CrossCultural Perceptions:

1
Cross-Cultural Perceptions

• Posttraumatic Stress Disorder (PTSD)
• and
• Cultural Bereavement

2
Definition of Trauma

• Trauma was initially a medical term referring
  to a wound. However, it also began to be used to
  refer to an emotional wound.
• By definition, emotional trauma is "emotional
  shock producing a lasting effect on a person"
  (Oxford, 1980, s.v. "trauma").

3
Trauma definition

• We all use the word "trauma" in every day
  language to mean a highly stressful event.
• But the key to understanding traumatic events is
  that it refers to extreme stress that overwhelms
  a person's ability to cope.
• There are no clear divisions between stress which
  leads to trauma and that which leads to
  adaptation.

4
Psychological and physiological

• Although we are talking about psychological
  trauma, it is also important to keep in mind that
  stress reactions are clearly physiological as
  well.

5
Trauma definition

• Psychological trauma is the unique individual
  experience of an event or enduring conditions, in
  which
• 1. The individual's ability to integrate (coping)
  his/her emotional experience is overwhelmed, or
• 2. The individual experiences (subjectively) a
  threat to life, bodily integrity, or sanity.
  (Pearlman Saakvitne, 1995, p. 60)

6
Exposure to potentially Traumatic Situations vs
Being Traumatized

• Trauma is defined by the subjective experience of
  the survivor.
• Two people could undergo the same event and one
  person might be traumatized, while the other
  person remained relatively unscathed.

7
Trauma is subjective

• It is not possible to make blanket
  generalizations such that "X is traumatic for all
  who go through it" or "event Y was not traumatic
  because no one was physically injured."
• You cannot assume that the details or meaning of
  an event that are most distressing for one person
  will be same for another person.

8
What is PTSD?

• PTSD is a concept introduced by the American
  Psychological Association, first appearing in
  1980 (see DSM III-IV),
• And based on specific symptom patterns found
  among some survivors of traumatic experiences in
  the US (initially Vietnam war veterans) and
  elsewhere.

9
PTSD

• Post Traumatic Stress Disorder (PTSD) is
  considered a normal reaction to a potentially
  traumatic event such as war, torture, rape,
  natural disasters, etc.
• However, it is still classified as a mental
  disorder within the DSM system.

10
Who develops PTSD?

• PTSD may affect some persons whose coping
  mechanisms are overwhelmed, but not everyone
  exposed to a certain event will go on to develop
  PTSD,
• just as not everyone will become traumatized
  by virtue merely of having lived through or
  witnessed violence.

11
DSM IV

• PTSD is characterized by intrusive,
  hyper-aroused, and avoidant symptoms related to
  the original (potentially traumatic) stressor.
• PTSD is an Anxiety Disorder in the DSM IV
  classification.

12
PTSD Symptom Prevalence

• Several studies, including those in post-conflict
  settings, indicate that approximately 25-33 of
  persons exposed to an extreme stressor/ violence
  experience will go on to develop PTSD symptoms
  (Breslau et al 1991, Kilpatrick et al 1992).
• Aprox 70 of persons exposed to a traumatic
  stressor will NOT develop PTSD symptoms. This may
  point to a certain level of inherent resilience/
  coping skills among the majority.

13
Co-morbid Disorders

• The two most frequently co-morbid (occurring at
  the same time) disorders with PTSD are substance
  abuse and major depression, both of which may be
  accompanied by a high risk of suicide.
• 80 of persons with long-term PTSD suffer from
  depression, another anxiety disorder, or
  substance abuse (International Society for
  Traumatic Stress Studies, 2000).

14
Who is most likely to develop PTSD symptoms?

• those who experience greater stressor magnitude,
  intensity, and duration
• those who experience stressors with a sexual
  assault component
• those with limited social support
• those with a social environment that produces
  shame, guilt, stigmatization, or self-hatred
• those with concurrent stressful life events.

15
PTSD Cluster Symptoms (A, B, C, D)

• A. STRESSOR exposure to (an extreme) stressor
  outside the range of normal human experience.
• B. INTRUSIVE
• Having nightmares
• Flashbacks/ invasive memories of the event

16
PTSD Symptoms cont.

• C. AVOIDANT/ NUMBING
• Trouble remembering
• Avoiding people or places that are reminders
• Numb, unable to feel any emotions (joy or pain)
• Sense of foreshortened future
• D. (Hyper) AROUSAL
• Feeling jumpy all of the time, exaggerated
  startle response
• Difficulty concentrating
• Difficulty sleeping
• Bursts of anger, yelling or crying frequently

17
Includes impaired functioning/subjective distress
symptoms must be present for 1 month

• The diagnosis of PTSD means that symptoms are
  interfering significantly with relationships or
  work (as confirmed by the subjective perception
  of the person), and that overall functioning of
  the individual has been reduced.
• In order to receive a diagnosis of PTSD, the
  symptom pattern related to avoidance, arousal,
  and intrusive behaviors and feelings must have
  been present for at least 1 month.

18
Onset of symptoms

• Symptoms can appear immediately after exposure or
  years later in response to a trigger.
• Example, adult survivors of childhood abuse with
  children
• Following onset, symptoms are usually
  characterized as chronic and recurrent for the
  majority of those with PTSD if left untreated. A
  few will however, spontaneously recover without
  treatment.

19
Ethno-cultural Research

• Several studies and existing biological research
  suggest there is a universal biological response
  to traumatic events (A. Marsella et al 1993).
• For example, intrusive thoughts/memories or
  flashbacks may transcend culture.

20
Ethno-cultural Research

• However,
• Avoidance/ numbing and arousal symptoms may be
  more specific to various cultural groups
• Some cultural groups may be more likely to
  describe physical symptoms (somatic complaints)

21
Ethno-cultural Research

• Ethno-cultural factors appear to play more of a
  role in individual vulnerability to PTSD
  (ie-prevalence rates within various cultures).
• People from some cultures may be more resilient,
  have better coping skills or protective factors.
• Some cultures also vary in PTSD treatment
  responsiveness (ex CBT).

22
Criticisms of PTSD Diagnosis (see Summerfield,
D.)

• Labels people as mentally ill when they are
  not.
• It is a culturally specific concept that supports
  culturally specific interventions based on
  biomedical systems that are stigmatizing (ie
  disorder).
• People from some cultures do not respond well to
  some types of interventions that arise from this
  diagnosis (ex success of cognitive and
  behavioral therapy).
• Just because we can ID similar symptom patterns
  does not mean that these symptoms have the same
  meaning in different cultures. What about the
  symptoms we cant ID (using DSM descriptions)?

23
Criticisms of PTSD Diagnosis (cont.)

• It attempts to replace traditional indigenous
  knowledge and meaning systems with an alternative
  truth (cultural imperialism).
• Focuses on the individual self to the exclusion
  of the communal context. The individual receives
  the diagnosis, not the family or community
  system.

24
An AlternativeCultural Bereavement

• The term was initially introduced by M.
  Eisenbruch in 1991 during research with Cambodian
  refugees
• Toward a culturally sensitive DSM Cultural
  bereavement in Cambodian refugees and the
  traditional healer as taxonomist.

25
Cultural Bereavement

• Is suggested that although the symptoms of CB may
  resemble PTSD to some extent, is not intended to
  be an alternative DSM diagnosis, but a term used
  to describe a part of a healthy rehabilitative
  response to multiple loss, migration and
  acculturation pressures at a community level.
• Attempts to give voice to alternative
  perspectives and provide a culturally correct
  taxonomy.

26
Cultural Bereavement

• Symptoms result from loss of home, identity,
  cultural values, social networks, institutions,
  routines and surroundings, acculturative stress
  and pressures of adaptation.not necessarily only
  from exposure to what we usually consider to be
  an initially (single) traumatic stressor.

27
Cultural Bereavement - Symptoms

• Continuing to live in the past
• Visitation by supernatural forces when asleep or
  awake
• Feelings of Guilt
• Trying to hold onto memories of the past
• (But) experiencing pain if memories of the past
  intrude into daily life
• Yearning to complete obligations to the dead
• Constantly struggling with various anxieties,
  morbid thoughts and (uncontrollable) anger
• Inability to function well in daily tasks due to
  the above.

28
Friedman and Jaranson in The Applicability of
PTSD to Refugees conclude

• We believe that (cultural bereavement) is
  complementary but certainly not an appropriate
  substitute for a PTSD focushaving reviewed
  criticisms of the PTSD model, we can not find any
  reason to reject it.concerns are easily
  incorporated into a clinical approach to refugees
  based on the PTSD modelwe believe it offers a
  useful conceptual and theoretic approach to the
  psychological impact of trauma on refugees from
  all ethnocultural backgrounds.

29
Do you agree?

• 1. Case Study review the criteria for a PTSD
  diagnosis and the criteria for cultural
  bereavement.
• 2. How would you conceptualize the symptom
  patterns exhibited by the client in the case
  study?
• 3. What implications might the conceptual
  framework you chose to embrace have for survivors
  self-perception and treatment interventions?