western conceptualisations and eastern experiences
TRANSCRIPT
CROSS CULTURAL ASSESSMENT AND
TREATMENT OF PSYCHOLOGICAL TRAUMA
AND PTSD: WESTERN CONCEPTUALISATIONS
AND EASTERN EXPERIENCES
Ms Neeraja Sanmuhanathan
Direct Services Counsellor, STARTTS
B.A (Psychology), MRehabClng, PhD Candidate, University of Sydney
Agenda
Culture and trauma: an overview
Clinical case study
Demographic
Trauma History
Presenting problems
Culture and Trauma
Cross cultural approach to assessment and treatment
Cultural bias and challenges to therapy
Moving forward – improving clinical practice
What is culture?
Traditions, values, rituals, belief systems, knowledge and skills
Presented externally (Marsella, 1988)
Rituals, customs, artefacts, institutions
Represented internally (Marsella, 1988)
Values, beliefs, worldview, pattern of behaviour
Collectively maintained and transformed by the ongoing interaction of societal members over time and space (D.T Giddens, 1993)
Not bound by physical and geographical boundaries
Contributes to social identity, distinguishes us and them
Culture is a significant contributor to psychological stability. It provides meaning and value to life
Culture and Trauma
Jerome Kroll and Laurence Kirmayer perceived the notion of trauma as a timeless, biological
response to adversity that occurs independently of culture as naive (Haslam, 2000)
Experience of psychological trauma varies according to culture, emotional reactions differ
from culture to culture
Trauma becomes part of the new cultural narrative for the individual and community
Demographic Information
Name: Krishna
Gender: Male
Age: 37
Country of birth: Sri Lanka
Religion: Hindu
Marital status: Single
Education: High School Advanced Level/Diploma in Nursing
Visa status: Bridging visa E
Date of arrival: May 2013
Date of referral: October 2016 (current referral)
Number of sessions to date: 12
Trauma History
1976: LTTE forms
1948: Sri Lanka’s
independence
2013 : Asylum
journey to Australia
2016: DIBP
Interview
1985 : Tensions
increase, family
is displaced2010: Sent to
Rehabilitation Centre
2009-12: Detained
in government
‘rehabilitation’ centre
2008:
Displacement
1958 : Anti Tamil
riots, displacement,
discrimination
1979– Birth
1998-2001 : War
rages in the north
and east
1991: Joins the
LTTE at age 12
2009: Final war ends
1987: Indian Peace
Keeping Army
2017: Uncertainty
regarding future
Assessment
Context, family, social , trauma history
Protective factors/risk factors identified
Harvard Trauma Questionnaire (HTQ), Hopkins Symptoms Check List (HSCL)
Culturally appropriate assessment
Cultural identity of the person
Cultural explanations of the person’s illness
Cultural factors related to psychosocial environment and level of functioning
Culture and Trauma
Acknowledgement that many assessment and treatment models were derived from
industrialised nations and applied to increasingly diverse cultural populations
Emotional display rules, how an individual is expected to respond to trauma (Sociologist Peggy
Thoits)
Cultural expression, response to trauma (shame, fear, guilt)
Father passes away at a young age (traumatic death)
Becomes a child soldier at the age of 12 (culture of violence, war culture, notion of
youth, breakdown of family structure)
Loss of friends, education and childhood
Cultural manifestations of trauma
Culture and Trauma
Protective Factors
Collectivist identity, increased social connection, deep rooted values, belief system
“I feel a little better when I speak to my old friends and the childhood we had together”, “my
mum is the most important person and I am motivated to be at least happy for her”
Risk Factors
Strong attachment to people, places leads to greater feelings of loss, helplessness
“During the final few days of the civil war, I had an opportunity to surrender or kill
myself. I chose to surrender. But I regretted not killing myself for a long time. I felt
that there was no honour in surrendering. Now I find myself here asking for a future
when so many of my friends were killed.”
Presenting problems
Psychological
Post Traumatic Stress Disorder (re-experiencing, avoidance, negative cognition and mood,
arousal)
Anxiety (difficulty concentrating, irritability, sleep disturbance)
Depression (diminished interest, low mood, reduced appetite)
Spiritual – not a believer in ‘God’, rather believes in moral compass and faith
Physical – psychosomatic pain, headaches, lethargy, fatigue
Interventions Overview
Creating safety and building rapport
Cognitive Behavioural Therapy strategies, Acceptance and Commitment Therapy
Elements of Narrative Exposure Therapy (re-working life story, life timeline)
Culturally appropriate clinical work
Exploring folk stories, rituals, traditional methods of mourning and healing
Identifying cultural idioms of distress and patterns of survival
Cultural empathy: traditional empathy theory focuses on feelings rather than
cultural meanings and the socio-political context in which the experience occurs in
(Green, 1995)
Interventions continued
Cultural idioms of distress, an expression of psychosocial distress
Individual level
Engal Thalaivithi (This is my fate)
I should have died as a martyr
My heart is heavy, my head is full
I don’t have the respect of my community
Family level
Orutharum oorilai illai (No-one is left in our village)
Community level
Ketkirathuku orutharum illai (No-one is left to ask questions)
Challenges to therapy
Transference/Counter transference
Complexity of the asylum legal pathway
Cultural element of clinician/client relationship (intercultural encounter during therapy)
Cultural bias (individualism, self defined goals, personal reflection versus compliance,
cooperation, interdependence)
Learning the client’s choice of words as well as cultural meaning attached to the words
Modification of the therapeutic relationship to the client’s culture (Comas-Diaz 2006)
Conclusion and Outcome
Outcomes
Increased self compassion
Managing intrusive thoughts and memories
Recognising post traumatic growth
Ongoing Challenges
Survivor guilt
Identity crisis
Where to from here?
Role of culture in intergenerational trauma – more research
Role of culture in collective identity and collective trauma in refugee populations
References
Comas-Dı´az, L. (2006). Cultural variation in the therapeutic relationship. In C. D. Goodheart, A. E. Kazdin, & R. J. Sternberg (Eds.), Evidence-based psychotherapy: Where practice and research meet (pp. 81–105). Washington, DC: American Psychological Association.
Giddens, D.T. (1993). “New rules of sociological method: A positive critique of interpretive sociologies”. Stanford University Press, Stanford, CA.
Green, J.W. (1995). Cultural awareness in the human services. Second Ed. Toronto: Allyn & Bacon.
Haslam, N. (2000). Psychiatric categories as natural kinds: essentialist thinking about mental disorders. Social Research , 67, 1031-1058.
Jegan, B. (2017). "Sarees In The Wind". N.p., 2017. Web. 26 Mar. 2017.
Marsella, A.J. (1988). Cross cultural research on serious mental disorders: Issues and findings. Acta Psychiatrica Scandinavica Supplement, 344, 7-22.
Randall, C. (2017). "Global Sojourns Photography". Global Sojourns Photography. N.p., 2017. Web. 26 Mar. 2017.
