Traumatology http://tmt.sagepub.

com/

Introduction to Special Issue: Culture and Trauma

Sandra Mattar, Boris Drozdek and Charles R. Figley Traumatology 2010 16: 1 DOI: 10.1177/1534765610385927 The online version of this article can be found at: http://tmt.sagepub.com/content/16/4/1

Published by:
http://www.sagepublications.com

Additional services and information for Traumatology can be found at: Email Alerts: http://tmt.sagepub.com/cgi/alerts Subscriptions: http://tmt.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav Citations: http://tmt.sagepub.com/content/16/4/1.refs.html

>> Version of Record - Jan 28, 2011 What is This?

Downloaded from tmt.sagepub.com by Madalina Cotiga on April 10, 2012

Introduction to the Special Issue on Culture and Trauma

Introduction to Special Issue: Culture and Trauma

Traumatology 4 16(4) 1 The Author(s) 2010 Reprints and permission: http://www. sagepub.com/journalsPermissions.nav DOI: 10.1177/1534765610385927 http://tmt.sagepub.com

In recent years there has been a significant growth in the field of trauma psychology due to developments in traumatology studies. A parallel growth phenomenon has occurred in the field of multicultural psychology. Rarely, however, have these two schools of thought come together within the context of mainstream psychology. The trauma field has paid a significant amount of attention to evidence-based treatments and randomized controlled trials and has marginalized the cultural context of suffering. Likewise, cultural psychology, while addressing trauma as a part of its discourse, seems to be disconnected from the developments in the traumatic stress field. Although advances in trauma studies, empirical research, and cultural psychology are welcome developments in the mental health field, there are multiple challenges that lie ahead when it comes to the implementation of knowledge. One important challenge is how to culturally translate the evidence provided in the traumatic stress study field. Another challenge is how to conceive and develop trauma-informed, culturally responsive, and client-friendly approaches. The latter is a significant factor in promoting more culturally sensitive treatments (U.S. Department of Health and Human Services, 1999). Yet another major challenge facing psychology today is how psychological treatments developed in one country and culture can be transferred to another culture. The underlying assumption behind the dispersal of these treatments is that we know what is better for them. This statement is materialized in disaster interventions across the world. Disaster psychologists have laudable intents in their interventions, but the impact of their actions on the postdisaster communities worldwide is not always positive. To address culture, an increasing number of practitioners and scholars in the trauma field have focused on culturespecific interventions emphasizing differences among different cultural groups. We propose that rather than focusing on specific cultures and how they handle trauma we need to make fundamental conceptual revisions of the current approaches to the study of trauma, and create new ones. These new approaches should include reconceptualizations of our notions of self, health, resilience, and trauma, and very important, a deep exploration of the multiple realities determined by context. The prevailing pathogenic-disease paradigm, in relation to our understanding of post-traumatic psychological damage, requires supplementation by a positive psychology advocating holistic health. We also need to include a discussion on the most appropriate scientific methods to address

the needs of the diverse populations. Finally, we need to create trauma assessment instruments that address the multiple cultural realities of our clients. Community-based studies that consider the natives point of view (Geertz, 1979) are a necessary component to promote external validity. We believe that one of the best ways to integrate culture and trauma is to do a serious revision of the range of applicability of the scientific method, to state the limitations of quantitative approaches, and to incorporate methodologies that best suit multicultural populations (i.e., qualitative methods, ethnographic approaches). The evidence-based practices dialogue is at the core of whether we will be able to integrate culture and trauma. It is extremely important. The general trend is to move toward clean, systematic, and reliable methods to treat trauma. Unfortunately, we are doing this without a proper understanding of the realities of the communities that we aim to treat. We invited a distinguished group of researchers and practitioners who are leaders both in the trauma field and the cultural psychology/psychiatry, cultural anthropology field, and asked them to address questions such as the following: 1. How can we expand our individualistic trauma models to include a collectivistic approach? 2. How relevant are the trauma models to the communities that you serve? 3. Do we need to redefine what a traumatic event is? 4. How do you understand resilience? 5. Give examples of culturally sensitive research projects. 6. Are we pathologizing culture-specific ways of coping with trauma? 7. How relevant is a sociohistorical approach in our trauma research? 8. How does oppression determine our reactions to trauma? 9. How to integrate qualitative and quantitative approaches to come up with the best evidence-based treatments. 10. Can culture coexist with evidence-based treatments? These are not the traditional scientific questions that are posed to trauma researchers. Advances in cultural psychology and psychiatry suggest that these questions MUST be asked to perform culturally sensitive research in these communities. The cultural formulation outline developed for the upcoming DSM-V has the potential to improve considerations of

Downloaded from tmt.sagepub.com by Madalina Cotiga on April 10, 2012

2 culture in our understanding of trauma and PTSD. It provides a more thorough understanding of symptoms by considering variables such as explanatory belief models, psychosocial environment, the patients identity and point of view, and the relationship with the diagnostician, among others. Understanding the relationship between traumatic reactions and cultural factors offers promising developments in the trauma field. The editors designed the special issue to have four different sections: Theory, training & supervision, research, and assessment & treatment.

Traumatology 16(4) disciplines (psychoanalysis, anthropology, etc.). The authors understand culture not as a fixed representation, which is the predominant view in trauma psychology. Their approach allows understanding culture as multiple subjective representations that are located within particular social, historical, political, and economic contexts. They present a case study that illustrates the coconstruction of cultural meanings between therapist and patient. This case also highlights the multiple contextual layers in asylum seekers/refugees and the need to understand these layers to fully encompass their traumatic experiences. Hill, Lau, and Sue examine the need to integrate indigenous perspectives in the trauma field, including providing a historical, cultural, and epistemological framework for understanding the impact of traumatic experiences. They challenge the trauma field to reconsider its theoretical and research inquiries and ensure a culturally responsive and credible traumatology.

Theory
This section focuses on the need for major epistemological and systemic changes to integrate notions of culture within trauma psychology. In his article, Droek uses a societal-level lens to analyze experiences of collective healing from trauma. He discusses different strategies of collective healing, the ways societies handle the truth, and the role of memory and reconciliation. Also, he reviews societal notions of justice and reminds us that reconciliation and restoration are processes deeply embedded in local histories and local sociopolitical and cultural contexts. The cultural/contextual analysis that Droek provides in his article is a necessary supplement to the victimcentered models of psychological healing (i.e., biomedical models) prevalent in the field of traumatology. Like many other authors in this issue, he reminds us not only that a traumatic experience should not be reduced to a PTSD category but also that societies, as much as individuals, have inherent mechanisms to overcome traumas. Marsella discusses major conceptual issues around the ethnocultural aspects of PTSD, its clinical considerations, and therapeutic practices. He provides an overview of the state of our knowledge of the interaction of culture and trauma and the influence of the Western paradigm on this knowledge. The author argues that culture influences a variety of dimensions, including clinical parameters of the diagnostic criteria for PTSD, psychosocial aspects of the traumatic response, coping mechanisms during and postdisasters and traumatic events, and intergenerational transmission of trauma, among others. He also recognizes universal aspects of PTSD. Marsella proposes a trauma event-person ecology interactional model that considers the different factors that contribute to trauma therapy outcomes. Finally, Marsella concludes that in spite of considerable progress in the inclusion of culture in the conceptualization, diagnosis, assessment, and treatment of trauma, there are institutional forces that limit advances in our understanding of PTSD. Sturm, Baubet, and Moro raised questions about the cultural context surrounding the diagnosis of PTSD. They focused on the lives of refugees and asylum seekers in France and used the ethnopsychoanalytic approach that integrates several

Training and Supervision

The field of trauma psychology is rapidly growing. It is therefore necessary to develop a competency model for educating and training future traumatologists. A critically important factor in facilitating this shift is to have a framework for addressing cultural responsiveness in trauma practice, education, and research. In this section, Mattar presents an overview of the state of training in trauma psychology at the graduate school level. She focuses on the need to develop culturally competent trauma-informed practices, which are crucial in addressing mental health disparities in the United States and across the globe. Mattar provides practical suggestions on how to include culture in trauma psychology education and training. Helms, Nicholas, and Green address in their article a subject that has been almost absent in the trauma literature and remains a very controversial one. They refer to the impact of racism and ethnoviolence in developing symptoms of PTSD and the idea of racism as a threat to ones life. The article brings into question the usefulness of current PTSD symptom criteria when applied to underprivileged groups. The authors urge traumatologists to use assessment and research methodology that can capture the impact of racism and ethnoviolence among ethnically diverse individuals. This methodology includes clinicians and researchers cultural self-assessment, a contextual approach to treating the client, and a clear understanding of the population we treat and study, including the impact of racism. Makhashvili, Tsiskarishvili, and Droek address public health interventions in postdisaster zones. The authors emphasize the importance of understanding the sociopolitical, historical, and cultural context of a community before engaging in postdisaster mental health efforts in those communities. Using the example of the Georgian conflict in 2008, they

Downloaded from tmt.sagepub.com by Madalina Cotiga on April 10, 2012

Mattar et al. provide an analysis of the numerous misunderstandings between international NGOs and local professional organizations and the unintended and regrettable outcomes for the survivors. They also provide alternative culturally responsive approaches to avoid future intervention disasters, including an in-depth analysis of the history of the Caucasus, the Soviet regime, and specific recommendations for building confidence in the target population. Like many other authors in this issue, they discuss the implications of applying the First World, individualistic disaster intervention protocols in countries that have different cultural values.

3 dysfunction rather than direct exposure to the patients traumatic material. The authors propose an organizational model for trauma centers, which is more conducive to a healthy environment. Glen, Knipscheer, Glabi, and Kleber discuss the effects of forced migration on mental health. The authors present results of an empirical study of the relationship between traumatic stress reactions and mental health symptoms among Kurdish women who have resettled in Turkey or in an European Union country. The authors raise awareness of the plight of displaced refugees as having a high prevalence of traumatic events, including discrimination due to their ethnic origin and/or national identity, war experiences, gender oppression, and displacement, among others. The findings emphasize the detrimental effects of gender-based violence. They propose a salutogenic as opposed to a pathogenic approach to treating displaced Kurdish women. Droek and Bolwerk present the results of an empirical study examining the rarely studied effects of group therapy for asylum seekers and refugees. The authors apply different modalities of the Den Bosch model, which combines psychodynamic, cognitive-behavioral (CBT), and supportive treatment approaches. In this model, group psychotherapy is applied together with three nonverbal therapies (psychomotor body therapy, art therapy, and music therapy), individual supportive sessions, and medication. The study suggests that trauma focus group psychotherapy combined with nonverbal therapies within a day-treatment program leads to better treatment results and a reduction in PTSD symptoms, than outpatient supportive group psychotherapy only. The study highlights the role of a nurturing healing environment, advocacy levels on behalf of asylum seekers, and the universal and specific healing aspects of group treatments.

Research
The following section focuses on culturally responsive research to approach the study of trauma. The topic of which research methodologies best capture the experiences of traumatized individuals from diverse backgrounds is a contentious one in the mental health field. The contributions to this section approach the study of trauma from both a qualitative and quantitative research methodology. These studies underscore the need for trauma research that is embedded in a cultural, sociopolitical, and historical context. Afana, Pedersen, Ronsbo, and Kirmayer present the results of a pilot study designed to investigate the social meanings assigned to trauma among Palestinians living in the Gaza Strip. Using ethnographic research methodology, the authors discuss the limitations and misrepresentations of terms used to refer to traumatic events and identify three emic representations and meanings of trauma. They highlight the cultural idioms of distress and the moral meanings ascribed to traumatic events in Palestinian survivors as determining mechanisms of psychopathology and health outcomes. The authors conclude that understanding the diverse modes of coping with trauma is crucial for the delivery of culturally responsive treatment services. Toby Measham and Cecile Rousseau present results of an exploratory study addressing the topic of how to disclose war trauma to children in Algerian and Congolese families. Using qualitative analysis, the authors explore the cultural meanings of disclosure of trauma and discuss the implications for trauma treatment. They remind us that incorporating traditions, spiritual beliefs, and family practices should be an integral part of trauma treatment. Finally, they argue that whether or not trauma disclosure will happen in treatment is very much determined by culture and context. Pross and Schweitzer discuss a topic rarely examined in traumatology, which is the impact of trauma-serving institution and organizational culture/structure on trauma workers stress-level. They identify specific trauma-related features in trauma therapists and teams such as martyr complex, narcissism, grandiosity, reenactment of trauma, and splitting behavior, among others. They conclude that workers burnout and stress levels are mainly due to institutional

Assessment and Treatment

Incorporating culture in trauma assessment and treatment is not an easy task. It requires a clear knowledge about the culture that we are treating as well as the therapists awareness of their own assumptions, values, and biases. Furthermore, a culturally sensitive therapy approach requires skills to develop appropriate intervention techniques. All the articles in this section are a good example of these three dimensions. Kira discusses notions of collective identity trauma and cumulative traumas as necessary components of every culturally responsive trauma treatment. Furthermore, he argues that it is relevant to differentiate between single and cumulative traumas dynamics, especially when working with patients from other cultures and those belonging to underprivileged groups. His analysis of the variance in individuals reactions to trauma and the identity salience has implications against generalizations of evidence-based practices. Kira advocates for a paradigm shift in models of trauma assessment and trauma intervention models. He proposes a multisystemic,

Downloaded from tmt.sagepub.com by Madalina Cotiga on April 10, 2012

4 multimodal, and multicomponent therapy model (MSMCT), which includes individual, family, and community-level interventions. Wiese discusses the impact of the immigration process and the trauma of the forced migration on the psychological functioning of refugee children and adolescents. She discusses some of the protective and risk factors and presents guidelines for treatment interventions with these special traumatized groups. Bala and Kramer discuss the need to adopt a wider conceptual framework from which to understand the PTSD diagnosis. Their article examines the challenges and dilemmas of working with traumatized refugee populations, including how to create space for cultural diversity and multiple meanings. They also urge trauma therapists to examine their own biases during intercultural encounters and to adopt a broad, flexible, and multifocal lens. More important, the authors remind readers of the importance of engaging in reflection on the role of oppressive ideologies and practices, and dominant political discourses in the traumatized clients life. Through examples of clinical encounters, they also emphasize the importance of negotiating meanings with the clients and being flexible in the therapeutic encounter, they illustrate how to tap cultural resources and handle cultural misunderstandings. Finally, Droek and Bolwerk present another study on group treatment of asylum seekers and refugees with the aim to determine the influence of different psychosocial stressors on psychopathology in this population prior to participation

Traumatology 16(4) in the Den Bosch model group treatment as well as to explore their influence on the treatment results. Among others, they conclude that there were no differences found in treatment results between asylum seekers and refugees and that torture survivors, war victims, and a combination war/torture group profit equally from participation in the group treatment. The manuscripts contained in this special issue do not necessarily provide all the answers to the questions we posed earlier. However, we hope that they served as catalysts for further discussion on culture and trauma research, education, and treatment. To create a shift in institutional thinking in traumatology, we need to ask new and challenging questions. The advancement of science and the effectiveness of the trauma field depend on this. Sandra Mattar, PsyD Boris Droek, MA, MD Guest Editors Charles R. Figley, PhD Journal Editor References
Geertz, C. (1979). From the natives point of view: On the nature of anthropological understanding. In P. Rabinow & W. M. Sullivan (Eds.), Interpretive social science (pp. 225-241). Berkeley: University of California Press. U.S. Department of Health and Human Services. (1999). Mental health: A report of the Surgeon General. Rockville, MD: Author.

Downloaded from tmt.sagepub.com by Madalina Cotiga on April 10, 2012