Cultural Influences and Response to Trauma

“A broad understanding of culture leads us to realize that ethnicity, gender identity and expression, spirituality, race, immigration status, and a host of other factors affect not just the experience of trauma but help-seeking behavior, treatment, and recovery.”

- National Child Traumatic Stress Network

As we broaden our service response to immigrants and refugees, victims of human trafficking, and children and grandchildren of persons who have experienced trauma in this country and others, it becomes apparent that the need for more information on how to respond to trauma survivors from a cultural perspective is crucial. Not only is it necessary to understand the trauma that has occurred within cultures, but it is also important to have an understanding that how cultures respond to trauma can impact the ability of a survivor to recover from complex trauma.

Culture is not limited to one’s ethnicity or birthplace, but also relates to age, disability, religion and spirituality, social class, sexual orientation, indigenous heritage, immigration or refugee status, and gender and sex.

Laura S. Brown, author of Cultural Competence in Trauma Therapy, states that being culturally competent involves being aware of our own personal relationship to each of the above identities and to be attentive to the phenomenon of dominant group privilege.

“Privilege lends power to one’s biases; if I am a lesbian biased against heterosexual people, I may suffer from being prejudiced but I lack the social power to declare all marriage between other-sexed persons illegal. The heterosexual person, biased against me has the privilege and power to legislate against me. Acknowledging one’s privilege can be a trust-engendering and relationship-building action in therapy (advocacy). Ignoring it or pretending that it does not matter will eventually undermine trust and endanger the working alliance of therapy (advocacy). Pg. 41

The ability of a person to recover from trauma is dependent on a number of factors. How culture views the traumatic event is one of the factors. A young woman raped on a college campus in this country faces many obstacles in her recovery but also has access to sexual assault crisis services and medical care. If she chooses to let her parents know of the event, she may or may not receive support. However, if she is living in a Middle Eastern or African country, there may be a possibility that the rape occurred as an act of war resulting in the loss of status for herself and her family and possibly her death at the hands of a family member.

In some Central American countries (and others) families have had sons and daughters “disappear” or killed by the government or people posing as authority. When they immigrate to this country they are often suspicious or frightened of anyone in a government agency or in authority because of this. If a social worker or advocate is unaware of this, they may see the fear as resistance or noncompliance.

One mistake that is made by advocates/therapist/case managers is assuming the cultural identity of another person. Persons of mixed racial heritage are often identified with a group with whom they may not choose to belong or proudly identify as a member of a group that others may not recognize as a possibility. Gender identity is often confused with sex when gender identity pertains to gender roles and sex is the biological makeup. Sexual orientation is a biological response. Assumptions in regards to race, ethnicity, gender, sex and sexual orientation can lead to re-victimization of a trauma survivor.

The effects of trauma can be transmitted across generations. Children of holocaust and/or genocide survivors have grown up in a family that recognizes that their ethnicity/religion/tribal affiliations have made them the target of extremists. This can lead to either a denial of their family roots or an increase in affiliation in order to maintain the cultural identity of the victimized group.

The group’s experience in the greater world can also determine how they respond to help. If the predominant and privileged culture is descendant from the same culture that perpetuated the abuses, it may be difficult for a family to seek help outside of their own affiliation. One example of this is the American Native. Their desire to maintain services and affiliation within the tribe is a result of trying to preserve their culture and their distrust of the predominant (conquering) culture. Keeping in mind a group’s history as an oppressed people can help us understand their reluctance to seek services. This phenomenon is also reflected in populations of immigrants living together within communities. It is very important to them to maintain their cultural affiliation and maintain a sense of safety within their own communities.

Within seemingly homogeneous cultures can be a number of identities that respond to trauma differently. In New England, the Yankee culture has a strong identity with a belief in the idea of “pulling one’s self up by the boot straps” and moving on without a lot of discussion of the event. Rural populations respond differently than urban and within each of those, there may be subsets of identities that respond differently. It becomes increasing important to learn as much about a person’s identity and affiliations as possible in order to be aware of any implications due to racism, classism, poverty, sexism, ageism, homophobia, et.al. and, as said before, be aware of any privilege or oppression that exists because of your own identity.

As it is very difficult to discuss all of the implications in regards to cultural trauma and competencies I highly recommend Laura S. Brown’s book, Cultural Competence in Trauma Therapy, Beyond the Flashback (APA Publishing, 2008). Even if you are not a therapist, this book is an excellent resource for expanding your understanding of the influence of identity on a person or a group’s experience of trauma.

4th National Conference on Women, Addiction, and Recovery – Thriving in Changing Times, Chicago, July 26-28, 2010

I attended the 4th National Conference on Women, Addiction and Recovery in Chicago last week. There were approximately 700 people in attendance, mostly women, and the agenda was full and motivating. It was sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA), Treatment Alternatives for Safe Communities (TASC, Inc.) and The ATTC Network. The focus of the conference was to support, engage, and motivate so that providers are able to continue to thrive in the changing environment and continue to provide excellent services to women and their children who are impacted by substance abuse. The following is a synopsis of the plenaries and the workshops that I attended.

The Honorable Pam S. Hyde, J.D. of SAMHSA and Carol McDaid of Capital Decisions presented open plenaries on the state of behavioral health and the future of the mental health and substance use disorders field post parity and health care reform. The major point was that mental health and substance abuse treatment coverage under health reform will be covered equal to medical coverage under all insurance plans. This will extend coverage for a number of people who were not covered before.

There was a video message from the Hon. Tammy Duckworth, M.A., Assistant Secretary for Public and Intergovernmental Affairs at the U.S. Department of Veterans Affairs. She noted that the number of women returning from Iraq and Afghanistan who have mental health and substance abuse disorders is increasing and their needs are complex, some having experienced sexual assault by fellow servicemen. The impact of their deployment on their families is also significant and the Ms. Duckworth expressed the commitment of the VA in providing the needed resources for these service members.

On Tuesday, Lisa Najavits, Ph.d., discussed Emerging Developments in Trauma and Addiction. She introduced the follow-up to her program, Seeking Safety, which will be coming out in the next year. It is called Seeking Change and moves beyond the areas addressed in Seeking Safety by helping the trauma survivor to address the actual traumatic events by moving through three steps – Establishing Safety in Body and Environment, Reconstruction of Trauma, Social Reconnection.

Francine Ward, J.D., presented her personal story of recovery. Francine was raised in poverty in South Bronx and eventually became a prostitute and addict in Las Vegas before being hit by a car when she was in her late 20s. She currently has over 31 years of sobriety and is a Georgetown University graduate and is practicing law. Her message is that recovery is possible if you are willing to do the foot work and if there is someone in your life that is willing to love you to the point where you can love yourself.

Gil Kerlikowske, M.A., President Obama’s Director of the White House Office on National Drug Control Policy discussed the White House’s commitment to family centered treatment as a major part of the office’s strategy to control drug use and trafficking in the United States. Mr. Kerlikowski has been visiting treatment programs throughout the country and listening to providers and consumers express their concerns and needs for more holistic means of addressing the issue.

On Wednesday morning, Jean Kilbourne, Ed.D, presented “Deadly Persuasion: Advertising, Addiction and Relationships.” In the same way that she has previously shown us in Killing Us Softly, Dr. Kilbourne was able to illustrate how advertisers use the psychology of addiction to target the 30% of people who drink 90% of the alcohol in this country. She noted that advertisers do not actually want people to drink responsibly because if everyone in this country drank what would be considered responsibly, then alcohol sales would decrease by 80%. Ads that show alcohol as sexy and desirable are playing into the addicts feelings that alcohol is their lover and friend. She also showed how advertising is directed to children in order to keep the number of consumers stable or growing. One shocking aspect that she discussed was how television and magazines basically sell the public as product, i.e. “if you advertise your beer in our magazine we can guarantee that you will have a certain number of readers who will see your ad and possibly buy your product.”

The workshops at this conference were well planned to provide time for lecture and discussion or to spend time with an expert in the field. On Monday, I attended a lecture on “Women, Addiction & Personality Disorders” given by Drs. Karen Dodge and Caterina Iapaolo of the Hanley Research Center in Florida. The premise was that substance abuse often presents with the same characteristics as a personality disorder and once the person becomes sober, the characteristics will diminish. They demonstrated this through case studies and research statistics. It was noted by many of the audience members that the same characteristics were reactions to trauma and that in each of the case studies trauma had occurred during the person’s childhood. The researchers had not made the same connection, but it was exciting to hear that the audience was well aware of trauma and its impact and were able to bring that information forward.

Lia Gaty, LCSW, from Iowa presented “Attachment Rhythms for Women in Trauma Recovery.” Through the use of emotionally engaging mirroring games she illustrated the rhythm of attachments through the states of attachment, disruption and repair.

Dr. Stephanie Covington, Dr. Sherri Green, and Niki Miller (of NH DOC) presented “A National Women’s Peer Recovery Support Initiative” and stressed the importance of gender responsive treatment programs that are trauma informed. The focus of the discussion was the increasing availability of peer support services. We discussed the development of a national leadership initiative that will train recovering women to be peer supports to women who are just becoming clean and sober. It was also discussed how this could be a great opportunity for domestic violence programs to have additional support for women in shelters. The domestic violence movement has had a long tradition of peer support and this can be expanded into enhancing services to trauma survivors with substance abuse issues.

On Tuesday morning I attended a workshop and facilitated discussion on “Racial/Gender Identity Development: Thriving in the Stages of Recovery.” Dr. Mary Henderson and Carolyn Ross of TASC led a lively discussion on the stages to developing racial and gender identity and how that influences a person’s recovery from drugs and alcohol. The audience was very diverse and the facilitators created a safe space for people to share from their own experience regarding how they and clients they have worked with have dealt with issues regarding race and gender identity.

On Tuesday afternoon I attended a tea with Dr. Stephanie Covington, author of A Women’s Way Through the 12 Steps” and four comprehensive, integrate, gender-responsive curricula that relate to the issues in the lives of women and girls, including trauma and substance abuse. She answered questions specific to curricula and more general questions regarding trauma informed care for women who are survivors of trauma. I found it validating to hear from other professionals about their concerns and their recognition that services have to be trauma informed in order to meet the needs of substance abusing women.

The conference was also very focused on providing a healthy environment for all attendees. On Tuesday evening, Joan Borysenko, a licensed psychologist, Harvard trained scientist and a pioneer in mind/body medicine led a work shop, “Revive: Creating Synergy in Mind, Body, Spirit and Work,” which gave participants to discuss what gives them joy, what stresses them out, and provided an opportunity to set goals for the future. All of this was done in an atmosphere that created a chance to meet new people and engage in lively conversation.

This conference is held every two years and it has not been decided where it will be held in 2012. It was encouraging and validating to see that trauma was a focus of a number of workshops and it is my hope that this will be expanded even more in the future. The conference planners also provided many opportunities to explore Chicago and continue discussions after hours.  I have posted links to various websites mentioned at the conference on this blog.