Cultural Aspects of Post-Traumatic Stress Disorder: Thinking on Meaning and Risk
Posted by epfinley on June 4, 2008
Over the past year and a half, I have been conducting research among male U.S. veterans who have served combat tours in Iraq and Afghanistan, most of whom have been diagnosed with Post-Traumatic Stress Disorder (PTSD). An anthropologist myself, I planned to follow the trail originally blazed by Victor Frankl and Robert Jay Lifton, psychotherapists who wrote a great deal about meaning in their descriptions of trauma and PTSD.
Early on, however, a psychiatrist whose work on trauma I admire opined to me that crises of meaning belong to the realm of depression rather than PTSD. He suggested that combat PTSD was best thought of as the physiological effects of living under conditions of extreme stress, while more meaning-related struggles were best understood as a symptom of depression. Given the frequency of comorbidity between PTSD and depression, I was for some time inclined to go along with his analysis.
Then two things happened. First, I began the work of talking with veterans themselves about their stories of trauma and PTSD, listening to how they describe their own experiences. And second, I began to explore the increasingly dominant Prolonged Exposure model of PTSD, which views the disorder as a pathology that develops when individuals fail to process their traumatic memories in the normal way.
Some background is important here. A recent RAND report suggests that as many as 18.5% of combat troops have gone on to develop PTSD after serving in Iraq or Afghanistan; alarming as that number is, it nonetheless demonstrates that the vast majority of combat-exposed individuals do not develop PTSD. However, most of the veterans I’ve spoken with – even those without a formal PTSD diagnosis – report experiencing some PTSD symptoms for a period of time following their combat deployment. Many of them dealt with such symptoms for a while – a month, three months, a year – before passing through this period of processing their memories and going on with their lives. They may be changed by their experiences in the war zone, but they are not broken by them, and may even describe them as resulting in personal growth and other positive effects.
The difference is for those individuals who seem to get, as Dr. David Riggs has described it, “stuck“. Dr. Riggs is Executive Director of the Center for Deployment Psychology and a long-time investigator of Prolonged Exposure therapy, a cognitive behavioral treatment developed by Dr. Edna Foa and colleagues in the 1980s and recognized in a 2007 Institute of Medicine report as best-proven for the reduction of PTSD symptoms. The model underlying this treatment goes roughly as follows: PTSD comes about as the result of an individual’s attempt to learn to avoid danger out in the world. Therefore, when a trauma occurs, the circumstances surrounding that trauma are imprinted on the memory in such a way that those circumstances become associated with high levels of physiological arousal and anxiety – an evolutionary mechanism intended to help the individual avoid similar dangers in future.
As a result, individuals with PTSD are likely to avoid what are called ‘triggers,’ sensory reminders of circumstances in which they experienced a threat. Because these people experience the traumatic memories and their associated triggers with intense anxiety, they avoid rather than processing and integrating them. Thus it is thought, under this model, to be the avoidance of painful memories that results in their uncontrolled intrusion into dreaming and waking life.
But what this model doesn’t explicitly account for is the determination of what memories are experienced as so horrifying, so disturbing, and so unmanageable that they can drive an individual to continually push them out of mind rather than working through them in the normal way. And it is here – it seems to me – that we can begin to appreciate the cultural place of meaning amidst the biocultural interactions at work in the acquisition of long-term PTSD.
For when veterans describe their traumas, they typically describe them in the context of other memories which – albeit difficult – they did not find to be traumatic. The soldier who describes the horror of working on mortuary duty in Iraq may also describe the comparatively mild distress (for him) of being under mortar attack. A soldier who describes seeing dead Iraqis and being unaffected by it – because he viewed Iraqis as the enemy – may then go on to describe being deeply upset by the injury of another American. On the other hand, certain traumas run along common lines. Many veterans narrate incidents involving children hurt or killed in the course of combat action. Frequently these individuals also describe how these children reminded them of a son or daughter, niece or nephew.
Looking at these veterans’ trauma stories as a collective, then, reveals two things. First of all, an event that is pathologically traumatic for one individual may not be so for the next, and as a result, we can conclude that there is considerable individual variation in the experience of trauma. This variation appears to be driven by both life history and genetic factors – e.g., for the veterans traumatized by seeing injury to children, their horror may be exacerbated both by having a beloved child in their own lives and/or by having a genetic vulnerability to experiencing events as traumatic.
Second – and with the potential to affect both individual and group variation in responses to trauma – there may after all be a role for meaning, inevitably embedded in cultural signs, systems, and beliefs, in determining what events are experienced as traumatic. If indeed it is avoidance that leads to the maintenance of PTSD symptoms over time, then what events will be perceived as so grisly, unjust, heart-breaking or shameful that the individual practices continuing avoidance? Culture, with its capacity for shaping the emotional resonance of events throughout the life course, would seem to play a central role in making this determination.
A certain sub-group of these veterans’ trauma narratives illustrates the place for culture – and in particular, meaning – in turning up (or down) the perceived trauma of an event. Many of the veterans in this sample, for example, were non-commissioned officers (NCOs) during their time in the military. The position of NCOs within the social and power structures of the military is marked by a responsibility to preserve the well-being of soldiers under their command. The importance of this responsibility is matched only by NCOs’ duty to complete their mission and to obey their commanders, following the orders that come down the command chain. When these obligations come into conflict the results can be devastating.
The classic example of this, and a running theme in NCOs’ trauma stories, occurs when a lower-ranking soldier is hurt while following orders to which the NCO personally objects. For example, one veteran told me about the day when one of “his” soldiers was wounded while following the unnecessarily risky orders of his superior, orders that he protested at the time but ultimately felt compelled to obey. His story, and others like it, reveal that the trauma of these events lies not only in the wounding of a fellow soldier, but in the inability to protect a subordinate for whom one feels deeply responsible, and the sense that the damage might have been prevented. Thus the meaning of events creates much of their resonance, and their cultural embeddedness – e.g. in the communal socialization and strict power structures of the military – is partially responsible for the emotional overload that defines trauma.
Exploring this thought, of course, leads one to the question: well, but aren’t there many events that would be universally experienced as traumatic? What about rape? Atrocity? The slaughter of children? Two thoughts jump to mind. First of all, I’m reminded of research reporting that certain fears can be acquired more easily than others – even in the absence of a direct threat from the feared object, say, a snake – which suggests there may be some pathway by which specific fears have been passed down over the course of human evolution (for an interesting discussion of these issues, see the February 2002 issue of Behavioral Research and Therapy). It seems likely that certain fears may approach universality, like rape or danger to children, and thus may appear more frequently in trauma narratives.
On the other hand, killing and the participation in atrocity may or may not be universally experienced as traumatic. What constitutes atrocity, for example, seems quite likely to be culturally determined. And while proximate killing, for example, has been argued to be a consistent predictor for PTSD by Lt. Col. Dave Grossman, among others, some veterans make clear distinctions between the ease of killing the ‘evil’ and the difficulty of killing the ‘innocent’, distinctions which themselves are deeply cultural.
In this way, it seems clear that meaning has a place in the conceptual models we build for understanding PTSD risk, with relevance for both domestic and cross-cultural research. In addition, it seems likely that in future it will be increasingly possible to link an appreciation for meaning with more biologically-grounded models for the neural pathways of stress disorders, helping to further bridge the connections between physiological and phenomenological in the processing of trauma.
For more on this research, where Erin Finley covers memory, narrative, healing and PTSD, click to see Part II.