Trauma and Culture

1. Trauma and Culture Multicultural aspects of Trauma and PTSD

2. What is culture?

3. no universally accepted definition • some relevant definitions are…

4. 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)

5. 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)

6. 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)

7. 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)

8. Theories on Culture and Trauma

9. Three dimensions • Universal dimensions • Cultural aspects • Personal Uniqueness (Marsella et al., 1996)

10. 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

11. 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

12. 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)

13. 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

14. 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)

15. Personal Uniqueness • Idiosyncratic aspects of the person • Individual differences in the influence of ethnocultural factors • Subjective experience • Patient as individual • Collectivist

16. Culture, Trauma and young children • Theories • But, no systematic (indirect) comparison (review) • No direct comparison • Only for behavioral problems (unrelated to trauma) • J. Weisz

17. 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?

18. 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)

19. Suggests: • For instance, differences in PTSS depending on type of grief • Empirical evidence?

20. 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 (?)

21. 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)

22. 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)

23. Discussion • Overall, individual differences stronger than ethnocultural difference?

24. 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)

25. 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

26. 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)

27. 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)

28. 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)

29. 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

30. 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

31. 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?

32. Other things to consider • Language is important • Rituals • Relevant studies on divorce and protective impact of rituals • ‘meaning making’

33. 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

34. 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

35. 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)