Beyond Trauma‐Focused Psychiatric Epidemiology: Bridging Research and Practice With War‐Affected Populations

Article (PDF Available)inAmerican Journal of Orthopsychiatry 76(4):409 - 422 · September 2006with81 Reads
DOI: 10.1037/0002-9432.76.4.409 · Source: PubMed
Abstract
This article examines the centrality of trauma-focused psychiatric epidemiology (TFPE) in research with war-affected populations. The authors question the utility of the dominant focus on posttraumatic stress disorder and other disorders of Western psychiatry, and they identify a set of critical research foci related to mental health work with communities affected by political violence. Core assumptions of TFPE and its roots in logical positivism and the biomedical model of contemporary psychiatry are explored. The authors suggest that an alternative framework—social constructivism—can serve as a bridge between researchers and practitioners by helping to refocus research efforts in ways that are conceptually and methodologically more attuned to the needs of war-affected communities and those working to address their mental health needs.
CE/CME
Beyond Trauma-Focused Psychiatric Epidemiology: Bridging Research
and Practice With War-Affected Populations
Kenneth E. Miller, PhD
Pomona College
Madhur Kulkarni, MS
University of Michigan
Hallie Kushner, MA
University of Chicago
This article examines the centrality of trauma-focused psychiatric epidemiology (TFPE) in research with
war-affected populations. The authors question the utility of the dominant focus on posttraumatic stress
disorder and other disorders of Western psychiatry, and they identify a set of critical research foci related
to mental health work with communities affected by political violence. Core assumptions of TFPE and
its roots in logical positivism and the biomedical model of contemporary psychiatry are explored. The
authors suggest that an alternative framework—social constructivism—can serve as a bridge between
researchers and practitioners by helping to refocus research efforts in ways that are conceptually and
methodologically more attuned to the needs of war-affected communities and those working to address
their mental health needs.
Keywords: PTSD, war, refugees, violence, mental health
The past 25 years have witnessed a remarkable increase in
research on the mental health effects of political violence and
forced migration. This surge of interest began in the 1980s, with
studies documenting the prevalence of psychiatric disorders
among Southeast Asian refugees who had fled their homelands in
the wake of the Vietnam War and the Cambodian genocide (Fels-
man et al., 1990; Harding & Looney, 1977; Kinzie et al., 1986).
Other conflicts heightened the growing interest in the pathogenic
nature of war and other forms of organized violence. Such con-
flicts included, for example, the “dirty wars” of Chile, Argentina,
Guatemala, and El Salvador (Aron, Corne, Fursland, & Zelwer,
1991; Bowen, Carscadden, Beighle, & Fleming, 1992; CODEPU
[Corporation for the Promotion and Defense of Human Rights of
the People], 1989; Padilla & Comas-Diaz, 1987); civil wars in
Lebanon, Sri Lanka, and the Sudan (Baron, 2002; Bryce et al.,
1989; Somasundaram, 1996); ethnic cleansing and genocide in
Bosnia and Rwanda (de Jong et al., 2001; Weine et al., 1998); and
the Israeli occupation and Palestinian intifadas in Gaza and the
West Bank (Punama¨ki, 1989).
We have accumulated by now a substantial body of literature on
the mental health of refugees and other war-affected populations;
in fact, a literature search conducted for this article identified over
a thousand empirical studies, book chapters, and clinical reports
that focused specifically on this topic. It is not our purpose here to
review that extensive body of research and clinical observation.
Although partial in scope, several published reviews collectively
bring together much of what is known about the mental health
problems experienced by survivors of political violence and forced
migration (Boothby, 1996; de Jong, 2002; Miller & Rasco, 2004;
van der Veer, 1998). As those reviews make clear, important
strides have been made in documenting the ways in which expo-
sure to organized violence significantly increases the risk of both
acute and enduring psychological distress.
Despite these critical first steps toward documenting the impact
of armed conflict, however, we believe that a problematic gap has
emerged between research and practice with survivors of war and
other forms of political violence. More specifically, we are con-
cerned that research with war-affected populations has too often
failed to provide practitioners with the sort of useful information
that could support the development of culturally appropriate, em-
pirically sound mental health interventions. Although notable ex-
ceptions exist (and are discussed later), the modal study in this
field is focused on assessing the prevalence of psychiatric symp-
tomatology, primarily symptoms of posttraumatic stress disorder
(PTSD), and to a lesser extent, other disorders of Western psychi-
atry. We suggest that this approach, referred to here as trauma-
focused psychiatric epidemiology (TFPE), is of limited value to
community-based mental health and psychosocial organizations,
which are concerned with a number of pressing questions that go
well beyond the prevalence of PTSD symptoms in the communi-
ties they serve.
These organizations need to know about local idioms of dis-
tress—the particular ways in which psychological distress is ex-
perienced, expressed, and understood in specific cultural contexts.
They need to understand culturally specific patterns of help-
seeking behavior and traditional ways of coping with emotional
Kenneth E. Miller, PhD, Psychology Department, Pomona College;
Madhur Kulkarni, MS, University of Michigan; Hallie Kushner, MA,
University of Chicago.
The authors wish to thank Lisa Rasco and Clark McCain for their
helpful comments on an earlier version of this article.
For reprints and correspondence: Kenneth E. Miller, PhD, Psychology
Department, Pomona College, 550 Harvard Avenue, Claremont, CA
91711. E-mail: ken.miller@pomona.edu
American Journal of Orthopsychiatry Copyright 2006 by the American Psychological Association
2006, Vol. 76, No. 4, 409 422 0002-9432/06/$12.00 DOI: 10.1037/0002-9432.76.4.409
409
distress and impaired functioning and to be able to identify locally
available resources within communities that can promote healing
and adaptation. They also need to learn about the mental health
problems and psychosocial stressors that community members
identify as most salient and about the impact that other forms of
violence (e.g., the structural violence of poverty, institutionalized
racism, gender-based discrimination, and the acute violence of
spouse and child abuse) may have on mental health in contexts of
political violence and forced migration. They need to understand
how healthy and impaired psychosocial functioning are defined
locally and how these definitions vary by factors such as age,
gender, ethnicity, and marital status. Finally, they need to know
what sorts of interventions have been shown to be effective in
similar settings, so that they can adapt elements of those interven-
tions rather than continually reinvent the wheel or rely on pro-
grams that may have intuitive appeal but lack empirical support.
It is curious that such a broad range of critical issues has received
comparatively little attention in the research literature despite more
than 25 years of scholarship on the mental health of communities
affected by organized violence. To understand this phenomenon, it is
helpful to consider the pervasive influence of TFPE on the conduct of
research in this area. TFPE, with its roots in the biomedical model of
psychiatry and the increasingly popular field of traumatology, has
shaped the agenda for research with survivors of political violence in
profound, although seldom acknowledged, ways. It has defined the
appropriate focus of empirical study (i.e., the prevalence and corre-
lates of PTSD and related psychiatric syndromes) and has legitimized
a particular set of methodologies for carrying out research (i.e.,
quantitative methods using symptom checklists or structured clinical
interviews). Consistent with its biomedical roots, it has defined the
individual as the appropriate unit of analysis; thus, we see few studies
examining the impact of political violence on social systems such as
families, communities, and communal institutions. Reflecting its
strongly positivist underpinnings, the TFPE framework has prioritized
the identification of universal patterns of distress, emphasizing find-
ings that can be generalized across diverse settings (e.g., PTSD as a
universal human response to traumatic events) while minimizing the
exploration of local variations in the ways that people understand,
react to, and are affected by their experiences of violence and
displacement.
It is not our contention that psychiatric epidemiology and trau-
matology have no roles to play in research with war-affected
populations. As we discuss later, psychiatric epidemiology, where
conceptually and methodologically appropriate, can play a critical
role in documenting the mental health problems and associated
risk and protective factors within a population. Also, the study of
trauma certainly has a role in research with communities that have
survived the terrifying events that organized violence entails. Our
concern is with the way in which these two fields have combined
so as to unnecessarily narrow the both the focus and methods of
research on mental health and psychosocial well-being in conflict
and postconflict settings (and with refugees in settings of resettle-
ment), to the point where several critical areas of inquiry—all
highly germane to the work of practitioners—have been largely
overlooked.
In emphasizing the lack of attention to a number of clinically
salient issues affecting war-affected communities, we are mindful
of wanting to avoid painting too broad a stroke by overlooking
important exceptions to the trend of TFPE-influenced research. We
recognize that a nascent trend has emerged among researchers who
have begun to critique the dominance of TFPE (Buitrago Cuella`r,
2004; Jenkins, 2004; Kagee & Naidoo, 2004; Phan, Steel, &
Silove, 2004; Summerfield, 1995, 1999; Wessells & Monteiro,
2004). They are questioning the presumed universality and cultural
relevance of PTSD as a response to traumatic stress and are
drawing attention to culturally specific syndromes of trauma-
related distress. They are also asking whether the current focus on
the traumatic sequelae of previously experienced war-related vio-
lence may cause us to inadvertently overlook ongoing stressors
that exert a significant influence on people’s mental health
(Breslau, 2004; Dawes & Donald, 1994; Miller et al., 2006a;
Silove, 1999). Paralleling these critiques—and in response to
them—a growing number of researchers are broadening their em-
pirical focus, moving beyond a narrow focus on PTSD to examine
a broader range of questions, and making use of an increasingly
diverse range of methods in their research. A second aim of this
article, therefore, is to highlight some of the important work being
done outside of the TFPE framework.
To date, however, efforts at transcending the limitations of the
TFPE framework have had a limited impact on the popularity of
that framework among researchers working with communities
affected by armed conflict. The assessment of PTSD and its
correlates remains a primary focus of research efforts in this area;
meanwhile, insufficient attention continues to be paid to other
issues of critical concern to practitioners. We believe there is,
therefore, a need to more effectively bridge the currently disparate
worlds of research and practice with communities affected by
political violence. In this article, we propose that an alternative
scientific framework, social constructivism, can serve as such a
bridge by helping to refocus research efforts in ways that are both
conceptually and methodologically more attuned to the needs of
war-affected communities and the organizations working to ad-
dress their mental health needs. It is not our position that all
research with war-affected populations should be guided by a
constructivist perspective; rather, we hope that familiarity with key
constructivist ideas may offer researchers a broader conceptual and
methodological toolbox from which to draw.
We begin by discussing the basic tenets and paradigmatic roots
of TFPE and social constructivism, taking care to note the poten-
tially useful roles that epidemiology and the study of trauma can
play when utilized appropriately. We also consider the historical
context in which the study of PTSD came to be prioritized in
research with survivors of political violence. We then examine
specific limitations of the TFPE model as a framework for research
with populations affected by armed conflict. Finally, we examine
several core areas of inquiry that are particularly relevant to
practitioners yet have received comparatively little attention in the
literature thus far. Case examples from our own research and
clinical experience are used to illustrate these core issues; in
addition, we present constructivist approaches to each area of
inquiry, using exemplars drawn from the small but growing num-
ber of studies that have been informed by a constructivist
perspective.
TFPE
TFPE is itself neither a scientific paradigm nor a formally
recognized field of study. Rather, it represents an integration of
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MILLER, KULKARNI, AND KUSHNER
two fields: (a) psychiatric epidemiology—the study of the preva-
lence, correlates, and causes of psychiatric disorders within a
population; and (b) traumatology—the study of psychological
trauma. Each of these fields has its own set of conceptual and
methodological priorities, yet both share a common set of para-
digmatic roots in the biomedical model of contemporary psychi-
atry, and more fundamentally, in the scientific framework of
logical positivism. To understand the influence of TFPE on re-
search with war-affected populations, it is therefore helpful to
consider not only the basic tenets of each field but also the
influence on both fields of the biomedical perspective and the
basic axioms of logical positivism regarding the nature and pur-
pose of scientific inquiry.
Logical Positivism
Logical positivism is the dominant scientific framework
within which research in the behavioral and social sciences has
been conducted for over 400 years (Gergen, 2001; Guba &
Lincoln, 1994). The primary purpose of positivist science is to
discover the nature of reality and to identify those universal
laws by which it is governed. Applied to the behavioral and
social sciences, positivist research aims to discover the under-
lying laws that govern and explain human behavior (Guba &
Lincoln, 1994). With regard to method, positivism emphasizes
deductive, hypothesis-driven research in which the truthfulness
of a priori assumptions is tested through experimental designs
that control (to the extent possible) for confounding influences.
The prescribed stance of the scientist is one of neutrality and
objectivity, in order to minimize the impact of investigator bias
on the research process. Legitimate research methods are pri-
marily quantitative, although there is a growing recognition that
qualitative methods may play a useful role within positivist
inquiry (Banyard & Miller, 1998; de Jong & van Ommeren,
2002; Dumka, Gonzales, Wood, & Formoso, 1998).
The Biomedical Model of Contemporary Psychiatry
The positivist influence on contemporary psychiatry and related
disciplines is evident in both the aims and methods of psychiatric
research, which prioritizes the use of hypothesis-driven designs
utilizing quantitative methods in the search for universal patterns
of psychiatric disorder and their underlying causal mechanisms.
Since its inception as a discipline in the mid-1800s, psychiatry has
been guided primarily by a biomedical model that emphasizes the
study of psychopathology in terms of dysfunctional or abnormal
intrapersonal processes and structures (Cohen, 1993).
1
Although
the biomedical model clearly specifies the individual as the critical
unit of analysis, factors external to the individual may be relevant
to the extent that they affect core intrapersonal processes. The
model implies an essentialist conceptualization of psychological
distress: Although the social context may exert some influence on
the expression of psychiatric disorders, the same underlying mech-
anisms are assumed to be at work within individuals across con-
texts, and careful assessment should be able to identify roughly the
same core patterns of psychiatric symptomatology largely inde-
pendent of the social context.
Psychiatric Epidemiology and Traumatology
The field of psychiatric epidemiology is a natural extension of
biomedically oriented clinical research. It entails assessing the
prevalence of psychiatric disorders within a given population, as
well as risk and protective factors for those disorders. Psychiatric
epidemiology may be viewed as a form of needs assessment,
providing practitioners with data that allow for the development of
mental health interventions tailored to the specific needs, vulner-
abilities, and resources of a particular population. For epidemio-
logical studies of mental health disorders to be useful, however,
they must assess categories of disorder that are empirically valid
and culturally meaningful; ideally, they should also assess prob-
lems that are of primary concern to community members. It is,
unfortunately, precisely on these two points that psychiatric epi-
demiology with war-affected populations has been problematic.
The emphasis has been on assessing the prevalence of Western
diagnostic categories without first examining the construct validity
of those categories, the degree to which they are culturally mean-
ingful, or the extent to which they are viewed as mental health
priorities by community members. It is critical to bear in mind that
the great majority of war-affected populations live in (or have been
displaced from) non-Western societies with highly diverse cos-
mologies. Here we see the essentialism of the biomedical model
and its positivist underpinnings—the a priori assumption of the
universal validity and cross-cultural salience of Western psychiat-
ric diagnoses.
Moreover, we see the powerful influence of the rapidly growing
field of traumatology, with its emphasis on the study of PTSD. To
understand the genesis of the assumption that PTSD should be the
primary focus of research with war-affected populations, it is
helpful to bear in mind the zeitgeist within Western psychiatry
during the early 1980s, when clinicians and researchers in the
industrialized nations were confronted by a massive influx of
refugees from Southeast Asia and Latin America (Haines, 1997;
Holtzman & Bornemann, 1990). The American Psychiatric Asso-
ciation had recently incorporated the newly developed diagnosis of
PTSD into the third edition of its Diagnostic and Statistical Man-
ual of Mental Disorders (DSM–III; American Psychiatric Associ-
ation, 1980), and there was considerable enthusiasm for exploring
the utility of the diagnosis among victims of a diverse range of
potentially traumatic events (e.g., child abuse, rape, violent crime,
natural disasters). Although the PTSD construct was originally
developed on the basis of research and clinical experience with
American veterans of the Vietnam War, the diagnostic criteria
stated clearly that the same constellation of symptoms could be
expected to appear among survivors of any event that was suffi-
ciently terrifying.
For researchers interested in the mental health of recently ar-
rived refugees, whose histories were replete with exposure to
frightening experiences of violence, the PTSD construct was un-
1
Clinical psychology has expanded the biomedical focus to include
psychological as well as biological factors as underlying causes of mental
disorder; however, it has generally retained the focus on factors internal to
the individual (e.g., internal conflicts, maladaptive working models of
attachment, and distorted cognitions). Therefore, we refer collectively to
psychiatry and clinical psychology when discussing psychiatric research
and the biomedical model.
411
TFPE AND WAR-AFFECTED POPULATIONS
derstandably compelling. Grounded firmly in the acultural essen-
tialism of the biomedical model, PTSD was presumed to represent
a universal response to traumatic events. Thus, there was no need
to examine local idioms of trauma-related distress among cultur-
ally diverse refugees, as the human response to traumatic stress
was assumed to be universal. It is noteworthy, however, that this
focus on PTSD among refugees quickly became predominant
specifically within the mental health disciplines (psychiatry, clin-
ical psychology, and clinical social work) where the influence of
the biomedical model was most evident; in contrast, among re-
searchers studying refugee well-being from the vantage of other
disciplines (e.g., medical anthropology, sociology), more contex-
tually grounded views of mental health and the effects of war-
related violence were evident (e.g., Farias, 1994; Hitchcox, 1990;
Manz, 1988).
Any critique of the cross-cultural validity and utility of the
PTSD construct must take into account the reality that symptoms
of PTSD, as well as the full syndrome, have in fact been docu-
mented—although with marked variability—in numerous studies
of war-affected populations (e.g., de Jong et al., 2001; Kinzie et al.,
1986; Weine et al., 1998). There can be little doubt at this point
that elements of the PTSD diagnosis—particularly symptoms en-
tailing the intrusive re-experiencing of traumatic events (e.g.,
nightmares, flashbacks, intrusive images) and symptoms of hyper-
arousal (e.g., heightened startle response, sleep disturbances)—are
found in diverse cultural contexts (Marsella, Friedman, & Spain,
1996). Moreover, there is growing evidence, based primarily on
research with American war veterans, of numerous psychophysi-
ological changes associated with the experience of psychological
trauma (e.g., reduced cortisol levels, increased opiod response to
trauma-associated stimuli; van der Kolk, 1996). Although these
data do not permit generalization across cultural contexts, there is
no reason to assume that trauma-related psychophysiological al-
terations would not also be found among non-Western trauma
survivors.
However, findings suggesting the cross-cultural occurrence
of PTSD symptoms must be interpreted cautiously for several
reasons. First, leading trauma researchers—including those
with a strong grounding in the psychophysiology of trauma
responses— have cautioned that the 17 items that constitute the
PTSD diagnosis fail to capture to the complexity and variability
that characterize the ways in which people are affected by
traumatic experiences (Briere, 1998; Marsella et al., 1996; van
der Kolk & McFarlane, 1996). Although evidence suggests that
reactions to traumatic stress include certain psychophysiologi-
cal correlates that may transcend cultural context, there is a
growing recognition that cultures exert a powerful influence on
the ways in which underlying psychopathology is expressed and
experienced (van der Kolk & McFarlane, 1996). As Briere
(1998) has noted, expressions of trauma-related psychopathol-
ogy that differ significantly from PTSD have been documented
in numerous cultural contexts. Jenkins (1996) and Farias
(1994), for example, have described the salience of calor and
nervios among Salvadoran refugees, indigenous idioms of dis-
tress clearly linked to the experience of traumatic events that
entail a combination of somatic and emotional symptoms that
overlap only moderately with PTSD.
Findings of PTSD among survivors of political violence must
also be tempered by a consideration of what Kleinman (1987) has
termed the category fallacy, which involves the erroneous assump-
tion that a diagnostic category developed in one cultural context is
meaningful in a different cultural context simply because the
symptoms that comprise it can be identified in both settings.
Cultural variations in the experience and expression of trauma are
very unlikely to be identified if one assesses only those symptoms
that are assumed a priori to comprise the trauma response. Al-
though symptoms of PTSD, and indeed the full syndrome, may be
found in a given culture, we cannot assume that the diagnosis has
the same meaning or salience as it does in the West; nor can we
can we presume to know how traumatic stress is understood and
experienced in that culture simply because people endorse items
on a measure of PTSD.
For example, one can readily identify symptoms of PTSD
among indigenous Guatemalans (Aron et al., 1989; Light,
1992); however, rural Guatemalans are more likely to under-
stand war-related distress in terms of susto and the aforemen-
tioned nervios, indigenous idioms of distress that share some
symptomatic overlap with PTSD, yet are also distinct from it
(Guarnaccia & Farias, 1988; Miller, 1994; Zur, 1996). Simi-
larly, in Afghanistan, people will generally report symptoms of
PTSD when asked specifically about them (Lopes Cardozo et
al., 2004; Malekzai et al., 1996); however, the construct has
little meaning within Afghan culture, and Afghans—who have
survived more than 23 years of war and repression—are much
more likely to describe their war-related distress in terms of
jigar khun (dysphoria associated with experiences of loss and
other hardships), asabi (a combination of nervousness and
anger), and fisha-e-bala (feeling highly pressured or stressed)
than PTSD (Miller et al., 2006).
Finally, regardless of how psychological trauma is concep-
tualized, there is reason to question its assumed primacy as a
mental health concern within war-affected communities. In the
small number of studies that have allowed survivors of political
violence to voice their own mental health priorities, numerous
other concerns have been identified as being more urgent than
symptoms of trauma. Such concerns include impaired psycho-
social functioning, family conflict, sadness and isolation result-
ing from the loss of social networks, spouse abuse, distress
related to the experience of poverty and the inability to provide
for one’s family, psychosis, substance abuse, sadness due to
separation from loved ones, grief associated with the death or
disappearance of family members, and distress regarding the
lack of opportunity to engage in culturally important rituals of
bereavement (Bracken et al., 1995; de Jong, 2002; Englund,
1998; Miller et al., 2002; Summerfield, 1999). It is interesting,
however, that when researchers are queried regarding the men-
tal health priorities of war-affected communities, they often
assume, incorrectly, that trauma related to political violence is
the most urgent problem (see de Jong, 2002, for an excellent
discussion of this phenomenon); consequently, the study of
PTSD is prioritized while other problems of equal or greater
concern to community members are inadvertently overlooked.
An Alternative Framework: Social Constructivism
Social constructivism is one of several “critical theories” (Ger-
gen, 1985; Guba & Lincoln, 1994) that have gained popularity
during the past few decades. In contrast to logical positivism, with
412
MILLER, KULKARNI, AND KUSHNER
its emphasis on knowing the way things “really are,” constructiv-
ism emphasizes the socially constructed nature of reality; it shifts
attention away from the search for universal truths and toward an
exploration of what is considered real within particular social
contexts. This does not negate the value of examining the way
similar phenomena may occur across diverse settings, but it does
represent a genuine shift toward understanding how people in
particular cultural contexts understand their world. With specific
regard to mental health, a constructivist perspective eschews the
search for universally valid definitions of mental health and dis-
order, focusing instead on exploring the variety of ways psycho-
logical well-being and distress are understood and expressed
across and within diverse cultural settings.
There are two key elements to this definition of constructivism
that distinguish it quite clearly from the positivist approach. First,
it suggests a conceptual and methodological shift from an etic
(outsider) to an emic (insider) approach; that is, exploring the ways
in which reality is constructed or understood in specific contexts is
prioritized over examining the universal validity of psychological
phenomena originally identified in a particular cultural context.
This implies a shift toward a greater use of exploratory research
methods that allow for the identification of culturally specific
values, beliefs, and behavioral systems. Hence, we see a much
greater utilization of inductive, qualitative methods in constructiv-
ist research, such as focus groups, narrative analysis, and
ethnography.
However, there is a common misperception that constructivist
inquiry relies exclusively on qualitative methods, and that con-
structivism is essentially synonymous with the ethnographic ap-
proach commonly used by anthropologists. In fact, quantitative
methods can play a critical role in constructivist research, and a
constructivist perspective can inform research that is primarily
quantitative and hypothesis-driven. For example, Miller et al.
(2006b) used narrative data gathered from interviews with 20
residents of Kabul to construct the Afghan Symptom Checklist, a
22-item measure that was subsequently administered to 320 adults
throughout the city. The interview data revealed several categories
of psychological disorder, including those caused by biological
factors (e.g., schizophrenia), those related to spirit possession
(jinns), and those resulting from painful life experiences. The
narrative data also revealed several indigenous indicators of dis-
tress (e.g., jigar khun, asabi, and fishar), as well as symptoms
common to Western psychiatry (e.g., insomnia, crying, lack of
appetite). The survey subsequently confirmed the researchers’
hypothesis that women were at higher risk than men of psycho-
logical distress and impairment and highlighted the particular
vulnerability of widows who had lost their husbands during the
war.
Similar mixed-methods designs using free-listing techniques,
ethnography, and questionnaire-based surveys have been used to
examine psychological distress among refugees from Sierra Leone
in the refugee camps of Guinea (Hubbard & Pearson, 2004),
Vietnamese refugees in Great Britain (Phan, Steel, & Silove,
2004), and psychosocial functioning among survivors of civil war
and genocide in Rwanda and Uganda (Bolton & Tang, 2002).
Interested readers are referred to de Jong and van Ommeren
(2002), who have provided a useful framework for integrating
qualitative and quantitative methods in the development of cultur-
ally grounded psychiatric epidemiology studies with war-affected
populations.
The point, then, is not that one set of methodologies should
be prioritized over another; on the contrary, a diversity of
methods allows us to examine a greater range of research
questions. Our concern here is with the limitations of relying
primarily on etic approaches that inappropriately assume a
universally shared set of meanings regarding important psycho-
social phenomena. The potential hazards of an exclusively etic
approach can be seen in a questionnaire-based study of delin-
quency and social integration among Palestinian youth in Gaza
and the West Bank (Barber, 2001). The study was unique in its
emphasis on development and adaptation among adolescents in
a conflict zone. However, rather than starting by exploring the
ways in which delinquent behavior is understood and expressed
locally, Barber used a four-item delinquency measure contain-
ing items such as cigarette smoking that have been associated
with delinquency among youth in the United States. The use of
North American criteria for delinquency ignores some rather
critical questions: What does smoking mean to Palestinian
youth living under the Israeli occupation? Does it reflect delin-
quency, or is it a normative behavior? How is delinquency itself
defined in a context where “normal” behavior (e.g., secretly
attending classes when education has been banned) is criminal-
ized and criminal behavior is legitimized by the corruption of
the local authorities and the frequent violation of civil and
human rights by the occupying power? Inductive methods are
essential precisely because they allow community members to
inform us about the meaning and indicators of core constructs
(e.g., delinquency) in particular social contexts. By failing to
attend to such local variations in the understanding and expres-
sion of psychosocial phenomena, we risk imposing our own
cultural definitions on these phenomena, thereby potentially
undermining the validity of our findings.
The second key point in the definition of constructivism offered
above is the explicit emphasis on human agency in the creation of
meaning and on the centrality of the meaning-making process in
mediating our responses to life experiences. This emphasis on the
social construction of meaning, and on the active way in which we
make sense of life events, has gained recognition among research-
ers in a number of areas, including research on stress and coping
(Lazarus & Folkman, 1984). Interest in appraisals reflects the
recognition that human beings do not respond automatically or
reflexively to challenging life experiences, including experiences
of organized violence (Dawes, 1990).
This point has significant implications for our how we view the
stressors associated with organized violence and their impact on
the human psyche. Implicit in much of the PTSD literature, in-
cluding the literature on political violence, is a fairly mechanistic
conceptualization of how people are affected by their exposure to
organized violence. Researchers measure exposure to stressful
events and assess their association with levels of PTSD symptom-
atology, implying (within the constraints imposed by correlational
designs) a direct causal relationship. It is important to note, how-
ever, that the strength of this association has varied markedly
across studies, suggesting that (a) many people exposed to orga-
nized violence do not develop elevated or enduring levels of PTSD
symptoms, and (b) a variety of factors likely moderate and mediate
413
TFPE AND WAR-AFFECTED POPULATIONS
the relationship between exposure to violence and the development
of trauma symptoms.
Although several recent studies with war-affected communities
have examined the stress-moderating role of environmental factors
such as instrumental and affective social support (e.g., Gorst-
Unsworth & Goldenberg, 1998), to date little attention has been
paid to the role of individual appraisals and socially shared belief
systems in protecting people from (or leaving them more vulner-
able to) the adverse effects of political violence.
2
A constructivist
perspective redirects our attention to this meaning-making process
and its potentially powerful role in shaping responses, including
the development of PTSD, to experiences of violence and forced
migration. Also, because constructivism emphasizes the inherently
interpersonal origins of individual appraisals, our attention is
drawn to the study of shared belief systems within communities
and their expression in the individual appraisal process.
Finally, constructivism emphasizes the fundamentally interper-
sonal nature of the research relationship and suggests that data
invariably reflect the quality of that relationship. Efforts to gather
valid data are framed within an understanding that research par-
ticipants are not rats in a Skinner box, reflexively completing
symptom checklists without critical reflection on the purpose of
the research or the perceived intentions of the researchers. We
gather data within a relational context, which itself is embedded
within the larger social context of the community where the
research takes place. A constructivist perspective considers the
influence of these multiple contexts on the data gathering process.
Anthropologist Patricia Omidian, in her work with Afghan refu-
gees in Northern California, noted that women in the community
initially presented as happy and well-adjusted to their new envi-
ronment; however, when she was able to gain their trust over a
period of time, they often revealed a deep, hidden grief at all they
had left behind and the enormous challenges of creating meaning-
ful lives in exile (Omidian, 1996). Clearly, the social context may
exert a significant effect on which aspects of their realities people
choose to share with us and which aspects they keep hidden
(Miller, 2004).
Having presented the basic tenets of trauma-focused psychiatric
epidemiology and its underlying biomedical and positivist roots, as
well as several key elements of an alternative scientific frame-
work—social constructivism—we turn now to an examination of
several domains of inquiry that have been comparatively neglected
in research with war-affected populations. The set of issues pre-
sented here is meant to be illustrative rather than exhaustive; we
have sought to prioritize topics of particular relevance to practi-
tioners working in the field. To illustrate each issue, we provide
vignettes drawn from our research and clinical work with war-
affected communities in Afghanistan, Mexico, and Guatemala, and
with Bosnian and Afghan refugees in the United States. We also
draw on the exemplary work of the growing number of individuals
whose research has been informed by a constructivist perspective.
Some Critical Areas of Inquiry With War-Affected
Populations
1. Examining Local Idioms of Distress
The experience of emotional distress occurs within specific
cultural contexts that shape the ways in which suffering is expe-
rienced, expressed, and understood (Rogler, 1989). As suggested
earlier, however, the essentialism of the biomedical model has led
researchers to presume that core elements of psychopathology are
expressed in similar ways across cultures, thereby legitimizing the
emphasis on Western psychiatric constructs such as PTSD, regard-
less of the cultural context. Unfortunately, this approach is of
limited value to practitioners who work in communities where the
PTSD construct and other disorders of Western psychiatry are
either unfamiliar or simply less salient than local idioms of dis-
tress. To communicate effectively and intervene appropriately,
practitioners must be familiar with locally meaningful mental
health constructs and culturally salient explanatory models of
suffering. Distress may be understood in spiritual or religious
terms and may be expressed in psychosomatic syndromes unfa-
miliar to Western clinicians. Moreover, symptoms of PTSD may
be present, but they may less salient than other manifestations of
distress.
Case 1: Jigar Khun in Afghanistan
Samed Khan was a member of our research team during a recent
study of mental health in Kabul (Miller et al., 2006b). An elected
leader of his community, Samed is a large, powerful man of 45
years, with a long beard, a turban, and a warm, infectious laugh,
and he is the patriarch of a large family on the outskirts of Kabul.
During one of our research team meetings, he told the following
story. One day during the war against the Soviet Union, he was
driving a small truck carrying his sister and her family along a
steep, windy mountain road. At a military roadblock, mujahedin
commanders forced the truck to stop and asked Samed to get out
of the truck and show his papers. In his haste to comply, he forgot
to set the hand brake and watched in horror as the truck rolled over
the side of a cliff and crashed hundreds of feet below. Everyone in
the truck was killed, their bodies mangled in the wreckage of the
truck. Samed Khan collected the remains of his sister’s family and
brought them back to Kabul for burial. He described becoming
jigar khun (literally “bloody liver,” or melancholic) for about 6
months, during which he was socially withdrawn, felt deeply sad,
and struggled with feelings of hopelessness. Eventually, however,
he made a decision to reengage with life, feeling that God had
given him the resources to cope—inner strength, a supportive
family, and patience (saber) in the knowledge that he could not
know God’s will. When asked about symptoms of PTSD, he said
that he initially experienced some intrusive imagery related to the
accident but added that “the images fade, they don’t last long. We
Afghans, we stop remembering the images after a while; it’s the
jigar khun that stays with you, sometimes forever.” The other
members of the research team, all of whom had lived through the
war, lost family members to the violence, and endured the destruc-
tion of their neighborhoods, nodded in agreement.
2
Important exceptions include the work of Victor Frankl (1963), a
survivor of the Auschwitz concentration camp, who noted the protective
function of religious faith among Jewish camp inmates; the work of South
African psychologists who have documented the stress-buffering capacity
of shared ideological conviction among Black youth detained and tortured
by the authorities (Dawes, 1990); and the work of Punama¨ki (1989), who
noted lower levels of distress among Palestinian women who reported
deeply held political beliefs.
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MILLER, KULKARNI, AND KUSHNER
An assessment of PTSD following Samed Khan’s accident
would likely have revealed various symptoms of psychological
trauma. However, it was the experience of jigar khun that he
focused on, describing his PTSD symptoms as comparatively
transient and of secondary concern. The agreement of the other
Afghans who were present while Samed Khan related his experi-
ence, all of whom had suffered traumatic stress during the war,
suggests the greater cultural salience of jigar khun relative to
PTSD as an expression of war-related distress in Afghanistan.
These initial observations were subsequently borne out in the
previously cited research by Miller et al. (2006a, 2006b), in which
PTSD symptoms were less salient than other forms of distress in
detailed narratives of war-related suffering and in two
questionnaire-based surveys of mental health among adults in
Kabul.
These findings have important implications for practitioners:
Afghans are more likely to engage in mental health interventions
when they address culturally salient idioms of distress such as
jigar khun than when they target symptoms that are of secondary
concern. This does not mean that symptoms of trauma should not
be addressed among Afghans but that a primary focus on healing
PTSD is likely to be perceived as out of sync with people’s actual
priorities.
As noted earlier, exploring the nature and salience of local
idioms of distress initially entails the use of qualitative methods
such as free-listing techniques, participant observation, semistruc-
tured interviews, and focus groups that generate descriptions and
explanations of common forms of distress and impairment. Once
these indicators of distress are identified, culturally grounded
assessment tools can be created for use in population surveys and
mental health screening; in addition, a variety of methods may be
used to identify clusters of related symptoms (e.g., pile sorts, factor
analysis), permitting comparison of indigenous syndromes with
western diagnostic constructs.
2. Identifying Local Mental Health Concerns and
Priorities
We have already discussed the seeming mismatch between the
current emphasis on PTSD in the literature and the actual mental
health concerns of war-affected communities. As suggested ear-
lier, this lack of fit does not negate the potential value of studying
trauma, but it does underscore the importance of broadening our
scope to ensure that we are examining those problems that com-
munity members themselves perceive as most pressing. Mental
health services are far more likely to be perceived as relevant when
they target priorities that communities themselves have articulated.
With its explicit emphasis on prior exposure to traumatic events,
the assessment of PTSD directs our attention to past experiences
and their traumatic sequelae. We are not questioning the impor-
tance of focusing on the impact of war-related violence; clearly,
such a focus is justified by the distressing nature of such violence
and its etiological link to emotional suffering and psychosocial
disability. There is, however, a growing recognition that a consid-
erable amount of the variance in reported distress within war-
affected communities is related not to violence experienced in the
past but to ongoing stressors in people’s day-to-day lives (Gorst-
Unsworth & Goldenberg, 1998; Miller et al., 2006a; Silove, 1999).
In our experience, survivors of political violence, particularly
when displaced from their homes and communities, are often more
concerned about such daily stressors as social isolation, a lack of
basic resources, difficulties negotiating their new environment,
and separation from loved ones.
For example, during interviews we conducted with Guatemalan
women in refugee camps in southern Mexico, the women readily
acknowledged having recurrent nightmares of the violence they
had experienced in Guatemala; however, they were generally more
distressed by the poverty that prevented them from providing for
their children’s basic nutritional and medical needs and, for those
who had left family members behind in Guatemala, a painful sense
of social isolation and loss of social support (Miller & Billings,
1994). Guatemalan refugees were not allowed to own land in
Mexico, leaving them impoverished and dependent on outside
food and medical assistance—both of which were scarce in the
camps. One woman, the mother of six children, described her
poverty-related distress in this way:
I want to work and plant crops and we can’t. How are we going to eat?
I feel sad because of our poverty. Sometimes I’d rather die because I
can’t work. I can’t buy medicine. I can’t earn money to buy medicine
(Miller & Rasco, 2004, p. 20).
Another woman, who had been separated from her family when
she went into exile, struggled with intense feelings of loneliness
and their impact on her daily functioning:
I have difficulty doing my work in the home because of desperation.
I have no one to talk with. I am lonely. I cry when I am alone in my
house. I don’t have parents or siblings who help me and visit me.
(Miller & Rasco, 2004, p. 20).
Similar concerns about poverty, isolation, and other
displacement-related stressors were mentioned frequently during
interviews we conducted with Bosnian refugees living in Chicago
(Miller et al., 2002; Miller & Rasco, 2004) and with Afghan
refugees living in northern California (Zahir, Kakar, & Miller,
2001). Such concerns underscore the importance of mental health
interventions that transcend a narrow focus on PTSD by focusing
not only on the resolution of psychological trauma but also on
fostering new social support networks, enhancing access to critical
resources, and promoting the development of locally relevant skills
and knowledge (Hubbard & Pearson, 2004; Tribe et al., 2004).
Another largely unexamined mental health concern among
women in war-affected communities is spouse abuse. Despite
anecdotal evidence suggesting the epidemic nature of domestic
violence in many low-income countries affected by political vio-
lence (Desjarlais, Eisenberg, Good, & Kleinman, 1995), few em-
pirical studies have assessed the contribution of spouse abuse to
the high levels of distress so often documented among war-
affected communities. In focusing so heavily on the traumatic
impact of previously experienced war-related violence, we may be
overlooking the highly distressing nature of the ongoing violence
occurring within people’s own homes. In our experience with
victims of spouse abuse in diverse war-affected communities,
war-related violence in the past may seem of secondary impor-
tance relative to their ongoing experience of victimization. Fur-
thermore, for refugee women who do not speak the language of
their host society and who are isolated from the support of family
members, the experience of abuse may transform their home into
a prison from which escape seems all but impossible.
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TFPE AND WAR-AFFECTED POPULATIONS
Case 2: Spouse Abuse of a Bosnian Refugee Woman and
Her Daughter in the United States
Mrs. K, a 45-year-old Bosnian Muslim, was a client at a refugee
mental health clinic in the United States where the first author
worked as a clinician. Mrs. K, who spoke no English and had no
other family in the United States, was being seen for depression
and PTSD by a Bosnian paraprofessional counselor. She was
always accompanied to the clinic by her husband, who would wait
anxiously while his wife was being seen. Although there was some
suspicion of spouse abuse by her husband, Mrs. K. denied being
abused, and the primary focus of treatment was on the traumatic
experiences Mrs. K had endured during the war in Bosnia. One
week she did not attend her counseling session, and we learned that
she had been hospitalized for a brief psychotic reaction at a nearby
community hospital. When we interviewed her in the hospital, we
found no evidence of psychosis; however, Mrs. K. was highly
agitated and anxious, crying heavily, and worried about her 5-year-
old daughter, who was at home with her husband. We asked what
had happened and she initially grew silent. However, when she
was asked whether her husband had beaten her, she became highly
animated, describing a 3-year pattern of imprisonment in her
apartment, during which she was raped daily in front of her
daughter and endured recurrent threats by her husband that she and
her daughter would be killed if they ever tried to leave him. She
described the physical and sexual violence at home as far worse
than the war she had lived through in Bosnia. We arranged for the
police to escort Mrs. K and her daughter to a shelter, where over
a period of several months Mrs. K’s mood and anxiety level
improved markedly, and her daughter, who had been completely
mute, enuretic, and withdrawn, began talking, stopped wetting the
bed, and started playing with other children. As we could not
identify a long-term safety solution for Mrs. K locally (her hus-
band was free within 3 days and could easily have found her in the
city’s small Bosnian community), she decided to return to Bosnia
with her daughter to live with family members there.
Given the severe and adverse impact of spouse abuse on wom-
en’s mental and physical health (Pico-Alfonso, 2005; Sutherland,
Bybee, & Sullivan, 2002), there is a pressing need to examine the
prevalence of domestic violence within war-affected communities.
Beyond the assessment of prevalence, however, it is important
identify the ways in which political violence and forced migration,
together with specific cultural beliefs and practices, may affect the
occurrence of abuse and the types of interventions that are most
likely to be effective in particular sociocultural contexts.
A constructivist perspective suggests the importance of inquir-
ing about the relative salience of different mental health concerns
within particular communities rather than assuming that we al-
ready know the most pressing variables on which to focus our
research and intervention efforts. Englund (1998), for example,
used ethnographic methods to study the psychological difficulties
experienced by Mozambican refugees in Malawi. He found that
their greatest concern was the lack of opportunity— because of
their experience of displacement—to engage in traditional rituals
of burial and bereavement. In contrast to cultures that emphasize
the continuity of relations with deceased ancestors (e.g., Cambo-
dian or Khmer culture), traditional Mozambican culture eschews
such continuity between the living and the dead; consequently,
Mozambicans have developed a variety of rituals meant to ensure
the smooth and complete transition of the spirits of the deceased to
a different realm. The inability to enact those rituals thus became
an ongoing source of acute psychological distress.
Studies of refugee children, like those of adults, have generally
shared a similar focus on the prevalence of PTSD and other
disorders of Western psychiatry (e.g., Arroyo & Eth, 1986; Kinzie
et al., 1986; Mghir & Raskin, 1999). However, it is interesting that,
in the few studies in which parents of war-affected children were
asked to identify their own concerns regarding their children’s
mental health, problems other than psychological trauma were
mentioned. For example, in a recent study of Afghan families in
the capital city of Kabul, de Berry and her colleagues found that
parents were most concerned about the impact of political violence
and displacement on children’s tarbia, or moral development as
reflected in their social behavior (de Berry et al., 2003). They were
also worried about their children’s lack of access to education and
about their becoming sad or worried as a result of other life
stressors such as poverty and experiences of family loss. Similar
concerns were voiced by the children, who also noted that family
violence was a source of significant sadness and worry for them.
3. Understanding the Effects of Organized Violence on
Multiple Levels
Perusing the literature on the psychological effects of organized
violence, one could easily get the impression that violence exerts
its effects primarily or exclusively on individual well-being. This
is untrue, of course, but the focus on individual psychopathology
does reflect the biomedical emphasis on the individual as the
essential unit of analysis. In reality, political violence takes its toll
on every level of society, affecting not only individuals but also
families, communities, and social institutions.
Latin American researchers have been at the forefront of efforts
to address the lack of knowledge regarding the multilevel impact
of organized violence. At the familial level, for example, psychol-
ogists in Chile (CODEPU, 1989) and Mexico (Bottinelli et al.,
1990) have documented the adverse impact of repressive violence
and forced migration on the structure and functioning of nuclear
and extended families. Among their findings are heightened family
conflict as familial roles change in the wake of parental detention
and the premature assumption of adult roles and responsibilities by
young people when a parent is killed or abducted.
At the community and societal levels, researchers in Colombia
and El Salvador have noted that civil war and political repression
generate psychosocial trauma, in which the networks of social
relations and institutions that form the basis of civil society are
shattered. Profound distrust develops within formerly harmonious
communities; animosity and wariness develop toward social insti-
tutions whose original mission to protect social well-being has
been corrupted; and violence is legitimized as an approach to
solving social conflicts (Buitrago Cuella´r, 2004; Martı´n Baro´,
1989).
Other reports have noted (a) the devastating impact of wartime
rape, not only on women and girls, but also on their families and
communities (Aron et al., 1991; Landesman, 2002; Petevi, 1996);
(b) the presence of former child soldiers who must be reintegrated
into the same communities against whom they caused terrible
harm (Boothby, 1990); and (c) in nearly every society affected by
organized violence, the creation of large numbers of widows,
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MILLER, KULKARNI, AND KUSHNER
orphans, and people with disabilities (e.g., land mine victims),
whose survival depends on the availability of scarce community
resources. Finally, ongoing violence may destroy the very social
fabric that binds communities together—the social ties and pat-
terns of interaction that create the basis for a sense of community
and that allow community institutions to function effectively.
The effects of organized violence on levels beyond the individ-
ual are not matters of concern solely to sociologists and political
scientists. On the contrary, they are highly relevant to the work of
mental health practitioners. There is a growing recognition that
individual mental health is intimately linked to the health of the
larger social ecology in which it is embedded (Bronfenbrenner,
1979; Kelly, 1986). To understand the effects of organized vio-
lence solely in terms of psychiatric symptomatology such as PTSD
ignores the social context in which individual distress occurs and
which mediates and moderates the impact of violence on individ-
ual well-being. It also presumes the primacy of individual distress
(i.e., psychiatric symptomatology) as a concern of community
members, when in fact, people may be more concerned about
family conflict or the dissolution of communal ties and social
networks. Furthermore, a narrow focus on individual psychopa-
thology and intrapersonal explanatory variables is likely to suggest
interventions that ameliorate distress by altering internal psycho-
logical factors while failing to address aspects of the social envi-
ronment that could promote healing and adaptation; thus, we see a
reliance on psychotherapy and psychiatric medication stemming
from the emphasis on PTSD and other psychiatric disorders.
In contrast, an ecological analysis is more likely to emphasize
comprehensive interventions that strengthen families and commu-
nities while also working directly to support the recovery of
distressed individuals. Such an approach is premised on the recip-
rocally influencing relationships that are presumed to exist be-
tween individuals and the multiple settings in which they live. That
is, just as healthy individuals are likely to positively influence the
functioning of their families and communities, so too can healthy
communities and well-functioning families facilitate individual
healing and adaptation. From this ecological perspective, there-
fore, mental health interventions with war-affected communities
are ideally multilevel in their focus. An illustrative example can be
found in the work of Corporacio´n AVRE in Colombia (Buitrago
Cuella´r, 2004). On the basis of an ecological analysis of the
psychosocial impact of violence in Colombian society, AVRE staff
developed a diverse array of interventions ranging from individual
and group counseling to social integration programs for displaced
families, conflict resolution programs to mend the rifts in divided
communities, and psychosocial support programs, including occu-
pational therapy, for women widowed by armed conflict.
With its emphasis on understanding how reality is socially
constructed in specific contexts, a constructivist approach encour-
ages us to ask (rather than assume we already know) how com-
munities are affected by their experiences of organized violence
and what their priorities are in terms of mental health and psycho-
social assistance. In any given context, there may be a greater
emphasis on individual trauma, on the difficulties faced by fami-
lies adjusting to the disappearance or death of loved ones, on the
distrust that has arisen within communities where neighbors have
betrayed each other, or on the challenge of integrating former child
soldiers.
4. Understanding Local Patterns of Help-Seeking
Behavior and Identifying Local Resources That Can
Promote Healing and Adaptation
The development of sound mental health interventions requires
an understanding of culturally sanctioned help-seeking behaviors.
It is of limited use to create professionally staffed psychiatric
clinics in communities where emotional distress is generally ame-
liorated by traditional healers or religious leaders and where dis-
cussion of individual and family problems with strangers is
strongly discouraged. Nonetheless, the cornerstone of the mental
health community’s response to war-affected populations has been
the development of mental health clinics offering psychotherapy
and psychopharmacology (Miller, 1999; Summerfield, 1999). This
response, although well-intentioned, is fundamentally ethnocentric
in its presumption that people in distress, regardless of their
cultural background, will seek out (and be helped by) Western
mental health services wherever they are made available. It is also
consistent with the assumptions of the biomedical model of West-
ern psychiatry; for if psychopathology is expressed universally
across diverse cultures and stems from the same underlying causal
mechanisms, then logically the same clinical interventions should
be appropriate, regardless of the cultural background of the af-
fected population.
The study of help-seeking behaviors entails documenting the
sources of assistance to which people turn when they are distressed
and the various conditions under which they use different types of
helping resources. For refugee communities, this may mean iden-
tifying resources that were previously utilized but which have been
disrupted or become unavailable in exile. Such resources may
include religious leaders, as well as traditional healers such as
Kruu Khmer in Cambodia or the spiritually oriented herbalists
known as curanderos who are popular throughout much of Latin
America. Spiritual belief systems, including religious rituals and
physical spaces such as churches, temples, and mosques, may also
play a critical role in helping people cope with distress, and
although Western mental health professionals generally steer clear
of religion, an understanding of local religious beliefs and prac-
tices as resources for healing may be very useful. This is especially
true when working in communities where religious leaders have
traditionally played a primary role in helping community members
cope with stressful life events.
Case 4: Using a Religious Leader to Help With
Complicated Bereavement
Mrs. J, a deeply religious 46-year-old Bosnian Serb refugee
living in a large Midwestern city in the United States, lost her son,
a young man of 20, during the war in Bosnia. She had been
grieving deeply for 5 years when she came to the refugee mental
health clinic at the urging of other family members. She presented
as deeply depressed, with her primary symptoms consisting of an
intensely dysphoric mood, insomnia, a lack of appetite, low mo-
tivation, and anhedonia. In light of the clear link between her
presenting symptoms and the loss of her son, she was diagnosed
with complicated bereavement and was started on antidepressant
medication and weekly supportive counseling. During her coun-
seling sessions, Mrs. J expressed intense feelings of guilt at the
idea of ending her grieving for her lost son and insisted that ending
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TFPE AND WAR-AFFECTED POPULATIONS
her bereavement would dishonor him and make her a bad mother.
No amount of reassurance that she had grieved sufficiently to
honor his memory seemed to lessen her sense of guilt and her
experience of being “stuck” in the grieving process. After several
months of counseling, as well as trials of several antidepressant
medications, her symptoms of unresolved grief had not abated. At
this point, the clinic staff thought that Mrs. J. might benefit from
meeting with a local Serb Orthodox priest, whose influence might
be greater than that of a counselor, even one who shared Mrs. J’s
religion and ethnic background. Unfortunately, the local Bosnian
Serb priest was regarded as a nationalist whose sentiments Mrs. J
did not share, and she declined to meet with him. However, she
agreed to meet with the head of the local Greek Orthodox Church,
who was sympathetic to her experience of war-related loss and her
struggle with the bereavement process. One meeting with this
priest accomplished what months of psychotherapy and medica-
tion had failed to achieve: After hearing the priest’s declaration
that she had grieved long enough for her son and had honored his
memory sufficiently, she finally felt liberated to move on with her
life and emerge from her state of prolonged grief. Her depression
lifted, and she subsequently terminated her individual therapy.
Valuing traditional help-seeking behaviors among war-affected
populations does not mean that mental health interventions must
be wholly consistent with those behaviors or that they must ac-
tively involve religious leaders or traditional healers in their im-
plementation. As Hubbard and Pearson (2004) have noted, the
scope and severity of war-related distress may overwhelm tradi-
tional coping resources and exceed the knowledge and skills of
traditional healers. Nonetheless, an understanding of culturally
specific help-seeking behaviors and coping resources allows for
the development of interventions that fit within the value system of
local communities, even as they introduce culturally unfamiliar
approaches to managing psychological distress. This can be seen in
the approach developed by Jon Hubbard and his colleagues in their
work with Sierra Leoneans in the refugee camps of Guinea (Hub-
bard & Pearson, 2004). The identification of traditional help-
seeking behaviors and healing rituals informed the development of
a trauma-focused intervention that combined Western group ther-
apy techniques and traditional rituals such as cleansing ceremo-
nies. Communal discussion and resolution of social problems was
a culturally accepted practice; consequently, although trauma-
focused group therapy was unfamiliar in the community, the group
discussion format was regarded as sufficiently consistent with
cultural norms to be accepted by community members.
5. Identifying Effective Intervention Strategies
There is a striking paucity of evaluation data regarding the
effectiveness of mental health interventions with war-affected pop-
ulations, whether clinical or community-based. Although there is a
fairly substantial body of published clinical recommendations re-
garding the psychotherapeutic and psychopharmacological treat-
ment of refugees, the empirical basis for such recommendations is
lacking (i.e., there is scant evidence for the effectiveness of the
clinical treatment of psychological distress among refugees). Fur-
thermore, although a few community-based programs have docu-
mented their effectiveness through sound evaluations (e.g., Hub-
bard & Pearson, 2004; Weine et al., 2004), most programs have
limited their efforts to process evaluations, which document levels
of participation and fidelity of implementation but not effective-
ness—the extent to which programs have achieved their intended
goals.
There has also been a tendency for programs that utilize mental
health paraprofessionals, a common approach in conflict and post-
conflict situations, to evaluate the quality of the training experi-
ence (e.g., Was the training well-received? Did participants ac-
quire the desired knowledge and skills?) but not the extent to
which trainees were able to successfully implement their newly
acquired capacities in their home communities. In fact, although
such programs are highly promising, they often face numerous
obstacles to successful implementation (Hubbard & Miller, 2004;
Kostleny & Wessells, 2004).
Case 5: Evaluating Obstacles to Implementing a Mental
Health Program in Guatemala
Working in the highlands of Guatemala, a collaborative team of
psychologists, teachers, and actors adapted an expressive arts-
based mental health intervention for children in war-affected com-
munities developed in Buenos Aires during the “Dirty War” in
Argentina. For a period of 2.5 years, members of rural communi-
ties throughout Guatemala’s devastated highlands—which had
borne the brunt of the army’s scorched earth campaign between
1978 and 1982—came together in a central location for week-long
trainings in the intervention. The trainings created a safe space in
which participants could learn experientially, sharing and reflect-
ing on their experiences of oppression, suffering, and resilience
while mastering a set of culturally relevant group-based interven-
tion concepts and strategies. The ultimate aim of the intervention
was for the participants to develop group interventions with chil-
dren in their home communities, fostering a process of healing and
adaptation by implementing what they had learned in the central-
ized trainings. However, when we evaluated the extent to which
participants had actually put their newly acquired knowledge and
skills into practice in their own communities, we were surprised to
find that after 2.5 years, none of the trainees had implemented the
intervention in their villages. A 3-day workshop was held during
which trainees were invited to share the obstacles they had en-
countered in working with the intervention. Numerous barriers
were identified, including a need for on-site supervision, the lack
of a written intervention manual, discomfort with some of the
intervention activities, threats by local military commanders to
punish anyone participating in mental health activities, and threats
by local evangelical leaders to report group participants to the
army as Communist subversives. This evaluation workshop en-
abled the program staff to address the numerous barriers that
trainees had encountered and led to an adaptation of the interven-
tion for use with Guatemalan refugees in the refugee camps of
southern Mexico.
We simply do not have sufficient evaluation data to justify the
development of a set of empirically informed “best intervention
practices” at this point, yet that is precisely what is needed: a list
of intervention strategies with well-documented effectiveness to
which practitioners can turn. At first glance, this advocacy of best
practices may seem to contradict our emphasis on interventions
that are tailored to specific cultural contexts. Indeed, a construc-
tivist perspective reminds us that interventions shown to be effec-
tive in one sociocultural context are likely to require some adap-
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MILLER, KULKARNI, AND KUSHNER
tation for use in other settings; absolute fidelity to the program’s
original design is neither necessary nor desirable (Schorr, 1997).
However, it is important to recall that constructivism acknowl-
edges the possibility of similar phenomena occurring across highly
diverse contexts; thus, for example, former child soldiers in dif-
ferent countries may face similar stressors as they struggle to
reintegrate in their communities (e.g., rejection by community
members, shame at whatever atrocities they may have committed,
fear of being re-abducted). Practitioners in one setting can benefit
greatly from the experiences of colleagues working under similar
circumstances elsewhere, bearing in mind the need to adapt inter-
vention strategies in ways that ensure their contextual fit.
Responsibility for the lack of sound evaluation data clearly
cannot be laid solely on researchers; practitioners have relied
heavily on clinical impression and intuition as the basis for eval-
uating the effectiveness of their interventions. On the other hand,
the empirical focus on TFPE has meant that researchers have not
lent sufficient time and energy to helping practitioners develop and
evaluate their work. Although we recognize the myriad difficulties
inherent in conducting sound evaluations in conflict and postcon-
flict situations, a variety of resources are available to help over-
come these obstacles (Hubbard & Miller, 2004). As researchers
work together with practitioners to identify which elements of their
interventions are effective and which require modification, com-
munities will be better served and a growing body of knowledge
about intervening effectively with war-affected populations will
develop.
Discussion
Our aim in this article has been to explore the continued dom-
inance of trauma-focused psychiatric epidemiology in research
with war-affected populations. It is our contention that researchers
influenced by the TFPE framework have tended to focus on an
overly narrow set of questions—namely, those regarding the prev-
alence and correlates of PTSD—while paying insufficient atten-
tion to a number of other critical issues that are of paramount
concern to practitioners. Consequently, research with communities
affected by organized violence has made itself less useful than it
has the potential to be.
We have presented social constructivism as an alternate con-
ceptual and methodological framework that can help us become
more attuned to precisely those issues of greatest concern to
war-affected populations and the organizations working to address
their mental health concerns. A constructivist perspective broadens
the range of what are considered legitimate methods of scientific
inquiry, according greater import to inductive methodologies that
allow communities to identify their mental health needs and pri-
orities for us (rather than our deciding for them).
There are a number of objections that might be raised to our
position. First, it might be argued that at least some of the respon-
sibility for the gap between research and practice lies with prac-
titioners, who may underutilize the existing research literature in
the design and implementation of their interventions. In our view,
this line of argument begs the question of why the research liter-
ature is being underutilized. We suggest that practitioners make
limited use of the available research precisely because it is not
sufficiently useful or relevant to their work. By focusing so heavily
on the assessment of psychiatric symptomatology, we have failed
to provide practitioners with the kind of data that could inform
development of mental health interventions tailored to the partic-
ular sociocultural contexts in they work.
A second objection to our emphasis on social constructivism is
that we are inappropriately minimizing the value of positivist
research and its potential contribution to understanding the mental
health needs of war-affected populations. In fact, our concern is
not with logical positivism per se as an approach to studying the
effects of organized violence; rather, we are concerned specifically
with the undue influence of trauma-focused psychiatric epidemi-
ology, a particular manifestation of positivist inquiry that has
borne limited fruit for those working with war-affected communi-
ties. There are without question elements of positivist science that
hold considerable potential for research in this area. Hierarchical
linear modeling, using culturally appropriate indicators of well-
being and distress, can be used to test the short- and long-term
effectiveness of mental health interventions (Goodkind, Hang, &
Yang, 2004) and to study the natural course of recovery (or lack
thereof) among war-affected individuals. Quasi-experimental de-
signs and between-groups comparisons that make use of naturally
occurring groups (e.g., those who choose to participate in an
intervention and those who choose not to or who drop out mid-
course) are similarly useful also for assessing the effectiveness of
mental health interventions and their constituent components
(Hubbard & Miller, 2004). Also, structural equation modeling, if
applied to latent constructs that are contextually meaningful, can
be helpful in the identification of variables that either moderate or
mediate the impact of war-related violence and daily stressors on
mental health, in effect laying out conceptual roadmaps for em-
pirically based interventions (Rasco & Miller, 2004).
In addition, we recognize that the positivist emphasis on iden-
tifying universal laws that govern human behavior may lead to
meaningful research with war-affected populations. It seems rea-
sonable to suppose that there are common patterns that may be
identified in the ways that people respond to experiences of vio-
lence and forced migration. We have already discussed certain
elements of posttrauma reactions that are evident across diverse
cultural contexts. With specific regard to forced migration, Eisen-
bruch’s (1990) identification of the cultural bereavement syn-
drome among refugees lends itself to empirical study to see
whether, in fact, cultural bereavement is meaningful construct
among diverse refugee populations and in what ways it differs
across different resettlement contexts (e.g., refugee camps, infor-
mal settlements, and countries of permanent resettlement).
Finally, it could be argued (and we agree) that there are addi-
tional factors not considered in this article that have likely con-
tributed to the ongoing popularity of the TFPE framework. For
example, growing interest in psychological trauma, particularly
since the terrorist attacks of September 11, 2001, has elevated
scholarly and popular interest in PTSD to unprecedented levels.
Although the available evidence, including several studies cited
above, suggests that factors other than war-related violence ac-
count for much of the psychological distress among people ex-
posed to armed conflict, suffering related to poverty, displacement,
poor health, spouse abuse, and social isolation simply does not
draw the same level of international interest and concern as war-
related trauma. Moreover, for researchers, there is considerable
kudos accorded to scholarship on PTSD; several professional
journals are dedicated specifically to the study of psychological
419
TFPE AND WAR-AFFECTED POPULATIONS
trauma, and funding for trauma-related research and interventions
is substantial. Our analysis of factors contributing to the continuing
dominance of TFPE is by necessity partial; rather than provide a
comprehensive analysis that is beyond the scope of this article, our
aim has simply been to contribute to an ongoing discussion of the
limits of the TFPE framework and to further legitimize the con-
sideration of alternative approaches to the study of war-affected
populations and their mental health needs.
Our emphasis on the utility of a constructivist framework is not
meant to further polarize the already contentious debate between
advocates of positivism and those of critical theories such as social
constructivism. Although such debate may have a useful role to
play in academic discourses, our concern here is simply with
increasing the familiarity of researchers with the range of concep-
tual frameworks available to guide their empirical efforts. More-
over, we hope to foster a greater degree of intentionality among
researchers in this area with regard to their selection of research
topics and methodologies. To the extent that researchers focus
their efforts based on a critical consideration of cultural context
and take into account those domains of inquiry of greatest concern
to practitioners and the communities they serve, a much needed
bridge between research and practice with war-affected popula-
tions will be constructed.
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Received August 22, 2005
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    • "seine Identität (erneut) aushandelt (Schwartz et al., 2013; Schwartz, Unger, Zamboanga, & Szapocznik, 2010 ). Damit wird auch über den auf Traumata bezogenen Fokus kontemporärer Flüchtlingsforschung (Fazel, Wheeler, & Danesh, 2005; Miller, Kulkarni, & Kushner, 2006 ) hinausgelangt . Die Arbeit behandelt dementsprechend die Prozesse, die zur Erschütterung der Identität von Flüchtlingen führen (Hadjiyanni, 2002; Mahmoud, 2014) und darüber hinaus auch jene, mithilfe derer Flüchtlinge ihre Identität konstruieren und vor allem vor dem Hintergrund des radikalen Kontextwechsels re-konstruieren (Ethier & Deaux, 1994). "
    [Show abstract] [Hide abstract] ABSTRACT: Refugees’ painful flight experiences, with their loss of homeland and the radical contextual changes through acculturation in the country of asylum, do not only lead to pathological symptoms, but above all to a crisis of identity. The literature review at hand explores the crisis from a developmental psychological perspective and names it a task that needs to be sufficiently resolved for the restitution of the central identity functions to be possible. Consequently, 23 primary studies investigate the flight-effect on social, personal and I-Identity levels. The refugees’ social identity is experienced as conflictious, because of the challenges in acculturation as well as the challenges in negotiating a relation between home and guest cultures. In their interactions with guest culture members, though trying to prevent exclusion with specific discursive strategies, refugees are still perpetuating their marginalized status. The identity crisis is especially arising on the I-identity level, for the pre- and post-migration identities are not able to integrate into a coherent and continuous self-concept. These three elements constitute the identity crisis, which can only be solved in so far as identities are reconstructed and integrated into one coherent life narrative. Given that a successful integration involves a process of mourning for the land left behind and a strong identity connection to it to begin with, political demands for dealings with refugees in Germany end up getting diverted.
    Full-text · Thesis · Jun 2016 · Culture Medicine and Psychiatry
    • "Inadequate assessment of post-migration stressors risks the misattribution of distress to prior war exposure, when it may be due partly or wholly to ongoing stressors that could readily be targeted for change. Miller et al. (2006) give the example of a Bosnian refugee whose severe PTSD and depression turned out to primarily the result of extreme and ongoing domestic violence, a fact that only emerged several months into her treatment for what was assumed to war trauma. How we respond to psychological difficulties depends on our understanding of their root causes. "
    [Show abstract] [Hide abstract] ABSTRACT: Early research on the mental health of civilians displaced by armed conflict focused primarily on the direct effects of exposure to war-related violence and loss. Largely overlooked in this war exposure model were the powerful effects of ongoing stressors related to the experience of displacement itself. An ecological model of refugee distress is proposed, drawing on research demonstrating that mental health among refugees and asylum seekers stems not only from prior war exposure, but also from a host of ongoing stressors in their social ecology, or displacement-related stressors. Implications of this model for addressing the mental health and psychosocial needs of refugees and other displaced populations are considered.
    Full-text · Article · Apr 2016
    • "The diagnostic construct of PTSD as response to previously experienced war-related violence has taken center stage in psychological and psychiatric research, playing a key role in both the assessment and treatment of the mental health impact of violent conflict in both western and non-western societies (Breslau 2004; Miller et al. 2006). First included in the third edition of the Diagnostic and Statistical Manual of "
    [Show abstract] [Hide abstract] ABSTRACT: In the aftermath of war and armed conflict, individuals and communities face the challenge of dealing with recollections of violence and atrocity. This article aims to contribute to a better understanding of processes of remembering and forgetting histories of violence in post-conflict communities and to reflect on related implications for trauma rehabilitation in post-conflict settings. Starting from the observation that memory operates at the core of PTSD symptomatology, we more closely explore how this notion of traumatic memory is conceptualized within PTSD-centered research and interventions. Subsequently, we aim to broaden this understanding of traumatic memory and post-trauma care by connecting to findings from social memory studies and transcultural trauma research. Drawing on an analysis of scholarly literature, this analysis develops into a perspective on memory that moves beyond a symptomatic framing toward an understanding of memory that emphasizes its relational, political, moral, and cultural nature. Post-conflict memory is presented as inextricably embedded in communal relations, involving ongoing trade-offs between individual and collective responses to trauma and a complex negotiation of speech and silence. In a concluding discussion, we develop implications of this broadened understanding for post-conflict trauma-focused rehabilitation.
    Full-text · Article · Mar 2016
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