Social Science & Medicine 67 (2008) 218–227

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Social Science & Medicine

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Debating war-trauma and post-traumatic stress

disorder (PTSD) in an interdisciplinary arena
Hanna Kienzler *
Anthropology, McGill University, 855 Sherbrooke Street West, Room 717, Montreal, Quebec H3A 2T7, Canada

a r t i c l e i n f o a b s t r a c t

Article history: Researchers have tried to determine and verify the effects of violent conflicts on the men-
Available online 29 April 2008 tal health of those affected by focusing on war trauma, posttraumatic stress disorder
(PTSD), and other trauma-related disorders. This, in turn, led to the development of differ-
ent kinds of theories and aid programs that aim at preventing and treating the conse-
Keywords: quences of violence and mental health. Until now, there is no agreement on the public
Trauma
health value of the concept of PTSD and no agreement on the appropriate type of men-
Psychiatry
tal-health care. Instead, psychiatrists have engaged in sometimes fierce discussions over
Anthropology
Discourse the universality of war trauma, PTSD, and other trauma-related disorders. The two most
Post-traumatic stress disorder (PTSD) polar positions are those who try to validate PTSD as a universal and cross-culturally valid
War psychopathological response to traumatic distress which may be cured or ameliorated
Violence with (Western) clinical and psychosocial therapeutic measures, and those who argue
that the Western discourse on trauma only makes sense in the context of a particular
cultural and moral framework and, therefore, becomes problematic in the context of other
cultural and social settings. Although these positions seem mutually exclusive, their
debates have led to the development of less radical approaches toward war-trauma and
PTSD.
The purpose of this literature review is to analyse the discourses on and debates over war-
trauma and PTSD in the psychiatric literature in order to establish a better understanding
for the diverse conceptualizations, interpretations and proposed healing strategies. More-
over, I discuss the cultural construction and conceptualization of war-trauma and PTSD
from an anthropological perspective and show how anthropologists contribute to psychi-
atric debates so as to ensure more sophisticated diagnoses and healing strategies in cultur-
ally diverse contexts.
Ó 2008 Elsevier Ltd. All rights reserved.

Introduction Researchers have tried to determine and verify the

In the last 60 years there have been over 200 wars and
armed conflicts, in which the main targets are often
marginalized ethnic groups and the poorest sectors of soci-
ety. Although it is well known that violent conflicts have
a profound impact on individuals, communities, and/or
specific ethnic groups, not enough attention has been
paid to local patterns of distress, long-term impacts on
health, and psychosocial consequences (Pedersen, 2002).
* Corresponding author. Tel.: þ1 514 933 0540.
E-mail address: hanna.kienzler@mail.mcgill.ca
effects of violent conflicts on the mental health of those
affected by focusing on war-trauma, PTSD, and other
trauma-related disorders. This, in turn, led to the develop-
ment of different kinds of theories and aid programs that
aim at preventing and treating the consequences of vio-
lence and mental health (Barudy, 1989). Until now, there
is no agreement on the public health value of the concept
of PTSD and no agreement on the appropriate type of
mental health care (McFarlane & Yehuda, 2000). Instead,
psychiatrists and psychologists have engaged in sometimes
fierce discussions over the universality of war trauma,
PTSD, and other trauma-related disorders.

0277-9536/$ – see front matter Ó 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.socscimed.2008.03.030
 H. Kienzler / Social Science & Medicine 67 (2008) 218–227
In the following I will review discourses on and debates
over war-trauma and PTSD in the psychiatric and anthropo-
logical literature in order to establish a better understand-
ing for the diverse conceptualizations, interpretations and
proposed healing strategies in culturally diverse contexts.
Emanating from this, I propose that through combined
‘‘division of labour’’ psychiatrists and anthropologists could
guarantee a more fine grained analysis of how Western
approaches to healing could be adequately embedded in
non-Western cultural and social settings.
The cultural construction of war-trauma and PTSD
Western psychiatrists and psychologists have shown an
increasing interest in the psychological consequences of
war-trauma and trauma-related disorders. One response
to violence and trauma was the development of the
concept of posttraumatic stress disorder (PTSD) which
was included in the DSM-III in 1980. Since then, the con-
cept has been widely recognized as valid and has been
used to explain reactions to trauma in different situations,
for example, with civilian and military casualties of war
(Bracken, Giller, & Summerfield, 1995).
As with other concepts developed in Western psychia-
try, it is important to examine how PTSD is embedded in
specific configurations of cultural meaning and social rela-
tionships (Kleinman, 1980). As anthropologists we inquire
about how the actors in a particular social setting think
about and act in health care by paying attention to their
beliefs about sickness, their decisions about how to act in
response to particular episodes of sickness, and their
expectations and evaluations of specific types of health
care. Thus, medical anthropologists have the opportunity
to conduct ethnographic research on the construction and
reconstruction of specific diseases and disorders such as
PTSD (Good, 1992), outline the characteristic lay and
professional interpretations of illness, and reveal how
these are constrained by different explanatory systems
(Kleinman, 1985).
Various scientific, sociological, historical, and philo-
sophical projects exist that aim at displaying or analysing
‘‘actual, historically situated, social interactions or causal
routes’’ (Hacking, 1999:48) that led to the development
and establishment of the posttraumatic stress disorder
syndrome. For example, the psychiatric discourse of the
American Psychiatric Association (2000) relates to PTSD
as a ‘‘non-contingent entity’’ (Hacking, 1999) which is the
inevitable result of a research trajectory. More specifically,
it was discovered that PTSD is an anxiety disorder that is
characterized by the ‘‘reexperiencing of an extremely trau-
matic event accompanied by symptoms of increased
arousal and by avoidance of stimuli associated with the
trauma’’ (American Psychiatric Association 2000:429). The
essential features of PTSD are the development of characteris-
tic symptoms that follow exposure to an extremely traumatic
event to which afflicted persons respond with ‘‘intense fear,
helplessness, or horror’’ (2000:463). The events that are
considered traumatic include, but are not limited to, mili-
tary combat, violent personal assault, being kidnapped, be-
ing taken hostage, terrorist attacks, torture, incarceration as
a prisoner of war or in a concentration camp, natural or
219
manmade disasters, severe automobile accidents, or being
diagnosed with a life-threatening illness. Individuals who
have recently emigrated from areas of considerable social
unrest and civil conflict are considered especially prone
to developing elevated rates of PTSD. Such individuals are
said to be especially vulnerable and reluctant to divulge
experiences of torture and trauma and, as a consequence,
specific assessments of traumatic experiences and related
symptoms are required for such individuals.
The American Psychiatric Association describes and
engages with disorders such as PTSD as though they were
timeless, universal, and cross-culturally valid. According
to Young (1995), the discourse is built on two themes: (a)
PTSD exists as an entity prior to and independently of the
ways in which psychiatric experts diagnose, study, and
treat it; and (b) chronology: retrospectively the disorder
has been identified in historical and literary figures such
as The Epic of Gilgamesh, Erichsen (1864) and Page
(1883) who were the first ones to recognize the posttrau-
matic syndrome, Kardiner (1941) who codified the disor-
der’s syndromal features, and the creation of the DSM-III.
Young, on the other hand, outlines ‘‘causal historical
processes’’ (Hacking, 1999) that led to the invention of
PTSD in the 1980s by arguing that, contrary to the assump-
tions outlined above, the disorder is not timeless, but
‘‘glued together by the practices, technologies, and narra-
tives with which it is diagnosed, studied, treated, and rep-
resented by the various interests, institutions, and moral
arguments that mobilize these efforts and resources’’
(Young, 1995:5). Hence, PTSD is a historical product that
originated in the scientific and clinical discourse of the
19th century. Until the 19th century, the concept of trauma
was identified primarily with physical injuries. Erichsen,
one of the first physicians to describe a syndrome similar
to PTSD, identified it during the 1860s when he examined
victims of railway accidents. He accredited the syndrome
to loosely defined neurological mechanisms and called it
‘‘railway spine syndrome’’ (Erichsen, 1864:16). A few years
later, Charcot (1889) proposed the earliest psychological
account of the syndrome arguing that patients suffering
from railway accidents were most likely to suffer from
hysteria. Janet (1903) and Freud (1922) developed this
idea further by explaining that the syndrome could also
be produced by a psychological trauma which is too diffi-
cult to process for the afflicted. Because the memories are
painful and unmanageable, the conscious personality sup-
presses them from awareness by storing it in the subcon-
scious (Janet) or unconscious (Freud). During World War
I, the analysis shifted from railway spine syndrome and hys-
teria to the diagnosis of a large number of soldiers with
traumatogenic shell shock. Kardiner codified its characteris-
tic features and identified its delayed and chronic forms in
the 1920s. However, only in the 1980s did the diagnosis re-
ceive official recognition and was included in the third edi-
tion of the DSM-III. The publication of the DSM-III is
described by Young as a ‘‘revolutionary event’’ for American
psychiatry. For the first time, it created a national standard
for ‘‘classifying and diagnosing mental disorders based on
an ‘atheoretical’ approach’’ (Young, 1995:127).
According to Young, the inclusion of PTSD in the DSM-III
was, however, not only a medical and psychiatric
220 H. Kienzler / Social Science & Medicine 67 (2008) 218–227
achievement, but included political as well as moral
debates led by American veterans of the Vietnam War. Dur-
ing the 1980s, psychiatrists noted high rates of mental
health problems and self-destructive behaviour in veterans
of the Vietnam War. At the same time, veterans pleaded for
a diagnostic criterion that would establish their eligibility
for disability compensation, legitimated victimhood, and
moral exculpation through a doctor-attested and officially
recognized disorder. Yet, Young does not mean to say that
people diagnosed with PTSD do not suffer. Similar to Hack-
ing’s notion of ‘‘interactive kinds’’ (Hacking, 1999:104), he
argues that it is possible for a thing to be real and socially
constructed at the same time since ‘‘to say that traumatic
memory and PTSD are constituted through a researcher’s
techno-phenomena and styles of scientific reasoning does
not deny the pain that is suffered by people who are diag-
nosed or diagnosable with PTSD. (.) The suffering is real;
PTSD is real’’ (Young, 1995:10).
Although scientific research on PTSD still largely focuses
on veterans, attention is shifting to post-conflict countries
in which high rates of PTSD are reported. Trauma advocates
working in war-torn areas across the globe claim that post-
traumatic stress becomes worse unless it is treated by
Western-style approaches. For example, the WHO Report
on ‘‘Mental Health in Emergencies’’ (WHO, 2003) claims
that most acute mental health problems during acute
emergency phases are best managed by the principles of
‘‘psychological first aid’’. During the reconsolidation phase
it is recommended to educate humanitarian aid workers
and community leaders in core psychological skills such
as psychological first aid, emotional support, providing
information, sympathetic reassurance, and recognition of
core mental health problems. Similarly, the Inter-Agency
Standing Committee (IASC, 2007) states that it is crucial
to protect and improve people’s mental health and psycho-
social well-being in the midst of an emergency through (a)
psychological first aid for people in acute trauma-induced
distress by a variety of community workers and (b) care
for people with severe mental disorders, including severe
PTSD, by trained and supervised health staff only. These
consensus criteria on approaches to trauma treatment
largely ignore the criticism voiced by several researchers
who argue that no convincing evidence of the efficacy of
the advocated practices seems to exist (Pupavac, 2002;
Summerfield, 1998). One wide spread criticism of intercul-
tural therapy is that its efficacy has not yet been proved by
quantitative measurement and that the application of psy-
chotherapy outside the European middle class milieu is
rather limited (Littlewood, 1992).
Debating war-trauma and PTSD in the
psychiatric arena
Medical knowledge of PTSD is a social and cultural
invention shaped through the therapeutic recounting of
traumatic events, the acknowledgement of stress response,
and the production of a formal diagnosis. As mentioned
above, there exists no agreement on the public health value
of the concept of PTSD and the appropriate type of mental
health care. Instead, psychiatrists and psychologists are
divided into several ‘‘camps’’ which engage in sometimes
heated debates over the universality of war-trauma, PTSD,
and other trauma-related disorders.
PTSD: a universalistic and cross-culturally valid
response to traumatic distress
The majority of psychiatrists and psychologists assume
that traumatic experiences lead to traumatic memories
which may result in PTSD. The syndrome itself is believed
to be a universal and cross-culturally valid psychopatholog-
ical response to traumatic distress (Young, 2006). However,
mental illnesses in culturally diverse populations have
been difficult to measure. Only recently, researchers have
reported that reliable and culturally validated screening
instruments for psychiatric distress have been developed.
That is, protocols and scales based on the symptom lists
such as the DSM and ICD have been translated into local
languages, thus permitting investigators to distinguish
traumatic suffering from seemingly similar kinds of psy-
chological distress (Mollica et al., 1992).
Until the late 1980s, standardized screening instru-
ments for measuring PTSD were mainly applied to the
assessment of American war veterans. Two of these mea-
sures were the Mississippi Scale for Combat-Related Post-
traumatic Stress Disorder and the Minnesota Multiphasic
Personality Inventory. However, due to the great flow of
refugees into the United States, the development of cultur-
ally sensitive psychological tests and symptom checklists
for assessing anxiety and depression has been promoted
(Mollica et al., 1992). These include amongst others, the
Harvard Trauma Questionnaire, the General Health Ques-
tionnaire-28, and the Medical Outcomes Study 20. The
HTQ is the most frequently applied screening tool and con-
sists of a checklist for measuring trauma, torture events,
and trauma-related symptoms. It is designed as a self-
report scale which includes three sections. The first section
comprises seventeen items that describe a range of trau-
matic experiences; section two consists of an open-ended
question that inquires about the respondents’ subjective
descriptions of the most traumatic event(s) that they expe-
rienced during their refuge; and the final section includes
thirty symptom items (Mollica et al., 1992). In contrast to
the HTQ, the GHQ-28 is used as a community screening
tool and for the detection of non-specific psychiatric disor-
ders in individuals in primary care settings. The mental
health status of the respective patients is measured with
the help of the four subscales: somatisation, anxiety, social
dysfunction, and depression. The MOS-20, on the other
hand, consists of twenty items on six different scales that
assess physical functioning, bodily pain, role functioning,
social functioning, mental health, and self-perceived gen-
eral health status. Generally, the three different scales are
chosen to obtain information on common, non-specific
psychiatric problems; to gather information on specific
psychiatric syndromes like PTSD and related traumatic
events; and to get a broad understanding of the level of so-
cial functioning and disability in the respective population
under study (Cardozo, Vergara, Agani, & Gotway, 2000).
Other screening tools include the Hopkins Symptom Check-
list-25, the Vietnamese Depression Scale, the Zung Scale for
Depression, the NIMH-Diagnostic Interview Schedule, the
 H. Kienzler / Social Science & Medicine 67 (2008) 218–227
Senegal Health Scales, the Post Traumatic Stress Disorder
Symptom Scale (PSS), and the Mini International Neuropsy-
chiatric Interview (MINI) (Solomon, 1996).
Researchers recognize that PTSD does not occur in
everyone who has experienced traumatic events and that
the traumatic event itself does not sufficiently explain
why PTSD develops or persists. So far, presumed risk factors
are divided into two categories: (a) those pertinent to the
traumatic event (severity of the type of trauma) and (b)
those relevant to individuals who experience the event
(gender, prior experiences, personality characteristics). Fur-
thermore, data have emerged that suggest biological or
even genetic risk factors for PTSD (Yehuda, 1999; see also
Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Shalev,
2002). Populations considered generally at great risk for
PTSD and other trauma-related disorders are refugees,
IDPs, people living in war zones, veterans of armed conflict,
and victims of a range of criminal acts such as sexual
assault, terrorist attacks, and torture (Fairbank, Ebert, &
Costello, 2000). Epidemiological studies focusing on these
risk populations attempt to assess the short and long-
term effects of trauma on mental health and disability. A
key issue is whether psychological reactions to trauma
persist over time and whether such reactions can become
disabling (Steel, Silove, Phan, & Bauman, 2002). Research
that focuses on individual vulnerability following the expo-
sure to trauma includes studies on war-affected people
from all over the world. For example, the Program in Refu-
gee Trauma conducted a study of exiled Burmese living in
Bangkok. The 140 participants reported an average of thirty
trauma events, poor health, and lack of social support. The
prevalence of elevated symptom scores was 38% for depres-
sive symptoms and 23% for criterion symptoms of PTSD.
Consequently, the research team concluded that the young
adults were severely affected by trauma and state that their
psychosocial well-being may deteriorate further without
legal protection to reduce the continuing stress and vio-
lence (Allden et al., 1996). Other epidemiological studies
on war-affected populations include surveys conducted
with Cambodian refugees who survived the regime of Pol
Pot (Boehnlein, Kinzie, Sekiya, & Riley, 2004; Mollica, Cui,
McInnes, & Massagli, 2002); Tamils suffering from the
effects of torture (Silove, 1999); Tibetans in exile (Mercer,
Ager, & Ruwanpura, 2005); Senegalese refugees (Tang &
Fox, 2001); Rwandan adolescents (Schaal & Elbert, 2006);
Bosnians (Momartin, Silove, Manicavasagar, & Steel,
2003); Kosovars (Cardozo et al., 2000), Israelis and Palesti-
nians living in Israel (Hobfoll, Canetti-Nisim, & Johnson,
2006); Holocaust survivors and their children (Golier
et al., 2002); and many more.
Besides vulnerability, epidemiologists consider resil-
ience a crucial construct within the traumatic stress re-
sponse (Paton & Volanti, 2006). Research that emphasizes
coping and resilience in survivors includes, for instance,
investigations that document the psychosocial adjustment
of young Cambodian refugees in Canada. Rousseau, Drap-
eau, and Rahimi (2003) argue that the trauma a family suf-
fered before leaving their homeland and prior to the
teenagers’ birth seems to play a protective role at various
times in adolescence with regard to externalized symp-
toms, risk behaviour, school failure in boys, and fosters
221
positive social adjustment in girls. It is concluded that these
reactions may be understood as overcompensation by the
children of the survivors of a massacre, to whom the
implicit duty to succeed has been passed on. Similar find-
ings are reported by Beiser, Turner, and Ganesan (1989)
as well as Tousignant et al. (1999), who studied Vietnamese
and Laotian refugees in Canada. Overall, these studies rec-
ognize that trauma-related mental illness seem to reduce
steadily over time, but that a subgroup of people with
a high degree of exposure to trauma has long-term psychi-
atric morbidity. It is concluded that it is important to estab-
lish mental health services for people who have been
exposed to extreme trauma (McFarlane & Yehuda, 2000)
in order return them and the regions they live in into stable
and productive environments (Cardozo et al., 2000).
In most cases, the application of Western psychothera-
peutic approaches and counselling has been suggested as
an important intervention in helping refugees and people
living in war-torn areas. The currently employed treat-
ments for PTSD focus on working through the trauma by
employing traditional psychosocial, pharmacological, and
cognitive-behavioural interventions (Foa & Rothbaum,
1998). The need for psychiatric intervention in war torn
areas and for refugees led to the development of different
kinds of aid programs that aim at preventing and treating
the effects of violence on mental health (Barudy, 1989).
Aid programs include international, non-governmental
(NGO), and academic organizations which are funded by
donations from individuals, corporations, governments,
and other organizations. The funding and delivery of hu-
manitarian aid is increasingly organised on an international
level to facilitate faster and more effective responses to ma-
jor emergencies affecting large numbers of people. For
example, the International Organisation for Migration
(IOM) (http://www.kosovomemory.iom.int/htm/uniting.htm)
established a Psychological and Cultural Integration Unit
that addresses psychological hardships of migrants
through a systematic and community oriented psychoso-
cial approach. Past and present activities include the Psy-
chosocial and Trauma Response in Kosovo, psychological
components of the Asylum National Program, an agree-
ment with the Psychotraumatology Center in Florence,
and qualitative research on the health of migrants in
Europe. Other NGOs concerned with mental health and
counselling are the Auroville Tsunami Relief Effort
(www.auroville.org/tsunami/projects.htm), the Center for
Survivors of Torture and War Trauma (www.stlcenterfor-
survivors.org), the Center for The Victims of Torture
(www.stlcenterforsurvivors.org), the Medical Foundation
to Train Trauma Counsellors in Kosovo (www.torturecar-
e.org.uk/about_us/overseas_work), the Program for the
Survivors of Torture and Severe Trauma (www.cmhswe-
b.org/programs/pstt.html), and the War Trauma Recovery
Project (www.umsl.edu/divisions/artscence/psychology/
ctr/projectswartrauma.html).
One of the most well-known academic projects is the
Harvard Program in Refugee Trauma (www.hprt-camridge.org).
HPRT is a multi-disciplinary program that has been pio-
neering the health and mental health care of traumatized
refugees and civilians in areas of conflict and natural disas-
ters. In collaboration with Ministries of Health around the
222 H. Kienzler / Social Science & Medicine 67 (2008) 218–227
world, the organization developed a community based
mental health service. Other academic institutions are the
Bellevue/NYU Program for Survivors of Torture (www.suri-
vorsoftorture.org/survivors/), the Boston Center for Refu-
gee Health and Human Rights (www.bcrhhr.org), the
International Institute of New Jersey (www.iinj.org), and
the Latin American Collective Psychosocial Work (Barudy,
1989). The goal of these programs is to permit elaboration
on the suffering at an individual, familial, and group level,
and to facilitate group dynamics that can trigger the poten-
tial of the victims to transform the conditions of violence
that cause and maintain their pain.
However, despite their enthusiastic engagement, psy-
chiatrists working in war-torn areas are often equipped
with inadequate resources and overwhelming demands.
Since their own psychological vulnerability is of growing
concern, they are considered to be a new risk group vulner-
able to PTSD and trauma-related disorders (McFarlane,
2006; see also Barbanel & Sternberg, 2006; Shalev, 2002).
PTSD: a EuroAmerican invention
In recent years, dissent has arisen among psychiatrists
that challenges and even denies the validity of the PTSD
concept. Critics state that PTSD is an example of how soci-
ety and politics have helped to create rather than discover
a mental illness. That is, psychological knowledge is the
product of a particular culture at a particular point in
time and, thus, an ethnomedical system among others.
From this point of view, intrusion-avoidance symptoms
are related to the search for meaning, meaning is always
related to cultural backgrounds, and, thus, PTSD is seen to
be the product not of trauma in itself but of trauma and
culture acting together. Accordingly, the globalization of
Western ideas about suffering and its remedies become
problematic in the context of other cultural and
societal settings (Almedom & Summerfield, 2004; Bracken,
1998, 2001).
Summerfield illustrates this by referring to Argenti-
Pillen’s (2004) queries about whether imported Western
trauma work could contribute to a destabilisation of cultur-
ally specific forms of Sri Lanka’s postwar organization.
Argenti Pillen focuses on coping strategies employed by
refugee Sinhalese women who live in rural slum communi-
ties and witnessed the death and disappearance of family
members. According to her, women avoid further cycles
of violence by employing domestic cleansing rituals and
‘‘cautious discourses’’ that undermine the risks and poten-
tial dangers of fearlessness. Their means of coping were,
however, severely challenged by non-governmental mental
health organizations promoting Western style trauma
counselling. The latter misconceived the local practices as
war-related illnesses and equated them with Western con-
cepts such as PTSD, depression, and psycho-somatisation.
Moreover, the international therapeutic model is
blamed for employing inadequate research methods and,
as a consequence, constructs war-affected populations as
traumatized, hopeless, or brutalized, thus, vengeful enough
to start a new cycle of violence (Summerfield, 2005).
According to McHugh and Treisman (2007), the question-
naires which are usually used with all victims of trauma
have significant flaws. Besides being over-inclusive, the
questionnaires wrongly assume that the subject under-
stands the question the same way as the researcher does.
Furthermore, it is not acknowledged that different psycho-
logical conditions manifest themselves with similar mental
symptoms or that not all cognitive or affective responses to
distress are forms of disorder or psychopathology.
Other researchers criticise that the staffs of counselling
programs are often unfamiliar with the situation they have
to address as they are ignorant of the history of the region,
its cultural, social, political, and economic systems, its
former and current power structure, and its health care
system. With regard to the former Yugoslavia, Richter
(1998) writes that as a result of the news coverage, an
influx of rape trauma projects flooded into the region,
and that most of the experts arrived with full confidence
to put their textbook wisdom into practice, particularly
with regard to PTSD. However, instead of long-term assis-
tance they offered therapeutic ‘‘quick fixes’’ (1998:121)
which confused the people they were meant to assist and
disrupted relations between them. Obviously, opponents
of mainstream trauma programs argue that it cannot be
presumed that people globally understand their suffering
through the psychology and their suffering may not neces-
sarily be addressed through therapeutic programs. What is
more, the dominance of the PTSD model is believed to sup-
press even other approaches and silence local perspectives
on what is helpful and important in the wake of disaster.
Instead, critics hold that distress and suffering are not
inevitably pathological responses to traumatic events, but
normal existential conditions (Summerfield, 2000, 2005).
According to researchers such as Almedom, Jones, and
Summerfield, suffering is resolved in a social context, and
familial, socio-cultural, religious, and economic activities
make the world comprehensible for people before, during
and after catastrophes (Almedom & Summerfield, 2004).
For example, during her work as a psychiatrist in Bosnia,
Jones (2004) came to realise that humanitarian programs
and mental health professionals approached the subject
of war trauma and children from the wrong perspective.
Disregarding their particular experiences, it was assumed
that traumatized children express their symptoms similarly
and that Western healing strategies would be helpful. How-
ever, the majority of children with whom Jones worked did
not fit this portrait. According to her, some of the children
indeed showed symptoms (such as poor concentration in
school or nightmares) but did not see them as an illness
requiring treatment. Instead, they desired improved living
conditions, more activities, supportive teachers, employ-
ment for their parents, and an end to corruption.
Examples such as this one are employed by researchers
to reveal that it is simplistic to regard survivors as passive
vessels of negative psychological effects. On the contrary,
they show that survivors act actively and in a problem solv-
ing way on their environment by negotiating disrupted life
courses, loss of status, culture shock, and the attitude of the
host society, thereby, shaping themselves, their communi-
ties, and ultimately the legacy of war itself (Summerfield,
1998; Turton, 1991). Emanating from this, it is argued that
we do not justice to the afflicted who have to reconstruct
their lives ‘‘when we assume that they are intrinsically
 H. Kienzler / Social Science & Medicine 67 (2008) 218–227
damaged human beings who cannot but hand this on to
their children’’ (Summerfield, 1998:29). Thus, new ques-
tions have to be asked in order to do adequate research
that does not follow a medicalised model, and, instead of
offering psychiatric counselling, the humanitarian aid pro-
grams should acknowledge resilience and retain the social
rehabilitation frameworks, starting with the strengthening
of damaged local capacities in line with local priorities.
Building bridges between different healing traditions
The fierce debates between researchers adhering to the
universalistic and relativistic perspectives were not fruit-
less. They led to the development of less radical and more
reflective approaches toward trauma and PTSD. That is,
approaches that incorporate selected ideas from both posi-
tions and that propose community oriented psychosocial
trauma intervention programs.
Similar to researchers adhering to the relativistic posi-
tion, transcultural psychiatrists argue that current Western
psychiatric nosology is based on the search for discrete
disorders and, thereby, de-contextualizes and essentialises
human problems. Lemelson, Kirmayer, and Barad (2007)
argue that Western psychiatry reflects a particular Ameri-
can and European view of concepts of psychopathology. It
is based on cultural conceptions of normality and deviance
that focus solely on problems located within the individual
and lack a developed conceptual vocabulary for relational,
social, communal, and cultural problems. Yet, remembering
and forgetting traumatic events depends on memory
systems that carve trauma not only on the body and brain,
but also on the social and political processes that aim to
regulate public and private recollection (see also de Jong,
2004; McNally, 2003). From this point of view, mainstream
Western psychiatry is considered to be insufficient to
explain and treat trauma cross-culturally. It is argued that
to comprehend stories of trauma, one has to understand
that dominant forms of violence are local and collective
in nature. They are embedded in and emerge from multiple
contexts, including biological processes of learning and
memory; embodied experiences of injury, pain, and fear;
narratives of personal biography; the knowledge and prac-
tices of cultural and social systems; and the power and
positioning of political struggles enacted on individual,
family, and community and national levels (Lemelson
et al., 2007; Pedersen, 2002).
In order to better understand war-trauma, traumatic
memory, and trauma-related disorders, Pedersen (2002)
postulates new research questions, these include: What is
the long-term health impact of ethnic conflict, political
violence, and wars in a given population? What about the
role of other psychosocial factors such as resilience, social
cohesion, coping skills, the density and quality of social
support networks? What is the role of other social factors,
such as racism and extreme nationalisms, alongside
poverty and wars, in determining the health of disease
equation? These questions elucidate that researchers and
practitioners adhering to a transcultural psychiatric per-
spective do not agree with critics who argue that concepts
of PTSD cannot and, therefore, should not be applied to
non-Western contexts. Instead, it is their goal to build
223
bridges between the clinical concerns of subjects and the
social and political contexts in which their experiences
and sufferings are embedded (see also Kagee & Naidoo,
2004). Papadopoulos (2001) adopted, for example, a sys-
temic perspective in order to grapple with issues concern-
ing the perception of refugee families, especially in the
context of supervision. According to him, the phenomenon
of refugeedom intersects a wide variety of dimensions and
is by no means exclusively of psychological nature; it
involves issues of political, ethical, ethnic, religious, finan-
cial, sociological, and ecological nature. Consequently, a sin-
gle approach to refugees cannot possibly be sufficient to
address its multifaceted complexity.
However, transcultural psychiatrists do not only wish to
build bridges between clinical concerns and the clients’ cul-
tural backgrounds, but between different traditions of heal-
ing as well. Healing is considered part of any system of
medicine and healing practices address central values and
concerns which are important for individuals and commu-
nities (Kirmayer, 2004). Emanating from this, transcultural
psychiatrists propose a community oriented approach to
healing that combines both emic and etic approaches (Kir-
mayer, 1989) so as to better understand local healing and
especially coping strategies (de Jong, 2000). Up to now,
only a small number of aid programs exist that combine
Western with traditional healing strategies. For example,
the collaborative program of the Transcultural Psychosocial
Organisation (TPO) aims at developing a multidisciplinary,
collaborative, sustainable, and culturally sensitive trauma
intervention program with focus on a community-oriented
and culturally sensitive public health response to the
psychosocial problems of refugees and victims of organised
violence. Programs join together experience and methodol-
ogy from public health, psychology, psychiatry, and anthro-
pology in order to capture idiomatic descriptions of mental
health problems that fit local cultural illness experiences. In
Cambodia, for instance, the TPO involved Buddhist monks,
professional traditional healers, mediums, and traditional
birth attendants in the intervention process (Eisenbruch,
de Jong, & van de Put, 2004; Somasundaram, van de Put,
Eisenbruch, & de Jong, 1999). Other existing projects
include: the Mobile Member Care Team in West Africa
(Carr, 2006); the Prevention and Access Interventions for
Families of refugees from Bosnia and Kosovo (Weine,
1998); Testimonial psychotherapy as discussed by Lustig,
Weine, Saxe, and Beardslee (2004); and the Collaborative
Praxis in Chajul in the Guatemalan Highlands (Lykes,
2002). All projects argue for the incorporation of traditional
healing practices, and, thus, for a pluralist healthcare sys-
tem. Researchers argue that the analysis that is required
for such an endeavour would be a phenomenological and
cultural one that provides a common ground on which
shared and disparate concerns of psychiatrists and social
scientists can be addressed and integrated (de Jong, 2004;
Pedersen & Bauffati, 1989).
Anthropological contributions to discourses on
war-trauma and PTSD
How are social scientists and especially anthropologists
involved in the discourse on and debate over war-trauma
224 H. Kienzler / Social Science & Medicine 67 (2008) 218–227
and PTSD? Are they merely detached bystanders who mon-
itor developments of psychiatric research, take note of and
analyse ongoing disputes between psychiatrists, and out-
line genealogies of certain nosologies? Or are they actually
participating in the debates as engaged critics and innova-
tive activists who seek to provide new means for a better
understanding of war-trauma and its related disorders? I
discussed the achievements of ‘‘bystanders’’ in the first
part of this essay and will now turn to those of the ‘‘critics’’
and ‘‘active participants’’ by relating them to current psy-
chiatric discourses.
In her article ‘‘Contract of Mutual (In)Difference’’, Pan-
dolfi (2003) states that we are witnessing a ‘‘massive trans-
formation’’ (2003:369) in the nature of global governance
as humanitarian networks, NGOs, and multi and bilateral
organizations are about to develop a new transnational
regime. According to her, these newly established transna-
tional regimes constitute a mobile apparatus which she
defines as ‘‘migrant sovereignties’’ (2003:369). That is,
within this new world order, at least two, often opposed,
sovereignties may coexist in one and the same national
territory: one is bound to a territorial entity whereas the
other results from the creation of non-territorialized forms
of organization like the humanitarian apparatus. The non-
territorialized forms of ‘‘power and governance’’ intervene
mostly at sites of crisis and humanitarian disaster by
employing the rhetoric of institution building and Western
democratization (2003:370). Pandolfi illustrates this by
referring to the international presence in Albania and
Kosovo in 1991 until the peak of the war. During this partic-
ular time, the international presence was immense and the
true agents of ‘‘military-economic-humanitarian action
were the various international organizations, agencies,
foundations and NGOs, whose operations were shaped by
a temporality of emergency’’ (2003:370). That is, as soon
as the conflict seemed to subside and the media moved
to new battle fields, ‘‘the theatre of generosity [lost] its
actors’’ (2003:380).
The contemporary humanitarian response to war
includes in addition to humanitarian aid and development
agencies, NGOs and international organizations which offer
trauma counselling to war-affected populations. Pupavac
(2001) states that due to these measurements, individual
emotions cease to be personal matters but become public
property and, subsequently, ‘‘any failure by public bodies
to provide psycho-social programs or any failure by indi-
viduals to take up the psycho-social support is viewed as
socially irresponsible’’ (2001:361). For example, Pupavac
discovered that in the post-war years, hundreds of thera-
peutic programs had been established in Kosovo which
presume that the population was massively affected by
trauma and, as a consequence, suffered from trauma-
related disorders.
Such assumptions, Scott (1990) explains, partly result
from the present orientation in psychiatry that considers
it ‘‘normal to be traumatized by the horrors of war’’
(1990:308) and calls for clinicians to take seriously the
patient’s war experience. The presumption of individual
vulnerability is, thus, the basis for psychiatric diagnosis as
well as treatment. However, Malkki (1995), an expert in
refugees and refugee experiences, counters that we can
neither assume psychological or mental illness beforehand,
nor can we claim to know the actual source of a person’s
affliction. On the contrary, war-affected populations are
often reluctant to accept Western mental health models
and are disinclined to speak to mental health specialists
about their experiences, as they do not consider their
symptoms pathological. Thus, she concludes that,
‘‘although many refugees have survived violence and loss
that are literally beyond the imagination of most people,
we mustn’t assume that refugee status in and of itself
constitutes a recognizable, generalisable psychological
condition’’ (1995:510).
The critical assessments outlined above are certainly
legitimate as a number of mainstream Western psychia-
trists actually deny resilience to war-affected populations
by interpreting it as evidence of psychological dysfunction-
alism. Yet, the critics seem to overlook or ignore recent de-
velopments in (mainstream) psychiatry where researchers
not only focus on resilience but acknowledge it as crucial to
the traumatic stress response. Moreover, several of the
critics homogenise the psychiatric discourse on war-
trauma and PTSD. That is, they pay no attention to the
achievements in transcultural psychiatry that is to say,
the latter’s willingness to actually document local ways of
coping and work with local healers and healing strategies.
To provide a sound critique of psychiatric approaches to
healing researchers have to actually provide ethnographic
examples of how resilience is enacted by individuals and
groups of individuals. Scattered observations of ‘‘local sus-
picion of mental health workers’’ or ‘‘low take-up rates of
psychiatric therapy’’ cannot be considered valid examples
and indicators for resilience and do not provide insight
into local healing and coping strategies.
The contribution of social scientists, especially anthro-
pologists, does not end here. In fact, they have created
a discourse that runs parallel to psychiatric discussions on
war-trauma and PTSD known as ‘‘social suffering’’. Like
the critics outlined above, medical anthropologists as well
as anthropologist-psychiatrists vehemently critique the
medicalisation of trauma survivors as it reduces individual
subjectivities to victims and, thereupon, patients (Klein-
man & Kleinman, 1997). Instead of giving those traumatized
the social status of a patient; researchers argue that we
need to better understand exactly how individuals,
families, and whole societies respond to violence. Thus,
although violence may be a very personal and subjective
experience, ‘‘larger social actors such as the state, inter-
national organizations, and the global media, as well as
transnational flows in finances and people’’ are all involved
in the creation, maintenance, and soothing of violence
(Das & Kleinman, 2000:2).
In order to adequately capture the impact of violence on
individuals and communities, medical anthropologists
introduced the concept of ‘‘social suffering’’ to the aca-
demic discourse. Kleinman (1995) explain that suffering
is a universal human experience in which individuals and
groups ‘‘undergo or bear certain burdens, troubles, and
serious wounds to the body and the spirit (.)’’
(1995:101). Yet, there is no one single way to suffer as
pain is perceived and expressed differently, even in the
same community. That is, local differences in gender, age
 H. Kienzler / Social Science & Medicine 67 (2008) 218–227
group, ethnicity, religion, and economic status as well as
global processes influencing local worlds turn suffering
into a partial and complex intersubjective experience (see
also DelVecchio Good, Brodwin, Good, & Kleinman, 1991;
Scarry, 1985). Suffering is, thus, considered a social experi-
ence in that it is first, an interpersonal engagement with
pain and hardship in social relationships; second, a societal
construction that serves as a cultural model and moral
guide of and for experience; and third, a professional
discourse that organises forms of suffering as bureaucratic
categories and objects of technical intervention (Kleinman,
1995). Obviously, the concept of social suffering comprises
conditions that are not initially related and comprise
health, welfare, legal, moral, and religious issues, among
others (Kleinman, Das, & Lock, 1997).
For example, Scheper-Hughes (1996) sensitizes readers
to violent practices and sentiments committed in Brazil
and South Africa against children of the lower social strata.
According to her, an invisible genocide is occurring against
street and township youths in both Brazil and South Africa.
These youths are considered dangerous and as a conse-
quence, certain adults not only seem to feel murderous
toward them but act on these sentiments. Whereas upper
class and white victims have names, personalities, histories,
and grieving family members, black deaths are merely
counted or remain even undocumented. Scheper-Hughes
concludes that recognizing the everyday violence and
invisible genocides practiced against the class of dangerous
and endangered youths is a necessary first step in improving
the current and abysmal state of the children of the world.
Farmer (1996) points out that the experience of social
suffering cannot easily be expressed by statistics and
graphs. Instead, ‘‘the texture of dire affliction is best felt
in the rough details of biography’’ (1996:263). To explain
social suffering, one must embed individual biography in
the larger matrix of culture, history, and political economy
and find how various large-scale forces come to be trans-
lated into personal distress and disease. An example that
connects biography to wider societal contexts is provided
by Schäuble (2006) who illustrates how the traumatic
experience of the Croatian militant conflict and subsequent
affliction are dealt with on an individual level. She draws on
an ethnographic example of a carnival episode in which
one of her key informants dressed up as a ‘‘suicide bomber’’
and employs the concept of ‘‘imagined suicide’’ to interpret
different layers of meaning. Marko’s costume consisted of
a mount of a discarded backpack on which he attached
two parallel gas cartridges equipped with pointed tips
and small blinking green and red lamps. The finishing
touch was provided by a cardboard sign that read ‘‘Hello
America, greetings to your twins! See you again next
year!’’ Schäuble argues that the terrifying concept of Mar-
ko’s play refers less to terrorism itself ‘‘than to the violence
he has experienced during war and still experiences within
his own body’’ (2006:8). His fears are not only connected to
the direct effects of his military service but to other, societal
factors. Like most young men, he went to war before com-
pleting his education and as a consequence, hardly had the
chance to train and qualify for work today. Thus, his trauma
is enhanced by factors including low economic status, fi-
nancial dependency, the feeling of government sanctioned
225
injustice, as well as the lack of recognition and perspec-
tives. Schäuble interprets his performance as a ‘‘vision’’
that is inspired by previous terrorist acts, attempting power
relations.
Despite the anthropologists’ effort to promote the con-
cept of ‘‘social suffering’’, it barely penetrates the psychiat-
ric discourse on war-trauma and PTSD. A rare exception is
the work published by Pedersen and Bauffati (1989) and
Pedersen (2002). According to him, it is crucial to connect
immediate stressful events and economic/political
hardships with the broader social structure; to document
non-western patterns of trauma-related conditions; and
to assess the conditions in which medical or psychological
interventions help or hinder long-term recovery from
traumatic experiences. In order to capture the complexities
involved in the experience of massive trauma, Pedersen
introduces the notion of social suffering as an alternative
to the PTSD model. According to him, the notion of social
suffering is a valuable concept as it stresses the need for
an understanding of the ways in which macro-social
dimensions interact with the micro-social in attempting
to explain both the construction of suffering and its oppo-
site, the production of health.
Conclusion
Although transcultural psychiatrists, psychiatrists
adhering to a relativistic perspective, anthropologist-
psychiatrists, and a considerable number of medical an-
thropologists claim that only an interdisciplinary approach
leads to valid investigations, data interpretations, and sub-
sequently intervention strategies (Eisenbruch et al., 2004;
Kleinman, 1980, 1985; Lemelson et al., 2007; Pedersen,
2002), influential interdisciplinary writs leading to action
have not been produced in anthropological nor in psychiat-
ric journals or anthologies. A rare exception is the work of
the collaborative program of the Transcultural Psychosocial
Organization that aims at integrating public health
workers, psychologists, psychiatrists, and anthropologists.
Psychiatrists seem to be captured by their internal
dispute with regard to the universality of war-trauma and
PTSD. As outlined above, the two most polar positions are
(a) those who try to validate PTSD as a universal and
cross-culturally valid psychopathological response to trau-
matic distress which may be cured or ameliorated with
(Western) clinical and psychosocial therapeutic measures
and (b) those who argue that the Western discourse on
trauma only makes sense in the context of a particular
cultural and moral framework and, therefore, becomes
problematic in the context of other cultural and social
settings. Although these positions seem mutually exclusive,
their debates have led to the development of less radical
approaches toward war-trauma and PTSD. These
approaches question the validity of most cross-cultural
research on PTSD as it fails to consider indigenous expres-
sions of disorder, idioms of distress, and ethnocultural
sensitivities in assessment including instrument norms,
formats, language, and concepts. At the same time, they
admit that responses to a traumatic event may share
some universal features, especially as the trauma becomes
more severe. Thus, they conclude that ethnocultural factors
226 H. Kienzler / Social Science & Medicine 67 (2008) 218–227
play an important role in individual vulnerability to trauma
and PTSD, the expression of PTSD, and the treatment
responsiveness of PTSD (Ehrensaft, 1995).
Medical anthropologists, on the other hand, have devel-
oped a discourse that runs parallel to the psychiatric dis-
course but does not necessarily influence it. When one
enters the keyword ‘‘social suffering’’ into search engines
like PubMed, Medline, or Ovid that are specialized on topics
concerning the life sciences, including psychiatry, no entry
can be found. Interestingly, the search results in psychiatric
or psychological journals which encourage anthropological
contributions are almost as meagre. Upon entering the
term ‘‘social suffering’’, titles appear that have nothing to
do with trauma, war-trauma, or trauma related disorders.
Instead, one can learn about internet marketing of bariatric
surgery; collective mobilization on muscular dystrophy;
anti-aging medicine; youth homelessness in San Francisco;
qualitative studies on motherhood; etc.
In order for anthropologists to become respected col-
leagues working alongside and with psychiatrists and psy-
chologist in the vast field of trauma, it is crucial to recognize
that anthropology and psychiatry are not disciplines
located on different poles of a continuum but separate
entities that tackle similar issues from different perspec-
tives, with different methodologies, and different goals in
mind. This does not mean that the two disciplines should
not or cannot influence each other. On the contrary, inter-
disciplinary research could lead to more holistic
approaches to health care that take local perceptions of
health and illness, ways of healing, capacities, desires, and
needs into consideration. Thus, instead of proposing the
concept of ‘‘social suffering’’ as replacement for ‘‘the PTSD
model’’, I argue for a ‘‘division of labour’’ between the
disciplines that guarantees a more fine grained analysis of
how Western approaches to healing could be adequately
embedded in non-Western cultural and social settings.
Acknowledgments
I would like to thank Allan Young and Duncan Pedersen
for their support and critical discussion of the article drafts.
I also thank Andrea Saunderson for her critical reading of
the paper and Cees van Dijk for helping me to think things
through.
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