Tag: mental health

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Assessment of Trauma in Children and Adolescents

The Child Trauma Screen is an assessment tool to identify children ages 6-17 who are experiencing symptoms of traumatic distress (Lang & Connell, 2018). It is short, free, and meant for use by a variety of professionals working with children. It is not meant to be comprehensive and screen for all possible symptoms or reactions, but rather a quick initial step to identify the most common reactions and exposures, for further follow up of clinical treatment or more comprehensive assessment. It is recommended to be conducted using an in-person interview, but it can also be used as a self-report measure, and also recommended to get both reports from the child and the caregiver or multiple caregivers. One concern I noted for the Child Trauma Screen is that all three of the studies listed on its hosted website which found it valid and reliable were all conducted by the creator of the screen (Child Health and Development Institute of Connecticut, Inc., 2021).

The context which I would use this assessment personally is within my practice as a Licensed Professional Counselor and Registered Play Therapist, specializing in treating trauma in children and adolescents. An ethical consideration is that if a child reports any abuse, I would need to report it to the Child Welfare office. Another consideration that I would prefer is to first have several sessions with the child to build rapport and safety before administering the screen, and I would also request that the parent leave the room. The child may not feel comfortable sharing in front of their parent for a variety of reasons, such as not wanting to upset them, fear over their reaction, or the parent instigating the abuse.

Reducing traumatic exposure for children and adolescents may ultimately not be possible, although developing better prevention and interventions to interrupt cycles of abusers could make a large difference. Still, trauma is present in nearly all of our lives (van der Kolk & McFarlane, 1996). In reducing the burden of trauma on children and adolescents, I believe we should instead focus on creating resilient support systems which help children process trauma in healthy ways and develop skills for self- and co-regulation of emotions.

See this image below depicting Bronfenbrenner’s Ecological Theory or socio-ecological model (Stanger, 2011). Using this theory, we could construct levels of systems, which all interact and influence each other, embedding resilience building factors into each level. Such a design might buffer negative mental health impacts for children after experiencing traumatic events.

Here is another image which shows the same concept but in a slightly different way which may be helpful (University of Minnesota, n.d.).

See here for a larger, clearer version from the source website.

This same resource listed multiple ideas on how to apply this model in practical applications. I believe these would apply to reducing the burden of trauma on children, adults, families, communities, society, and so on.

  • Promote individual and family solutions to support mental well-being (e.g., self-efficacy) 
  • Learn and teach others to manage stress and cope with adversity
  • Provide health education to support parent-child/caregiver-child relationships
  • Promote social connections – between family, neighbors, employees, etc.
  • Expand youth development in schools
  • Increase skill-based learning to promote adaptability, coping and resilience  
  • Coordinate mental health prevention efforts at the federal, state, and local levels 
  • Support local communities taking an active role in co-creating solutions
  • Increase collaboration between service organizations to strengthen service coverage, access and the referral process for a more integrative, comprehensive approach
  • Leverage the role of service providers to increase natural social support systems 
  • Fund mental health promotion research and community-based supports 
  • Promote equitable resource allocation

(University of Minnesota, n.d., par. 8).

References

Child Health and Development Institute of Connecticut, Inc. (2021). Child Trauma Screen. https://www.chdi.org/our-work/mental-health/trauma-informed-initiatives/ct-trauma-screen-cts/

Lang, J., & Connell, C. (2018). The Child Trauma Screen: A follow-up validation. Journal of Traumatic Stress, 31(4), 540-548.

Stanger, N. (2011). Moving “eco” back into socio-ecological models: A proposal to reorient ecological literacy into human developmental models and school systems. Human Ecology Review, 18, 167-173.

University of Minnesota. (n.d.). Mental health and well-being ecological model. Center for Leadership Education in Maternal & Child Public Health. https://mch.umn.edu/resources/mhecomodel/

Van der Kolk, B.A. & McFarlane, A.C. (1996). Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. New York, NY: The Guilford Press. 

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Assessment-Based Ethical Referral of Traumatized Individuals to Psychosocial Services

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When conducting assessments for trauma as a psychologist, it is important to have a plan in place on the provision of mental health services and resources for the client or participant. Those participants who screen as having posttraumatic stress disorder (PTSD), complex posttraumatic stress disorder (CPTSD), acute stress disorder (ASD), or who may not qualify for a disorder but still have significant symptoms in amount or severity should be referred for more in-depth assessments or treatment. The International Society for Traumatic Stress Studies (ISTSS) (Forbes et al., 2020) suggests treatments of varying evidence bases for recommendations. This also aligns, and in some cases conflicts, with ethical standards as proposed by the American Psychological Association (APA) (2017) and the International Union of Psychological Science (IUPS) (2008). However, a crucial consideration is the barriers to such treatments, such as cultural factors, socioeconomics, and available resources, which may be difficult to access in some areas of the world.

Trauma assessments could occur in at least two different scenarios, either within the context of a research assessment, or in a clinical environment. In a research context, the APA’s Ethical Principles of Psychologists and Code of Conduct (2017) states in section 8.08 that in order to reduce the risk of harm to participants, debriefing should occur quickly following the conclusion of the research. However, this is conflictual with debriefing as an early intervention in a clinical setting following assessment. The ISTSS (Forbes et al., 2020) reviewed evidence and found that debriefing interventions were largely ineffectual, including psychoeducation, in both individual and group interventions. It must be noted, though, that this was specific to those who had been exposed to trauma within the prior three months, and there appeared to be little research included for its use with survivors and refugees of civil war and genocide. This is relevant because the author of this paper, Emily Lutringer, is working to adapt the International Trauma Questionnaire (ITQ) (Cloitre et al., 2018) into cultural idioms of distress for Syrians, who have significant rates of multiple trauma exposures occurring for potentially over a decade (Hassan et al., 2015). In doing an assessment for research purposes, individuals may have been exposed to trauma longer than three months ago. ISTSS (Forbes et al., 2020) guidelines found strong evidence to recommend the following psychological treatments for adults with PTSD: cognitive processing therapy, cognitive therapy, EMDR, trauma-focused CBT, and prolonged exposure.

In conducting clinical assessments, there may be clients who are recently exposed to trauma, and therefore could partake in prevention and early interventions if they show symptoms of trauma on the assessment. ISTSS (Forbes et al., 2020) found that single sessions of EMDR and Group 512 PM had emerging evidence to prevent or treat symptoms of PTSD. Brief dyadic therapy and self-guided internet-based interventions also showed emerging evidence for multiple-session prevention. Stronger evidence was found in early treatment multi-session interventions of trauma-focused CBT, cognitive therapy, and EMDR. Of pharmacological interventions, only hydrocortisone showed emerging evidence.

In any situation in which an individual screens positively for trauma symptoms or PTSD, there may be barriers to accessing the most effective treatments – or even any interventions at all. Firstly, the interventions proposed by ISTSS (Forbes et al., 2020) are primarily Western models, and may not be culturally appropriate in other contexts (Narvaez, 2019). While ISTSS (Forbes et al., 2020) offers a few treatments which may have limited efficacy which could be culturally accessible, such as acupuncture, it is notably lacking in covering the evidence for interventions from indigenous psychologies which would be highly culturally relevant.

Another serious concern is the lack of access, such as low rates of mental health providers, remote areas, high demand with limited availability, and socioeconomic factors (Patel, 2007). Rojas et al. (2019) found that mental health care could be utilized in such situations through the use of internet-based interventions in a variety of formats, such as virtual counseling, phone apps, and specialized video games. As more people worldwide have access to the use of internet and cellphones, these interventions could reach larger populations and at lower costs. There are two caveats to this, though. Firstly, there are still many areas of the world without such internet or cell phone access. Secondly, internet and phone-based interventions appear to have mixed results in their effectiveness, although ISTSS was able to give a standard recommendation for the use of guided internet-based trauma-focused CBT in adults diagnosed with PTSD (Forbes et al., 2020).

Other barriers include stigma and poor mental health literacy (Wong et al., 2019). For example, Syrians typically hold strong stigmas around mental health and may be afraid to seek help for how others may judge them or their families (Hassan et al., 2015). Wong et al. (2019) had positive results in their pilot study evaluating the reduction of stigma through a mental health course in Hong Kong. Similar strategies for psychoeducation and normalization may be valuable when working with people in high-stigma cultures, as they may otherwise resist any PTSD intervention.

 Any mental health resources should include facilities or providers who have experience working with the specific population, to meet the ethical standard of competency (APA, 2017; IUPS, 2008). A researcher would ideally, finding an option that participants could engage in immediately after the study if they chose would allow them to process any trauma that came up without a waitlist. As the assessments are specifically measuring for trauma, a participant may suddenly become aware for the first time that they are suffering from a mental illness and may need immediate support. Furthermore, providing exceptional mental health and other resources is critical to preventing the re-enactment of trauma or intergenerational trauma which could lead to a continued cycle of violence (van der Kolk & McFarlane, 1996). It constitutes the ethical responsibilities of beneficence and nonmaleficence, fidelity and responsibility, justice, and respect for people’s rights and dignity (APA, 2017) not only to individual participants, but in taking a responsibility in the reduction of harm in communities as well.

References

American Psychological Association [APA]. (2017). Ethical Principles of Psychologists and Code of Conduct. https://www.apa.org/ethics/code

Cloitre, M., Shevlin M., Brewin, C.R., Bisson, J.I., Roberts, N.P., Maercker, A., Karatzias, T., Hyland, P. (2018). The International Trauma Questionnaire: Development of a self-report measure of ICD-11 PTSD and Complex PTSD. Acta Psychiatrica Scandinavica. DOI: 10.1111/acps.12956

Hassan, G., Kirmayer, L.J., Mekki-Berrada A., Quosh, C., el Chammay, R., Deville-Stoetzel, J.B., Youssef, A., Jefee-Bahloul, H., Barkeel-Oteo, A., Coutts, A., Song, S. & Ventevogel, P. (2015). Culture, Context and the Mental Health and Psychosocial Wellbeing of Syrians: A Review for Mental Health and Psychosocial Support staff working with Syrians Affected by Armed Conflict. Geneva: UNHCR.

International Union of Psychological Science [IUPS]. (2008). Universal Declaration of Ethical Principles for Psychologists. https://www.iupsys.net/about/governance/universal-declaration-of-ethical-principles-for-psychologists.html

Narvaez, D.F. (October 20, 2019). Indigenous Psychologies Contrast With Western Psychology. Psychology Today. https://www.psychologytoday.com/us/blog/moral-landscapes/201910/indigenous-psychologies-contrast-western-psychology

Patel, V. (2007). Mental health in low-and middle-income countries. British medical bulletin, 81(1), 81-96.

Rojas, G., Martínez, V., Martínez, P., Franco, P., & Jiménez-Molina, Á. (2019). Improving Mental Health Care in Developing Countries Through Digital Technologies: A Mini Narrative Review of the Chilean Case. Frontiers in public health, 7, 391. https://doi.org/10.3389/fpubh.2019.00391

Van der Kolk, B.A. & McFarlane, A.C. (1996). Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. New York, NY: The Guilford Press. 

Wong, P. W. C., Arat, G., Ambrose, M. R., Qiuyuan, K. X., & Borschel, M. (2019). Evaluation of a mental health course for stigma reduction: A pilot study. Cogent Psychology, 6(1), Article 1595877. https://doi.org/10.1080/23311908.2019.1595877

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Trauma, Physical Health, & Psychological Wellbeing in the Context of Adverse Life Events

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Exposure to adverse or traumatic events in life is a common experience (van der Kolk & McFarlane, 1996). These events can vary from minor to severe, can affect individuals or communities, and people react to them in different ways. Many people are resilient, but some develop symptoms of posttraumatic stress disorder (PTSD), have lower physical health, higher rates of mental disorders, and lower psychological well-being. Furthermore, these reactions can vary in how they are expressed between cultural contexts, can be vastly different for everyone, and can both improve or worsen over time. PTSD relates to numerous biological processes, including brain chemistry and hormonal changes. McFarlane (2010) writes, “…PTSD is not simply a psychosocial disorder, but one underpinned by a major neurobiological disruption” (p. 8). In assessing the whole-person impact of PTSD, it is important to consider and treat a variety of factors.

Allostatic load refers to the cumulative stress on the hypothalamic pituitary adrenal axis (HPA) as well as the autonomic nervous system (McFarlane, 2010). Exposure to trauma may not elicit symptoms of PTSD, nor acute stress disorder (ASD), for a significant time (more than 6 months) after the event; this is called delayed-onset PTSD. Furthermore, those who have experienced depression or been diagnosed with ASD may be able to initially manage symptoms to the point of remission – only later to have a resurgence of symptoms. In the case of ASD, this would change the diagnosis to PTSD. Research speculates that this is related to another traumatic event, or even the cumulation of smaller stressors, until the system becomes overloaded. This commonly results in somatic manifestations.

Chronic pain without a medical cause has a strong relationship to PTSD (Andreski et al., 1998), largely thought of to be related to the allostatic load (McFarlane, 2010). In those with chronic pain and PTSD, there are also noticeable changes in the hippocampus, cortisol, amygdala, and gene expressions. These biologic reactions also correspond with fibromyalgia, chronic fatigue, and irritable bowel syndrome. Furthermore, individuals with PTSD are at an increased risk for hypertension and cardiovascular disease, connected with repeated traumatic triggering leading to hyperactivity of the sympathetic nervous system. Significantly higher levels of cholesterol and triglycerides have been found in people with PTSD, even when compared to individuals with depression (Karlovic et al., 2004). Individuals with PTSD are also more likely to be overweight or obese or have coronary heart disease (McFarlane, 2010).

In a study of pregnant Peruvian women, there was shown to be a high correlation between those that had both migraines and PTSD (Friedman et al., 2017). Interestingly, the authors explain that there are numerous overlaps in brain chemistry and hormones between both migraines and PTSD, including lower levels of cortisol, plasma, norepinephrine, higher levels of pro-inflammatory cytokines, and reduced or unstable levels of serotonin. A study of Syrian and Iraqi refugees similarly found increased pro-inflammatory cytokines among those who had PTSD, depression, or anxiety (Grasser et al. 2020).

All of these medical issues are frequently comorbid with individuals with PTSD. Interestingly, many of them also correspond with common cultural idioms of distress in collectivistic cultures, such as in Syria, who often describe trauma and mental distress symptoms as having headaches, racing or pressure on the heart, insomnia, unexplained pain, and stomach pain (Hassan et al., 2015). Systemic, social, cultural, and community factors should also be addressed – especially if one is from a collectivistic society, or the traumatic event impacted a group – a family, a community, or a whole culture or country, such as in the case of war and genocide.

Furthermore, general psychological well-being is also often dramatically reduced in conjunction with traumatic stress. Roberts et al. (2020) write that more than “80% of individuals with PTSD will experience at least one additional lifetime mental health disorder, and around 50% will experience three or more comorbidities” (p.417) in the general population. Common psychological comorbidities are depression, anxiety and panic disorder, substance use disorders, severe mental illnesses, and personality disorders, especially borderline personality disorder. ADHD is also a common comorbidity (van der Kolk & McFarlane, 1996). Furthermore, people impacted by PTSD tend to organize their whole lives around the trauma, such as recreating the pattern in their relationships, and avoiding any hint of a traumatic trigger, causing profound changes in their thoughts, feelings, and behaviors (van der Kolk & McFarlane, 1996). Adults with a large number of adverse childhood experiences have significantly increased risk of a poor mental well-being (Hughes et al., 2016). Such individuals also have shown to have significantly lower social well-being (Mosley-Johnson et al., 2019).

Clinical implications are that treatment and assessment needs to expand to consider all of these factors. Traditionally, the use of anti-depressants and cognitive behavioral therapy have been the norm in treating PTSD (McFarlane, 2010), and medical doctors treat physical problems as separate issues. The ideal treatment would occur shortly after the traumatic event, even if an individual has not yet expressed symptoms, to train one’s psychophysiology to regulate itself early on. A study of Tutsi genocide survivors showed high rates of PTSD and CPTSD, and their children also suffered secondary symptoms of trauma (Shrira et al., 2019). Both parents and offspring had lower rates of resilience when parents suffered from CPTSD. Had trauma focused interventions occurred shortly after the genocide, it is possible that intergenerational trauma may have been avoided. Additionally, co-morbid symptoms both psychological and physical should be addressed in holistic approaches. One promising recent therapeutic modality that seeks to do this is Somatic Experiencing, which has been found to reduce symptom severity of PTSD and depression (Brom et al., 2017) and in PTSD-related chronic pain and disability (Andersen et al., 2017).

Clearly, the implications of the havoc of PTSD are severe. “There is the potential for a pervasive disruption of an individual’s neurobiology and psychophysiology following exposure [of traumatic stress], and PTSD is only one end point…exposure to traumatic stress leads to a general disruption of an individual’s underlying homeostasis” (McFarlane, 2010, p.7). Trauma-exposed individuals should be treated immediately even without symptoms and should be educated to self-assess over their lifespan. Holistic models which treat both physical and mental disruptions and comorbidities are paramount. Culture and environmental factors also should be carefully considered in assessment and treatment. Trauma changes us to our very core and in our entire well-being; increasing awareness and treating it as such is critical for both sufferers, and medical and mental health providers.

References

Andersen, T. E., Lahav, Y., Ellegaard, H., & Manniche, C. (2017). A randomized controlled trial of brief Somatic Experiencing for chronic low back pain and comorbid post-traumatic stress disorder symptoms. European Journal of Psychotraumatology, 8(1). https://doi-org.tcsedsystem.idm.oclc.org/10.1080/20008198.2017.1331108

Andreski P, Chilcoat H, & Breslau N. (1998). Post-traumatic stress disorder and somatization symptoms: a prospective study. Psychiatry Res, 79, 131-8.

Brom, D., Stokar, Y., Lawi, C., Nuriel, P. V., Ziv, Y., Lerner, K., Ross, G., & Nuriel-Porat, V. (2017). Somatic Experiencing for Posttraumatic Stress Disorder: A Randomized Controlled Outcome Study. Journal of Traumatic Stress, 30(3), 304–312. https://doi-org.tcsedsystem.idm.oclc.org/10.1002/jts.22189

Friedman, L. E., Aponte, C., Perez Hernandez, R., Velez, J. C., Gelaye, B., Sánchez, S. E., Williams, M. A., & Peterlin, B. L. (2017). Migraine and the risk of post-traumatic stress disorder among a cohort of pregnant women. The journal of headache and pain, 18(1), 67. https://doi.org/10.1186/s10194-017-0775-5

Grasser, L. R., Burghardt, P., Daugherty, A. M., Amirsadri, A., & Javanbakht, A. (2020). Inflammation and Trauma-Related Psychopathology in Syrian and Iraqi Refugees. Behavioral Sciences, 10(4), 75. doi:10.3390/bs10040075

Hassan, G., Kirmayer, L.J., Mekki-Berrada A., Quosh, C., el Chammay, R., Deville-Stoetzel, J.B., Youssef, A., Jefee-Bahloul, H., Barkeel-Oteo, A., Coutts, A., Song, S. & Ventevogel, P. (2015). Culture, Context and the Mental Health and Psychosocial Wellbeing of Syrians: A Review for Mental Health and Psychosocial Support staff working with Syrians Affected by Armed Conflict. Geneva: UNHCR.

Hughes, K., Lowey, H., Quigg, Z. et al. (2016). Relationships between adverse childhood experiences and adult mental well-being: results from an English national household survey. BMC Public Health, 16,222. https://doi.org/10.1186/s12889-016-2906-3

Karlovic D, Buljan D, Martinac M et al. (2004). Serum lipid concentrations in Croatian veterans with post-traumatic stress disorder, post-traumatic stress disorder comorbid with major depressive disorder, or major depressive disorder. J Korean Med Sci, 19, 431-6.

McFarlane A. C. (2010). The long-term costs of traumatic stress: intertwined physical and psychological consequences. World psychiatry : official journal of the World Psychiatric Association (WPA), 9(1), 3–10. https://doi.org/10.1002/j.2051-5545.2010.tb00254.x

Mosley-Johnson, E., Garacci, E., Wagner, N., Mendez, C., Williams, J. S., & Egede, L. E. (2019). Assessing the relationship between adverse childhood experiences and life satisfaction, psychological well-being, and social well-being: United States Longitudinal Cohort 1995-2014. Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation, 28(4), 907–914. https://doi.org/10.1007/s11136-018-2054-6

Roberts, S.E., Mueser, K.T., & Murray, L.K. (2020). Treatment considerations for PTSD comorbidities. In Effective Treatments for PTSD, 3rd ed. Forbes, D., Bisson, J.I., Monson, C.M., & Berliner, L., eds. The Guilford Press.

Shrira, A., Mollov, B., & Mudahogora, C. (2019). Complex PTSD and intergenerational transmission of distress and resilience among Tutsi genocide survivors and their offspring: A preliminary report. Psychiatry research, 271, 121–123.   Van der Kolk, B.A. & McFarlane, A.C. (1996). Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. New York, NY: The Guilford Press. 

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Comorbidity of PTSD and CPTSD with Other Mental & Physical Disorders in Syrian Populations

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Comorbidities, both physical and mental, are quite common with PTSD and CPTSD (van der Kolk & McFarlane, 1996). This is especially so among those who have been exposed to significant trauma, including from community violence and war. Hoppen and Morina (2019) conducted a meta-analysis on the comorbidity between PTSD and depression in war survivors worldwide and found that nearly half of those with PTSD also had major depression.

Al-Smadi et al. (2016) found that among Syrian refugees in Jordan, in more than half the participants, chronic diseases were comorbid with PTSD and depression. Chung et al. (2020) found that participants with lower physical health and social health scores had significantly higher rates of posttraumatic stress. Kizilhan (2017) discusses how people from Syria and other collectivistic cultures typically express PTSD through somatic symptoms and chronic pain. Grasser et al. (2020) noted co-morbidities in their sample of Syrian and Iraqi refugees between PTSD, anxiety, and depression. Furthermore, they collected saliva samples from participants and were able to find a correlation between these psychological disorders with higher rates of inflammatory responses, lower immunity, and increased susceptibility to diseases.

Middle Eastern cultures, such as those from Syria, are collectivistic and highly tied to their family groups (Chung et al., 2020; Kizilhan, 2017). As such, an “occurrence of trauma to a family member means trauma to the whole family. In other words, PTSD is a within-and-between-individuals phenomenon for an Arabic family” (Chung et al., 2020 p.6). In most peoples, but especially in those in collectivistic cultures, rely heavily on social networks, which buffer against both physical and mental health problems (Powell et al., 2020). Oppression as experienced by Syrian refugees and internally displaced persons is both individual and collective, and is linked with higher rates of PTSD, CPTSD, poor physical health, higher suicidality, and existential annihilation anxiety (Ibraheem et al., 2017).

References

Al-Smadi, A. M., Halaseh, H. J., Gammoh, O. S., Ashour, A. F., Gharaibeh, B., & Khoury, L. S. (2016). Do chronic diseases and availability of medications predict post-traumatic stress disorder (PTSD) among Syrian refugees in Jordan. Pak J Nutr, 15(10), 936-941.

Chung, M. C., AlQarni, N., AlMazrouei, M., Al Muhairi, S., Shakra, M., Mitchell, B., Al Mazrouei, S., & Al Hashimi, S. (2020). Posttraumatic stress disorder and psychiatric co-morbidity among Syrian refugees: the role of trauma exposure, trauma centrality, self-efficacy and emotional suppression. Journal of mental health (Abingdon, England), 1–9. https://doi.org/10.1080/09638237.2020.1755023

Grasser, L. R., Burghardt, P., Daugherty, A. M., Amirsadri, A., & Javanbakht, A. (2020). Inflammation and Trauma-Related Psychopathology in Syrian and Iraqi Refugees. Behavioral Sciences, 10(4), 75. doi:10.3390/bs10040075

Hoppen, T. H., & Morina, N. (2019). The prevalence of PTSD and major depression in the global population of adult war survivors: a meta-analytically informed estimate in absolute numbers. European journal of psychotraumatology, 10(1), 1578637. https://doi.org/10.1080/20008198.2019.1578637

Al Ibraheem, B., Kira, I. A., Aljakoub, J., & Al Ibraheem, A. (2017). The health effect of the Syrian conflict on IDPs and refugees. Peace and Conflict: Journal of Peace Psychology, 23(2), 140. https://doi.org/10.1037/pac0000247

Kizilhan, J. I. (2018). Trauma and pain in family-orientated societies. International journal of environmental research and public health, 15(1), 44.

Powell, T. M., Shin, O. J., Li, S. J., & Hsiao, Y. (2020). Post-traumatic stress, social, and physical health: A mediation and moderation analysis of Syrian refugees and Jordanians in a border community. PloS one, 15(10), e0241036. https://doi.org/10.1371/journal.pone.0241036

Van der Kolk, B.A. & McFarlane, A.C. (1996). Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. New York, NY: The Guilford Press. 

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Using the International Trauma Questionnaire (ITQ) in Diverse Global Populations

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The International Trauma Questionnaire (ITQ) was developed based on the criteria for posttraumatic stress disorder (PTSD) and complex posttraumatic stress disorder (CPTSD) as outlined in the International Classification of Diseases, 11th ed. (ICD-11) (Cloitre et al., 2018). The ICD-11 is a covers physical and mental health illnesses and serves as a diagnostic guide and is widely used worldwide (World Health Organization [WHO], 2019). The ITQ has been translated and utilized within many populations and cultures. This is in contrast to the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), the primary diagnostic manual used for mental disorders in the U.S. (American Psychological Association [APA], 2009). The literature on the ITQ’s use within cultures in the Middle East, Africa, and Asia will be examined.

The ITQ is an instrument which measures an individual’s level of PTSD and CPTSD. It is brief, easy to understand, and is designed for individuals to be able to fill it out themselves (Cloitre et al., 2018). It was developed to serve as a diagnostic tool, because the ICD-11 uses a narrative description of symptoms format rather than specific diagnostic criteria. The development of the ITQ focused on inclusion of questions which addressed the core symptoms, rather than every possible symptom. The majority of the questions use a Likert scale of 1-5. An individual taking the assessment can be diagnosed with PTSD or CPTSD, but not both. Early analyses of the ITQ found some questions to have poor reliability, so they were removed or changed. Additionally, the ITQ was found to work well within both community and clinical populations. The ITQ has been translated into at least 28 languages, has a version for children and adolescents, and is freely available in the public domain (The International Trauma Consortium, n.d.). The ITQ has been found to be valid and reliable among many populations internationally, however, additional adaptations to match cultural context and idioms of distress could be useful in capturing the true experience of trauma for many populations.

In the Middle East, a study of Syrian refugees in Lebanon (Vallieres et al., 2018) tested the use of the ITQ and the ICD-11 in their accuracy in measuring PTSD and CPTSD within this group. They found that CPTSD was more common than PTSD, and there were high amounts of traumatic exposure. The most distressing events as rated by participants were the deaths of loved ones, being separated from family and friends, forced displacement, and bombings. Overall, participants found that the ITQ seemed to accurately reflect their experiences. Limitations of the ITQ were that it lacked any questions related to somatic symptoms such as amnesia and poor concentration (Vallieres et al., 2018), or fainting, dizziness, weakness, and chronic pain, all of which are common cultural idioms of mental and emotional distress for Syrians (Barkil-Oteo et al., 2018). Another issue is that some participants showed hesitancy in answering, exhibiting signs of paranoia and hypervigilance. To address this, trust and rapport may first need to be built with the person administering the ITQ. However, the use of the ITQ helped create a language and normalization for participants and assisted them in opening up in subsequent therapy sessions (Vallieres et al., 2018). Overall, both the ICD-11 and the ITQ were found be culturally viable within this population in this study.

In Africa, Owczarek et al. (2019) tested the ITQ among community members in Kenya, Ghana, and Nigeria. In this study, the ITQ was found to be a valid assessment within these different cultural populations, with a very good internal consistency. There were some differences in the types of traumatic exposures between the countries, as well as levels of PTSD and CPTSD. The limitations described by the authors discuss the lack of generalizability, as the sample demographics were different from the general population, such as having a much higher rate of higher education, which has been shown to be correlated with lower levels of PTSD symptoms. Additionally, the data collection was done online, limiting access. Another study by Barbieri et al. (2019) compared the rates of PTSD and CPTSD between the DSM-V and the ITQ in a clinical sample of African refugees in Italy. 79% of the participants met the criteria for PTSD using the DSM-V. Using the ITQ, 38% met criteria for PTSD and 30% for CPTSD, with a combined total of 68%, showing a statistically significant difference compared to the DSM-V. Understandably, this population of treatment-seeking refugees showed much higher rates of both PTSD and CPTSD than in the study of community members by Owczarek et al. (2019), but it also found the ITQ to be a valid measure for this population (Barbieri et al., 2019).

Examining the ITQ in Asia, Tian et al. (2020) found that the assessment had good validity and reliability among Chinese young adults. They found that the rate of CPTSD was significantly higher at 13.35% as compared to PTSD at 5.85%. One possible explanation is the high rate of childhood maltreatment in China, and early trauma exposure is a major risk factor for CPTSD, in addition to other cultural factors. This study also measured posttraumatic growth (PTG), a heightened state of resilience. PTG was lower among those with CPTSD symptoms than those with PTSD only. Limitations of this study were also a lack of generalizability due to the narrowness of the sample, and that all participants had experienced at least one traumatic event. Another study examined the validity of the ITQ in young adults across multiple Asian cultures – China, Hong Kong, Japan, and Taiwan (Ho et al., 2020). This study also found that PTSD and CPTSD were valid separate diagnoses using the ITQ within these populations, and the association of increased childhood negative experiences (though not necessarily traumatic) correlated with higher rates of CPTSD. This study also found higher rates of CPTSD than PTSD, like Tian et al. (2020).

From these studies, it appears that the ITQ is indeed valid across multiple populations in determining PTSD and CPTSD, and validating the legitimacy of these two related, but different, diagnoses. Despite initial impressions that there should be more specific cultural adaptations more than language translations, these studies show that symptomology of these disorders remains in similar clusters cross-culturally. Still, there is a continued question of if these results would shift if the questions were adapted to use the specific cultural idioms and expressions of emotional distress. As there do not appear to be any studies which modify the ITQ in such a way, there is no current way to compare this.

References

American Psychological Association. (2009, October). ICD vs. DSM. Monitor on Psychology, 40(9). http://www.apa.org/monitor/2009/10/icd-dsm

Barbieri, A., Visco-Comandini, F., Alunni Fegatelli, D., Schepisi, C., Russo, V., Calò, F., Dessì, A., Cannella, G., & Stellacci, A. (2019). Complex trauma, PTSD and complex PTSD in African refugees. European Journal of Psychotraumatology, 10(1), 1700621–1700621.                   https://doi.org/10.1080/20008198.2019.1700621

Barkil-Oteo, A., Abdallah, W., Mourra, S., & Jefee-Bahloul, H. (2018). Trauma and resiliency: A tale of a Syrian refugee. American journal of psychiatry, 175(1), 8-12.

Cloitre, M., Shevlin, M., Brewin, C. R., Bisson, J. I., Roberts, N. P., Maercker, A., Karatzias, T., & Hyland, P. (2018). The International Trauma Questionnaire: development of a self‐report measure of ICD‐11 PTSD and complex PTSD. Acta Psychiatrica Scandinavica, 138(6), 536–546. https://doi-org.tcsedsystem.idm.oclc.org/10.1111/acps.12956

Ho, G., Hyland, P., Shevlin, M., Chien, W. T., Inoue, S., Yang, P. J., Chen, F. H., Chan, A., & Karatzias, T. (2020). The validity of ICD-11 PTSD and Complex PTSD in East Asian cultures: findings with young adults from China, Hong Kong, Japan, and Taiwan. European journal of psychotraumatology, 11(1), 1717826. https://doi.org/10.1080/20008198.2020.1717826

Owczarek, M., Ben-Ezra, M., Karatzias, T., Hyland, P., Vallieres, F., & Shevlin, M. (2020). Testing the Factor Structure of the International Trauma Questionnaire (ITQ) in African Community Samples from Kenya, Ghana, and Nigeria. Journal of Loss & Trauma, 25(4), 348–363. https://doi.org/10.1080/15325024.2019.1689718

The International Trauma Consortium. (n.d.). International Trauma Questionnaire. https://www.traumameasuresglobal.com/itq

Tian, Y., Wu, X., Wang, W., Zhang, D., Yu, Q., & Zhao, X. (2020). Complex posttraumatic stress disorder in Chinese young adults using the International Trauma Questionnaire (ITQ): A latent profile analysis. Journal of affective disorders, 267, 137–143. https://doi.org/10.1016/j.jad.2020.02.017

Vallières, F., Ceannt, R., Daccache, F., Abou Daher, R., Sleiman, J., Gilmore, B., Byrne, S., Shevlin, M., Murphy, J., & Hyland, P. (2018). ICD‐11 PTSD and complex PTSD amongst Syrian refugees in Lebanon: the factor structure and the clinical utility of the International Trauma Questionnaire. Acta Psychiatrica Scandinavica, 138(6), 547–557. https://doi-org.tcsedsystem.idm.oclc.org/10.1111/acps.12973

World Health Organization. (2019).  International Statistical Classification of Diseases and Related Health Problems (ICD). https://www.who.int/standards/classifications/classification-of-diseases

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Symptoms of PTSD and Complex PTSD in Western Cultures & Syrian Culture

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Post-traumatic stress disorder (PTSD) is a psychological disorder which is included in both the DSM and the ICD-11, but only the ICD-11 explicitly includes a distinction of Complex PTSD (CPTSD) (Cloitre et al., 2019). The inclusion of CPTSD is important, as it encompasses research on how PTSD manifests within prolonged or repeated trauma exposure, particularly in early childhood, but also include the impacts of cultural and collective trauma (Hirschberger, 2018), such as that which is experienced in mass catastrophic events such as war, genocide, slavery, colonization, racial trauma (Comas-Díaz et al., 2019), etc., and intergenerational trauma (Yehuda & Lehrner, 2018). The civil war in Syria, ongoing since 2011, is one example of such a significant collective trauma, which may have lasting intergenerational trauma effects. However, the Western medical-style model of diagnosis of mental illnesses does not explicitly account for cultural differences in how Syrians experience, understand, and express trauma.

Van der Kolk and McFarlane (1997), who provide a deep understanding of the multitude of ways that trauma can manifest beyond what manuals like the DSM provide or ICD-11 provide, write that “experiencing trauma is an essential part of being human; history is written in blood” (p.3). Traumatic experiences can vary in their intensity, and whether they develop into the pathology of PTSD depends on their context, and the coping skills of the individual experiencing the event. Some people can process such traumatic exposures in ways which allow them to return to healthy functioning, while others do not. Those that develop PTSD start to develop unhealthy defense mechanisms and behaviors to avoid even subtle reminders of the trauma, which can affect the entire way that they structure their lives. “The core issue is the inability to integrate the reality of particular experiences, and the resulting repetitive replaying of the trauma in images, behaviors, feelings, physiological states, and interpersonal relationships” (van der Kolk & McFarlane, 1997, p.7). In most cases, PTSD is spurned from a singular event, or tightly clustered events, while CPTSD occurs when there is repeated or prolonged exposure to traumatic situations, such as child abuse at a critical stage of development. Due to the nature of PTSD broadly, trauma victims tend to reenact (usually subconsciously) the trauma in other aspects of their lives, leading to continued traumatic experiences, further deepening the complexity of CPTSD (Foa et al., 2009).

Whole societies and cultures can also be traumatized and can follow “roughly similar patterns of adaptation and disintegration” (van der Kolk & McFarlane, 1997, p. 3) as traumatized individuals. States can react to traumatized populations in various ways – in the U.S. it is typically with some immediate compassion, but a fallback on an attitude of blaming victims as their own responsibility for the trauma, seeking to maintain the status quo, and projecting a message of safety for society (van der Kolk & McFarlane, 1997). When considering the case of Syria, the authoritarian regime has sought to eradicate trauma narratives and instead impose their own version of the story through such tactics as monopolizing higher education to maintain their power and enforce their political agenda. (Al Azmeth et al., 2020). Matos et al. (2021) found that “…war severely disrupted Syrians’ sense of collective self, and that they repeatedly engaged in search for meaning, appraisals of the war, and reappraisals of shattered beliefs, life goals, and sense of purpose, both during wartime and in resettlement” (p.1).

Vallieres et al. (2018) conducted a study of Syrian refugees in Lebanon, using the International Trauma Questionnaire (ITQ) and the ICD-11 in examining both CPTSD and PTSD levels and validity for this population. They found that CPTSD was more prevalent than PTSD, and that the ICD-11 and ITQ were cross-culturally applicable – with some limitations. The levels of traumatic exposure were high, with the events ranked as most distressing by participants being forced displacement, bombings, and losing loved ones both through unexpected deaths and forced separations. Participants shared that they felt that the questionnaire seemed to be understanding of their experience. One noted limitation was that common symptoms were amnesia and lack of concentration, but these weren’t addressed in the ITQ questionnaire. Participants also felt some of the questions were irrelevant to their situation and cultural context. It was also noted that completing the questionnaire was unfamiliar and challenging to many refugees – so it may be that the use of such assessments give poor reliability within this cultural context. Furthermore, the trauma of some participants made them hesitant in answering some of the questions, invoking what would appear to be paranoia and hypervigilance. The authors suggest that the use of such questionnaires or assessments may first require a building of rapport and trust with the person administering them. This challenges the Western model of research, in which the researcher is to remain unbiased and emotionally removed from the participants (Jhangiani & Tarry, 2014).

Syrians express trauma and mental illness differently from Western societies. A study on PTSD and CPTSD using the ICD-11 in the US did not include questions or measures on somatic symptoms (Cloitre et al., 2019). The above study on Syrian refugees by Vallieres et al. (2018) similarly did not include somatic symptoms. However, somatic descriptions were commonly found as expressions of mental illness, distress, and trauma in other studies (Barkil-Oteo, 2018; Borho et al., 2021; Hassan et al., 2015). Barkil-Oteo et al. (2018) state that traditional, even culturally adapted, measures were insufficient in capturing the true range of symptoms experienced by refugees, who, in addition to prior trauma exposures, have “both repeated and ongoing traumatic triggers (fear from the past, current uncertainties, new traumas)” (p.9). They noted high prevalence of fainting, dizziness, weakness, and chronic pain in this population which had been ruled out of medical causes. Patients often first presented with such physical complaints before sharing emotional or mental distress. Borho et al. (2021) found a high correlation between somatic complaints and traumatic exposures, stress, and depression and anxiety symptoms in Syrian refugees in Germany. Syrians “do not separate somatic experience and psychological symptoms, because body and soul are interlinked in explanatory models of illness” (Hassan et al., 2015, p. 22).  One explanation for this emphasis on psychical symptoms is that mental illness is not well understood and is highly stigmatized in Syrian culture. Furthermore, the cultural framework within both Islam and Christianity (the primary religions of Syria) is that suffering is a part of being alive and does not need special interventions unless it is severe. However, with the increased normalization of mental health within host countries and among communities of refugees, knowledge and awareness of mental health and PTSD are growing and losing some of their stigma.

Hasan et al. (2015) provide a comprehensive overview of culturally specific idioms of distress for Syrian peoples. For example, saying one is tired or their psyche is tired “refers to a general state of ill being and may stand for a range of emotional symptoms, but also for relationship difficulties” (Hassan et al., 2015, p. 22). Ruminative thoughts are attributed to the influence of the devil, and severe mental and emotional disorders are sometimes considered to be the work of mischievous or evil spirits such as jinn. Symptoms of mental distress, which can also be comorbid with PTSD and CPTSD include such things as anxiety, depression, cognitive difficulties, helplessness, anger or aggression, and extreme stress, are often described in proverbs or metaphors. Western-trained professionals may misconstrue these as psychotic indicators. An example of a somatic description of fear or anxiety is a literal sensation of one’s heart crumbling or falling. An example of a metaphorical description for helplessness is “the eye sees but the hand is short or cannot reach” (Hassan et al., 2015, p. 23).

There is very little research on Syrians’ mental health, including trauma rates and responses, from before the onset of the war in 2011. Therefore, much of the research today comes from Syrian refugees residing outside of Syria. Furthermore, nearly all the research is focused on trauma exposures and PTSD rather than CPTSD. As noted previously, notions of mental illness and trauma are becoming increasingly normalized in this population, so, the conceptualizations and experiences of trauma may also be shifting to align more with those of the host countries’. Collective trauma is extensive in the case of the Syrian war, and the primary coping method of social connection (Hassan et al., 2015) – of extreme importance in collectivistic cultures – is radically disrupted, damaging possible resilience pathways for many Syrians.

References

Al Azmeh, Z., Dillabough, J., Fimyar, O., McLaughlin, C., Abdullateef, S., Aloklah, W. A., … &      Kadan, B. (2021). Cultural trauma and the politics of access to higher education in    Syria. Discourse: Studies in the Cultural Politics of Education, 42(4), 528-543.

Barkil-Oteo, A., Abdallah, W., Mourra, S., & Jefee-Bahloul, H. (2018). Trauma and resiliency: A    tale of a Syrian refugee. American journal of psychiatry, 175(1), 8-12.

Borho, A., Morawa, E., Schmitt, G.M. et al. (2021). Somatic distress among Syrian refugees          with residence permission in Germany: analysis of a cross-sectional register-based study. BMC Public Health 21, 896. https://doi.org/10.1186/s12889-021-10731-x

Cloitre, M., Hyland, P., Bisson, J. I., Brewin, C. R., Roberts, N. P., Karatzias, T., & Shevlin, M.     (2019). ICD‐11 Posttraumatic Stress Disorder and Complex Posttraumatic Stress   Disorder in the United States: A population‐based study. Journal of Traumatic Stress,   32(6), 833–842.

Comas-Díaz L, Hall, G. N., & Neville, H. A. (2019). Racial trauma: theory, research, and      healing: introduction to the special issue. The American Psychologist, 74(1), 1–5.

Foa, E.B., Keane, T.M., Friedman, M.J., & Cohen, J.A. (2009). Effective Treatments for PTSD.        Practice Guidelines from the International Society for Traumatic Stress Studies (2nd ed.).        New York, NY: The Guilford Press. 

Hassan, G., Kirmayer, L.J., Mekki-Berrada A., Quosh, C., el Chammay, R., Deville-Stoetzel,          J.B., Youssef, A., Jefee-Bahloul, H., Barkeel-Oteo, A., Coutts, A., Song, S. & Ventevogel,          P. (2015). Culture, Context and the Mental Health and Psychosocial Wellbeing of      Syrians: A Review for Mental Health and Psychosocial Support staff working with     Syrians Affected by Armed Conflict. Geneva: UNHCR.

Hirschberger, G. (2018). Collective trauma and the social construction of meaning. Frontiers of     Psychology, 9, 1441.

Jhangiani, R. & Tarry, H. (2014). Conducting research in social psychology. Principles of social     psychology – 1st international ed.             https://opentextbc.ca/socialpsychology/chapter/conducting-research-in-social-            psychology/

Matos, L., Costa, P.A., Park, C.L., Indart, M.J., & Leal, I. (2021). ‘The war made me a better   person’: Syrian refugees’ meaning-making – Trajectories in the aftermath of collective        trauma. Int. J. Environ. Res. Public Health, 18. https://doi.org/10.3390/ijerph18168481

Vallières, F., Ceannt, R., Daccache, F., Abou Daher, R., Sleiman, J., Gilmore, B., … & Hyland, P.       (2018). Are posttraumatic stress disorder (PTSD) and complex-PTSD distinguishable            within a treatment-seeking sample of Syrian refugees living in Lebanon?. Global Mental       Health, 5. DOI: 10.1111/acps.12973

Van der Kolk, B.A. & McFarlane, A.C. (1996). Traumatic Stress: The Effects of Overwhelming            Experience on Mind, Body, and Society. New York, NY: The Guilford Press.  Yehuda, R., & Lehrner, A. (2018). Intergenerational transmission of trauma effects: Putative role   of epigenetic mechanisms. World Psychiatry, 17(3), 243–257

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Traumatic Stress and Syrian Cultural Conceptualizations

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Defining traumatic stress is a complex task because it incorporates so many different presentations, triggering events, brain developments, resources, and can be individual or collective (van der Kolk, et al., 1996). Non-traumatic stress differs primarily in that it is an almost unavoidable aspect of daily human life, and while it can range from small stressors to significant stressors, and can occur from both positive and negative situations, this stress can range from annoyances to exacerbating or experiencing mental health issues – or propel us forward and give us motivation and positive outcomes (Yeager & Roberts, 2003). Stress also releases certain biological responses and hormones, such as a temporary increase in cortisol production (Richter-Levin & Sandi, 2021). However, in the case of traumatic stress, cortisol takes longer and longer to revert to normal – in some cases that are chronic and severe, this may lead to constantly high levels of cortisol, which can further progress to the point that cortisol is completely depleted and unable to be created, leading to adrenal fatigue.

When one has been exposed to significant non-traumatic stress repeatedly, and does not have adequate coping skills, this can develop into acute stress disorder or post-traumatic stress disorder. However, Richter-Levin and Sandi (2021) write that the most “common reaction to stress is resilience, indicating that resilience is the rule and stress-related pathology the exception” (p.1).

While non-traumatic stress can develop into traumatic stress, traumatic stress itself is usually defined by exposure to a traumatic event with which one is unable to process or cope with (Foa, et al., 2009). Commonly considered forms of traumatic events include such things as war, violence, rape, childhood abuse, natural disasters, and other experiences which dramatically shake one’s sense of safety (van der Kolk, et al., 1996). But what constitutes a sense of safety can vary dramatically, and previous exposure to traumatic stress can make one more susceptible to further traumatic stressors. PTSD is most often viewed as a response to a specific, singular event – however, new research and understandings are evolving on complex trauma, such as in cases of ongoing childhood abuse which dramatically impact the lifelong behaviors, thought patterns, and emotional states within the brain development of those children.

The DSM, used to diagnose psychological disorders, has fairly strict, black and white, guidelines on what symptoms need to be expressed for a diagnosis. However, van der Kolk et al. (1996) point out that these symptoms are manifested in vastly different ways for different people. And culture also frames how we experience these symptoms and behaviors. Western societies, namely the USA, tend to shift towards individualism and place blame often on victims in order to maintain a sense of safety within society, and tends to follow the medical model (such as the use of the DSM) of checklists of symptoms to determine a diagnosis, with emphasis placed on the psychopathologies and mental illnesses in terms of the mind. A century or so ago, individuals used more somatic descriptions in their symptoms of PTSD, which, aside from a few authors pushing research on this topic today such as van der Kolk and the recently developed somatic therapies, is not the mainstream. In many other cultures, mental distress of any sort is often described somatically.

Syrian refugees, like many war-exposed refugees, have been exposed to major levels of traumatic stress – within Syria, during migration, and post-migration all carry their own different circumstances which constitute extreme levels of stress, much of which is traumatic (Mahmood et al., 2019). Syria is a collectivistic society, so cultural trauma is felt very deeply within the interconnected web of individuals, damaging the sense of self dramatically (Matos et al., 2021) and is worsened by the separation of family members and communities as refugees find asylum in different countries or from internal displacements (Kakaje et al, 2021). Furthermore, mental illness has been stigmatized within Syria even prior to the onset of the war, with very limited clinicians and resources available, relying mainly on medical staff without mental health training for supports (Kakaje et al., 2021). This worsened even further as medical facilities have been explicitly targeted to be bombed in the war. Syrians tend to express mental illness, including PTSD, in terms of somatic complaints such as insomnia, headaches, and stomach or chest pain (Borho et al., 2021). Because Syrians express trauma in ways that are different from the Western model, some authors have questioned the efficacy of other studies, even when they use “adapted” Western-made diagnosis instruments (Barkil-Oteo et al., 2018).

References

Barkil-Oteo, A., Abdallah, W., Mourra, S., & Jefee-Bahloul, H. (2018). Trauma and resiliency: A tale of a Syrian refugee. American Journal of Psychiatry, 175(1).

Borho, A., Morawa, E., Schmitt, G.M. et al. (2021). Somatic distress among Syrian refugees with residence permission in Germany: analysis of a cross-sectional register-based study. BMC Public Health 21, 896. https://doi.org/10.1186/s12889-021-10731-x

Foa, E.B., Keane, T.M., Friedman, M.J., & Cohen, J.A. (2009). Effective Treatments for PTSD. Practice Guidelines from the International Society for Traumatic Stress Studies (2nd ed.). New York, NY: The Guilford Press. 

Kakaje, A., Al Zohbi, R., Hosam Aldeen, O., Makki, L., Alyousbashi, A., & Alhaffar, M. (2021). Mental disorder and PTSD in Syria during wartime: A nationwide crisis. BMC psychiatry, 21(1), 2. https://doi.org/10.1186/s12888-020-03002-3

Mahmood, H.N., Ibrahim, H., Goessmann, K. et al. (2019). Post-traumatic stress disorder and depression among Syrian refugees residing in the Kurdistan region of Iraq. Confl Health 13(51). https://doi.org/10.1186/s13031-019-0238-5

Matos, L., Costa, P.A., Park, C.L., Indart, M.J., & Leal, I. (2021). ‘The war made me a better person’: Syrian refugees’ meaning-making – Trajectories in the aftermath of collective trauma. Int. J. Environ. Res. Public Health, 18. https://doi.org/10.3390/ijerph18168481

Richter-Levin, G. & Sandi, C. (2021). Labels Matter: Is it stress or is it Trauma?. Transl Psychiatry 11, 385. https://doi.org/10.1038/s41398-021-01514-4

Van der Kolk, B.A. & McFarlane, A.C. (1996). Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. New York, NY: The Guilford Press. 

Yeager, K. & Roberts, A. (2003). Differentiating Among Stress, Acute Stress Disorder, Crisis Episodes, Trauma, and PTSD: Paradigm and Treatment Goals. Brief Treatment and Crisis Intervention, 3. 10.1093/brief-treatment/mhg002.

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Sway Presentation: Traumatic Stress & Syrian Cultural Conceptualizations

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Social determinants of mental health in a global context

The readiness of a woman for pregnancy can impact the mental health of both the mother and child.  This is not necessarily related to age – in the U.S., teenage pregnancy is seen as a problem, but it is not in many other cultures (Sorel, 2013). However, socioeconomic factors can be a major influencer.  Poor nutrition increases risk of birth defects, as does exposure to toxins – both of which are increased among those living in poverty, in addition to lack of education around pregnancy needs and medical checkups, as well as abstaining from tobacco, alcohol, and drugs. Additionally, to create the best environment for mental health, the CDC suggests that the mother should be in a safe environment, have healthy behaviors, and a strong support system, and recommends counseling to understand genetic risks, mental health issues, and domestic violence.

In early childhood, a strong bond between the mother or parent to the child is critical to healthy social and emotional development (Sorel, 2013).  If the primary caregiver suffers from depression, this can impact the formation of this bond. Breastfeeding reduces risk of later obesity in children, protects infants from illness and infection, and breastfeeding for 6 months or longer reduces risk of mental health issues later in life. Children who are breastfed longer have less behavioral problems.  Socioeconomic factors in here as well – “mothers who breastfed for less than six months were younger, less educated, poorer, and more stressed and were also more likely to be smokers than the mothers who breastfed longer.  They were also more likely to suffer from postpartum depression…” (Sorel, 2013, p. 80).  In the U.S., Mexican-Americans and White mothers, higher incomes, and mothers over 30 increased the likelihood that a baby was breastfed.  African Americans have a much lower rate, likely connected to the stigma of breastfeeding from historically being forced to be wet nurses during slavery. And throughout childhood, the environment plays a large role in development of mental health, and again often is connected to socioeconomic status.

Even without a diagnosable mental illness, people can fall anywhere along the spectrum of mental health and mental illness (Sorel, 2013). Some people are able to function while having some mental illness, while others are not.  Some people are subject to environmental and social factors which impair their ability to maintain good mental health, and impede their ability to avoid mental illness.  There is a strong link between mental health and physical health, both impacting the other. Other factors include low quality or unstable housing, violent relationships, poor nutrition and adequate food, job insecurity, high crime rates, and alcohol and drug use (p.85). Factors which contribute to positive mental health include: “intact family, maternal attachment, public safety, social support and inclusion, housing quality, food security, quality education, employment, income security, access to quality health care, religiosity, and moral values” (Sorel, 2013, p.85). The inverse of these increases risks for mental illness.

In addition to the factors above, it must be reiterated that the biggest structural driver of social determinants of mental health is poverty. This also connects to an individual’s location – often those in poverty are forced to live in areas with limited access to resources, from public transportation to health care to recreational opportunities (Sorel, 2013, p.88).  They also are more likely to have poor quality housing, high crime rates, gangs, poor education, and unemployment, among other things. “These inequalities in the allocation, distribution, acquisition, and utilization of resources affect mental well-being and create conditions of unequal hardship and opportunity, racism, discrimination, and stigmatization, all of which result in negative mental health outcomes” (Sorel, 2013, p.88). In order to change these conditions, governments as well as individuals will need to challenge them and actively work to improve the allocation and utilization of resources.

The best promotion of good mental health is prevention.  To do so takes both external and internal support for the community.  Internally, people can be trained in parenting education and then become trainers themselves for others in their community, for example (Sorel, 2013).  Schools can develop policies which build their relationship with parents, increase parental involvement, and provide information on the emotional and cognitive needs of their kids. Sorel (2013) outlines numerous ideas for the government to improve social determinants for mental health.  Some of these include: reducing inequalities in education, economic status, housing, and health care, utilizing welfare systems to help people find and keep jobs, make college education more affordable, including personal economics classes as part of the core curriculum in schools, using tax credits and incentives to promote positive social determinant factors, expanding healthcare policy to include mental health and meet the needs of those who need it most, and focus on prevention, using employee assistance programs to provide needed mental health care to workers, and including mental health promotion programs in emergency and crisis response.

References

Carr, S. C. (2003).  Poverty and psychology: An introduction.  In S. C. Carr, & T. S. Sloan (Eds.), Poverty and psychology: From global perspective to local practice (pp. 1-15).  New York, NY: Kluwer Academic/Plenum Publishers 

Collins, P., Patel, V., & Joestl, S. S. (2011).  Grand challenges in global mental health.  Nature, 475, 27-30. 

Knifton, L. (2012).  Understanding and addressing the stigma of mental illness with ethnic minority communities.  Health Sociology Review, 21(3), 287-298.

Sorel, E. (2013).  21st Century global mental health.  Burlington, MA: Jones & Bartlett Learning. Chapter 4, p. 73-94.

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Psychological Impacts of Terrorism

Tanielian and Stein (2006) write about the impacts on and needs for addressing the psychological impacts of terrorism. While terrorism is an act which is marked by physical destruction, loss of life, economic collapse, violence, and political aims, it is also intended to provoke fear in the population. It has psychological effects additionally through targeting “the social capital of a nation – cohesion, values, and ability to function. Therefore, successful counterterrorism and national continuity depend on effective interventions to sustain the psychological, behavioral, and social functioning of the nation and its citizens” (Tanielian & Stein, 2006, p.690). However, this aspect is woefully under addressed and not well understood.

Emotional and psychological responses to terrorism, even by those not immediately affected or witness to the event itself, can be present from no reaction at all, to mild symptoms, to development of severe mental illnesses (Ursano, Morganstein, & West, 2020). Distress reactions include changes in sleep, reduced sense of safety, isolation and avoidance, and irritability and distraction. Health risks include increased behaviors of smoking, alcohol, becoming overly involved in work or other tasks, separation anxiety, and fears about traveling nationally, internationally, or even outside one’s neighborhood or home. Psychiatric disorders can include anxiety, PTSD, acute traumatic stress, depression, and complex grief. In others, or in initial stages of a “honeymoon period” following an attack in those who later develop symptoms of mental distress or illness, there may be a sense of resiliency, of bonding, of heroism, and optimism. There can also be a reaction of anger and wanting retaliation. This can lead to pressure to develop harsher policies toward a broad group perceived to be associated with an attack, such as in the case of anti-Muslim policies in the U.S. following 9/11 and leading to the “Muslim ban” implemented by former President Trump (Haner, et al., 2019). This can also lead to a reaction of building of a group identity, framing those with any perceived association with the attack as bad and devaluing their humanity, and leading to the formation of extremist groups, further escalating conflict (Staub, 2012).

Tanielian & Stein (2006) discuss the need for further support and research of psychological reactions and distress from terrorist attacks. They note that “little national or local policy has focused on the importance of addressing psychology or mental health” as a part of the counterterrorism funding, policies, and response in the U.S.  Many research articles have studied the frequency, type, and intensity of psychological and mental health consequences of terrorism and natural disasters such as earthquakes. Both indirect and direct victims of a terrorist attack can experience psychological symptoms, but the most heavily affected are those who were directly affected, in the immediate area, or first responders. Vulnerable populations are also heavily impacted, “such as children, racial and ethnic minorities, and those with an existing psychiatric illness” (Tanielian & Stein, 2006, p.693). The article specifically details impacts on children, and how the interactions between parents and children can either increase symptoms in children, or possibly increase parents’ reporting of distress in their children. The article does make a cross-cultural reference to studies in Israel and compares it to studies in the U.S.

The article does also mention that there may be differences in reactions between ethnic and cultural groups, identifying disparities in increases of PTSD and lower utilization of medications and mental health services among Black and Latino people compared to White people (Tanielian & Stein, 2006). This is attributed to “various cultural factors, including valuing self-reliance, expressing emotions in certain ways, and having reservations about sharing emotions with others” (Tanielian & Stein, 2006, p.694). Considering this article was written in 2006, there was a lot less awareness of structural and systemic racism than there is today in 2021 in the U.S. I would argue that what is missing from this analysis of disparities in seeking services is the general distrust of the medical – inclusive of mental health – systems among Black communities due to a history of being abused by such services. This includes experiments done on slaves, and the infamous Tuskegee Syphilis study (Wells & Gowda, 2020). Other factors to consider in this population is the severe lack of Black physicians which are much preferred by the Black community, White physicians lacking cultural competency, history of segregated cities, and socioeconomic barriers.

Additionally, Latinos are the least likely ethnic group in the U.S. to utilize mental health services (Barrera & Longoria, 2018). Reasons for this also include socioeconomics, acculturation issues for immigrants (such as language barriers or not understanding the health care system), cultural stigma towards mental illness, and distrust of the medical and mental health systems due to “past experiences of discriminatory treatment or ineffective care” (Barrera & Longoria, 2018, p.3). The article by Tanielian & Stein (2006), while it touches lightly on the disparities and the need for increased cultural competence in delivering mental health services following a terrorist attack, does not fully account for such deep-rooted issues, which could limit much needed mental health care. Understanding the depth of these systemic factors are incredibly important for not just improving mental and physical health for minority populations in general, but even more so after an acute event such as a terrorist attack.

Tanielian & Stein (2006) note that one of the most important and beneficial strategies for reducing psychological distress after a terrorist attack is to build and strengthen community relationships. They also suggest that response strategies target the needs of specific groups such as victims, vulnerable groups, and first responders. They discuss the use of psychological first aid, and how the Red Cross has recently (as of the time of the article in 2006) begun a Disaster Mental Health program to specialize in and provide these services following disaster incidents, including terrorist events. The authors do note that there may be still problems with this, however, with a lack of cultural-specific training and training specific to terrorist attacks. I am a Disaster Mental Health volunteer with the Red Cross, and I find this absolutely to be the case – I did not receive any training for how to change services or tactics dependent on the type of disaster, nor any training on how to work with people of different cultural groups.

Tanielian & Stein (2006) focus their article on working on the psychological distress with victims following a terrorist attack. However, they fail to include broader implications in preventing the victimized groups developing their own group identity and resorting to retaliatory violence and extremist ideologies, dehumanizing anyone who might be perceived, often incorrectly, of having some association to the terrorists. This potentiality can build into exacerbated group conflict and encourage a cycle of dehumanization and violence towards the ‘other’ (Staub, 2012). While addressing mental health issues both short and long term for victims of a terrorist attack is incredibly important, I think it is also important to incorporate prevention plans to mitigate the growth of retaliatory group identities and future conflict. Finally, any mental health interventions must include comprehensive cultural training for professionals providing aid, including understandings of implicit bias and systemic factors.

References

Barrera, I., & Longoria, D. (2018). Examining cultural mental health care barriers among    Latinos. CLEARvoz Journal, 4(1).

Haner, M., Sloan, M. M., Cullen, F. T., Kulig, T. C., & Lero Jonson, C. (2019). Public concern       about terrorism: Fear, worry, and support for anti-Muslim policies. Socius, 5,   2378023119856825. https://doi.org/10.1177%2F2378023119856825

Staub, E. (2012). The roots and prevention of genocide and related mass violence. Chapter 2 in    Anstey, M., Meerts, P. & Zartman, I. W. (eds). The slippery slope to genocide: Reducing identity conflicts and preventing mass murder. New York: Oxford University Press.

Tanielian, T. & Stein, B.D. (2006). Understanding and preparing for the psychological        consequences of terrorism. McGraw-Hill Companies, Inc., 2006.             https://www.rand.org/pubs/reprints/RP1217.html.

Ursano, R.J., Morganstein, J.C., & West, J.C. (2020). Essential issues on terrorism: Planning for      acute response and intervention. In Vermetten, E., Frankova, I. Carmi, L., Chaban, O.,   Zohar, J. (eds). (2020). Risk management of terrorism induced stress. IOS Press.

Wells, L., & Gowda, A. (2020). A Legacy of Mistrust: African Americans and the US Healthcare      System. Proceedings of UCLA Health, 24.