The applicability of Western trauma models to non-Western populations: a study in Burundi (Preliminary results)

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The applicability of Western trauma models to non-Western populations: a study in Burundi (Preliminary results). Background. Rise in violence around the globe. Increasingly common psychological component to humanitarian interventions.
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The applicability of Western trauma models to non-Western populations: a study in Burundi(Preliminary results) Background populations: a study in Burundi
  • Rise in violence around the globe.
  • Increasingly common psychological component to humanitarian interventions.
  • Increasing popularity of PTSD construct and Western trauma discourse both at home and abroad
  • Need to further assess the applicability of such constructs to these culturally foreign settings before applying them both in the U.S. and the country of origin.
  • Constructs populations: a study in Burundi
  • Post-traumatic Stress Disorder specifically
  • “Traumatization” in general
  • Post-Traumatic Stress Disorder populations: a study in Burundi
  • First defined in 1980 in DSM – III
  • Criteria: identifiable event causing intense fear, horror, or hopelessness
  • Symptom subcategories: intrusion, avoidance/numbing, hyperarousal
  • Symptoms lasting more than one month after the event
  • Significant distress or decrease in functioning
  • PTSD Controversies populations: a study in Burundi
  • The Criterion A event - criterion creep
  • Nature of traumatic memory
  • Many symptoms overlap with other disorders
  • Overemphasis on traumatic event as causal
  • 70% don’t develop PTSD (Bryant, 2004)
  • PTSD as universal entity or cultural artifact?
  • PTSD as a cultural construction? populations: a study in Burundi
  • The search for biological correlates and mechanisms
  • The search for PTSD symptoms across cultures
  • Some important dissenting voices:
  • Shephard (2003) argues that British military history shows that WWI war neuroses were the product of incentives and an expectation of pathology.
  • Summerfield (2004) : PTSD as a product of a culture focused on vulnerability rather than on resiliency; a medicalization of distress that overlooks resilience and protective factors
  • Potential impact of importing PTSD populations: a study in Burundi
  • Risk of pathologizing people who in fact show resilience (Kagee & Del Soto, 2003)
  • Failure to recognize broader symptom set (Pupavec, 2002)
  • Draws attention away from the underlying political and social causes of an event (Wessells, 1999)
  • Central Question populations: a study in Burundi
  • To what degree do the symptoms of PTSD describe a universal response to traumatic events? To what degree might it be a culturally determined construct?
  • Literature on PTSD in non-Western cultures populations: a study in Burundi
  • Namibia: 35% (N=20) met criteria for PTSDmethod: asked about PTSD symptoms (McCall & Resick, 2003)
  • Sierra Leone: 49% (N=55) met for PTSD, 80% exceeded anxiety cut-off; 85% depression cut-off (Fox & Tang, 2000)
  • Sierra Leone: 99% met for PTSD (Raymond, 2000) N=245
  • Sudan: diverse symptoms; commonly somatic in nature, primary concerns were not psychological; used semi-structured interviews (Baron, 2002)
  • South Africa: 20% (N=201) met for PTSD; depression and somatization also high
  • Rwandan children 79% (N=1800) met for PTSD
  • Trends suggest intrusion and hyperarousal are universal and avoidance/numbing are culturally determined (Marsella, 1996)
  • Limitations within current research populations: a study in Burundi(Much depends on how you try to answer the question)
  • Diverse findings
  • Poor translation; lack of back-translation
  • Lack of involvement of local staff in design and data collection
  • Commonly only assess for PTSD
  • Use of unvalidated questionnaires
  • The Need for a Broader Assessment populations: a study in Burundi
  • Jenkins’ (1996) category fallacy
  • De Jong’s (2004) overlapping constructs
  • Separate constructs One within the other Overlapping PTSD Local idiom of distress Additional Influences populations: a study in Burundi
  • Power Differential
  • Social Desirability / Secondary Gain
  • Prior exposure to Western Trauma Discourse
  • Power Differential populations: a study in Burundi
  • Overvaluation of Western culture (Wessels, 1999)
  • Denigration of local perspectives (Peddle et al., 1999)
  • Western knowledge is privileged (Summerfield, 1999)
  • Social Desirability/ Secondary Gain populations: a study in Burundi
  • Influence of suggestion
  • Symptom suggestibility - iatrogenesis (Skelton, 1996)
  • Sick BuildingSyndrome (Rothman & Weintraum, 1995)
  • Local need for resources
  • “Being a victim is more advantageous than being a survivor” (Summerfield, 2001)
  • Exposure to Western Trauma Discourse populations: a study in Burundi
  • An aspect of social desirability/ secondary gainwhich may increase persistence of symptoms (Kagee & Del Soto, 2003)
  • Given the realities of iatrogenesis, could there be a relationship between symptoms and familiarity with Western models?
  • A study in Burundi populations: a study in Burundi
  • My Master’s thesis: examining a relationship between exposure to western trauma models and the variability in symptom type presentation
  • African Great Lakes Initiative
  • May 2005
  • Possible types of exposure to Western trauma discourse populations: a study in Burundi
  • Visits to non-traditional health care staff
  • Radio programs about stress or mental health
  • Brochures read about stress or mental health
  • Workshops attended about stress or mental health
  • Contact with foreign humanitarian organizations
  • Specific Hypotheses populations: a study in Burundi
  • Hypothesis (1): That prior exposure to Western trauma discourse will be related to a greater severity of PTSD symptoms.
  • Hypothesis (2): That prior exposure to Western trauma discourse will be related to the greater presentation of PTSD symptoms (as opposed to non-PTSD sx).
  • Hypothesis (3): That prior exposure to Western trauma discourse will be more highly correlated with PTSD symptoms when solicited by self-report measure than it will when solicited in an open-ended interview.
  • Burundi populations: a study in Burundi Burundi populations: a study in Burundi Burundian Civil War, 1993-2001 (approximately) 200,000 - 250,000 killed (AFSC, 2001) National Burundian context populations: a study in Burundi
  • South of Rwanda, similar culture and ethnic groups, yet a different history
  • History of post-colonial conflict between Hutu majority and Tutsi minority
  • 1993 – first Hutu president assassinated, leading to civil instability over the last 12 years
  • 2005 – end of three year transitional period; new president elected in August, 2005
  • Local Burundian context populations: a study in Burundi
  • Burasira in Ngozi province, north central Burundi
  • Many Tutsis resettled in what have become Internally Displaced Persons (IDP) camps
  • IDP camp residents often walk 2-3 hours to their fields
  • Gradual return to homes and land
  • Participants populations: a study in Burundi
  • Rural Burundian sample (N=80), ages 18-50 of mixed ethnicity and gender in two different Internally Displaced Persons camps (Burasira and Ruhororo)
  • Varied traumatic history
  • All future participants of the Healing and Reconciling Our Communities (HROC) workshop
  • How to solicit symptoms populations: a study in Burundi
  • As reported in a semi-structured qualitative interview using open-ended questions
  • As reported on the Harvard Trauma Questionnaire – IV(HTQ-IV) (Mollica et al., 1992)
  • As reported on Hopkins Symptom Checklist -25(HSCL-25) (Hesbacher, Rickels, & Morris, 1980)
  • Qualitative Semi-structured Interview populations: a study in Burundi
  • In the days and weeks after the event, what were you thinking and how were you feeling?
  • Did your experience change you?  In what ways?
  • When you think about your experience now what comes to mind?
  • Did people notice anything different about you as a result of your experience?
  • Preparation populations: a study in Burundi
  • Development, translation into Kirundi, and back-translation of measures in consultation with Burundian program staff
  • Review items for content and semantic equivalence (Flaherty, 1988)
  • Pre-assessment training of staff on issues of responding to distress, confidentiality, rapport building
  • Procedures populations: a study in Burundi
  • Description of purpose: general health and past experiences prior to workshop
  • Assess traumatic experiences history
  • Assess symptoms and prior exposure to Western culture
  • Conducted by Burundian trauma counseling staff
  • Coding of Qualitative Data populations: a study in Burundi
  • Responses to open-ended questions
  • Responses to Western trauma discourse questions
  • Interrater reliability established
  • Sample Descriptives populations: a study in Burundi
  • Average age: 38
  • 36% female
  • Education
  • 65% completed 4-6 years
  • 21% less than four years
  • 14% more than 6 years
  • Residence: 45% live in IDP camps with an average stay of 11 years
  • Sample Descriptives populations: a study in Burundi
  • Ever Married: 74%
  • Widowed: 19%
  • Children born: 5 (mean), 0-15 (range)
  • Children dead: 1 (mean), 0-11 (range)
  • Unrelated children in the home
  • .5 (mean), 0 - 4 (range)
  • Trauma History populations: a study in Burundi
  • Forced to Hide 100%
  • Combat situation 100%
  • Lack of shelter 97%
  • Lack of food and water 96%
  • Ill health and no medical care 91%
  • Loss of personal property 91%
  • Narrowly escaping death 78%
  • Unnatural death of family member 72%
  • Betrayed and placed at risk of death 33%
  • Trauma History populations: a study in Burundi
  • Serious physical injury from combat 20%
  • Imprisonment 20%
  • Forced to harm or kill a stranger 17%
  • Disappearance/kidnapping of spouse 13%
  • Forced to hide among the dead 13%
  • Forced to harm or kill a friend/family 12%
  • Rape 12%
  • Sexual abuse/humiliation 8%
  • Disappearance/kidnapping of child 5%
  • Trauma History populations: a study in Burundi
  • Total events experienced (from list)
  • Mean 9.5 (1.9); range 5-15
  • Total events (experienced, witnessed, or heard about)
  • Mean 16.0 (3.0); range 9-19
  • Self-selected “most distressful event” populations: a study in Burundi
  • Family member(s) killed 28.2%
  • Almost killed 23.1%
  • Flight and homelessness 12.8%
  • Loss of house and possessions 10.3%
  • Arrest/prison 3.8%
  • Family member almost killed 2.6%
  • Other 19.2% Note: 69% of these events occurred prior to 1996
  • Prior exposure to general Western culture populations: a study in Burundi
  • Spoken with foreigners previously 15%
  • Has foreign born friends 2%
  • Received assistance from NGO’s 85%
  • Received non-traditional medical care 93%
  • Heard radio or watched TV “most days” 78%
  • Prior exposure to Western trauma models populations: a study in Burundi
  • Have learned about traumatic stress
  • Attended trauma workshops 14%
  • radio transmissions or reading (1-2x each) 76%
  • Do you know the word?:
  • Post-traumatic Stress Disorder No: 97%
  • Trauma No: 73%
  • Ihahamuka No: 25%
  • Responses to open-ended questions populations: a study in Burundi Response examples populations: a study in Burundi
  • Intrusion:
  • Even today when I meet those people, the images of the event come back to me and I feel bad
  • If those thoughts come back in me, I feel as if I become crazy. It is why I do not like thinking about it again.
  • Avoidance:
  • I decided to no longer greet anyone from my native area because these people reminded me of what happened
  • Arousal:
  • Whenever I hear something making noise, my heart jumps high. When someone calls me, first I feel jumpy.
  • Response examples populations: a study in Burundi
  • Nonspecific anxiety
  • I had much fear and shakiness inside
  • Much worry
  • Nonspecific depression
  • I felt emptiness in my heart
  • I am very silent person; before I was a laughter person. Now I'm lonely person
  • Response examples populations: a study in Burundi
  • Material
  • I fled at harvest time; I suffered from hunger.
  • No food, no money to go to the doctors, raising children without my husband
  • Medical
  • I have trouble in my stomach
  • Dissociation
  • My mind goes blank and I am not thinking anything; just standing there
  • Evil thoughts/revenge
  • Bad thoughts were coming into my mind. I will revenge.
  • PTSD subcategories populations: a study in Burundi(open-ended questions)
  • Intrusion
  • Intense psychological distress at exposure to cues associated with event (63%)
  • Physiological reactivity to cues (17%)
  • Least common: Recurrent dreams (2%)
  • PTSD subcategories populations: a study in Burundi (open-ended questions)
  • Avoidance
  • Sense of a foreshortened future (56%)
  • Restricted range of affect (22%)
  • Least common: inability to recall aspect of the traumatic event and diminished participation in significant activities (0%)
  • PTSD subcategories populations: a study in Burundi (open-ended questions)
  • Arousal
  • Irritability or anger outbursts (40%)
  • Hypervigilance (35%)
  • Least common: difficulty falling or staying asleep (0%)
  • Conclusions from open-ended questions populations: a study in Burundi
  • Complaints of material needs predominate
  • PTSD and depressive/anxious symptoms are both reported
  • Difficult to compare frequencies in qualitative data
  • Intrusion (43%) and Avoidance (33%) more frequently reported than Arousal symptoms (24%)
  • Some specific PTSD symptoms not evident
  • Conclusions from self-report measures populations: a study in Burundi
  • Strong relationship between traumatic events experienced and different symptoms types
  • With PTSD symptoms (r = .50)
  • With depressive symptoms (r = .42)
  • With somatic symptoms (r = .31)
  • With anxiety symptoms (r = .26) Yet, only 11% were considered “symptomatic for PTSD”.
  • Conclusions from self-report measures populations: a study in Burundi
  • Exposure to western trauma models not significantly related to severity of trauma symptoms; but were more strongly related than to severity of depressive/anxious symptoms
  • HTQ and WTDE, r =.15
  • SCL and WTDE, r =-.02
  • Hotelling’s test: t=-1.88, p=.06
  • Conclusions from self-report measures populations: a study in Burundi
  • Participation in workshops and trauma-related media were significantly related to severity of symptoms
  • r = .28, p=.02, R2 = .08
  • And when controlling for events experienced . . .
  • R=.53, R2 = .28, adjusted R2 = .27, change in R2 = .03 (p=.07)
  • b= .12, SEb = .03, p<.001, 95%CI: .07-.17 (events experienced)
  • b= .039, SEb = .02, p=.07, 95%CI: .00-.08 (trauma media/workshops)
  • Possible Interpretations populations: a study in Burundi
  • We can only conclude that there may be a non-causal relationship
  • Possible explanations
  • Exposure to western trauma models influence severity of PTSD symptoms
  • People with more severe PTSD sought out western trauma model information
  • A third variable is responsible for the relationship
  • Conclusions from self-report measures populations: a study in Burundi
  • Prior exposure to Western trauma models was significantly related to PTSD symptoms when solicited by self-report measure but not when solicited with open-ended questions
  • What’s going on here?
  • Prior knowledge is influencing symptom presentation either truthfully or via malingering
  • People don’t think of the symptoms they have unless specifically asked
  • Poor methodology in open-ended questions
  • Summary populations: a study in Burundi
  • PTSD remains a controversial construct even in the West
  • Symptoms should be assessed broadly even when traumatic history is evident
  • Material needs outweigh psychological issues
  • Whether exposure to western trauma models can influence symptoms needs further investigation
  • Caution against conveying an expectation of vulnerability and pathology over and an expectation of resilience
  • Many thanks to: populations: a study in Burundi
  • Adrien Niyongabo
  • Ernest Ndayishimiye
  • Jean-Marie Nibizi
  • Rose Kadende-Kaiser
  • Arancha Del Soto
  • James Herbert
  • Evan Forman
  • Doug Porpora
  • Related Search
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