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Given that culture permeates every facet of human behavior (Kleinman et al. 1978; Littlewood and Lipsedge 1987), and that trauma and its aftereffects are experienced and processed by individuals, families and the culture at-large in ways that are both universal and culturally specific (Boehnlein, 2002), researchers and clinicians in the field of traumatic stress are required to deepen their understanding of the interplay of psychological trauma and culture.

Not only are we obligated to address the diverse and culturally grounded world we are living in, but also the unraveling of culture and its many varied dimensions serves to expand our overall knowledge of trauma in all aspects, including exposure, meaning, biology, symptoms, repercussions, treatment and prevention. This increased understanding can only occur if we think about culture in a richer way than an item on a demographic scale or membership within a category.

The U.S. National Institute of Mental Health (NIMH) also recognizes this need by including enhanced “understanding of how cultural diversity may influence the developmental trajectories of mental illness” as part of their four research priorities (“Strategy 2.2,” 2012). The NIMH also specifies that research move beyond the descriptive toward a “more explanatory focus on the mechanisms by which specific components of cultural experience (e.g., beliefs, stigma, acculturation pressures), combined with biological factors, impact mental health outcomes and differential responses to preventive and treatment interventions.” Specifically, the need for sensitivity to cultural issues in diagnosing PTSD was addressed by the authors of the DSM-5 white paper monograph, A Research Agenda for DSM-V, in their chapter “Beyond the Funhouse Mirrors: Research Agenda on Culture and Psychiatric Diagnosis” (Alarcon et al., 2002).

As an international organization, ISTSS has tried to ensure that more diverse experiences and perspectives are represented in the dialogue on trauma; however, increased focus on cultural aspects associated with traumatic experiences, treatment, and recovery is necessary to enhance our understanding of the full lived experience of the trauma survivors with whom we work. 

The construct of Posttraumatic Stress Disorder is an extraordinarily rich area of research in cultural psychiatry and cultural diagnosis (Boehnlein & Alarcon 2000), particularly because charges of Western-centrism have been more intense for it than for other clinical entities (Boehnlein & Kinzie 1992; Marsella et al. 1996; Young 1995) and many groups have been shown to have a disparately high risk for PTSD development (e.g. women; ethnic minority individuals; lesbian, gay, bisexual and transgender individuals) (Gaillot, 2010; Gilman et al., 2001).

Scholarship has suggested several universal and culture-specific aspects of the relationship between psychological trauma and culture. Proposed universal aspects include the existence of traumatic events (Drožđek, 2007; Marsella, 2010; Marsella, Friedman, Gerrity, et al., 1996; Wilson, 2007) biological responses to stressors (e.g., fight-or- flight response) (Marsella, 2010; Marsella, Friedman, & Spain, 1996) and psychobiological impact of traumatic stress (Friedman, 2000; Wilson, Friedman, & Lindy, 2001). 

Culture-specific aspects appear to include: one’s cultural position in respect to type and amount of traumatic exposure (e.g., Brown & Pantalone, 2011; Balsam, Rothblum & Beauchaine, 2005); cross-cultural differences in the meaning of the criterion A2 across cultures and within a culture (reviewed in Hinton & Lewis-Fernández, 2010); cultural influence on coping with trauma-related stress (Marsella & Christopher, 2004; Wilson, 2007); culturally appropriate treatment of both the survivor and the survivor’s family and friends (Drožđek, 2007; Marsella, 2010; Marsella & Christopher, 2004; Patel, 2000; Pole, Gone, & Kulkarni, 2008); and cultural aspects of symptom expression (reviewed in Cohen et al., 1998; Frey, 2001; Kirmayer & Sartorius, 2007; Marsella & Christopher, 2004; Marsella, Friedman, Gerrity, et al., 1996; Pole et al., 2008; Wilson, 2007).

Although an increasing number of scientists and trauma professionals now recognize that many aspects of trauma-related difficulties are shaped by cultural determinants (Drozdek & Wilson, 2007; Marsella, 2010; Wilson, 2007; Wilson & Tang, 2007), much effort is needed to educate and train trauma professionals on the implications this has for diagnosis, assessment, and treatment. Resistance to considering the role of culture in trauma-related disorders continues.  For example, many clinical and research procedures and protocols fail to include a focus on cultural factors that may influence symptom presentation or treatment response. This is particularly interesting considering across common traumas and cultural groups, professionals consistently find variations in symptom expression as well as response to treatment.

The welcoming of cultural realities into the trauma recovery/treatment experience can be a challenge to us as providers. It requires us to acknowledge how our own identities (areas of privilege and oppression) impact our work and presence in the treatment room, how our cultural identities and history shape our conceptualization of trauma and recovery, and pushes us to acknowledge the boundaries of our knowledge, and to be open to being informed about other realities (Brown, 2008). Without this, however, we have an inadequate understanding of our work and of trauma. Professional organizations such as ISTSS can play an important role in promoting awareness and highlighting the need to assess for the cultural determinants of trauma, consistent with its goal of addressing the diversity of trauma-based clinical and research work.

In upcoming issues of StressPoints we will attempt to highlight the discussion on the relationship between trauma and culture through a focus on several specific areas, such as the experience of traumatic events and their meaning; manifestation of trauma-related distress; coping; barriers to care and treatment approaches and the impact on family.

About the Authors

Ateka Contractor, MA,is a third-year doctoral student (clinical psychology) at University of Toledo. She obtained her master’s degree in clinical psychology at Eastern Illinois University. Her main research and clinical interests are the interaction between PTSD and culture, and PTSD's comorbidity with depressive and impulse-based disorders using structural equation modeling techniques.
Laura Johnson, PsyD, is a clinical psychologist at the Edith Nourse Rogers Memorial Veterans Hospital in Bedford, MA. Her main research and clinical interests are trauma recovery, multicultural competence, and lesbian, gay, bisexual and transgender communities' (LGBT) mental health needs. She is the chair of the LGBT special interest group at ISTSS.

Bita Ghafoori, PhD, is a doctoral level clinical psychologist and a professor of counseling at California State University Long Beach. Her current research focuses on mental health disparities in traumatized populations, cultural considerations in the assessment and treatment of traumatic stress, and the dissemination of evidence-based, trauma focused therapies.

Yael Caspi, ScD, MA, is a doctoral level clinical psychologist and a researcher. She is the director of the veterans' psychiatric outpatient services at the Rambam Medical Health Center in Haifa, Israel. She received her ScD degree from the Harvard School of Public Health in Boston, where she investigated the impact of refugee trauma in a community sample of Cambodian refugees. During the past few years she has been writing and advocating for increased awareness of war trauma and its impact on Bedouin servicemen in the Israel Defense Forces and their families.
Stefanie F. Smith, PhD, is a doctoral level clinical psychologist and associate professor at the California School of Psychology at Alliant International University, San Francisco Clinical PsyD Program.  Her main research and clinical interests include neurophysiological and sensorimotor effects of complex trauma and corresponding interventions, cultural influences on trauma symptomatology, and complex trauma's impact on health and risky health behaviors. 
Elisa Triffleman, MD, is a psychiatrist and chair of the ISTSS Diversity Committee, a group within ISTSS that focuses attention on the overlap between diversity and trauma in the field and within ISTSS. She lives in Port Washington, NY.


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