Sunday, September 2, 2012

Trauma doesn't cause PTSD in all cultures

One of the real problems when  dealing with trauma such as child abuse or rape or war - is the assumption that there is a universal scientific model of psychological trauma. "Trauma in - PTSD out." The traumatized individual is assumed to have been betrayed, his/ her personal boundaries crossed, felt helpless, experienced depression, lost self-esteem and ability to trust others. The intrapsychic needs to be dealt with, understood and repaired when a wide variety of trauma occurs. In fact, however, in non-Western societies trauma might be not even be experienced or is manifest primarily in somatic symptoms or rejection by family and society resulting more in shame than personal degradation. Torture in some communities is best understood by reference to political or social concepts rather than psychological ones. This is I believe the major cause of dissatisfaction of Modern Western educated observant Jews who are embarrassed to find that the "obvious" traumas of child abuse, rape and other indignities - are apparently not a significant concern in the traditional Jewish literature. They readily assume that there is a coverup and ignoring or ignorance of PTSD resulting from various traumatic situation- or that G-d or rabbis don't care. In fact it seems that much of the trauma in traditional Jewish society was damage to social status or betrayal of religious norms of either the victim or perpetrator - rather than to the psyche. This is a major topic and one that Western mental health workers have trouble accepting or even understanding.

 The issue is what is the trauma? If it primarily comes because of psychological damage- then an event such as abuse or rape will have a wide range of consequences in different cultures - especially ones in which the psychological dimension is relatively small.

See Victor Frankl who was shocked to discover that the impact of being in a concentration camp varied greatly - depending on how the events were perceived. See Gail Sheehy's book  Spirit of Survival (1987) about her adopted Cambodian daughter - who experienced the horror of the "killing fields" and yet didn't seem to have been traumatized by the events.

The article is saying to stop viewing certain events as if they were objective and clearly defined forces. The impact of these events is mediated by the victims perception and it is not a mechanical cause and effect paradigm. This is a major theme in Jewish writings about suffering

To put it another way - should rape and war be viewed as being equivalent to being beaten. Depending upon where the blows fall and the person's strength - a particular blow will have varying effects. However  for the same blow in the same spot and the same personal strength - there will be a high degree of consistency of damage.

This other model says that the impact of rape or abuse is largely determined by how it is viewed in a particular culture by a particular individual. For some it will be totally devastating but for others the impact will be minimal.

There is also a consequence for therapy. A mechanical model says that all traumatic events produce serious damage. Therefore the therapy looks for and encourages acknowledgement of this damage - catharsis.

The other model says that the main focus should be on developing cognitive frames that minimize the impact of these events and that it is possible that little or no damage has actually occurred and therefore encourage catharsis or talking about these events actually is more damaging than the original events.

There is evidence that the cathartic focus in catastrophe counselling is actually counterproductive - even in Western society.

 
The following article just provides a brief - but very intelligent - introduction to the topic.
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Psychotherapy, as practiced in western countries, largely takes the form of an individual client consulting a therapist. In Africa and other Third World settings most therapy directly involves other family members and sometimes the wider community. When it comes to responding to the effects of violence western style psychotherapy can have the effect of 'individualising' the suffering of the person involved. Psychotherapy of this mode might be inappropriate and indeed harmful in more "sociocentric" societies where the individual's recovery is intimately bound up with the recovery of the wider community. This is true for individuals and communities still living in the Third World but also for refugees who are living in western countries. 

Thus it is apparent that what will be effective healing healing for victims of violence, will be largely determined by the cultural and social context. Such factors will also determine what types of healing are available. Indeed Herman makes the point that the therapeutic strategies associated with the western discourse on trauma have only become available because of particular political developments during the past 20 years:

The systematic study of psychological trauma therefore depends on the support of a political movement. Indeed, whether such study can be pursued or discussed in public is itself a political question. The study of war trauma becomes legitimate only in a context that challenges the sacrifice of young men in war. The study of trauma in sexual and domestic life becomes legitimate only in a context that challenges the subordination of women and children 

Conclusion
All scientific approaches to understanding use metaphors at a very basic level. Certain metaphors underlie the approaches of modern biomedicine and psychiatry. Even though these metaphors may be the source of problems for the conceptualisation of psychiatric illness in the West, at least in this part of the world they are metaphors widely used and endorsed by society. In parts of the world where such forms of understanding are not the norm the introducing of concepts such as PTSD based as it is on a likening of the mind to an 'information processing instrument' may be at best confusing. Fear and suffering are facts of human life that belie simple explanatory models, and attempts to account for them in terms of such models have to be, at most, tentative.

If we ignore these problems, we are at risk of introducing inappropriate treatment models and strategies in our attempt to help the rehabilitation of individuals and communities who are the victims of violence and trauma. In addition, because such models of therapy involve expertise, training and a new 'language', the possibility of creating a new 'expert syndrome' arises and with it the possibility of undermining already existing medical and non-medical approaches to the alleviation of distress caused by organised violence. This in turn may have the effect of undermining local community structures, the very forces which act as 'protective' elements with regard to the effects of trauma and the very structures which need to bear testimony in their own terms.

18 comments:

  1. I am a assuming that this post is related to this http://daattorah.blogspot.com/2012/06/playing-with-children-earliest.html?m=1 your write here

    "They readily assume that there is a coverup and ignoring or ignorance of PTSD resulting from various traumatic situation" but the issue is not about PTSD, it is about the suffering and damage, even if this suffering does not fit into the modern PTSD.

    I will point out some problems I have with this post.

    The article does not mention any examples of children in third world countries simply getting over being molested. I do not believe, and I am sure you don't believe that a 5 year old boy living in some 3rd world country, that is sexually molested by his uncle everyday, even non aggressively, Will have no negative, personal psychological effects. In fact the example in the article that showed the victim view the torture in a positive light was a 40 year old man, who was mature enough to find spiritual meaning in his suffering, thus his religious and political environment effected is trauma, but what does a 5 year old know about religion and politics? I do not believe that having sex with a 3 year old girl, even if she would feel no pain, is simply wrong because she is living in a certain society, surely a child living is Syria, is a child, and surely it would be intrinsically negative for a man to have sex with her is this not destroying her childhood no matter where in the world she is from?

    I think that it is very reasonable to assume that children that are victims in 3rd world countries are effected. this article does not prove your point at all, I don't think you intended it to prove your point, but I think it is important for me to mention. I wonder if the authors of this article would agree with you.

    Another problem is this you write "In fact it seems that much of the trauma in traditional Jewish society was damage to social status or betrayal of religious norms of either the victim or perpetrator - rather than to the psyche"

    The article explains that in western society there is a great importance give to the individual, he is regarded as a "dynamic center of awareness" in contrast with other cultures were an individual is merely apart of wider society. But while Judaism regards family and society as infinitely important, it also regards the individual as infinitely important, thus the sages say adam was created as an individual...
    I am sure that children in the time of the gemorah were told that they are unique and that they as an individual have a lot of responsibilities. In fact did the west not get there idea of individual importance and responsibility from Judaism? Thus even is your assumption is correct this would apply to the romans, not the Jews that valued the individual.

    You see it is not disrespectful to say that the sages were not aware of the damage of sexual abuse, if we were living then we would also not be aware of it, but I think it is dangerous to say that child molestation is not universally harmful without actual scientific data.

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    1. you make some excellent points. To clarify - I am not saying that rape or abuse isn't harmful. I am saying that the PTSD Western model is not universal. Having a model that simply says - if a child is abused he will be permanently damaged forever without intensive psychotherapy is true only in some cases. But not only is there variablity of degree of damage but there is a variablity of what the damage is - not all is to the psyche.

      While I am just raising this as an important issue to consider ie, it is a hypothesis - you fail to bring more than conjecture that it is not true.

      Your issue about individualities is also important - but the individuality of the Talmudic times or the middle ages - is not the same as we have today. How it is different needs to be investigated as it has impact on the damage and type of therapy.

      I agree that rabbis have been unaware of the degree of trauma but it is also apparently true that in some ages and some cultures the seriousness of damage is significantly less than ours and the damage manifests itself in different ways.

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    2. If PTSD is a neuropsychiatric response to traumatic events (brain scan changes, etc.) then it doesn't really matter if a culture has a unique name for the behaviors that can result (as we know from the literature of many cultures can happen from war or violence) from prolonged fear of death, exposure to dangerously loud noise, killing, seeing ones comrades killed, etc, fits it into an existing category, or ignores it.

      The article is correct that different cultures will view, for example, contact with dead bodies in different ways, and that to reintegrate someone into his culture afterwards, different procedures will be employed. Western culture employs a particular definition of individuality and so on.

      If those procedures produce improvement in, say, outbursts of fear or rage, jumpiness at loud noises, cortisol dysrhythmias, brain scans, then it doesn't really matter whether they fit our cultural model of psychiatry -- which isn't an exact science yet, anyway.

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    3. The issue is what is the trauma? If it primarily comes because of psychological damage- then an event such as abuse or rape will have a wide range of consequences in different cultures - especially ones in which the psychological dimension is relatively small.

      See Victor Frankl where he was shocked to discover that the impact of being in a concentration camp varied greatly - depending on how the events were perceived. See Gail Sheehy's book Spirit of Survival (1987) about her adopted Cambodian daughter - who experienced the horror of the "killing fields" didn't seem to have been traumatized by the events.

      The article is saying to stop viewing certain events as if they were objective and clearly defined forces. The impact of these events is mediated by the victims perception and it is not a mechanical cause and effect paradigm.

      To put it another way - should rape and war be viewed as being equivalent to being beaten. Depending upon where the blows fall and the person's strength - a particular blow will have varying effects. However for the same blow in the same spote and the same personal strength - there will be a high degree of consistency of damage.

      This other models says that the impact of rape or abuse is largely determined by how it is viewed in a particular culture by a particular individual. For some it will be totally devastating but for others the impact will be minimal.

      There is also a consequence for therapy. A mechanical model says that all traumatic events produce serious damage. Therefore the therapy looks for and encourages acknowledgement of this damage - catharsis.

      The other model says that the main focus should be on developing cognitive frames that minimize the impact of these events and that it is possible that little or no damage has actually occurred and therefore encourage catharsis or talking about these events actually is more damaging than the original events.

      There is evidence that the cathartic focus in catastrophe counselling is acutally counterproductive - even in Western society.

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    4. What is clear is that with correct cognitive input and sustained effort, regional brain activity can be altered long term. This was originally established with meditators, and cognitive therapy in depression approaches appear to produce brain activity changes similar to those produced by effective drug therapy.

      Certainly, in the popular mind catharsis is a central part of psychotherapy, but that doesn't make it so. And as you state, the cathartic approach in catastrophe counseling is probably usually counterproductive. It might be better not to treat than to treat wrongly, but that's not true only in PTSD.

      You mentioned cognitive approaches; here's some support: http://www.hadassah.org/site/apps/nlnet/content2.aspx?c=keJNIWOvElH&b=7730783&ct=11551049&notoc=1

      It may not be correct that culture determines outcome, see the Wikipedia article (yes, I know but some of the papers cited look good) on PTSD. It suggests familial factors (unless you include that in culture) and also biological ones.



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  2. If the question is - how does one deal with the consequences of torture, abuse, etc? - it might well be that there are better approaches than the psychoanalytical one, that it is more important to be supported by a loving community than seeing a psychologist once a week. It might even be that there are cultural differences as to what is the best way of coping.

    but if you mean that marrying the perpetrator is an adequate means of coping with rape, as proposed in the torah, I don't think so.

    If you mean that rape is primarily a crime against the husband or fiancé of the victim, and that there is no crime when she is not engaged or married - as postulated in the torah - I don't think so.

    If you mean that it is OK to sell small daughters off into marriage because the torah allows so - I don't think so.

    If you mean that a female prisoner of war is not traumatised by rape - I don't think so.

    If you think that it is OK to cover up sexual abuse of children and silence the victims because many hareidim practice it - I don't think so!

    You should watch "La mala educacion" by Almodovar. It is about a catholic boarding school, but I suppose the sequence of events would not be that different if it was a yeshiva.

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    1. I agree with most of your points.

      However normative practise has changed. Today no normal individual would marry off their 5 year old daughter. But it was acceptable at one time.

      You also need to acknowledge that there are cultures and times where these halachos do make sense. Marrying a rapist - while defintiely disgusting but there are times when it makes sense.

      John and Mary have been dating steadily for 5 years. One night he was overcome by lust and raped Mary. What is so horrible about giving her the option of marrying him? Especially if they live in a society where a raped woman is stigmatized and is not likely to find a mate? In some cultures a raped woman is expected to commit suicide. If Mary doesn't want to marry him she doesn't have to - but it does give her a useful option in that culture.

      Again - I am not dismissing abuse and rape and being simply "happenings" in certain culture. But I am arguing how these events are seen and their psychological consequences do vary and that

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    2. That it was acceptable to society to marry off a five-year-old to a much older man she did not chose does not mean it was acceptable to the five-year-old. And even if some five-year-old who went through this ordeal were able to cope later in life, it does not mean that every five-year-old who goes through this ordeal is able to cope.

      Take Yemen, where these kinds of things were practiced not so long ago by muslims, so I suppose that jews living there find it normal too.

      the fact that no-one hears the cries of the victim does not mean it is OK.

      The same goes for slavery in the US before it was banned: they had no-where to go, society accepted how they were treated, but this does not make it OK!

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    3. Agreed. I am simply saying these practices are not proof of evil people or society and that they definitely served a constructive purpose at various points of history.

      I think we are merely disagreeing over "ok". I am not approving or advocating these practices. Just trying to show them in context.

      It is like the famous statement, "Democracy is a horrible system - but it is better then the other options."

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    4. I think, on the contrary, that such practices (like slavery with physical abuse or forcibly marrying an underage girl) are evil wherever they occur and that societies who deem them acceptable are evil.

      This is what the torah says about sdom: injustice might happen - humans are humans - this is not the end of the world as long as society is ready to sanction and punish it, and save the victim, look to it that the victim's damage is compensated. But a society that builds a justice system on injustice deserves to be wiped out. The best example I could come up with in recent history is the nazi regime.

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    5. This is where we disagree. You assert that there is no good associated with slavery. I am saying that the Jewish halacha of slavery does in fact have positive aspects. Is a long prison sentence for robbery better and more moral than a period as a Jewish slave?

      Is underage marriage worse than the alternative of selling the girls for slavery or prostitution or a life of begging?

      You are saying these are absolutely evil in all circumstances and ages - and I disagree with you. I do agree that in a society such as ours they would be evil.

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    6. you did not read properly what I said. I specifically mentionned the case of "slavery with physical abuse".

      But, yes, I agree that slavery is no good - for the simple reason that a worker without pay, without liberty, has no motivation to work, so slavery will automatically lead to physical abuse in order to force the slaves to work
      And because I am convinced that no human should have absolute power over another...

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    7. I think underage marriage and forced marriage are evil, I also think that any kind of rape (i.e. intercourse where one party does not agree) is evil. It might be that forced prostitution is worse than forced marriage, but that does not make forced marriage better...

      If a woman wants to be saved from a lifelong of begging, she can marry out of her own free will. Forced marriage is unacceptable, no matter what...

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    8. It might be that forced prostitution is worse than forced marriage, but that does not make forced marriage better...
      ================
      what does this mean?1 Of course it makes it better!

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    9. the fact that forced prostitution exists and may be worse than forced marriage does not take anything away from the intrinsic horrors of forced marriage!

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    10. Brad you logically you can't say that something is worse without making the other better. I agree that both are bad but there is the lesser of evils to be considered.

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    11. It is comparatively better, but intrinsicly bad.

      It's like temperatures: if you have -10°C in New York in -30°C in Montreal, the fact that Montreal is colder than New York will not change the fact that -10°C is still cold. It will not change the -10°C to -8°C...

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  3. I can accept that the equation "rape = trauma" might be culturally based. But so is the social disgrace! Why would Chazal codify that social construct and not this one? As far as I understand, we would not say that Chazal based halacha for all time on their particular generation.

    Also, the very fact that there is a social stigma on one who has been raped is frankly just wrong! In society today we are fighting against that stigma precisely because it makes no sense. How can Chazal make halacha based on that?

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