Trauma and Culture

Multicultural aspects of Trauma and PTSD

What is culture?

• no universally accepted definition

• some relevant definitions are…

Conceptual DistinctionsCulture, Race, Ethnicity

• Culture– Traditions, values, customs (of child-care +

socialization practices)– Includes rituals and artifacts (symbolizing group’s

belief systems)– Provides psychic structure for social relationships +

helps to make meaning of physical world– Learned/transmitted primarily through language and

everyday interactions

(Lewis, 2000a)

Conceptual DistinctionsCulture, Race, Ethnicity

• Culture– Learned behavior, transmitted from

generations to promote adjustment and adaption

– Presented externally: artifacts, roles, institutions

– Represented internally: values, beliefs, attitudes, cognitive style, epistemologies, consciousness patterns(Marsella, 1988)

Conceptual DistinctionsCulture, Race, Ethnicity

• Ethnicity and race– Ethnicity: Subjective social identity of

individual within larger group– Race: based on phenotypic features, primarily

skin color– Typically, individuals identify their

• Country of origin, and ethnicity

(Lewis, 2000b)

Conceptual DistinctionsCulture, Race, Ethnicity

• Culture as a different sources– E.g., child growing up in US, with dark skin

color categorized by US census as ‘black American’ (race)

– but may be Jamaican American (ethnicity)– and as part of fourth-generation immigrant,

her cultural heritage is ‘American’ (culture)

Theories on Culture and Trauma

Three dimensions

• Universal dimensions

• Cultural aspects

• Personal Uniqueness(Marsella et al., 1996)

Universal dimensions

• even possible to identify?• Universal capacity to experience and

express basic emotions (e.g. Izard, 1994) – Joy, fear, anger, sadness, disgust, shame,

guilt

• Strongly challenged (e.g. Russell, 1994)• Intermediate position

– Fear expressed + perceived universally– Cultural influences for other emotions

Universal dimensions

• Suggests:– All humans have capacity to experience and

express fear, helplessness, horror…(to meet A2 PTSD diagnosis)

• Although, cultural factors may influence likelihood that fear will be evoked or expressed

Universal dimensions

• Evolutionary– Capacity to cope with stress crucial– adaption

• PTSD symptoms– Intrusions (B) and arousal (D) universal– Avoidant/numbing (c) cultural

(Friedman & Marsella, 1996)

Cultural aspects

• Culture and mental illness– Certain psychiatric disorders (e.g.

schizophrenia, depression) around the world– Range of cultural expressions– Mix of universal and culture-specific factors

Cultural aspects

• Ethno-cultural factors (Draguns, 1994)

– identity of the individual– explanations of illness– related to psychosocial environment/level of

functioning– Elements of relationships between individual +

clinician– Assessment for diagnosis + care

• Individualism-collectivism dichotomy– Many traditional culture = collectivists – Position on spectrum implications for assessment and

intervention (Rosenthal & Feldman, 1992)

Personal Uniqueness

• Idiosyncratic aspects of the person

• Individual differences in the influence of ethnocultural factors

• Subjective experience– Patient as individual– Collectivist

Culture, Trauma and young children

• Theories

• But, no systematic (indirect) comparison (review)

• No direct comparison

• Only for behavioral problems (unrelated to trauma)– J. Weisz

Culture and Trauma: Risk and Protection

• Culture can be protective– Providing context in which social support and

other positive and uplifting events experienced

• This also comes with a risk– Strong attachment to persons and lifestyles

leads to great sense of loss(deVries, 2000; Lewis & Ghosh Ippen, 2004)

• Question/Critique: Empirical evidence?

• Culture creates meaning systems– E.g., traditional cultures assign causation to

god or gods

• Rituals and symbolic places– E.g., grief

• Medical system embodies ideas of illness and health (hope + expectation of solutions)(Stamm & Friedman, 2000)

• Suggests:– For instance, differences in PTSS depending

on type of grief

• Empirical evidence?

Culture as a Mediator of Trauma(to young children)

• Three ways that culture interacts with children’s reactions to extreme stress (Aptekar & Stoecklin, 1997)– Possible range of responses from PTSD– Means to cope (use socio-cultural environment to

transform circumstances into opportunities)– Stigmatization of groups

• Note that multiple stresses increase risk of PTSD– More likely to occur in developing world (?)

Acculturation and Assimilation

• Acculturation (acculturative stress)– Loss of friends, family, work, home, etc.– Decreased opportunity for social interaction

(language, etc.)

• Assimilation– Culture loss– Overpowered by dominant culture

• E.g., forcibly stripped

(Lewis & Ghosh & Ippen, 2004)

Intergenerational Transmission of Trauma

• Historical Trauma response (Brave Heart, 2000)

• Trauma transmitted inter-generationally– Culture may affect this– Collectivism: trauma experienced by society

(neighbors, friends, acquaintances) (Lewis et al., 1997)

Discussion

• Overall, individual differences stronger than ethnocultural difference?

Some empirical evidence

• Adults (Stamm & Friedman, 2000)

• Ethnocultural aspects of mental disorders and PTSD (Marsella et al., 1996)

• Review of disaster victims (Norris et al., 1999)

PTSD in traditional backgrounds?

• Argument whether PTSD cross-cultural applicable– Not applicable to non-western culture

(Bracken et al., 1995)– Implicitly endorse a Western ontology

• Questions about cross-cultural validity of DSM-IV (Lewis-Fernandez & Kleinman, 1995)

• BUT: DSM/ICD = official taxonomy

PTSD detected among non-Americans

• Southeast Asian refugees• Sri Lankans exposed to civil war• Civilian survivors of the war in Afghanistan• Cyclone survivors in Fiji and Sri Lanka• Earthquake survivors in Mexico, Ecuador, Japan, and

China• Volcano survivors in Columbia• Political torture detainees in South Africa• American Vietnam vets:

– African-American, Hispanic-American, American-Indian, Asian-Pacific Islander (and Caucasian)

(Stamm & Friedman, 2000)

Goodness-of-fit of PTSD diagnosis

• That PTSD can be detected in non-Westerners doesn’t tell anything about goodness-of-fit

• Two major components of pos-traumatic distress among non-Westerners– Somatization– Dissociation

Somatization is missing DSM-IV PTSD and one can meet PTSD criteria without dissociation

(Kirmayer, 1996)

• Depression– Associated with significant loss

• Cultural losses

• Complex PTSD– Multiple traumas (e.g. refugee camp)

• Post-traumatic culture-bound syndromes– May be more a reaction to Western-industrialized

biomedicine– E.g. somatic blindness in Cambodian refugees,

‘ataques de nervios’ in Latin Americans(Stamm & Freidman, 2000)

Only direct cultural comparison

• American Vietnam veterans from different cultural backgrounds (Kulka et al., 1990; Beals, 1997)

– African-American, Hispanic-American, American-Indian, and Caucasian

– Exposed to the same traumatic event (!)– Pre-military, military, post-military risk factors for

PTSD– Race/ethnicity per se only weak predictor of PTSD– But, race/ethnicity = risk factor for exposure to

specific events (physical abuse, parental alcoholism, atrocities in Vietnam, social support)

• Freq/multi exposure to these event = increased risk of PTSD

Disaster victims

• Norris et al. (1999) • Review of 200 articles on disaster

– 1981 - 2001– 60,000 individuals

• Ethnic minority youth at greater risk of developing PTSS (66%)– Severity of exposure– Culturally specific attitudes that impeded help

seeking

• Problem: Traumatic events often occur at particular time/place and culture– E.g. Hurricane, war, etc.

• But, could look at individuals exposed to violence (or terror)– Violence experienced differently in culture?

Other things to consider

• Language is important

• Rituals– Relevant studies on divorce and protective

impact of rituals

• ‘meaning making’

Other things to consider

• Treatment issues– Paucity of published randomized clinical trials

on PTSD (Stamm & Friedman, 2000)

– Non-Western therapy approaches• Yoga

– Mindfulness approaches– Rituals

Critique/Problems of research area

• Many case reports (qualitative analysis)– From psychoanalytic tradition

• Few quantitative studies?

• Little methodological sound research

• Mostly chapters (no research articles?)

• Confusion in definition of culture and trauma

Problems of research area

• Compare studies on Trauma and PTSD from different countries/cultures– E.g., to see if difference in PTSS

• But, diversity of existing studies– Sample, Trauma, etc. (can’t really compare)

• What would be needed:– Compare same Trauma in individuals from different

cultures– Some adult studies with Vietnam Vets (see Stamm &

Friedman, 2000)