Trauma construction and traumatic events
In the first part of their essay series on cultural psychology, Kate and Mohammad draw attention to Dr Derek Summerfield’s critique of Western trauma narratives and reveal the limitations in our approaches to global mental health.
The era of white saviourism
Content warning: This article contains mentions of mental illness and racism.
In his groundbreaking work on decolonising trauma and post-traumatic stress disorder in Palestinian territories, Dr Derek Summerfield calls for the reform of the treatment and overmedicalisation of mental health, particularly in humanitarian circumstances. The following two-part essay series understands trauma, in line with Summerfield's arguments, to be a condition manufactured by Western psychiatry, whereby the complex, unique, and often collective suffering of individuals is reframed as a technical problem to which short-term, individually-delivered solutions are applicable. In the second essay, the implications of Western framings of post-traumatic stress disorder will be explored further through the actions of non-governmental organisations such as Médecins Sans Frontières. The series concludes by suggesting ways in which decolonising psychological care can improve inequalities in access to and treatment of mental health globally, as well as raise awareness surrounding the complexity of human nature and psyche.
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Western social constructions of trauma and traumatic events
“despite the fact that the diagnosis of PTSD was built from the specific experiences of male American veterans, its entry into the DSM-III meant that it became the definition applied to all, irrespective of culture, experience, background, ethnicity, or gender.”
Definitions of post-traumatic stress disorder (PTSD) first appeared in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III). PTSD is described as “a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event” and is diagnosed through a series of DSM criteria, including “intrusion symptoms” like nightmares or flashbacks, and “negative alterations” in mood or reactivity like feelings of isolation and anger. The DSM-III and its subsequent versions (the DSM-5 being the most recent edition) are American-made manuals that have become used globally, supposedly offering a guide to psychiatry written in a “universal language for clinicians”. However, understandings of trauma were first premised on the early experiences of American soldiers returning from the Vietnam war in 1975. In part, the trauma experienced by these soldiers was given the label PTSD as a means to depict these soldiers as solely victims of the United States’ military establishment as opposed to individuals who had also perpetrated atrocities. In this case, the PTSD diagnosis legitimised the suffering of Vietnam veterans, and offered short-term relief to their distressing symptoms. Yet, despite the fact that the diagnosis of PTSD was built from the specific experiences of male American veterans, its entry into the DSM-III meant that it became the definition applied to all, irrespective of culture, experience, background, ethnicity, or gender.
The diagnosis of PTSD has spread to all countries subject to Western imperialism. The transition of PTSD from its localised socio-political origins into ‘objective biomedicine’ demonstrates the power of colonial channels and Western ideologies. Temporally specific diagnoses of trauma that emerged during America’s war on Vietnam have been erroneously regarded as universal and context independent, and thus applied worldwide. Suman Fernando—a lead scholar in the correlation between mental health treatment and racism—describes this as an imperialistic process: Western powers “marginalise other ways of knowing, destroy diversity, make alternatives to psychiatry vanish and create monocultures of the mind”.
“Temporally specific diagnoses of trauma that emerged during America’s war on Vietnam have been erroneously regarded as universal and context independent, and thus applied worldwide.”
How do Western conceptions of trauma engender inequality in mental health treatment?
In areas of conflict, Western non-governmental organisations distribute and deploy trained medical staff to deal with the fallout of violence and to treat early trauma signs. However, the deployment of medical staff trained in Western-centred psychiatric medicine in non-Western contexts is self-defeating. The challenge for Western medical staff is attempting to apply a ‘one-size-fits-all’ approach to mental healthcare in individuals with symptoms unexplained or not understood by Western training. In taking such an approach, ownership of what is deemed important in traumatic events is transferred from those experiencing it to Western bodies deemed to know better, those “whose knowledge carries a stamp of authority”. The understanding of Western psychiatry as a globally-applicable science implies that the vast experiences of trauma survivors can be easily reduced into a single mental illness classification of “PTSD”. Thinking of trauma in this regard is simplistic, and invalidates the experiences of trauma survivors.
“ownership of what is deemed important in traumatic events is transferred from those experiencing it to Western bodies deemed to know better”
For example, on the premise of a PTSD diagnosis, many patients receive Western treatments such as counselling or medication, which “offer little in the way of alleviating the underlying causes of collective trauma”. Collective trauma refers to the “psychological reactions to a traumatic event that affects an entire society”. Acknowledgement of collective trauma is vital to validating the stories and emotions of survivors both before and during the traumatic events. By accounting for broader frameworks of “social justice, quality of life, human rights and human security”, a more nuanced understanding of the survivors' responses within the collective memory and experiences of their society can be gained, and adequate treatment provided.
“Western narratives arguably regard sufferers of collective trauma and psychological ill-health as passive bodies in need of treatment, as opposed to survivors with valid experiences.”
Furthermore, emotional distress experienced by survivors is generally hard to empirically measure in the categoric style of Western psychiatry—a limitation further exacerbated by a lack of cultural understanding. Deployed medics’ lack of knowledge or willingness to understand local idioms of distress leads to misdiagnosis and misinterpretation, pathologising of symptoms, and prescribing medication that is in some cases unnecessary and of little effect. Western narratives arguably regard sufferers of collective trauma and psychological ill-health as passive bodies in need of treatment, as opposed to survivors with valid experiences. This narrow understanding shapes and often rewrites the ways in which people view themselves as victims, which can worsen or complicate existing experiences of psychological ill health.
The dominance of Westernised trauma narratives is contingent upon the funding of Western psychiatric research and the value attributed to the Westernised methods, with very little insight into varied cultural understandings of trauma and the local idioms in which they arise. Studies that are academically and financially valued are those which underpin Western institutions’ own understanding of trauma narratives, thereby deepening Western-centric knowledge systems, while simultaneously excluding the experiences, symptoms, and accounts of trauma globally—a symptom of the colonial legacy in scientific research. With many international organisations prioritising Western-centric understandings of psychology, along with research funding being allocated to institutes mainly in the West, culturally sensitive research is excluded from international policies.
“Studies that are academically and financially valued are those which underpin Western institutions’ own understanding of trauma narratives, thereby deepening Western-centric knowledge systems, while simultaneously excluding the experiences, symptoms, and accounts of trauma globally”
For example, in tracing the history of Palestinian mental health diagnosis and treatment, Giacaman et al. emphasise the importance of “separating clinical responses to mental illness from the public health response to mass political violation”. It must be recognised that war and violence is a collective experience. Summerfield states that when witnessing the destruction of their social world, survivors lose embodiments “of their history, identity and living values and roles”. Therefore, to exclude such experiences, and to exclude context-specific socio-political understandings of trauma, can only cause further harm to survivors. The authors emphasise the need for a shift from the individual focus of Western medical indicators to broader global factors in trauma, such as a lack of human security and human rights violations.
In sum, the trend of excluding cultural contexts of trauma sustains global hierarchies. The West and “the rest” mentality reinforces centuries-old colonial structures and channels of power that depend upon stereotypes and generalisations. Such power imbalances result in an inability to reconcile different cultures, widens racial inequalities, and limits access to proper mental healthcare in resource-poor settings.
Western conceptions of trauma
In the second part of their essay series on cultural psychology, Kate and Mohammad take a closer look at the origins of international aid group Médecins Sans Frontières and discuss future directions for the continuing decolonisation of global mental health.
The case of Médecins Sans Frontières
Content warning: This article contains mentions of mental illness, racism, and discriminatory language.
Trauma projects and expeditions to ‘aid’ victims in resource-poor settings have become increasingly attractive and are fashionable for Western donors and non-governmental organisations (NGOs). However, the permeation of Western schools of thought surrounding trauma limits the degree to which the actions of these non-governmental organisations are effective or helpful. For example, Médecins Sans Frontières (MSF) deploys hundreds of their staff to conflict situations or areas affected by natural disasters. They have saved the lives of people worldwide, providing medical aid to all regardless of differences in their race, religion, creed, or political affiliation. Whilst MSF and their staff (from Western and non-Western countries) have shown courage and selflessness in their attempts to care for those most vulnerable around the world, their acts of goodwill do not come without criticism. This second part of this essay series will explore the extent to which NGOs are manipulating situations in areas of conflict and natural disaster by constructing trauma narratives as ‘epidemics’ in urgent need of attention to gain further donations, publicity, and resources. Lastly, we will explore the damaging consequences of being depicted as receptive patients or helpless victims by aid missions.
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Founded in France in the second half of the twentieth century, MSF is a private international association of doctors and healthcare professionals working to “provide assistance to populations in distress”. Despite their pledge to observe “neutrality and impartiality”, their humanitarian aim is deeply rooted in Western ideals of human rights. The rigidity of these ideals mean issues are framed and solutions are generated through the lens of colonial thinking. In the simplest sense: a humanitarian mission originating from a European country to help people deemed to be in need in Africa or Asia resembles colonial civilising missions. More specifically, in the case of post-traumatic stress disorder (PTSD), repetitive quotes in the media referring to trauma as the “hidden epidemic” likens the psychological condition to concrete communicable diseases capable of causing mass pathology. Framing localised trauma as Westernised conceptions of PTSD provides an incentive and authority for companies such as MSF to “resolve the issue”.
For example, the MSF handbook on refugee health makes claims that “20% of survivors of traumatic experiences will not recover without professional help.” Such language works to posit MSF as saviours and superior bearers of knowledge and healing, linguistically reflecting a “modern echo of the age of Empire when Christian missionaries set sail to cool the savagery of primitive peoples and gather their souls, which would otherwise be lost”. The colonial use of language was exemplified in the wake of the Rwandan genocide, when European NGOs sought out to make an early psychological intervention for the Tutsi refugees as a “preventative measure to thwart the later development of more serious mental problems,” inciting a sense of fear towards trauma and a need to “control the mentally ill of the global south”. However, the NGOs failed to provide adequate treatments, as concepts integral to the English understanding of trauma such as ‘stress’ and ‘family member’ were not translatable in Kinyarwanda and didn’t apply to Rwandan social contexts. As such, Western knowledge and its tools are incapable of identifying the expressions of trauma and the appropriate treatments cross-culturally. Further, such absolute depictions of trauma not only simplify it as a biological entity to be ‘fixed’, but pathologise human emotions and victims of traumatic events.
“Members and employees past and present of MSF made attempts to challenge their work environment through publishing of an independent report exposing the racism, discrimination, and abhorrent behaviours observed within the organisation.”
The white saviour complex at the centre of MSF's ideology is a symptom of a historical mindset that is accepting of discriminatory language and generalisations. Members and employees past and present of MSF made attempts to challenge their work environment through publishing an independent report exposing the racism, discrimination, and abhorrent behaviours observed within the organisation. As an employee of MSF relays, “I hear harmful generalisations and racist comments all the time when working internationally for MSF, from fellow international colleagues.” Employees went on to take note of their experiences in varied settings, stating they have overheard senior colleagues using hateful and ignorant language such as “These people aren't careful”, “They smell bad”, “People here can't figure it out”, “People here don't know how to do s***.” Yet the organisation's work sustains its faultless appearance, continuing to appeal to the Western eye and be championed for its exemplary humanitarian action.
“MSF joins many other Western non-government organisations in an inability to concede and amend their colonial history, address their white saviorism discourse, and dismantle their archaic protocols and procedures.”
MSF's exacerbation of white supremacy and neo-colonialism—the use of power by developed countries “to produce a colonial-like exploitation” and maintain control—are further evidenced within its division of labour: workers are split into both ‘international’ and ‘national’ categories, providing individuals in the same role with varied rates of pay and privileges dependent on their nationality and passport. Such divisions were described by MSF staff as "coded racialised language", with over 50% of its workers reporting experiences of racism. Since many ‘international’ workers depend on MSF for employment, it is hard for them to confront the administration and demand tough reforms for fear of losing their jobs.
Members of the organisation have made considerable attempts to stand against their work’s ethos, calling for MSF to look deeper into its history and what it represents, and demanding accountability for their harmful actions. Their stance is summarised by present MSF staff in the MSF dignity report published in 2021: it is impossible to view current activities and policies in MSF “outside the legacies of colonialism itself, from which MSF and the wider humanitarian sector grew, or contemporary power dynamics that maintain oppressions”. However, the impact of the report has done little to tarnish the reputation of MSF, or to change the lived experiences of both its staff and those on the receiving end of its ‘aid’. MSF joins many other Western non-government organisations in an inability to concede and amend their colonial history, address their white saviorism discourse, and dismantle their archaic protocols and procedures.
“the West medicalises and objectifies despair—responses to mass social upheaval, poor human rights, and diminishing social security—by categorising them into identifiable somatic symptoms”
The future of trauma narratives
“non-Western expressions of trauma are either falsely medicalised, untreated, misdiagnosed, or underrepresented, leading to inequalities in access to treatment for poor mental health globally”
To conclude, modern Western psychiatry and the clinical protocols and manuals that form it are based on biased Western research and experiences that are not inclusive of other cultural understandings nor the contexts in which mental ill-health arises. It is argued that the West medicalises and objectifies despair—responses to mass social upheaval, poor human rights, and diminishing social security—by categorising them into identifiable somatic symptoms. The 5th and most recent edition of the DSM has been criticised for its cultural bias and tendency to categorise all mental illnesses that do not align with Western understandings of psychology as “culture-bound syndromes”—that is, diseases or illnesses that are deemed to be specific to a particular culture or society. Subsequently, non-Western expressions of trauma are either falsely medicalised, untreated, misdiagnosed, or underrepresented, leading to inequalities in access to treatment for poor mental health globally. Implications of these discriminations bleed into the social lives of those afflicted and can have adverse effects on survivors. As Western diagnoses and understandings are prioritised, traditional coping strategies and idioms of distress are no longer meaningful to discuss patients' suffering, nor utilised as a common language for survivors, therefore exacerbating mental illness itself.
“The decolonisation movement emphasises the diversity of human experience, arguing that no single lens or methodology can encapsulate various understandings, ways of life, or experiences without falling into generalisations and omitting elements of people’s existences.”
To address colonial cycles in healthcare, critics are calling for a decolonised approach to psychology. A decolonised approach places human diversity as a priority in its thinking through actions like rewriting the curriculum used in medical schools to expand upon the limited Western frameworks currently used. The decolonisation movement emphasises the diversity of human experience, arguing that no single lens or methodology can encapsulate various understandings, ways of life, or experiences without falling into generalisations and omitting elements of people’s existences. In the case of NGOs such as MSF, training should be provided to inform their staff of the cultures that they work in. Learning about the ideas and practices intrinsic to other cultures would be a step towards acknowledging the gap between their expertise and those of local healthcare workers, community leaders, and healers. Culturally-cognisant work empowers locals to lead humanitarian agencies towards the concerns of their survivor groups, and guide them in understanding their way of life through respecting their rights, integrity, and traditional ways of coping.