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 can’t 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 Alternative: Cultural 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: 1. Continuing to “live in the past”; 2. Visitation by supernatural forces when asleep or awake; 3. Feelings of Guilt; 4. Trying to hold onto memories of the past; 5. (But) experiencing pain if memories of the past intrude into daily life; 6. Yearning to complete obligations to the dead; 7. Constantly struggling with various anxieties, morbid thoughts and (uncontrollable) anger; 8. 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 focus…having 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 model…we 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?