Reflections on universal_and_culturally

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REFLECTIONS ON UNIVERSAL AND CULTURALLY - SPECIFIC
FEATURES OF TRAUMATIC STRESS.
Alex Stolberg
Paper presented at V European Congress of Psychology (Dublin, 1997)
Abstract.
Repetitive emotional abuse and mobbing in everyday social life can become the
source of unbearable traumatic stress (Leyman, 1990; Westhues, 1994). The severity
of stress produced by social maltreatment heavily depends on subjective meanings,
which traumatized persons attribute to events. The predominant trend for
individualization and medicalization of interpersonal sensitivity conceals the effects
of differences in values and normative background (Ingleby, 1982; Habermas, 1993;
Schaler, 1995). The role of cultural or between-group contradictions in attributing
different meaning to the same context has rarely been taken in account (Kirmayer,
1989; Southgate, 1995). The potency of cultural differences in values, their hierarchy
and symbolic expression to produce traumatic interactions compromises the
psychiatric claim that the form of mental illness is universal and only the content is
historically or culturally variable (Bracken, 1993; Fernando, 1991). What is regarded
in one culture as mental illness may be understood differently elsewhere. The present
work considers some culturally specific features of reaction to psychological trauma.
It is argued that in the cases of intercultural insanity ascriptions and destructiveness
the criteria of self-regulation and cognitive integration should be complemented by
that of normative rightness of the individual.

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Dear ladies and gentlemen.
I am pleased to talk here about the value of cultural sensitivity in our time.
Today, cultural diversity is important factor in social relationships. The scope
of cross-cultural contacts grows and continuously expands. Now more often people
encounter non-traditional modes of thinking and lifestyles in their close surroundings.
In the last decade as a result of rapid economic growth, the end of cold war,
the breakdown of totalitarian systems and permanent revolution in communication
technologies, national borders cease to be major barrier for business, informational
and personal exchange. Various beliefs, philosophies and lifestyles easily cross the
borders and find their adherents everywhere. Therefore, the ability to deal with
collisions of cultures and mentalities become irreplaceable virtue. It appears the time
matures to treat culture as one of the central rather than marginal concepts of
contemporary psychology (Pedersen, 1996; Pulier, 1997).
Apparently, psychosocial analysis of cultural differences poses serious
challenge to researchers. Thus, the simplest way to analyze cultural differences is to
focus on national identities. Collective programming in national societies starts in the
cradle, reinforced in kindergarten, school and working place. It convinces each and
everybody, that they are normal, others are different or eccentric. However
determining national characteristics is a difficult task, full with inaccurate assessments
and surprising exceptions. Characteristic traits of people of different nations
frequently overlap. There are excitable Finns, wooden Italians, shy Americans.
International and interracial marriages, differences in sexual orientation, waves of
immigration undermine generalizations about national character and cultural
homogeneity of any society. National character though remains to be useful concept

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to deal with groups, is not sufficient to understand interpersonal communication and
individual behavior.
Therefore, there is good reason to follow psychosocial definitions of culture.
Broad view of culture as "the collective programming of the mind, which
distinguishes members of one category of people from another" (Hofstede, 1991) goes
beyond national features. It posits psychological dimension of cultural influence on
interpersonal communication as a central issue. Psychosocial definitions emphasize
the phenomenon of multiple cultural identities, which dynamically interact and any
one of them may become psychologically salient within given situation (Pedersen,
1996). They view culture as a more or less transitory mental state where certain
recollections, reaction patterns, feelings and desires reinforce one another and are
shared by other people in one's current affiliation (Pedersen, 1996). Psychosocial
approach implies that the same person could be part of a professional community in
one context, family member in another, be part of ethnic culture in third and religious
group in the fourth. In this framework a person can identify oneself simultaneously
with several cultures and integrate them in the process of individual life. Thus,
cultural norms become a subject of rational thought and discourse, as inner states or
feelings.
Internalized cultural symbols and hierarchy of values may affect management,
relationships at working place and personal contacts (Leymann, 1990; Westhues,
1994; Lewis, 1996). It appears that in the next century management and personal
success will require as a must cultural sensitivity and skills to deal with cultural
diversity.

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Cultural approach to collisions tends to avoid labeling of problematic
situations as illnesses or abnormalities. It stresses critical thinking, ability to be open,
to learn from new and unknown experience and to bridge communication gaps.
In its essence cultural diversity could be praised as a vast source of new ideas,
new creativity and new liveliness. It is truly stimulating to discover and discuss high
potential of cultural diversity, multicultural empathy and cooperation. However, not
all consequences of cultural differences are positive and my talk is dedicated to
different and I would say delicate issue.
I deal today with cultural dimension of traumatic stress and some specific
conditions, which can lead to negative influences of cultural differences on
relationships and mental health. I would try to address the question whether cultural
differences indeed can cause serious stress and what role if any can be assigned to
cultural dimension of traumatic stress.
On the first sight cultural differences are harmless and even common sense is
sufficient to build smooth cross-cultural communication. With regard to trauma there
is broad consensus that it is usually induced by horrible events, which are universal
for all cultures and is rooted in traumatic experiences of childhood (van der Kolk,
1994). Could cultural differences be so horrible as to induce traumatic consequences?
Prevailing paradigm implies that it is not unbearable social stressors, but low
tolerance to stress of given individual determines lasting effect of traumatic
experience. Survivors of severe trauma have repeatedly been described as continuing
to react with extremes to even minor emotional stressors. They seem to keep
responding to stimuli reminiscent of the trauma with conditioned psychobiological
stress responses which do not extinguish over time (van der Kolk et al., 1991). The
main concern of clinicians and practitioners dealing with consequences of

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psychological trauma is to treat emotional vulnerability, depressive mood, inadequate
perception and to eliminate intrusive thoughts (van der Kolk, 1994). This approach
does not take in account possible crisis in values, their hierarchy, dramatic changes in
philosophical frame of orientation of traumatized individual (Ingleby, 1980; Schuster,
1996; Conrad, 1980).
It seems however, that many traumatic experiences result from abuse of trust
in atmosphere of double standards or clash of different mentalities. Political torture,
mobbing, betrayal, spiritual abuses are only few of examples. Such crises can not be
reduced to distresses produced by exclusively individual vulnerability. Although
philosophically oriented therapies long time ago emphasized the role of crisis in
values, personal meanings and lifetime goals, only few modern psychotherapeutic
approaches explicitly aware influence of world-views and cultural orientations on the
lives of their clients (Schuster, 1995; 1996; Southgate, 1995; Schaler, 1995). It might
be that search for brief therapies reduced interest to existential problems in last
decades. But in any case liberating and enlightening bedrock of philosophy tends to
be overlooked in psychiatry. Philosophical penetration was usually seen as a form of
pre-scientific dogmatism, which one should be glad to escape.
The trend of reduction the problems of individual to general vulnerability and
low tolerance to normal and mild stress of life I would call individualization. This
tendency leads to overlooking the role of existential values of individual, separating
one's problems from the problems of society to which one belongs and thus changes
the social role of mental health practices. Instead of preventing mental illnesses,
health services sometimes add personal problems to targeted individuals. Cultural
approach implicates different way of understanding of individual differences, looking
for social and philosophical roots of personal meanings and vulnerability.

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It assumes that in general, each country trains their citizens to adopt certain
concepts and values. Many of these concepts are shared by other societies. Honor,
duty, love, justice, gratitude and revenge are basic tenets of the American, German,
Israeli, Russian, Chinese, and Arab societies alike. However, almost each country has
different notions of these concepts. Chinese duty is not an American duty. English
notion of revenge bears little similarity to Sicilian or Caucasian. Romantic love, honor
and gratitude are seen differently in North America, France or Russia. Although in
each country parents and teachers give their children the best advice they can, it fits
them out for successful interaction only in their own culture, where good and bad,
right and wrong, normal and abnormal are clearly defined.
Thus, theoretically, it might not appear so surprising, that cultural insensitivity
can lead to negative effects. We make sense of the events in the context of our
cultural and philosophical background. We are selective in our perception and analyze
chains of events in different successions. As a result, people draw conclusions on
different factual basis and collisions become inevitable. Negative consequences of
insensitivity can include destructiveness and violent conflicts, demoralization,
traumatic stress and even violation of mental stability (Westhues, 1994; Rotenberg et
al., 1996; Lewis, 1996). Collisions produced by conflicting interests, opposing
positions, different lifestyles and underlying philosophies become accelerated in our
time of rapid technological and normative changes. Multicultural nature of majority of
countries, increased migration and informational explosion, globalization
continuously cause to appearance of previously unknown practices, unusual and non-
traditional groups, lifestyles, forms of thinking and communication. Free,
nonconformist self-actualization can look bizarre for external observers (especially
when it comes as individual protests and public disobedience to power) and often felt

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as irrational and dangerous to order and consensus in group or society. However, in
view of multicultural context of society, behaviors which appear bizarre from a
distance could become intelligible or reveal ingenious thinking in the light of reasons
provided by the identified persons.
One of the sensitive problems here is that what assumed to be special in one
culture can be seen as marginal and deviant in another. Thus, paradoxically, in
multicultural media high expectations of communication can be treated as bizarre
pretensions, explicit expression of affectionate bonds can be taken for symbiotic
attachment, bitter outcomes of interaction can be disqualified as such and taken for
excessive vulnerability, non-standard approaches can be treated as sickness and far-
going idealizations before the feedback is provided - for delusions. As a result of
consistent and perfectly logical cultural misinterpretations the humanitarian
dimension of contacts can be completely lost. If one predisposed to attribute any
disruptions in communication to personal vulnerability and resulting cognitive
distortions then existential losses can be interpreted just as triggers of traumatic
response. In multicultural context there could be a problem to detect precise meaning
of communication and then disruption of contacts becomes virtually irreversible.
Neglect of symbols and hierarchy of values of the person, whose intelligence is
judged in public discourse were more neutral, if issues of mental health would not be
involved.
It is the matter of fact that non-traditional and non-conformist behaviors can
be designated as abnormalities, the more they deviate from predominant norms of a
given society. As a consequence they can be treated as biologically determined
disorders (some genetic or acquired biological deficiencies, like, kind of mental
illness) or antisocial activity (practices spread in totalitarian countries). Alternatively,

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collision can be viewed as socially or culturally determined, reflecting conflict of
group interests or different lifestyle orientations.
Psychosocial definitions of culture could be applied not only to analysis of
intercultural conflicts but to collisions within each society as well. Analysis of
intercultural conflicts in supposedly homogeneous society requires critical social
theory. One good example of such intercultural conflict is dissident movement in
former USSR, based on collision between people devoted to values of freedom,
human rights and democracy and dominant culture of totalitarian state. It is well
known that one of important means to neutralize political and cultural opposition in
that case was psychiatric imprisonment. The history of abuse of psychiatry in USSR
consisted in declaring dissident thinkers mentally ill. Live embodiment of totalitarian
establishment, former Director of Serbski Forensic Hospital in Moscow Academician
Morozov denied use of psychiatry in political goals until 90s, when historical
rightness of those dissidents has become quite clear.
Different case of intercultural conflict, involved judgment about mental health,
was treatment of homosexuals in United States. Whereas it constitutes a peaceful,
deviant lifestyle and kind of shared mentality it was once labeled as mental illness in
Diagnostic Manual. Following bitter tension this diagnosis was abandoned and the
collision has become basically lifted. What arouses concern however is the tendency
to transform private personal problems, social and cultural conflicts into the issue of
mental health.
Thus, in many crises it is not fear, lack of physical safety and security
constitutes major traumatic stressors, but accompanying meaning of destruction of
person's top ranked values, life prospect and key cultural orientations pose the main
threat. It is not accidentally that patients with PTSD have keen feeling of

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foreshortened future (DSM-IV), in fact they can not even imagine their place in
posttraumatic world.
Cultural approach leads to new appreciation of the role of vulnerability and
tolerance to stress. It can be argued that differential tolerance to various combinations
of stressors is one of the clues for understanding cultural differences. Differential
tolerance is mostly important for interaction between supposedly friendly cultures.
Collisions between hostile cultures bring rather stoicism and violence than
traumatization. Physical torture is frequently met with heroism in such cases (history
of World War II is full with the examples of heroism against occupants).
In contrast, relationships between supposedly friendly cultures or within a
multicultural society (which is supposedly homogenous one) are different. Mobbing
in one's own culture and prolonged isolation, social vacuum and neglect in
subjectively friendly cultures underlie deep traumatic conflicts, rooted in cultural
differences (Westhues, 1994). Highly vulnerable in this sense are value-driven
immigrants from cultures, which undergo transition and period of existential search
for frame of orientation (Rotenberg et al., 1996). The mechanism of traumatization
here is that their positive attitude, far-going idealizations and reverence to friendly
culture paradoxically induces cultural aversion in response.
The paradox is that persistent maltreatment from the side of people of
supposedly friendly culture can become traumatic for people, who earlier stoically
opposed to oppressors. In new situation they fail to discriminate new forms of
segregation in time.
These problems were not meaningful enough, if they would not interfere with
definition of mental illness as it is presented in DSM-IV. The predominated now
theory of mental illness focuses mainly on biological determinants of behavioral

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disturbances. Although it was long time challenged by cultural interpretation of
interpersonal conflicts and antagonisms, it seems to be obstructed by the persistence
of several beliefs in biological psychiatry (Pope, 1996; Southgate, 1995; Habermas,
1993; Kirmayer, 1989; Bracken, 1993; Fernando, 1991; Kleinman & Cohen, 1997).
The first belief is that the forms of mental illness everywhere display similar
degrees of prevalence. Second one holds that biology is solely responsible for the
origin and the structure of a disease, whereas cultural beliefs shape only the specific
ways in which a person experiences it. The third belief states that culture-specific
mental disorders are unusual. The fourth belief held by many mental health experts,
that not much can be done to treat mental illness (Kleinman & Cohen, 1997;
Southgate, 1995).
DSM-IV dedicates some portion in majority of articles to deal with cultural
differences. However, anthropologists still view it as a "little more than a sop thrown
to cultural psychiatrist and psychiatric anthropologists" (Kleinman & Cohen, 1997).
They claim that current trend is to discount the uniqueness of symptoms found
in a particular culture and to search instead for manifestations of mental illness that
are culturally independent and could be more closely linked to the biological basis of
an illness. Theoretical bias to focus mainly on culturally independent, biologically
sound mental illnesses, lack of definite biological markers for key disorders,
combined with tendency to qualify relatively slight deviations and eccentric acts as
mental disorders, create a mess as to what should be called mental health. As a result
any emotional forms of behavior can become subject for psychiatric labeling. I would
mention here the proposal to treat happiness as a psychiatric disorder (Bentall, 1992).
The main argument was that happiness leads to cognitive distortions, which can be
unpleasant to close surrounding of individual. That the happiness is non-violent and

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constitutes one of top rank values and goals of individual life to be classified as major
affective disorder, author dismissed as scientifically irrelevant argument (Bentall,
1992). The main argument was that happiness leads to cognitive distortions, which
can be unpleasant to close surrounding of individual. That the happiness is non-
violent and constitutes one of top rank values and goals of individual life to be
classified as major affective disorder, author dismissed as scientifically irrelevant
argument (Bentall, 1992). Actually in modern paradigm there are no obstacles for
proposals to treat love, friendship, religious beliefs and other devotions as a kind of
mental illness. As a matter of fact in the DSM-IV a state of sanity is not defined and a
therapist is given no positive guidance concerning therapy's goal. It seems that in
DSM-IV, sanity is negatively defined, and means absence of everything in its pages.
Because most descriptions of psychiatric symptoms are psychosocial
and include such terms as “vague speech”, "bizarre gestures", "withdrawn manner",
“blank looks”, “cry without a cause”, “exaggerated feelings of happiness or despair”
and “laughing in a sad moment”, there are problems with diagnostics. Thus, in the
third world, according to data of World Health Organization physicians misdiagnose
their clients in half number of cases (Kleinman & Cohen, 1997). One major problem
here is that with all progress in psychobiology, biological markers of presumed
disorders are mostly indirect.
In an effort to equate psychiatry with other medical "hard" science disciplines,
psychiatrists have intentionally focused on the biological bases of mental disorders
and discounted the importance of culture and socio-economic status. However
psychiatry differs from other medical disciplines. Whereas in cardiology incorrect
diagnostic assumption can be falsified by subsequent testing and concerns about
serious illness can be lifted by physiological evidence, in psychiatry inaccurate

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diagnostics leads to labeling, violation of psychosocial stability and still can not be
subjected to psycho-physiological falsification (Rosenhan, 1973; Pope, 1996).
Stigmatization in itself is the very serious factor causing damage to mental
health of individual. American psychologists, who oppose to practices inducing false
memory syndrome in their clients uncover in detail this aspect of contemporary
challenge to biological psychiatry (Pope, 1996).
Current model of mental health has allowed psychiatrists to categorize an
extensive array of psychiatric symptoms into a more manageable and coherent system
of diagnostic classes. Unfortunately it assumes that majority of behavioral
disturbances and inconsistencies constitute biological rather than psychosocial
problem. Multiple discoveries of drugs, effectively changing moods, create
impression that illnesses like depression are totally biologically determined.
Theoretically, however, each emotional reaction has underlying biological substrate
and therefore can be influenced pharmacologically. The question is do we really need
to cure humans from emotions? It is understandable if emotions lead to antisocial,
violent behavior, violations of the law or attempts of self-mutilation and suicide. But
if they reflect cognitive and social processes of search the ways for mutual
understanding and exploration of unknown environment, do we need to treat humans
from these non-violent emotions?
I do not mention here emotions that constitute top-rank valued experiences of
individual and definitely have their own biological substrate and can in principle be
pharmacologically influenced. The fact that we can influence emotions
pharmacologically does not mean that such interventions always make sense.
Thus, although depression is now a disvalued state in Western cultures,
passivity and withdrawal have elsewhere been positively evaluated as "mature

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inwardness" or "desirable interpersonal sensitivity" (Kirmayer, 1988). Eventually it is
normal to react with sadness to injustice, oppression and discrimination, especially
when no effective ways to fight them are available in a long run.
It was demonstrated that appearance of mental illnesses depends on social
change. Thus, recently it was found that in Taiwan the mass migration and the rapid
industrialization were accompanied by the highest suicide rates. Those rates are now
stable. However, in China now occur more than 40 percent of all suicides in the
world. China's suicide rate appears to be twice as high as that of the U.S. and is most
common among rural women. For troubled women in rural China, suicide appears to
be almost a normative strategy for coping with distress. Elsewhere, it is men who are
most at risk.
Surprisingly, depression is three to five times less common in China than in
the West; the country also has much less substance abuse.
These results are almost impossible to reconcile with today's emphasis on the
underlying biological commonality of all mental illnesses.
One of the most vivid illustration for the role of psychosocial and cultural
factors in diagnostics of mental illness (so called reactive psychosis) is the case of
Stalinist repressions against the eminent citizens in 30s. .
Reactive psychosis was a term used in Soviet psychiatry to designate acute
states of deep disorganization of mental activity occurring as stress reactions to
unexpected mental trauma. Such traumas were distinctive clinical feature of the group
of persons who went through forensic psychiatric evaluation during the period of
mass repressions in 30s. A person who had occupied an eminent leading position just
yesterday might today be arrested, stripped of his rights, on an absurd charge for

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which the prospects were torture, the firing squad, the ruin of his family, and public
shame.
The abruptness with which social status changed, the collapse of all a person's
life positions, and the reality of torment and death explain the massiveness of reactive
psychoses in people who the day before had been entirely normal mentally.
The manifestations of reactive psychoses varied: some arrested individuals
literally turned to stone, becoming immobile and losing their capacity for oral
communication; others became like little children who understood nothing, called
their persecutors "little uncles," smacked their lips, clapped their hands senselessly,
and made foolish grimaces; and still others began to behave like animals in the full
sense of the word they would run about on all fours, take their food only from dishes
on the floor, and lick the dish like a dog.
Despite the diversity of clinical manifestations of psychoses, the fact was that
the investigators were unable to interrogate their psychotic victims; they did not react
to questions and would not sign any documents, thus no evidential procedures could
be conducted with them. The frequency of psychoses and the search for ways to treat
them made it necessary to invent a special clinical syndrome of reactive states.
Experts established that a person had a mental disorder, but indicated that it had
developed after arrest and that there was therefore no need to release the person from
legal responsibility on the grounds of mental illness.
After death of Stalin and end of mass repressions, these reactive psychoses
almost completely disappeared.
Thus, it is not just physical torture but its embracing meaning and abuse of
trust are mostly traumatic in inter- and intra-cultural relationships. The torture from

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the side of hostile culture appear to be less dangerous for mental health than mobbing
in one’s own or supposedly friendly culture.
It is relatively easy to oppose overt hostility, but if one is related by
affectionate bonds to supposedly friendly culture or social group one can be
unprotected for significant period of time against abuse and maltreatment.
One example is culture shock induced by repatriation or other kinds of value-
driven immigration. Culture shock theory is usually used to explain problems of
integration of immigrants into the new society (Rotenberg et al., 1996; Lewis, 1996).
It is interesting that it makes sense to talk about culture shock not only on behalf of
immigrants but on behalf of host population as well. Culture shock can lead to
misinterpretation of facts, which can in turn distort cognitions of both sides. I would
add to the notion of culture shock one another notion of cultural aversion. The
development of aversion can make misunderstanding and factual mistakes from both
sides irreversible. It is development of such aversion leads to traumas and
destructiveness.
Aversion develops not only with regard to hostile cultures, but not less
importantly it can rise unconsciously with regard to friendly cultures in context of
maltreatment and abuse. Cultural origin of stigmas and aversion reveals in repeated
mobbing stories of individuals, taking initial friendly attitudes to groups of people as a
function of cultural predispositions.
Cultural aversion seems to be an emotional basis of severe traumatic stress and
destructive behavior. What is important that it could be prevented or identified and
neutralized by communication, education and investigation..
Thus, when group faced with a crisis of a radical challenge to its normative
background, at least two options are available to manage situation: 1) to reach consent

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about the situation through open investigation of conflict situation and proper
feedback provision; 2) if consent seems to be unattainable it is necessary to rule out
vicious circle and destructiveness: to judge separately sincerity, cognitive logic and
normative logic on the basis of available facts from the standpoint of disputed
individual. It is necessary to take in account that only combined breakdown of
cognitive and normative logic indicates onset of mental illness and loss of
communication abilities. In any other case psychiatric labeling should be precluded
and recovery from a crisis requires cognitive-behavioral approach, communication
with feedback, stimulation of thinking and search activity of traumatized individual.
Success of humanistic therapies and philosophical counseling combined with progress
in biomedical diagnostics of mental illnesses will give to social sciences more humane
perspective.
CONCLUSIONS
Thus, judging mental health in cross-cultural settings one has to be sure that
none of ordinary ways of finding conduct intelligible actually works. For that purpose
behavior should be analyzed at least in three dimensions: that of intelligibility,
sincerity and of normative rightness.
Models of rationality and reason and the practices predicated upon them which
expel moral issues from consideration can not be treated as fully rational. They create
confusion as to what should be treated as a social problem and what is the matter of
mental health. Medicalization and individualization in modern psychiatry restrict the
focus to isolated individual and confine the whole discourse to simplistic, sometimes
inadequate, medical and technical terms.

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Although normative rightness can not replace comprehensive cognition and
does not imply universal rightness it must be thoroughly scrutinized to judge mental
health of individual in any cross- cultural setting.
Thank you very much.
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10. Ingleby, D. Understanding mental illness, In: Critical Psychiatry. The
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