It has long been recognised that war and conflict have devastating and long-term effects on mental health. However, there has been growing recognition over the last fifty years that conflict-related trauma is as much a cultural as a biological phenomenon, which must be treated as such by the medical and aid community alike. From understanding the diversity of beliefs about healing in post-conflict Nepal, to dealing with the mental health of the millions of forcibly displaced persons across the globe, anthropology is a key, yet still underused tool in bringing social, cultural and political issues to the fore in humanitarian interventions today.
Questioning assumptions about trauma
The concept of ‘trauma’ first came to western medical attention following the Vietnam War, in relation to traumatised American veterans. Trauma was defined as an event that is markedly distressful to almost anyone. However, outside of biomedical discourse this definition has been contested by many. Several key assumptions are made in a medical diagnosis of trauma, or Post Traumatic Stress Disorder (PTSD), which need to be reconsidered particularly in relation to designing and implementing effective interventions that are aimed at those affected by war and conflict.
Assumption 1: Trauma is individual
Trauma counselling in the west usually revolves around the internal psychological processes of the individual. However, at the Centre for Victims of Torture (CVICT) in Nepal, practitioners put a strong focus both on the individual as well as the social in ‘psychosocial’ counselling, in recognition of the Nepali saying ‘Dukha pokhyo bhane dukha kam hunchha’ (after sharing your pain it becomes less). ‘Psychosocial’ interventions, which mean care for individual and collective psychological wellbeing, are becoming increasingly popular with international NGOs as ways of dealing with conflict’s impact on mental health.
In Nepal, this means borrowing from anthropological concepts to work with wider community connections, existing ways of healing, and Nepali culture and values. Some Nepalese believe that hungry spirits cause illness. Illness can also be caused by bewitchment (control of spirits by witches), loss of soul (fright can cause the soul to leave the body) and spirit possession. Shamanic ritual, Ayurvedic healers, jharpuke vaidyas (healers that work through ‘blowing’ of mantras and ‘sweeping’ to remove evil influences), visiting priests and doing Hindu puja, are all used to cure illness by driving out distress inflicted by spirits. These rituals demonstrate how signs and symptoms of illness are performed in a ‘theatre of belief’, where religious beliefs shape expectations of what is needed to cure illness. Psychological counsellors at the CVICT purposefully reflect these expectations in their own treatment practices for conflict-related trauma, such as relaxation exercises or working with eye-movements in EMDR (eye movement desensitisation and reprocessing).
Assumption 2: Trauma is universal
PTSD in western psychiatry is a universalistic concept, which assumes that trauma-associated phenomena will be the same everywhere. In contrast, ‘transcultural’ psychiatric studies show that the huge variety of human belief systems and values influences interpretations of traumatic symptoms in different ways, even within the same country. Psychiatrist Pat Bracken talked to a 40-year old Ugandan man who was beaten and humiliated while being interrogated as a political prisoner during the Ugandan civil war, yet denied having experienced any great distress because of his strong identification with the suffering of Jesus Christ. Meanwhile Ria Reis, an anthropologist, found that in Northern Uganda many Acholi children, particularly former child soldiers, complain of being haunted by cen, spirits of people who died during the war. Cen are associated with multiple feelings including guilt, fright, or sadness.
Understandings of trauma are innately political, because power expresses itself in its ability to define what is ‘normal’. The western concept of PTSD pays little attention to the multiple cultural, social and political subtexts underlying the expression and reception of trauma in different settings. In post-conflict Northern Ireland, for example, opposing political narratives of trauma still compete for social recognition. Elsewhere, in rural Mozambique, war-affected populations employ a wide range of traditional rituals to help them deal with the traumas of war, as illness is seen to result from the intervention of malevolent valoyi (witches and sorcerers) or ancestral spirits.
Assumption 3: One treatment methods fits all
There is a common assumption that western forms of psychotherapy are appropriate in all contexts.
For Cambodian refugees in the US, a traumatic nightmare is interpreted as a defect in a person’s protective barriers against assault from violent khmaoch spirits, who symbolise the violence of the Khmer Rouge regime and the Pol Pot period. Multiple cultural practices are performed in an effort to strengthen protective layers and to extrude maleficent forces and spirits. Devon Hinton incorporates a cultural understanding of traditional trauma healing beliefs and practices into his treatment recommendations for Cambodian refugees with nightmares: he suggests that when prescribing medication, the therapist should discuss with the patient how the medicine increases bodily energy and protects against assault by a khmaoch. In this context, anthropological understanding of the patient’s cultural background, particularly their conception of the self and its relationship to the supernatural, is of much greater importance than the exploration of internal psychological cognition and emotion as a form of therapy or healing.
The task ahead
In 2007 the World Health Organisation (WHO) issued guidelines for humanitarians working to protect and improve mental health and psychosocial well-being in emergencies. The guidelines stress the importance of learning local cultural practices and tailoring assessment tools to meet the local context. This shows recognition among the international aid community of the importance of working in a culturally informed way across diverse conflict-affected contexts. That being said, there is much to be done: the ‘mental health time bomb’ posed by eight million child refugees means that recognising anthropology’s role to play in humanitarian interventions is now more critical than ever.