By: Amani M. Abusoboh
North American mental health professionals have sought to diagnose and treat individuals with Post-Traumatic Stress Disorder (PTSD) using the (PTSD) scale in countries in other continents. Despite their good intentions, using this diagnostic model and suggesting PTSD treatment to other societies assumes that this approach is universally applicable. There is doubt about the universally applicability of the PTSD (Kanaenh & Netland, 2003). Recognizing the impact of ethnocultural factors on reactions to trauma is essential if mental health professionals want to help non-western individuals who suffer from war-induced traumatic experiences (Breslau, 2000; Kanaenh & Netland, 2003; Khamis, 2008). The purpose of this paper is to review the literature discussing the U.S. Post-Traumatic Stress Disorder (PTSD) diagnostic scale as it is overlaid in other contexts. Special consideration is given to the applicability of this scale to the Palestinian context.
Post-Traumatic Stress Disorder Scale and Palestinian Trauma
There is no one solution for societies affected by complex political circumstances such as war. Each society has its own history and culture. Therefore, a “one size fits all” approach should be approached with care. Psychological diagnosis and treatment are much the same when addressing people with war-induced traumas: a customized approach of identifying issues, applying diagnoses and prescribing treatments for traumatized people (Walsh, 2007; Pupavac, 2008; Marsella, 2010). Despite the common conditions that are conducive to a state of emotional instability, each war-torn society has its own cultural, psychological, and historical characteristics that impact the people’s experiences. Problems arising from complex political emergencies, particularly trauma, are best addressed through a psychosocial and cultural framework (Hernandez, 2002; Pupavac, 2008).
North American mental health professionals have sought to diagnose and treat individuals with Post-Traumatic Stress Disorder (PTSD) using the PTSD scale in other countries. Despite their good intentions, using this diagnostic model and suggesting PTSD treatment to other societies assumes that this approach is universally applicable. There is doubt about the universal applicability of the PTSD scale (Kanaenh & Netland, 2003). Recognizing the impact of ethnocultural factors on reactions to trauma is essential if mental health professionals want to help non-western individuals who suffer from war-induced traumatic experiences (Breslau, 2000; Kanaenh & Netland, 2003; Khamis, 2008). The purpose of this paper is to review the literature discussing the U.S. (PTSD) diagnostic scale as it is used in other contexts. Special consideration is given to the applicability of this scale in the Palestinian context.
Post-Traumatic Stress Disorder (PTSD) Definition
Post-Traumatic Stress Disorder (PTSD) is a syndrome characterized by persistent, anxiety-related symptoms provoked by a traumatic event.Traumatic events include serious, confusing, and sudden events characterized by extreme force and cause fear and anxiety, and they can affect a single person or society. Examples include earthquakes, hurricanes, invasions, and wars (Elsass, 2001). The symptoms provoked by a traumatic event are comprised of three clusters: (1) re-experiencing symptoms such as recurrent, obsessive thoughts about the trauma, nightmares, and flashbacks, (2) numbing symptoms such as separation from others and loss of interest in usual activities, and (3) diverse symptoms including an overdrawn wince response, sleep disorders, and memory weakness (Punamaki, 1988; Elsass, 2001; Kanaenh & Netland, 2003).
PTSD was first defined in the DSM–III (American Psychiatric Association, 2013) following strong political pressure placed on the mental health field to recognize the psychological effects of war that were observed among Vietnam veterans as well as concentration camp survivors (Kanaenh & Netland, 2003). The recognition of this unique disorder laid the groundwork for governments to provide specific mental health services to veterans who had previously been ignored, court-martialed, or sent away to mental hospitals for general treatments (Gersons & Carlier, 1992; Hernandez, 2002; Kanaenh & Netland, 2003). This diagnosis enabled the soldiers who came back from Vietnam to acquire a medical certificate of having illness and disability that prevented them from working and from taking care of themselves or their families. This certificate also enabled them to take lifelong compensation to cover their living expenses along with the expenses of the extensive psychotherapy that can last for years. It is anticipated that the introduction of a new definition in the DSM-V will increase claims due to expansion of the definition of qualifying events (Levin et al., 2014). Knowing the origin of the scale was not only to diagnose patients, but also to provide means for those who suffered from the syndrome shows a national context which would not be applicable in other countries.
Applying the (PTSD) Scale in a Non-Western Context
Western mental health professionals have applied the U.S. PTSD scale without reviewing differences in cultures, affiliations, languages, histories, and life experiences. Therefore, the approach, content, and results of these studies are separate from the historical periods from which they emerged (Kananeh & Nitland, 2003). According to Gersons and Carlier (1992), researchers have identified at least four problems with applying the (PTSD) scale to non-western societies. First, the PTSD scale was developed out of the need to diagnose and treat dysfunctional behavior of the American soldiers who fought and returned to their country. At the same time, the psycho-health specialists enhanced the use of the PTSD scale as a diagnosis classification for soldiers’ treatments to enable them to receive psychological services and to learn about the devastating effects of war on the individual’s functionality (Gersons & Carlier; 1992; Kananeh & Nitland, 2003). The violent acts included in the scale questions are based on the mental health professionals’ explanations of the traumatic events that occurred. The significance of this fact is that the violent acts can differ among researchers according to their respective backgrounds and resources (Kananeh & Nitland, 2003). These backgrounds and resources did not include traumatic events from wars in which western societies did not participate. Therefore, this classification does not fit all war victims in the world (Dinicola, 1986; Kananeh & Nitland, 2003; Johnson, Thompson & Downs, 2009).
Secondly, western clinicians make assumptions that western diagnoses and treatment strategies are the best approaches for use in non-western societies (Hernandez, 2002). Researchers are operating with a Universalist approach which assumes that a phenomena associated with trauma in one situation will be similar to a phenomena found in another situation. As seen in the historical development and current use of the PTSD scale, this scale is regionally oriented and does not take into consideration the nature of another society’s culture. Jenkins (1999), stated that
In a study on Salvadoran women following exposure to trauma, 19 out of 20 participants did not engage in avoidance behaviors or experience emotional numbing. Instead, they endured salient bodily symptoms that they labeled as nervous, which were not labeled as possible severe reactions to traumatic events in the DSM-IV-TR. Despite their suffering, they could not be diagnosed with PTSD because they did not meet criteria for the disorder (p.8).
Jenkins’ example illustrates how the PTSD scale was not universally applicable in this situation because of differences in societies and in people’s reactions toward traumatic events. Thus, this discredits the overlay of the PTSD model in a non-western country; westerners may deem this scale to be global while, in fact, it is not.
Thirdly, the western notion of individuality is also not universal, as there are cultures in which the concept of the self does not include individuality and boundedness (Kananeh & Nitland, 2003). According to Bracken, Giller, and Summerfield (1995),
“western therapists use a way of treatment such as talk-therapy that inherently assumes that a person, as an individual, can be separated from his or her environment and placed alone in the clinical context. This treatment may have the effect of individualizing the suffering of the person involved and may be harmful in societies where the individual’s recovery is intimately bound up with the recovery of the wider community” (p.5).
Therefore, the self and its relationship with others when taken as a given in traumatic events further decreases the applicability of this scale when overlaid in other social, political, and cultural contexts. Likewise, treatment approaches based on psychodynamic, behavioral, and cognitive models would trigger the same facts (Gersons & Carlier, 1992; Bracken, et al (1995); Kananeh & Nitland, 2003).
Finally, the PTSD scale also minimizes some psychological reactions because the statistical interdependence of the reactions is not sufficient. The attempt to gauge human emotions, feelings, and reactions buy reducing them to numerical estimates that can be collected and compared to each other results in data that are inexact, if not erroneous, and does not reflect the breadth and depth of trauma experiences. The PTSD scale also tends to exclude the most violent events, which could have the most impact on one’s sense of self since it does not include all types of violence suffered by the person (Hinton & Fernandez, 2010). Thus, the PTSD scale does not measure all the effects on the psyche and the numbers do not reflect the intensity and quality of the violent events. Even if it were possible to measure the intensity and the most impactful violent event, the mental health professional using the scale would need to be an expert in the culture of the person being tested (Kananeh & Nitland, 2003; Hinton & Fernandez, 2010).
The evidence reviewed in this paper offers strong support that the PTSD diagnostic concept is not designed for the cultural context of other societies. The scale is also not applicable for survivors of prolonged, repeated trauma (Herman, 1992).
The social, cultural, or political factors associated with deprived and oppressed people need to be considered by the therapists who treat them. (Burton & Kagan, 2003). To create an efficient and successful intervention, Palestinian and western psychologists must not isolate trauma patients from their realities or their cultural and social contexts. Therefore, when considering mental health issues in other societies, it is important to consider the social context of that society.
Due to the successive traumas endured by Palestinian citizens individuals have a multitude of psychological disorders because of the arrests, invasions, injuries, and deaths that occur in Palestinian society. Palestinian patients experience violence on a day-to-day basis (Kananeh & Nitland, 2003). Additionally, there are daily traumas from the experience of each generation. When a child listens to a parent or grandparent, he or she not only sees what is going around him or her at that time, but also hears similar stories of displacement, poverty, and violence. This circle of suffering is also very different from an event that had a beginning and an end. According to Altawil, Harrold, & Samara (2008),
“the war and the long term occupation in Palestine have exposed children to chronic traumatic events which violate every child’s rights: the right to live, to learn, to be healthy, to live with his or her family and community, to develop his or her personality, to be nurtured and protected, and the right of enjoying childhood” (p.10).
Therefore, the potential for having a normal childhood in Palestine is unlikely in the current circumstances and the future psychological well-being of Palestinian children is at risk of being compromised by on-going traumatic experiences.
The PTSD scale is inappropriate for Palestinians because it measures trauma on the micro level not the macro level. Palestinians are subjected to ongoing military aggression. The trauma in this military aggression condition is collective, therefore, the Palestinians suffer collectively because they all exposed to the same aggression caused by the same source. Therefore, their trauma is not individual, or at micro level, but instead collective, or at macro level (Makkawi, 2009). For example, a Palestinian restaurant owner is not merely traumatized for only himself but also for his patrons, friends, family, and neighbors.
Based on these limitations in using the PTSD model in the Palestinian society, it is necessary to pay attention to the collective concept in analyzing the violence and trauma that occur in the society. In many cases, the groups to which the individuals belong to and the places in which they live are determinants of the events’ levels of violence. This leads to useless excess in focusing on individual therapy when there is a possibility of reaching a treatment from the community. Given that community support is weakened in times of war, the PTSD treatment focus on individual therapy and bonding is misguided. These environments can help an individual self-adjust during wartime and other stressful circumstances that have negative consequences for an individual’s mental well-being ( Jaqaman, Saab, Gilham, Abdullah, & Naser, 2004; Johnson & Chronister, 2010).
Establishing a base of knowledge and methodology for how to deal with psychological phenomena in the Palestinian context is possible. Instead of applying the PTSD scale that is socially and culturally is not applicable for the Palestinian context, qualitative studies using the grounded-theory methodology could explore and describe post-traumatic phenomena in terms of how the respondents cope with the trauma they deal with in their everyday lives. Recounting personal stories and experiences, while exploring the connectivity of these ongoing events will create the space for researchers to describe the effects of these experiences, so as to identify the proper diagnosis and treatments, including the times they may enact them (Rasras, 2005). The themes that emerge from the application of such methodology could even form the groundwork for the establishment of psychological scales in the Palestinian context that are consistent with the cultural and the social variables, rather than applying a scale that is from a different cultural and social context. Thus, a systematic investigation of individual who have experienced trauma caused by military aggression in the Palestinian society, would help mental health professionals diagnose and treat patients in this collective society.
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Amani Abusoboh was born and raised in Palestine. She holds a BA in Psychology and Education and an MA in community psychology, both from Bir Zeit University in Palestine. She also holds an MA in Organization Development from St. Edward’s University. She hopes to apply her skills in developing and improving mental health systems in Palestine. Amani now works as an office assistant for the ESL Services at the University of Texas, Austin.
Her basic purpose in business is to design and improve mental health services for Palestinians. The Palestinian society overall is disrupted by the military, social, and economic impact of the Israeli occupation in multiple domains, an occupation which undermines mental health in a variety of interrelated ways. The Palestinians suffer from direct military threat, movements restricted through checkpoints and the Wall the Israeli built around the Palestinian region, from economic distress, social stagnation and the crash of basic societal infrastructure. Effectiveness of the performance in any aspect of life requires a state of balance and psychological stability; having good mental health services will help to empower individuals to be active members in their community. She carries values that push her to develop her ability in order to serve her communityrespect, empathy, cooperation and teamwork, responsibility and commitment, excellence, honesty, professionalism, and personal development.