Principles of Social Psychiatry

11 Culture and identity Julian Leff Institute of Psychiatry, King's College London, London, UK In the image of a pebble thrown into a pond, invoked in hensive. Identity is another multifaceted concept. A Chapter 1, culture occupies the outermost circle of person’s sense of being a unique individual is a influences from the social environment. This does not composite derived from the various roles he/she oc- signify that culture is peripheral to the individual, nor cupies: woman, man, child; mother, daughter, grand- that it is weaker than more proximal influences. On the father, aunt; doctor, undertaker, plumber, and so on. contrary, culture pervades every aspect of a person’s However, culture is a major determinant of identity life and social relationships, from the food they eat and and throughout history has been responsible for wars, the utensils they eat with, to the deity they worship. civil and international, slavery, persecution and gen- Investigating the nature of culture is then a mammoth ocide. In this chapter we will focus on a person’s undertaking, which would be beyond the means of a cultural identity and its relationship to the develop- single researcher if the intention were to be compre- ment of psychotic illnesses. 11.1 THE MEASUREMENT OF CULTURAL IDENTITY Before reviewing the instruments developed to mea- Influences flow in both directions, although the stron- sure cultural identity, it is necessary to define the key ger flow is usually from the established culture to the terms used by researchers in this area. Research has newcomers. However, it is evident in the UK that the been spurred by the mass migration of peoples during eating habits and musical taste of the British have been the twentieth century as a result of world wars, civil strongly influenced by migrant groups. Curry has strife (‘push factors’) and of seeking a better life by displaced fish and chips as the most popular food, those in conditions of hardship in their country of while African-Caribbean music has become a domi- origin (‘pull factors’). In 2003 the Office of the United nant idiom in popular music. Nations High Commissioner for Refugees estimated Migrants can respond in various ways to the perva- that 38 million people were displaced worldwide. sive influence of the host culture. They may strive to Migrant groups find themselves brought into close maintain their own traditional culture and distance proximity with the people forming the host culture. themselves from their hosts (separation) [1], they can Principles of Social Psychiatry, second edition Edited by Craig Morgan and Dinesh Bhugra Ó 2010 John Wiley & Sons, Ltd.

134 COMPONENTS OF THE SOCIAL WORLD attempt to acquire the characteristics of the host who feel comfortable in both cultures. La Fromboise culture or they may make an effort to straddle both and colleagues [10] point out that while minority cultures. These possibilities were formulated by Sza- groups usually become assimilated into the majority pocznik and Kurtines [2] in terms of acculturation group at the price of their ethnic identity, biculturalism occurring along two independent dimensions: an ac- grows out of an ability to alternate between two commodation to the host culture and a complex cultures. They argue that greater control over relation- process of retaining or relinquishing the characteris- ships with the majority culture reduces the likelihood tics of the culture of origin. Whichever strategy of experiencing the negative effects of acculturation members of the minority culture adopt, the outcome stress. Conversely, if the attempt to assimilate is cannot be independent of the response of the majority vigorously resisted by the dominant group, then the culture to them. Members of minority ethnic groups individual is constrained to occupy a marginal posi- can be either accepted (mainstreamed) or rejected tion, unless he/she re-establishes a connection with (alienated/marginalized) by the majority indigenous their original cultural group. cultural group [3]. The position of the minority ethnic It follows from this discussion that in order to group in the structures of the host society is deter- identify biculturalism an instrument designed for the mined by the level of acceptance by the majority study of ethnic minority groups must be able to culture. How far a migrant is included or excluded identify the individual’s strength of adherence to their is based on a set of criteria used by this core group in a culture of origin and also their facility in operating in multifaceted way. These include a range of socio- the majority cultural group. Many research groups economic factors, but in most societies those farthest have developed their own instruments, usually tar- from the colour and/or culture of the majority group geted at particular minority ethnic groups, and most of are often the most marginalized [4,5]. In ‘Mister Pip’, the work has been conducted in the multicultural a novel about the only white man on an island popu- societies of the US, Canada or Australia–New Zeal- lated by black people [6], in teaching the island’s and. Rogler [11] points out that acculturation scales children about colours, Mr Watts announces that are often based on bipolar models, which force re- ‘Above all...white is a feeling.’ After reflecting on spondents to choose between more of one culture and this for a while, he adds, ‘This is true. We feel white less of the other. As a consequence, ‘increments in the around black people.’ One of the children pipes up, acquisition of host society cultural elements are taken ‘We feel the same...We feel black around white to signify proportionate decrements of cultural ele- people.’ ments brought from the society of origin, a zero-sum Individuals who choose to reject completely the process’. This format of a scale makes it impossible to values and customs of their culture of origin and aspire detect biculturalism. to assimilate into the majority culture, but are rejected To measure biculturalism Szapocznik and Kur- by its representatives, become marginalized. Gold- tines [2] modified their original 1978 acculturation berg [7] defined a marginal individual as one who is on scale by separating it into two independent scales, one the margin of two cultures that are in permanent for each culture (Cuban/white American). Thus a contact, but who belongs to neither. It can be argued bipolar scale was replaced by two parallel scales, one that marginality itself constitutes a culture. Green [8] measuring the degree of involvement in the host concurred in considering that there are advantages to culture, the other in the culture of origin. This marginality, and proposed that it only has adverse approach was also promoted by Burnam et al. [12] effects on the individual if he/she internalizes the who suggested that individuals who were high on conflict between the cultures. Park [9], one of the both scales could be considered truly bicultural, earliest commentators on acculturation, suggested while those who scored low on both scales would be that marginality led to psychological conflict, a di- marginal. The scale they developed consisted of 26 vided self, and a disjointed person. items, half of which concerned language, a character- Szapocznik and Kurtines [2] introduced the term istic of many of the existing scales. Factor analysis ‘biculturalism’ to designate the position of individuals suggested a unidimensional scaling of the 26 items,

CULTURE AND IDENTITY 135 indicating that this instrument cannot be used to across several ethnic groups. There have been several assess biculturalism. attempts to measure acculturation in two or more Some researchers have made the questionable as- different ethnic minorities simultaneously. Clark sumption that mastery of the hosts’ language is the key et al. [16] used an innovative approach of including indicator of acculturation. However, there are many a picture identification test to supplement questions on aspects of life that can be affected by or untouched by attitudes and participation in cultural activities. The contact with the host culture. Fluency in the host pictures represented the cultures of white Americans, language will undoubtedly increase the likelihood of Japanese and Mexicans, and included images of tradi- employment in a host enterprise, and hence increase tional cultural artefacts, well-known locations, typical contact with the ethnic majority, but can have opposite foods, popular figures and historical personages. effects on well-being. A study of Southeast Asian These researchers used the measure to assess Japanese refugees to Canada [13] found that after ten years in Americans and Mexican Americans. They identified the country, English language fluency was a signifi- six different profiles, which they interpreted as repre- cant predictor, not only of employment but also of senting different styles of bicultural life. Since each depression, particularly for women. Job security and type of profile contained members of both ethnic an increased income are conducive to peace of mind, groups, the researchers argued that the types are gen- but increased exposure to the hosts can entail risks of eralizable beyond a single ethnic group. Their ap- adopting injurious behaviours. Substance abuse was proach to data analysis and interpretation is relatively much more common among Mexican Americans born unsophisticated, which is a pity given their unique in the US than in Mexican American immigrants, and pictorial test. It is clear that some of the emic pictures this was particularly dramatic for women [14]. would have been unrecognizable to members of the Oetting and Beauvais [15] argue against scales that other ethnic group. This is an unavoidable feature of a are focused on one area of interaction between two ‘universal’ acculturation scale. Berry [17] considers cultural groups in contact. They criticize two-dimen- that there is limited possibility of creating a ‘standard’ sional research models of acculturation for shaping acculturation measure that can be used with every the way most data are gathered and the results acculturating group, because there are many unique achieved, and instead propose a multidimensional features to each acculturation situation, including the model of acculturation, which emphasizes that there differing nature of the domains that are issues between is no limit to the combinations of cultural identifica- them. While this is undoubtedly correct, it may still be tion or changes. possible to identify sufficient commonality between Any study that involves more than a single ethnic the main concerns of two or more minority ethnic group requires a measure of acculturation, which groups in contact with the same majority culture to inquires into a comprehensive range of attitudes, pre- develop a ‘standard’ schedule applicable across the ferences, activities and behaviours and is applicable groups, albeit with some group-specific sections. 11.2 DEVELOPMENT OF THE CULTURE AND IDENTITY SCHEDULE (CANDID 1) 11.2.1 Background to the study Aetiology and Ethnicity in Schizophrenia and other Psychoses (AESOP), has produced incidence rates Reviews of the literature on migrants and their off- nine times that of whites for schizophrenia and eight spring have shown that almost all ethnic minority times for mania [19]. An earlier study [20] found that groups living in a host society have elevated incidence the incidence of schizophrenia in South Asians in the rates of schizophrenia [18]. However, the excess of UK (3.7 per 1000, CI 2.6–4.3) was only slightly psychoses, both schizophrenia and mania, among elevated compared to that of whites (3.0 per 1000, African-Caribbeans in the United Kingdom (UK) is CI 2.1–4.0). The disparity in incidence rates between remarkable. The largestepidemiological study to date, South Asians and African-Caribbeans, both ethnic

136 COMPONENTS OF THE SOCIAL WORLD minority groups living in a predominantly white self-ascribed ethnicity. Two patients of mixed ances- country, demanded an explanation. The Culture and try were excluded from the study. Identity Schedule was developed specifically to test Each patient was matched with a healthy control the hypothesis that African-Caribbean patients with subject on age, sex and ethnicity, providing a total of schizophrenia would prove to be marginalized, 200 subjects. Control subjects were selected using a whereas South Asian patients would be deeply rooted multistage quasi-random sample design with cluster- in their traditional culture. This hypothesis required ing and stratification, which included the nonprob- the development of a schedule that could be used in ability modified random walk method developed by both cultures, allowing direct comparison of the pa- Brown and Ritchie [23]. The controls were selected tients and a group of matched, mentally healthy con- from the general population living in the same areas as trols. The structure of the schedule was sketched out the patients. The CANDID 1 schedule was adminis- initially before being tested in field studies. An ex- tered to each case and control belonging to the tensive range of areas of life was included [21]: self- two minority ethnic groups, yielding 76 African- ascription of ethnicity, religious practices, language Caribbean subjects and 48 South Asians. usage, attitudes to marriage and relationships, deci- A principal components analysis was conducted on sions about family matters, responsibility for children, the African-Caribbean and South Asian data sets. The education, employment, housing, leisure and social two versions of the CANDID 1 schedule proved to interaction, links with the country of origin or descent, have similar factor structures and a considerable food and role models in public life. The completed congruence of items with high loadings on the fac- schedule contains 15 sections. It was necessary to add tors [24]. This indicates the possibility of using the a domain to the Asian version that was not relevant to same instrument, albeit with the additional section on the African-Caribbean culture, namely attitudes to arranged marriage, to compare cultural attitudes and arranged marriages. behaviour across these two ethnic groups. Two versions of the schedule were prepared, one in English for African-Caribbeans and the second for the South Asians, all of whom were from India, in Hindi 11.2.2 Comparison of control subjects and Punjabi. Bhugra, from north India himself, trans- across ethnic groups lated and tested the South Asian version, while Mal- lett, from Barbados, tested the African-Caribbean Direct comparison of the African-Caribbean and version. Each schedule was discussed with commu- South Asian control subjects was possible on 11 nity and religious leaders and was piloted on a number sections of the CANDID 1 schedule, there being of individuals and modified accordingly. The two insufficient data on the other four sections; for ex- ethnic versions were then employed in the Ethnicity ample, the section on marriage could only be com- and Psychosis Study (EPS) [22]. pleted for the four African-Caribbean controls who The design of this case-control study was epide- were married. In each section two scores were ob- miological, cases being ascertained when they made tained by summation, generating a traditional score a first contact with the psychiatric services. Two and a nontraditional score. The expectation was that catchment areas were screened for potential cases, the South Asian controls would score more highly one in south-east London with a large African- on traditional scores than the African-Caribbeans, and Caribbean population, the other in west London with this proved partly to be the case. The comparison of a predominance of South Asians. Over the course of traditional scores showed that South Asian controls the study 100 patients were collected with a research were considerably more traditional than African-Car- diagnosis of schizophrenia, who were making contact ibbean controls in their practice of religion, their use with the psychiatric services in the two catchment of language and their leisure activities. However, the areas for the first time. Of these, 38 were white, 38 African-Caribbeans were more traditional than South African-Caribbean and 24 Asian, according to their Asians in their attitudes to relationships with white

CULTURE AND IDENTITY 137 people, their food-shoppingand eating habits and their significantly higher than the African-Caribbeans, both wish to retire to their lands of origin. The comparison on traditional and nontraditional scales. In addition to of nontraditional scores showed that South Asians demonstrating the independence of the two scales, this were more nontraditional than African-Caribbeans in indicates that the South Asians possess a bicultural their attitudes to relationships with white people and facility with language, being equally conversant with in their use of language, while African-Caribbeans their mother tongue and with English. Hence this were more nontraditional in their practice of religion. comparison of the two ethnic population groups has The most surprising finding was that the African- validated the ability of CANDID 1 to detect traditional Caribbeans were more reluctant to form relationships and nontraditional attitudes and behaviours as distinct with white people than South Asians. In view of the entities, and to demonstrate biculturalism. enduring custom of arranged marriages among the UK South Asian community, it was anticipated that they would not favour relationships with white people. The 11.2.3 Comparison of cases and controls explanation may lie in the commercial relationships within each ethnic group between South Indian shopkeepers, who often run convenience stores in British towns, and their white The next step was to compare healthy controls and customers. In addition, the unprovoked murder of the their matched patients with schizophrenia within each African-Caribbean student Stephen Lawrence by a of the two ethnic groups. The hypothesis being tested group of white racist youths has had a profound was that the African-Caribbean patients would be alienating effect on the UK African-Caribbean significantly less traditional and more nontraditional community. than their controls compared with the South Asian The findings concerning food-shopping and cuisine patients and their controls. The original pairwise may be related to white eating habits, as curries are the matching of cases and controls was retained and the most popular dish for British whites and are readily analysis was carried out on the differences in scores available in every town in the UK, through Indian between each pair. The traditional scores of the con- restaurants and a large variety of precooked curries in trols were subtracted from the traditional scores of the supermarkets. By contrast, Caribbean foodstuffs and patients, so that a positive difference means that the restaurants are restricted to a few centres in the larger patients are more traditional, while a negative differ- cities and are rarely used by whites. The assimilation ence means that the controls are more traditional. The of Asian food into white eating habits is a prime same procedure was followed for the nontraditional example of the reverse flow of culture from a minority scores. The significance of the differences between to a majority ethnic group. patients and controls was evaluated with t tests, with a To assess the ability of the schedule to discriminate probability level of 0.02 in view of the fact that 44 between traditional and nontraditional attitudes and comparisons were made for the two ethnic groups. customs, the scores on these two scales were com- South Asian patients scored on the borderline of pared. In two sections, the practice of religion and significance (p < 0.021) for being less traditional than relationships with white people, the nontraditional controls on a single section only – religion – and this scores were the mirror image of the traditional scores. was mirrored in the nontraditional scores. Patients However, for three of the sections that showed a were more traditional than controls on sex roles only significant difference between the two ethnic groups (p < 0.011). We can conclude from these findings that on traditional scores, there was no mirroring in the the South Asian patients were firmly rooted in their nontraditional scores. This demonstrates that the two culture of origin and showed little or no evidence of a sets of scores are not invariably the inverse of each drift towards marginalization. By contrast, African- other, but tap into unrelated areas of attitude and Caribbean patients were significantly less traditional behaviour. This appears most convincingly in the than their controls in five domains, their use of lan- section on language, where the South Asians scored guage (p < 0.018), sex roles (p < 0.019), desire to live

138 COMPONENTS OF THE SOCIAL WORLD among and work with whites (p < 0.0001) and to 4.4 times the white rate. For ethnic densities between spend their leisure time with whites (p < 0.0001). these two extremes, the rate for African-Caribbeans They were also less traditional than controls in their was 3.6 times the white rate. These observations are wish for little contact with their relatives (p < 0.0002). subject to two alternative explanations: a migration of They were more traditional than the controls in only a African-Caribbeans predisposed to schizophrenia into single area, reluctance to form relationships with areas largely inhabited by white people and a possible whites (p < 0.0001). The nontraditional scores of pathogenic effect of marginalization, echoing the patients and controls mirrored these findings with the long-standing debate between social drift and social exception of sex roles, where the patients showed no breeder hypotheses [27]. However, the linear increase difference from controls. in risk with decreasing density of African-Caribbeans The most striking findings for the African-Carib- favours the second hypothesis. A more direct test is bean patients relate to their attitudes to whites. Com- feasible now that samples of patients with schizo- pared with their healthy controls, they have a strong phrenia include third-generation African-Caribbeans, desire to live in white areas, to work with white people since it would be possible to link these data with place and to spend their leisure time with them. Paradoxi- of birth, hence identifying the stability of residence. If cally, they are much less willing than their controls to it was found that geographical drift could not explain forge relationships with whites. At the same time they the ethnic density phenomenon, it would support the show considerably less interest in being in contact with causal influence of marginalization on the develop- their relatives. These patients’ ambivalence towards ment of schizophrenia. whitesreflects anaspiration toenjoythe samelife-style as they do, with all the associated benefits, but still to 11.2.4 Testing the cross-cultural validity maintain a social distance from them. This reluctance to attempt to form friendships may stem from two of CANDID 1 sources, an awareness of the strength of racial intol- erance, both individual and institutional, in the white Data have now been collected as part of the AESOP community, and its manifestation in the murder of study that will allow this test to be conducted [19]. In Stephen Lawrence and the indictment of the police some respects AESOP is a development of the EPS, investigation as revealing institutional racism. Taken but with much larger numbers of cases and controls, together with the reduced contact with relatives, a clear and including psychological and biological measures picture of marginalization emerges. The African-Car- as well as psychosocial enquiries. It was conducted in ibbean patients have moved away physically and three British cities, London, Nottingham and Bristol, emotionally from their own community, losing its and collected all patients with a first contact with support, and have gravitated towards the White ma- mental health services for a psychotic illness. It was jority, among whom they do not wish to seek friends. thus also more inclusive than the EPS in its diagnostic There is evidence that these expressed attitudes do categories. Furthermore, whereas the EPS had a spe- indeed reflect a reality. Research in the 1930s in the cific focus on African-Caribbean and Asian subjects, city of Chicago [25] revealed that black people who the AESOP study included subjects of any ethnicity. lived in predominantly white areas had a higher first The case-collection strategy was the same in both admission rate for schizophrenia than black people studies, but there was less of an attempt to match cases who lived surrounded by members of their own ethnic and controls on age, sex and ethnicity in the AESOP group. This observation became known as the ethnic study. Over 500 patients were accumulated and over density phenomenon and has recently been replicated 300 controls, making the subject base more than four for African-Caribbeans living in London [26]. The times as large as the EPS. incidence of schizophrenia for African-Caribbeans The main ethnic minority groups represented in the living in areas with a high density of their own ethnic AESOP data base are whites, African-Caribbeans and group was 2.4 times the white rate, while for African- Africans. There is a relatively small group of Asians, Caribbeans living in predominantly white areas it was 26 in all. The size of the sample and the inclusion of

CULTURE AND IDENTITY 139 these four ethnic groups provided an opportunity to items from the ‘language’ and ‘responsibilities in the test more rigorously the validity of using CANDID 1 family’ domains loaded highly on one factor across widely differing cultures. The total number of (factor 3). Overall, findings from exploratory ana- subjects from these groups who completed this sche- lyses pointed to the presence of both a strong general dule was 605: 258 cases and 347 controls. Their data dimension and several domain-specific latent vari- were pooled and analysed. Cases predominantly had a ables representing the dimensional structure of CAN- diagnosis of nonaffective psychosis. DID item responses. Exploratory factor analysis was conducted and A confirmatory factor analysis was largely in accord indicated both a one-factor and an eight-factor solu- with these findings, identifying a general factor with tion. Most of the CANDID items loaded highly on the high item discrimination shown by ‘language’, first factor in the one-factor solution, suggesting that ‘responsibilities in the family’, ‘sex roles’, ‘work/live a strong single dimension may be an adequate re- with other ethnic group’ and ‘media’ domains. For the presentation of the CANDID item response structure. specific factors uncorrelated with the general factor, However, this solution was not adequately supported moderate to high item discriminations were found for by the sample data compared with the baseline data. the ‘relationship with other ethnic group’, ‘sex roles’, The eight-factor solution displayed a good model fit ‘work/live with other ethnic group’ and ‘media’ do- and corresponded reasonably well with the a priori mains. Our conclusions are that CANDID 1 identifies a CANDID domains. Items of six out of eight domains single general factor that encompasses all four ethnic loaded strongly to seven distinct factors, representing groups included in this analysis. In addition there are the domains of ‘religion’ (factor 1), ‘relationship item-specificfactorswithcontributions fromparticular with other ethnic groups’ (factor 6), ‘sex roles’ domains. These findings endorse the use of CANDID 1 (factor 2), ‘work/live with other group’ (factor 5), across widely differing cultural groups, and also affirm ‘satisfaction with media representation of own ethnic our initial concept of covering a wide range of domains group’ (factor 7) and ‘preferred food’ (factor 8). Only including both attitudes and reported behaviours. 11.3 CONCLUSION The data from the EPS and AESOP studies underline tional racism wherever it is detected. These endea- the importance of using an instrument that is based on vours would necessarily require strong governmental bipolar scales, as argued by Burnam et al. [12] and support. This may sound utopian at present, but the operationalized by Szapocznik and Kurtines [2]. It is stakes are high. If these proposed actions stemmed the also clear that scales dominated by an emphasis on alarming increase in schizophrenia for African-Car- facility in the host language will fail to identify ibbeans and Africans in the UK it would constitute important aspects of behaviour, attitudes and aspira- evidence for marginalization as a cause of schizo- tions in which biculturalism and marginalization may phrenia and would be applicable to the many immi- be manifested. The study of marginalization has an grant groups at risk globally [28]. important implication for prevention of the develop- ment of schizophrenia in minority ethnic groups. One can conceive of actions that would focus on strength- REFERENCES ening the ties of young peoplewith their community of origin, particularly their families. There are prece- 1. Berry, J. W. (1980) Acculturation as varieties of adap- dents in Black Pride movements that aim to elevate the tation, in Psychological Dimensions on the Accultura- self-esteem of members of that ethnic group. It would tion Process: Theory, Models and Some New Findings also be necessary to take measures to equalize the (ed. A. M. Padilla), Westview Press, Boulder, Colorado. opportunities for higher education and employment 2. Szapocznic, J. and Kurtines, W. (1980) Acculturation, for young people genuinely and to combat institu- biculturalism and adjustment among Cuban Americans,

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12 Globalization and psychiatry 1 2 Rahul Bhattacharya, Susham Gupta and Dinesh Bhugra 3 1 East London NHS Foundation Trust, London, UK 2 East London NHS Foundation Trust, London, UK 3 NIH Biomedical Research Centre and Institute of Psychiatry, King's College London, London, UK 12.1 INTRODUCTION Globalization means different things to different peo- emotional boundaries of the nation state. It also ple – from simply an economic shift of resources to a changes the way individuals perceive time and much more far-reaching transformation in cultural, space [2,3]. It is inevitable that the process of globa- social and economic structures as a consequence of lization works both in positive and negative ways. revolutions in transport and communications. These Societies have always evolved and changed as a result changes impact on societies at large and on indivi- of invasions, migration and natural forces such as duals, and cast complex and subtle influences on the famine and floods. Globalization, however, produces incidence and prevalence of mental disorders in po- a level of change that is faster and equally unpredict- pulations. In addition, the ways in which mental dis- able. The resulting social and economic disintegra- order is understood and managed will be shaped by tion, the unequal distribution of wealth, the limited these ongoing global shifts, as individuals are exposed opportunities for many individuals and changing so- to ideas and information from a vast array of sources. cial or political norms will no doubt influence attitudes These sources most obviously include the Internet. It is and responses to the process of globalization. Global inevitable that such ready access to information will economic forces have weakened poor countries and affect philosophical, ideological and political world communities, on the one hand, and reinforced the views, which explains why some countries will not economic status of wealthy countries, on the other [4]. allow access to certain websites. These changes will However, there have been changes in countries such as affect the mental health of families and individuals at a Brazil, Russia, India and China where economic number of levels and in a number of ways. growth by and large has been impressive. Within these Jones [1] observes that the term ‘globalization’ has countries, this has come at a price, with evidence of both been overused and abused. The process of glo- resulting social fragmentation and greater inequal- balization changes the technological, economic and ities. Thus, links between globalization and the health Principles of Social Psychiatry, second edition Edited by Craig Morgan and Dinesh Bhugra Ó 2010 John Wiley & Sons, Ltd.

142 COMPONENTS OF THE SOCIAL WORLD ofthesocietiesandindividualsarecomplexandhaveonly over the personal space. This kind of shift in a socio- recently been explored. Lee [3] suggests that a clearly centric or kinship-based society will create new ways definedresearchandpolicyagendaneedstobedeveloped. of producing and relating to others. Cities tend to Globalization has also been defined by Tomlin- improve their economic efficiency by marginalizing son [5] as ‘the continuation of a long historical process and excluding marginal areas and segments of the of Western ‘imperialist’ expansions ... representing population [7]. Consequently, more space is allocated an historical pattern of global cultural hegemony’. to commercial activities, thereby reducing personal or Such a definition suggests that people are still being public green space further, which may produce further manipulated and are not really able to make choices. overcrowding and stress. Using Ahmedabad in Gujar- The use of time and space has certainly altered as a at, India, as an example, Mahadeivia [7] notes that, result of globalization (see below). Personal space has post-globalization and economic liberalization, the given way to economic space where survival activities debt burden on the city has increased eightfold, lead- are marginalized by the activities of the rising global ing to the city withdrawing from its nonobligatory business class [6]. The communal place also takes functions. 12.2 IMPACT OF GLOBALIZATION The term globalization has become emotionally these rates will increase further. This will be compli- charged. It is often alternately seen as a further ex- cated by poor physical health that may occur as a result tension of US hegemony or as a promise of interna- of overwork, poor health and safety conditions and tional civil society [8]. There is indeed an emerging other factors. global culture heavily influenced by the US. However, Berger ([8], p. 10) suggests that impinging globa- the extent and reach of this homogenization of culture lization can paradoxically also lead to a revitalization is questionable. For example, McDonald’s in India of indigenous cultural forms. The response in return provides no beefburgers but instead offers only vege- may lead to the development of new religions, to tarian options. This modification may seem super- becoming more extreme (as in the case of the Hindu ficial, but it indicates that the hard core of American fundamentalist party in India) and to influences on the values may not necessarily take root in other cultures. media (which again in India have become more The emergent global culture then becomes dissipated sensationalist than before). These cultural conflicts, through popularmovementsof onekindoranother[8]. argues Berger [8], lead to a turbulent situation that is Interestingly, Berger [8] also suggests that the dis- very hard to control. Cultural globalization is closely semination of the Protestant work ethic through interlinked with economic and social globalization. ‘missionaries’ may have influenced globalization. There is also a broader view of the term globalization, Thus, aspirations, expectations and reality may clash where it is seen as a multifaceted phenomenon and with each other, adding to the stress of globalization. appraised in a social context: ‘as the intensification of Following from this, Bhavsar and Bhugra [9] note that worldwide social relations which link distant local- economic inequalities are already associated with ities in such a way that local happenings are shaped by higher rates of mental disorders, and if globalization events occurring many miles away and vice increases economic inequalities then it is likely that versa’ [10]. 12.3 HISTORY However, is globalization really that recent? People expanded their boundaries. They have interacted, have since time immemorial crossed borders and settled in new lands or travelled back home, bringing

GLOBALIZATION AND PSYCHIATRY 143 in elements from which both parties learn and change of the features of modern globalization is the creation their manners, knowledge and other aspects of social of networks that overcome traditional political, cul- functioning. Migration has been driven by aspira- tural or social boundaries. This has happened within tions for a better future or in order to flee persecution, psychiatry with, for example, the formation of the and therefore is similar to the modern day asylum World Psychiatric Association. The interactions and seeker or the economic immigrant. Migration has interdependencies fostered and nurtured by globaliza- been influenced by political and military endeavours, tion have stretched the boundaries of social relations, religious missions or by ideas of sheer exploration. activities and, potentially, people’s aspirations and From the Silk route to the ancient colonies, from the identities. The thing that has made some of these Spanish and Portuguese conquistadores to the Dutch changes possible is an unprecedented rate of devel- and British East India Companies, interaction across opment in the fields of communications and travel. the borders has always been there. The era of in- These tools of globalization seem to have qualitatively corporating much of the world through trade and transformed the concept of boundaries by allowing colonization (fifteenth to nineteenth centuries) is interactions across the borders in real time, essentially now often (retrospectively) referred to as the ‘First transforming our concept of time and space. Hence we Era of Globalization’. Globalization suffered a set- are in an age of globalization like never before. In this back with the gold crisis and the Great Depression of chapter, the term ‘globalization’ refers to this modern the 1920s and 1930s. However, it is arguable that the era of globalization. only significant recent departure is that boundaries Globalization is then simply the intensification of are becoming more permeable. global interconnectedness [11]. Inda and Rosaldo After the World Wars the term globalization entered [11] note that this interconnectedness works at our vocabulary and the modern era of globalization different levels, including processes that operate on started. World economies wanted to ensure and safe- a global scale and ceaselessly cut across national guard against another future decline in international geographical boundaries, connecting and integrating interactions (or trade). Their works led to the Brent cultures and communities in new space–time com- Woods Conference, and this was followed by several binations. Thus, the world as a result of globalization agreements to reduce barriers to ensure free(er) trade, has a rapid flow of capital, people, goods, images and e.g. the General Agreement on Tariffs and Trade ideologies, making closer connections and compres- (GATT). Organizations such as the International sing the time and space across the countries. The Monetary Fund (IMF), the World Bank and the World world may be connected through better and faster Trade Organization (WTO), which has its roots in means of communication but the overall impact and GATT, were not only driven by reducing trade bar- influence of globalization remains uneven. Partly it is riers, but also wanted protection against free move- related to language and partly to cultures themselves ment of intellectual property, and therefore were keen (whether they are inward looking or outward look- to enforce supranational patency. Supranational gov- ing). The ‘intensification of circuits of economic, ernmental or political organizations such as the United political, cultural and ecological interdependence’ Nations and the European Union added another [11] can lead both to advantages and disadvantages. dimension to this. There were also social and profes- Inda and Rosaldo [11] suggest that a fundamental sional organizations that went international, e.g. reordering of time and space is occurring. The speed- Amnesty International, M edecins Sans Fronti eres and ing up of economic and social processes have shrunk Doctors Without Borders. Some of these organiza- the globe; distance and time no longer appear to be tions had been formed earlier but have benefited from major constraints on the organization of human the process of globalization. Through the 1970s and activity [12]. News around the world can be accessed 1980s, many of the commercial enterprises them- in real time – the most striking recent example being selves had spread across borders and had become the use of ‘Twitter’, a kind of instant messaging mammoth global players, e.g. General Motors, service, in the Mumbai bombings in November McDonalds and, more recently, Microsoft. Hence one 2008. With limited effort hundreds of thousands of

144 COMPONENTS OF THE SOCIAL WORLD people around the globe can be kept informed as struggle. The distancing between those who ‘have’ it events unfold. (status, skills or choices) and those who do not be- Harvey [12] notes that the process of globalization comes significant in understanding the development is neither sudden nor continual but occurs in short and the management of mental distress. spurts, and once one technology has settled down, its Stiglitz [14] cautions that globalization will result variants or replacements emerge. The centralized in increasing inequality among the world’s popula- mass production in one site has given way to multiple tion: ‘Market deregulation favours the dominant, production sites around the globe where components strong economies of the West and fails to offer devel- are made and then brought together somewhere oping countries an opportunity to strengthen their else for assembly. Thus the social factors leading to infrastructure sufficiently to compete in a global stress have a domino effect directly or through economy. Globalization, by this logic, will lead to repeated visualization, as was seen in repeated view- further poverty, inequality and social injustice.’ Ex- ing of images of the 9/11 attacks. As noted earlier, acerbation of wealth inequalities between and within Inda and Rosaldo [11] indicate that (global) space is societies is a possible outcome of this process. This shrinking and time is speeding up. Thus the system could lead to social inequalities, which will in turn relies on people who may be far away from each other. increase rates of certain mental disorders. Is it this These authors suggest that the cultural dynamics of simple? Probably not, as lots of other factors will need globalization have produced de/territorialization of to be taken into account. To view globalization as a culture (p. 10) by pulling culture away from its process that only benefits the developed world at the particular locales. People and cultures move across expense of the poorer regions is inaccurate, even previously rigid geographical boundaries and cultural though it may be perceived as such. The need for values have unhinged from geographically located cheaper labour has led to shifting of both manufactur- cultural groups. Inda and Rosaldo (p. 11) note that ing and service-based industries to the developing this cultural de/territorialization is invariably the oc- world, thereby generating local jobs and wealth even casion for reinsertion of culture into new time–space though their spread may be inequitable. Also, eco- contexts. nomic gains from one region can benefit another. Does this process lead to homogenization of cul- Remittance from external migrants back to their fa- tures or does it produce more rigid nationalist extre- milies is an important source of income for some mism? Both results are possible and it really depends countries. on how the cultures see themselves, whether they Technological advances have led to a diminution in are able to absorb the impact of newer factors and absolute poverty in Western countries but without whether the contact is friendly, or social, economic or stricter state controls inequality has increased drama- political. Inda and Rosaldo (pp. 13–14) have talked tically. Although benefits are assumed to ‘trickle about cultural imperialism as part of the globalization down’ to the least well off in society, the technological process. Contemporary migrants will bring with them nature of these gains favours those at the top of the different values but also similar ones as a result of a food chain. The UN Human Development Report [15] shrinking world. These authors also raise the question indicates that progress has been made worldwide to of whether the flow is all one way from the West to the lift millions of people from poverty, especially in East, which is obviously not the case. Migrants carry places like China, parts of Asia, Africa and the their cultures with them wherever they go, but they Americas. For the first time in history, more people also develop coping and managing strategies in new live in urban and developed areas than not, primarily cultures. The disjointed connections between them due to massive and unprecedented internal economic and those who have been left behind raise further migration, rather than to economic development in the questions about managing stress and distress. There developing world. Both internal and external migra- will undoubtedly be peoplewho are multilingual, have tion thus produce changes in stressors and social multiple identities, multiple residences and move support networks, making individuals more vulner- effortlessly between cultures [13], whereas others will able to psychological factors.

GLOBALIZATION AND PSYCHIATRY 145 12.4 SOCIAL INEQUALITIES AND MENTAL ILLNESS A positive linear relationship between income in- population coverage and hence less reflective of social equality (measured by the ratio of the income share stratification, for which income inequality is a marker. of the richest 20% of the population to the poorest Eibner, Sturn and Gresenz [18] found a correlation 20 %) and the prevalence of any mental disorder in between an index of relative deprivation and higher developed countries exists [16]. With increased avail- risks of developing depression and anxiety. However, ability of data looking at the relationship between an association between living in an income unequal psychological functioning and social inequalities area and depression in women shows variable re- across the globe, it should be possible to delineate sults [19]. The relationship between gender itself, more precisely the relationship between income in- gender role expectations and income inequality means equality, mental disorder and deprivation in the high the inability of women to reach their full potential and low and middle income countries. Changes may could lead to a further sense of poorer aspiration, be related to changes in social cohesion and inclusion, achievement incongruence and powerlessness. As negative perceptions of the self and real or perceived depression is more common in women and in certain loss of control over work and life. Wilkinson and settings rates of deliberate self-harm are higher in Pickett [17] observein a systematic review that studies women, changes related to globalization and migra- finding no association between inequality of income tion may affect women more, and this deserves to be and health tend to be smaller in geographical and studied further. 12.5 CHANGES IN PERCEPTIONS OF MENTAL DISORDERS Globalization will influence individual perceptions Reference [20]). These factors also lead to a shift in both of the understanding of mental disorders as well identity development and response to stressors that as of the way mental health services are accessed. may well put the individual in direct conflict with the Although the numbers of trained mental health pro- culture or with those members of a culture who may fessionals are low in many regions of the world, quite not have changed or acculturated at the same level or often the training is more likely to follow a Wester- same speed. For example, parents may hold on to more nized concept of mental illness. Culture-specific as traditional views and their children may develop more well as transculturally sensitive training of mental modern views, thereby causing a culture clash. On the health workers is needed to comprehend the true other hand, it is equally likely that children may not prevalence of psychological problems and deliver necessarily hold modern attitudes but show these in appropriate treatment. order to fit in with their peers, thereby causing even It is also highly likely that with increased indus- more internalized conflict. With inequitable economic trialization and urbanization, access to Western sys- changes within societies, the chances of divergence in tems of medicine will be more common and may be the mode of delivery of care are quite high, especially seen as more sophisticated, and cultural shifts as in areas where public health services are inadequate. a result of media exposure may lead to altered ex- Unregulated growth of private health providers may planatory models of health. In addition, traditional exploit high (and often unrealistic) expectations of idioms of distress may change with exposure to other those who are to afford such care. cultural norms. It has been argued that with changes in There are more direct effects of globalization. One society there may well be an alteration in the locus of anecdotal example is that the explosion in call-centre control in health care beliefs from external (e.g. super- employment in India has increased presentations of natural) to internal (e.g. psychological factors) (see substance abuse, domestic problems, depression and

146 COMPONENTS OF THE SOCIAL WORLD anxiety to local psychiatrists though the employers between nations may lead to direct and indirect con- have often not taken this seriously [21]. Walker [22] flict. The feeling of being exploited and of power- argues that in the globalized world, income and edu- lessness towards a process beyond the control of cational disparities, as well as financial and job in- individual countries can generate anger, frustration security, have grown in parallel with increasing feel- and mental disorder. This could be channelled through ings of hopelessness and isolation. He goes on to violent responses. However, globalization also plays a emphasize that sociopolitical stressors will add to the protective role with greater international consensus prevalence of depressive disorders and also influence and better cultural awareness among nations, as ex- their conceptualization and treatment. This is further emplified through the development of various global compounded by the waning of protection of rights of economic and political forums. Bauman [25] illus- individual workers and trade union power in many trates how the role of the media in the portrayal of parts of the world [23]. poverty, famine and natural disasters in faraway lands With increasing economic freedom, individuals makes individuals in developed countries desensitized are less dependent on social and family units and to the impact of these tragedies As noted above, sociocentric societies are likely to become more in- culture influences the idioms of distress, sources of dividualistic or egocentric. Social psychologists like help, pathways into care and both the patient’s and the Maercker [24] have shown that the prevalence of clinician’s explanatory models as well as the social psychiatric disorders varies according to the type response to distress and to disability [26]. Globaliza- of society; e.g. sociocentric societies have lower rates tion will change an individual’s ethnic identity and of common mental disorders. Social isolation can be will affect the multiplicity of identities and responses both a factor and a product of mental disorders. This is an individual will carry in a clinical encounter. particularly true for older people, who are often Combined with a sense of alienation (when indi- dependent on their families for support in the absence viduals in their culture are left behind while some are of adequate social benefits and pension schemes. With getting ahead) and marginalization, individuals can the increasing breakdown of the family unit and the react in a number of ways, but most of these are likely migration of the younger population, in many parts of to bring more stress on the individual. Mental disorder the world the elderly are more likely to be left to fend by itself cannot be isolated from the processes of for themselves. This can add to the worsening of globalization. Kirmayer and Minas [27] argue that morbidity in the absence of well-developed mental globalization affects psychiatry through its effect on health systems. the forms of individual and collective identity, through With increased competition from agrarian to the impact of economic inequalities on mental health industrialized societies, rising expectations for aca- and through the shaping and dissemination of psy- demic achievement, peer pressure and cultural chiatric knowledge itself. On the one hand the culture dissonance may lead to children and adolescents may assert its identity by maximizing its character- becoming susceptible to emotional problems. With istics – good and bad – or it may ‘creolize’ the identity increasing proximity, political and cultural clashes and cultural idioms. 12.6 GLOBALIZATION, IDENTITY AND CULTURAL PSYCHIATRY One’s identity of self is the core to one’s sense of being, reconstructed and reshaped to local levels. Ethnic iden- and a source of vulnerability or resilience as an indivi- tity remains a fluid concept in migrant populations. dual. Awareness andmigration exposes people to multi- People may have an identity that retains elements of ple social orders and hierarchies, local and global. their culture of origin, but might also involve decon- Living at the interface of the local and the global struction and loss of other elements of their root culture, necessitatesapluralistic frameofreference.Bibeau[28] oversuccessivegenerations.Thisprocessmaybeunder- calls this a ‘creolizing world’ where global ideas are stood as a stage in the migration life cycle, a stage

GLOBALIZATION AND PSYCHIATRY 147 characterized by constant shifting and assembling of bicultural identity in the process of managing multiple new hybridized identities [29]. The process of devel- cultural environments and group loyalties and bilingual oping the reconstructed identity is associated with competence, and perceiving one’s two cultural identi- acculturation. It is important that social strategies avoid ties as integrated, appears to be an important antece- marginalization or segregation. In fact, developing a dents of beneficial psychological outcomes [30]. 12.7 HEALTH AS A COMMODITY Globalization has been driven by the market economy grown, 750 000 Americans travelled abroad to seek and deregulation. As it promotes consumerism, it has health care in 2007 [32]. Health tourism had tradi- ‘commodified’ everything that has come its way and tionally been the remit of interventional medicine, but health is no exception [31]. While technological ad- we do get psychiatric patients who request medicine vances bring in a light of optimism, consumerism in not yet licensed or marketed in the UK. This is either medicine undermines society’s contract with the doc- driven by information or prescription while travelling tor. Psychiatry is no exception. In the US, specialist abroad. We also come across patients who travel interventional medicine has boomed, administrative abroad to seek spiritual or alternative healing for their overheads swollen and litigation is rampant. This has psychic distress. This can be looked on as another come at a cost to the patient and the doctor [31]. form of health tourism. Health tourism to the devel- Patient (consumer) satisfaction is low with the gen- oping countries is a relatively new phenomenon. Does eralist forming only 30% of the medical workforce in this mean a move towards an equitable access to health the US [31]. Doctors face the risk of being de-skilled care technology across the globe? It does offer an in bedside procedures with excessive dependence on opportunity for certain fractions of people from de- technology and new-found interventions. If health veloping economies. It also offers facilities to people care is a product that can be bought, then if you are from wealthier nations who lack the resources to avail unhappy with the local service, why not get it some- care in their local setting [33]. However, it does not where else, maybe cheaper. Historically people (who necessarily ensure distribution of the benefits of trans- could afford it) came from the developing world to fer of such technology in an equitable manner and seek health care in the West. As dissatisfaction has therein lies the challenge that society faces today. 12.8 GLOBALIZATION OF DRUGS: THE PRESCRIBED AND THE NOT PRESCRIBED While most of our patients still do not travel abroad to drugs. In a study looking into the relative cost of the obtain treatment, most of the medications are now illicit drugs heroin and cocaine, Costa Storti and De manufactured abroad. Though most patents are held Grauwe [35] found a decline in the retail prices of with the West, an increasing proportion of the manu- drugs, related to the strong decline in the intermedia- facturing has moved to the developing economies, tion margin in the drug business, and concluded that particularly in recentyears. Manufacturing sites in India globalization was the main driving force behind this and China now comprise 40% of the FDA registered phenomenon. The drug costs have come down with foreign sites, and there were 145000 ‘line entries’ of increased efficiency of the distribution of drugs, re- foreign drugs from more than 160 countries [34]. This duced risk premium involved in dealing with drugs also raises anxieties over standardization of the drugs and increased competition in the drug markets. This being manufactured and dispensed [34]. poses a challenge for psychiatry. Illicit drugs are Cheap production in countries with cheap labour associated with predisposing, precipitating and perpe- and cheap and efficient transport to connect the pro- tuating psychiatric morbidity. Globalization has ducer with the consumer is not limited to prescribed increased exposure to these risks.

148 COMPONENTS OF THE SOCIAL WORLD One rather unique challenge of globalization is seen consider it as just another exotic vegetable. Some in the increased use of khat in the West. Import is professionals panic with the amphetamine derivative driven by demand, often from migrant populations, in khat and the risk of mental illness associated it, particularly from East Africa. There is a lack of while anthropologists see this ‘moral panic’ as arising political as well as professional consensus on this from a failure to appreciate the use of khat within its issue. Legally, while some countries ban khat, others social and ethnological context [36]. 12.9 REVOLUTION IN INFORMATION SHARING AND MENTAL HEALTH Expertise is no longer the sole domain of the globalization. Today technology is shared over the ‘specialist’: it can be available across the globe and World Wide Web; and a lot of it offers immense is often shared or marketed freely through the World benefit to us through the sharing of relevant evidence Wide Web. One can order ‘newer’ pharmaceutical and literature. It has also helped in the formation of productsovertheInternet,asgovernmentalregulations support groups for conditions that are sometimes rare struggle to enforce standardizations and restrictions. In or stigmatized. However, as with most things, so with mental health this is relevant in people ordering sleep- globalization, there are negatives – information ing tablets, pills that make them happy or aphrodisiacs, sharing on how to home-grow cannabis, for example. and slimming tablets, which are often worryingly This leaves many vulnerable populations exposed to unsafe or unknown quantities. Recent examples in- another risk (with the known adverse effects of clude sildenefil, fluoxetine and dihydroxy epiandros- cannabis on mental health). As a profession we are terone. Rather paradoxically, though globalization was also continuously challenged by ‘alternative med- promoted to protect intellectual property, it has ended icine’, which can range from the evidence based up deregulating certain products like never before. to the obscure and unknown, from the culturally While this is a debate on its own, this also high- diverse and traditional to popular science or lights the fact that nobody is actually ‘in charge’ of pseudo-science. 12.10 MIGRATION AND MENTAL HEALTH Globalization has been facilitated by cheaper and and discrimination. Depending on the level of indi- more accessible travel and this has led to migration vidual and collective strength in the person’s identity around the world on an unprecedented scale. Figures and their experience of response from the host com- from the UK show a huge flux of migration reaching a munity, the individual can be integrated, assimilated, peak in 2005: ‘The highest net inflow (204 000) was in segregated or marginalized [38]. Individuals who have 2005 when 563 000 people moved into the UK and been persecuted, who have been tortured or who have 359 000 left’ [37]. However, we often forget migration not received a privileged upbringing or education is rampant across the globe and not an exclusive are less likely to be equipped with the skills that are phenomenon faced by the West, though there is little valued, and are therefore potentially less likely to literature in migrant populations in non-Western be aware of what to expect in their host country and countries, e.g. Afghans in Iran, Sudanese in Egypt are more likely to be sensitive to perceived discrimi- and so on. Migration is uprooting and displacing, nation and face real discrimination or racism. On the especially if it is driven by persecution or natural other hand, the sudden arrival of a large number of disasters, as this form of migration allows less scope people who are perceived as competing for limited for planning. Migration often comes with loss of resources can be worrying to the host community, and social support, poverty and potentially deprivation it would be unfair to label this anxiety as racism [39].

GLOBALIZATION AND PSYCHIATRY 149 These dynamics can potentially have a long-lasting population. A study in Oslo found that PTSD affected effect and can leave generations to come with poor 46.6% of all the refugees [41]. While some of these self-esteem. A reflection of this can be found in the associations are easily understandable, some associa- increased prevalence of bulimia, a behaviour asso- tions are difficult to explain. Schizophrenia has been ciated with poor self-esteem in children of Asian consistently found to be increased among Black Car- background coming from a more traditional back- ibbeans in the UK and the Netherlands, without a ground in Bradford [40]. Because immigrants often corresponding increase in the original sending popu- come from a traumatic past, it is not surprising that lations [42,43]. Migration and psychosis is discussed there is a relatively high incidence of PTSD in this in Chapter 15 (see also Reference [44]). 12.11 GLOBALIZATION AS A CAUSE OF MENTAL DISORDER An elegant study that came up with rather worrying culture many factors adversely affect the mental results was one carried out in the islands of Fiji by health of children and their families. These include Becker et al. [45]. There was an association between loss of extended family support, maternal blame, increased exposure to television and symptoms of pressure in schools, a breakdown in the moral author- vomiting to control weight (though the authors did ity of adults, family life being busy and ‘hyperactive’, not formally diagnose bulimia). Like the Mumford and a market economy value system that emphasizes study, one can argue that the ‘global’ notion of what is individuality, competitiveness and independence [48]. aesthetic and acceptable by society in terms of one’s Diagnostic manuals in psychiatry ensure a degree of physical appearance has led to an undermining of self- reliability, but the validity of conditions remains ex- confidence in the local population. posed to challenges. As with inattention, hyperactivity One might ask whether the rates of morbidity are and impulsivity in ADHD, personality disorders pose a going up or are we ‘medicalizing’ behaviour? Atten- similar challenge, as boundaries between normality tion deficit/hyperactivity disorder (ADHD) can be andpsychiatricconditionsare inevitablyarbitrary[49]. taken as another example. It is a condition often The challenge that globalization adds to this debate is diagnosed using questionnaires, e.g. Connor’s Ques- that globalization tries to impose global norms insen- tionnaire. Though the assessments for ADHD have sitive to the cultural context. Therefore thediagnosis of been standardized, raters’ perceptions and interpreta- personality disorders is highly dependent on how a tions of behaviours may vary across cultures (Mann society views certain behaviour. Self-concept, adapta- et al. 1992 [46]). This can affect cross-cultural relia- tion and social context are important aspects of the bility and validity of ADHD as a diagnosis [46]. These cultural dimensions of personality disorders. Due to findings were similar to another study that compared globalization and migration processes, clinicians and Hispanic and white American raters. They concluded: therapists are increasingly called upon to assess the ‘Overall, the present investigation suggests that level of personality functioning, not only in patients teachers’ reports of ADHD behaviour will need to be from different ethnic backgrounds but also in trauma- viewed with caution since the use of the published tized refugees and migrants. Multiple social and cul- cutoffs to determine the level of pathology appears tural factors have an influence on each level of the questionable with Hispanic groups.’ However, teacher diagnostic and therapeutic process. At one level this or rater ethnicity is rarely considered in real life. The demands a new level of cultural competency and diagnosis of ADHD has risen to epidemic proportions sensitivity [50]; at another level it poses a fundamental in recent years. Timimi has tried to explain this challenge regarding the cross-cultural validity of these phenomenon from a cultural perspective [47]. The diagnoses. There is a debate to be had on whether the immaturity of children is a biological fact, but the diagnosis of conditions such as antisocial personality ways in which this immaturity is understood and made disorder in the DSM-IV represents undue medicaliza- meaningful is a fact of culture. In modern Western tion of societal challenge.

150 COMPONENTS OF THE SOCIAL WORLD 12.12 DISCONTENT, DISPARITY AND INCREASED RISK Proponents of globalization believe the market is a and possibly the relationship is bidirectional, with self-regulating system, a sort of natural selection low socioeconomic status affecting health [54]. There where the ‘fittest’ will end up at the top and the is a fear that globalization has increased poverty, benefits trickle down to the society. Advocates of and this can potentially increase psychological mor- globalization, such as Jeffrey Sachs, point to the bidity. It is also hypothesized that women might be at above-average drop in poverty rates in countries, increased risk, with deprivation affecting women such as China, where globalization has taken a strong more with their domestic and childcare responsibil- foothold, compared to areas less affected by globa- ities [55]. With increasing economic freedom and lization, such as Sub-Saharan Africa, where poverty Western individualistic values, social psychologists rates have remained stagnant [51]. There is a flip have shown that the prevalence of mental disorders side to this. The gross produce of the world has varies according to type of society; e.g. individualistic increased and the rich have become richer; multi- societies have a higher incidence of common mental nationals are often worth more than the gross domes- disorder [24]. To members of nonegocentric cultures, tic product of some nations. The divide between the autonomous thinking with a free range of choices is rich and the poor therefore has increased [14]. While alien. With globalization and the fragmentation of one can argue disparity is perhaps not new to human society, and with increasing alienation from society, history, the situation today is different due to one can understand why time and again globalization ‘knowledge’ of the inequalities made available by has been seen as promoting ‘anomie’ by social scien- the information revolution through globalization. It tists. Emile Durkheim described anomie as a state is possible that the psychological impact of this in which norms are unclear or confusing or even painful information on an individual who is often absent in the face of large-scale social changes powerless to make a difference in their lives will in beyond the control of the individual [56]. Though some cases be so severe as to lead to a breakdown in traditionally related to the phenomenon of suicide, functioning. anomie has been invoked to explain increased inci- As already noted, psychiatric disorders are more dence of schizophrenia in progressively smaller common in lower socioeconomic groups [52,53] migrant groups [57]. 12.13 TRAINING AND RESEARCH AND PSYCHIATRY AND GLOBALIZATION It is not only patients who have travelled, psychiatrists tries as diverse as the US, Denmark and Nigeria [58]. themselves have travelled in many directions. There While Coverdale et al. recently commented on the have been people who have come to the West to train, globalization of psychiatric research [59], there has settled or returned and trainees who have travelled also been increased concern over the methodology and within the West or have gone for ‘elective’ training ethics of research from lower and middle income away from their home. All this has not only exposed countries (with respectto Westernstandards). Whether the psychiatrist to a rich and diverse clinical experi- these studies are deemed methodologically poor due to ence but also has led to them being trained in different the limited representation of psychiatry in their work- countries and styles. To ensure standardization, ex- place, to the author’s inexperience in research or to a aminations such as the Professional Linguistics and Western selection bias remains unanswered. However, Board for entry into the UK were set up. Globalization it does bring forward one of the fundamental para- has also brought into our awareness the recruitment doxes of globalization: that it promotes cultural plur- difficulty that psychiatry as a discipline faces in coun- ality, yet wants to ensure standardization.

GLOBALIZATION AND PSYCHIATRY 151 12.14 CONCLUSION One aspect of the modern phenomenon of globaliza- The melting of geographical, emotional, econo- tion is awareness of the impact of the process on mic, social and cultural boundaries as a result of subjectivity [60]. One can argue that cultural psychia- globalization will contribute to stress on individuals try as a discipline is a result of this subjective aware- and their families, as will how individuals manage in ness of the pluralistic society we live in, and deals with changing environs. The question that needs to be the social, cultural or individual processes that are asked is whether these boundaries were permeable threatened by globalization [61]. The main challenge enough already in order to allow globalization to of cultural psychiatry is to balance cultural sensitivity take place. Whatever the answer, the impact of with avoidance of stereotyping. Diversity, heteroge- globalization – in terms of economic factors that neity and pluralism lead us to question the heuristic affect mental health that in turn influences the distinctions traditionally made by social sciences economy, thus setting up a vicious cycle – cannot between cultures and social orders [62,63]. be ignored. ACKNOWLEDGEMENTS The authors wish to acknowledge that sections of this 6. Friedman, J. (2002) Globalization and localization, chapter have appeared previously in S. Gupta and D. in The Anthropology of Globalization: A Reader (eds Bhugra (2009) Globalization, economic factors and J. X. Inda and R. Rosaldo), Blackwell, Oxford, prevalence of psychiatric disorders, published in In- pp. 233–246. ternational Journal of Mental Health 38(3), 53–65. 7. Mahadeivia, D. (2002) Communal space over life space: saga of increasing vulnerability in Ahmedadbad. Published here with kind permission of M.E. Sharp Economic and Political Weekly, 37 (48), 4850–4858. Inc. with thanks from the authors. 8. Berger, P. L. (2002) The cultural dynamics of globali- zation, in Many Globalizations: Cultural Diversity in REFERENCES the Contemporary World (eds P. L. Berger and S.P. Huntington), Oxford University Press, New York, pp. 1–16. 1. Jones, R. J. B. (1995) Globalization and Interdepen- dence in the International Political Economy, Polity 9. Bhavsar, V. and Bhugra, D. (2008) Globalization: Press, London. mental health and social economic factors. Global Social Policy, 8 (3), 378–396. 2. Kunitz, S. J. (2000) Globalization, states and the health of indigenous people. American Journal of Public 10. Giddens, A. (1990) The Consequences of Modernity, Health, 90, 1531–1539. Polity Press, London. 3. Lee, K. (2000) The impact of globalization on public 11. Inda, J. X. and Rosaldo, R. (2002) Introduction: a world health: implicationsfor theUK Faculty of Public Health in motion, in The Anthropology of Globalization (eds Medicine. Journal of Public Health Medicine, 22, J. X. Inda and R. Rosaldo), Blackwell, Oxford, pp. 1–36. 253–262. 12. Harvey, D. (1989) The Condition of Post-Modernity, 4. Bhugra, D. and Mastrogianni, A. (2004) Globalization Blackwell, Oxford. and mental disorders: Overview with relation to 13. Hall, S. (1995) New cultures for the old, in A Place in depression. British Journal of Psychiatry, 184 (1), the World? Places, Cultures and Globalization (eds 10–20. D. Massey and P. Jess), Oxford University Press, New 5. Tomlinson, J.(1997) Internationalism, globalizationand York, pp. 175–213. cultural imperialism, in Media and Cultural Regulation 14. Stiglitz, J. (2002) Globalization and Its Discontents, (ed. K. Thompson), Sage, London, pp. 117–162. Penguin, London.

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13 Trauma and disasters in social and cultural context 2 1 3 Laurence J. Kirmayer, Hanna Kienzler, Abdel Hamid Afana and Duncan Pedersen 4 1 Division of Social and Transcultural Psychiatry, McGill University and Culture and Mental Health Research Unit, Jewish General Hospital, Montreal, Canada 2 Department of Anthropology, McGill University, Montreal, Canada 3 International Rehabilitation Council for Torture Survivors (IRCT), Copenhagen, Denmark 4 Douglas Mental Health University Institute and Division of Social and Transcultural Psychiatry, McGill University, Montreal, Canada 13.1 INTRODUCTION Trauma and disasters are important causes of human technological development have increased, so too has suffering both in terms of the sheer numbers of people the scale of disasters. Climate change, economic affected and the complexity of the mental health disparities and political conflicts all can be expected problems that may follow. Violence has become one to compound the number and complexity of disasters of the leading causes of death worldwide for people in the years to come [4]. aged 15–44 years [1]. Of the total number of global Social psychiatry has a long engagement with injury-related deaths, about two-thirds are of understanding the individual and collective impacts ‘nonintentional’ origin (e.g. traffic accidents) while of trauma and disasters. Much of this interest has been one-third are due to intentional violence, including driven by experiences of the impact of war on soldiers suicides, homicides and organized violence (terror- and civilian populations [5]. The Holocaust and other ism, wars and armed conflict, genocide and ethnic genocides have forced consideration of the effects of cleansing) [2]. Both the frequency and the numbers of massive human rights violations on the survivors as people affected by violence and disasters have in- well as on subsequent generations. The experience of creased markedly over the last 100 years, while the refugees has drawn attention to the impact of displa- proportion of people surviving has also risen [3]. This cement, forced migration and torture on mental health. means that there are many more survivors who may be Of course, trauma is not only a consequence of affected psychologically by traumatic events. As the such large-scale events but also a common occur- density of human habitation and the intensity of rence in domestic life. Early psychodynamic theory Principles of Social Psychiatry, second edition Edited by Craig Morgan and Dinesh Bhugra Ó 2010 John Wiley & Sons, Ltd.

156 COMPONENTS OF THE SOCIAL WORLD recognized the importance of childhood trauma as a to establish the first community mental health centre factor in psychopathology, although this was largely in the US in 1948 [9]. Kai Erikson’s study of the displaced by an emphasis on intrapsychic conflict [6]. Buffalo Creek flood in 1973 drew attention to the From the 1970s onward, the recognition of the high long-term effects on wellbeing of the destruction of prevalence of child abuse and its long-term conse- communal bonds and connectedness [10]. In recent quences has given renewed impetus to the study of years, disaster psychiatry and psychology have trauma in psychiatry [7]. emerged as distinct areas of study with textbooks, Research on the impact of natural disasters has journals and societies devoted to research and dis- also influenced the development of psychiatric the- cussion of clinical and social issues [11]. This ory and practice. Eric Lindemann’s study of the development of the field has brought recognition aftermath of the fire at the Coconut Grove nightclub that trauma and disasters may be associated with emphasized the processes of normal grieving and the particular types of mental health problems requiring value of crisis intervention to reduce pathological culturally informed interventions at both individual outcomes of trauma and loss [8]. His work led him and community levels [12]. 13.2 DEFINING AND DELIMITING TRAUMA AND DISASTER Trauma is a term originally applied to physical injury explaining distress; coping responses and adaptation; and some of its immediate effects. Since the late patterns of help-seeking and treatment response. Most 1800s, trauma has increasingly come to refer to a importantly, culture gives meaning to the traumatic range of psychological impacts of the experience or event itself, allowing individuals, families and com- threat of violence, injury and loss [13]. Events that are munities to make sense of violence and adversity in considered traumatic include violent personal assault, ways that may moderate or amplify their impact. rape, physical or sexual abuse, severe automobile Disasters are situations or events involving eco- accidents, being diagnosed with a life-threatening logicaldisruption,threattolifeorinjurythatnegatively illness, natural or technological disasters, being kid- affect large numbers of people and that overwhelm napped, military combat, being taken hostage, terror- local capacity for adaptation, usually by destroying ist attacks, torture and incarceration as a prisoner of infrastructure. Disasters vary widely in their scale, war or in a concentration camp. The term ‘trauma’ scope and significance. It is useful to distinguish be- emphasizes what is common across these different tween natural and human-caused disasters. Natural events, but clearly each has its own particular mean- disasters include geophysical and meteorological ings and consequences. events like earthquakes, floods, tsunamis, tornados, Traumatic events vary widely in terms of the nature volcanoesanddrought.Human-causeddisasterscanbe of the threat or injury, its frequency and duration, its divided into: (i) technological accidents, such as air- personal significance (which may change over time), line or other mass transportation accidents, industrial the relationship of the victim to the perpetrator (in the accidents and structural collapses of bridges or build- case of interpersonal violence or abuse), and the ings; and (ii) willful or intentional events such as mass broader collective meaning and social response. What murders, terrorism, war and genocide. The distinction constitutes a trauma then is not entirely dependent on between natural and human-caused, however, is often the nature of the event but also on the personal and difficult to make and may change with new informa- social interpretation of the event and the responses of tion and interpretations; for example, the destruction the affected person, their family and community, as following an earthquake may become a human-caused well as the wider society. Culture influences the in- disaster when it is realized that most of the deaths are dividual and collective experience of trauma at many due to the collapse of houses built with shoddy work- levels: the perception and interpretation of events as manship due to corruption in the construction threatening or traumatic; modes of expressing and industry. Many disasters span the natural and the

TRAUMA AND DISASTERS IN SOCIAL AND CULTURAL CONTEXT 157 human-caused because they stem from the ways hu- famine. The frequent coexistence and mutual aggra- mankind has modified the environment (e.g. famine vation of natural and human-instigated disasters is due to the interaction of methods of intensive agri- central to the notion of complex emergency, defined as culture and drought). Natural and human-made dis- a catastrophic situation marked by the destruction of a asters may co-occur and interact in ways difficult to population’s social, economic, and political disentangle. For example, drought or famine can be infrastructure [14,15]. caused by warfare and warfare can be ignited by 13.3 UNDERSTANDING TRAUMA From an evolutionary perspective human beings have 15–20% of people exposed to such acute events have lived with the threat of violence, injury and death symptoms and impairment lasting for several days or throughout history. We might expect therefore that weeks [19]. Acute stress disorder (ASD), introduced there are mechanisms available to help us adapt to in DSM-IV, occurs within the first 4 weeks of trauma threats that do not destroy us [16]. The most common exposure and is similar to PTSD but with prominent response to mild or moderate levels of trauma is acute dissociative symptoms [20]. A severe acute stress distress followed rapidly by recovery. We are biolo- response is a predictor of longer term distress, includ- gically primed to learn to be fearful and avoidant of ing PTSD [21]. potentially life-threatening situations [17]. When DSM-IV-TR classifies PTSD as an anxiety disorder threats are more severe and inescapable, other me- that is characterized by the ‘re-experiencing of an chanisms come into play, including dissociation, a extremely traumatic event accompanied by symptoms cognitive and attentional process of blocking out or of increased arousal and by avoidance of stimuli compartmentalizing memory and experience. This too associated with the trauma’ ([20], p. 429). The essen- may have adaptive functions, allowing individuals to tial features of PTSD are the development of specific survive intolerable situations like torture or confine- symptomsfollowingexposure toaneventthatinvolved ment, but it can also impair later adaptation. actual or threatened death, or serious injury, to which Although trauma can aggravate any psychiatric con- the person responded with ‘intense fear, helplessness, dition, certain disorders are presumed to have a direct or horror’ (p. 463). In addition to the stressor criterion causal link to trauma exposure. In any traumatic event, A, the criteria for PTSD include three main symptom some individuals will have more severe or incapacitat- clusters:(B)intrusiverecollection–intrusive thoughts, ing acute symptoms and some will go on to have distressing dreams, reliving or dissociative chronic distress and disability. Others may do well ‘flashbacks’, psychological distress and physiological initially but manifest significant symptoms at a later reactivity when exposed to reminders; (C) avoidant/ time. These pathological outcomes reflect both indivi- numbing – efforts to avoid thoughts, feelings, con- dual and social vulnerabilities. Among the problems versations or activities associated with the stressor, specifically linked to trauma are grief and other normal difficulty remembering the traumatic event, social forms of reactive distress, depressive and anxiety dis- withdrawal and emotional numbing; and (D) hyperar- orders, and post-traumatic stress disorder (PTSD). ousal – sleep problems, irritability or angry outbursts, Trauma exposure may result in a variety of short- concentration problems, hypervigilance and an exag- and long-term adaptive and pathological responses. gerated startle response. The diagnostic criteria for Common responses during or immediately after the PTSD in ICD-10 are similar but do not include numb- traumatic event include intense autonomic arousal ing and do not require functional impairment; these associated with fear, agitated behaviour or ‘freezing’, differences result in higher prevalence rates for PTSD and dissociative symptoms with an altered sense of with ICD-10 criteria [22]. time speeding up or slowing down, and feelings of PTSD has an explicit causal mechanism built into derealization and depersonalization [18]. About its diagnostic criteria: exposure to an unexpected or

158 COMPONENTS OF THE SOCIAL WORLD unpredictable event that involves serious risk of injury population. Surveys in the US have found 50–60% of or death to oneself or others and leads to appraisal of individuals are exposed to a traumatic event at some the event as threatening and so to intense fear, help- point in their lives [30]. The likelihood of developing lessness, horror and other negative emotions (shame, PTSD after a traumatic event varies with the type of guilt, anger); these in turn influence memory and other event and the magnitude of the trauma, ranging from cognitive-emotional-sensory processing of the event 5 to 10% of those exposed to a natural disaster, to 20% such that it leaves lasting traces in the brain and of those exposed to criminal assault, 40% of those behaviour [23]. A major component of the syndrome exposed to combat and more than 50% of those of PTSD is subserved by a conditioned emotional exposed to rape [30,31]. Women appear to have a response of fear [17]. Reminders of the context where greater risk of developing PTSD after trauma expo- threat originally occurred evoke anxiety and this is sure, although this may partly reflect gender differ- managed by cognitive and behavioural efforts to avoid ences in symptom expression [22]. such contextual cues, resulting in emotional numbing PTSD was initially framed as a normal or at least and withdrawal. inevitable response to extreme circumstances. How- Fear conditioning can be long lasting, but in the ever, longitudinal research soon clearly showed that ordinary course of events, repeated exposure to only some individuals exposed to the same type of the same cues without any fearsome outcome even- severely traumatic event develop PTSD and that pre- tually results in a decrease in conditioned fear, hyper- morbidpersonalityandpsychopathologyareimportant arousal and avoidance behaviour–a process called determinants of vulnerability. As most people who ‘extinction’. It is now known that extinction involves show transient symptoms resembling PTSD (heigh- a type of learning distinct from fear conditioning, tened arousal, anxiety, irritability, nightmares, intru- involving different neural pathways. In fact, the ori- sive thoughts) will recover over a period of days,weeks ginal conditioned fear is not erased or replaced but or months (depending on the severity of the trauma), simply suppressed by extinction learning. The two PTSD can be viewed as a disorder of recovery [32]. types of learning have different characteristics; fear Meta-analyses of risk and protective factors for PTSD conditioning is quicker and generalizes more easily show thatamongthestrongest predictorsofPTSDafter than extinction learning. As a result, a small change in trauma exposure are life stress and lack of social environmental cues can reinstate the originally support [33]. Thus, social factors determine the risk learned fear [24,25]. This helps to account for the of exposure to trauma and the likelihood of recovery. phenomenon of triggering or reactivation of symp- These risk and recovery factors are related to each toms in patients with PTSD [26]. other through the structures of family, community and These biological mechanisms are important for wider social institutions. It is useful, therefore, to think understanding the causes and chronicity of PTSD, of a social ecology of trauma risk and recovery [34]. the dynamics of triggering and re-experiencing, and Depression is also a common response in many the effectiveness of exposure therapy as a treatment, situations involving trauma, particularly when there but PTSD involves additional cognitive and beha- has been significant loss. The losses commonly asso- vioural responses mediated by forms of learning and ciated with trauma and disasters may include loss of memory, as well as processes of recall and narrative loved ones and possessions, but also loss of status, elaboration that are regulated by the personal meaning role, home, community and the familiar routines of of the traumatic events [27]. Both recollection and everyday life. The co-occurrence of depression and narration also involve social processes so that trau- PTSD complicates the course of each disorder [35]. matic outcomes reflect the culturally sanctioned occa- Somatic symptoms are common consequences of sions for remembering and forgetting [28]. trauma and may reflect physiological dysregulation as The prevalence of PTSD in any population depends, well as culturally shaped idioms of expression of in part, on rates of exposure to trauma which, in turn, distress [36,37]. For example, a study of Salvadoran depend on social circumstances [29]. Traumatic women refugees in North America, who had fled El events are common but unequally distributed in the Salvador to escape large-scale political violence,

TRAUMA AND DISASTERS IN SOCIAL AND CULTURAL CONTEXT 159 found that the women described their suffering as generalized anxiety disorder or depression, there ‘nervios’, a cultural idiom that covered an array of are other processes of physiological dysregu- dysphoric emotions (anxiety, fear, anger) and diverse lation, increased muscle tension and bodily preoccu- somatic complaints, including bodily pains, shaking, pation mediated by cognitive and social processes trembling and calor (sensations of heat). Although that contribute to such ‘medically unexplained’ some of the bodily symptoms that follow trauma symptoms [38]. exposure may be related to PTSD, panic disorder, 13.4 DISASTERS Disasters have health impacts at multiple levels, in- Disasters are associated with increased levels of dividual (physiological, psychological), family, com- medically unexplained somatic symptoms both munity, societal, international and global. The social acutely and over survivors’ life spans [42]. impact of disasters reflects their magnitude, the level of Disasters lead to psychiatric morbidity through pre-existing infrastructure, level of infrastructure pre- many pathways: physical injury, exposure to terrifying served, the meaning of events (human-caused or not); events, loss of loved ones, loss of employment, liveli- the response of the community and local population; hood and income, loss of familiar environment, do- the response of government and larger society; and the mestic and communal place. These losses and injuries international response. The impact of most disasters is interact with other social determinants of health in- more severe in developing countries, which lack re- cluding pre-existing social structural and political sources and infrastructure to respond adequately. problems. For the same amount of loss and physical Although a whole population or community may be damage, human-made disasters may have more severe exposed to a disaster, people are affected differently. psychological consequences owing to the ways they The psychological impact of a disaster on any given underminebasicsocial emotionsof trust andsolidarity. individual depends on both the personal and collective There are three broad approaches to the impact of significance of and response to the catastrophic event. trauma and disaster on mental health outcomes. The Groups recognized to be at particular risk for mental clinical psychiatric approach focuses on the effects of health consequences include women (especially preg- trauma in causing psychopathological conditions like nant women, single mothers, widows) and children. PTSD, depression and other potentially disabling Internally displaced people, refugees and others pre- conditions. Individual vulnerability due to pre-exist- viously exposed to trauma are also at increased risk for ing personality traits, coping styles and mental health psychological re-traumatization. In general, people problems help predict who will develop persistent with pre-existing mental health problems, including problems after trauma exposure. depression and anxiety, are especially vulnerable [39]. A second approach focuses on individuals’ re- The prevalence of psychiatric morbidity following sources and resilience. For example, conservation of a disaster is associated with its magnitude but also resources (COR) theory, developed by Hobfoll, with the level of perceived threat to life and risk of groups resources into four broad categories: object recurrence, lack of predictability and controllability, resources (e.g. material possessions with either func- loss, injury, exposure to the dead and grotesque, and tional utility or symbolic value); condition resources the extent of destruction of community infrastruc- (e.g. social roles or status like marriage, employment, ture [40]. Estimates of PTSD following a disaster membership in groups or organizations); personal range from 30 to 40% among those directly exposed characteristic resources (e.g. values, traits or attitudes to 10–20% for rescue workers and 5–10% for the like optimism, sense of meaning and purpose); and general population [29]. Symptoms of depression and energy resources (e.g. time, money, information) [43]. demoralization are strongly related to the degree of Resource loss due to trauma is associated with dis- loss experienced as a result of the disaster [41]. tress [44]. Disasters produce distress and limit coping

160 COMPONENTS OF THE SOCIAL WORLD by reducing individuals’ resources in each of these example, there is evidence for an effect of maternal areas. Coping and adaptation, therefore, can be im- stress during the ice storm on the subsequent cogni- proved by interventions that maximize these re- tive development of their infants who were exposed sources. Of course these resource domains are not in utero [46]. independent but correlated in ways that reflect a At the other extreme in terms of the magnitude community’s social structure and dynamics. of disaster, in Sri Lanka following the tsunami of A third approach recognizes the dynamic nature of 26 December 2004 there was massive loss of life and the interaction between different resource domains destruction of entire settlements and villages along and focuses on the role of social positioning in in- two-thirds of the country’s coast. This occurred dividual and group vulnerability and resilience. This against a backdrop of political violence that had more dynamic view could be termed ‘social affected the country for decades, eroding family sta- ecological’, in that it sees each person as located bility and community solidarity [47]. A survey in one within a system that has its own dynamics. Disasters severely affected area found that 40% of the popula- differ from isolated traumatic events affecting indi- tion had mild to moderate symptoms of depression, viduals in that they affect thewhole community, which anxiety or PTSD [48]. Another survey of children ordinarily provides the secure base for each person’s living in three tsunami affected areas found rates of adaptive responses to stress, trauma and loss. Depend- PTSD that were not related to the tsunami of ing on the degree towhich a disaster disrupts the social 4.6–8.5%, while tsunami related PTSD was found in fabric and weakens bonds between people, commu- an additional 13.9–38.8% [49]. Another study of nities may respond with mobilization and increased adolescents from two villages in southern Sri Lanka solidarity or with demoralization, disorganization and found that post-tsunami depressive and PTSD symp- disintegration. The level of psychiatric distress in the toms were associated with prolonged displacement, population plays a role in these social responses, but social losses, family losses and their mothers’ level of they have their own dynamics that reflect local his- mental health problems [50]. A positive mother–child tories and systemic issues of politics, identity and relationship had a protective effect. community. These local systemic dynamics are em- Generally, human-caused disasters result in more bedded in larger global economic and political re- psychiatric morbidity than those that are attributed sponses that influence the mental health outcomes of to natural events [51]. When events can be attributed disasters. to specific individuals or groups, fear and anger In the face of a disaster that do not destroy too may be directed towards them. When the human much infrastructure, communities may pull together causes are harder to identify, emotional distress may and experience a high degree of solidarity. For be more diffuse and anger may be harder to resolve, example, in January 1998, Quebec experienced an with greater risk for long-term mental health ice storm in which the accumulation of ice brought consequences. down the main power transmission lines into the city Disasters due to terrorism are a dramatic illustration of Montreal, leaving 3 million people without elec- of these factors both because terrorist acts are directly tricity in the midst of winter. Despite the challenge caused by individual agency and because they delib- posed by this loss of power and cold temperatures, erately aim to maximize the anxiety, insecurity, help- there was an enhanced sense of comradery among lessness and vulnerability of a population [52]. In the neighbours, who heated water for coffee over camp- wake of the attacks of 11 September 2001, high levels ing stoves and huddled around battery-operated of symptomatology were reported not only among radios waiting for news. There was no increase in those directly affected at the ground zero, or living in use of mental health services by patients with severe the city of New York, but across the country. A survey mental illness [45]. However, even during this rela- immediately following the attacks found that 44% of tively limited event, with little social disruption or adults had one or more ‘substantial’ symptoms of loss of life, many people experienced high levels distress [53]; two months later this dropped to of stress with potential long-term sequelae. For 16% [54]. New categories of trauma emerged, like

TRAUMA AND DISASTERS IN SOCIAL AND CULTURAL CONTEXT 161 vicarious PTSD incurred while watching repetitive and urges the survivor to follow a morally upright TVimages of the attacks [55]. The threat of recurrence path. On the other hand, karma implies an ultimate became an ongoing preoccupation, contributing to a moral order that would ensure that the perpetrators of new sense of collective vulnerability. the atrocities will pay for their actions in future Of course, the distinction between ‘natural’ cata- miserable rebirths. Political circumstances also may strophes like earthquakes, tsunami, hurricanes and limit any possibilities to name perpetrators and seek human-caused catastrophes like industrial accidents, justice or redress. war or terrorism depends on specific ways of inter- Even events that seem to be entirely natural exert preting events. Some people in the US believe that their effects unequally on a population in ways that government should control the forces of nature; hence reveal pre-existing social inequalities and injustices. natural disasters can be blamed on human error or In recent earthquakes, the pattern of destruction has malfeasance [56]. From some religious or cultural reflected economic disparities and corruption as perspectives, all events may have moral meaning as those with substandard housing, built by ‘cutting part of causal chains that include human or spiritual corners’, were most affected. The flooding of New agency (like karma, sin or divine judgement). Contra- Orleans due to hurricane Katrina had differential riwise, people may view even events caused by human effects on the poor and marginalized that reflected agency as preordained or following an impersonal the long history of racial discrimination [58]. Thus a logic. Thus, in the Cambodian genocides perpetrated natural disaster laid bare the structural violence of by the Khmer Rouge, many people interpreted the society. This social meaning has both material and catastrophe as following from their individual kamma moral consequences, influencing who finds safe (karma) and so felt a measure of responsibility for haven and looks forward to rebuilding their life and their own misfortune [57]. This attribution mutes the who endures prolonged displacement, neglect and external expression of anger and desire for revenge despair. 13.5 TECHNOLOGICAL DISASTERS Urbanization and industrialization have brought with distress, even among those who emigrate from the them many benefits but also new types of collective site of disaster [60]. Those who are evacuated may be vulnerability. Mass transportation has created the at increased risk for mental health problems owing to potential for accidents that affect hundreds of people the disruption of their lives. However, those who in an instant. New technologies have created new remain in the vicinity of an industrial accident may types of disaster with unique characteristics that fol- face the greatest challenge. In the case of the Three low from their unique physical properties. For exam- Mile Island nuclear reactor accident, people who ple, the release of radioactivity from the Chernobyl continued to live near the reactor reported feeling less disaster had long-term and long-range effects with an control over their lives and this was associated, in turn, increase in cancer and other radiation-related dis- with higher levels of somatic, anxiety and depressive eases [39]. The petrochemical disaster in Bhopal symptoms even years after the event [61]. resulted in an enormous range of respiratory, ocular, The legal and political meaning of technological gastrointestinal and other conditions [59]. In both disasters may bring vulnerable populations into direct cases, there were also long-term psychological effects conflict with powerful commercial interests. Techno- on the exposed populations, with persistent feelings of logical disasters may be viewed as accidents due to anxiety, depression and medically unexplained risks inherent in a useful technology or as stemming symptoms. from human errors, action or inaction. To the extent Independent of actual exposure, the conviction that theyareviewed as due to human action, there is always one has been exposed to toxic chemicals or radiation some person or corporate entity to blame. However, may be a risk factor for long-term psychological largecorporationsoftenareabletodeflecttheeffortsof

162 COMPONENTS OF THE SOCIAL WORLD individuals or groups to seek redress. Ongoing litiga- ities,creatingsevereeconomichardship,butthosewho tion and struggle over restitution from those respon- wereplaintiffsinthecivilsuitsufferedgreaterlevelsof sible for the catastrophes can greatly complicate the stress over the course of the litigation. The persistent prospects for recovery, as illustrated by the protracted angerassociatedwithperceivedinjusticesthathavenot struggles over compensation following the Exxon been acknowledged or redressed contributes to long- Valdez oil spill [62]. The spill disrupted fishing activ- term distress following technological disasters [63]. 13.6 WAR AND POLITICAL VIOLENCE Ethnic conflict, organized violence and wars have Eritrean refugees in Ethiopia and Gaza in Palestine, been major causes of suffering, ill health and mortality de Jong, Komproe and Van Ommeren compared rates throughout history [2]. In recent decades, the number of depression, anxiety disorders, PTSD and somato- of victims and survivors of traumatic events has form disorders among those exposed to armed-con- significantly increased as war, armed conflict and flict-associated violence and those without such ex- political upheaval have engulfed civilian populations posure [66]. Overall, PTSD was the most common worldwide, contributing to additional burden of dis- disorder for those directly exposed to violence, while ease, death and disability. War has always exposed anxiety disorders were the most common disorder for both combatants and civilians to trauma but, with the those not directly exposed. There were high levels of adoption of new methods of warfare, recent years have comorbidity of PTSD with anxiety or mood disorders seen a dramatic increase in the proportion of civilian in Algeria and Cambodia. However, there was also casualties. During World War II, about 50% of the substantial variation in the overall prevalence and direct casualties were civilians; in the 1980s this figure relative rates of disorders, which was due not only to rose to 80% and by 1990 it was fully 90%, with the the nature or severity of the disorder but to cultural largest number being women and children [64]. variations in modes of expression of distress. For War and political conflicts have structural causes example, in Cambodia, anxiety disorders were more and often occur in societies that are already facing common than PTSD among those exposed to vio- economic hardship. The collapse of formal economies lence. Somatoform disorders were more common and the emergence of economic crises in the marginal among those exposed to violence only in the Palestine areas of the global economy lead to further impover- sample. ishment, food insecurity and ethnic and religious The health consequences of political violence and tensions over diminishing resources. Consequently, wars extend beyond death, disease and trauma-related predatory practices, rivalry, political violence and psychiatric illness, to include the pervasive effects of internal wars may erupt [65]. In the last 60 years there destruction of the economic and social institutions and have been over 200 wars and armed conflicts, in which the whole fabric of society. As such, the consequences the main targets are often the poorest sectors of society of violent conflict can be observed not only in in- and marginalized ethnic groups. dividuals – in their biographies and life trajectories – Armed conflict results in significant psychiatric but also in collective memory and identity and com- morbidity but the pattern varies across cultures. In a munal strategies for coping with violence and study of 3048 respondents in Algeria, Cambodia, adversity [65,67]. 13.7 REFUGEES Refugees fleeing war or persecution are very vulner- responsible for threatening and persecuting them. The able as they cannot count on protection from their own 1951 Refugee Convention defines a refugee as some- state, and it is often their own government that is one who ‘owing to a well-founded fear of being

TRAUMA AND DISASTERS IN SOCIAL AND CULTURAL CONTEXT 163 persecuted for reasons of race, religion, nationality, Vietnam and Laos who were resettled in Canada after membership of a particular social group, or political having lived in refugee camps for a variable period of option, is outside the country of his nationality, and is time, found that although chronic strain (such as flight, unable to or, owing to such fear, is unwilling to avail internment and resettlement) was a major risk for himself of the protection of that country’ [68]. The mental health problems, post-migration factors, includ- Refugee Convention obligates governments to pro- ingsupportfromtheethniccommunityandtheprospect vide a safe haven for those fleeing persecution. How- for integration in the receiving society, were crucial ever, many countries treat refugee claimants with determinants of outcome [74]. For refugee children as suspicion and have policies aimed at discouraging well as for adults, the quality of their post-migration others from seeking asylum [69]. These policies of reception in the new country is a better predictor than deterrence, which may include detention under harsh pre-migration trauma exposure of mental health [75]. conditions, have serious mental health effects [70]. Survivors of political violence, persecution or tor- Epidemiological studies have demonstrated both ture, who must flee their countries of origin to survive, short- and long-term effects of trauma on refugee suffer complex losses and transitions associated with mental health and disability. For example, a survey forced migration, the process of seeking asylum and of Vietnamese refugees who resettled in Australia the enduring dilemmas of exile [69]. The process of found that 8% of the participants had mental disor- convincing immigration authorities that one has been ders [71]. Trauma exposure was the strongest pre- tortured and so has a valid claim to refugee status may dictor of mental health status. Although the risk of a in itself become a situation of psychological retrau- mental disorder decreased over time, people who matization [69,76,77]. This may be exacerbated by the suffered more than three traumatic events had a higher fact that such individuals may be reluctant to divulge risk of mental illness after 10 years compared with experiences like torture, rape or other forms of trauma people with no traumatic exposure. A longitudinal in health care settings. Refugees also may have con- study of Bosnian refugees found that fully 45% met tinuing fears for the safety of family left behind and DSM-IV criteria for depression, PTSD or both [72]. uncertainty about the possibility of reuniting with Ameta-analysisof56reportspublishedfrom 1959to loved ones. Despite the profound impact of trauma 2002, representing 22 221 refugees, found that mental on wellbeing, post-migration factors including social health status was worse among those living in institu- supports, employment and occupational status are tional accommodation, with restricted economic op- among the strongest predictors of positive out- portunity, internally displaced, repatriated to a country come [73,74,78]. Effective resettlement policies and they had fled or with unresolved conflicts in their programmes can therefore make a significant contri- country of origin [73]. A study of 1348 refugees from bution to refugee mental health. 13.8 TORTURE Torture constitutes an extreme form of trauma in which torture to extract information – human rights violations the perpetrator actively seeks not only to threaten the in which health care professionals took part [81–84]. In victimwithpain,injuryordeathbutalsotodehumanize, reality, torture yields unreliable information and is used control, humiliate and oppress the victim, and through primarilyasatoolforrepressingpoliticaloppositionand them, a whole community [79]. Despite international instillingfearinthecommunityandsocietyatlarge.The efforts to prevent torture as a human rights violation, it politicaluseoftorturehasacorrosiveeffectonthemoral continues to be practised by many countries [80]. The order of a society and constitutes an important obstacle attackontheWorldTradeCentreon11September2001 to the development of democratic institutions and uni- led to an increase in torture practices when many versal human rights [85]. countries joined the so-called ‘war on terror’, using the Compared to other forms of trauma or natural sloganof‘protectingpublicsecurity’tojustifytheuseof disasters, torture constitutes a profound violation of

164 COMPONENTS OF THE SOCIAL WORLD personal integrity and dignity because it undermines ference and superstitious thinking. Chronic pain may the moral basis of human relatedness and community. reflect neuropathic damage from torture, links be- Perpetrators create a situation of extreme powerless- tween bodily sensations of memories of torture, pro- ness, uncertainty and loss of control in their victims, cesses of somatic amplification due to psychological but the effects of torture spread far beyond the im- distress and culturally shaped idioms of distress that mediate victim to include fragmentation of family and encourage a focus on the body [100–102]. community networks through the spread of fear and Feelings of violation, anger and injustice, while not mistrust, and the erosion of social and political always correlated with PTSD or another psycho- solidarity [86–90]. pathology, may constitute significant clinical pro- Torture involves a wide range of methods of physical blems in their own right [103]. The anger and aggres- and psychological abuse with diverse consequences for sion that survivors often experience as a consequence survivors.Rapeandrelatedformsofsexualtorture have of their torture experiences may be displaced on to especially severe effects for both men and women [91]. other people, particularly their families. Even when Survivors who had strong political convictions and there is no overt conflict or abuse within the family, were prepared for the possibility of being tortured due children may be strongly affected by the suffering of to their activism generally fare better than those for their parents and the community. For example, Puna- whom the torture was arbitrary or unrelated to their maki, Qouta and El Sarraj found that exposure to convictions [92,93]. Many forms of torture leave vic- traumatic events increased Palestinian children’s po- tims with profound feelings of shame, guilt and dis- litical activities and psychological adjustment grace because of the powerlessness, degradation and problems’ – both effects were independent of the humiliation they have experienced, and this may im- quality of perceived parenting [104]. Rehabilitation pede help-seeking [94,95]. Individuals who must con- interventions therefore must be extended to include tinue to live in proximity to the perpetrators of violence the families and communities of the victims. and torture must suppress or ‘manage’ their feelings to Treatment of survivors of torture requires a broad maintain the social order [96,97]. perspective on mental health that encompasses family, Common sequelae of torture include symptoms of community and the politics of social integration. anxiety, depression and symptoms of acute stress Community-based approaches have become increas- disorder with dissociative symptoms [98]. Post-trau- ingly accepted as an integral part of treatment. This matic stress disorder (PTSD) is very common among model calls for a broader role for health professionals survivors and its likelihood increases with the severity as advocates and facilitators whowork collaboratively of the torture [83,93,99]. Other common symptoms with other nonmedical professionals from law, media, that may occur with PTSD or independently include: community development and human rights to promote chronic pain, sexual dysfunction, phobias, night- empowerment as survivors are assisted to help them- mares, memory impairment, social withdrawal, diffi- selves. The focus of rehabilitation is on strengths culty maintaining intimate or long-term relationships, rather than weaknesses, resilience rather than vulner- and psychotic-like symptoms including ideas of re- ability, health not disease. 13.9 GENOCIDE The United Nations Convention on the Prevention and group; causing serious bodily or mental harm to Punishment of the Crime of Genocide (CPPCS), members of the group; deliberately inflicting on the defines genocide as: group conditions of life calculated to bring about its physical destruction in whole or in part; imposing measures intended to prevent births within the group; ... any of the following acts committed with intent to [and] forcibly transferring children of the group to destroy, in whole or in part, a national, ethnical, racial another group. or religious group, as such: killing members of the

TRAUMA AND DISASTERS IN SOCIAL AND CULTURAL CONTEXT 165 The Holocaust and other genocides (e.g. in Rwa- nature of suffering. A parent who has endured great nada, Bosnia–Herzegovina, Cambodia) have starkly trauma in a concentration camp may react in many presented the immediate and transgenerational ef- ways: with irritability, distraction or overprotective- fects of massive human rights violations and the ness. Each of these will have different effects on the systematicdestructionofcommunities[105].Despite child, all of which might be attributed to the parent’s recognition of these catastrophes, there has been a trauma. In most cases, these are not PTSD but pro- tragic lack of political will in the international com- blems in adjustment, anxiety, interpersonal relation- munity to intervene in ways that could prevent or ships and so on. mitigate the loss of life. Yehuda and colleagues examined transgenera- Clearly genocide, involving violence on a massive tional trauma in a group of adult offspring of Holo- scale, can have severe effects on survivors’ mental caust survivors and a demographically similar com- health. A study of four communities affected by the parison group [111]. Although adult offspring of genocide in Rwanda found the prevalence of PTSD Holocaust survivors did not experience more trau- symptoms depended on traumatic exposure and varied matic events, they had a greater prevalence of current from 12.2 to 33.8% [106].A study of refugee survivors and lifetime PTSD and other psychiatric diagnoses of the genocide in Bosnia-Herzegovina who resettled than the demographically similar comparison sub- in Australia found no differences in PTSD risk for the jects. The findings demonstrate an increased vulner- group most exposed to human rights violations (in- ability to PTSD and other psychiatric disorders ternment in concentration camps, torture) compared among offspring of Holocaust survivors, thus iden- to the general war-exposed group [107]. Exposure to a tifying adult offspring as a possible high-risk group threat to life predicted PTSD, while both threat to life within which to explore the individual differences and traumatic loss were associated with symptom that constitute risk factors for PTSD. Other studies severity and disability. have little evidence of increased psychopathology in Mass human rights violations such as those that the second- and third-generation children of Holo- occur in situations of political violence, ethnic cleans- caust survivors [112]. ing or genocide have effects at many levels. At the Individual stories of trauma serve to ground col- level of the individual, Silove has described these lective identity and call for a moral and political effects in terms of different adaptive systems, includ- response. The appropriation of trauma to stabilize a ing systems involved in safety, attachment, sense of collective identity may have benefits for the indivi- justice or fairness, existential meaning and social role dual. There must be a public place for stories of trauma or identity [87,108]. Each of these biosocial systems for them to be told, acknowledged and legitimated. gives rises to specific forms of distress in response to Collective identity, history and legal mechanisms can specific types of threat or loss (Table 13.1). There are a play a role in creating this place. Transgenerational variety of psychological and social adaptive responses links may serve psychological and political functions, that aim to re-establish the normal functioning or becoming a central theme in the individual’s identity equilibrium of the system and when those fail, parti- and a basis for the political aspirations of a group or cular forms of psychopathology may result. Interven- even a nation [113]. tion strategies can be viewed as acting to restore these For example, for indigenous peoples in North adaptive functions. These same mechanisms operate America, current mental health problems prevalent in other forms of trauma and disasters to varying in some communities have come to be seen as the degrees. consequence of historical trauma following from There has been much interest in the possibility of European colonization of the Americas and subse- transgenerational transmission of trauma in the con- quent policies of forced assimilation [114,115]. The text of genocide [109,110]. Clearly, however, the effort to survive as a people when a whole way of life experience of the second and third generation is not has been undermined and dismantled poses special precisely the same as the first and the pathways of social, moral and psychological challenges that are transmission point also to a transformation in the not captured by constructs like PTSD [116,117].

166 COMPONENTS OF THE SOCIAL WORLD Pathological outcomes Anxiety PTSD GAD disorder Panic Depression anger Chronic mistrust and Paranoia Antisocial behaviour Alienation Helplessness Passivity Demoralization Isolation Withdrawal Despair reassurance and self fear bereavement establishing or revitalization strategies and safety toward of mastery and and others rights of redress and activism community institutions tradition of Adaptive Seeking Self-soothing Protectiveness others Cognitive Mourning rituals Reaffirming with bonds Reassertion Restitution Social Rebuilding and Reclamation, reinvention others response flight trust of violations Initial Fear Hypervigilance or Fight Grief Nostalgia Homesickness Anger of Lack Suspicion Confusion Aimlessness Confusion Disorganization rights or or [47]. human other injustice, violations status suppression and social suppression life of Reference and death ones or attachment and of institutions core of way from torture or loved of place of of Discrimination, rights work of Destruction, denigration Destruction, denigration and trauma, Threat Injury Loss Loss objects human Loss economic symbols observations severe community positively and cognitive with by system danger bonds of social of and of self of stability modified affected of of and exchange of sense and [108]; systems Function Avoidance Maintenance family of Maintenance equity, reciprocity Maintenance valued personhood Maintenance coherence plans of and [87] Adaptive system security meaning References 13.1 and Attachment fairness, role, from Table Adaptive Safety Justice, equity Social identity Existential Adapted

TRAUMA AND DISASTERS IN SOCIAL AND CULTURAL CONTEXT 167 13.10 INTERVENTIONS Current clinical guidelines for the treatment of trauma emerging consensus on best practices in disaster man- emphasize cognitive behavioural therapy, exposure agement, although the evidence base is limited [126]. therapy and the treatment of comorbidity (most often The WHO Report on ‘Mental Health in Emergencies’ depression, anxiety disorders, substance use) [118]. and the Inter-Agency Standing Committee (IASC) There is some evidence for the effectiveness of trau- emphasize that it is crucial to protect and improve ma-focused psychotherapeutic interventions for indi- people’s mental health and psycho- social wellbeing in viduals with persistent trauma-related symptoms or the midst of an emergency through (a) psychological PTSD [119]. first aid provided by a variety of community workers Prolonged exposure therapy aims to allow extinc- for people experiencing acute trauma-induced distress tion of conditioned emotional responses of fear. Cog- and (b) care by trained and supervised health staff for nitive behaviour therapy works more broadly to people with severe mental disorders, including severe change modes of interpreting and responding to PTSD [127,128]. The principles of psychological first trauma cues, reduce catastrophizing thoughts and aid include: maintaining a calm presence, providing a reinforce adaptive coping. Narrative exposure therapy safe and comfortable setting, stabilizing emotionally involves a blend of approaches and can be used with overwhelmed survivors, gathering information about both children and adults across cultures [120–122]. It current needs and concerns, providing practical assis- involves constructing a life narrative than includes a tance, giving information about common psychologi- review of traumatic experiences, revisiting the asso- cal reactions and appropriate coping strategies, and ciated emotions and bodily feelings to allow habitua- linking the individual with local services and sources tion to the physiological arousal; the process of narra- of further help. Humanitarian aid workers and com- tion gives the trauma memories and experiences munity leaders need training in the basic psychological structure through retelling and composing a written skills required to provide psychological first aid, emo- testimony. tional support and recognition of common mental Althoughantidepressants and other medications are health problems that should be referred to pro- widely used, there is little evidence for the effective- fessionals [129]. ness of pharmacotherapy in the treatment of PTSD or Despite the consensus on best practices in an initial trauma-related disorders [123]. Treatment is usually disaster response, there are still many questions about symptomatic, to improve sleep, control pain and treat appropriate interventions. The interventions offered in concomitant depression and anxiety. Beta-blockers disaster situations are diverse and include material have been used to reduce autonomic arousal. There support (shelter, food, clothing), psychoeducation, is intriguing evidence that the use of propranolol psychological debriefing, cognitive behavioural ther- during a guided process of trauma recall can diminish apy (CBT), narrative exposure therapy, eye movement emotional arousal on subsequent recollection without desensitization and reprocessing (EMDR) and com- the presence of the medication [124]. This raises the munity-based interventions. CBT and narrative expo- prospect that it may be possible to decouple trauma sure therapy have been shown to be helpful for memory from some of its distressing and disabling individuals with trauma-related PTSD [122,130], and physical effects. community-based approaches that work towards There is increasing recognition of the need to con- strengthening social supports and reintegration may sider mental health issues in disaster relief. The 2004 fit better in some cultural contexts [131]. However, guidelines produced by the Sphere Project, which there is a lack of strong evidence for any specific involved a global consultation process to establish treatment. minimum standards for humanitarian response, cover Although exposure therapy has proven effective for mental health for the first time [125]. There is an isolated discrete traumas, it remains uncertain

168 COMPONENTS OF THE SOCIAL WORLD whether it is equally effective for those exposed to emergencies affecting large numbers of people. As a multiple, repetitive or pervasive trauma like that seen result, however, disaster scenes may be inundated by in survivors of torture or genocide [132,133]. There is mental health professionals and other disaster workers little evidence that psychoeducational approaches can who further strain local resources and inadvertently help prevent post-traumatic disorder or other types of contribute to the problems rather than to their solution. psychological distress [134]. While there may be other There is agreement that post-disaster strategies benefits from existing interventions, and they may must address the broad impact of disasters, promoting work for some individuals or groups, more work is a sense of safety, calming, self- and collective efficacy, needed to identify effective prevention strategies. feelings of connectedness and hope [136]. Translating Psychological debriefing, which until recently was these general goals into specific interventions, how- a popular intervention, is no longer recommended. ever, requires consideration of individual and com- Debriefing is based on the assumption that retelling munity psychology, an ecosocial perspective and the trauma story provides emotional release, relearn- awareness of local social, economic and political ing and cognitive reorganization. One influential ver- constraints and cultural meaning systems. Cultural sion was developed as a group intervention in the US, issues have been only minimally integrated into cur- as a support method for fire fighters [135]. This was a rent disaster guidelines [137]. work group of professionals who knew each other, Cultural issues raise important considerations in the who were exposed to similar traumatic events, were practical response to disaster that may have mental trained to respond to disasters and remained con- health consequences. Efforts to rebuild infrastructure nected to a larger stable social environment. All of that do not sufficiently consider the social and cultural these contextual elements may not be present when context may have negative effects on post-disaster the method is applied in other settings: the people adaptation. Following the 2004 tsunami, large quan- affected may have been thrown together by the events, tities of aid poured into several Asian countries (in part they may have experienced very different levels and because foreigners saw the tsunami as a blameless types of threat and loss, they may face a profoundly misfortune) and communities pulled together to con- disrupted social environment and they may come from front and cope with adversities [138]. In Sri Lanka, for a cultural background that does not encourage open example, the aid was used to reconstruct housing in expression of private feelings or potentially shameful ways that have proved problematic for some commu- events. Even in the US, there is evidence that the nities. Fishermen were moved inland and resettled in intense re-exposure that may occur in psychological houses built without the accustomed level of privacy, debriefing can retraumatize some individuals. organization of interior space and ability to accom- The funding and delivery of humanitarian aid is modate extended family [139]. Lack of attention to increasingly organized on an international level to cultural context undermined the effectiveness of this facilitate faster and more effective responses to major well-intentioned support. 13.11 CONTINUING CONTROVERSIES In addition to the unresolved questions about The construct of PTSD has been valuable for focus- treatment efficacy, there are broader controversies ing attention on one specific form of anxiety response, in the field of trauma and disaster mental health, but limited in terms of the wide range of impacts and concerning the cross-cultural applicability and uti- the importance of other personal and social factors in lity of the diagnosis of PTSD; the value of testi- producing resilient outcomes or prolonged suffering mony or explicit talk about trauma versus contain- and pathology. The field of trauma and disaster psy- ment; and the role of Truth and Reconciliation chiatry is far wider than the compass of PTSD. Commissions or other forms of restorative justice Although the symptoms of PTSD can be identified in recovery. across cultures, its clinical and social relevance

TRAUMA AND DISASTERS IN SOCIAL AND CULTURAL CONTEXT 169 remain contentious. Structured diagnostic interviews On this view, instead of offering psychological coun- and self-report scales based on the diagnostic criteria selling, humanitarian aid programmes should ac- for PTSD have been translated into local languages, knowledge resilience and retain the social rehabilita- permitting investigators to distinguish trauma-related tion frameworks, starting with the strengthening of disorders from similar kinds of psychological distress. damaged local capacities in line with local Other scales are available to assess the level of trauma priorities [148]. exposure and trauma-related symptomatology [140]. A related controversy concerns the appropriate These include the Harvard Trauma Questionnaire strategy for dealing with severe trauma of the sort (HTQ) and measures for assessing anxiety and de- found among refugees and survivors of torture. While pression [141]. These instruments can be adapted to some approaches to rehabilitation of survivors of new cultural groups, though problems of clinical and torture, genocide or other human rights violations cultural validity remain [142]. However, symptoms emphasize the importance of giving testimony, this tend to be nonspecific indicators of distress and, in may not fit well with all social, cultural or religious themselves, do not demonstrate the presence of a contexts. Thevalue of testimonyhas been embraced in discrete disorder of clinical significance. Measures of Latin America and taken up by the International functional impairment are essential to define a thresh- Rehabilitation Council for Torture Victims in Copen- old for disorder warranting clinical attention. hagen [149]. However, many Asian traditions empha- Critics argue that mainstream approaches to diag- size the values of equanimity and containment and nosis and treatment overlook the extent to which may view the open airing of suffering as unhealthy and trauma experience is culture-specific. The Western disruptive to the social order. Political and mental discourse on trauma is embedded in a particular health goals then come into conflict with social norms cultural and moral framework and becomes proble- and cultural values and the implications of this for matic in other cultural contexts [143]. Personal, po- trauma outcomes remain uncertain. Part of the benefit litical, social and cultural factors mediate the experi- in telling one’s story comes from giving it a coherent ence of war or other forms of violence. Practitioners frame, part comes from having a sympathetic other unfamiliar with the local culture and situation apply person bear witness and part comes from the larger generic assessment tools and interventions that force social–historical process of recording a personal and individuals into a limited repertoire of categories and collective truth. However, all of these depend to some responses [144]. People are encouraged to understand extent on the social reception of the testimony. Further their suffering through the prism of individualistic work is needed to understand the tradeoffs involved in psychological models that may not fit local values and speaking out or remaining silent in specific social, concepts of the person [145]. As well, the dominance cultural and political contexts [150,151]. of the PTSD model tends to suppress other approaches The functions of testimony have taken on new and silence local perspectives on what is helpful and dimensions in the context of Truth and Reconciliation important in the wake of a disaster. Commissions like that of South Africa, which aim to The distress and suffering that accompany war or restore justice and moral order to a community rent by other forms of collective violence are not necessarily longstanding political violence and injustice. This, in pathological responses to traumatic events, butmay be turn, has raised questions about the social mechanisms normal responses to existential predicaments [146]. for reconciliation and forgiveness that hope to repair Such suffering is resolved in a social context through both the justice and existential systems by ensuring familial, sociocultural, religious and economic activ- public acknowledgement of past human rights viola- ities that make the world comprehensible for people tions and providing a healing ritual that brings some before, during and after catastrophes [14,147]. closure to otherwise unassimilable events. The meta- The roots of recovery from trauma and disaster lie in phor of the psychological wound and the notion of the restoration of the functional social environment, healing have governed the truth and reconciliation i.e. through improved living conditions, activities, process. However, this is an inaccurate or incomplete employment, a stable community and social order. model of the complex psychological and social

170 COMPONENTS OF THE SOCIAL WORLD processes put into play; the process involves issues of their condition [154]. The public, ‘quasi-legal’ con- justice, equity and safety as well as woundedness and text of the Truth and Reconciliation Commission may wholeness [152]. be threatening to some people and destabilizing for a The ability of victims and their families to partici- community. Mental health practitioners have a role to pate in legal proceedings or other public means of play to ensure that the process of recounting does not holding perpetrators accountable may provide com- cause further damage. This may involve helping to fort for them; it may also act as an effective tool for the design a setting and procedure that is therapeutic (e.g. prevention of torture [153]. In some instances, how- by giving control to the narrator) and supporting ever, the truth and reconciliation process can be individuals participating in Commission hear- harmful to participants. Individuals who already have ings [155]. Other forms of restorative justice based PTSD may benefit little and may have their traumatic on traditional methods of conflict resolution face memories activated and experience an exacerbation of similar challenges when applied to mass violence. 13.12 CONCLUSION Trauma has become a dominant trope in discussions of fessions that organize forms of suffering as the contemporary world [156]. Like any metaphor it bureaucratic categories and objects of technical reveals and it conceals. What the metaphor of trauma intervention [158]. reveals is the supervenient effects of extreme violence Understanding stories of trauma requires an un- on suffering. Even healthy people can be torn down derstanding of the collective dimensions of violence and permanently marked by the most severe forms of and social suffering. Trauma experience is em- violence. Yet the response of most people, even to bedded in and emerges from multiple contexts, serious trauma, is resilience and recovery. including biological processes of learning and mem- A social and cultural perspective suggests that it ory; embodied experiences of injury, pain and fear; is crucial for clinicians to understand traumatic narratives of personal biography; the knowledge and events and disasters in their broader social, eco- practices of cultural and social systems; and the nomic and political context. These politics shape power and positioning of political struggles enacted the production of psychiatric knowledge about trau- on individual, family, community and national ma, the personal social and cultural contexts that levels [27]. are singled out for clinical attention, the ways that The language of trauma, however, tends to draw a professionals and institutions apply trauma diag- simple arc from the violent event through the psycho- noses and treatment, the dynamics of social support logical processes of the individual (where they may and the processes of conflict resolution. Although exhibit resilience or vulnerability) to bodily symp- violence always has very personal impacts, it is toms of affliction. In reality, the events we call trauma clear that states, international organizations, global are part of larger configurations of suffering that have economic institutions and mass media are all in- their own social ecology and political economy. Dis- volved in the creation, maintenance and resolution crete trauma and disasters occur against a backdrop of of the conflicts that lead to structural, interpersonal structural violence that renders some groups and and mass violence [157]. Suffering is fundamentally individuals far more vulnerable; focusing exclusively a social experience in several ways: it involves an on the trauma may deflect attention from these en- interpersonal engagement with pain and hardship during forms of disadvantage – in some instance, lived in intimate and communal social relationships; however, a catastrophe may throw these into stark it is framed in terms of available cultural models of relief as was seen, for example, with hurricane Ka- the nature of adversity and corresponding appro- trina. It is important for mental health practitioners priate moral responses; and it is part of professional and psychiatric researchers to appreciate these larger discourses of medicine and the mental health pro- social contexts of suffering. Without such awareness,

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Part Three Social determinants



14 Fundamental social causes of health inequalities Jo C. Phelan and Bruce G. Link Mailman School of Public Health, Columbia University and New York State Psychiatric Institute, New York, USA This chapter focuses on a theoretical framework that inequalitiesinpsychiatricillnessandhowwecanexpect we developed to explain persistent and robust socio- the socioeconomic patterning of psychiatric illness to economic inequalities in mortality across time and change as more effective means of preventing and place. As such, the scope of the theory goes beyond treating these illnesses are developed and adopted in the problem of psychiatric illness. At the same time, the population.We beginwiththe set offacts motivating psychiatric illness fits squarely within the theory, and the theory; then we will describe the theory, present the fundamental cause perspective may provide a some empirical data evaluating it and finally discuss the new lens for considering the causes of socioeconomic implications of the theory for psychiatric illness. 14.1 SOCIOECONOMIC AND RACIAL INEQUALITIES IN HEALTH AND MORTALITY In the last century, humans greatly expanded their inequalities and for the kind of research and action that capacity to control disease and death. Any explanation are likely to help reduce those inequalities. of current health inequalities by factors such as socio- There is a strong, well-established and very economic status (SES) or race must take account of robust association linking both morbidity and mor- this fact. We will argue that the capacity to control tality to educational attainment, occupational stand- disease and death creates inequalities – that when we ing, and income [1–3]. Figure 14.1 provides a recent make gains in our ability to control disease, people example of this association. It shows adjusted death with more knowledge, money, power, prestige and rates per 100 000 by educational status for people beneficial social connections are better able to harness between the ages of 25 and 64 years in the United the benefits of our new-found capacities, thereby States in 2004. For both men and women, adjusted creating inequalities. If this line of thinking is correct, mortality rates are much higher for those with less it has important implications for explaining health than 12 years of education compared with those Principles of Social Psychiatry, second edition Edited by Craig Morgan and Dinesh Bhugra Ó 2010 John Wiley & Sons, Ltd.

182 SOCIAL DETERMINANTS 900 839 800 700 619 600 486 < 12 years 500 12 years 400 345 13+ years 300 251 167 200 Figure 14.1 All cause age-adjusted death rates 100 per 100 000 people aged 25–64 by education – 0 2004 [4] Males Females with 13 or more years. Similar patterns exist for with lower SES or minority racial status. Genetic black–white mortality differences in the US. Health vulnerability explanations, by contrast, argue that United States reports that all-cause age-adjusted vulnerability leads to illness, which in turn impairs a death rates per 100 000 population in 2004 were person’s ability to attain or maintain socioeconomic substantially higher for black (1027) than for white position. A slightly different genetic explanation (786) groups [4]. views genes as strong influences on factors like These strong mortality gradients based on SES and intelligence or on personality dimensions such as race are not new. For SES, the association was conscientiousness, which in turn influence both observed in Mulhouse, France, in the early nine- health and SES. teenth century, in Rhode Island in 1865, in Chicago Each approach offers a different explanation of the in the 1930s (see Reference [1]), and currently in the processes causing socioeconomic or racial gradients United States and Europe [2–5]. Similarly for racial and carries different implications for how we might differences, life expectancy has been much lower for address them. Because of the critical nature of the African Americans than for white Americans as far facts at issue, it is important to know which explana- back as such data have been available. How can we tion or explanations are correct. This is a longstanding explain the persistence of these inequalities? Why debate that we believe has been dramatically altered should SES and race have such an enduring and with regard to physical illness by changing circum- widespread association with mortality? stances. In order to construct an explanation that fits Two broad types of explanation have been offered these circumstances we turn attention to evidence of and debated. Social causation explanations find the trends in the improvement in health over the past half- answer in the stress or adversity that is associated century. 14.2 IMPROVEMENTS IN POPULATION HEALTH Figure 14.2 shows an increase in life expectancy at These improvements apply to many diverse causes of birth in the US from only 47 years in 1900 to 77 years death, including some of the major killers of our time. in 2000. Although much of this improvement is due to Age-adjusted mortality rates per 100 000 people due dramatic declines in infant mortality, life expectancy to heart disease plummeted from 587 in 1950 to 258 in has also increased across the life span. For example, 2000. The figures are equally dramatic for stroke, the average American man turning 65 years old in where rates fell from 181 per 100 000 in 1950 to 2000 can expect to live almost a year longer than the 61 per 100 000 in 2000. For all cancers combined, age- average man turning 65 years old in 1990. This is a adjusted mortality rates rose through 1990 but then remarkable change in a very short period of time. began to drop significantly. Turning to infectious