Culture, trauma and dissociation: A broadening perspective for our field

ABSTRACT

In the field of trauma and dissociation, culture has a significant influence on the clinical presentation of patients. A growing body of literature addresses the relationship between culture and dissociation. Studies of this relationship though, evoke the important, but at the same time extremely sensitive issue of cross-cultural comparisons. In this editorial, I provide a limited overview of various ways in which cultural influences have been addressed in the field of trauma and dissociation. Most studies have examined the occurrence of dissociative disorders in clinical populations in different cultures and countries. Some have focused on normative dissociation as a response to traumatic events in non-clinical samples from different cultures. This editorial also explores the concepts of double consciousness and black consciousness, which have emerged from the fields of social psychology and black psychology; and how these concepts influence our thinking about non-clinical dissociation. Culture-related challenges in the field of trauma and dissociation create opportunities for training in cultural competence for therapists. Qualitative research methods might be best suited to future research on the relationship between culture, trauma and dissociation. The chances of reaching a thorough and deep understanding of the influence of culture on trauma and dissociation might be best if the entire spectrum of dissociation is studied – from normal to pathological dissociation, and in its different manifestations from universal to those unique to certain cultural groups.

KEYWORDS:

• Dissociation
• culture
• response to trauma
• clinical vs non-clinical
• double consciousness
• race

The field of trauma and dissociation is arguably one of the fields where culture has the greatest influence on the clinical presentation of patients. For example, increasing global migration and its associated trauma have resulted in an increasing awareness of the influence of culture on how people respond to traumatic events. Accordingly, a growing body of literature addresses the relationship between culture and dissociation. Studies of this relationship evoke the important, but at the same time extremely sensitive issue of cross-cultural comparisons.

In this editorial, I provide a limited overview of various ways in which cultural influences have been addressed in the field of trauma and dissociation. The overview will highlight several culture-related challenges in this field. Most of the studies in the field of culture, trauma and dissociation have examined the occurrence of dissociative disorders in clinical populations in different cultures and countries. Some on the other hand, have focused on normative dissociation in non-clinical populations in different cultures. I will explore both contexts, and consider recent developments in other social sciences contexts. One of the main challenges is that the terms culture, ethnicity and race are often used in various ways by different authors, practitioners, politicians and the general public. There are no universally accepted definitions of these concepts.

Dissociative disorders in clinical samples across cultures

In the clinical realm, numerous authors have demonstrated that pathological dissociation, diagnosable dissociative disorders and possession phenomena occur at comparable rates in many different cultures or countries (see below). These studies confirm the universal aspects of pathological dissociation.

Dissociative identity disorder (DID) in particular, is found in prevalence studies around the world whenever researchers conduct systematic assessments using validated interviews (Brand et al., 2016). A systematic search by the same authors of published, peer-reviewed DID studies during the period 2005–2013 yielded 340 articles (Brand et al., 2016). Seventy studies, from 48 institutions in16 countries, were empirical research studies of patients diagnosed with DID, where 40% of studies used structured interviews to diagnose DID (Brand et al., 2016).

Numerous clinical studies have provided fascinating accounts of unique cultural manifestations of dissociation, dissociative disorders and possession phenomena. These studies originate from many countries, states or territories, e.g., Argentina (Baita, 2006); Brazil (Delmonte, Lucchetti, Moreira-Almeida, & Farias, 2016; Negro, Palladino-Negro, & Louzã, 2002), China (Fung, 2018); China and Canada (Ross, 2011); China and Japan (Kleindorfer, 2006); French Canadian students (Martin & Marchand, 2003); Guinea Bissau (de Jong & Reis, 2013); Hawaii (Rhoades, 2006); Hong Kong (Hong Wang Fung, Ross, Yu, & Lau, 2019); India (Chaturvedi, Desai, & Shaligram, 2010); Iran (Firoozabadi et al., 2019; Kianpoor & Rhoades, 2013); Israel (Somer, 2006); Mauritius (Pietkiewicz & Lecoq-Bamboche, 2017); Nepal (Sapkota et al., 2014); Pakistan (Roland, 2010); Philippines (Gingrich, 2006); Puerto Rico (Lewis-Fernández, Martínez-Taboas, Sar, Patel, & Boatin,  2007) (Lewis-Fernández et al., 2002; Martínez-Taboas, 1999; Wilson & Tang, 2007); South Africa (Krüger, 2016); Turkey (Şar, Akyüz, & Doğan, 2007; Sar, Alioglu, & Akyuz, 2014); and Uganda (van Duijl, Kleijn, & de Jong, 2013, 2014; van Duijl, Nijenhuis, Komproe, Gernaat, & de Jong, 2010).

Dorahy et al. (2014) point out that cultural variation in the clinical manifestation of DID remains under-researched. Dissociative identity disorder is intrinsically related to experiences of self and personhood, which in turn are culturally constructed (Dorahy et al., 2014). The varying nature of identity across cultures and identity-related cultural differences complicate comparative DID research (Dorahy et al., 2014).

Not surprisingly then, research on DID has shifted away from the clinical context toward how healthy people’s unique cultural backgrounds may influence their response to traumatic events. Although these responses may be referred to as non-pathological dissociation, these responses can also be considered on a continuum from normal to pathological dissociation. Some of these studies of dissociation in non-clinical samples are explored below.

Not all authors use the term ‘culture’ in the same way. Some authors refer to ethnicity or race rather than culture. Studying the role of culture in trauma and dissociation is difficult when different terms are used to describe subcultural groups, making generalization to other cultural groups impossible. However, it is beyond the scope of this editorial to explore the myriad ways in which subgroups of people are categorized by researchers. Rather, I clarify the specific way in which researchers used the terms culture/race/ethnicity, as the variable use of these terms might affect the interpretation of their results.

Dissociation as a response to traumatic events in non-clinical samples from different cultures

Auerbach, Mirvis, Stern, and Schwartz (2009) used a qualitative approach to study the relationship between cultural aspects of people’s lives, past trauma and dissociation. They studied archival interviews done with 20 non-clinical Holocaust survivors, living in the USA, who had adjusted well after the war. The researchers used grounded theory methods to analyze whether the structural dissociation theory of van der Hart, Nijenhuis, and Steele (2006) could explain the good postwar adaptation of Holocaust survivors (Auerbach et al., 2009). The themes that emerged mapped well onto the structural dissociation therapeutic framework, suggesting that dissociation of traumatic memories helped the survivors to create a ‘normal’ life after the war. When at a later stage they managed to deal with the traumatic memories, they created a meaningful life narrative in which their traumatic past was integrated.

Auerbach et al. (2009) defined their sample as a nonclinical, non-high risk population of Jewish Holocaust survivors who had been interned in Nazi concentration camps and ghettos or who had been in hiding during World War II. Their relatively narrow definition resulted in a culturally homogeneous sample, which simplified the interpretation of findings.

Quantitative studies have also explored the relationship between dissociation and other psychological variables in various cultural/ethnic/racial groups (Anglin, Polanco-Roman, & Lui, 2015; Douglas, 2009; Finklestein & Solomon, 2009). These authors differed in the ways that they categorized participants into subgroups for analysis.

Finklestein and Solomon (2009) studied 478 Jewish Ethiopian (non-clinical) refugees who had migrated to Israel in three separate waves – the so-called Moses immigrants, Solomon immigrants and Family Reunification immigrants. Self-report questionnaires were used to assess dissociation, stressful events, posttraumatic symptoms and post-migration difficulties. Cumulative trauma was significantly related to PTSD symptoms, but not to dissociation. Stepwise multiple regression analyses showed that in the different groups of refugees, different patterns of pre-/peri-/post-migration difficulties predicted level of dissociation. The results were contrary to most of the previous research in clinical samples on the link between dissociation and trauma. The results were interpreted as suggesting that a tendency to dissociate among Ethiopian immigrants may represent a cultural, functional, learned defense pattern (Finklestein & Solomon, 2009).

Finklestein and Solomon (2009) defined their subgroups according to the periods during which the immigrants had arrived in Israel, viz., Moses immigrants in the early 1980s, Solomon immigrants in 1991, and Family Reunification immigrants in 1995 – as drawn from the national immigration registry of the Ministry of Interior. The cultural distinction between the subgroups was considered to have derived from, i.a., shared religious and political convictions (Finklestein & Solomon, 2009).

In the United States (U.S.), Anglin et al. (2015) investigated the relationship between trauma, dissociation and prodromal psychosis while accounting for the possible role of cultural variation. They administered self-report measures of attenuated psychotic symptoms, traumatic life events and dissociative style in response to traumatic experiences to 549 healthy New York students who came mostly from self-identified ethnic minority groups, as conceptualized in the U.S. (see more about this below). Mediation analyses were done using hierarchical linear regression models. Dissociation mediated the relationship between traumatic life events and attenuated positive psychotic symptoms, but mainly in the Black students. The authors concluded that a dissociative response style to traumatic life events may be more common among black young adults with subclinical psychotic experiences than in young adults from other cultural groups (Anglin et al., 2015).

How did Anglin et al. (2015) define their ethnic minority groups? They drew their sample from a larger study of 644 university students who had been pre-screened for self-identifying as Black/African American/African or as being first- or second-generation immigrants, to maximize recruitment of young ‘ethnic minority’ adults (Anglin et al., 2015). Participants could choose from a mixture of racially and ethnically based choices, e.g., Middle Eastern, Hispanic, and Asian/Pacific Islander (Anglin et al., 2015). However, “in order to have reasonably similar groups”, participants’ answers were then grouped into categories corresponding closely to the groupings used in the U.S. Census. The authors used the term ethnicity, defined as; (a) Black (including individuals born in the U. S., Africa, or the Caribbean), (b) Hispanic/Latino, and (c) Asian/Pacific Islander.

The question arises whether the interpretation of results in Anglin et al. (2015) might have been different if different cultural subgroup definitions had been used. The issue of what is race, what is ethnicity, what is culture, who decides about these definitions, and how they vary across countries, remain a source of confusion that complicates the interpretation of research results.

Still in the U.S., Douglas (2009) studied racial differences in dissociation in 317 healthy Connecticut students using self-report measures of dissociation, depression, anxiety and, stressful or traumatic life events. The author recorded participants’ race according to their self-identification with one of the following options: White, Asian American, Black, Latino, or biracial (Douglas, 2009).

Students from different racial groups did not differ with respect to depression, anxiety and, stressful or traumatic life events (Douglas, 2009). However, African and Asian American students recorded higher dissociation scores. For White and Latino students, higher dissociation scores were associated with higher scores on the other psychological measures, whilst Black and Asian students showed a different relationship between dissociation and the other measures. In particular, Black students with higher dissociation scores were more likely to have less psychological distress. Similar, but weaker relationships were described for Asian American students. Douglas (2009) suggested that dissociation may serve as a protective mechanism against psychological distress especially for Black students.

Douglas (2009) acknowledged that using the U.S. social construct of race to categorize participants disregarded potential influences from culture, region, language, or nationality, limiting the potential contribution of their study for a deeper understanding of the relationship between culture and dissociation.

The way that race and ethnicity are studied may also vary according to the cultural context of the studies. In some instances, using race as a key variable in research studies has been considered problematic. For example, the way in which race was used in two very recent South African research articles sparked controversy. One study done at the University of Stellenbosch focused on cognitive functioning in Colored South African women (Nieuwoudt, Dickie, Coetsee, Engelbrecht, & Terblanche, 2019). The article was retracted when racial biases underlying the study were pointed out, i.e., a possible perception that certain racial groups had lesser cognitive ability than others. A second study involving a staff member of the University of Cape Town focused on intelligence and slave exports from Africa (Asongu & Kodila-Tedika, 2019). In response to the latter study, criticism was directed toward the flawed assumption about the cognitive ability or intelligence of entire countries, which produced the effect of victim blaming and pathologizing Africans (Isaacs & Daniels, 2019, quoting Adam Haupt). In both these studies, researchers ran the risk of assuming that race is a stable, natural scientific category deserving of condescension and pity, rather than a social and political construct (Isaacs & Daniels, 2019, quoting Adam Haupt).

Returning to the phenomenon of dissociation, researchers in the fields of social psychology and black psychology have embraced the term ‘black’ – even as a racial descriptor – in the service of advancing their thinking about the effect of power and political relationships on the consciousness of Black people and other marginalized groups. The concept of double consciousness will be explored below, and its potential implications for thinking about non-clinical dissociation examined tentatively.

Double consciousness associated with cultural differences

The concept of double consciousness was coined by W.E.B. du Bois (1868–1963), a Harvard and German trained, American sociologist of African descent, in a psychosocial theory of race (Du Bois, 1989). Double consciousness arises from the difference between how others see you (negatively) versus how you see yourself (positively). This distinction then gets internalized as two alternate and co-existing views of oneself. Frantz Fanon (1925–1961), a French West Indian psychiatrist, political philosopher and revolutionary; and Steve Biko (1946–1977), a South African anti-apartheid activist further developed the concept of double consciousness (Biko & Malan, 1997; Biko & Stubbs, 1987; Fanon, Philcox, & Appiah, 2008; Fanon, Philcox, Sartre, & Bhabha, 2004). Fanon and Biko contributed the concept of black consciousness – which represents a specific example of double consciousness, and at the same time a positive philosophy of self-emancipation and transcendence of racial self-hatred (Biko & Malan, 1997; Biko & Stubbs, 1987; Fanon et al., 2008, 2004).

The work of these pioneers and others in the field of black psychology suggests that there is no universal psychiatric reality and that, in terms of psychological knowledge and practice, the only valid perspective is one that reflects the culture of the people served (Gaines, 1992; Nobles, 2013). In line with this thinking, the concept of double consciousness has been applied in a variety of non-clinical contexts and fields of study.

In the context of immigration, Werbner (2013) wrote about migrants’ experience of double consciousness and that no return home can reverse that. Mensah (2008) found and explored double consciousness in Sub-Saharan African professors teaching at a predominantly white university in the Midwest of the U.S. Lobban, an ex-South African immigrant analyst in North America, explored double consciousness from a therapist’s perspective, while becoming aware of their own double consciousness and ability to experience a variety of selves – a “hybrid me-ness” (Lobban, 2006, 2013). In this instance, double consciousness was not based on race, but more on being a foreigner in a relatively inflexible host cultural environment. What remains though, is the struggle to integrate different senses of self that depend on different contexts or perspectives.

In an educational context, Brannon, Markus, and Taylor (2015) highlighted the functioning of double consciousness as two self-schemas – an independent self-schema tied to mainstream American culture and an interdependent self-schema tied to African American culture. They demonstrated that incorporating African American culture within U.S. educational settings and facilitating identification with the interdependent self-schema had positive academic consequences for students. Activating the interdependent self-schema may improve and enhance African-American students’ sense of fit and identification, academic performance and academic persistence (Brannon et al., 2015).

Similarly, Okech and Harrington (2002) studied 120 African American male college students and found a direct, significant relationship between black consciousness and academic self-efficacy, and between black consciousness and self-esteem, illustrating the positive value of black consciousness.

In the field of social psychology, Schindler, Reinhard, Knab, and Stahlberg (2016) conducted an experimental study in German-Polish bicultural people and demonstrated a ‘cultural identity switch’ whereby bicultural people switch their cultural identification and behavioral patterns according to situational cultural frames. These results further indicate that culture-related psychological variables are not necessarily fixed, static phenomena, and not necessarily either normal or pathological.

The potential value of social sciences concepts such as double consciousness and cultural identity switching for our understanding of the influence of culture on trauma and dissociation remains to be explored. For example, future studies might focus on the potentially adaptive nature or normality of double consciousness and its possible deleterious effect or pathological nature, while also measuring dissociation. Such research could contribute to understanding the whole spectrum of dissociation.

A pioneer in the field of trauma and dissociation, Vedat Sar, made important contributions to understanding societal influences on individual dissociation (Sar, 2017a, 2017b; Şar, 2016; Sar & Ozturk, 2007, 2013). Sar developed a theory of functional dissociation of the self, according to which a person’s ‘sociological self’ gets differentiated from their ‘psychological self’ in the context of an ‘apparently normal family’. The ‘sociological self’ is prone to being mind-controlled, to fusionary tendencies, and mass effects, e.g., mass hysteria (Cassady et al., 2005; Mattoo, Gupta, Lobana, & Bedi, 2002; Sethi & Bhargava, 2009). The ‘trauma self’ is a part of the ‘psychological self’ that gets segregated further, and may show resistance in therapy. These concepts are further refined in Sar’s subsequent identity-based model of mind that relies on cultural influences on trauma and dissociation (Sar, 2017a, 2017b).

Implications for the work of the International Society for the Study of Trauma and Dissociation (ISSTD)

Although cultural competence for therapists has been an important focus of research and training, we need to recognize that cultural competence may be context-bound. In a Hawaiian context, Rhoades (2006) reviewed several therapeutic considerations to facilitate culturally sensitive trauma and dissociation treatment. He pointed out the benefits of determining how traditional the patient’s cultural upbringing had been and how traditional the patient is in the practice of their culture. In an American context, Gómez (2018) noted that an understanding of ‘cultural betrayal trauma theory’ may contribute to culturally competent treatment for minority victim groups. Where possible, communication with the patient in their first language allows for better and unique access to traumatic memories. Schwanberg (2010) studied 19 Spanish-American bilingual patients with significant childhood trauma that had been processed inadequately at the time. The patients showed a much higher emotional intensity when accessing traumatic memories in their first language (Schwanberg, 2010).

These findings about cultural competence of therapists, as well as the above findings relating to double consciousness, might be further developed in the Professional Training Programme of the ISSTD. The ‘how’ might have to be worked out carefully, as double consciousness is not necessarily a pathological phenomenon. But sensitizing professionals and creating awareness about the many different and variable cultural manifestations of consciousness is a good start.

The educational role of the ISSTD extends beyond the training of psychotherapists to creating guidelines for allied professionals, policy statements and resources for the general public. New insights about the role of culture in trauma and dissociation might well assist in the diversification of ISSTD’s educational offerings in other contexts.

The challenges inherent in cross-cultural research on trauma and dissociation also invite the exploration of a variety of research methodologies to increase the social relevance of empirical studies.

Future research that approaches race as a fluid, social construct might lead to different findings from research that approaches race as a stable, natural, biological category – although these approaches might not necessarily be mutually exclusive. Participants’ views on what race and culture mean in their own contexts might lead to deeper insights into how culture may influence dissociative processes. In the field of trauma and dissociation, Laria and Lewis-Fernändez (2008) have also pointed out that qualitative methods are more sensitive to the study of cultural phenomena than quantitative methods, and that qualitative and quantitative methods may be integrated.

Qualitative research methods generally embrace an ontology of multiple realities and an epistemology of knowledge becoming known through the subjective experiences of people (Creswell & Poth, 2018). As such, qualitative research methods might be best suited to future research on the relationship between culture, trauma and dissociation. Other than exploring the meaning that people make of the influence of culture on their own trauma and dissociative experiences, researchers will need to think carefully about how to formulate good research questions for appropriately assessing the impact of culture.

As a society, our chances of reaching a thorough and deep understanding of the influence of culture on trauma and dissociation might also be best if we study the entire spectrum of dissociation – from normal to pathological dissociation, and in its different manifestations from universal to those unique to certain cultural groups. With regard to the normal-pathological continuum, see also the recent work of Paul Dell on hypnotizability (Dell, 2017, 2019). What is normal and what is pathological may be culturally determined and context specific. Notwithstanding the complexity of these issues, such a broad perspective will likely contribute to mainstreaming the important work of the ISSTD.