PTSD & war trauma

The Symptomology of PTSD PTSD is characterized by two dimensions of symptoms: intrusion - which includes nightmares, startle reaction, hyper-vigilance and insomnia and avoidance characterized by social withdrawal, low interest, poor concentration, and avoidance of past memories. According to James Boehnlein (1985) the avoidance symptomology appears to be resistant to change. There are also come culturally bound symptoms which do not fit into either of these symptom categories; for example, shame seems to be the culturally acceptable coping style of Cambodians who survived the Khmer Rouge killing fields. Intensive emotional upset may be triggered by stimuli that symbolize the traumatic event, eg. anniversaries or relevant films/newscasts. In a study to determine the effect of such stimuli on mental processing, McNally et al (1990) did a study of the Stroop test with Vietnam war veterans diagnosed with PTSD and a control group. There was no significant between group difference in the time required to read the lists of words. However, when words were included which were related to the Vietnam War, the PTSD group experienced significantly higher levels of interference. There is comorbidity (the co-occurrence of one or more disorders) with other disorders, particularly depression and substance abuse. PTSD patients also tend to experience marital problems, poor physical health, sexual dysfunction, and occupational impairment. Often they also exhibit stress-related psychophysical problems such as low back pain, headaches, and gastrointestinal disorders. Some children regress losing already acquired developmental skills, eg. speech or toilet training (Davison, Neale, and Kring). PTSD in survivors of ethnic cleansing may evolve with a different pattern of symptom clusters than it does in cases resulting from disasters or combat. Survivors of genocidal trauma do not have a few discrete traumatic memories that come and go; their lives are continuously inundated with traumatic images. One man said that he does not have memories of the war. He insists that what he has are films of traumas that constantly play in his head (Weine, 1995). The chronic nature and universality of symptoms have differentiated concentration camp victims from others suffering from PTSD. Concentration camp victims symptoms often directly impeded their social adjustment and resulted in a passive, fatalistic personality, hopelessness, and a loss of previously enjoyed activities. Research by Peter Suedfeld (2003) examined the attributional patterns in Holocaust survivors. Suedfeld argues that the trauma of genocide and state sponsored oppression creates a situation in which the explanatory constructs that once might have served under

normal circumstances now became untenable. Janoff-Bulman (1992) refers to this as the shattering of the assumptive world. Suedfeld found that the attributional style of the Holocaust survivors tends to be much more external ie. luck, God, fate. Interestingly, when asked why someone survived the Holocaust, survivors were more likely than a Jewish control group to mention help from others including help from Gentiles, which was not mentioned by any members of the comparison group. Although help from others was prominently mentioned in the study, survivors nevertheless have low trust in others and a skeptical view of their benevolence. In Steven Weines (1995) research on PTSD among Bosnian refugees in the USA, he found some interesting manifestations of symptomology. 65% of the refugees he interviewed met the DSM-IIIR criteria for PTSD and 35% for depression. Of subjects older than 18, all but one met diagnostic criteria for PTSD; none of the subjects less than 18 years old met criteria for PTSD. Correlational analysis indicated that older age was associated with higher PTSD severity scores (r = 0.60; p<0.0001). He concluded that traumatic exposure in adolescents often does not take the form of adult PTSD, but is manifest in traumatic play, behavioural reenactments, and cognitive distortions. This makes a universal diagnostic strategy for PTSD improbable at best.

The Aetiology of PTSD The following are the more traditional explanations of the aetiology of PTSD. Cognitive theorists, such as Horowitz (1986), argue that invasive memories are either consciously suppressed or repressed; the basis of the disorder is an internal struggle to integrate the trauma into the patients existing beliefs about himself and the world. There is also evidence that biology may play a role in PTSD. Evidence suggests that trauma may stimulate the noradrenergic system raising norepinephrine levels (Davison, Neale, and Kring). A genetic predisposition also appears to be possible; PTSD is said to pass intergenerationally in societies (Hauff and Vaglum, 1994). However, the vast number of studies today tend to focus on a more social-based approach. For example, current diagnostic literature suggests that experiences with racism and oppression are predisposing factors for PTSD. In his review of the literature, Roysircar (2000) cites research that among Vietnam War veterans 20.6% of Black and 27.6% of Hispanic veterans met the criteria for a current diagnosis of PTSD compared to 13% of whites (Kukla et al, 1990). In his research on PTSD in Rwandan children, Dyregrov (2000) goes a step further, arguing that threat of death was the factor that evidenced the strongest influence on

intrusion and avoidance symptomology. This appears to have support in research in Bosnia, where in 1998 close to 73% of girls and 35% of boys in Sarajevo suffered from symptoms of PTSD; Kaminer, Seedat, Lockhart and Stein (2000) credited the higher rate of PTSD in girls to fear of rape. The implications of the research in post-genocidal societies is significant. With the growing evidence that social factors may play a significant role in PTSD, Karen Hanscom argue that we need to expand the treatment model beyond the office and shift to communityoriented approaches.

The Treatment of PTSD In this section, western methods of treatment are discussed. In the Bosnia section, Steven Weines work with testimonial therapy will be discussed. In the section on cultural considerations, Karen Hanscoms work on community-based approaches will be discussed. Until recently, majority of the therapy for PTSD has been based on a cognitive/behavioural approach. Often medication anti-depressants and tranquilizers is used to deal with conditions comorbid to PTSD that may impair therapy. Boehnlein (1985) found in his study of Cambodian refugees that tricyclics were helpful in treating the depression as well as the PTSD symptoms of nightmares, startle reactions and intrusive thoughts. Benzodiazapines seemed ineffective. He also argued that traditional psychoanalysis had little effect in alleviating PTSD symptoms; he attributes these therapeutic failures to the difficulty of entering into a therapeutic alliance with these patients. Edna Foa has proposed what she calls exposure goals. She argues that there are four goals of cognitive behavioural therapy: 1. Create a safe environment that shows that the trauma cannot hurt them. 2. Show that remembering the trauma is not equivalent to experiencing it again. 3. Show that anxiety is alleviated over time. 4. Acknowledge that experiencing PTSD symptoms does not lead to a loss of control (Davison, Neale, and Kring). Though exposure therapy has yielded positive results, Keane (1992) has pointed out that patients may become initially worse in the initial stages of therapy, and therapists themselves may leave upset when they hear about the patients experiences. In addition, contrary to Foas third goal, Dyregrov, Gjestad and Raundalen (1999) found that time alone did little to alleviate IES (Impact of Event Scale) scores among Iraqi children and adolescents following the Gulf War. The IES is a rather reliable indicator of PTSD. As a result of such traumatic events as school shootings, we have seen the development of a field of psychology called traumatology. With the increase in interest in this area of

treatment, we have seen the development of the Critical Incident Stress Debriefing more commonly known as crisis intervention. These are the teams of psychologists that arrive at the scene to help the survivors and witnesses of a traumatic event. It is based on the assumption that it is best to intervene with survivors 24 72 hours after the traumatic incident, before PTSD sets in. Its effectiveness, however, is open to debate. First, the majority of people who experience trauma never develop PTSD. It appears that PTSD manifests itself in approximately 25% of people exposed to trauma. In cases of rape and ethnic cleansing, the numbers are significantly higher. Mayou et al (2000) argues that crisis intervention may do more harm than good; Immediately following a disaster, people are best served by the social support usually available to them in their families and communities; the coercion to be treated by strangers, even if well-intentioned, is not helpful and may even be intrusive and harmful.

The Case of Bosnia After his father disappeared into a concentration camp early in the conflict, a young Bosnian spent several months searching for his father before giving up and fleeing to Muslim controlled central Bosnia to find his mother. When he eventually found her, she refused to take him in because he was a Muslim and she was a Serb. From Bradley Steins Working with Adolescent Victims of Ethnic Cleansing in Bosnia. There appear to be two major sets of studies done on survivors of the Bosnian conflict. The first set was based on treatment administered locally within Bosnia. Some of the key psychologists who have written on this are Bradley Stein, Lynne Jones, and I. Zivcic. The second set was based on the treatment of Bosnian refugees to the USA; the key psychologists who have written on this are Gargi Roysircar, Paul L Geltman, and Stevan Weine. Bradley Steins work in Bosnia Bradley Steins work in post-war Bosnia faced many obstacles. The key obstacle for the IRC (International Rescue Committee) to set up trauma treatment centers was the lack of qualified staff. There were few mental health resources available since psychiatrists and psychologists had fled or been killed, and there were only a handful of individuals with a background in mental health. Stein worked primarily with Bosnian adolescents, setting up group sessions to help them discuss the war. Perhaps because of the age of his sample, victims did not always present the classic PTSD triad of intrusive thoughts, hyper arousal, and emotional numbing. Although many were emotionally numb, few had symptoms of intrusive thoughts, and most had no hyper arousal, although behavioral problems were quite common. We will see that this was

also true of adolescents in the Massachusetts study by Weine. Stein argues that one of the key differences between survivors of ethnic cleansing and those of other trauma, is that ethnic strife affects all of the support structures within a society; it finds its way into schools, villages, and families, damaging all aspects of civilised society. This exacerbates the psychological effects of the trauma by damaging all social structures that provide support in times of stress. Geltman and Stover (1997) have argued that trauma is an attack on meaning. This is best illustrated by Steins work with young men who had been disabled by the war and are now in wheelchairs. The majority of these men showed symptoms of PTSD and depression. Many were isolated from family and friends due to the stigma of their disability, and they often isolated themselves from each other in the rehabilitation centre. In the former Yugoslavia these men would have been institutionalized due to their injuries, and these men expected to be fully banished from society. Stein developed a wheelchair basketball program in order to give meaning to the lives of these young men. Although initially greeted with great skepticism, eventually participants began to support each other, forming a tight-knit group. They held all night bull sessions, discussing wartime experiences, future hopes and fears. They encouraged each other in physical rehabilitation and educational sessions. They summoned up the courage to go into town together to bars and cafes. Several became romantically involved with women in the town. And most significantly their overall mental health improved. Research on Bosnian refugees in the USA As with Steins research, adolescent Bosnian refugees also did not show the classic symptomology of PTSD. However, Geltman et al (2000) explained that 77% of 189 Bosnian refugee children resettled in Massachusetts manifested behaviour problems. Their cultural norms regarding intimate relationships, family cohesion, and religious values were significantly more conservative than the society into which they had moved. Among adults, Weine (1995) found that in severity ratings of DSM-IIIR symptoms of PTSD, the most common symptom cluster was: intrusive memories; avoiding thoughts of the war; feeling future is unclear. Nearly all the refugees emphasized the shock that came with the sudden occurrence of human betrayal by neighbors, friends, and relatives. Roysircar (2004) in his case study of a child soldier who was now living in the USA, argues that the addictive effects of violence and deprivations during war overwhelm the coping skills of children and leave them vulnerable to externalizing (delinquency) and internalizing (depression) adjustment difficulties. He also argues that acculturative stress (stress related to adjusting to new culture) compounds the difficulties of dealing with trauma. Refugees often spoke of the feeling of estrangement that developed as they attempted to assimilate into the

US culture, which appeared oblivious to the trauma that they had suffered. Eisenbruch (1991) has described Cambodians in the USA, who continue to live in the past, feel guilty about abandoning home and about unfilled obligations to the dead, haunted by painful memories and unable to concentrate on the tasks facing them in their new society. He points out that Cambodians in Australia, where there was less pressure to conform and where they were given a chance to practice some traditional ceremonies, did better than did their counterparts in the USA (in Bracken, Giller, and Sommerville). In his work with Bosnian refugees, Stevan Weine (1998) has employed testimony psychotherapy as means of helping patients overcome their PTSD. According to Weine, traditional treatment is said to work by deactivating networks of fear in the psyche. Testimony is based on theories that consider collective traumatization to be at least as significant as individual traumatization. Bosnians approach matters of traumatization as a matter of collective as well as individual experience. What was targeted in the genocide was not only their individual lives, but also their collective way of life. An essential component of testimony therapy is the creation of an oral history archive, to collect, study, and disseminate the survivors memories. This gives meaning and purpose to the experience of the survivor. Testimony therapy is integrative. It is an opportunity for the survivor to assimilate dissociated fragments of traumatic memory and to associate affective and cognitive aspects of the experience through the guidance of a therapist who has adequate knowledge of the historical events that the survivor has experienced. Testimony provides a time for an individual to look back over and reconsider his or her previous attitudes concerning ethnic identity, forgiveness, and violence. It also allows them to consider how their experience has affected how they feel about their lives today. For the survivor, the process of testimony permits the entry into meaning. In Weines study, all patients were diagnosed by using the PTSD symptom scale, which had been translated into Bosnian and then back translated for accuracy. All testimonies were conducted in Bosnian, translated into English, and then translated back so that the interpreter and the survivor could together correct mistakes and add possible new recollections and details. The final document was given back to the survivor at the final session, and the survivor signed the document verifying its accuracy. There are many survivors who are highly disinclined to seek or accept psychiatric treatment from a clinician but who would participate in testimony psychotherapy in the community. Weine found that the rate of PTSD decreased from 100% at pre-testimony to 75% posttestimony, 70% at 2-month follow up, and 53% at 6-month follow-up.

Cultural Considerations of PTSD Karen Hanscom has been a fore-runner in the development of community based projects which are sensitive to the cultural issues which underlie the treatment of PTSD. Many of the examples below come from her work in Guatemala, working with the Mayan people who suffered ethnic cleansing in the 1980s. It is very common for survivors to initiate treatment with someone due to somatic complaints or newly developed anger control problems. According to the DSM, somatic symptoms of PTSD are atypical. Kleinman (1987) argues that it is irrational and ethnocentric to make out that non-western forms of this disorder are atypical, the form commonly seen in the West being assumed to be the norm. Often non-Western survivors exhibit what are called body memory symptoms. One example is the dizziness experienced by one woman which was found to be a body memory of her repeated experience of being forced to drink large amounts of alcohol and then being raped and tortured (Hanscom 2001). Very often therapists in the west focus on the core syndrome, the cluster of symptoms that were used in the diagnosis of the disorder. However, it has been found that in the treatment of patients who underwent torture for their political convictions, if these convictions are ignored during therapy, such people have difficulty making sense out of their experience. Some therapists have addressed this political aspect by using testimony against the torturers as part of the treatment or by encouraging a reintegration into the political struggle. Hanscom advocates providing therapy through the use of locally trained assistants. The approach is called the HEARTS approach. The acronym stands for:

H Listening to the HISTORY E Focusing on EMOTIONS and Reactions A- ASKING about Symptoms R Explaining the REASON for Symptoms T TEACHING Relaxation and Coping Skills S Helping with SELF-CHANGE

Hanscom trained Mayan women to assist in post-war Guatemala. Training them involved both sharing what the West has learned about PTSD, but also understanding the support structures that already exist in the local community. When teaching about how to listen to the history, Hanscom found that Mayan women avoid looking directly into the eyes of a person speaking of sadness, believing that to do so would transfer the emotional pain into

their souls. She also learned that the term stress is not used in Guatemala. Neither of these cultural variations need be an obstacle to treatment, but simply force the Western psychologist to reassess how treatment should be approached. Often symptoms need clarification, as the individual may describe them in ways that are culturally bound. Guatemalan survivors often say, My spirit has left me. Another woman spoke of her conditioned response to the sound of rain, which results in the stress of reexperiencing the day she hid while her fellow villagers were all massacred. Hanscom believes it is essential to assist the survivor in understanding that there are physical and psychological reasons why specific symptoms are occurring. They learn that these symptoms are a normal reaction that normal people have to an abnormal even such as war trauma and torture. An important component of the HEARTS approach is teaching relaxation and coping skills. In Guatemala, Buddhist Mindfulness made relevant to Mayan culture is taught. The Mayan women become mindful of their surroundings through the focused use of their senses. Since water is such an important part of their daily life, women are taught to use water as their signal throughout the day to take a deep abdominal breath and use all of their senses to focus in the present moment. Bracken et al. (1995) go further in arguing that the social, political, and cultural realities structure the context in which violence was experienced and determine the subjective meaning given to the violence, the way in which distress associated with the violence is experienced, the type of support available to the individual, and the therapy which will be appropriate. Community cohesiveness plays a significant role in how trauma is experienced. Here is an example cited by Bracken et al:

A 45 year old man who was tortured during counter-insurgency operations in Luwero (Uganda) had both hands cut off by soldiers and was separated from his wife whom he has never seen or heard of since. A remarkable operation, performed by a surgeon in a rural mission hospital, in which the bones and muscles of his forearm were divided had given him some use in one of the stumps, but apart from this he was totally dependent on his neighbours. He was referred to as a victim of torture but when we interviewed him in his home four years after his traumatic experience he reported no symptoms of PTSD or any other psychiatric syndrome. He remarked that the support and solidarity shown

to him by his neighbours had allowed him to return to a fairly normal life. His current difficulties were all of a practical nature.
One example of where this social cohesion often breaks down is in cases of rape. This can be seen in the following example, again provided by Bracken et al:

A 34 year old woman with five children had been rejected by her husband because of the fact that she had been raped by two soldiers five years prior to her interview with us. He had turned her off the small- holding which she had cultivated. As the rest of her own family had perished or been dispersed in the war, she had to survive on what she could find in the bush until ultimately she found her way to the home of some distant relatives who took her in. Unable to explain what had happened to her because of the shame she felt regarding her circumstances and the fear of further rejection if her plight was known, she relinquished any rights she had to the land and to her children and remained in the position of a servant in her relatives home. Five years later she was still suffering terrible grief over the loss of her children and had had no other relationship during that period. The lack of support because of social attitudes towards rape and the political position of women at that time in Uganda prevented her from asserting any rights she may have had regarding the custody of her younger children.
Ignoring the social, political and cultural aspects of PTSD attributes the symptoms solely to the manner in which an individual processes his/her trauma. Cultural psychologists argue that PTSD is experienced on both an individual and a collective dimension, and to focus solely on the individual is not an adequate approach to healing.

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