Table of Contents
PTSD and Cross-cultural considerations
Universal validity of PTSD
According to the American Psychiatric Association (2013), Posttraumatic Stress Disorder (PTSD) is defined in the DSMV (Diagnostic and Statistical Manual for Mental Disorders Firth Edition) as a group of psychiatric related symptoms after exposure to actual or threatened death, serious injury, or sexual violence by direct experience, witnessing or distant learning of a traumatic event that occurred to a close person. These symptoms include distressing memories and dreams of the traumatic event, dissociative reactions and marked psychological reactions to internal and external cues that symbolize the event, avoidance of or efforts to avoid distressing memories, thoughts or feelings, negative alterations in cognitions like dissociative amnesia and feeling of detachment, angry outbursts, irritability behavior, recklessness, hypervigilance and sleep disturbance. The diagnosis of PTSD is established when the above mentioned symptoms persist for one month and exhibit clinical manifestations, significant distress of impairment in social and occupational functioning not associated with a substance abuse (alcohol or drug) (Taylor and Asmundson, 2008).
Introduced in the 1980 in the DSMIII after the Vietnam War, PTSD concept was however not new in the history of Medicine. It has evolved historically from the time of Homer and has been recognized and described for the past century (Rosenbeck and Fontana, 1996). The holocaust and more recently the American World Trade Center attack has brought into the trauma theory with more publications been released (Craps, 2014). From its definition in the DSMV, PTSD is viewed as a result of an abrupt, singled traumatic event and its consequences on the human psyche resulting in pschychiatric symptoms as I mentioned above. From this angle, the definition of PTSD is non inclusive expressing an individualized, monoculture and unilateral historic considerations which is argued as a Euro-American culture-bound syndrome that does not apply traditional cultures (Summerfield, 2004). On the other hand, for other psychologists and psychiatrists the new concept of PTSD (as defined in the DSMV) is thought to have provided an operational definition applicable for many clinical situations, showed a link between physical pain and psychological event, recognized the extend of a traumatic exposure and more importantly fertilized the relationship between clinicians and researchers working with victims of many different catastrophic experiences (Rosenbeck and Fontana, 1996).
Looking at the two parallel structured PTSD tenets, to determine whether PTSD is a Eurocentric construct one would want to know about the perceptions of PTSD among non-Euro-American cultures, if the streams of diagnostic and treatment approaches are globally identical, inclusive, universal or discriminative; and if there are new approaches serving as a bridge between the two creeds. I will answer these questions in what follows.
PTSD and Cross-cultural considerations
Trauma may be experienced differently in societies and cultures based on religion, beliefs, customs, traditions and the way the world is perceived and lived in. The posttraumatic symptoms that emerge from a painful event (simple or complex) may be silently or stridently expressed .Cultural understanding of this process play a significant role and should be acknowledged because the healing process and treatment encompass considerations about culture diversity, counseling and medical care. In this regard, the adaptation of a particular population after a massive or excessive forceful traumatic event differs from the one following a death of a closed person and it’s been influenced by local practices and culture. For instance in the Tsunami case of 2004 in Thailand (Leitch, 2005) or the Rwanda Genocide of 1994 (Stone, Leyden, and Fellows, 2009) or the Tsunami’s experience in Sri Lanka (Watters, 2010), whereby American therapists methods were viewed as impolite and inappropriate by the victims. It’s clearly observed that the adaptive mechanisms and healing of posttraumatic disorders are culturally influenced in these communities. Like Watters (2010) continued to argue that there are many controversies about if western-developed interventions are appropriate for use in non-western Countries and cultures that have experienced the disaster. The experience about trauma and the healing process is not unequivocal in all cultures. This view is thoroughly demonstrated by Wilson (2010, pp 5) when narrating about the ‘’journey to healing after the Vietnam War’’ of a certain ‘’Tommy Roundtree’’ (not his real name) who was a two-tour combat veteran who had been highly decorated for his valor and courage in combat with the 101st Airborne Brigade between 1967 and 1969. In this book, Tommy, a Lakota Sioux Vietnam combat veteran explained to Wilson that by keeping to the traditional ways, abstaining from alcohol, and working to help others who had adverse residual traumatic war injuries, he could live in harmony and balance in all affairs of live-the Lakota way, the great cycle of life. And Wilson with the Western mind of trauma healing was curious when Tommy asked him if he thinks the veteran was mad.
This shows how the Lakota community perceives the American ideology around trauma and post trauma healing. The western–oriented trauma theory and the healing process hardly incorporate the experience of racial and/or cultural aspect of the others. PTSD symptoms may differ from one culture to another and the equivalent to it may be inexistent in other non- western communities. The PTSD definition lacks inclusiveness and is too narrow to explain the cause based on what is defined as stressors (sudden traumatic event). Cultural background and beliefs are viewed as essential to a successful healing process. Marsella (2010) has stressed this aspect by demonstrating the importance and effect of ethnoculture on PTSD. Cultures influence the clinical parameters of the diagnostic criteria of PTSD and stress related disorders that may occur in response to a ‘’traumatic’’ event. The acceptance or rejection of the traumatic event, the manifestation of the symptoms including the cause, progression and outcome are all routed in cultural background.
Moreover , those who experience other type of trauma due to political or economical oppressions should not only be diagnosed as sufferers that need psychosocial counseling but the deep rooted cause of this derangement should be addressed by understanding the impact of different cultural traditions on the way trauma is experienced and on the process of healing. Some people with different cultures in our society also go through daily stressors like racism, sexism, homophobia, xenophobia, classism that may not be qualified as stressors of PTSD diagnosis because most often there is no act of violence .The increase in social inequalities, injustice, freedom deprivation, prolonged interpersonal violence and similar social ills also may constitute silent stressors that may not be seen as predictors to PTSD in the western construct. The power of culture is seen in the interpretation of traumatic events (e.g. natural: earthquakes, Tsunamis, Volcanoes or man-made: wars, genocides, nuclear, etc) and the healing methods of different patterns of culture-bound disorders that may not meet western diagnostic criteria. These healings processes include rituals, ceremonies and/or expiatory sacrifices that could be seen as ‘’inferior’’ by the Western methodology scholars at least for the past decades. In a post-tsunami study by Levy, Slade and Ranasinghe (2008), survivors of Tsunami believing in Karma were associated with poor health outcome and hold a pessimistic explanatory style to the catastrophe. The study provided an opportunity to examine the capacity of two disparate ways to predict health: the culturally specific approach of belief in Karma and the universal approach of explanatory style.
The fact that Euro-American society has military and economic monopoly dominance does not justify its supremacy over local cultural concepts of trauma and its subsequent predicaments. And Watters (2010) supports this view and amid that the American system professes a strong desire to respect cultural pluralism, but it defaults to imposing its view of diagnosis and treatment. Simply because the system works with a diagnostic code and assume it is rooted in universal responses of the brain. And the European model of PTSD management is based on individual psychotherapy thus does not include collective culture, psychosocial and historical considerations (Summerfield, 2004). Although the Euro-American construct is believed to improve working with victims from different catastrophic experiences, it has failed the principle of creating new forms of communities by marginalizing and ignoring the traumatic events of non-western or minority cultures and by taking for granted the universal definition of trauma and recovery that had developed outside the western modernity thus creating a cynicism about trauma theory that risks assisting in the perpetuation of the very beliefs, practices and structures that maintain injustice and inequalities (Craps,2014).
Having said this, the question whether PTSD is the best idiom of distress from one culture to another will be analyzed in the next paragraphs by looking into the universal validity of the concept.