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Post-traumatic stress disorder and the trauma model
Medicalization of human suffering has resulted in the ‘trauma model’ and the ubiquitous diagnostic category of PTSD. While the philosophical assumptions and concepts of the ‘trauma model’ are rooted in Western science and psychology, the trauma model is assumed to be relevant to the needs of all societies (Bracken et al. 1995; Pupavac 2002) and as such constitutes “an unwitting perpetuation of the colonial status of the non-Western mind” (Summerfield 2000: 422). The trauma model appears to be dominated by a value system of humanistic psychology that promotes self-assertion, autonomy, and relativity in values and situational ethics (Bergin 1980). These values are very different from the values of many refugee women, which stress interdependence and deference to authority in social relationships. Even when service providers make a nod in the direction of acknowledging that different cultures and belief systems respond to adversity differently, there is nevertheless an assumption that refugee women are traumatized (Pupavac 2002) and in need of urgent professional assistance without which they will not be able to recover (Summerfield 1999). Moreover, in contemporary Anglo-American culture, trauma confirms suffering and confers moral status and the basis for legal rights, so there is a readiness for individuals to identify themselves as traumatized (Brown 1995). It is in this context that PTSD has become an attractive diagnosis (Dean 1997; Summerfield 2001). In other societies where trauma does not confer the same status, individuals do not like to identify themselves as traumatized and tend to exhibit stoicism. The Buddhist influenced worldview, for example, teaches that hardship and suffering are given in life and that complaints are a sign of weakness and lack of character. Thus, suppression is the usual way of coping with conflicts (Morris and Silove 1992). PTSD was first introduced into the Diagnostic and Statistical Manual of DSM-III (APA 1980) “to address the need for common diagnostic category covering a wide range of clinical syndromes associated with a traumatic experience” (Fischman 1998: 28). The diagnosis, originally intended to apply to the aftermath of extraordinary experiences, has been increasingly applied to a wide range of life difficulties such as crime, complicated childbirth or traffic accidents (Summerfield 1999b). Moreover, the most recent reformulation of PTSD in DSM-IV has included secondary traumatization; e.g., trauma resulting from listening to accounts of torture or war atrocities. Many consider PTSD, along with depression, the most prevailing albeit controversial (my emphasis) psychological disorder among refugees (Turner and Velsen 1990). Surveys of populations who have experienced violence indicate that between 25 to 75 percent experience PTSD (Desjaralis et al. 1995). Arcel and colleagues (1995) at the International Rehabilitation Council for Torture Victims in Copenhagen assert that 25 to 30 percent of refugees develop PTSD and need the help of skilled mental health professionals. Similarly, Medicine Sans Frontieres (1997) claims that 20 percent of survivors of traumatic experiences will not recover without professional assistance and that in refugee situations the morbidity rates are much higher. Many of these statistics stem from biased sampling (Watters 2001; Silove 1999). The literature shows that the highest rates of PTSD have been recorded within Western psychiatric clinic populations. For example, between 18 and 53 percent of Bosnian refugees in treatment presented PTSD symptoms (Mollica et al. 1999). Intermediate rates have been recorded in sampled community groups, and the lowest rates have been identified in epidemiological samples (Silove 1999). In an epidemiological study Mollica found that only 15 percent of Cambodians in a refugee camp on the Thai-Cambodian border suffered from PTSD (Mollica et al. 1993). Recent studies suggest that psychiatric illness among refugees might not be as prevalent as we have been led to believe by existing studies (Hollifield 2005: 1283). A meta-analysis of interview-based studies of the prevalence of PTSD, major depression, psychotic illness, and generalized anxiety disorder in refugees 10