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234
Herbert, J. D., & Forman, E. M. (2010). Cross-cultural
perspectives on posttraumatic stress. In G. M. Rosen & B. C.
Frueh (Eds.), Clinician's Guide to Posttraumatic Stress Disorder
(pp. 235-261). Hoboken, NJ: Wiley.
TREATING THE FULL RANGE OF POSTTRAUMATIC REACTIONS
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D. HERBERT
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M
ost cultures have historically framed reactions to tra:lma within
the context of religion, with priests and shamans offering interof the causes or meanings of traumatic events, while also serv-
ing in the role of healer. Within Western cultures, beginning in the
mid-19th century, physicians gradually began to expand their
to
include psychological reactions to trauma. This process culminated
in the creation of the medical diagnosis of posttraumatic stress disorder
(PTSD) in 1980, which completed the transformation of reactions to
trauma from the religious domain to a biomedical framework. This transled by American psychiatry, clinical nsycholo(!Y, and related
fields, has exerted widespread influence. The
adigm," in which human suffering and
exist independent of local
Hwnru'<
to
has resulted in a loss of
that cultural factors
an important role in the development and treatment of posttraumatic reactions. Despite such concerns, Western biomedical models of trauma and associated interventions are increasingly
exported throughout the world. According to the United Nations, there
are currently over 12.8 million
displaced persons, 9.8 million
refugees, and an additional 10J
of concern" worldwide
•
,"
235
236
2006).
traumatic
increasingly
events per modern diagnostic ~lallUctlU~
targeted Western interventions toward them.
central thesis is twofold.
cal
237
Posttraumatic Stress Disorder
CROSS-CULTURAL PERSPECTIVES ON POSTTRAUMATIC STRESS
a
including factors typically
shape reactions to traumatic events,
be viewed as pathological. While such cultural effects impact many
rnnnrtant in the case
areas within a country (e.g., "Canadian maritime culture"), all the way
down to local communities such as
groups. When examining
vocational, religious. or even
to trauma, it is important to keep in
the wide range
reactions
levels that
make up such factors. Also, at
level one examines, no culture is
static.
in addition to a cross-sectional comparison of
at a given time point, one can compare the
torical periods.
an understanding of cultural factors
is critical when
and treating individuals posttrauma. We begin
our discussion of these concerns by briefly considering what is meant by
n
We then review the predominant biomedical model of post-
POSTTRAUMATIC STRESS DISORDER
In terms of the
classification,
treatment
American beliefs and practices have become
traumatic reactions, focusing on the diagnostic construct of PTSD. We
examine the many ways in which psychological, environmental,
tural factors shape reactions
to
trauma, including the prevalence and
nature of pathological reactions. We
that cultural effects can be
cross-sectionally (by comparing
groups at a
point
in time), as well as historically across time (within a continuously evolving culture across time). We
what
of the third edition of the
Jtagnost!c and Statistical Manual of Mental Disorders in 1980 (DSM; APA,
1980), and with respect to psychological reactions to trauma,
prevailing
has viewed posttraumatic reactions within a biomedical context-specifically as the medical condition of
its introduction in the DSM-I11 (APA, 1980), interest in PTSD
a historical perspec-
tive yields on the question of cultural factors in posttraumatic reactions.
stress,
we consider the assessment and treatment of
grown rapidly among scholars,
and the public at large.
the definition of what constitutes trauma, and therefore risk
PTSD, has expanded in subsequent editiuns uf the DSM (e.g., DSM-
PTSD, within a culture-sensitive framework.
IV; APA,
Qualifying traumatic events have been extended
to
learning about or witnessing another person's exposure to a life-
WHAT IS CULTURE?
Derivation of the word "culture"
psy-
the idea of fostering and nur-
commonalities among individuals. While cultural anthropolohave not reached consensus on a
definition
term, the
United Nations Educational, Scientific and Cultural Organization provides a useful description: "Culture should be regarded as the set of
event. Traumatic events no longer need to be outside the
range of normal experience, nor do they need to be
standards external to the individual. Within
ityof
have experienced at least one event that
traumatic stressor (Breslau &
2001). This gradual and
of traum,l has led PTSD to become the
tinctive spiritual, material, intellectual and emotional features of
by which reactions to a wide range of adverse evet1($ are understood.
or a social group ... in addition to art and literature, lifestyles, ways of
Accompanying this development is the ever-increasing
human
(Summerfield,
together, value systems, traditions and beliefs" (UNESCO, 2002).
The term
and
can refer to broad groups that share certain beliefs
extending across several nations
by national boundaries
"Western culture"),
"French culture"), to
of
There are a variety of consequences
model to understand
as a "natural kind,"
As with
238
CROSS-CULTURAL PERSPECTIVES ON
POSTTRAUMATIC
conditions, PTSD is assumeJ
other
to
STRESS
Pnsnraumatic
be
239
Across Culwres
found. Terheggen, Stroebe, and Kleber
) documented that Tibetans
itself consistently with a unique symptom
ranked destruction of religious symbols as the most traumatic event
tures, both at any given time point as well as
possible, ahead of other events such as death of a friend or even
way biomedical diseases work. However, unlike bone fractures or viral
infections that may entail the same causal agents regardless of time or
A biomedical perspective suggests that rates of PTSD
conditions such as PTSD are presumably socially constructed and
therefore culture-bound.
consis-
traumatic events.
exposed to
to
this
and between cultures. For example, studies of recent LDmugrants
to
industrialized countries as well as of Iutiona!s within developing coun-
POSTTRAUMATIC RESPONSES ACROSS
CULTURES
tries reveal widely variable rares of PTSD (see Yeomans and
2009).
estnnates of the
of PTSD within a culture
what consti-
are highly variable depending on factors such as gender and ethnicity.
of such events, varies
The National ComorbiJity Survey fuund an overall rate of PTSD among
An often overlooked aspect of PTSD is the fact that
by culture. Summerfield
American men of
as compared to 20A°!..) among women (Kessler,
Sonnega, Bromet, Hughes, & Nelson, 1995). Pule, Best, Ml.:'tzler, and
There is nothing quintessential abullt a particular traumatic
experience. The attitudes of wider society (which may
over time) shape what individual victims feel has been done
to them, and shape thc vocabulary they usc to describe
whether or how they seck help, and thcir expectations of
recovery. The more a society sees a traumatic cvent (rape,
example) as a scriolls risk t,) the present or future hcalth and
victim the nwre it may turn out to be. In
other words, societally constructed ideas about outcomes, which
carry a
include the pronouncement:-.
the mental health
Mannar (
reviewed evidence that Latinos in the UniteJ States
demonstrate higher rates of PTSD than white or black counterparts.
The observatiun that posttraumatic reactions in other cultures du not
necessarily conform to Western expectations is consistent with
culturally sensitive research. Yeomans, Herbert and Forman (2008) used ,)
of qualitative interviews by native speakers and swndardi:ed
instruments to assess posttraumatic reactions among internally displaced
in the central African nation of Burundi. In mJer to avoid respnns(:'
ur
contamination resulting from expectancies,
measure of self-fulfilling prophecy (p. 232)
trained native interviewers preceded the aSSessment c)f specific sympwms.
All of the interviewees had experienced at least nne, and
traumatic within one
ceived by
sexual
are not
~o
per-
traumatic events. Content
rather than
intense foclls in Western socieries as a cnmll1un traumatic event
to
PTSD. An act of fellatil) between a pubt:'scent
of the Interview data revealed that
which ha,; received
and an older man
would be universally condemned as childhood sexual abuse
Western
However, such acts arc a COmml1I1 nte of passage among tracultures (Bo\-m, 1996). Even within American
ture, the assumption of inevitable lasting traumatic effects of childhood
abuse has been questioned (Rind, Tromovitch, and
1998). Outside the sexual realm, cultural dIfferences contmue to be
symptoms. Assessment uf
toms of somatization, anxiety, and depression, with relatively few
symptoms of PTSD per se. Similarly, Baron (2002) found that the distress
of Sudanese
in Northern Uganda focused more lm material cun-
cerns such as lack of food, poor health care, and the ongoing threat of violence rather than DsvcholOllical symptums. The majority did not
distressing symptoms, and for thuse who
of anxiety, somatic complaints, and
these tended to take the fl)rl11
symptoms.
240
colleagues
In their review of
of those affected,
of individuals who respond with persistent symptoms, posttraumatic
reactions tend to differ across cultures. They noted that the intrusive
symptoms of PTSD tended to occur across cultures, while
symptoms were not consistently observed. Marsella suggested
that PTSD symptoms Inay be hil2hest in cultures in which avoidance and
in mainare more common, because these symptoms are
241
intervention"
853 ).
among the minor-
&
ACfl),s
Posttraumatic
CROSS-CULTURAL PERSPECTIVES ON POSTTR.'\UMATIC' STRESS
social support and other cultural factors can
more
than the actual traumatic event. Wang et al. (2000) compared
the reactions of inhabitants in two villages, both hit by the
mentioned severe earrhquake in northern China. Wang found that the
village with the higher level of initial exposllre to the
a higher level of post-earthquake support. Rather than
rates of PTSD in accord with a dose-response model
other aspects of the disorder.
the town residents With greater exp(lsure actually had lower rares pf
Culture and Resilience
PTSD. Evidently, social sUl'purt f<lctors act as a strong buffer to promote
and natured r",covery after trauma.
who \'isit survivors of severe
countries are often
natural disasters in
Times,
by the resilience of the native
David Brooks (2008)
the
As
Sichuan Province in Western China
quake that killed approximately
POSTTRAUMATIC RESPONSES ACROSS HISTORY
people on May
81>0V(:,
displaying few signs of
2008. Despite
of the
literature
the reactions of the survivors he
perspecuve. That is, the nor-
mative reactions to trauma vary
interviews, and I don't
in the minds of
to
which
to 11IStorica I
upbeat and
by
scenes of horrific devastation, the local
These were
another means
nant cultural theories ahout the
Consider t~)r
over time, and retlect the domiof trauma (Herbert &
\'arious trauma-related conditions that
mid-19th century.
on or go crazy.
Work
together.
tn
Similar observations
to (Urrellt
of the 2004 Asian tsunami
for 280,000 deaths
those from a
mechanisms exist at individual and
resilience in the face of adversity and enable normal
helie\'ed
that resultt·,1
in the symptoms of railway spine.
demonstrated
effects were due
the
culture and the
in the
Delboeuf, 1
to
When care was taken to avoid
expecrattons
242
CROSS-CULTURAL PERSPECTIVES ON POSTTRAUMATIC STRESS
of any
not be
of
symptoms, Charcot's hypnotic demonstrations could
avoidof rest with an
expectation of
of pensions for
two World Wars were
century, railway spine was widely viewed as a posttraumatic psychological condition rather than a result of physical insult. Nevertheless, the
specific symptoms of railway spine, particularly hysterical paralysis, stand
243
(1999)
This led Hippolyte Bernheim and Joseph Delboeuf to
emphasize the importance of fostering positive expectancies by means of
an intervention they termed "psychotherapy." By the turn of the 20th
Reactions
flicts, with
decreases
in stark contrast to the symptom picture of modern PTSD.
Similar lessons have been learned in military settings (Jones &
2005; Shephard, 2000). During the First World War, for exama large number of psychiatric causalities were evaluated as a consequence of the relentless trench warfare that took place. The most
common symptom presentation among psychiatric casualties in that war
included mutism, hysterical crying, and intractable trembling (termed
Kriegszitterer or "war trembling"
the Germans). Strong contrasts were
noted between British soldiers' lack of improvement from "shell-shock"
and French soldiers' swift recovery. This difference has been attributed to
the fact that French soldiers were treated near the front without excessive messages of the seriousness of the condition, whereas British soldiers
The popularity of currenr
com-
with a Western ethnocentric
tive, hZls led to the Widespread
is
cultures. To the contrary,
of po:ittraumatic symptoms
time. The lessons of the past century, and in particular of the two
Wars, highlight the critical importance of expectancies in the
aftermath of trauma in shaping subsequent
call into question the
the nature of PTSD.
were evacuated to hospitals in England. During the last two years of the
war, the British also adopted a program of rapid psychotherapeutic intervention near the front lines, resulting in dramatic reductions in psychiatric casualties (Shephard, 2000). In anticipation of the entrance of the
United States into the war, the American physician Thomas Salmon
(1917) further developed the French and English program into a strategy
that came to be known
the acronym "PIE," for
immediacy,
and expectancy. Posttraumatic casualties were treated immediately and
as close as possible to the front, \'iith clear expectancies for full improvement. After a brief rest period, soldiers were given meaningful work, and
ASSESSMENT OF POSTTRAUMATIC REACTIONS
With an appreciation for the variations that Occur in posttraumatic reacwe can now turn our attention to iSSlles of a:;sessment and treatment. A summary of key pOints for clinicians to conSider is
Il1
Tahle 10.1 on the follOWing page.
Assessment of posttraumatic reactions
cussion of
returned to their units as quickly as .
the First World War, psychoanalysis became the dominant
of psychopathology in both Europe and the United
and
the powerful role of suggestion in posttraumatic reactions was all but
forgotten. The initial campaigns of the Second World War
alarming psychiatric casualty rates, which at one point even exceeded
the rate of troop mobilization (Glass, 1973). When Salmon's PIE was
topics can he more
Chinese and Latino men) than
& Ibanez, 2001; Wang et
with a dis-
244
Assessment of P,)sttraumatic Reactions
CROSS-CULTURAL PERSPECTIVES ON POSTTRAUMATIC STRESS
Table 1O.l Recommendations for a Culturally Informed Approach to
Posttraumatic Stress
Assessment
• Assume neirher vulnerabiliry nor resilience.
• AvoiJ framing questions in such a way as to lead [he
ro conform ro Western expecrations of responses to trauma.
Be aware rhat some mJidduals arc culturally normed
•
[0
minimize symptoms.
• Cast a broad net !Ii rhe assessment of symptoms.
• Beware of assessment tools thar are not carefully rranslated and
validated into indigent languages.
Formularion
• Understand the impact of a traumatic ~\'ent within the context
of the meaning ascflbed bv an individual's culture. Don't assume
that events have the same impacr "etOSS individuals/cultures.
• Acknowledge thar the way people cope with traumatic srress
.-!,"N'n,~inv un a numj,cr of tactClfs, including cultural
•
Be aware of unconscious and conscious motivations to present
with posttraumaric symprums, espeClally of PTSD.
ro interH'ntion, wirh rreamlent
Treatment
•
Do not suggest dlrecrly or mdirectly thar an indi\'lJual wit!
exhibit chronic symptoms or wHI develop PTSD. Avoid
or administer only With extreme caution.
•
Utilize culturally Cl)l1sistcnt sources of recovery (e.g.,
and ex tended social
• Utilize CBT treatmenrs across cultures. with sensitivity
to cultural differences and incorpl)raring relevant cultural
practices.
• Work [() reduce clinician-chent power imbalance that may be
exacerbared by cultural differences.
When conducting an assessment interview, clinicians must avoid suggestive questions that could shape an individual's memory of the traumatic event (Loftus, 1997) and/or establish morbid expectancies. This
keen interviewing skills and sensitivity to the individual's current state of mind, In addition, the clinician must be mindful of relevant
norms and mores. Resources such as the classic book Ethnicity and
Family Therapy (McGoldrick, Giordano, & Garcia-Preto, 2005) are useful
guides to typical cultural patterns associated with various ethnic groups.
245
A trusting therapeutic rapport is critical. and questions should be
posed in an open-ended manner, especially initially. It is also critical for
the clinician to suspend his or her own beliefs about how individuals
"should" respond to traumatic events. In fact, it is helpful to go out of
one's way to seek evidence that might contradict one's beliefs. Otherwise
it is far too easy to succumb to what is known as "confirmation bias" (the
highlighting and remembering of belief-congruent information over data
that contradicts expectations).
A variety of clinician-rated interviews and self-report questionnaires
have been developed to assess posttraumatic symptums.
such measures can provide useful quantitative symptom indices, they
are not without limitations. All currently popular questionnaires and
interview-hased measures were de\'eloped in English, and few have
been translated and validated into other languages. Some attempts
at translation have revealed linguistic difficulties, as some common
English concepts do not exist in other cultures. For
no word for "trauma" in Kurundi (the language of
We are aware of one particular fmuma workshop in Burundi that spent
hours attempting to translate the word, and finally chose a phrase that
means "having one's heart turned upside down" (A. Niyongabo, personal communication, March 15, 2005).
More fundamentally, there is the question of whether the concept of
PTSD best reflects the experience of individuals in non-Western cultures, Consider that the most common approach to studying PTSD in
non-Western countries typically involves these steps: translate PTSD
symptoms into a native language checklist; approach an mdigent population; assess the listed symptoms; find the extent to which they are
endorsed by traumatized groups; report PTSD rates; and conclude that
PTSD exists in that culture. This exercise and the findings that result are
then used to support PTSD's presumed universality. An example of such
a study was conducted by McCall and Resick (Z003), They approached
the Ju'hoansi tribe of Kalahari Bushmen, and with the help of village
elders, identified individuals who had experienced domestic violence
and who were symptomatic. They then presented these individuals wtth
a translation of the DSM symptoms of PTSD. Not sumrisin"ly, 35°/il of
the sample endorsed symptoms of PTSo.
246
CROSS-CULTURAL PERSPECTIVES UN PUSTTRAUMATIl STRESS
of
A critical problem with such an approach is that any
to a certain
will
symptoms among distressed
the
endorsement
of distress
number of positive cases.
of a prous little to
symptoms
suppose that we claim to have
pused taxonomic entity. For
we will call "post-ampua new dIagnostIc category,
tee neurosis" (PAN). We claim that indi\'lduals who have lost a
symptom pattern
especially as
result of trauma, will display a
esteem,
Assessment of Pllsttraumatlc Redctk,ns
contexts, it is possible that
IpYC'ln(if"r
the
could be retro-
diagnosed with severe narcissistic
disorder for want-
ing to conquer the world, and a possible psychotic
in multiple gods, including one who
bolts to
Earch and another who created love with
issues may intll!ence the assessment of
responses, especially in non-Western
Individuals may be motivated to
of hypersomnia, joint pain (outside uf the
responses according to their rerceptions of what an
dissociative episodes, and intennittenr periods of
able response
NOW,
we translate a list of these symptoms into local
approach victims of the civil \.\'ar in the Darfur region of Sudan, We
seek out amputees in particular, read off (lur checklist, and ask if they
these symptoms. We would not be surprised to find that
number endorse some of the symptoms. Moreover, we
a
that ampltel'S endorse symptoms at a higher wte than non-amputees,
and double-amputees endorse more symptoms than single amputees.
these results validate the existence of PAN? Obviously nor. Note that the
more distressed the group, the more likely
will endorse symptoms of
And of course, amputees are likely to he more disnon-amputees (and double arnrlltees more
than
amputees wtll endorse more symptoms of
PAN, or of mOst anything else on a psychiatric checklist, for that matter,
In order w assess how individual~ fwm elitlerem cultures
to trauma, one must avoid elecontextualized checklists and
247
be. Such etlens are rarticularly problematic given
the power imbalance that typically exists
Western researchers
and indigent porlilations. Western knowledge is often tacitly held tll
to local
context (Wessels, 1
This can result in individuals modifying their reports, and
e\'en their actual experience, to match the percei\'ed
researchers, One example of this effect was
by Yeomans,
and Forman (2008). In this study, indigent rural
with greater
exposure to Western PTSD psychoeducation reported more symptoms of
to those with
reports of traumatic reactions. Individuals in poverty-stricken societies may be motivated to report symptoms of psychulogical distress in hopes uf
resources
toward those determined to
most needy (Kagel' &
Naidoo,
resources for individuab in
soci-
instead cast a broader net. As the example of PAN illustrates, the nature
eties are sometimes contingent upon
of j1usttrdllmatic responses assessed m
For examole. current nolicy of the American Veterans Administration
used, Mackowiak and Batren
a function of the
recently used the symp-
tom checklist method in an
(Alexander the Great,
and Florence
PTSD. Of course, an examination uf
clers might very possibly have
manifestatiun of symptoms.
compensation for PTSD-related disability, but
payment ceases if symptoms remit (Frueh, Smith, & Barker, 1
Such
incentives to
maintain, and
report symptoms. This is not to suggest
individuals are necessmily
for many different elisorin the conclusion that these indi-
viduals fulfilled criteria in each mstance, Thus, a depression checklist
a Danic checklist to a
could lead to a diagnosis of
historical
alld so on.
of panic
of symptoms undoubtedly sometimes occurs, Rather secondary gain may reinforce the actual
experience of posttraumatic symptoms. A parallel example exists among
for Dolitical asylum for whom ~uccess sometimes
symptoms convince a
of the
on
243
Sensitive Treatment
CROSS-C\:LTl1RAL PERSPECTIVES ON POSTTRAl't-IATIC STRESS
that these incentives
to
I t is
of their trauma
exist for rhe clinician as well, if (or no other reason than wanting to
their clients. These concerns have been discllssed
Derek Suma British psychiatrist who views PTSD as a Western "invention"
that has heen improperly imDosed on non-Western cultures (Summerfield,
2001; 2002; 2004; 2005).
that rely on decontextualized checkissues related to perceived social desirabIltty, power
and subject, and possible secondary gain,
that strive to avoid these
Tf"p'lrrh'>T
factors in order to provide the most accurate picture of responses to
trauma. Examples of good practices include so-called
interviews by native interviewers that precede
toms in order to avoid contamination.
CULTURALLY SENSITIVE TREATMENT
it is important
to posttraumatic reactions.
conventional wisdom among many mental
of
who experience traumatic events
& Wilson, 2005). Most will be
a variety of
symptoms, but will recover within a matter of days to weeks. It is therefore important that interventions acknowledge and address the short-term
distress that most people experience, while simultaneously supporting factors that encourage resilience. Second, it is becoming increasinglv clear
in the immediate aftermath of traurna, people are
to
suggestions
expectations of how one
such messages may corne from the cultnre at large, they are
especially powerful when delivered by health care professionals. If one
Cl)!1\,eys expectations that the tr::luma is likely to result in persistent symptoms, the likelihood of such symptoms increases. If, on the other bnd. a
experience as temporary,
clinician
expectatransient reactions to extraordinary circumstances, with the
tion of full recovery, then the likelihood of recovery increases.
249
this overall pattern of resilience, a minority of
continue to experience persistent and clinically significant symptoms.
These individuals can benefit from SCientifically supported treatments.
Yet, even this group should not be subjected to interventions that convey that drawn-out posttraumatic symptoms are the normative reaction
to trauma. Clinicians should avoid over-natholo"izin(! an individual's
reactions to adversity.
tal disorder can lead to
of Burundian war trauma survivors, those
to attend an intervention workshop that
educational component about PTSD had worse outcomes than those
assigned to an eqUivalent inter\'ention without the
component (Yeomans, Forman, & Herbert, in press).
Taken together, these facts suggest that a phased approach to intervention is most appropriate, with interventions linked to the stage
an individual finds him- or herself in relation to the traumatic event.
Therefore, we discuss intervention efforts in three stages: the acute posttraumatic phase, the subacute phase, and the chronic phase (Herbert &
Forman, 2006; Herbert &
2002).
Acute Phase
The most important priority immediately following a traumatic event is
attending to the material needs
the traumatized individual, including
safety, food, and medical intervention, as needed. Psvcholo£!ical interventions should focus on restorative and
measures, in the
context of supportive, encouraging, and
regarding
full recovery. The individual's reactions should be
without
undue attention. This is nut the time for introspective analysis of the
behind one's symptoms. Adequate rest is essential and medication can be prescribed as a sleep aid if neccssary.
It is
to cllcourage meantngtul activities to minimi:e murpreoccupation with the trauma and one's symptoms. This is not t\1
suggest that individuals sh,luld be encouraged w avoid thoughts of the
trauma or distressing feelings associated with it, or from speakinl! about it
if they wish. Indeed, a
body of evidence suggests that
cal avoidance can be quite prohlematic (e.g., Haves et a!., 2004).
250
CROSS-CULTURAL PERSPECTIVES ON POSTTRAl.IMATIC STRESS
SClblfln?
the idea is to encourage an individual to engage in meaningful actin-
Trc,nment
This type of inten'entitll1 can l<c
251
a
ties to avoid morbid preoccupation with the traumatic event, to encour-
a traumatic event to thuse whose symptl)mS 11<1\'e nnt
age a sense of self-efficacy, and, as much as possible, to restore a sense
resolved on their own. Research has shown that short-term CBT in the
of normalcy. In this regard, indigenous cultural practices and rituals can
aftermath of trauma can he effective in preventing the development l)f
be especially helpful. Thus, in certain Native American and Southeast
chronic problems (Bryant et aI.,
Asian cultures, a specific set of post-trauma rituals has developed
cleanse the spirit and restore the soul (Wilson, 2006). In more collec-
as d result of their symptoms.
relevant. For example, after the 2008 Chinese earthquake, survivors
Hearst-Ikeda, &
should
tivist cultures in particular, community-building efforts can be
set about burying the dead,
1999, 2003;
1995). It is important to emphasize that this type of intervention
to
I
nus, unlike aebnetmg programs
that are improperly recommended for all sut\"ivnrs, short-term CBT pro-
rubble, and reconstructing
grams are rargeted only for individuals with clinically significant symptOIl1S
schools and other communal buildings. Such community-building efforts
that have liersisted weeks follmvine the event. As in the acute posttrau-
have been empirically demonstrated to powerfully mitieate the effects
be ;)voi(bl and th;lt
of trauma in collectivist societies (Wang et al.,
clinicians shuuld promote
forces ,)f emotional and
and
social support I and remain
responses that follow take place within a cultural context.
As important as what to do in the immediate aftermath of a trauma is
what not to do. There is growing evidence that cenam common posttrau-
Chronic Phase
In the aftermath ot" trduma, SGme
10
experience a
chronic symptom picture, with
research literature supports the effectiveness of
matic intervention programs (e.g., Critlcal Incident Stress Debriefing)
interventions
are at best ineffective, and at worse can be harmfuL
such as the United
continue
been conducted with
Western
across
for Clinical Excellence guidelines, explicitly caution against the use
indi-
posmaumatic psychological debriefing (Mayor, 2005). Certainly, clini-
cators
cians do not want to export to non-Western cultures a treatment model
samples of trauma victims in a number
has failed in its own
the
were diverse
ies have
Subacute Phase
apy
PTSD with racial minority populations. For instance,
Even if morbid suggestions and expectations are caretully aVOIded, some
individuals develop persistent symptoms and require tre;1tmenr. There is
and Foa (1999) compared the responses of African
Americans and Caucasians
no clear consenslIs on exactly when normal, transient reactions cross the
line to become "symptoms" of a disorder. As a general rule, we suggest
that clinicians consider treatment within weeks
Western effl'ctiveness studies
of a traumatic event if
(0
exposure trt'atmt'nt and found
and improvement rates. Similarly,
published series of uncon-
trolled case studies concluded that exposure treatmen t
reduced PTSD symptoms among low-income African American women
reactions remain highly distressing and cause impairment in functioning,
(Feske, 2001). Third, the specific techniques of CBT appear
as iud£ed within the context of the individual's social group and culture.
on sound, universal
to what treatment is advised during the subacute phase,
With
several studies in Western countries have supported the use of short-term
be
to
be based
to cur across cultural lines (Rllsen & Davison, 2003). Fourth,
there are a limited, but growing, set of studies of CBT-based interventions
252
for non-Western trauma victims that echo findings with Western
2001). In one study. 43 Sudanese
tions (e.('., Paunovic &
Uganda were randomly
to receive either
counseling, or psychoeducation
cation, rsychoeducation plus
narrative exposure therapy. Only those receiving exposure therapy
experienced decreases in PTSD symptoms (Neuner, Schauer, Klaschik,
Karunakara, & Elbert, 2004).
On the basis of the above, we suggest th"lt clinicians operate on the
that standard CBT interventions, especially
interventions, should be the treatment of
symptoms in persons of varying cultural backgrounds. One important caveat
is
the intervention program, while
its core components, must
to be culturallv
sensitive, and appropri
be
ADDITIONAL STRATEGIES AND CONCERNS
Stress inoculation training: Closely related to cognitive restructuring
is Stress Inoculation Training (SIT; Meichenbaum, 1993), a multicomponent intervention comprised of
guided self-dialogue, covert
(visualizing the successful confrontation of an anxiety-provoking
subvocally saying the
situation), role-playing, and thought
,. to interrupt distressing ruminative thou"hts)' Althou£1h SIT
appears to be
exposure and
1991; Foa et
suggests that
such
as thought
may, in
(Harvey & Bryant, 1998).
the frequency and intensity of the
Acceptance-based therapies: The paradoxical effects of thought stopping
point to the more general role of psychological avoidance (i.e. the avoidance of aversive thoughts, memories, images, emotions, etc.; Herbert,
& England, 2009) in the development and maintenance of
PTSD. Several
and Concerns
Additional
CIWSS-CULTURAL PERSPECTIVES ON POSTTRAUMATiC STRESS
little
has yet invesri-
2009;
cognitive behavioral intervention
Krakow et al., 2001) is a
can target nightmares
sleep disturbances associated with PTSD.
In addition to standard sleep hygiene interventions, IRT involves having the patient write down a disturbing dream. The patient then modifies the dream however he or she desires, and the
version is
Initial
At the same time, clinicians should
he sensitive to
when dreams are thoullllt to
content
Treatments to Avoid
clinicians work with
it is as impurtant to know
treatments to avoid as what treatments to offer. For example, there is little evidence to suggest that traditional psychoanalytic or supportive psychotherapy are effective treatments for chronic posttraumatic symptoms.
Another approach lacking support is that of "psychoeducation," at
as
it has been applied during
in Western settings. As
noted. there is, in
some
that
Western
concerns with
culture. In this
or a waithst control. The two workin that one intervention included a psychoeducational
component. Results indicated that rhe psychoeducational component
reduced the beneficial aspects of the interventiun program, presumably bv
creating a morbid expectation on the part of the participants.
or "energy" therapies have been
A number of so-called
aggressively promoted over the past
for PTSD and rehlted Cllnthe
in the treat-
253
254
References
CROSS-CULTURAL PERSPECTiVES ON f\)STTRAU,lATlC STRESS
255
claim to operate via unusual mechanisms. and promise much more rapid
clinical innovations into posttraumatic reactions. Such work has
and effective treatment than standard d1erapies. includim, state-of-the-
important fruit. \Ve have gained a clearer picture of normative reactions
art exposure-based treatments. The evidence,
EMDR has been shown to be
to aversive events and factors that impede or promote recovery.
treatments have been developed for those with persistent symptoms. And
but no more so
we have an increasingly clear sense of what not to do.
existing treatments, and in some cases somewhat less so (Davidson &
Parker, 2001; Devilly, 2002; Devilly & Spence, 1999) Importantly, the
The picture is not entirely positive, however. Despite these achievements, the construct of PTSD has become reified, coinmonly viewed as a
therapist-induced stimulation-does not contribute to its effects, sug-
"natural kind" that exists relatively independent of its sociocultural con-
cognitive-behavior and exposure-
text. The results of cross-culwral and historical studies argue against thiS
based techniques (Herbert ct aI., 2000). Similarly, there is no scientific
perspective. There is mounting evidence that posttraumatic reactions are
support for the miraculous claims made regarding TFT and its variants.
by a variety of factors. Among the most critical of these factors
that EMDR is but a variant
Despite these negative findings, power therapies have been exported
is the cultural context, which largely determines not only which events
to Third World countries in curious forms
are experienced as traumatic, but the nature and degree of
for all manner
aft1ic-
tions. The interested clinician can do an Internet search for these meth-
of subsequent reactions. History demonstrates that normative postrrau-
ods to find various examples (e.g., work in Africa by the Association for
matie symptoms have changed over time, while cross cultural research
Fidd Therapy). We strongly rewmmend that therapists avoid
shows that despite some commonalities, symptoms appear
to
differ across
the power therapies, in favor of more scientifically supported treatments
cultures even today. In addition, the popularity of PTSD tends to draw
whose claims are consistent with the availahle evidence.
attention away from one of the most striking facts about posttraumatic
By hlf the most potentially damaging treatment approaches for posttraumatic reactions are programs aimed at "recovering" repressed mem-
reactions: Most individuals show remarkable resilience even
severe traumatic events. It is critical that mental health
rather than inadvertently
ories of traumatic events. Such therapies may involve any number of
techniques, including hypnosis, age regression, and guided imagery, that
ting it
are
Rather than subsuming all posttraumatic reactions under the rubric of
a sin!ode biomedical
hood sexual
traumatic
Research has now
is inconsistent with the way memory
works
can actuthat these
(Schacrer,
create memories ot ahWie that never actually occurred, which are
but miseuideJ efforts.
del1Ce that such reactions are best understooJ in their
context.
Clinicians will find that their assessment and intervention efforts arc
most
when infused with culturally sensitive
then experienced as veridical (Loftus, 2003). Therapists should
such approaches, and should be eSDeciallv mindful of the risk of inadvermemories t:hrough
CONCLUDING POINTS
In the past three decades, a tremendous imerest in the
effects of traumatic experiences has develnp<.'"d. Creation of the diagnostic
construct of PTSD in 1980 served as a
t:o jump-start research
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