Trauma, Mental Health & Psycho-social Well-being: Definitions & Conceptual Issues

This section presents definitions for the main concepts related to: Mental health, Trauma, Post Traumatic Stress Disorder (PTSD), Cultural trauma, Psychosocial Well-being (including the notions of psychological; social and cultural well-being; psychosocial symptoms; psychosocial disorders; psychosocial interventions) and Traditional healing. It also addresses some of the conceptual issues attached to them. The most concrete challenges attached to the application of these concepts in policies and programs are addressed in the section Key Debates and Implementation Challenges.

Mental health

According to the World Health Organization, mental health is "a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her own community."1 Others further expand on this definition to define mental health as "a state of complete mental well-being including social, spiritual, cognitive, and emotional aspects."2

Historically, the term 'mental health' has been used by the health sector to differentiate it from physical health, and describes primarily biologically-based phenomena with a focus on individuals. Many humanitarian agencies, especially those outside the health sector, prefer to speak about psychosocial well-being as compared to mental health, deeming the latter term too narrow and the former to include psychological and social and cultural well-being.3 This supports the notion that "mental health should be understood within the broader context of the psychosocial well-being of post-conflict societies."4

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"Trauma is a term that defines a response to an extraordinary event. It is a response to an event that overwhelms the individuals coping resources, making it difficult for him or her to function effectively in society. Traumatic situations are those in which the person is rendered powerless and where great danger is involved. Trauma generally includes events involving death or injury or the possibility of death or injury. The word trauma is generally used to include both natural catastrophes...and man-made violence."5

From there, most professionals stress the importance of the cultural, political and social context in which the trauma is embedded. "...The definition of trauma entails the cultural and ecological systems that mediate human experience and provide resources for coping and meaning making. Furthermore, the detection of traumatic stress disorder implies that the stressful event has overtaxed personal and in some cases, community capacities..."6 For that reason, trauma "is not simply a collection of symptoms as it is often portrayed in fact symptoms may not follow all traumatic situations. In its essence, trauma is the destruction of individual and/or collective structures of a societyWhat needs to be 'healed' is therefore the multitude of individual, political, social and cultural responses to a traumatic situation and its aftermath."7

Those who caution against an excessive medicalization of trauma consider that "'Traumatisation' is widely used to denote a war-induced psychological, but there is no consistent working definition of the term. [...]Suffering or distress-- observed or imputed-- is objectified, turning it into a technical problem-- 'traumatisation'-- to which technical solutions are seen to be applicable. Yet, for the vast majority of survivors, 'traumatisation' is a pseudo-condition; distress or suffering per se is not psychological disturbance."8

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Post Traumatic Stress Disorder

Post traumatic stress disorder (PTSD) is an anxiety disorder that can develop following exposure to one or more traumatic event. It is a severe and ongoing emotional reaction to an extreme psychological trauma. "Exposure takes many forms including direct victimization or indirect exposure through witnessing traumatic events such as accidents, domestic violence, murder, terrorism and war. The defining characteristic of a traumatic event is its capacity to provoke fear, helplessness or horror in response to the threat of injury or death."9 The degree of the stress is such that usual psychological defenses are incapable of coping.

According to Dr. Syed Arshad Husain of the University of Missouri, "post-traumatic stress disorder (PTSD), as this form of psychological distress is commonly known, involves the development of characteristic symptoms following a psychologically distressing event that is outside the range of normal human experience...Traumatic events become internalized in the minds of victims and are relived by them long after the events are over."10

PTSD is a condition distinct from traumatic stress, which is of less intensity and duration, and combat stress reaction, which is transitory.11

The origins of PTSD stem from the Western worlds classifications of veterans in the aftermath of the Vietnam War. The American Psychological Association formally added PTSD to their manual in 1980. Even when they approach the trauma differently, many specialists continue to use the PTSD language to describe the problems they address. "For the diagnosis of PTSD, a person must have been exposed to an extreme traumatic stressor to which he or she responded with fear, helplessness or horror and to have 3 distinct types of symptoms consisting of re-experiencing of the event, avoidance of reminders of the event and hyperarousal, for at least one month People who are exposed to traumatic events are at risk for PTSD as well as for major depression, panic disorder, generalized anxiety disorder and substance abuse, as compared with those who have not experienced traumatic events. A number of factors contribute to the outcome following trauma, including aspects of the event and the exposure; the characteristics of the victim and family; and sociocultural factors."12 It is worth noting that studies on PTSD have shown that families of those who suffer extreme traumatic stress can also develop post-traumatic stress disorder.13 So do their helpers: an increasing attention has been paid to the trauma experienced by mental health professionals working with survivors.14

The degree of adequacy of PTSD in non-Western contexts is the object of many debates.

Go to Key debate: Medicalizing trauma and healing the individual: The use of PTSD

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Cultural Trauma

"Cultural Trauma occurs when members of a collectivity feel they have been subjected to a horrendous event that leaves indelible marks upon their group consciousness, marking their memories forever and changing their future identity in fundamental and irrevocable ways."15 Particularly in situations where mass crimes have been committed, "the religious, cultural and symbolic dimensions of the trauma can be as important as the more 'objective' ones, since they are both factual and immediate, such as with the disappearance or death of a loved one, or the experience of torture."16 In situations such as in Guatemala and Cambodia, "the genocidal project had the declared intention of destroying a culture and a history. In the narratives of victims and survivors, these aspects form an integral part of the violation of their rights and their emotional experience."17 For those who advocate a close attention to these dimensions, "it is this cultural trauma the capture and distortion of cultural symbols, the twisting of history and symbolic categories, the redefinition of ethnicity that must also be countered if cultural symbols are not to retain their valence as tools of war. Ancient or contemporary symbols, practices, naming devices and myths must be reclaimed and reconstructed after mass crimes, taking full account of what was done to these symbols by conscious effort during the period of violence."18 In that perspective, "cultural trauma is both an intended and a hidden consequence of mass violence."19

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Psychosocial Well-being

Psychological, social and cultural well-being

Many aid agencies, especially those outside the health sector, speak about psycho-social well-being as including psychological, social and cultural well-being.20 The United Nations Childrens Fund (UNICEF) and Save the Children define psychosocial well-being as "involving peoples relationships, feelings, behavior and development."21 In this view, it is defined with respect to three core domains: human capacity, social ecology, and culture and values. "These domains map in turn the human, social and cultural capital available to people responding to the challenges of prevailing events and conditions."22

Psychosocial symptoms

"Psychological symptoms are those that have to do with thinking and emotions, while social symptoms relate to the relationship of the individual with the family and society."23

Psychosocial disorders

"Psychosocial disorders relate to the interrelationship of psychological and social problems, which together constitute the disorder. The term psychosocial is used to underscore the close and dynamic connection between the psychological and the social realms of human experience. Psychological aspects are those that affect thoughts, emotions, behavior, memory, learning ability, perceptions and understanding. Social aspects refer to the effects on relationships, traditions, cultures and values, family and community, also extending to the economic realm and its effects on status and social networks."24 Those social attributes are perceived to play a key role in human development at large and are therefore important to consider by practitioners.25 The term 'psychosocial' is also intended to warn against focusing narrowly on mental health concepts (e.g., psychological trauma) at the risk of ignoring aspects of the social context that are vital to well-being. "The emphasis on psychosocial also aims to ensure that family and community are fully integrated in assessing needs and interventions."26

Psychosocial interventions

"Psychosocial interventions can be defined as actions that seek to address the interplay of social conditions and psychological well-being."27 The approach towards psychosocial intervention looks at people from a broader perspective, as part of a wider social fabric of relationships and structures.28

The notions of psychosocial rehabilitation and psychosocial treatment have also been used in reference to the same set of issues.

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Traditional Healing

Traditional healing has been defined as "that sum total of knowledge and practices, whether rational or not, used in the diagnosis, elimination and prevention of physical, mental or social imbalance and which relies mostly on practical experience, observation or knowledge handed down from generation to generation verbally, by apprenticeship or in writing."29

Go to Traditional and informal justice systems

1. "What is Mental Health," Online Q&A (World Health Organization, 3 September 2007).
2. Florence Baingana, "Mental Health and Conflict," Social Development Notes: Conflict Prevention and Reconstruction 13 (2003): 1.
3. "IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings" (Geneva: Inter-Agency Standing Committee, 2007), 1.
4. Alastair Ager, BA, MSc, PhD, AFBPsS, and Maryanne Loughry, PhD, "Science-based Mental Health Services: Psychosocial Programs," in Book of Best Practices: Trauma and the Role of Mental Health in Post-Conflict Recovery (Rome, Project 1 Billion, International Congress of Ministers of Health for Mental Health and Post-Conflict Recovery, December 2004).
5. Hugo Van Der Merwe and Tracy Vienings, "Coping with Trauma," in Peacebuilding: A Field Guide, eds. Luc Reychler and Thania Paffenholz, 343-351. (Boulder, CO: Lynne Reinner Publishers, Inc., 2001).
6. Lisa Tsoi Hoshman, "Cultural-Ecological Perspectives on the Understanding and Assessment of Trauma," in Cross-Cultural Assessment of Psychological Trauma and PTSD, International Cultural Psychology Series, ed. Anthony J. Marsella, PhD (US: Springer, 2007).
7. David Bloomfield, Teresa Barnes, and Luc Huyse, eds. Reconciliation after Violent Conflict: A Handbook (Sweden: International Institute for Democracy and Electoral Assistance, 2003), 77-8.
8. Derek Summerfield, The Impact of War and Atrocity on Civilian Populations: Basic Principles for NGP Interventions and a Critique of Psychosocial Trauma Projects (London: RRN-ODI, 1996), 14-15.
9. A. Attari, S. Dashty and M. Mahmoodi, "Post Traumatic Stress Disorder in Children Witnessing a Public Hanging in the Islamic Republic of Iran," Eastern Mediterranean Health Journal 12, no. 1 & 2 (January March 2006).
10. Judy Barsalou. Training to Help Traumatized Populations, Special Report 79 (Washington DC: United States Institute of Peace, December 2001).
11. Diagnostic and statistical manual of mental disorders: DSM-IV. Washington, DC: American Psychiatric Association, 1994; A. Brunet, V. Akerib, and P. Birmes, "Don't throw out the baby with the bathwater" Canadian Journal of Psychiatry 52, no. 8 (2007): 501-3.
12. Attari, et al, "Post Traumatic Stress Disorder in Children Witnessing a Public Hanging in the Islamic Republic of Iran."
13. "Post-Traumatic Stress Disorder," American Psychological Association Help Center, 1999.
14. Comments by Yael Danieli, 1 October 2008; Yael Danieli, ed., Sharing the Front Line and the Back Hills: International Protectors and Providers, Peacekeepers, Humanitarian Aid Workers and the Media in the Midst of Crisis (Amityville, New York: Baywood Publishing Company, Inc., 2002); Yael Danieli, "Groups for mental health professionals working with survivors," in Psychological Effects of Catastrophic Disasters: Group Approaches to Treatment, eds. Leon A. Schein, Henry I. Spitz, Gary M. Burlingame, Philip R. Muskin and Shannon Vargo, 841-876 (Binghamton, NY: The Haworth Press Inc. 2006).
15. Jeffrey C. Alexander, "Toward a Theory of Cultural Trauma," in Cultural Trauma and Collective Identity, eds. Jeffrey C. Alexander, Ron Eyerman, Bernhard Giesen, Neil J. Smelser, Piotr Sztompka (California: University of California Press, 2004).
16. Batrice Pouligny, Bernard Doray and Jean-Clment Martin, Methodological and ethical problems: A trans-disciplinary approach, In After Mass Crimes: Rebuilding States and Communities, Pouligny et al., eds. (New York: United Nations University Press: 2007), 37.
17. Ibid.
18. Roberta Culbertson and Batrice Pouligny, "Re-imagining peace after mass crime: A dialogical exchange between insider and outsider knowledge," In After Mass Crimes: Rebuilding States and Communities, Pouligny et al., eds. (New York: United Nations University Press, 2007), 271-278.
19. Ibid, 278.
20. "IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings," 1.
21. Baingana, "Mental Health and Conflict"; Florence Baingana, Ian Bannon, and Rachel Thomas, Mental Health and Conflicts: Conceptual Framework and Approaches (Washington, DC: The International Bank for Reconstruction and Development/World Bank, 2005).
22. The Psychosocial Working Group, Psychosocial Intervention in Complex Emergencies: A Conceptual Framework. (Edinburgh: The Psychosocial Working Group, 2003), 2.
23. Ibid.
24. Baingana, et al., Mental Health and Conflicts: Conceptual Framework and Approaches.
25. Maryanne Loughry and Carola Eyber, eds., Psychosocial Concepts in Humanitarian Work with Children: A Review of the Concepts and Related Literature (New York: Roundtable on the Demography of Forced Migration, National Research Council, Program on Forced Migration and Health at the Mailman School of Public Health, Columbia University, 2003), 1.
26. Baingana, et al., Mental Health and Conflicts: Conceptual Framework and Approaches, 8.
27. Ager and Loughry, "Science-based Mental Health Services: Psychosocial Programs,"113.
28. Brechtje Kalksma-van Lith, Donatien de Graaf, Eveline Jansveld and Ans de Jager, State of the Art: Psychosocial Interventions with Children in War-Affected Areas (Amsterdam: War Child Holland, 2007), 8.
29. Seggane Musisi, MD and Pratiwi Sudarmono, MD, Traditional Healing in Conflict/Post-Conflict Societies, in Book of Best Practices: Trauma and the Role of Mental Health in Post-Conflict Recovery (Rome: Project 1 Billion, International Congress of Ministers of Health for Mental Health and Post-Conflict Recovery, December 2004), 94.

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