Download Trauma and disasters in social and cultural context

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13
Trauma and disasters in social
and cultural context
Laurence J. Kirmayer,1 Hanna Kienzler,2 Abdel Hamid Afana3 and Duncan Pedersen4
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Division of Social and Transcultural Psychiatry, McGill University and Culture and Mental Health Research Unit,
Jewish General Hospital, Montreal, Canada
Department of Anthropology, McGill University, Montreal, Canada
International Rehabilitation Council for Torture Survivors (IRCT), Copenhagen, Denmark
Douglas Mental Health University Institute and Division of Social and Transcultural Psychiatry, McGill University,
Montreal, Canada
13.1
INTRODUCTION
Trauma and disasters are important causes of human
suffering both in terms of the sheer numbers of people
affected and the complexity of the mental health
problems that may follow. Violence has become one
of the leading causes of death worldwide for people
aged 15–44 years [1]. Of the total number of global
injury-related deaths, about two-thirds are of
‘nonintentional’ origin (e.g. traffic accidents) while
one-third are due to intentional violence, including
suicides, homicides and organized violence (terrorism, wars and armed conflict, genocide and ethnic
cleansing) [2]. Both the frequency and the numbers of
people affected by violence and disasters have increased markedly over the last 100 years, while the
proportion of people surviving has also risen [3]. This
means that there are many more survivors who may be
affected psychologically by traumatic events. As the
density of human habitation and the intensity of
technological development have increased, so too has
the scale of disasters. Climate change, economic
disparities and political conflicts all can be expected
to compound the number and complexity of disasters
in the years to come [4].
Social psychiatry has a long engagement with
understanding the individual and collective impacts
of trauma and disasters. Much of this interest has been
driven by experiences of the impact of war on soldiers
and civilian populations [5]. The Holocaust and other
genocides have forced consideration of the effects of
massive human rights violations on the survivors as
well as on subsequent generations. The experience of
refugees has drawn attention to the impact of displacement, forced migration and torture on mental health.
Of course, trauma is not only a consequence of
such large-scale events but also a common occurrence in domestic life. Early psychodynamic theory
Principles of Social Psychiatry, second edition Edited by Craig Morgan and Dinesh Bhugra
! 2010 John Wiley & Sons, Ltd.
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COMPONENTS OF THE SOCIAL WORLD
recognized the importance of childhood trauma as a
factor in psychopathology, although this was largely
displaced by an emphasis on intrapsychic conflict [6].
From the 1970s onward, the recognition of the high
prevalence of child abuse and its long-term consequences has given renewed impetus to the study of
trauma in psychiatry [7].
Research on the impact of natural disasters has
also influenced the development of psychiatric theory and practice. Eric Lindemann’s study of the
aftermath of the fire at the Coconut Grove nightclub
emphasized the processes of normal grieving and the
value of crisis intervention to reduce pathological
outcomes of trauma and loss [8]. His work led him
13.2
to establish the first community mental health centre
in the US in 1948 [9]. Kai Erikson’s study of the
Buffalo Creek flood in 1973 drew attention to the
long-term effects on wellbeing of the destruction of
communal bonds and connectedness [10]. In recent
years, disaster psychiatry and psychology have
emerged as distinct areas of study with textbooks,
journals and societies devoted to research and discussion of clinical and social issues [11]. This
development of the field has brought recognition
that trauma and disasters may be associated with
particular types of mental health problems requiring
culturally informed interventions at both individual
and community levels [12].
DEFINING AND DELIMITING TRAUMA AND DISASTER
Trauma is a term originally applied to physical injury
and some of its immediate effects. Since the late
1800s, trauma has increasingly come to refer to a
range of psychological impacts of the experience or
threat of violence, injury and loss [13]. Events that are
considered traumatic include violent personal assault,
rape, physical or sexual abuse, severe automobile
accidents, being diagnosed with a life-threatening
illness, natural or technological disasters, being kidnapped, military combat, being taken hostage, terrorist attacks, torture and incarceration as a prisoner of
war or in a concentration camp. The term ‘trauma’
emphasizes what is common across these different
events, but clearly each has its own particular meanings and consequences.
Traumatic events vary widely in terms of the nature
of the threat or injury, its frequency and duration, its
personal significance (which may change over time),
the relationship of the victim to the perpetrator (in the
case of interpersonal violence or abuse), and the
broader collective meaning and social response. What
constitutes a trauma then is not entirely dependent on
the nature of the event but also on the personal and
social interpretation of the event and the responses of
the affected person, their family and community, as
well as the wider society. Culture influences the individual and collective experience of trauma at many
levels: the perception and interpretation of events as
threatening or traumatic; modes of expressing and
explaining distress; coping responses and adaptation;
patterns of help-seeking and treatment response. Most
importantly, culture gives meaning to the traumatic
event itself, allowing individuals, families and communities to make sense of violence and adversity in
ways that may moderate or amplify their impact.
Disasters are situations or events involving ecological disruption, threat to life or injury that negatively
affect large numbers of people and that overwhelm
local capacity for adaptation, usually by destroying
infrastructure. Disasters vary widely in their scale,
scope and significance. It is useful to distinguish between natural and human-caused disasters. Natural
disasters include geophysical and meteorological
events like earthquakes, floods, tsunamis, tornados,
volcanoes and drought. Human-caused disasters can be
divided into: (i) technological accidents, such as airline or other mass transportation accidents, industrial
accidents and structural collapses of bridges or buildings; and (ii) willful or intentional events such as mass
murders, terrorism, war and genocide. The distinction
between natural and human-caused, however, is often
difficult to make and may change with new information and interpretations; for example, the destruction
following an earthquake may become a human-caused
disaster when it is realized that most of the deaths are
due to the collapse of houses built with shoddy workmanship due to corruption in the construction
industry. Many disasters span the natural and the
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human-caused because they stem from the ways humankind has modified the environment (e.g. famine
due to the interaction of methods of intensive agriculture and drought). Natural and human-made disasters may co-occur and interact in ways difficult to
disentangle. For example, drought or famine can be
caused by warfare and warfare can be ignited by
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famine. The frequent coexistence and mutual aggravation of natural and human-instigated disasters is
central to the notion of complex emergency, defined as
a catastrophic situation marked by the destruction of a
population’s social, economic, and political
infrastructure [14,15].
UNDERSTANDING TRAUMA
From an evolutionary perspective human beings have
lived with the threat of violence, injury and death
throughout history. We might expect therefore that
there are mechanisms available to help us adapt to
threats that do not destroy us [16]. The most common
response to mild or moderate levels of trauma is acute
distress followed rapidly by recovery. We are biologically primed to learn to be fearful and avoidant of
potentially life-threatening situations [17]. When
threats are more severe and inescapable, other mechanisms come into play, including dissociation, a
cognitive and attentional process of blocking out or
compartmentalizing memory and experience. This too
may have adaptive functions, allowing individuals to
survive intolerable situations like torture or confinement, but it can also impair later adaptation.
Although trauma can aggravate any psychiatric condition, certain disorders are presumed to have a direct
causal link to trauma exposure. In any traumatic event,
some individuals will have more severe or incapacitating acute symptoms and some will go on to have
chronic distress and disability. Others may do well
initially but manifest significant symptoms at a later
time. These pathological outcomes reflect both individual and social vulnerabilities. Among the problems
specifically linked to trauma are grief and other normal
forms of reactive distress, depressive and anxiety disorders, and post-traumatic stress disorder (PTSD).
Trauma exposure may result in a variety of shortand long-term adaptive and pathological responses.
Common responses during or immediately after the
traumatic event include intense autonomic arousal
associated with fear, agitated behaviour or ‘freezing’,
and dissociative symptoms with an altered sense of
time speeding up or slowing down, and feelings of
derealization and depersonalization [18]. About
15–20% of people exposed to such acute events have
symptoms and impairment lasting for several days or
weeks [19]. Acute stress disorder (ASD), introduced
in DSM-IV, occurs within the first 4 weeks of trauma
exposure and is similar to PTSD but with prominent
dissociative symptoms [20]. A severe acute stress
response is a predictor of longer term distress, including PTSD [21].
DSM-IV-TR classifies PTSD as an anxiety disorder
that is characterized by the ‘re-experiencing of an
extremely traumatic event accompanied by symptoms
of increased arousal and by avoidance of stimuli
associated with the trauma’ ([20], p. 429). The essential features of PTSD are the development of specific
symptoms following exposure to an event that involved
actual or threatened death, or serious injury, to which
the person responded with ‘intense fear, helplessness,
or horror’ (p. 463). In addition to the stressor criterion
A, the criteria for PTSD include three main symptom
clusters: (B) intrusive recollection – intrusive thoughts,
distressing dreams, reliving or dissociative
‘flashbacks’, psychological distress and physiological
reactivity when exposed to reminders; (C) avoidant/
numbing – efforts to avoid thoughts, feelings, conversations or activities associated with the stressor,
difficulty remembering the traumatic event, social
withdrawal and emotional numbing; and (D) hyperarousal – sleep problems, irritability or angry outbursts,
concentration problems, hypervigilance and an exaggerated startle response. The diagnostic criteria for
PTSD in ICD-10 are similar but do not include numbing and do not require functional impairment; these
differences result in higher prevalence rates for PTSD
with ICD-10 criteria [22].
PTSD has an explicit causal mechanism built into
its diagnostic criteria: exposure to an unexpected or
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unpredictable event that involves possible serious
injury or death to oneself or others and leads to
appraisal of the event as threatening and so to intense
fear, helplessness, horror and other negative emotions
(shame, guilt, anger); these in turn influence memory
and other cognitive-emotional-sensory processing of
the event such that it leaves lasting traces in the brain
and behaviour [23]. A major component of the syndrome of PTSD is subserved by a conditioned emotional response of fear [17]. Reminders of the context
where threat originally occurred evoke anxiety and
this is managed by cognitive and behavioural efforts to
avoid such contextual cues, resulting in emotional
numbing and withdrawal.
Fear conditioning can be long lasting, but in the
ordinary course of events, repeated exposure to
the same cues without any fearsome outcome eventually results in a decrease in conditioned fear, hyperarousal and avoidance behaviour–a process called
‘extinction’. It is now known that extinction involves
a type of learning distinct from fear conditioning,
involving different neural pathways. In fact, the original conditioned fear is not erased or replaced but
simply suppressed by extinction learning. The two
types of learning have different characteristics; fear
conditioning is quicker and generalizes more easily
than extinction learning. As a result, a small change in
environmental cues can reinstate the originally
learned fear [24,25]. This helps to account for the
phenomenon of triggering or reactivation of symptoms in patients with PTSD [26].
These biological mechanisms are important for
understanding the causes and chronicity of PTSD,
the dynamics of triggering and re-experiencing, and
the effectiveness of exposure therapy as a treatment,
but PTSD involves additional cognitive and behavioural responses mediated by forms of learning and
memory, as well as processes of recall and narrative
elaboration that are regulated by the personal meaning
of the traumatic events [27]. Both recollection and
narration also involve social processes so that traumatic outcomes reflect the culturally sanctioned occasions for remembering and forgetting [28].
The prevalence of PTSD in any population depends,
in part, on rates of exposure to trauma which, in turn,
depend on social circumstances [29]. Traumatic
events are common but unequally distributed in the
population. Surveys in the US have found 50–60% of
individuals are exposed to a traumatic event at some
point in their lives [30]. The likelihood of developing
PTSD after a traumatic event varies with the type of
event and the magnitude of the trauma, ranging from
5 to 10% of those exposed to a natural disaster, to 20%
of those exposed to criminal assault, 40% of those
exposed to combat and more than 50% of those
exposed to rape [30,31]. Women appear to have a
greater risk of developing PTSD after trauma exposure, although this may partly reflect gender differences in symptom expression [22].
PTSD was initially framed as a normal or at least
inevitable response to extreme circumstances. However, longitudinal research soon clearly showed that
only some individuals exposed to the same type of
severely traumatic event develop PTSD and that premorbid personality and psychopathology are important
determinants of vulnerability. As most people who
show transient symptoms resembling PTSD (heightened arousal, anxiety, irritability, nightmares, intrusive thoughts) will recover over a period of days, weeks
or months (depending on the severity of the trauma),
PTSD can be viewed a disorder of recovery [32]. Metaanalyses of risk and protective factors for PTSD show
that among the strongest predictors of PTSD after
trauma exposure are life stress and lack of social
support [33]. Thus, social factors determine the risk
of exposure to trauma and the likelihood of recovery.
These risk and recovery factors are related to each
other through the structures of family, community and
wider social institutions. It is useful, therefore, to think
of a social ecology of trauma risk and recovery [34].
Depression is also a common response in many
situations involving trauma, particularly when there
has been significant loss. The losses commonly associated with trauma and disasters may include loss of
loved ones and possessions, but also loss of status,
role, home, community and the familiar routines of
everyday life. The co-occurrence of depression and
PTSD complicates the course of each disorder [35].
Somatic symptoms are common consequences of
trauma and may reflect physiological dysregulation as
well as culturally shaped idioms of expression of
distress [36,37]. For example, a study of Salvadoran
women refugees in North America, who had fled El
Salvador to escape large-scale political violence,
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found that the women described their suffering as
‘nervios’, a cultural idiom that covered an array of
dysphoric emotions (anxiety, fear, anger) and diverse
somatic complaints, including bodily pains, shaking,
trembling and calor (sensations of heat). Although
some of the bodily symptoms that follow trauma
exposure may be related to PTSD, panic disorder,
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generalized anxiety disorder or depression, there
are other processes of physiological dysregulation, increased muscle tension and bodily preoccupation mediated by cognitive and social processes
that contribute to such ‘medically unexplained’
symptoms [38].
DISASTERS
Disasters have health impacts at multiple levels, individual (physiological, psychological), family, community, societal, international and global. The social
impact of disasters reflects their magnitude, the level of
pre-existing infrastructure, level of infrastructure preserved, the meaning of events (human-caused or not);
the response of the community and local population;
the response of government and larger society; and the
international response. The impact of most disasters is
more severe in developing countries, which lack resources and infrastructure to respond adequately.
Although a whole population or community may be
exposed to a disaster, people are affected differently.
The psychological impact of a disaster on any given
individual depends on both the personal and collective
significance of and response to the catastrophic event.
Groups recognized to be at particular risk for mental
health consequences include women (especially pregnant women, single mothers, widows) and children.
Internally displaced people, refugees and others previously exposed to trauma are also at increased risk for
psychological re-traumatization. In general, people
with pre-existing mental health problems, including
depression and anxiety, are especially vulnerable [39].
The prevalence of psychiatric morbidity following
a disaster is associated with its magnitude but also
with the level of perceived threat to life and risk of
recurrence, lack of predictability and controllability,
loss, injury, exposure to the dead and grotesque, and
the extent of destruction of community infrastructure [40]. Estimates of PTSD following a disaster
range from 30 to 40% among those directly exposed
to 10–20% for rescue workers and 5–10% for the
general population [29]. Symptoms of depression and
demoralization are strongly related to the degree of
loss experienced as a result of the disaster [41].
Disasters are associated with increased levels of
medically unexplained somatic symptoms both
acutely and over survivors’ life spans [42].
Disasters lead to psychiatric morbidity through
many pathways: physical injury, exposure to terrifying
events, loss of loved ones, loss of employment, livelihood and income, loss of familiar environment, domestic and communal place. These losses and injuries
interact with other social determinants of health including pre-existing social structural and political
problems. For the same amount of loss and physical
damage, human-made disasters may have more severe
psychological consequences owing to the ways they
undermine basic social emotions of trust and solidarity.
There are three broad approaches to the impact of
trauma and disaster on mental health outcomes. The
clinical psychiatric approach focuses on the effects of
trauma in causing psychopathological conditions like
PTSD, depression and other potentially disabling
conditions. Individual vulnerability due to pre-existing personality traits, coping styles and mental health
problems help predict who will develop persistent
problems after trauma exposure.
A second approach focuses on individuals’ resources and resilience. For example, conservation of
resources (COR) theory, developed by Hobfoll,
groups resources into four broad categories: object
resources (e.g. material possessions with either functional utility or symbolic value); condition resources
(e.g. social roles or status like marriage, employment,
membership in groups or organizations); personal
characteristic resources (e.g. values, traits or attitudes
like optimism, sense of meaning and purpose); and
energy resources (e.g. time, money, information) [43].
Resource loss due to trauma is associated with distress [44]. Disasters produce distress and limit coping
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by reducing individuals’ resources in each of these
areas. Coping and adaptation, therefore, can be improved by interventions that maximize these resources. Of course these resource domains are not
independent but correlated in ways that reflect a
community’s social structure and dynamics.
A third approach recognizes the dynamic nature of
the interaction between different resource domains
and focuses on the role of social positioning in individual and group vulnerability and resilience. This
more dynamic view could be termed ‘social
ecological’, in that it sees each person as located
within a system that has its own dynamics. Disasters
differ from isolated traumatic events affecting individuals in that they affect the whole community, which
ordinarily provides the secure base for each person’s
adaptive responses to stress, trauma and loss. Depending on the degree to which a disaster disrupts the social
fabric and weakens bonds between people, communities may respond with mobilization and increased
solidarity or with demoralization, disorganization and
disintegration. The level of psychiatric distress in the
population plays a role in these social responses, but
they have their own dynamics that reflect local histories and systemic issues of politics, identity and
community. These local systemic dynamics are embedded in larger global economic and political responses that influence the mental health outcomes of
disasters.
In the face of a disaster that seems to come from
‘outside’ and that does not destroy too much infrastructure, communities may pull together and experience a high degree of solidarity. For example, in
January 1998, Quebec experienced an ice storm in
which the accumulation of ice brought down the main
power transmission lines into the city of Montreal,
leaving 3 million people without electricity in the
midst of winter. Despite the challenge posed by this
loss of power and cold temperatures, there was an
enhanced sense of comradery among neighbours, who
heated water for coffee over camping stoves and
huddled around battery-operated radios waiting for
news. There was no increase in use of mental health
services by patients with severe mental illness [45].
However, even during this relatively limited event,
with little social disruption or loss of life, many people
experienced high levels of stress with potential long-
term sequelae. For example, there is evidence for an
effect of maternal stress during the ice storm on the
subsequent cognitive development of their infants
who were exposed in utero [46].
At the other extreme in terms of the magnitude
disaster, in Sri Lanka following the tsunami of
26 December 2004, there was massive loss of life and
destruction of entire settlements and villages along
two-thirds of the country’s coast. This occurred
against a backdrop of political violence that had
affected the country for decades, eroding family stability and community solidarity [47]. A survey in one
severely affected area found that 40% of the population had mild to moderate symptoms of depression,
anxiety or PTSD [48]. Another survey of children
living in three tsunami affected areas found rates of
PTSD that were not related to the tsunami of
4.6–8.5%, while tsunami related PTSD was found in
an additional 13.9–38.8% [49]. Another study of
adolescents from two villages in southern Sri Lanka
found that post-tsunami depressive and PTSD symptoms were associated with prolonged displacement,
social losses, family losses and their mothers’ level of
mental health problems [50]. A positive mother–child
relationship had a protective effect.
Generally, human-caused disasters result in more
psychiatric morbidity than those that are attributed to
natural events [51]. When events can be attributed to
specific individuals or groups, fear and anger may be
directed towards them. When the human causes
are harder to identify, emotional distress may be
more diffuse and anger may be harder to resolve,
with greater risk for long-term mental health
consequences.
Disasters due to terrorism are a dramatic illustration
of these factors both because terrorist acts are directly
caused by individual agency and because they deliberately aim to maximize the anxiety, insecurity, helplessness and vulnerability of a population [52]. In the
wake of the attacks of 11 September 2001, high levels
of symptomatology were reported not only among
those directly affected at the ground zero, or living in
the city of New York, but across the country. A survey
immediately following the attacks found that 44% of
adults had one or more ‘substantial’ symptoms of
distress [53]; two months later this dropped to
16% [54]. New categories of trauma emerged, like
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vicarious PTSD incurred while watching repetitive
TV images of the attacks [55]. The threat of recurrence
became an ongoing preoccupation, contributing to a
new sense of collective vulnerability.
Of course, the distinction between ‘natural’ catastrophes like earthquakes, tsunami, hurricanes and
human-caused catastrophes like industrial accidents,
war or terrorism depends on specific ways of interpreting events. Some people in the US believe that
government should control the forces of nature; hence
natural disasters can be blamed on human error or
malfeasance [56]. From some religious or cultural
perspectives, all events may have moral meaning as
part of causal chains that include human or spiritual
agency (like karma, sin or divine judgement). Contrariwise, people may view even events caused by human
agency as preordained or following an impersonal
logic. Thus, in the Cambodian genocides perpetrated
by the Khmer Rouge, many people interpreted the
catastrophe as following from their individual kamma
(karma) and so felt a measure of responsibility for
their own misfortune [57]. This attribution mutes the
external expression of anger and desire for revenge
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and urges the survivor to follow a morally upright
path. On the other hand, karma implies an ultimate
moral order that would ensure that the perpetrators of
the atrocities will pay for their actions in future
miserable rebirths. Political circumstances also may
limit any possibilities to name perpetrators and seek
justice or redress.
Even events that seem to be entirely natural exert
their effects unequally on a population in ways that
reveal pre-existing social inequalities and injustices.
In recent earthquakes, the pattern of destruction has
reflected economic disparities and corruption as
those with substandard housing, built by ‘cutting
corners’, were most affected. The flooding of New
Orleans due to hurricane Katrina had differential
effects on the poor and marginalized that reflected
the long history of racial discrimination [58]. Thus a
natural disaster laid bare the structural violence of
society. This social meaning has both material and
moral consequences, influencing who finds safe
haven and looks forward to rebuilding their life and
who endures prolonged displacement, neglect and
despair.
TECHNOLOGICAL DISASTERS
Urbanization and industrialization have brought with
them many benefits but also new types of collective
vulnerability. Mass transportation has created the
potential for accidents that affect hundreds of people
in an instant. New technologies have created new
types of disaster with unique characteristics that follow from their unique physical properties. For example, the release of radioactivity from the Chernobyl
disaster had long-term and long-range effects with an
increase in cancer and other radiation-related diseases [39]. The petrochemical disaster in Bhopal
resulted in an enormous range of respiratory, ocular,
gastrointestinal and other conditions [59]. In both
cases, there were also long-term psychological effects
on the exposed populations, with persistent feelings of
anxiety, depression and medically unexplained
symptoms.
Independent of actual exposure, the conviction that
one has been exposed to toxic chemicals or radiation
may be a risk factor for long-term psychological
distress, even among those who emigrate from the
site of disaster [60]. Those who are evacuated may be
at increased risk for mental health problems owing to
the disruption of their lives. However, those who
remain in the vicinity of an industrial accident may
face the greatest challenge. In the case of the Three
Mile Island nuclear reactor accident, people who
continued to live near the reactor reported feeling less
control over their lives and this was associated, in turn,
with higher levels of somatic, anxiety and depressive
symptoms even years after the event [61].
The legal and political meaning of technological
disasters may bring vulnerable populations into direct
conflict with powerful commercial interests. Technological disasters may be viewed as accidents due to
risks inherent in a useful technology or as stemming
from human errors, action or inaction. To the extent
they are viewed as due to human action, there is always
some person or corporate entity to blame. However,
large corporations often are able to deflect the efforts of
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individuals or groups to seek redress. Ongoing litigation and struggle over restitution from those responsible for the catastrophes can greatly complicate the
prospects for recovery, as illustrated by the protracted
struggles over compensation following the Exxon
Valdez oil spill [62]. The spill disrupted fishing activ-
13.6
ities, creating severe economic hardship, but those who
were plaintiffs in the civil suit suffered greater levels of
stress over the course of the litigation. The persistent
anger associated with perceived injustices that have not
been acknowledged or redressed contributes to longterm distress following technological disasters [63].
WAR AND POLITICAL VIOLENCE
Ethnic conflict, organized violence and wars have
been major causes of suffering, ill health and mortality
throughout history [2]. In recent decades, the number
of victims and survivors of traumatic events has
significantly increased as war, armed conflict and
political upheaval have engulfed civilian populations
worldwide, contributing to additional burden of disease, death and disability. War has always exposed
both combatants and civilians to trauma but, with the
adoption of new methods of warfare, recent years have
seen a dramatic increase in the proportion of civilian
casualties. During World War II, about 50% of the
direct casualties were civilians; in the 1980s this figure
rose to 80% and by 1990 it was fully 90%, with the
largest number being women and children [64].
War and political conflicts have structural causes
and often occur in societies that are already facing
economic hardship. The collapse of formal economies
and the emergence of economic crises in the marginal
areas of the global economy lead to further impoverishment, food insecurity and ethnic and religious
tensions over diminishing resources. Consequently,
predatory practices, rivalry, political violence and
internal wars may erupt [65]. In the last 60 years there
have been over 200 wars and armed conflicts, in which
the main targets are often the poorest sectors of society
and marginalized ethnic groups.
Armed conflict results in significant psychiatric
morbidity but the pattern varies across cultures. In a
study of 3048 respondents in Algeria, Cambodia,
13.7
Refugees fleeing war or persecution are very vulnerable as they cannot count on protection from their own
state, and it is often their own government that is
Eritrean refugees in Ethiopia and Gaza in Palestine,
de Jong, Komproe and Van Ommeren compared rates
of depression, anxiety disorders, PTSD and somatoform disorders among those exposed to armed-conflict-associated violence and those without such exposure [66]. Overall, PTSD was the most common
disorder for those directly exposed to violence, while
anxiety disorders were the most common disorder for
those not directly exposed. There were high levels of
comorbidity of PTSD with anxiety or mood disorders
in Algeria and Cambodia. However, there was also
substantial variation in the overall prevalence and
relative rates of disorders, which was due not only to
the nature or severity of the disorder but to cultural
variations in modes of expression of distress. For
example, in Cambodia, anxiety disorders were more
common than PTSD among those exposed to violence. Somatoform disorders were more common
among those exposed to violence only in the Palestine
sample.
The health consequences of political violence and
wars extend beyond death, disease and trauma-related
psychiatric illness, to include the pervasive effects of
destruction of the economic and social institutions and
the whole fabric of society. As such, the consequences
of violent conflict can be observed not only in individuals – in their biographies and life trajectories –
but also in collective memory and identity and communal strategies for coping with violence and
adversity [65,67].
REFUGEES
responsible for threatening and persecuting them. The
1951 Refugee Convention defines a refugee as someone who ‘owing to a well-founded fear of being
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persecuted for reasons of race, religion, nationality,
membership of a particular social group, or political
option, is outside the country of his nationality, and is
unable to or, owing to such fear, is unwilling to avail
himself of the protection of that country’ [68]. The
Refugee Convention obligates governments to provide a safe haven for those fleeing persecution. However, many countries treat refugee claimants with
suspicion and have policies aimed at discouraging
others from seeking asylum [69]. These policies of
deterrence, which may include detention under harsh
conditions, have serious mental health effects [70].
Epidemiological studies have demonstrated both
short- and long-term effects of trauma on refugee
mental health and disability. For example, a survey
of Vietnamese refugees who resettled in Australia
found that 8% of the participants had mental disorders [71]. Trauma exposure was the strongest predictor of mental health status. Although the risk of a
mental disorder decreased over time, people who
suffered more than three traumatic events had a higher
risk of mental illness after 10 years compared with
people with no traumatic exposure. A longitudinal
study of Bosnian refugees found that fully 45% met
DSM-IV criteria for depression, PTSD or both [72].
A meta-analysis of 56 reports published from 1959 to
2002, representing 22 221 refugees, found that mental
health status was worse among those living in institutional accommodation, with restricted economic opportunity, internally displaced, repatriated to a country
they had fled or with unresolved conflicts in their
country of origin [73]. A study of 1348 refugees from
13.8
Torture constitutes an extreme form of trauma in which
the perpetrator actively seeks not only to threaten the
victim with pain, injury or death but also to dehumanize,
control, humiliate and oppress the victim, and through
them, a whole community [79]. Despite international
efforts to prevent torture as a human rights violation, it
continues to be practised by many countries [80]. The
attack on the World Trade Centre on 11 September 2001
led to an increase in torture practices when many
countries joined the so-called ‘war on terror’, using the
slogan of ‘protecting public security’ to justify the use of
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Vietnam and Laos who were resettled in Canada after
having lived in refugee camps for a variable period of
time, found that although chronic strain (such as flight,
internment and resettlement) was a major risk for
mental health problems, post-migration factors, including support from the ethnic community and the prospect
for integration in the receiving society, were crucial
determinants of outcome [74]. For refugee children as
well as for adults, the quality of their post-migration
reception in the new country is a better predictor than
pre-migration trauma exposure of mental health [75].
Survivors of political violence, persecution or torture, who must flee their countries of origin to survive,
suffer complex losses and transitions associated with
forced migration, the process of seeking asylum and
the enduring dilemmas of exile [69]. The process of
convincing immigration authorities that one has been
tortured and so has a valid claim to refugee status may
in itself become a situation of psychological retraumatization [69,76,77]. This may be exacerbated by the
fact that such individuals may be reluctant to divulge
experiences like torture, rape or other forms of trauma
in health care settings. Refugees also may have continuing fears for the safety of family left behind and
uncertainty about the possibility of reuniting with
loved ones. Despite the profound impact of trauma
on wellbeing, post-migration factors including social
supports, employment and occupational status are
among the strongest predictors of positive outcome [73,74,78]. Effective resettlement policies and
programmes can therefore make a significant contribution to refugee mental health.
TORTURE
torture to extract information – human rights violations
in which health care professionals took part [81–84]. In
reality, torture yields unreliable information and is used
primarilyas a tool for repressingpolitical oppositionand
instilling fear in the community and society at large. The
political use of torture has a corrosive effect on the moral
order of a society and constitutes an important obstacle
to the development of democratic institutions and universal human rights [85].
Compared to other forms of trauma or natural
disasters, torture constitutes a profound violation of
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personal integrity and dignity because it undermines
the moral basis of human relatedness and community.
Perpetrators create a situation of extreme powerlessness, uncertainty and loss of control in their victims,
but the effects of torture spread far beyond the immediate victim to include fragmentation of family and
community networks through the spread of fear and
mistrust, and the erosion of social and political
solidarity [86–90].
Torture involves a wide range of methods of physical
and psychological abuse with diverse consequences for
survivors. Rape and related forms of sexual torture have
especially severe effects for both men and women [91].
Survivors who had strong political convictions and
were prepared for the possibility of being tortured due
to their activism generally fare better than those for
whom the torture was arbitrary or unrelated to their
convictions [92,93]. Many forms of torture leave victims with profound feelings of shame, guilt and disgrace because of the powerlessness, degradation and
humiliation they have experienced, and this may impede help-seeking [94,95]. Individuals who must continue to live in proximity to the perpetrators of violence
and torture must suppress or ‘manage’ their feelings to
maintain the social order [96,97].
Common sequelae of torture include symptoms of
anxiety, depression and symptoms of acute stress
disorder with dissociative symptoms [98]. Post-traumatic stress disorder (PTSD) is very common among
survivors and its likelihood increases with the severity
of the torture [83,93,99]. Other common symptoms
that may occur with PTSD or independently include:
chronic pain, sexual dysfunction, phobias, nightmares, memory impairment, social withdrawal, difficulty maintaining intimate or long-term relationships,
and psychotic-like symptoms including ideas of re-
13.9
GENOCIDE
The United Nations Convention on the Prevention and
Punishment of the Crime of Genocide (CPPCS),
defines genocide as:
. . . any of the following acts committed with intent to
destroy, in whole or in part, a national, ethnical, racial
or religious group, as such: killing members of the
ference and superstitious thinking. Chronic pain may
reflect neuropathic damage from torture, links between bodily sensations of memories of torture, processes of somatic amplification due to psychological
distress and culturally shaped idioms of distress that
encourage a focus on the body [100–102].
Feelings of violation, anger and injustice, while not
always correlated with PTSD or another psychopathology, may constitute significant clinical problems in their own right [103]. The anger and aggression that survivors often experience as a consequence
of their torture experiences may be displaced on to
other people, particularly their families. Even when
there is no overt conflict or abuse within the family,
children may be strongly affected by the suffering of
their parents and the community. For example, Punamaki, Qouta and El Sarraj found that exposure to
traumatic events increased Palestinian children’s political activities and psychological adjustment
problems’ – both effects were independent of the
quality of perceived parenting [104]. Rehabilitation
interventions therefore must be extended to include
the families and communities of the victims.
Treatment of survivors of torture requires a broad
perspective on mental health that encompasses family,
community and the politics of social integration.
Community-based approaches have become increasingly accepted as an integral part of treatment. This
model calls for a broader role for health professionals
as advocates and facilitators who work collaboratively
with other nonmedical professionals from law, media,
community development and human rights to promote
empowerment as survivors are assisted to help themselves. The focus of rehabilitation is on strengths
rather than weaknesses, resilience rather than vulnerability, health not disease.
group; causing serious bodily or mental harm to
members of the group; deliberately inflicting on the
group conditions of life, calculated to bring about its
physical destruction in whole or in part; imposing
measures intended to prevent births within the group;
[and] forcibly transferring children of the group to
another group.
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The Holocaust and other genocides (e.g. in Rwanada, Bosnia–Herzegovina, Darfur) have starkly presented the immediate and transgenerational effects of
massive human rights violations and the systematic
destruction of communities [105]. Despite recognition of these catastrophes, there has been a tragic lack
of political will in the international community to
intervene in ways that could prevent or mitigate the
loss of life.
Clearly genocide, involving violence on a massive
scale, can have severe effects on survivors’ mental
health. A study of four communities affected by the
genocide in Rwanda found the prevalence of PTSD
symptoms depended on traumatic exposure and varied
from 12.2 to 33.8% [106]. A study of refugee survivors
of the genocide in Bosnia-Herzegovina who resettled
in Australia found no differences in PTSD risk for the
group most exposed to human rights violations (internment in concentration camps, torture) compared
to the general war-exposed group [107]. Exposure to a
threat to life predicted PTSD, while both threat to life
and traumatic loss were associated with symptom
severity and disability.
Mass human rights violations such as those that
occur in situations of political violence, ethnic cleansing or genocide have effects at many levels. At the
level of the individual, Silove has described these
effects in terms of different adaptive systems, including systems involved in safety, attachment, sense of
justice or fairness, existential meaning and social role
or identity [87,108]. Each of these biosocial systems
gives rises to specific forms of distress in response to
specific types of threat or loss (Table 13.1). There are a
variety of psychological and social adaptive responses
that aim to re-establish the normal functioning or
equilibrium of the system and when those fail, particular forms of psychopathology may result. Intervention strategies can be viewed as acting to restore these
adaptive functions. These same mechanisms operate
in other forms of trauma and disasters to varying
degrees.
There has been much interest in the possibility of
transgenerational transmission of trauma in the context of genocide [109,110]. Clearly, however, the
experience of the second and third generation is not
precisely the same as the first and the pathways of
transmission point also to a transformation in the
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nature of suffering. A parent who has endured great
trauma in a concentration camp may react in many
ways: with irritability, distraction or overprotectiveness. Each of these will have different effects on the
child, all of which might be attributed to the parent’s
trauma. In most cases, these are not PTSD but problems in adjustment, anxiety, interpersonal relationships and so on.
Yehuda and colleagues examined transgenerational trauma in a group of adult offspring of Holocaust survivors and a demographically similar comparison group [111]. Although adult offspring of
Holocaust survivors did not experience more traumatic events, they had a greater prevalence of current
and lifetime PTSD and other psychiatric diagnoses
than the demographically similar comparison subjects. The findings demonstrate an increased vulnerability to PTSD and other psychiatric disorders
among offspring of Holocaust survivors, thus identifying adult offspring as a possible high-risk group
within which to explore the individual differences
that constitute risk factors for PTSD. Other studies
have little evidence of increased psychopathology in
the second- and third-generation children of Holocaust survivors [112].
Individual stories of trauma serve to ground collective identity and call for a moral and political
response. The appropriation of trauma to stabilize a
collective identity may have benefits for the individual. There must be a public place for stories of trauma
for them to be told, acknowledged and legitimated.
Collective identity, history and legal mechanisms can
play a role in creating this place. Transgenerational
links may serve psychological and political functions,
becoming a central theme in the individual’s identity
and a basis for the political aspirations of a group or
even a nation [113].
For example, for indigenous peoples in North
America, current mental health problems prevalent
in some communities have come to be seen as the
consequence of historical trauma following from
European colonization of the Americas and subsequent policies of forced assimilation [114,115]. The
effort to survive as a people when a whole way of life
has been undermined and dismantled poses special
social, moral and psychological challenges that are
not captured by constructs like PTSD [116,117].
Avoidance of danger
Maintenance of bonds
of family and community
Maintenance of social
equity, exchange and
reciprocity
Maintenance of positively
valued sense of self and
personhood
Maintenance of cognitive
coherence and stability
of plans
Safety and security
Attachment
Justice, fairness,
equity
Social role,
identity
Existential meaning
Reclamation, revitalization or
reinvention of tradition
Confusion
Destruction, suppression or
denigration of core
symbols and way of life
Disorganization
Rebuilding community
and institutions
Aimlessness
Destruction, suppression or
denigration of social and
economic institutions
Social activism
Confusion
Restitution and redress
Reassertion of rights
Seeking safety and reassurance
Self-soothing
Protectiveness toward self and
others
Cognitive mastery of fear
Mourning and bereavement
rituals
Reaffirming and establishing
bonds with others
Adaptive strategies
Loss of work and status
Lack of trust
Suspicion of others
Homesickness
Anger
Nostalgia
Loss of place or other
objects of attachment
Discrimination, injustice,
human rights violations
Grief
Fear
Hypervigilance
Fight or flight
Initial response
Loss of loved ones
Injury or death
Threat
Adapted from References [87] and [108]; modified with observations from Reference [47].
Function of system
Adaptive system
Adaptive systems affected by severe trauma, torture and human rights violations
Isolation
Withdrawal
Despair
Passivity
Demoralization
Helplessness
Paranoia
Antisocial
behaviour
Alienation
Chronic anger
and mistrust
Panic disorder
Depression
Anxiety
PTSD
GAD
Pathological
outcomes
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Table 13.1
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13.10
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INTERVENTIONS
Current clinical guidelines for the treatment of trauma
emphasize cognitive behavioural therapy, exposure
therapy and the treatment of comorbidity (most often
depression, anxiety disorders, substance use) [118].
There is some evidence for the effectiveness of trauma-focused psychotherapeutic interventions for individuals with persistent trauma-related symptoms or
PTSD [119].
Prolonged exposure therapy aims to allow extinction of conditioned emotional responses of fear. Cognitive behaviour therapy works more broadly to
change modes of interpreting and responding to
trauma cues, reduce catastrophizing thoughts and
reinforce adaptive coping. Narrative exposure therapy
involves a blend of approaches and can be used with
both children and adults across cultures [120–122]. It
involves constructing a life narrative than includes a
review of traumatic experiences, revisiting the associated emotions and bodily feelings to allow habituation to the physiological arousal; the process of narration gives the trauma memories and experiences
structure through retelling and composing a written
testimony.
Although antidepressants and other medications are
widely used, there is little evidence for the effectiveness of pharmacotherapy in the treatment of PTSD or
trauma-related disorders [123]. Treatment is usually
symptomatic, to improve sleep, control pain and treat
concomitant depression and anxiety. Beta-blockers
have been used to reduce autonomic arousal. There
is intriguing evidence that the use of propranolol
during a guided process of trauma recall can diminish
emotional arousal on subsequent recollection without
the presence of the medication [124]. This raises the
prospect that it may be possible to decouple trauma
memory from some of its distressing and disabling
physical effects.
There is increasing recognition of the need to consider mental health issues in disaster relief. The 2004
guidelines produced by the Sphere Project, which
involved a global consultation process to establish
minimum standards for humanitarian response, cover
mental health for the first time [125]. There is an
emerging consensus on best practices in disaster management, although the evidence base is limited [126].
The WHO Report on ‘Mental Health in Emergencies’
and the Inter-Agency Standing Committee (IASC)
emphasize that it is crucial to protect and improve
people’s mental health and psycho- social wellbeing in
the midst of an emergency through (a) psychological
first aid provided by a variety of community workers
for people experiencing acute trauma-induced distress
and (b) care by trained and supervised health staff for
people with severe mental disorders, including severe
PTSD [127,128]. The principles of psychological first
aid include: maintaining a calm presence, providing a
safe and comfortable setting, stabilizing emotionally
overwhelmed survivors, gathering information about
current needs and concerns, providing practical assistance, giving information about common psychological reactions and appropriate coping strategies, and
linking the individual with local services and sources
of further help. Humanitarian aid workers and community leaders need training in the basic psychological
skills required to provide psychological first aid, emotional support and recognition of common mental
health problems that should be referred to professionals [129].
Despite the consensus on best practices in an initial
disaster response, there are still many questions about
appropriate interventions. The interventions offered in
disaster situations are diverse and include material
support (shelter, food, clothing), psychoeducation,
psychological debriefing, cognitive behavioural therapy (CBT), narrative exposure therapy, eye movement
desensitization and reprocessing (EMDR) and community-based interventions. CBT and narrative exposure therapy have been shown to be helpful for
individuals with trauma-related PTSD [122,130], and
community-based approaches that work towards
strengthening social supports and reintegration may
fit better in some cultural contexts [131]. However,
there is a lack of strong evidence for any specific
treatment.
Although exposure therapy has proven effective for
isolated discrete traumas, it remains uncertain
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whether it is equally effective for those exposed to
multiple, repetitive or pervasive trauma like that seen
in survivors of torture or genocide [132,133]. There is
little evidence that psychoeducational approaches can
help prevent post-traumatic disorder or other types of
psychological distress [134]. While there may be other
benefits from existing interventions, and they may
work for some individuals or groups, more work is
needed to identify effective prevention strategies.
Psychological debriefing, which until recently was
a popular intervention, is no longer recommended.
Debriefing is based on the assumption that retelling
the trauma story provides emotional release, relearning and cognitive reorganization. One influential version was developed as a group intervention in the US,
as a support method for fire fighters [135]. This was a
work group of professionals who knew each other,
who were exposed to similar traumatic events, were
trained to respond to disasters and remained connected to a larger stable social environment. All of
these contextual elements may not be present when
the method is applied in other settings: the people
affected may have been thrown together by the events,
they may have experienced very different levels and
types of threat and loss, they may face a profoundly
disrupted social environment and they may come from
a cultural background that does not encourage open
expression of private feelings or potentially shameful
events. Even in the US, there is evidence that the
intense re-exposure that may occur in psychological
debriefing can retraumatize some individuals.
The funding and delivery of humanitarian aid is
increasingly organized on an international level to
facilitate faster and more effective responses to major
13.11
emergencies affecting large numbers of people. As a
result, however, disaster scenes may be inundated by
mental health professionals and other disaster workers
who further strain local resources and inadvertently
contribute to the problems rather than to their solution.
There is agreement that post-disaster strategies
must address the broad impact of disasters, promoting
a sense of safety, calming, self- and collective efficacy,
feelings of connectedness and hope [136]. Translating
these general goals into specific interventions, however, requires consideration of individual and community psychology, an ecosocial perspective and
awareness of local social, economic and political
constraints and cultural meaning systems. Cultural
issues have been only minimally integrated into current disaster guidelines [137].
Cultural issues raise important considerations in the
practical response to disaster that may have mental
health consequences. Efforts to rebuild infrastructure
that do not sufficiently consider the social and cultural
context may have negative effects on post-disaster
adaptation. Following the 2004 tsunami, large quantities of aid poured into several Asian countries (in part
because foreigners saw the tsunami as a blameless
misfortune) and communities pulled together to confront and cope with adversities [138]. In Sri Lanka, for
example, the aid was used to reconstruct housing in
ways that have proved problematic for some communities. Fishermen were moved inland and resettled in
houses built without the accustomed level of privacy,
organization of interior space and ability to accommodate extended family [139]. Lack of attention to
cultural context undermined the effectiveness of this
well-intentioned support.
CONTINUING CONTROVERSIES
In addition to the unresolved questions about
treatment efficacy, there are broader controversies
in the field of trauma and disaster mental health,
concerning the cross-cultural applicability and utility of the diagnosis of PTSD; the value of testimony or explicit talk about trauma versus containment; and the role of Truth and Reconciliation
Commissions or other forms of restorative justice
in recovery.
The construct of PTSD has been valuable for focusing attention on one specific form of anxiety response,
but limited in terms of the wide range of impacts and
the importance of other personal and social factors in
producing resilient outcomes or prolonged suffering
and pathology. The field of trauma and disaster psychiatry is far wider than the compass of PTSD.
Although the symptoms of PTSD can be identified
across cultures, its clinical and social relevance
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remain contentious. Structured diagnostic interviews
and self-report scales based on the diagnostic criteria
for PTSD have been translated into local languages,
permitting investigators to distinguish trauma-related
disorders from similar kinds of psychological distress.
Other scales are available to assess the level of trauma
exposure and trauma-related symptomatology [140].
These include the Harvard Trauma Questionnaire
(HTQ) and measures for assessing anxiety and depression [141]. These instruments can be adapted to
new cultural groups, though problems of clinical and
cultural validity remain [142]. However, symptoms
tend to be nonspecific indicators of distress and, in
themselves, do not demonstrate the presence of a
discrete disorder of clinical significance. Measures of
functional impairment are essential to define a threshold for disorder warranting clinical attention.
Critics argue that mainstream approaches to diagnosis and treatment overlook the extent to which
trauma experience is culture-specific. The Western
discourse on trauma is embedded in a particular
cultural and moral framework and becomes problematic in other cultural contexts [143]. Personal, political, social and cultural factors mediate the experience of war or other forms of violence. Practitioners
unfamiliar with the local culture and situation apply
generic assessment tools and interventions that force
individuals into a limited repertoire of categories and
responses [144]. People are encouraged to understand
their suffering through the prism of individualistic
psychological models that may not fit local values and
concepts of the person [145]. As well, the dominance
of the PTSD model tends to suppress other approaches
and silence local perspectives on what is helpful and
important in the wake of a disaster.
The distress and suffering that accompany war or
other forms of collective violence are not necessarily
pathological responses to traumatic events, but may be
normal responses to existential predicaments [146].
Such suffering is resolved in a social context through
familial, sociocultural, religious and economic activities that make the world comprehensible for people
before, during and after catastrophes [14,147].
The roots of recovery from trauma and disaster lie in
the restoration of the functional social environment,
i.e. through improved living conditions, activities,
employment, a stable community and social order.
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On this view, instead of offering psychological counselling, humanitarian aid programmes should acknowledge resilience and retain the social rehabilitation frameworks, starting with the strengthening of
damaged local capacities in line with local
priorities [148].
A related controversy concerns the appropriate
strategy for dealing with severe trauma of the sort
found among refugees and survivors of torture. While
some approaches to rehabilitation of survivors of
torture, genocide or other human rights violations
emphasize the importance of giving testimony, this
may not fit well with all social, cultural or religious
contexts. The value of testimony has been embraced in
Latin America and taken up by the International
Rehabilitation Council for Torture Victims in Copenhagen [149]. However, many Asian traditions emphasize the values of equanimity and containment and
may view the open airing of suffering as unhealthy and
disruptive to the social order. Political and mental
health goals then come into conflict with social norms
and cultural values and the implications of this for
trauma outcomes remain uncertain. Part of the benefit
in telling one’s story comes from giving it a coherent
frame, part comes from having a sympathetic other
person bear witness and part comes from the larger
social–historical process of recording a personal and
collective truth. However, all of these depend to some
extent on the social reception of the testimony. Further
work is needed to understand the tradeoffs involved in
speaking out or remaining silent in specific social,
cultural and political contexts [150,151].
The functions of testimony have taken on new
dimensions in the context of Truth and Reconciliation
Commissions like that of South Africa, which aim to
restore justice and moral order to a community rent by
longstanding political violence and injustice. This, in
turn, has raised questions about the social mechanisms
for reconciliation and forgiveness that hope to repair
both the justice and existential systems by ensuring
public acknowledgement of past human rights violations and providing a healing ritual that brings some
closure to otherwise unassimilable events. The metaphor of the psychological wound and the notion of
healing have governed the truth and reconciliation
process. However, this is an inaccurate or incomplete
model of the complex psychological and social
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processes put into play; the process involves issues of
justice, equity and safety as well as woundedness and
wholeness [152].
The ability of victims and their families to participate in legal proceedings or other public means of
holding perpetrators accountable may provide comfort for them; it may also act as an effective tool for the
prevention of torture [153]. In some instances, however, the truth and reconciliation process can be
harmful to participants. Individuals who already have
PTSD may benefit little and may have their traumatic
memories activated and experience an exacerbation of
13.12
their condition [154]. The public, ‘quasi-legal’ context of the Truth and Reconciliation Commission may
be threatening to some people and destabilizing for a
community. Mental health practitioners have a role to
play to ensure that the process of recounting does not
cause further damage. This may involve helping to
design a setting and procedure that is therapeutic (e.g.
by giving control to the narrator) and supporting
individuals participating in Commission hearings [155]. Other forms of restorative justice based
on traditional methods of conflict resolution face
similar challenges when applied to mass violence.
CONCLUSION
Trauma has become a dominant trope in discussions of
the contemporary world [156]. Like any metaphor it
reveals and it conceals. What the metaphor of trauma
reveals is the supervenient effects of extreme violence
on suffering. Even healthy people can be torn down
and permanently marked by the most severe forms of
violence. Yet the response of most people, even to
serious trauma, is resilience and recovery.
A social and cultural perspective suggests that it
is crucial for clinicians to understand traumatic
events and disasters in their broader social, economic and political context. These politics shape
the production of psychiatric knowledge about trauma, the personal social and cultural contexts that
are singled out for clinical attention, the ways that
professionals and institutions apply trauma diagnoses and treatment, the dynamics of social support
and the processes of conflict resolution. Although
violence always has very personal impacts, it is
clear that states, international organizations, global
economic institutions and mass media are all involved in the creation, maintenance and resolution
of the conflicts that lead to structural, interpersonal
and mass violence [157]. Suffering is fundamentally
a social experience in several ways: it involves an
interpersonal engagement with pain and hardship
lived in intimate and communal social relationships;
it is framed in terms of available cultural models of
the nature of adversity and corresponding appropriate moral responses; and it is part of professional
discourses of medicine and the mental health pro-
fessions that organize forms of suffering as
bureaucratic categories and objects of technical
intervention [158].
Understanding stories of trauma requires an understanding of the collective dimensions of violence
and social suffering. Trauma experience is embedded in and emerges from multiple contexts,
including biological processes of learning and memory; embodied experiences of injury, pain and fear;
narratives of personal biography; the knowledge and
practices of cultural and social systems; and the
power and positioning of political struggles enacted
on individual, family, community and national
levels [27].
The language of trauma, however, tends to draw a
simple arc from the violent event through the psychological processes of the individual (where they may
exhibit resilience or vulnerability) to bodily symptoms of affliction. In reality, the events we call trauma
are part of larger configurations of suffering that have
their own social ecology and political economy. Discrete trauma and disasters occur against a backdrop of
structural violence that renders some groups and
individuals far more vulnerable; focusing exclusively
on the trauma may deflect attention from these enduring forms of disadvantage – in some instance,
however, a catastrophe may throw these into stark
relief as was seen, for example, with hurricane Katrina. It is important for mental health practitioners
and psychiatric researchers to appreciate these larger
social contexts of suffering. Without such awareness,
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we risk becoming part of the machinery that deflects
attention from social inequalities and structural violence on to individuals’ psychology.
The war on terror, global warming and the press of
humanity seeking to escape political violence and
natural catastrophes all make the problems of trauma
and disaster important issues in contemporary psychiatry. We need a body of research that takes social
and cultural context carefully into consideration and
clinical approaches that address the real concerns of
individuals, families and communities responding to
the range of challenges brought by trauma and disaster
in all their myriad forms.
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