On the Importance of Considering Culture When Defining Trauma
September 24, 2013
Post-traumatic stress disorder (PTSD) is a unique psychiatric diagnosis, one of the few disorders with an etiology specified in the DSM criteria. The definition of Criterion A, considered the gatekeeper for the diagnosis, as well as the controversies about what constitutes a traumatic event, have been at the core of the discourse regarding PTSD (Weathers & Keane, 2007). Not only is PTSD based on the experience of certain factual, objective traumatic stressors, but it also includes an assessment of the immediate reactions to the traumatic stressor, captured formerly by DSM-IV A2 criteria and currently by DSM-5 alterations in mood/cognitions criteria (APA, 2013; Friedman, Resick, Bryant, & Brewin, 2011).
During the lengthy process that led to the publication of DSM-5, critiques ranged from restricting the scope of experiences included within the category of Potentially Traumatizing Events (PTEs)(Friedman at al., 2011), to eliminating the subjective assessment introduced by the DSM-IV in Criterion A2 (Pereda & Forero, 2012), and even abolishing Criterion A altogether (Brewin, Lanius, Novac, Schnyder, & Galea, 2009). In spite of the significant changes in PTSD Criterion A between the DSM-IV and DSM-5, the influence of cultural factors remains unknown and in need of consideration as far as (1) the objective definition of a traumatic stressor, and (2) the subjective reactions to the traumatic stressor.
Objective definition of a traumatic stressor
The cross-cultural validity of any of the definitions of trauma that had been in use since 1980 or, in fact, even the relevance in other cultures of the specific issues raised in these debates remains elusive (Hinton & Lewis-Fernández, 2011). However, the frequent changes to the definition of traumatic events may have inadvertently accentuated the importance of addressing the culture-specific dimension of trauma and with that, the need to assess severe stressors within their social-political-moral context (Kleinman & Kleinman, 1991). This type of approach could assist researchers and practitioners to become more cognizant of systemic cultural issues, such as microaggressions, racism, ageism, heterosexism, community violence, economic instability and human security (Bajpai, 2000).
Conversely, most cross-cultural studies refrain from investigating whether the actual concept of trauma is inherent or innate to cultures other than the Western culture. It has been suggested that the identification of specific stressful life events as causing psychiatric disability that requires medical intervention is a social construct (Summerfield, 1998; Summerfield, 2001) and therefore culture-specific and not necessarily fitting the complexity of expressed distress across the differing contexts in which people endure traumatic experiences (Bracken, 2002). Furthermore, using the Western construct of trauma puts the focus on individual experiences rather than on social and political realities (Summerfield, Loughrey, Nikapota, & Parry-Jones, 1997) that are often at the root of the traumatizing events. In fact, different cultures may have different labels of experiences (Drožđek & Wilson, 2007). Indeed, a growing body of evidence suggests that cultural factors influence which communities are more likely to experience traumatic events; this in turn has historically influenced what events are included in Criteria A1 (Smith, in press).
Definition of experiences as “traumatic” are often influenced by societal and professional outcry (Hoshmand, 2007), which can be influenced by the nature of communities with traumatic experiences and the rates of traumatic event exposure. It is quite evident that culture, in its wider definition, is related and may even dictate rates of exposure to trauma (Roberts, Gilman, Breslau, Breslau& Koenen, 2011).
For example, communities with low socioeconomic status (SES) face greater exposure to community violence, with women specifically being more vulnerable to sexual assault and domestic violence and men more vulnerable to physical assault (Ghafoori et al., in press). Refugees experience higher rates of trauma exposure than non-refugees, a status which may have been engendered by other identity variables, such as ethnicity (Keller, 2006). Lesbian, gay, bisexual and transgender (LGBT) persons experience higher rates of trauma exposure than heterosexual individuals (Brown & Pantalone, 2011; Balsam, Rothblum & Beauchaine, 2005), in addition to high rates of normative loss (e.g. family and peer rejection) that LGBT populations face (Brown, 2003).
Subjective reactions to the traumatic event
Although the DSM-5 no longer includes Criterion A2, it is likely that the meaning assigned to an event affects whether it is considered traumatic by members of a specific cultural group. The DSM-5does still link emotional responses with traumatic events under the umbrella of “pervasive negative emotional states including fear, horror, anger, guilt, or shame” as one of the mood/cognitions criteria (APA, 2013). It is imperative to have more research on emotional reactions to traumatic exposure in different cultural groups as these symptoms may be influenced by the cultural meaning associated with the traumatic event. Inversely, the cultural experience of these emotions may impact the very perception of the event and the complexity of its effect (Caspi, 2009).
The topics of trauma, responses to traumatic events, and healing/treatment of affected individuals and communities, which will continue to be addressed in later volumes of Traumatic StressPoints, are inseparable from the culture-specific construction of the relationship between individuals and their environments. As researchers and clinicians we must not undertake the task of defining and describing traumatic symptomatology and designing effective interventions without challenging what we consider as “traumatic.”
In effect, our definitions and attitudes toward trauma can impact our detection of base rates (Hoshmand, 2007) and consequentially the resources allocated to prevention and treatment. Looking at how culture impacts the definition, emotional salience, and exposure rates of traumatic events can only enrich our understanding of the construct of trauma.
About the Authors
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. Yael 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.
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.
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 impacts of complex trauma and corresponding interventions, cultural impacts on trauma symptomatology, and complex trauma's impact on health and risky health behaviors.
Ateka Contractor, MA, is a third-year doctoral student (clinical psychology) at University of Toledo. She has 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 comorbidity with depressive and impulse-based disorders using structural equation modeling techniques.
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