Western Trauma Discourse

Running head: EXPOSURE TO WESTERN TRAUMA DISCOURSE

Western Trauma Discourse Exposure and Posttraumatic Symptoms among Burundians with

Traumatic Event Histories

Peter D. Yeomans, James D. Herbert, and Evan M. Forman

Drexel University

Author’s Note

Peter D.Yeomans, Department of Psychology, Drexel University; James D. Herbert,

Department of Psychology, Drexel University; Evan M. Forman, Department of Psychology,

Drexel University.

The authors wish to acknowledge Adrien Niyongabo, Ernest Ndayishimiye, and Jean-Marie

Nibizi, for their assistance in conducting this study. This paper is based on a Masters thesis.

Correspondence concerning this article should be addressed to James Herbert, Department

of Psychology, Drexel University, MS 988, 245 N. 15th Street, Philadelphia, PA 19102-1192.

(ph: 215-762-1692; fax: 215-762-8706). Email: jh49@drexel.edu

Word count: 5876

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Western Trauma Discourse

Abstract

Posttraumatic Stress Disorder (PTSD) has been increasingly applied in diverse cultural settings,

despite controversy over the degree to which the symptoms of PTSD are biologically based and

therefore relatively universal or are culturally constructed. We hypothesized that prior exposure to

Western trauma discourse would be associated with PTSD symptoms among indigent Burundian

trauma victims. Analyses indicated that exposure to Western ideas about trauma was predictive of

more severe PTSD symptoms, and yielded a predictive trend when controlling for quantity of event

types experienced. Despite severe trauma histories, the sample reported relatively low levels

ofPTSD symptoms. The implications of the findings in relation to the validity of the PTSD

construct in non-Western settings are discussed.

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Western Trauma Discourse Exposure and Posttraumatic Symptoms among Burundians with

Traumatic Event Histories

Western aid to impoverished countries has increasingly included mental health services

(Summerfield, 1999). Such services have also included intervention programs for the psychological

sequelae of trauma. Some scholars, however, have raised questions about the applicability of

Western models of traumatic stress response to the non-Western world (Kagee & Del Soto, 2003;

Summerfield, 2004). It is critical to examine the relevance and the effect of these models when

exported to cultures that may hold a different understanding of terror and loss.

Posttraumatic Stress Disorder

Posttraumatic Stress Disorder (PTSD) as a diagnosis was first recognized in the third edition

of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) (APA, 1980). Since its

inception PTSD has been embroiled in debate over multiple issues. Controversies include the

influence of the political climate in which it was conceived (Herbert & Forman, in press; McNally,

2004), the broadening definition of the range of events that qualify as traumatic stressors (McNally,

2004; Mol et al., 2005; Rosen, 2004), and the notion that traumatic memories can be actively

repressed such that they are inaccessible (Lynn, Knox, Fassler, Lillienfeld, & Loftus, 2004;

McNally, 2003). Researchers and clinicians also debate the degree to which the traumatic stress

response as identified by PTSD is largely biologically determined or culturally constructed.

Is PTSD a universal disorder?

Historical and cross-cultural research represent two methods for investigating the

universality of PTSD. Evidence in British military history suggests that the severity and nature of

posttraumatic reactions are largely the result of cultural forces (Shephard, 1999). Herbert &

Sageman (2004) point to the cultural evolution of traumatic stress symptoms from paralysis to

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mutism to trembling over the last one hundred years. Summerfield (2004) argues that PTSD is born

out of an era of presumed vulnerability over resilience as a normative reaction to traumatic events.

Whereas traumatic events destabilize people everywhere, the exportation of Western models of

PTSD to the rest of the world presupposes the construct’s applicability (Kagee & Del Soto, 2003;

Pupavec, 2002). The application of PTSD to foreign populations risks inadvertently pathologizing

people who might otherwise display significant resilience. A professional community’s expectation

of protracted symptomatology may be as much the agent of the perpetuation of posttraumatic stress

symptoms than the traumatic event itself. These dissenting perspectives suggest that caution should

be exercised in applying the PTSD model in non-Western cultures.

PTSD in Africa

A comprehensive review of PTSD prevalence rate studies found that only 6% of studies (8

out of 135) used samples from developing countries (De Girolamo & McFarlane, 1996). There is

predictably a paucity of data on the assessment of traumatic stress reactions in Africans in non-

Western countries. McCall and Resick (2003) found that 35% of a sample of Ju/’hoansi (Kalahari

Bushmen) of Namibia met criteria for PTSD; 85% reported at least some avoidance/numbing

symptoms, but not to the degree that DSM-IV criteria were met. Fox and Tang (2000) assessed a

sample of Sierra Leonean refugees in The Gambia and found that 49% of the sample yielded scores

indicative of PTSD. Eighty and 85% of the sample scored above the clinical cut-off levels for

anxiety and depression, respectively. Medicins Sans Frontières assessed for PTSD symptoms

among 245 Internally Displaced Persons (IDP’s) near Freetown, Sierra Leone, and found that 99%

of respondents had scores indicative of PTSD (Raymond, 2000). This study used the Impact of

Events Scale (IES; Horowitz, Wilner, &Alvarez, 1979), a measure not yet validated in this region of

the world, and that has been abandoned by other researchers after determining accurate translation

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to be unfeasible (Terheggen, Stroebe, & Kleber, 2001). Dyregrov, Gupta, Gjestad, and Mukanoheli

(2000) conducted a study one year after the Rwandan Genocide involving 1,830 Rwandan children.

Seventy-nine percent of the children exceeded the IES cutoff for PTSD. Some of the studies cited

above used supplemental measures to assess symptoms beyond the domain of PTSD while others

did not. The omission of an assessment of possible symptoms outside of the diagnosis of PTSD

risks failing to identify the full range of symptoms experienced.

A few studies have applied less structured interview techniques in an effort to capture a

breadth of symptoms. Paardekooper, de Jong, and Hermanns (1999) conducted semi-structured

interviews with 216 Sudanese children living as refugees and with 80 Ugandan children who had

not experienced war and flight. Sudanese refugees reported more traumatic events, more memory

disturbances, more worries about their future, and more suicidal ideation. Baron (2002) reported a

consistent pattern of anxiety, somatic complaints, depressive symptoms, estrangement from friends

and family, and loss of motivation to care for family and self among Sudanese refugees in Uganda.

Limitations of the current literature

The literature on traumatic stress reactions in people living in non-Western cultures is

limited and has yielded diverse results. The research to date has found highly variable prevalence

rates of PTSD and posttraumatic symptoms (Marsella, Friedman, Gerrity, & Scurfield, 1996). Many

studies suffer from various methodological limitations, including absence of back-translation, the

use of unvalidated measures, failure to assess symptoms beyond PTSD, the potential influences of a

pre-existing power imbalance between participant and researcher, social desirability, and the

possible benefits of secondary gain.

The effect of prior Western trauma discourse exposure

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In addition to these factors, we hypothesize that prior exposure to Western trauma discourse

(WTDE) may have inadvertent suggestive effects. Research has demonstrated that both direct and

indirect morbid suggestion can impact the nature of psychological symptoms (Beckman, 2003;

Rothman & Weintraub, 1995; Skelton, Loveland, & Yeagly, 1996). However, none of the studies of

PTSD reviewed above assessed the possible influence of prior exposure to Western

conceptualizations of the psychological response to traumatic events. Radio programs, written

literature, and psychoeducational workshops are potential sources of information as to how the

Western medical establishment conceptualizes traumatic stress reactions. Kagee and Del Soto

(2003) theorize that prior exposure to Western trauma discourse and its concomitant expectations

about protracted symptoms may increase the likelihood that posttraumatic symptoms will persist.

The present study aimed to examine whether prior WTDE would predict the nature and

severity of symptoms associated with response to traumatic events in a sample of rural Burundians

who had experienced traumatic events. We hypothesized that WTDE would be positively associated

with greater severity of PTSD symptoms, and that WTDE would be more highly associated with

PTSD symptoms than with general symptoms of anxiety, depression, and somatization.

Additionally, we predicted that material complaints and general psychological symptoms of anxiety

and depression would be more frequently endorsed than specific PTSD symptoms in response to an

open-ended interview.

Methods

Participants

Participants were recruited through a trauma healing and reconciliation program run by a

small nongovernmental organization in Burundi in central Africa. Following 30 years of

intermittent violence, a civil war erupted in 1993 between the mostly Tutsi government and Hutu

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rebel forces. As the two ethnicities lived interwoven in the same communities, widespread

neighbor-upon–neighbor conflict ensued, throwing entire communities into disarray. Studies

estimate that well over 200,000 people have been killed in the conflict since 1993 (AFSC, 2001).

Individuals who had been referred to the reconciliation program were invited to participate

in the study. Among the 78 participants, 28 (36%) were female and 50 (64%) were male. The mean

age was 37.7 years (SD = 13.6). Only 14% of the sample had completed more than six years of

education. The entire sample lived in a rural area in the north central region of the country

approximately 50 miles from the paved road connecting Burundi’s two largest towns. All

participants in this study had been directly victimized by violence during or since the civil war

began in 1993. The participants were referred to the workshop through a network of local elders

who identified them as experiencing ongoing distress related to traumatic events associated with the

civil war, with hopes that their distress would be ameliorated by the workshop. According to the

elders, the referred individuals were representative of the larger population of distressed individuals

in the community, and there was no reason to believe that they were particularly responsive to the

influences of Western trauma models. Participants received reimbursement for transportation

expenses, participated voluntarily, and gave fully informed consent to participate.

Participants were administered Part I of the Harvard Trauma Questionnaire (HTQ;

Mollica et al., 1992) to asses traumatic event history. Participants indicated whether they had

experienced, witnessed, heard about, or had no exposure to each event. The mean number of

types of events experienced was 9.5 (SD = 1.9) and the mean number of types of events

experienced, witnessed, or heard about was 16 (SD = 3.0). Events endorsed as directly

experienced included combat situation (100%), narrowly escaping death (78.2%), unnatural

death of a family member (71.8%), serious physical injury from combat (17.9%), and being

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forced to hide among the dead (12.8%). The sample had minimal formal education and limited

contact with Westerners. All had experienced one or more Criterion A events even by the

strictest of definitions.

Measures

All instruments were translated into Kirundi by native Burundian speakers with fluency in

both Kirundi and English who lived either in Burundi or in the United States. Burundian natives

then backtranslated the instruments and discussed refinements in a dynamic process with the

principal investigator.

Event history. Each participant’s history was collected using the HTQ (Part I), a 19-item

event checklist that specifies whether various traumatic events were directly experienced,

witnessed, or heard about. Mollica et al. (1992) report an interrater reliability of .93, internal

consistency of .90, and test-retest reliability of .89 for Part I of the HTQ.

Semi-structured interview of symptoms of distress. Using methods derived from Kagee

(2004), we utilized a semi-structured interview to assess symptoms associated with traumatic

response. Open-ended questions were used to solicit how each participant had been affected by a

self-identified “most-distressful” traumatic event. The central question was, “What are the main

problems that affect you as the result of those events?” (Wilk & Bolton, 2002; Kagee, 2004).

Secondary questions explored how participants remember the experience, what they associate with

it, and in what ways other people perceived them as different from prior to the experience. These

interviews in Kirundi were audio taped and then translated by the interviewer into English the same

day.

Interview responses were coded over a process of two reviews. In the first review, items

were categorized as to whether or not they represented a symptom of PTSD. In a second pass all

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remaining responses were sorted into other categories. Responses that had already been coded as

PTSD were not recoded into these additional categories, thereby effectively reducing the responses

that could have been considered for other symptom categories. The non-PTSD symptom categories

were derived by the first coder through a dynamic process in which categories were developed in

response to emerging themes in the data. A second coder was trained in the resulting categories and

the coding system. The second coder was then randomly assigned 25% of the data for coding. An

inter-rater reliability of 87.8% was calculated the percent agreement (i.e., dividing the number of

items agreed upon by the total number of items).

Quantitative symptom reports. The Hopkins Symptom Checklist-25 (HSCL-25; Hesbacher,

Rickels, & Morris, 1980) was used to assess symptoms of distress. The HSCL-25 was designed as a

self-report measure and uses a 4-point Likert scale (1 = not at all to 4 = extremely) for an anxiety

subscale (10 items) and a depression subscale (15 items). Given that somatic symptoms have been

reported as reactions to trauma in prior studies of non-Westerners (Marsella et al., 1996;

Paardekooper et al., 1999), the standard HSCL-25 was modified by adding the somatic subscale of

the HSCL-90 (Derogatis, 1994). The HSCL-25 total score can be used universally as a global

measure of emotional distress (Mollica, Wyshal, deMarneffe, Khuon, & Lavelle, 1987). When

matched to diagnoses based on clinical interview, the HSCL-25 has been shown to have a

sensitivity of .88 and specificity of .73 (Mollica et al., 1987), and internal reliability of .86-.95

across multiple languages (Kleijn, Hovens, & Rodenburg, 2001).

The Harvard Trauma Questionnaire (Part IV) (HTQ; Mollica et al., 1992) uses a 4-point

Likert scale (1 = not at all to 4 = extremely) to assess severity and nature of traumatic stress

symptoms. The HTQ – Part IV is a symptom checklist of PTSD symptoms as defined by the DSM-

III-R. Mollica et al. (1992) reported a sensitivity of .78 and a specificity of .65 when validated

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against results from a diagnostic semi-structured interview. Mollica et al. reported an interrater

reliability of .98, internal consistency of .96, and test-retest reliability of .92 at one week for Part IV

of the HTQ. The HTQ has been translated into multiple languages and consistently yields sufficient

reliability (internal reliability of .74-.89 in Russian, Serbo-Croatian, Farsi, and Arabic; Kleijn et al.,

2001).

Western Trauma Discourse Exposure. Participants were asked to report on the degree to

which they had experienced trauma psychoeducation workshops, radio programs, and written

materials. These data was coded according to a scale based on rankings by Burundian natives

assisting with the project. Each Burundian had received a list of the components of the WTDE

construct and was asked to rank them as indicators of exposure to Western models of

traumatization. Once the data was collected, a second coder was utilized as described previously.

An inter-rater reliability of 85.0% was calculated based on the percent agreement method. Media

contact was determined by summing the scores of both trauma-related radio contact and trauma-

related reading. Psychoeducational workshops were tallied independently.

Procedures

Interviews were conducted in Kirundi by two native Burundian staff. The principal

investigator was not present during the interviews but remained nearby to consult with staff in the

event of questions or ambiguities. Measures were administered verbally due to participant illiteracy.

The metric of the Likert scale was demonstrated visually with glasses containing varying degrees of

water (see Terheggen et al., 2001).

Each participant first endorsed traumatic event items on the HTQ – Part I. They then

responded to open-ended questions about current symptoms and prior Western Trauma Discourse

Exposure (WTDE). This was followed by the HTQ - Part IV, the three HSCL subscales, and a short

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sociodemographic form. The open-ended interview preceded the standardized measures to avoid

biasing participants’ reports with suggestions from these measures.

Results

Symptom reports

Anxiety, depression, and somatization. Mean scores on the HSCL subscales (anxiety,

depression, and somatization) are reported in Table 1. For the purposes of comparison, established

norms for various groups are also included (Derogatis, 1994). Anxiety and somatization were

markedly higher than found in a Western psychiatric inpatient sample, whereas depressive

symptoms were comparable to what would be found in such a sample. Mollica et al. (1987)

established a critical cutoff of 1.75 on the HSCL-25 indicative of “substantial distress” in a non-

Western southeastern Asian sample. In the present sample, 32.1% exceeded this cutoff on the

depression subscale and 57.7% on the anxiety subscale. Though Mollica et al.’s cut-off does not

specifically apply to the somatization scale from the HSCL-90, it is noteworthy that 56.4% of the

sample exceeded the cut-off in the somatization subscale. Thus, these nonspecific symptoms of

anxiety, depression, and somatization generally exceeded inpatient psychiatric norms.

Posttraumatic stress measure. Mollica et al. (1992) determined a critical cut-off of 2.5 for

the HTQ – Part IV in an indigenous southeastern Asian sample and stated that scores above this

threshold are indicative of being symptomatic for PTSD. Our sample’s mean score on the HTQ –

Part IV was 1.83 (SD = .47). Only 11.5% of the sample exceeded the cut-off.

The HTQ - Part IV also offers a traumatic stress construct that includes an additional 14

items intended to capture more culturally variable traumatic stress reactions. Mollica et al. (1992)

showed that the addition of these 14 items significantly improved the accuracy of the scale for the

Southeastern Asian sample used in their study. The authors state that the same cut-off of 2.5 is

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indicative of being symptomatic for PTSD. Only 9.0% of our sample exceeded this cut-off (mean

1.75 (.49)).

Exposure to Western trauma discourse

Participants reported the frequency with which they had been exposed to particular

sources of Western models of traumatization. The mean score for degree of exposure to Western

models was 5.9 (3.6). Frequencies for each question are found in Table 2. The majority (85.9%)

had never attended a workshop or similar training program on the topic of trauma. The frequency

with which participants had been exposed to trauma-related media (e.g., radio programs, written

material) was more variable and normally distributed, with the modal response, endorsed by

39.7% of the sample, indicating 3 to 4 instances of such exposure.

Primary hypotheses

WTDE associated with PTSD symptoms. Our first hypothesis, that WTDE would positively

correlate with severity of PTSD symptoms, was first assessed using the symptom report from the

HTQ score. This score represents responses to the items that reflect the specific DSM criteria for

PTSD, as opposed to Mollica et al.’s (1992) larger HTQ construct that includes 14 items reflecting

additional traumatic stress symptoms reported by refugees. Western trauma discourse exposure was

significantly correlated with traumatic stress symptoms as assessed (r = .28, p = .02). The more the

participants had been exposed to Western models of trauma, the more their symptoms fit a PTSD

symptom profile.

WTDE associated with PTSD symptoms relative to nonspecific symptoms. Our second

hypothesis was that WTDE would be more positively correlated with PTSD symptoms than with

non-PTSD symptoms. The WTDE and the combined HSCL three subscales were not significantly

correlated (r = .12, p = .31); as noted above, the correlation between WTDE and traumatic stress

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symptoms (HTQ) was significant (r = .28, p = .02). Hotelling’s test of the difference between two

dependent correlation coefficients revealed a significant difference between these two correlations (t

= -2.38, p =. 02). Exposure to trauma-related media and workshops was more strongly associated

with posttraumatic stress symptoms than with non-PTSD clinical symptoms.

A hierarchical multiple regression was conducted predicting traumatic stress symptoms, first

entering general symptoms (sum of 3 HSCL subscales) and then entering WTDE. This resulted in a

significant change in R2 (r = .85, R2 = .72, adj. R2 = .71, ∆R2 = .02 (p = .02); HSCL (Β = .81, p

< .001); WTDE (Β =.15, p = .02). Thus, even while controlling for more general symptoms of

distress, WTDE was significantly predictive of traumatic stress symptoms.

To better elucidate the relationship between traumatic stress symptoms (HTQ) and WTDE,

we reexamined this relationship while controlling for total of types of events experienced. A

hierarchical multiple regression was conducted predicting traumatic stress symptoms, first entering

total number of type of events experienced and then entering WTDE. Though ∆R2 fell just slightly

short of significance, the correlation and the amount of variance explained was notable (r = .53, R2

= .28, adj. R2 = .27, ∆R2 = .03 (p = .065); total type of events experienced (Β =.46, p < .001); WTDE

(Β =.19, p = .065). Thus, even while controlling for number of event types experienced, WTDE

showed a trend for predicting traumatic stress symptoms.

Response to open-ended questions. Frequency of endorsement of different responses to the

open-ended questions were counted. No participants endorsed sufficient symptoms qualitatively to

meet criteria for a PTSD diagnosis. Complaints of a material nature (70.5% had at least one

complaint) were comparable in frequency to psychological complaints of any kind (69.2% had at

least one complaint). PTSD symptoms were less frequent than depressive symptoms and as frequent

as anxiety symptoms. Frequencies are reported in Table 3.

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Discussion

Exposure to Western trauma discourse

The present results revealed that WTDE was a significant predictor of traumatic stress

symptoms, even when controlling for the number of event types experienced. These results suggest

that well intentioned psychoeducational efforts may be associated with an increase in PTSD

symptoms. It is possible that psychoeducation that forecasts vulnerability to pathology may actually

undermine resiliency or at least alter the symptom profile in the Burundian population. One might

conclude that WTDE is associated with a general increase across all symptoms categories. A partial

test of this would be to compare the correlations between WTDE and trauma symptoms and WTDE

and general symptoms. WTDE was also more strongly associated with posttraumatic symptoms

than with more general clinical symptoms of anxiety, depression, and somatic concerns. This

pattern of results suggests that trauma psychoeducation is not associated with an increase in clinical

symptoms generally, but rather with a specific increase in symptoms of PTSD.

Given the cross-sectional nature of the study design, we cannot determine the direction of

causal effects. It may be that individuals who were experiencing PTSD symptoms sought out

media content and workshops that described the symptoms they had acquired. However, that

WTDE and event history were so weakly correlated (r = .19) makes such an explanation less

likely. Determining the chronology of the occurrence of symptoms and of exposure was beyond

the scope of this investigation. Future research is needed to identify causal relationships.

Event history and symptom levels

Our sample was drawn from a population of rural Burundians, all of whom reported

histories of multiple extremely distressful events. These events included being forced to harm or kill

others, the murder of family members, and rape. In most cases, the worst of the events took place

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more than ten years prior to the investigation. An average of nine events was endorsed. Given that

the list was predetermined and given that there was no solicitation of additional events, it is likely

that the participants experienced additional traumatic events.

Despite significant histories of multiple traumas, the participants reported relatively low

levels of PTSD symptoms. According to Mollica et al.’s (1992) cutoff for the HTQ, only 11.5%

could be considered symptomatic for PTSD. One explanation for the low level of PTSD

symptomatology relative to the substantial trauma history is a gradual abatement of symptoms over

the years. However, this explanation stands in contrast to conventional claims that PTSD is

unremitting without treatment (e.g., traumatized Vietnam veterans who experienced trauma over 30

years ago; see Rosenheck & Fontana, 1994). Such findings are strikingly similar to Bryant’s (2004)

reports that the vast majority of people either recover naturally or are resilient such that they never

develop full-scale PTSD.

A second possibility is that participants were underreporting. However, the Burundian

interviewers, whose presence should have facilitated disclosure, reported that they did not see

indications of underreporting. It is difficult to support an argument for the possibility of the specific

underreporting of PTSD symptoms, when material complaints and certain other clinical symptoms

were endorsed at substantial levels. Underreporting is also unlikely given that the mean scores on

the HSCL anxiety and somatic subscales far exceeded inpatient clinical means.

A third explanation for the low levels of PTSD in this sample is that PTSD symptoms do not

accurately capture the type of posttraumatic stress reactions of these individuals. In the quantitative

data, many more participants exceeded Mollica et al.’s (1987) cutoff for substantial distress on the

HSCL than they did on the HTQ. In the qualitative data, response rates between estimates of PTSD

symptoms and nonspecific anxiety and depression symptoms were comparable. Clearly, a trauma

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history in this sample is associated with diverse elevated clinical symptoms as well as material

complaints, rather than being composed of predominately PTSD symptoms. The absence of severe

PTSD symptoms in the presence of profound and multiple stressors support continued skepticism as

to how well the PTSD construct captures the experience of traumatized indigent non-Western

peoples.

Qualitative symptom reports

The qualitative data reveal that PTSD symptoms are just one of a number of symptom

profiles associated with a traumatic history. Material complaints were endorsed as often as

psychological ones, and symptoms of anxiety and depression were more common than specific

PTSD symptoms. These findings are consistent with Baron (2002), who used open-ended questions

as opposed to symptom checklists to determine the nature of the distress people were experiencing.

The interview questions employed in the current study were adopted from Kagee (2004) who, while

finding some presence of PTSD symptoms among South African torture survivors, reported that

these symptoms are significantly outnumbered by somatic and economic concerns.

Study strengths and limitations

Our procedures did not allow for careful assessment of the specific content that was

captured in the WTDE construct. The data collected qualitatively may have been compromised by

inconsistent efforts on the part of the interviewers to follow-up responses to questions. Additional

training and preparation of the interviewers in future studies would strengthen the validity of the

qualitative data. Our assessments were largely symptom-focused, and as in most similar studies,

failed to assess functional impairment.

Despite these methodological limitations, the study possessed notable strengths. Measures

were carefully translated and backtranslated by native Burundians, and the study procedures were

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refined in consultation with them. Interviews were conducted entirely by local Burundian staff in

the native Kirundi dialect. The use of open-ended questions informed a more culturally sensitive

approach to interviewing and decreased the demand characteristics inherent in standardized

measures. The sample was markedly provincial with minimal exposure to Western culture. The use

of open-ended interview methods as a complement to standardized quantitative instruments permits

assessment of a clearer picture of traumatic stress reactions. The chronological relationship between

WTDE and the development of symptoms would be an important issue to examine in future

research.

The application of a standardized PTSD symptom measure without careful consideration of

the possible effects of social desirability, a power differential between researcher and an indigenous

sample, and the need for a broader assessment of symptoms may lead to a premature conclusion as

to the degree to which PTSD captures a universal response to trauma. The present results suggests

that posttraumatic symptoms among an indigenous African population are diverse, are not confined

to a discrete PTSD construct, are substantially material in nature, and may be subject to

psychoeducational or cultural influences. The support for the proposed hypotheses suggests that

additional research on the effects of WTDE on symptom presentation in such settings is

recommended. The current results speak to the importance of appropriate caution when presuming

vulnerability in non-Western populations, especially vulnerability constructed in the image of

PTSD.

The debate as to the degree to which PTSD is more biologically or culturally determined

will continue. The possibility remains that Western trauma models capture a traumatic stress

response that is as of yet unarticulated by indigenous groups. On the other hand, the degree to which

PTSD is “universal” may be substantially driven by the degree to which the cultural ideas inherent

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in contemporary Western trauma discourse are exported to foreign lands. Our findings do not aim to

minimize the intense suffering that our sample of participants reported. The morality of the horrors

they experienced is independent of a determination of the nature of their distress. Further research is

critical to discern the degree to which the application of Western trauma models promotes recovery

or constitutes a risk of shaping clinical symptoms and even pathologizing normal responses to

traumatic events.

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Table 1

HSCL mean scores and norms

__________________Current Sample________ Published Norms ______________

Sample mean Nonclinical Psychiatric Psychiatricmeana outpatient meana inpatient meana

HSCL-25 total 1.83 (.54) .33 (.37) 1.63 (.91) 1.61 (1.07

Depression subscale 1.68 (.52) .36 (.37) 1.79 (.94) 1.74 (1.08)

Anxiety subscale 2.07 (.69) .30 (.37) 1.47 (.88) 1.48 (1.05)

Somatization subscale 1.96 (.58) .36 (.42) .87 (.75) .99 (.84)

3 subscales combined 1.87 (.52) - - -_______________________________________________________________________

Note. Standard deviations in parentheses. HSCL = Hopkins Symptom Checklist.

a Derogatis, L. R. (1994). SCL-90-R: Administration, scoring and procedures manual third - edition. Minneapolis, MN: National Computer Systems, Inc.

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Table 2

Responses to questions regarding exposure to Western Trauma Discourse

Have you ever attended workshops or trainings about how people are affected by extremely frightening or traumatic events?

Never: 85.9%< 1 day: 7.7%< 2 days: 1.3% 2 days: 1.3%2+ days: 3.8%

Have you ever listened to radio programs/read literature about how people are affected by extremely frightening or violent events?

Never: 19.2%1-2 times: 16.7%3-4 times: 39.7%4+ times: 15.4%7+ times: 9.0%

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Western Trauma Discourse

Table 3

Percentage of participants reporting one, two, or more than two psychological symptoms or other complaints in reference to their “most distressful” event.

Number of responses within each category

Category 1 2 >2 Met diagnostic criteria for PTSD/MDE

PTSD 30.8% 6.4% 2.6% None

MDE 20.8% 1.3% 0% None

Nonspecific depression 38.5% 2.6% 0%

Nonspecific anxiety 30.8% 3.8% 0%

Material 70.5% 15.4% 3.8%

Somatic/medical 23.1% 2.6% 0%

Anger 11.5% 0% 0%

Bad/evil thoughts 21.8% 1.3% 0%

Thoughts of revenge 12.8% 0% 0%Note. PTSD = Posttraumatic Stress Disorder. MDE = Major Depressive Episode.

25