Reprinted from "Trauma and Victimization" issue of Visions Journal, 2007, 3 (3), pp. 10-12
Canada is a multi-cultural nation. Our neighbours, colleagues, spouses and parents have diverse ethnic and racial backgrounds. In the last decade the psychiatric literature has been full of research and scholarly work devoted to the significance of transcultural issues.1
Health care practitioners must be increasingly sensitive to cross-cultural concerns. This article explores the challenges presented by the crossing point of trauma and culture.
The competent cultural assessment
Consider the following clinical scenario. A Bosnian woman in her young forties, previously a science teacher in her home country, has insomnia, low self-esteem, anxiety, feelings of guilt and marital stress. She uses alcohol to keep her anxiety under control. She arrived in Canada 13 years ago with her husband and small child, when ethnic war was ravaging the former Yugoslavia. The family was sponsored by a relative in Canada. The couple left reluctantly, mostly for the sake of their child. The family appears to have integrated into the new culture: both adults have professional jobs and a small number of friends, and their teenager is functioning relatively well at school.
Complex post-traumatic stress disorder
Problems in the following areas may result after experiencing totalitarian control, including sexual and domestic violence:
As a capable clinician, you have completed a decent assessment of mental status. You have been mindful that this woman has had a life history in a different social context. You have explored with her the meaning of her physical and psychological complaints from the point of view of her native culture. The client expresses herself well in English, but, nevertheless, you check in with her for misunderstandings.
You have taken the time to evaluate how the uprooting affected her, what it is like to cope with daily stress away from the protective powers of one’s culture.2 The client readily talks about her sadness that she has no immediate family. She misses drinking the infamous black coffee with her parents and the intense heart-to-heart conversations with friends, to name just a few of the customs she took for granted.
Indeed, you have done an impressive amount of reading on the history and complexity of the ethnic structure in the Balkans. You have consulted with colleagues on their experience with refugees and immigrants from that region.
It is important, in this case, to screen for post-traumatic stress disorder (PTSD)—a condition that may develop after the experience of a life-threatening event. PTSD involves a response of intense fear or horror, helplessness, reliving the event through persistent memories, dreams or intrusive thoughts, and emotional numbing or extreme irritability, among other symptoms. Your findings on that are negative. Furthermore, your client’s immediate family and relatives have not been involved directly in the war, and no one has been harmed. You have inquired whether faith plays a role in the client’s life, as this is a way of evaluating strengths and coping skills.
The plan is to offer treatment for depression related to grief from losing her native land and couples work to assess the severity of marital conflict.
Generally, you relate with ease to this woman—she is well-spoken and impassioned when presenting her issues. Yet, as treatment begins, you find yourself feeling frustrated.
It is difficult to keep the focus in the sessions—the client brings up seemingly unrelated issues and talks in circles.
She has trouble speaking when she tries to revisit some experiences from the final days with her students in Bosnia. She avoids eye contact; her narrative becomes confusing—it’s hard to keep the chronology of events clear. She refers to atrocities she didn’t witness but knows her students and friends suffered. She presents them with such blandness and lack of emotion that you feel an urge to change the topic, to find material that is more understandable.
Obviously, it is time to reconsider the diagnosis.
PTSD is a diagnosis derived primarily from single isolated incidents. Resuming life after fleeing a traumatized society, however, is much more complicated. Complex PTSD is a term used by the psychiatric community to reflect the adaptation to trauma that arises from an accumulation of incidents. It might be a more meaningful framework for this case.3-5
Let’s re-examine the symptoms from this angle.
The literature on traumatic stress describes fragmentation of narrative (story) when trying to put words to frightening memories.3,6 The neurobiology of PTSD teaches us the biological basis for this: exposure to traumatic experiences is associated with “turning off” Broca’s area, the part of the brain responsible for speech production. This experience is sometimes called “speechless terror.”4
The depression and drinking need not be perceived as co-existing problems; rather they are part of the trauma. Using substances suggests she could be having difficulties regulating her emotions after surviving traumatic stress. The patient doesn’t verbally report symptoms of numbing, but it is expressed in the matter-of-fact manner of telling about horrors.
The client’s insomnia may be present because she doesn’t allow herself to fall asleep for fear of terrifying dreams. Her poor self-esteem and chronic sense of guilt take on a different meaning considering that her basic trust in a society been grossly violated. Relations breaking down within the family is understandable in light of the inability to feel intimate and close to others after terror and betrayal.
To conclude: as health care professionals, we need to be aware that culture does influence our ability to make precise diagnoses. The best work is done when we maintain a nonjudgmental stance of respectful compassion.
About the author
Inna is a Psychologist in Vancouver who specializes in trauma and collaborates with the Cross Cultural Clinic located at Vancouver General Hospital.
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deVries, M.W. (1996). Trauma in cultural perspective. In B.A. van der Kolk, A.C. McFarlane & L. Weisaeth (Eds.). Traumatic stress: The effects of overwhelming experience on mind, body and society (pp. 398-416). New York: Guilford Press.
Herman, J. (1992). Trauma and recovery: The aftermath of violence—from domestic abuse to political terror. New York: BasicBooks.
van der Kolk, B.A. (1996). The body keeps the score: Approaches to the psychobiology of post-traumatic stress disorder. In B.A. van der Kolk, A.C. McFarlane & L. Weisaeth (Eds.). Traumatic stress: The effects of overwhelming experience on mind, body and society (pp. 214-241). New York: Guilford Press.
Briere, J. (2002). Treating adult survivors of severe childhood abuse and neglect: Further development of an integrative model. In J.E.B. Myers, L. Berliner, J. Briere et al (Eds.). The APSAC Handbook on Child Maltreatment (2nd ed.) (pp. 175-204). Thousand Oaks, CA: Sage Publications.
Chu, J. (1998). Rebuilding shattered lives: The responsible treatment of complex post-traumatic and dissociative disorders. New York: John Wiley & Sons, Inc.