mary

e Stree

a r t i c l e i n f o

Article history:Available online 29 April 2008

Keywords:TraumaPsychiatryAnthropologyDiscourse

ety. Although it is well known that violent conicts havea profound impact on individuals, communities, and/orspecic ethnic groups, not enough attention has beenpaid to local patterns of distress, long-term impacts onhealth, and psychosocial consequences (Pedersen, 2002).

aim at preventing and treating the consequences of vio-lence and mental health (Barudy, 1989). Until now, thereis no agreement on the public health value of the conceptof PTSD and no agreement on the appropriate type ofmental health care (McFarlane & Yehuda, 2000). Instead,psychiatrists and psychologists have engaged in sometimeserce discussions over the universality of war trauma,PTSD, and other trauma-related disorders.

* Corresponding author. Tel.: 1 514 933 0540.E-mail address: hanna.kienzler@mail.mcgill.ca

Contents lists available at ScienceDirect

Social Science

lsev

Social Science & Medicine 67 (2008) 218227ally diverse contexts. 2008 Elsevier Ltd. All rights reserved.

Introduction

In the last 60 years there have been over 200 wars andarmed conicts, in which the main targets are oftenmarginalized ethnic groups and the poorest sectors of soci-

Researchers have tried to determine and verify theeffects of violent conicts on the mental health of thoseaffected by focusing on war-trauma, PTSD, and othertrauma-related disorders. This, in turn, led to the develop-ment of different kinds of theories and aid programs thatPost-traumatic stress disorder (PTSD)WarViolence0277-9536/$ see front matter 2008 Elsevier Ltddoi:10.1016/j.socscimed.2008.03.030a b s t r a c t

Researchers have tried to determine and verify the effects of violent conicts on the men-tal health of those affected by focusing on war trauma, posttraumatic stress disorder(PTSD), and other trauma-related disorders. This, in turn, led to the development of differ-ent kinds of theories and aid programs that aim at preventing and treating the conse-quences of violence and mental health. Until now, there is no agreement on the publichealth value of the concept of PTSD and no agreement on the appropriate type of men-tal-health care. Instead, psychiatrists have engaged in sometimes erce discussions overthe universality of war trauma, PTSD, and other trauma-related disorders. The two mostpolar positions are those who try to validate PTSD as a universal and cross-culturally validpsychopathological response to traumatic distress which may be cured or amelioratedwith (Western) clinical and psychosocial therapeutic measures, and those who arguethat the Western discourse on trauma only makes sense in the context of a particularcultural and moral framework and, therefore, becomes problematic in the context of othercultural and social settings. Although these positions seem mutually exclusive, theirdebates have led to the development of less radical approaches toward war-trauma andPTSD.The purpose of this literature review is to analyse the discourses on and debates over war-trauma and PTSD in the psychiatric literature in order to establish a better understandingfor the diverse conceptualizations, interpretations and proposed healing strategies. More-over, I discuss the cultural construction and conceptualization of war-trauma and PTSDfrom an anthropological perspective and show how anthropologists contribute to psychi-atric debates so as to ensure more sophisticated diagnoses and healing strategies in cultur-Anthropology, McGill University, 855 Sherbrook t West, Room 717, Montreal, Quebec H3A 2T7, CanadaHanna Kienzler *Debating war-trauma and post-traudisorder (PTSD) in an interdisciplin

journal homepage: www.e. All rights reserved.atic stressarena

& Medicine

ier .com/locate/socscimed

H. Kienzler / Social Science & Medicine 67 (2008) 218227 219In the following I will review discourses on and debatesover war-trauma and PTSD in the psychiatric and anthropo-logical literature in order to establish a better understand-ing for the diverse conceptualizations, interpretations andproposed healing strategies in culturally diverse contexts.Emanating from this, I propose that through combineddivision of labour psychiatrists and anthropologists couldguarantee a more ne grained analysis of how Westernapproaches to healing could be adequately embedded innon-Western cultural and social settings.

The cultural construction of war-trauma and PTSD

Western psychiatrists and psychologists have shown anincreasing interest in the psychological consequences ofwar-trauma and trauma-related disorders. One responseto violence and trauma was the development of theconcept of posttraumatic stress disorder (PTSD) whichwas included in the DSM-III in 1980. Since then, the con-cept has been widely recognized as valid and has beenused to explain reactions to trauma in different situations,for example, with civilian and military casualties of war(Bracken, Giller, & Summereld, 1995).

As with other concepts developed in Western psychia-try, it is important to examine how PTSD is embedded inspecic congurations of cultural meaning and social rela-tionships (Kleinman, 1980). As anthropologists we inquireabout how the actors in a particular social setting thinkabout and act in health care by paying attention to theirbeliefs about sickness, their decisions about how to act inresponse to particular episodes of sickness, and theirexpectations and evaluations of specic types of healthcare. Thus, medical anthropologists have the opportunityto conduct ethnographic research on the construction andreconstruction of specic diseases and disorders such asPTSD (Good, 1992), outline the characteristic lay andprofessional interpretations of illness, and reveal howthese are constrained by different explanatory systems(Kleinman, 1985).

Various scientic, sociological, historical, and philo-sophical projects exist that aim at displaying or analysingactual, historically situated, social interactions or causalroutes (Hacking, 1999:48) that led to the developmentand establishment of the posttraumatic stress disordersyndrome. For example, the psychiatric discourse of theAmerican Psychiatric Association (2000) relates to PTSDas a non-contingent entity (Hacking, 1999) which is theinevitable result of a research trajectory. More specically,it was discovered that PTSD is an anxiety disorder that ischaracterized by the reexperiencing of an extremely trau-matic event accompanied by symptoms of increasedarousal and by avoidance of stimuli associated with thetrauma (American Psychiatric Association 2000:429). Theessential features of PTSD are the development of characteris-tic symptoms that follow exposure to an extremely traumaticevent to which aficted persons respond with intense fear,helplessness, or horror (2000:463). The events that areconsidered traumatic include, but are not limited to, mili-tary combat, violent personal assault, being kidnapped, be-ing taken hostage, terrorist attacks, torture, incarceration asa prisoner of war or in a concentration camp, natural ormanmade disasters, severe automobile accidents, or beingdiagnosed with a life-threatening illness. Individuals whohave recently emigrated from areas of considerable socialunrest and civil conict are considered especially proneto developing elevated rates of PTSD. Such individuals aresaid to be especially vulnerable and reluctant to divulgeexperiences of torture and trauma and, as a consequence,specic assessments of traumatic experiences and relatedsymptoms are required for such individuals.

The American Psychiatric Association describes andengages with disorders such as PTSD as though they weretimeless, universal, and cross-culturally valid. Accordingto Young (1995), the discourse is built on two themes: (a)PTSD exists as an entity prior to and independently of theways in which psychiatric experts diagnose, study, andtreat it; and (b) chronology: retrospectively the disorderhas been identied in historical and literary gures suchas The Epic of Gilgamesh, Erichsen (1864) and Page(1883) who were the rst ones to recognize the posttrau-matic syndrome, Kardiner (1941) who codied the disor-ders syndromal features, and the creation of the DSM-III.

Young, on the other hand, outlines causal historicalprocesses (Hacking, 1999) that led to the invention ofPTSD in the 1980s by arguing that, contrary to the assump-tions outlined above, the disorder is not timeless, butglued together by the practices, technologies, and narra-tives with which it is diagnosed, studied, treated, and rep-resented by the various interests, institutions, and moralarguments that mobilize these efforts and resources(Young, 1995:5). Hence, PTSD is a historical product thatoriginated in the scientic and clinical discourse of the19th century. Until the 19th century, the concept of traumawas identied primarily with physical injuries. Erichsen,one of the rst physicians to describe a syndrome similarto PTSD, identied it during the 1860s when he examinedvictims of railway accidents. He accredited the syndrometo loosely dened neurological mechanisms and called itrailway spine syndrome (Erichsen, 1864:16). A few yearslater, Charcot (1889) proposed the earliest psychologicalaccount of the syndrome arguing that patients sufferingfrom railway accidents were most likely to suffer fromhysteria. Janet (1903) and Freud (1922) developed thisidea further by explaining that the syndrome could alsobe produced by a psychological trauma which is too dif-cult to process for the aficted. Because the memories arepainful and unmanageable, the conscious personality sup-presses them from awareness by storing it in the subcon-scious (Janet) or unconscious (Freud). During World WarI, the analysis shifted from railway spine syndrome and hys-teria to the diagnosis of a large number of soldiers withtraumatogenic shell shock. Kardiner codied its characteris-tic features and identied its delayed and chronic forms inthe 1920s. However, only in the 1980s did the diagnosis re-ceive ofcial recognition and was included in the third edi-tion of the DSM-III. The publication of the DSM-III isdescribed by Young as a revolutionary event for Americanpsychiatry. For the rst time, it created a national standardfor classifying and diagnosing mental disorders based onan atheoretical approach (Young, 1995:127).

According to Young, the inclusion of PTSD in the DSM-IIIwas, however, not only a medical and psychiatric

H. Kienzler / Social Science & Medicine 67 (2008) 218227220achievement, but included political as well as moraldebates led by American veterans of the VietnamWar. Dur-ing the 1980s, psychiatrists noted high rates of mentalhealth problems and self-destructive behaviour in veteransof the VietnamWar. At the same time, veterans pleaded fora diagnostic criterion that would establish their eligibilityfor disability compensation, legitimated victimhood, andmoral exculpation through a doctor-attested and ofciallyrecognized disorder. Yet, Young does not mean to say thatpeople diagnosed with PTSD do not suffer. Similar to Hack-ings notion of interactive kinds (Hacking, 1999:104), heargues that it is possible for a thing to be real and sociallyconstructed at the same time since to say that traumaticmemory and PTSD are constituted through a researcherstechno-phenomena and styles of scientic reasoning doesnot deny the pain that is suffered by people who are diag-nosed or diagnosable with PTSD. (.) The suffering is real;PTSD is real (Young, 1995:10).

Although scientic research on PTSD still largely focuseson veterans, attention is shifting to post-conict countriesinwhich high rates of PTSD are reported. Trauma advocatesworking in war-torn areas across the globe claim that post-traumatic stress becomes worse unless it is treated byWestern-style approaches. For example, the WHO Reporton Mental Health in Emergencies (WHO, 2003) claimsthat most acute mental health problems during acuteemergency phases are best managed by the principles ofpsychological rst aid. During the reconsolidation phaseit is recommended to educate humanitarian aid workersand community leaders in core psychological skills suchas psychological rst aid, emotional support, providinginformation, sympathetic reassurance, and recognition ofcore mental health problems. Similarly, the Inter-AgencyStanding Committee (IASC, 2007) states that it is crucialto protect and improve peoples mental health and psycho-social well-being in the midst of an emergency through (a)psychological rst aid for people in acute trauma-induceddistress by a variety of community workers and (b) carefor people with severe mental disorders, including severePTSD, by trained and supervised health staff only. Theseconsensus criteria on approaches to trauma treatmentlargely ignore the criticism voiced by several researcherswho argue that no convincing evidence of the efcacy ofthe advocated practices seems to exist (Pupavac, 2002;Summereld, 1998). One wide spread criticism of intercul-tural therapy is that its efcacy has not yet been proved byquantitative measurement and that the application of psy-chotherapy outside the European middle class milieu israther limited (Littlewood, 1992).

Debating war-trauma and PTSD in thepsychiatric arena

Medical knowledge of PTSD is a social and culturalinvention shaped through the therapeutic recounting oftraumatic events, the acknowledgement of stress response,and the production of a formal diagnosis. As mentionedabove, there exists no agreement on the public health valueof the concept of PTSD and the appropriate type of mentalhealth care. Instead, psychiatrists and psychologists aredivided into several camps which engage in sometimesheated debates over the universality of war-trauma, PTSD,and other trauma-related disorders.

PTSD: a universalistic and cross-culturally validresponse to traumatic distress

The majority of psychiatrists and psychologists assumethat traumatic experiences lead to traumatic memorieswhich may result in PTSD. The syndrome itself is believedto be a universal and cross-culturally valid psychopatholog-ical response to traumatic distress (Young, 2006). However,mental illnesses in culturally diverse populations havebeen difcult to measure. Only recently, researchers havereported that reliable and culturally validated screeninginstruments for psychiatric distress have been developed.That is, protocols and scales based on the symptom listssuch as the DSM and ICD have been translated into locallanguages, thus permitting investigators to distinguishtraumatic suffering from seemingly similar kinds of psy-chological distress (Mollica et al., 1992).

Until the late 1980s, standardized screening instru-ments for measuring PTSD were mainly applied to theassessment of American war veterans. Two of these mea-sures were the Mississippi Scale for Combat-Related Post-traumatic Stress Disorder and the Minnesota MultiphasicPersonality Inventory. However, due to the great ow ofrefugees into the United States, the development of cultur-ally sensitive psychological tests and symptom checklistsfor assessing anxiety and depression has been promoted(Mollica et al., 1992). These include amongst others, theHarvard Trauma Questionnaire, the General Health Ques-tionnaire-28, and the Medical Outcomes Study 20. TheHTQ is the most frequently applied screening tool and con-sists of a checklist for measuring trauma, torture events,and trauma-related symptoms. It is designed as a self-report scale which includes three sections. The rst sectioncomprises seventeen items that describe a range of trau-matic experiences; section two consists of an open-endedquestion that inquires about the respondents subjectivedescriptions of the most traumatic event(s) that they expe-rienced during their refuge; and the nal section includesthirty symptom items (Mollica et al., 1992). In contrast tothe HTQ, the GHQ-28 is used as a community screeningtool and for the detection of non-specic psychiatric disor-ders in individuals in primary care settings. The mentalhealth status of the respective patients is measured withthe help of the four subscales: somatisation, anxiety, socialdysfunction, and depression. The MOS-20, on the otherhand, consists of twenty items on six different scales thatassess physical functioning, bodily pain, role functioning,social functioning, mental health, and self-perceived gen-eral health status. Generally, the three different scales arechosen to obtain information on common, non-specicpsychiatric problems; to gather information on specicpsychiatric syndromes like PTSD and related traumaticevents; and to get a broad understanding of the level of so-cial functioning and disability in the respective populationunder study (Cardozo, Vergara, Agani, & Gotway, 2000).Other screening tools include the Hopkins SymptomCheck-list-25, the Vietnamese Depression Scale, the Zung Scale forDepression, the NIMH-Diagnostic Interview Schedule, the

H. Kienzler / Social Science & Medicine 67 (2008) 218227 221Senegal Health Scales, the Post Traumatic Stress DisorderSymptom Scale (PSS), and theMini International Neuropsy-chiatric Interview (MINI) (Solomon, 1996).

Researchers recognize that PTSD does not occur ineveryone who has experienced traumatic events and thatthe traumatic event itself does not sufciently explainwhy PTSD develops or persists. So far, presumed risk factorsare divided into two categories: (a) those pertinent to thetraumatic event (severity of the type of trauma) and (b)those relevant to individuals who experience the event(gender, prior experiences, personality characteristics). Fur-thermore, data have emerged that suggest biological oreven genetic risk factors for PTSD (Yehuda, 1999; see alsoKessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Shalev,2002). Populations considered generally at great risk forPTSD and other trauma-related disorders are refugees,IDPs, people living inwar zones, veterans of armed conict,and victims of a range of criminal acts such as sexualassault, terrorist attacks, and torture (Fairbank, Ebert, &Costello, 2000). Epidemiological studies focusing on theserisk populations attempt to assess the short and long-term effects of trauma on mental health and disability. Akey issue is whether psychological reactions to traumapersist over time and whether such reactions can becomedisabling (Steel, Silove, Phan, & Bauman, 2002). Researchthat focuses on individual vulnerability following the expo-sure to trauma includes studies on war-affected peoplefrom all over the world. For example, the Program in Refu-gee Trauma conducted a study of exiled Burmese living inBangkok. The 140 participants reported an average of thirtytrauma events, poor health, and lack of social support. Theprevalence of elevated symptom scores was 38% for depres-sive symptoms and 23% for criterion symptoms of PTSD.Consequently, the research team concluded that the youngadults were severely affected by trauma and state that theirpsychosocial well-being may deteriorate further withoutlegal protection to reduce the continuing stress and vio-lence (Allden et al., 1996). Other epidemiological studieson war-affected populations include surveys conductedwith Cambodian refugees who survived the regime of PolPot (Boehnlein, Kinzie, Sekiya, & Riley, 2004; Mollica, Cui,McInnes, & Massagli, 2002); Tamils suffering from theeffects of torture (Silove, 1999); Tibetans in exile (Mercer,Ager, & Ruwanpura, 2005); Senegalese refugees (Tang &Fox, 2001); Rwandan adolescents (Schaal & Elbert, 2006);Bosnians (Momartin, Silove, Manicavasagar, & Steel,2003); Kosovars (Cardozo et al., 2000), Israelis and Palesti-nians living in Israel (Hobfoll, Canetti-Nisim, & Johnson,2006); Holocaust survivors and their children (Golieret al., 2002); and many more.

Besides vulnerability, epidemiologists consider resil-ience a crucial construct within the traumatic stress re-sponse (Paton & Volanti, 2006). Research that emphasizescoping and resilience in survivors includes, for instance,investigations that document the psychosocial adjustmentof young Cambodian refugees in Canada. Rousseau, Drap-eau, and Rahimi (2003) argue that the trauma a family suf-fered before leaving their homeland and prior to theteenagers birth seems to play a protective role at varioustimes in adolescence with regard to externalized symp-toms, risk behaviour, school failure in boys, and fosterspositive social adjustment in girls. It is concluded that thesereactions may be understood as overcompensation by thechildren of the survivors of a massacre, to whom theimplicit duty to succeed has been passed on. Similar nd-ings are reported by Beiser, Turner, and Ganesan (1989)as well as Tousignant et al. (1999), who studied Vietnameseand Laotian refugees in Canada. Overall, these studies rec-ognize that trauma-related mental illness seem to reducesteadily over time, but that a subgroup of people witha high degree of exposure to trauma has long-term psychi-atric morbidity. It is concluded that it is important to estab-lish mental health services for people who have beenexposed to extreme trauma (McFarlane & Yehuda, 2000)in order return them and the regions they live in into stableand productive environments (Cardozo et al., 2000).

In most cases, the application of Western psychothera-peutic approaches and counselling has been suggested asan important intervention in helping refugees and peopleliving in war-torn areas. The currently employed treat-ments for PTSD focus on working through the trauma byemploying traditional psychosocial, pharmacological, andcognitive-behavioural interventions (Foa & Rothbaum,1998). The need for psychiatric intervention in war tornareas and for refugees led to the development of differentkinds of aid programs that aim at preventing and treatingthe effects of violence on mental health (Barudy, 1989).Aid programs include international, non-governmental(NGO), and academic organizations which are funded bydonations from individuals, corporations, governments,and other organizations. The funding and delivery of hu-manitarian aid is increasingly organised on an internationallevel to facilitate faster andmore effective responses toma-jor emergencies affecting large numbers of people. Forexample, the International Organisation for Migration(IOM) (http://www.kosovomemory.iom.int/htm/uniting.htm)established a Psychological and Cultural Integration Unitthat addresses psychological hardships of migrantsthrough a systematic and community oriented psychoso-cial approach. Past and present activities include the Psy-chosocial and Trauma Response in Kosovo, psychologicalcomponents of the Asylum National Program, an agree-ment with the Psychotraumatology Center in Florence,and qualitative research on the health of migrants inEurope. Other NGOs concerned with mental health andcounselling are the Auroville Tsunami Relief Effort(www.auroville.org/tsunami/projects.htm), the Center forSurvivors of Torture and War Trauma (www.stlcenterfor-survivors.org), the Center for The Victims of Torture(www.stlcenterforsurvivors.org), the Medical Foundationto Train Trauma Counsellors in Kosovo (www.torturecar-e.org.uk/about_us/overseas_work), the Program for theSurvivors of Torture and Severe Trauma (www.cmhswe-b.org/programs/pstt.html), and the War Trauma RecoveryProject (www.umsl.edu/divisions/artscence/psychology/ctr/projectswartrauma.html).

One of the most well-known academic projects is theHarvard Program in Refugee Trauma (www.hprt-camridge.org).HPRT is a multi-disciplinary program that has been pio-neering the health and mental health care of traumatizedrefugees and civilians in areas of conict and natural disas-ters. In collaboration with Ministries of Health around the

H. Kienzler / Social Science & Medicine 67 (2008) 218227222world, the organization developed a community basedmental health service. Other academic institutions are theBellevue/NYU Program for Survivors of Torture (www.suri-vorsoftorture.org/survivors/), the Boston Center for Refu-gee Health and Human Rights (www.bcrhhr.org), theInternational Institute of New Jersey (www.iinj.org), andthe Latin American Collective Psychosocial Work (Barudy,1989). The goal of these programs is to permit elaborationon the suffering at an individual, familial, and group level,and to facilitate group dynamics that can trigger the poten-tial of the victims to transform the conditions of violencethat cause and maintain their pain.

However, despite their enthusiastic engagement, psy-chiatrists working in war-torn areas are often equippedwith inadequate resources and overwhelming demands.Since their own psychological vulnerability is of growingconcern, they are considered to be a new risk group vulner-able to PTSD and trauma-related disorders (McFarlane,2006; see also Barbanel & Sternberg, 2006; Shalev, 2002).

PTSD: a EuroAmerican invention

In recent years, dissent has arisen among psychiatriststhat challenges and even denies the validity of the PTSDconcept. Critics state that PTSD is an example of how soci-ety and politics have helped to create rather than discovera mental illness. That is, psychological knowledge is theproduct of a particular culture at a particular point intime and, thus, an ethnomedical system among others.From this point of view, intrusion-avoidance symptomsare related to the search for meaning, meaning is alwaysrelated to cultural backgrounds, and, thus, PTSD is seen tobe the product not of trauma in itself but of trauma andculture acting together. Accordingly, the globalization ofWestern ideas about suffering and its remedies becomeproblematic in the context of other cultural andsocietal settings (Almedom & Summereld, 2004; Bracken,1998, 2001).

Summereld illustrates this by referring to Argenti-Pillens (2004) queries about whether imported Westerntraumawork could contribute to a destabilisation of cultur-ally specic forms of Sri Lankas postwar organization.Argenti Pillen focuses on coping strategies employed byrefugee Sinhalese womenwho live in rural slum communi-ties and witnessed the death and disappearance of familymembers. According to her, women avoid further cyclesof violence by employing domestic cleansing rituals andcautious discourses that undermine the risks and poten-tial dangers of fearlessness. Their means of coping were,however, severely challenged by non-governmental mentalhealth organizations promoting Western style traumacounselling. The latter misconceived the local practices aswar-related illnesses and equated themwith Western con-cepts such as PTSD, depression, and psycho-somatisation.

Moreover, the international therapeutic model isblamed for employing inadequate research methods and,as a consequence, constructs war-affected populations astraumatized, hopeless, or brutalized, thus, vengeful enoughto start a new cycle of violence (Summereld, 2005).According to McHugh and Treisman (2007), the question-naires which are usually used with all victims of traumahave signicant aws. Besides being over-inclusive, thequestionnaires wrongly assume that the subject under-stands the question the same way as the researcher does.Furthermore, it is not acknowledged that different psycho-logical conditions manifest themselves with similar mentalsymptoms or that not all cognitive or affective responses todistress are forms of disorder or psychopathology.

Other researchers criticise that the staffs of counsellingprograms are often unfamiliar with the situation they haveto address as they are ignorant of the history of the region,its cultural, social, political, and economic systems, itsformer and current power structure, and its health caresystem. With regard to the former Yugoslavia, Richter(1998) writes that as a result of the news coverage, aninux of rape trauma projects ooded into the region,and that most of the experts arrived with full condenceto put their textbook wisdom into practice, particularlywith regard to PTSD. However, instead of long-term assis-tance they offered therapeutic quick xes (1998:121)which confused the people they were meant to assist anddisrupted relations between them. Obviously, opponentsof mainstream trauma programs argue that it cannot bepresumed that people globally understand their sufferingthrough the psychology and their suffering may not neces-sarily be addressed through therapeutic programs. What ismore, the dominance of the PTSD model is believed to sup-press even other approaches and silence local perspectiveson what is helpful and important in the wake of disaster.Instead, critics hold that distress and suffering are notinevitably pathological responses to traumatic events, butnormal existential conditions (Summereld, 2000, 2005).

According to researchers such as Almedom, Jones, andSummereld, suffering is resolved in a social context, andfamilial, socio-cultural, religious, and economic activitiesmake the world comprehensible for people before, duringand after catastrophes (Almedom & Summereld, 2004).For example, during her work as a psychiatrist in Bosnia,Jones (2004) came to realise that humanitarian programsand mental health professionals approached the subjectof war trauma and children from the wrong perspective.Disregarding their particular experiences, it was assumedthat traumatized children express their symptoms similarlyand thatWestern healing strategies would be helpful. How-ever, the majority of childrenwith whom Jones worked didnot t this portrait. According to her, some of the childrenindeed showed symptoms (such as poor concentration inschool or nightmares) but did not see them as an illnessrequiring treatment. Instead, they desired improved livingconditions, more activities, supportive teachers, employ-ment for their parents, and an end to corruption.

Examples such as this one are employed by researchersto reveal that it is simplistic to regard survivors as passivevessels of negative psychological effects. On the contrary,they show that survivors act actively and in a problem solv-ing way on their environment by negotiating disrupted lifecourses, loss of status, culture shock, and the attitude of thehost society, thereby, shaping themselves, their communi-ties, and ultimately the legacy of war itself (Summereld,1998; Turton, 1991). Emanating from this, it is argued thatwe do not justice to the aficted who have to reconstructtheir lives when we assume that they are intrinsically

H. Kienzler / Social Science & Medicine 67 (2008) 218227 223damaged human beings who cannot but hand this on totheir children (Summereld, 1998:29). Thus, new ques-tions have to be asked in order to do adequate researchthat does not follow a medicalised model, and, instead ofoffering psychiatric counselling, the humanitarian aid pro-grams should acknowledge resilience and retain the socialrehabilitation frameworks, starting with the strengtheningof damaged local capacities in line with local priorities.

Building bridges between different healing traditions

The erce debates between researchers adhering to theuniversalistic and relativistic perspectives were not fruit-less. They led to the development of less radical and morereective approaches toward trauma and PTSD. That is,approaches that incorporate selected ideas from both posi-tions and that propose community oriented psychosocialtrauma intervention programs.

Similar to researchers adhering to the relativistic posi-tion, transcultural psychiatrists argue that current Westernpsychiatric nosology is based on the search for discretedisorders and, thereby, de-contextualizes and essentialiseshuman problems. Lemelson, Kirmayer, and Barad (2007)argue that Western psychiatry reects a particular Ameri-can and European view of concepts of psychopathology. Itis based on cultural conceptions of normality and deviancethat focus solely on problems located within the individualand lack a developed conceptual vocabulary for relational,social, communal, and cultural problems. Yet, rememberingand forgetting traumatic events depends on memorysystems that carve trauma not only on the body and brain,but also on the social and political processes that aim toregulate public and private recollection (see also de Jong,2004; McNally, 2003). From this point of view, mainstreamWestern psychiatry is considered to be insufcient toexplain and treat trauma cross-culturally. It is argued thatto comprehend stories of trauma, one has to understandthat dominant forms of violence are local and collectivein nature. They are embedded in and emerge frommultiplecontexts, including biological processes of learning andmemory; embodied experiences of injury, pain, and fear;narratives of personal biography; the knowledge and prac-tices of cultural and social systems; and the power andpositioning of political struggles enacted on individual,family, and community and national levels (Lemelsonet al., 2007; Pedersen, 2002).

In order to better understand war-trauma, traumaticmemory, and trauma-related disorders, Pedersen (2002)postulates new research questions, these include: What isthe long-term health impact of ethnic conict, politicalviolence, and wars in a given population? What about therole of other psychosocial factors such as resilience, socialcohesion, coping skills, the density and quality of socialsupport networks? What is the role of other social factors,such as racism and extreme nationalisms, alongsidepoverty and wars, in determining the health of diseaseequation? These questions elucidate that researchers andpractitioners adhering to a transcultural psychiatric per-spective do not agree with critics who argue that conceptsof PTSD cannot and, therefore, should not be applied tonon-Western contexts. Instead, it is their goal to buildbridges between the clinical concerns of subjects and thesocial and political contexts in which their experiencesand sufferings are embedded (see also Kagee & Naidoo,2004). Papadopoulos (2001) adopted, for example, a sys-temic perspective in order to grapple with issues concern-ing the perception of refugee families, especially in thecontext of supervision. According to him, the phenomenonof refugeedom intersects a wide variety of dimensions andis by no means exclusively of psychological nature; itinvolves issues of political, ethical, ethnic, religious, nan-cial, sociological, and ecological nature. Consequently, a sin-gle approach to refugees cannot possibly be sufcient toaddress its multifaceted complexity.

However, transcultural psychiatrists do not only wish tobuild bridges between clinical concerns and the clients cul-tural backgrounds, but between different traditions of heal-ing as well. Healing is considered part of any system ofmedicine and healing practices address central values andconcerns which are important for individuals and commu-nities (Kirmayer, 2004). Emanating from this, transculturalpsychiatrists propose a community oriented approach tohealing that combines both emic and etic approaches (Kir-mayer, 1989) so as to better understand local healing andespecially coping strategies (de Jong, 2000). Up to now,only a small number of aid programs exist that combineWestern with traditional healing strategies. For example,the collaborative program of the Transcultural PsychosocialOrganisation (TPO) aims at developing a multidisciplinary,collaborative, sustainable, and culturally sensitive traumaintervention programwith focus on a community-orientedand culturally sensitive public health response to thepsychosocial problems of refugees and victims of organisedviolence. Programs join together experience andmethodol-ogy from public health, psychology, psychiatry, and anthro-pology in order to capture idiomatic descriptions of mentalhealth problems that t local cultural illness experiences. InCambodia, for instance, the TPO involved Buddhist monks,professional traditional healers, mediums, and traditionalbirth attendants in the intervention process (Eisenbruch,de Jong, & van de Put, 2004; Somasundaram, van de Put,Eisenbruch, & de Jong, 1999). Other existing projectsinclude: the Mobile Member Care Team in West Africa(Carr, 2006); the Prevention and Access Interventions forFamilies of refugees from Bosnia and Kosovo (Weine,1998); Testimonial psychotherapy as discussed by Lustig,Weine, Saxe, and Beardslee (2004); and the CollaborativePraxis in Chajul in the Guatemalan Highlands (Lykes,2002). All projects argue for the incorporation of traditionalhealing practices, and, thus, for a pluralist healthcare sys-tem. Researchers argue that the analysis that is requiredfor such an endeavour would be a phenomenological andcultural one that provides a common ground on whichshared and disparate concerns of psychiatrists and socialscientists can be addressed and integrated (de Jong, 2004;Pedersen & Bauffati, 1989).

Anthropological contributions to discourses onwar-trauma and PTSD

How are social scientists and especially anthropologistsinvolved in the discourse on and debate over war-trauma

H. Kienzler / Social Science & Medicine 67 (2008) 218227224and PTSD? Are theymerely detached bystanders whomon-itor developments of psychiatric research, take note of andanalyse ongoing disputes between psychiatrists, and out-line genealogies of certain nosologies? Or are they actuallyparticipating in the debates as engaged critics and innova-tive activists who seek to provide new means for a betterunderstanding of war-trauma and its related disorders? Idiscussed the achievements of bystanders in the rstpart of this essay and will now turn to those of the criticsand active participants by relating them to current psy-chiatric discourses.

In her article Contract of Mutual (In)Difference, Pan-dol (2003) states that we are witnessing a massive trans-formation (2003:369) in the nature of global governanceas humanitarian networks, NGOs, and multi and bilateralorganizations are about to develop a new transnationalregime. According to her, these newly established transna-tional regimes constitute a mobile apparatus which shedenes as migrant sovereignties (2003:369). That is,within this new world order, at least two, often opposed,sovereignties may coexist in one and the same nationalterritory: one is bound to a territorial entity whereas theother results from the creation of non-territorialized formsof organization like the humanitarian apparatus. The non-territorialized forms of power and governance intervenemostly at sites of crisis and humanitarian disaster byemploying the rhetoric of institution building and Westerndemocratization (2003:370). Pandol illustrates this byreferring to the international presence in Albania andKosovo in 1991 until the peak of thewar. During this partic-ular time, the international presence was immense and thetrue agents of military-economic-humanitarian actionwere the various international organizations, agencies,foundations and NGOs, whose operations were shaped bya temporality of emergency (2003:370). That is, as soonas the conict seemed to subside and the media movedto new battle elds, the theatre of generosity [lost] itsactors (2003:380).

The contemporary humanitarian response to warincludes in addition to humanitarian aid and developmentagencies, NGOs and international organizations which offertrauma counselling to war-affected populations. Pupavac(2001) states that due to these measurements, individualemotions cease to be personal matters but become publicproperty and, subsequently, any failure by public bodiesto provide psycho-social programs or any failure by indi-viduals to take up the psycho-social support is viewed associally irresponsible (2001:361). For example, Pupavacdiscovered that in the post-war years, hundreds of thera-peutic programs had been established in Kosovo whichpresume that the population was massively affected bytrauma and, as a consequence, suffered from trauma-related disorders.

Such assumptions, Scott (1990) explains, partly resultfrom the present orientation in psychiatry that considersit normal to be traumatized by the horrors of war(1990:308) and calls for clinicians to take seriously thepatients war experience. The presumption of individualvulnerability is, thus, the basis for psychiatric diagnosis aswell as treatment. However, Malkki (1995), an expert inrefugees and refugee experiences, counters that we canneither assume psychological or mental illness beforehand,nor can we claim to know the actual source of a personsafiction. On the contrary, war-affected populations areoften reluctant to accept Western mental health modelsand are disinclined to speak to mental health specialistsabout their experiences, as they do not consider theirsymptoms pathological. Thus, she concludes that,although many refugees have survived violence and lossthat are literally beyond the imagination of most people,we mustnt assume that refugee status in and of itselfconstitutes a recognizable, generalisable psychologicalcondition (1995:510).

The critical assessments outlined above are certainlylegitimate as a number of mainstream Western psychia-trists actually deny resilience to war-affected populationsby interpreting it as evidence of psychological dysfunction-alism. Yet, the critics seem to overlook or ignore recent de-velopments in (mainstream) psychiatry where researchersnot only focus on resilience but acknowledge it as crucial tothe traumatic stress response. Moreover, several of thecritics homogenise the psychiatric discourse on war-trauma and PTSD. That is, they pay no attention to theachievements in transcultural psychiatry that is to say,the latters willingness to actually document local ways ofcoping and work with local healers and healing strategies.To provide a sound critique of psychiatric approaches tohealing researchers have to actually provide ethnographicexamples of how resilience is enacted by individuals andgroups of individuals. Scattered observations of local sus-picion of mental health workers or low take-up rates ofpsychiatric therapy cannot be considered valid examplesand indicators for resilience and do not provide insightinto local healing and coping strategies.

The contribution of social scientists, especially anthro-pologists, does not end here. In fact, they have createda discourse that runs parallel to psychiatric discussions onwar-trauma and PTSD known as social suffering. Likethe critics outlined above, medical anthropologists as wellas anthropologist-psychiatrists vehemently critique themedicalisation of trauma survivors as it reduces individualsubjectivities to victims and, thereupon, patients (Klein-man & Kleinman,1997). Instead of giving those traumatizedthe social status of a patient; researchers argue that weneed to better understand exactly how individuals,families, and whole societies respond to violence. Thus,although violence may be a very personal and subjectiveexperience, larger social actors such as the state, inter-national organizations, and the global media, as well astransnational ows in nances and people are all involvedin the creation, maintenance, and soothing of violence(Das & Kleinman, 2000:2).

In order to adequately capture the impact of violence onindividuals and communities, medical anthropologistsintroduced the concept of social suffering to the aca-demic discourse. Kleinman (1995) explain that sufferingis a universal human experience in which individuals andgroups undergo or bear certain burdens, troubles, andserious wounds to the body and the spirit (.)(1995:101). Yet, there is no one single way to suffer aspain is perceived and expressed differently, even in thesame community. That is, local differences in gender, age

H. Kienzler / Social Science & Medicine 67 (2008) 218227 225group, ethnicity, religion, and economic status as well asglobal processes inuencing local worlds turn sufferinginto a partial and complex intersubjective experience (seealso DelVecchio Good, Brodwin, Good, & Kleinman, 1991;Scarry, 1985). Suffering is, thus, considered a social experi-ence in that it is rst, an interpersonal engagement withpain and hardship in social relationships; second, a societalconstruction that serves as a cultural model and moralguide of and for experience; and third, a professionaldiscourse that organises forms of suffering as bureaucraticcategories and objects of technical intervention (Kleinman,1995). Obviously, the concept of social suffering comprisesconditions that are not initially related and comprisehealth, welfare, legal, moral, and religious issues, amongothers (Kleinman, Das, & Lock, 1997).

For example, Scheper-Hughes (1996) sensitizes readersto violent practices and sentiments committed in Braziland South Africa against children of the lower social strata.According to her, an invisible genocide is occurring againststreet and township youths in both Brazil and South Africa.These youths are considered dangerous and as a conse-quence, certain adults not only seem to feel murderoustoward them but act on these sentiments. Whereas upperclass andwhite victims have names, personalities, histories,and grieving family members, black deaths are merelycounted or remain even undocumented. Scheper-Hughesconcludes that recognizing the everyday violence andinvisible genocides practiced against the class of dangerousandendangeredyouths is a necessaryrst step in improvingthe current and abysmal state of the children of the world.

Farmer (1996) points out that the experience of socialsuffering cannot easily be expressed by statistics andgraphs. Instead, the texture of dire afiction is best feltin the rough details of biography (1996:263). To explainsocial suffering, one must embed individual biography inthe larger matrix of culture, history, and political economyand nd how various large-scale forces come to be trans-lated into personal distress and disease. An example thatconnects biography to wider societal contexts is providedby Schauble (2006) who illustrates how the traumaticexperience of the Croatian militant conict and subsequentafiction are dealt with on an individual level. She draws onan ethnographic example of a carnival episode in whichone of her key informants dressed up as a suicide bomberand employs the concept of imagined suicide to interpretdifferent layers of meaning. Markos costume consisted ofa mount of a discarded backpack on which he attachedtwo parallel gas cartridges equipped with pointed tipsand small blinking green and red lamps. The nishingtouch was provided by a cardboard sign that read HelloAmerica, greetings to your twins! See you again nextyear! Schauble argues that the terrifying concept of Mar-kos play refers less to terrorism itself than to the violencehe has experienced during war and still experiences withinhis own body (2006:8). His fears are not only connected tothe direct effects of his military service but to other, societalfactors. Like most young men, he went to war before com-pleting his education and as a consequence, hardly had thechance to train and qualify for work today. Thus, his traumais enhanced by factors including low economic status, -nancial dependency, the feeling of government sanctionedinjustice, as well as the lack of recognition and perspec-tives. Schauble interprets his performance as a visionthat is inspired by previous terrorist acts, attempting powerrelations.

Despite the anthropologists effort to promote the con-cept of social suffering, it barely penetrates the psychiat-ric discourse on war-trauma and PTSD. A rare exception isthe work published by Pedersen and Bauffati (1989) andPedersen (2002). According to him, it is crucial to connectimmediate stressful events and economic/politicalhardships with the broader social structure; to documentnon-western patterns of trauma-related conditions; andto assess the conditions in which medical or psychologicalinterventions help or hinder long-term recovery fromtraumatic experiences. In order to capture the complexitiesinvolved in the experience of massive trauma, Pedersenintroduces the notion of social suffering as an alternativeto the PTSD model. According to him, the notion of socialsuffering is a valuable concept as it stresses the need foran understanding of the ways in which macro-socialdimensions interact with the micro-social in attemptingto explain both the construction of suffering and its oppo-site, the production of health.

Conclusion

Although transcultural psychiatrists, psychiatristsadhering to a relativistic perspective, anthropologist-psychiatrists, and a considerable number of medical an-thropologists claim that only an interdisciplinary approachleads to valid investigations, data interpretations, and sub-sequently intervention strategies (Eisenbruch et al., 2004;Kleinman, 1980, 1985; Lemelson et al., 2007; Pedersen,2002), inuential interdisciplinary writs leading to actionhave not been produced in anthropological nor in psychiat-ric journals or anthologies. A rare exception is the work ofthe collaborative program of the Transcultural PsychosocialOrganization that aims at integrating public healthworkers, psychologists, psychiatrists, and anthropologists.

Psychiatrists seem to be captured by their internaldispute with regard to the universality of war-trauma andPTSD. As outlined above, the two most polar positions are(a) those who try to validate PTSD as a universal andcross-culturally valid psychopathological response to trau-matic distress which may be cured or ameliorated with(Western) clinical and psychosocial therapeutic measuresand (b) those who argue that the Western discourse ontrauma only makes sense in the context of a particularcultural and moral framework and, therefore, becomesproblematic in the context of other cultural and socialsettings. Although these positions seemmutually exclusive,their debates have led to the development of less radicalapproaches toward war-trauma and PTSD. Theseapproaches question the validity of most cross-culturalresearch on PTSD as it fails to consider indigenous expres-sions of disorder, idioms of distress, and ethnoculturalsensitivities in assessment including instrument norms,formats, language, and concepts. At the same time, theyadmit that responses to a traumatic event may sharesome universal features, especially as the trauma becomesmore severe. Thus, they conclude that ethnocultural factors

H. Kienzler / Social Science & Medicine 67 (2008) 218227226play an important role in individual vulnerability to traumaand PTSD, the expression of PTSD, and the treatmentresponsiveness of PTSD (Ehrensaft, 1995).

Medical anthropologists, on the other hand, have devel-oped a discourse that runs parallel to the psychiatric dis-course but does not necessarily inuence it. When oneenters the keyword social suffering into search engineslike PubMed,Medline, or Ovid that are specialized on topicsconcerning the life sciences, including psychiatry, no entrycan be found. Interestingly, the search results in psychiatricor psychological journals which encourage anthropologicalcontributions are almost as meagre. Upon entering theterm social suffering, titles appear that have nothing todo with trauma, war-trauma, or trauma related disorders.Instead, one can learn about internet marketing of bariatricsurgery; collective mobilization on muscular dystrophy;anti-aging medicine; youth homelessness in San Francisco;qualitative studies on motherhood; etc.

In order for anthropologists to become respected col-leagues working alongside and with psychiatrists and psy-chologist in the vast eld of trauma, it is crucial to recognizethat anthropology and psychiatry are not disciplineslocated on different poles of a continuum but separateentities that tackle similar issues from different perspec-tives, with different methodologies, and different goals inmind. This does not mean that the two disciplines shouldnot or cannot inuence each other. On the contrary, inter-disciplinary research could lead to more holisticapproaches to health care that take local perceptions ofhealth and illness, ways of healing, capacities, desires, andneeds into consideration. Thus, instead of proposing theconcept of social suffering as replacement for the PTSDmodel, I argue for a division of labour between thedisciplines that guarantees a more ne grained analysis ofhow Western approaches to healing could be adequatelyembedded in non-Western cultural and social settings.

Acknowledgments

I would like to thank Allan Young and Duncan Pedersenfor their support and critical discussion of the article drafts.I also thank Andrea Saunderson for her critical reading ofthe paper and Cees van Dijk for helping me to think thingsthrough.

References

Allden, K., Poole, C., Chantavanich, S., Ohmar, K., & Aung, N. N., et al.(1996). Burmese political dissidents in Thailand: trauma and survivalamong young adults in exile. American Journal of Public Health, 86(11),15611569.

Almedom,A.,&Summereld,D. (2004).Mentalwell-beinginsettingsofcom-plex emergency: an overview. Journal of Biosocial Science, 36, 381388.

American Psychiatric Association. (2000). Diagnostic and statisticalmanual of mental disorders-IV-TR. Washington, DC: American Psychi-atric Association.

Argenti-Pillen, A. (2004). Masking terror: How women contain violence inSouthern Sri Lanka. Philadelphia, PA: University of Pennsylvania Press.

Barbanel, L., & Sternberg, R. (2006). Introduction. In L. Barbanel, & R.Sternberg (Eds.), Psychological interventions in times of crisis. NewYork: Springer Publishing Company. (pp. xxv).

Barudy, J. (1989). A programme of mental health for political refugees:Dealing with the invisible pain of political exile. Social Science &Medicine, 28(7), 715727.Beiser, M., Turner, J., & Ganesan, S. (1989). Catastrophic stress and factorsaffecting its consequences among Southeast Asian refugees. SocialScience & Medicine, 28(3), 183195.

Boehnlein, J., Kinzie, D., Sekiya, U., & Riley, C. (2004). A ten-year treatmentoutcome study of traumatised Cambodian refugees. Journal of Nervous& Mental Disease, 192(10), 658663.

Bracken, P. (1998). Hidden agendas: Deconstructing post traumatic stressdisorder. In P. Bracken, & C. Petty (Eds.), Rethinking the trauma of war(pp. 3859). New York: Free Association Books.

Bracken, P., Giller, J., & Summereld, D. (1995). Psychological response towar and atrocity: the limitations of current concepts. Social Science &Medicine, 40(8), 10731082.

Bracken, P. J. (2001). Post-modernity and post-traumatic stress disorder.Social Science & Medicine, 53(6), 733743.

Cardozo, B., Vergara, A., Agani, F., & Gotway, C. (2000). Mental health,social functioning, and attitudes of Kosovar Albanians following thewar in Kosovo. JAMA, 284(4). 578577.

Carr, K. (2006). The Mobile Member Care Team as a means of respondingto crisis. West Africa. In L. Barbanel, & R. Sternberg (Eds.), Psycholog-ical interventions in times of crisis (pp. 7598). New York: SpringerPublishing Company.

Charcot, J. M. (1889)Clinical lectures on diseases of the nervous systemdelivered at the Inrmary of La Salpetiere, Volume III. London: NewSydenham Society.

Das, V., & Kleinman, A. (2000). Introduction. In V. Das, A. Kleinman, M.Ramphele, & P. Reynolds (Eds.), Violence and subjectivity (pp. 118).Berkeley: University of California Press.

DelVecchio Good, M. J., Brodwin, P., Good, B., & Kleinman, A. (Eds.). (1991).Pain as human experience: Anthropological perspectives. Berkeley, CA:University of California Press.

Ehrensaft, E. (1995). Culture in the diagnosis and treatment of post-traumatic stress disorder. Transcultural Psychiatry, 32, 395406.

Eisenbruch, M., de Jong, J. T., & van de Put, W. (2004). Bringing order outof chaos: a culturally competent approach to managing the problemsof refugees and victims of organized violence. Journal of TraumaticStress, 17(2), 123131.

Erichsen, J. E. (1864). Railway and other injuries of the nervous system. Lon-don: Longmans.

Fairbank, J., Ebert, L., & Costello, E. (2000). Epidemiology of traumaticevents and post-traumatic stress disorder. In D. Nutt, J. Davidson, &J. Zohar (Eds.), Post-traumatic stress disorder. Diagnosis, managementand treatment (pp. 1728). London: Martin Dunitz Ltd.

Farmer, P. (1996). On suffering and structural violence: a view from below.Daedalus, 125(1), 261283.

Foa, E., & Rothbaum, R. (1998). Treating the trauma of rape: Cognitive-behavioural therapy for PTSD. New York: Guilford Press.

Freud, S. (1922). Beyond the pleasure principle. London: InternationalPsycho-Analytical Press.

Golier, J., Yehuda, R., Lupien, S., Harvey, P., & Grossman, R., et al. (2002).Memory performance in Holocaust survivors with PosttraumaticStress Disorder. American Journal of Psychiatry, 159, 16821688.

Good, B. (1992). Culture and psychopathology: directions for psychiatricanthropology. In T. Schwartz, G. White, & C. Lutz (Eds.), New directionsin psychological anthropology (pp. 181204). Cambridge, MA:Cambridge University Press.

Hacking, I. (1999). The social construction of what? Cambridge, MA:Harvard University Press.

Hobfoll, S., Canetti-Nisim, D., & Johnson, R. (2006). Exposure to terrorism,stress-related mental health symptoms, and defensive coping amongJews and Arabs in Israel. Journal of Consulting & Clinical Psychology,74(2), 207218.

IASC. (2007). IASC guidelines on mental health and psychological support inemergency settings. Geneva: IASC.

Janet, P. (1903). Lautomatisme psychologique: essai de psychologie experi-mentale sur les formes inferieures de lactivite humaine. Paris.

Jones, L. (2004). Then they started shooting. Growing up in wartime Bosnia.Cambridge, MA: Harvard University Press.

de Jong, J. (2000). Traumatic stress among ex-combatants. In N. Pauwels(Ed.),War force to work force. Global perspectives on demobilization andreintegration. Baden-Baden: Nomos Verlag.

de Jong, J. (2004). Public mental health and culture: disasters as a chal-lenge to western mental health care models, the self, and PTSD. InJ. Wilson, & B. Drozdek (Eds.), Broken spirits. The treatment of trauma-tised asylum seekers, refugees, war and torture victims (pp. 159178).New York: Routledge.

Kagee, A., & Naidoo, A. V. (2004). Reconceptualizing the sequelae of polit-ical torture: limitations of a psychiatric paradigm. TransculturalPsychiatry, 41(1), 4661.

Kardiner, A. (1941). The traumatic neuroses of war. New York: Paul B. Hoeber.

Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995).Posttraumatic stress disorder in the National Cormorbidity Survey.Archives of General Psychiatry, 52, 10481060.

Kirmayer, L. (1989). Cultural variations in the response to psychiatric disor-ders and emotional distress. Social Science & Medicine, 29(3), 327339.

Kirmayer, L. (2004). The cultural diversity of healing: meaning, metaphor

(Eds.), Who gets PTSD? Issues of posttraumatic stress vulnerability.Springeld, IL: Charles C. Thomas Publisher, LTD.

Pedersen, D. (2002). Political violence, ethnic conict, and contemporarywars: broad implications for health and social well-being. SocialSciences & Medicine, 55, 175190.

Pedersen, D., & Bauffati, V. (1989). Healers, deities, saints and doctors:

H. Kienzler / Social Science & Medicine 67 (2008) 218227 227and mechanism. British Medical Bulletin, 69, 3348.Kleinman,A. (1980).Anthropologyandpsychiatry.Theroleofculture incross-

cultural research on illness. British Journal of Psychiatry, 151, 447454.Kleinman, A. (1985). Interpreting illness experience and clinical mean-

ings: how I see clinically applied anthropology. Medical AnthropologyQuarterly, 16(3), 6971.

Kleinman, A. (1995). Writing at the margin. Discourse between anthropol-ogy and medicine. Berkeley, CA: University of California Press.

Kleinman, A., Das, V., & Lock, M. (Eds.). (1997). Social suffering. Berkeley,CA: University of California Press.

Kleinman, A., & Kleinman, J. (1997). The appeal of experience; The dismayof images; Cultural appropriations of suffering in our times. In A.Kleinman, V. Das, & M. Lock (Eds.), Social suffering (pp. 124). Berke-ley, CA: University of California Press.

Lemelson, R., Kirmayer, L., & Barad, M. (2007). Trauma in context: Inte-grating cultural, clinical and biological perspectives. In L. Kirmayer,R. Lemelson, & M. Barad (Eds.), Understanding trauma, Integrating bi-ological, clinical, and cultural perspectives (pp. 451474). New York:Cambridge University Press.

Littlewood, R. (1992). How universal is something we call, therapy? InJ. Kareem, & R. Littlewood (Eds.), Intercultural therapy (pp. 3958)Oxford: Blackwell.

Lustig, S. L., Weine, S. M., Saxe, G. N., & Beardslee, W. R. (2004). Testimo-nial psychotherapy for adolescent refugees: a case series. Transcul-tural Psychiatry, 41(1), 3145.

Lykes, B. (2002). A critical re-reading of post-traumatic stress disorder froma cross-cultural/community perspective. In D. Hook, & G. Eagle (Eds.),Psychopathology and Social Prejudice. Cape Town: University of CapeTown Press.

Malkki, L. (1995). Refugees and exile: from Refugee studies to thenational order of things. Annual Review of Anthropology, 24, 495523.

McFarlane, A., & Yehuda, R. (2000). Clinical treatment of posttraumaticstress disorder: conceptual challenges raised by recent research.Australian & New Zealand Journal of Psychiatry 940953.

McFarlane, C. (2006). Psychological vulnerability among international aidworkers. In J. Violanti, & D. Paton (Eds.),Who gets PTSD? Issues of post-traumatic stress vulnerability. Springeld, IL: Charles C. ThomasPublisher, LTD.

McHugh, P., & Treisman, G. (2007). PTSD: a problematic diagnosticcategory. Journal of Anxiety Disorders, 21, 211222.

McNally, R. J. (2003). Progress and controversy in the study of posttrau-matic stress disorder. Annual Review of Psychology, 54, 229252.

Mercer, S., Ager, A., & Ruwanpura, E. (2005). Psychosocial distress ofTibetans in exile: integrating western interventions with traditionalbeliefs and practices. Social Science & Medicine, 60, 179189.

Mollica, R., Caspi-Yavin, Y., Bollini, P., Truong, T., & Lavelle. (1992). TheHarvard Trauma Questionnaire: validating a cross-cultural instru-ment of measuring torture, trauma and posttraumatic stress disorderin Indochinese refugees. Journal of Nervous and Mental Disease, 180,111116.

Mollica, R., Cui, X., McInnes, K., & Massagli, M. (2002). Science-basedpolicy for psychosocial intervention in refugee camps. A Cambodianexample. Journal of Nervous and Mental Disease, 190(3), 158166.

Momartin, S., Silvoe, D., Manicavasagar, V., & Steel, Z. (2003). Dimensionsof trauma associated with posttraumatic stress disorder (PTSD) case-ness, severity and functional impairment: a study of Bosnian refugeesresettled in Australia. Social Science & Medicine, 57, 775781.

Page, H. W. (1883). Injuries of the spine and spinal cord without apparentmechanical lesion, and nervous shock, in their surgical and medico-legalaspects. London: Churchill.

Pandol, M. (2003). Contract of mutual (IN)difference: governance andthe humanitarian apparatus in contemporary Albania and Kosovo.Indiana Journal for Global and Legal Studies 369381.

Papadopoulos, R. (2001). Refugee families: issues of systemic supervision.Journal of Family Therapy, 23, 405422.

Paton, D., & Volanti, J. (2006). Vulnerability to traumatic stress: personal,organisational and contextual inuences. In J. Violanti, & D. Patonelements for the analysis of medical systems. Social Science & Medi-cine, 29(4), 487496.

Pupavac, V. (2001). Therapeutic governance: psycho-social interventionand trauma risk management. Disasters, 25(4), 358372.

Pupavac, V. (2002). Pathologizing populations and colonizing minds:international psychosocial programs in Kosovo. Alternatives, 27,489511.

Richter, A. (1998). Sexual violence in wartime. Psycho-socioculturalwounds and healing processes: the example of the former Yugoslavia.In P. Bracken, & C. Petty (Eds.), Rethinking the Trauma of War (pp.112127). New York: Free Association Books.

Rousseau, C., Drapeau, A., & Rahimi, S. (2003). The complexity of traumaresponse: a 4-year follow-up of adolescent Cambodian refugees. ChildAbuse & Neglect, 27, 12771290.

Scarry, E. (1985). The body in pain. New York: Oxford University Press.Schaal, S., & Elbert, T. (2006). Ten years after the genocide: trauma

confrontation and posttraumatic stress in Rwandan adolescents.Journal of Traumatic Stress, 19(1), 95105.

Schauble, M. (2006). Imagined suicide: self-sacrice and the making ofheroes in post-war Croatia. Anthropology Matters Journal, 8(1), 114,Available from: http://www.anthropologymatters.com.

Scheper-Hughes, N. (1996). Small wars and invisible genocides. SocialScience & Medicine, 43(5), 889900.

Scott, W. (1990). PTSD in DSM-III. A case in the politics of diagnosis anddisease. Social Problems, 37(3), 294310.

Shalev, A. (2002). Treating survivors in the immediate aftermath of trau-matic events. In R. Yehuda (Ed.), Treating trauma survivors with PTSD(pp. 157188). Washington, DC: American Psychiatric Publishing, Inc.

Silove, D. (1999). The psychosocial effects of torture, mass human rightsviolations, and refugee trauma: toward an integrated conceptualframework. Journal of Nervous & Mental Disorders, 187(4), 200207.

Solomon, S., Keane, T., Newman, E., & Kaloupek, D. (1996). Choosing self-report measures and structural interviews. In E. Carlson (Ed.), Traumaresearch methodology (pp. 5681). Lutherville: Sidran.

Somasundaram, D. J., van de Put, W. A. C. M., Eisenbruch, M., & de Jong, J.(1999). Starting mental health services in Cambodia. Social Science &Medicine, 48, 10291046.

Steel, Z., Silove, D., Phan, T., & Bauman, A. (2002). Long-term effect of psy-chological trauma on the mental health of Vietnamese refugees reset-tled in Australia: a population based study. The Lancet, 360, 10561062.

Summereld, D. (1998). The social experience of war and some issues forthe humanitarian eld. In P. Bracken, & C. Petty (Eds.), Rethinking theTrauma of War (pp. 937). New York: Free Association Books.

Summereld, D. (2000). Conict and health: war and mental health:a brief overview. British Medical Journal, 321, 232235.

Summereld, D. (2005). Then they started shooting: growing up in wartime Bosnia. Times Literary Supplement. 2006, 5366.

Tang,S., &Fox,S. (2001).Traumaticexperiencesand thementalhealthofSen-egalese refugees. Journal of Nervous &Mental Disease, 189(8), 5075012.

Tousignant, M., Habimana, E., Biron, C., Maol, C., & Sidoli-Leblanc, E., et al.(1999). The Quebec Adolescent Refugee Project: psychopathology andfamily variables in a sample from 35 nations. Journal of the AmericanAcademy of Child & Adolescent Psychiatry, 28, 17.

Turton, D. (1991). Warfare, vulnerability and survival: a case from South-western Ethiopia. Disasters, 15, 254264.

WHO. (2003). Mental health in emergencies. Mental health and socialaspects of health of populations exposed to extreme stressors. Geneva:Department of Mental Health and Substance Dependence, WorldHealth Organization Geneva.

Weine, S. (1998). A prevention and access intervention for survivorfamilies. National Institute of Mental Health. (RO1 MH5957301).

Yehuda,R. (1999). Introduction. InR.Yehuda (Ed.),Risk factorsofposttraumaticstressdisorder.Washington,DC:AmericanPsychiatric Press. (pp.xiiixxi).

Young, A. (1995). The harmony of illusions. Inventing post-traumatic stressdisorder. Princeton, NJ: Princeton University Press.

Young, A. (2006). Inventing posttraumatic stress disorder. Availablefrom: www.healingthewar.org.

Debating war-trauma and post-traumatic stress disorder (PTSD) in an interdisciplinary arenaIntroductionThe cultural construction of war-trauma and PTSDDebating war-trauma and PTSD in the psychiatric arenaPTSD: a universalistic and cross-culturally valid response to traumatic distressPTSD: a EuroAmerican inventionBuilding bridges between different healing traditionsAnthropological contributions to discourses on war-trauma and PTSDConclusionaclink2blink1