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The trauma debate

The trauma debate

When they think of psychosocial work with war-affected people many assume that this involves working with trauma or with traumatized people. The word has become so popular that assumptions are very quickly made about experiences of war leading to trauma automatically. 'Trauma' is used to talk about the resulting state of distress in an individual, a group, a community, or a nation.

There has been a lot of debate about the concept of trauma and how it has been applied. While trauma remains a dominant model used by many psychological practitioners who seek to provide assistance to war-affected populations, the voices of criticism have been growing louder. It is important briefly to outline the basic lines of argument.

First the issues will be presented from the perspective of those practitioners who make use of the concept of trauma and find it useful.

The concept of PTSD

Central to the notion of trauma is the concept of post-traumatic stress disorder (PTSD). The experiences of the Vietnam War veterans were important in developing this diagnosis (Marlowe 2000) . The veterans had difficulties adjusting to civilian life after they returned, many becoming alcohol dependent, committing criminal offences, and displaying aggressive behaviour in public. There was a high rate of divorce. The returning soldiers experienced a number of symptoms associated with their experiences, such as flashbacks to extremely distressing situations, sleep disturbances, avoidance of situations that triggered memories of distressing events, difficulties in feeling emotional responses, and, occasionally, memory loss. These symptoms occurred so frequently amongst this group that a new psychiatric disorder was developed by the American Psychiatric Association which was included in the third edition of their Diagnostic and Statistical Manual of Mental Disorders (DSM) published in 1980 - PTSD. It consists of a number of symptoms related to:

  • the re-experiencing of the distressing event
  • the avoidance of things that remind one of the event, and
  • increased physical problems such as not being able to concentrate or difficulties with sleeping
    If these symptoms affect the person to such a degree that they are no longer able to function in social, vocational, or other important areas of their life, and if they persist for more than one month, a person may be diagnosed with having PTSD.

PTSD is a term now commonly used when some psychological practitioners talk about the effects of distressing events such as displacement, witnessing or participating in armed conflict, bombings, torture, rape, or attacks. For an example of such research, see Krinsley and Weathers (1995) . Researchers use PTSD checklists in countries around the world such as Sierra Leone, Sri Lanka, and Columbia, on the basis of the belief that this is a universal concept that can be applied to everyone regardless of cultural, ethnic, religious background, age, gender, or context. They assert that the same symptoms will appear in anyone who has been traumatized, whether they be an American war veteran or an Angolan adolescent displaced by war.

Using PTSD as a diagnosis means that people who suffer from its symptoms can be diagnosed as having a mental disorder. While this was the initial 'clinical' intention behind the development of this diagnostic category, it has also been used:

 

  • to conduct research in order to understand better the effects of war on different populations
  • to conduct needs assessments among affected populations in order to argue for the allocation of resources for mental health or psychosocial programmes
  • to conduct evaluations of the impact of psychosocial programmes. This is usually done by measuring the numbers of symptoms before and after a psychosocial intervention, to see if there has been a decrease in symptoms.
  • to identify specific individuals or groups in a population that have been particularly negatively affected and who need additional support.

Websites

Krinsley and Weathers 1995 http://www.ptsd.va.gov/professional/newsletters/research-quarterly/V6N3.pdf
Marlowe 2000 http://www.rand.org/publications/MR/MR1018.11/MR1018.11.ch9.html

Other aspects of the concept of trauma

The concept of PTSD is central to understanding trauma and has become the 'gold standard' for understanding the effects of armed conflict and displacement on people. Many people equate war-related distress with trauma, and equate trauma with PTSD. However, the concepts of trauma and traumatization are broader than PTSD. For example, some psychological professionals are of the opinion that PTSD is just one of many mental health problems that can arise as a consequence of traumatization (Newman et al. 1996) . Depression and anxiety are the two other most frequently diagnosed psychiatric disorders, and research is being conducted into the frequency with which they occur amongst war-affected populations (Friedman and Marsella 1996) .

While the symptoms of PTSD are 'found' and diagnosed in individuals, some scholars argue that psychological practitioners should focus on the traumatization of whole communities where they have been subjected to large-scale displacement, genocide, or constant attacks from armed groups (International Trauma Research Net Conference 2002). This results in the breakdown of social relations, and can lead to an increase in interpersonal conflict, domestic violence, and alcohol and drug use (see Weisaeth and Eitinger 1991 ).

Some psychologists have argued that trauma can be transmitted from generation to generation (Danieli 1997) . Research was first conducted by scholars studying trauma symptoms in the children of Holocaust survivors (Kestenberg and Brenner 1996) . The central idea here is that, unless some intervention takes place, parents will transmit to their children their unresolved feelings about the distressing events they have experienced, resulting in the traumatization of the next generation.

Websites
Danieli 1997 http://www.ptsd.va.gov/professional/newsletters/research-quarterly/V8N1.pdf
International Trauma Research Net Conference 2002, http://www.traumaresearch.net/con_xx.htm
Weisaeth and Eitinger 1991 http://www.ptsd.va.gov/professional/newsletters/research-quarterly/V2N2.pdf
Key readings and psychological studies:
Danieli, Y., Rodley, N., and Weisaeth, L. (eds), International Responses to Traumatic Stress. New York: Baywood, 1996.
Marsella, A., Friedman, M., Gerrity, E., and Scurfield, R. (eds), Ethnocultural Aspects of Posttraumatic Stress Disorder. Washington, DC: American Psychological Association, 1996 http://www.ptsd.va.gov/professional/newsletters/research-quarterly/V3N2.pdf
Mollica, R. 'Assessment of Trauma in Primary Care. MSJAMA, vol. 285, 2001. http://jama.ama-assn.org/cgi/content/full/285/9/1213
National Institute of Mental Health http://www.nimh.nih.gov/publicat/violence.cfm
Van der Kolk, McFarlane, A., and Weisaeth, L. (eds), Traumatic Stress. The Effects of Overwhelming Experiences on Mind, Body and Society. New York: Guilford Press, 1996. Yule, W. (ed.), 'Post-Traumatic Stress Disorders. Concepts and Therapy'. Chichester: Wiley, 1999.

Criticism of the trauma concept

The concept of trauma has come under criticism in the past few years. Critics have focused on several key issues:

1. Aid agencies and funders have focused on trauma and traumatization as the 'flavour of the month'. This means that they frequently arrive in post-emergency situations with a preset agenda of providing psychosocial assistance where communities may actually identify other issues and concerns as more important (Bracken and Petty 1998) . The material conditions and economic needs may be neglected by aid agencies who have received funding to implement psychosocial projects. Bracken et al. (1995) believe that this reflects a Eurocentric agenda rather than the expressed needs of war-affected populations themselves. Political and historical issues are also ignored in favour of emotional and mental health issues (Summerfield 1999) .

2. Trauma is a Western concept that cannot be applied to non-Western populations. Trauma and PTSD arise out a Western psychiatric diagnostic system and are inappropriate to different cultural contexts, where people not only have different diagnostic systems but also different understandings of distressing events and how to survive them (Boyden and Gibbs 1997) . People make sense of their experiences in reference to cultural frameworks and local cosmologies, and their reactions are, to a great extent, influenced by their perceptions of the meaning of those events These meanings may not be psychological or medical but may be spiritual, cultural, or political. By imposing this Western trauma framework on other populations, psychological practitioners have largely ignored the role that culture plays in issues of distress and mental health, instead focusing on interpreting the suffering of people by means of pre-determined psychiatric categories and PTSD symptom checklists. Where attempts have been made to implement culturally sensitive programmes, these have often been guided by the notion that cultural factors are potential barriers to be overcome in the provision of psychological services, rather than resources. The distress and suffering caused by war cannot, therefore, be captured in universal concepts, and are instead related to context and local culture. At times, Western models of trauma may be in direct opposition to local cultural understandings of distress, or fit poorly with local cosmologies, norms, and values (Wessells 1999) .

3. Interventions that aim to alleviate trauma are often inappropriate and ineffective. A consequence of point 2 is that Western treatment and intervention practices tend to use uniform programmes which are implemented regardless of the cultural context within which they work, thereby failing to acknowledge local diversity in expression, understanding, and treatments (Adjukovic 1997) . Psychosocial projects have been described as ineffective at best, and as having a destructive influence at worst when indigenous efforts to cope with the social and material devastation are overridden and undermined by Western 'trauma experts' (Richters 1998) .

4. Local resources and systems are ignored. Communities have resources for coping with distress that they draw on in situations of adversity, a fact frequently ignored by psychological professionals, who focus more on what they see as weaknesses and deficits than on strengths and abilities (Summerfield 2001) . Recognition needs to be given to the important role of local healing practices and coping strategies, as these are central to strengthening community reconstruction in post-conflict situations, as well to the many ways in which people engage in 'world-making' after events of armed conflict (Nordstrom 1997) .

5. Talking about people as traumatized presents them as passive victims. The presentation of people and communities as traumatized implies 1) that they have a mental disorder, and 2) that they are passive victims who need the assistance of western-trained 'experts' (Bracken 1998) . In fact, most people are not traumatized in the sense that they become dysfunctional, and only a small minority ever require special help. Claims of vast numbers of 'traumatized' people and generational transmission overexaggerate the percentage of people who may be unable to cope with their distressing experiences.

Websites
Bracken et al. 1995 http://www.sciencedirect.com/science?_ob=MImg&_imagekey=B6VBF-3YS8BF9-6-2&_cdi=5925&_user=126524&_orig=browse&_coverDate=04%2F30%2F1995&_sk=999599991&view=c&wchp=dGLbVlb-zSkzk&md5=6cd1a8cb6fd6be9905db0c0d2ada0b45&ie=/sdarticle.pdf
Summerfield 1999 http://www.sciencedirect.com/science?_ob=MImg&_imagekey;=B6VBF-3WR495S-F-1&_cdi;=5925&_orig;=search&_coverDate;=05%2F31%2F1999&_qd;=1&_sk;=999519989&wchp;=dGLbVtb-lSzBk&_acct;=C000010360&_version;=1&_userid;=126524&md5;=2d8665f861909103249f2bac6f7c6d59&ie;=f.pdf
Summerfield 2001 http://earlybird.qeh.ox.ac.uk/rfgexp/rsp_tre/student/natconf/toc.htm
Boyden, J. and Gibbs, S., Children of War. Responses to Psycho-social Distress in Cambodia. Geneva: United Nations Research Institute for Social Development, 1997.
Bracken, P. and Petty, C., Rethinking the Trauma of War. London: Free Association Books, 1998.
Gilbert, J., 'Responding to Mental Distress in the Third World: Cultural Imperialism or the Struggle for Synthesis?' Development in Practice, vol. 9, no. 3, 1999. http://www.developmentinpractice.org/abstracts/vol09/v9n3a04.htm
Summerfield, D., 'A Critique of Seven Assumptions Behind Psychological Trauma Programmes in War-affected Areas'. Social Science and Medicine, vol. 48, 1999. http://www.sciencedirect.com/science?_ob=MImg&_imagekey=B6VBF-3WR495S-F-1&_cdi=5925&_orig=search&_coverDate=05%2F31%2F1999&_qd=1&_sk=999519989&wchp=dGLbVtb-lSzBk&_acct=C000010360&_version=1&_userid=126524&md5=2d8665f861909103249f2bac6f7c6d59&ie=f.pdf
—, 'Childhood, War, Refugeedom and 'Trauma': Three Core Questions for Mental Health Professionals'. Transcultural Psychiatry, vol. 37, no. 3, 2000. http://tps.sagepub.com/cgi/content/abstract/37/3/417?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&author1=summerfield&searchid=1107958214379_65&stored_search=&FIRSTINDEX=0&sortspec=relevance&volume=37&journalcode=sptps

Victims or survivors: the resilience/vulnerability debate

Studies have found that in countries where almost everyone has been exposed to or witnessed distressing incidents (for instance, Rwanda, Bosnia, Cambodia), people appear to be remarkably resilient. In a survey of 3,000 residents of Sierra Leone, where a ten-year civil war has brought suffering, death, and displacement to most of the country's population, 59 per cent of the respondents described themselves as 'generally a happy person'. Ehrenreich (2002) points out that these figures are comparable to findings in similar surveys in North America and Europe, where people were not experiencing armed conflict.

The debate to what extent war-affected people can be described as being vulnerable or resilient in relation to their experiences and how they cope with these has been a constant feature in psychology since World War II (Cairns 1996) . Some psychologists are interested in the question why some people suffer more serious psychological consequences than others, while other psychologists seek to identify the factors that promote resilience in children and adults affected by adversity. Some of the commonly described factors that may play a role in how well people cope with distressing experiences are:

  • social environment such as emotional, moral, and practical support from family, friends, neighbours, and support groups
  • individual factors such as age, personality and previous experiences, and coping strategies
  • ideological factors such as political commitment or religious faith
  • cultural resources and collective coping strategies such as mass funerals, rituals and ceremonies.

It has been argued that studies of the psychosocial effects of armed conflict have concentrated too much on vulnerability at the expense of neglecting people's strengths and abilities to cope (Boyden 2000) . While there have been reasons for this, for example placing the psychological well-being of forced migrants on the international agenda, the consequence has been to present war-affected people primarily as victims. Victimhood is frequently a disempowering position, in that it implies helplessness and the need for someone to intervene and assist. It should not be assumed that people want or require psychosocial assistance. Summerfield (2001) discusses findings by Somasundaram (1996) , who asserts that large numbers of Sri Lankans suffer from PTSD following aerial bombings, but that none of them considered themselves psychiatrically ill and just saw their symptoms as an inevitable part of the war. The majority of Sri Lankans were able to adjust to their symptoms and function in their social and vocational lives. The help they asked for was primarily economic.

Placing the emphasis on resilience does not mean that people who are resilient do not experience symptoms of distress. It does, however, take as a starting point people's abilities and capacities to deal with their experiences, and necessitates - at the very least - providing assistance that they themselves need and want.

Websites
Boyden 2000 http://www.lse.ac.uk/collections/DESTIN/pdf/WP05.PDF
Summerfield 2001 http://earlybird.qeh.ox.ac.uk/rfgexp/rsp_tre/student/natconf/toc.htm
Last updated Mar 13, 2014