpersonal problems.

Kinzie (1978) proposes a model with three main principles to be used in cross-ethnocultural treatment. The first principle involves the appropriate use of the medical or psychiatric model of PTSD. A focus on the medical model is suggested because it is viewed as generic, value-free, and nonjudgmental and allows for the presentation of and acknowledgment of somatic complaints. Second, there must be recognition on the part of the clinician of the nonverbal modes of communication. Finally, the clinician must be sensitive and attentive to the subjective meaning-making processes of the patient. These general orienting or guiding principles are considered more important than the actual treatment techniques employed, as a technically valid treatment may be ineffective when presented in an inappropriate context.

Juris Draguns (2001) provides the following universal components of effective intervention in Posttraumatic Stress Disorder, which are suggested for all posttrauma treatment:

1. Intervene immediately or promptly after the traumatic event.

2. Focus on presenting complaints or current distress.

3. Use specific and possibly directive techniques.

4. Deal with any guilt or self-blame early and directly.

5. Experience and communicate empathy readily.

6. Strengthen the client's sense of competence, autonomy, and self-worth.

7. Help clients make sense of the traumatic event in the context of their lives (including culture).

8. Deal with any object losses early and directly.

Draguns (2001) augments this model with the following culturally variable components of intervention to work within an ethnocultural model:

1. Use of interpretations and their rationale and basis.

2. Extent and nature of verbal interaction between the client and therapist.

3. Role of verbal communication.

4. Role differentiation between client and therapist.

5. Respective weights of physical and somatic and psychological distress.

6. Role of ritual in psychotherapy.

7. Use of metaphor, imagery, myth, and storytelling in psychotherapy.

8. Nature of relationship between therapist and client.

With regard to psychopharmacological issues in treatment, research has shown interethnic differences in response to various psychotropic drugs. Differences have been found in the following:

Pharmacogenetics: the interplay between genetic factors in the metabolism of a particular medication

Pharmacodynamics: the mechanism of action of pharmacologic compounds affecting the physiological system

Environmental factors: variation that occurs when drugs are exposed to different diets, environmental toxins, and other drugs

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