Cultural Aspects of Post-Traumatic Stress Disorder: Thinking on Meaning and Risk

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.

32 thoughts on “Cultural Aspects of Post-Traumatic Stress Disorder: Thinking on Meaning and Risk

  1. Excellent article…look into the etymology of the term “nostalgia,” coined by physician Johannes Hofer in 1668; meaning homesickness (Greek: nos+aglia; German: heimweh), Hofer invoked this term in diagnosing Swiss mercenaries suffering from war trauma.

  2. To the author,

    Enjoyed this post. I recently came across a (completely uncited) claim in an article in the New Yorker on members of of Papua New Guinea tribe that alleges their warriors never suffer from PTSD as a consequence of their participation in war. Given your research and interest in the effects of culture, I’d love to get in touch off line to get your thoughts on this. (I also spent three years in Iraq if that’s an inducement to talk).

    I’m at bungdan “at” yahoo . com
    Thanks and best

  3. Good stuff, but you missed one of the cultural conflicts that I am seeing quite a lot of these days. (I am a veteran and also interact with veterans from all conflicts). That is- the internal conflict predicated by the moral stresses of participating in acts that you don’t really believe in. In other words, quite a few soldiers, in spite of training, are questioning the morality of participating in a war/conflict/police action/etc. that they can’t consciously support. I have talked with more than one veteran that feels terribly cheated for having been involved with a war over ??? oil ? corporate profiteering ? policing a civil war ?
    I am seeing resentment and anger over those issues and more. Some soldiers feel that they were victims and being ‘used’ simply as tools in a president’s personal spite war to enrich himself and his cronies. Politics aside, more and more veterans do exhibit this feeling of having been taken advantage of. The most highly trained and best equipped army (ever) being used – not for a defined war, but as political tools for undefined gains. Very few believe that Iraq is about democracy or peace keeping. In retro thinking, very few Vietnam veterans also believe that their war had anything to do with protecting home and hearth from communism.
    What you end up with (years later, especially) are veterans who have deep-set internal conflict and trust issues (and more…) concerning the government that so heavily brain washed them to be tremendous soldiers, then virtually wasted them in a meaningless conflict that had little or nothing to do with protecting the USA. At best, they were unintentional ‘hit men’ for whatever administration was running things. Quite a few wonder if their sacrifices warranted the suffering they are doing now for a nation that “really doesn’t care”.
    Depression is common. So is self-medicating..
    Using patriotism as an emotional ‘hook’ only works if the soldier, after the fact, really believes he was doing the right and honorable thing…

  4. Richard, REally appreciate your “telling it like it is”. I have never heard things put this bluntly before. I was an peacenik in Vietnam era, and for awhile worked with returning vets, Native American Indian and Chicano, many of whom had been manipulated to sign on.

    For many complex reasons these guys didn’t draw the connections quite as clearly as you have, about the wrongs that they were fighting for…to me this is part of every war…more blatant now because we are supposed to have freedom of choice, we’re not being rounded up and drafted for 25 years like peasants in the Austro-Hungarian Empire, etcetera.

    My question to you is: Do you think that those who’ve had this experience can come together and work for change? – what I call PEACEFUL WARRIORS?

    I am a qigong teacher who has focused on elders and people with “health projects” for many years. Now I’m interested in working with others to develop wellness centers where the people you’re speaking of can turn, not only for Recovery, but for Renewal, which means work toward being able to perform real service – not as atonement, but to gain some satisfaction.

    I hope to go to large oompanies like Chevron and persuade/demand that they create meaningful Green Jobs, and pay for training. This work could be global. G-d knows it’s needed now.

    WEll I simply wanted to commend you for what you’ve written. There’s a book I’m reading now,
    WAR AND THE SOUL, by Edward Tick, which says many of the things you say.

    Anyway, if you feel this could be worthwhile in any way, I invite you to get in touch.

    Where the heck are you located anyway?

    bett martinez
    well-being at

  5. The issue of moral conflict that you describe is very important. It was, based on my experience with Vietnam veterans prior to starting this research, something I expected to hear quite a bit about. What has been striking to me has been how rarely I hear about this from the OIF/OEF veterans I’ve been working with; their focus at this point seems to be on different concerns. There are a number of books which discuss this issue among Vietnam veterans, if you’re interested, including Jonathan Shay’s work, Tick’s book, and Robert Jay Lifton’s ‘Home from the War.’

  6. As an amateur and a patient with a diagnosis of PTSD/dissociative disorder I wonder whether the initial breaking down of personal (civilian) boundaries in basic training plays some role in laying the groundwork for a potential PTSD reaction from combat.

    Passing through basic training raises (one presumes) the level of expectation regarding trust within the group. Trusting the chain of command, one’s fellows, one NCOs, etc. (Or, as it were, not trusting them but being helpless to disagree and remain within the law.)

    Where do the PTSD similarities reside among say, the population of incest survivors and the population of combat vets regarding the betrayal of expectations, the violation of trust?

  7. Thank you for an insightful comment. I think military socialization may well play a role in laying the groundwork for a potential PTSD reaction, as you say, in creating an expectation of trust. On the other hand, I think it may also work to provide significant resilience, because that trust often becomes a survival skill, and also because there may be some stress inoculation effects in teaching young people to face their own limits.

    I have done very little work with incest survivors, but when I have asked clinicians about their experience working with both combat veterans and abuse survivors, they frequently answer that the similarities outweigh the differences. The hypervigilance may be in response to different stimuli because the traumas are different, and the self-presentation may be different because of military training, but many of the same issues of hyperarousal and difficulty with trust arise for both groups.

    Something I’ve been thinking about lately as well: I wonder whether PTSD may be more difficult to face when the trauma is not shared with those around you. I’ve been reading descriptions of life in Europe after WWII, when much of the population had lived through the horrors of the war and there was some sense of shared suffering. It seems very different from being a survivor of abuse or combat on foreign soil, in which case one emerges from the threat to find oneself surrounded by those who haven’t lived it and find it hard to understand. I think this may make the normal symptoms of post-traumatic stress feel less normal, and therefore create greater alienation and greater anxiety. I don’t know, but it’s something I’ve been wondering about.

  8. Excellent points, Erin, on the nature of cultural resiliency. Thank you.

    If modern “military socialization” is a synthetic structure which exploits the evolutionary tendencies of reaction within a group faced with peril then it would make sense that any shortcomings in this synthetic cultural structure would impair or fail to impart resiliency among some of its members, perhaps most notably in those lacking an ongoing (life long) group dynamic following traumatic experiences.

    also of interest:

    Society for Neuroscience
    SAN DIEGO, November 6, 2007 – New research identifies a characteristic physiological response in veterans with post-traumatic stress disorder (PTSD) that could be used as a biomarker to diagnose the disease. Other findings show how trauma disables normal brain functioning and highlight deficits in basic mechanisms of learning and memory. Recent findings also show that a common neurological basis explains altered emotional responses in veterans with PTSD, and that fear learning caused by trauma is different from other types and may explain why it is more difficult to treat….Although people with PTSD can temporarily learn to extinguish fear, they are unable to retain this ability.”

    I found the above paper quite interesting, given the ongoing observation and practice required to recognize/extinguish inappropriate fears when a “trigger” fires.

  9. also of interest:
    Antonio Damasio, Professor of Neuroscience, University of Southern California; Director, USC Brain and Creativity Institute. A two part lecture on Brain and Mind: from Medicine to Society 1/2

    “His research has helped to elucidate the neural basis for the emotions and has shown that emotions play a central role in social cognition and decision-making. His work has also had a major influence on current understanding of the neural systems, which underlie memory, language and consciousness.”

  10. PTSD is becoming a serious problem in todays society with the wars going on overseas. I think the government needs a better Vet system and give them more benefits.

  11. Nice post thanks. PTSD is really becoming a serious problem nowadays, especially because of the wars we are into. Government should think more on meaning and risks

  12. What is difference between PTSD and CPTSD?

    PTSD is what you can get from witnessing a car crash. Or being in a car crash. Or earthquake. Or involved in a shooting. And then on top of that, you start having bad dreams about it. Or flashbacks. But, the trauma is OVER. IT’s done. It’s not happening again and again and again. That’s CPTSD.

    CPTSD is when a soilder is sent to battle, 5 times in 5 years, and keeps experiencing the same war zone. PTSD is no longer the diagnosis here. The trauma went on too long.

    CPTSD can also occur in caregivers of severely disabled or autistic persons who exhibit intracable, prolonged, extreme self-injurious or assaultive behaviors. Witnessing repeated acts of such complex, high risk behaviors, where the person must constantly protect the other person is classic CPTSD, in a situation that is episodic, chronic and acute. It is one of the most undereported conditions facing families raising disabled children with extreme, challenging behaviors which require constant emergency interventions. The constant state of emergency and pressure of providing safety is what leads to CPTSD in primary caregivers. It is also seen in caregivers of dementia patients, who are without relief or respite care. Incessant or disruptive vocalizations often exacerbate the stress loads on caregivers of dementia patients, further contributing to CPTSD, as auditory overload, insult factors.

  13. I have a dear friend who suffered from Post Traumatic Stress Disorder for many years. He was a Green Beret in the British Special Forces, and a medic and is now retired. He still has bad nightmares, is a recovering alcoholic, and his last suicide attempt was just a few years ago. I have a number of relatives (including some younger people) currently in the military, and I worry about their futures, given that they are still deployed in Afghanistan. They all express the same discouragement concerning the ineptness of their immediate commanders and the incoherence of the occupation of that country, given the hostility of the locals and the fact that they do not appear to be a real threat to our own nation.

    I have read quite a lot of the material published by David Grossman and am fascinated by the material you presented here.

    As anthropologist, I have been trying to formulate some way of understanding this phenomenon that makes sense in terms of our evolutionary history, on the assumption that the kind of intergroup cooperative violence that we would class as warfare was a rather late development in human cultures. In my own fieldwork in Africa I lived for a time with Kalahari foragers, and then with pastoral and horticultural tribal people in West Africa. I was struck by the rarity of violence – even of violent games- among the foragers. There were incidents, even one murder, but the social stigma against violence was very strong. In West Africa, despite apparent recent violent clashes, the ethnic groups involved had a long history of trade, intermarriage, as well as friendship, and less intimate joking relationships at the ethnic boundary. There were two coups d’etat while I was there, which occured along ethnic lines, and considerable violence, but these relationships endured throughout, although the participants were discreet during the worst of it.

    I find it hard to believe that we are, as a species, inclined to cooperative inter-group violence, although I do think we have a tendency to interpersonal violence stemming from strong emotional conflicts. I suspect that mandated inter-group warfare arose as a cultural adaptation to sedentism, rising population/resource ratios, and resulting conflicts over rights to fixed resources and livestock. I do not think that this happened in many foraging economies: even after 8000 years on the NW American coast, it appears that the tribes tended to resolve things as often with redistributive feasts as with warfare.

    In fact, I wonder if the very frequency of PTSD among soldiers could be considered as evidence that humans did not evolve under conditions of frequent and intimate experience of violence.

  14. I’m in grad school for clinical psych, and I know this post is almost 10 years old, but I’m currently doing research into the culture bound aspects of PTSD – the idea that cultural acceptance may sometimes negate PTSD compared to other cultures that consider the same act or event traumatic. I was wondering if you could recommend any sources or journal articles for me to look at.

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