Thinking Through Trauma: Models, Measures, and Methodological Challenges (Summary of 10/15 Focused Discussion)

Thinking Through Trauma

Models, Measures, and Methodological Challenges

Notes and Summary

FPR CMB Network Meeting

Moderated by Laurence Kirmayer via Zoom

October 15, 2021

Present: Carole Browner, Suparna Choudhury, Constance Cummings, Maria Gendron, Laurence Kirmayer, Shinobu Kitayama, Brandon Kohrt, Robert Lemelson, Daniel Lende, Michael Lifshitz, Sally Seraphin, Jeffrey Snodgrass, Seinenu Thein-Lemelson, Kathy Trang

Introduction (38:19 mins)

Laurence Kirmayer moderated today’s discussion, which followed up on the last meeting’s chat comments on conceptualizing trauma.

Maria Gendron talked about some of the struggles that she and Kathy Trang have encountered on their project “to understand and predict health-related outcomes for an aging Vietnamese sample that has variable wartime exposure.” The project is subsampling from a larger longitudinal study [Vietnam Health and Aging Study; VHAS] looking at early life trauma exposure and late life health “to assess life course perspectives on scarring and resilience.”

In particular, Gendron wondered about using the term trauma. Many of the individuals have experienced traumatic-like events because of proximity to or direct involvement in the Vietnam War via, for example, bombing exposure or military service. Gendron said that “trauma” is a starting place, but the term may not necessarily capture the broad range of experiences among individuals enrolled in the parent study. Some of the individuals Gendron and Trang will be sampling had acute experiences of existential threat; others may have had more deprivation-related experiences, physical and environmental stressors. Further, individuals with the same level of exposure may differ widely in terms of response. Gendron said they will have access via the parent study to more detailed information about the wartime exposure, including loss of family members, or instances of deprivation. Gendron and Trang also intend to collect more elaborated measures of trauma exposure as well as data on everyday impacts such as daily functioning and social connections with people or social withdrawal.

Trang said work on the VHAS project is limited to North Vietnam (versus South Vietnam). Another project they are involved in, funded by LEGO Foundation and MacArthur Foundation, looks at play-to-learn interventions among Rohingya refugees in Bangladesh and Syrian refugees in Jordan. A third project looks at the longitudinal impact of maternal mental health and trauma on child development in the first thousand days of life. Trang identified some of the challenges inherent in this work: (1) the conceptualization of trauma and its impact on early childhood development, and (2) balancing project theories/hypotheses with the goals of funders. She is working with Paul Bolton of USAID [US Agency for International Development] on integration of mental health and more attention to MH policy (including a pragmatic objective, e.g., more funding to prevent and treat mental health disorders, promote well-being).

Jeffrey Snodgrass posted three questions in the chat:

Is diagnosis of “PTSD” and “trauma” helpful to recovery, or more harmful? – He talked about the 2004 tsunami in Sri Lanka and harmfulness of revisiting disturbing memories and trigger warnings.
Is it advisable to substitute local idioms of distress for clinical diagnostic labels such as trauma and PTSD?
Are there medical reasons to even eschew clinical diagnosis and labeling altogether, and instead turn to what clinical psychologists, such as the UK’s Lucy Johnstone, refer to as “formulation,” i.e., putting a patient’s strengths and resources into the context of their life challenges. He said diagnostic labels can become lifelong identity labels, which can be debilitating; a formulation approach might avoid some of these issues. As Kirmayer later remarked, the PTSD diagnosis is a powerful social and psychological intervention.

This led to a brief discussion on diagnostic labels, idioms of distress, and looping effects. For Snodgrass, diagnosis and categories – Western psychiatric or local – are helpful for comparative purposes. Gendron said it might be helpful to hear counterarguments to including idioms of distress in measurement. She said the idea of mixing clinical tools and local idioms is something she and Trang anticipate grappling within. Kirmayer said diagnosis is a useful tool clinically/explanatorily/scientifically in terms of establishing how well things hang together. PTSD symptoms do so to some degree and also relate to basic research on fear and threat. Referring to the trauma book, Kirmayer said fear is a well-established conditioned response, which is highly conserved across species including humans; understanding predictive biomarkers and fear learning and fear extinction pathways have important clinical and real-world implications. [For a recent review on stages of memory consolidation and inhibition, see Maddox et al., Neuron, 2019; for a recent predictive biomarkers study, see McLean et al., Molecular Psychiatry, 2020.]

But a better approach methodologically might be collecting data for symptom network analysis. PTSD lumps together many symptoms with different underlying mechanisms that happen to activate at the same time in certain situations. The situations Maria and Kathy are describing cause so many things to happen simultaneously to people: terror, grievous loss, instability of lifeworlds. Kirmayer mentioned Derrick Silove’s ADAPT model and the fundamental disruptions caused by mass conflict to safety, social networks, sense of justice, identity, existential meaning. Kirmayer gave an example of someone with PTSD who startled at night, but their complaints concerned their immediate pressing problems, their children, getting a job, etc. Further, Kirmayer said idioms of distress can be orthogonal to symptoms, ataque de nervios does not map onto any single disorder, but does predict psychiatric vulnerability. Over the course of in-depth interviews, Kirmayer also said that people may have an initial, more socially acceptable complaint about rheumatism or chest pains but later reveal their traumatic stories, the point being how people attribute things has an impact.

Kitayama recommended finding a way to simplify things. He suggested coming up with a simple process-oriented theory which specifies how information is transformed. People exposed to a traumatic event may experience distress but at another level are also subject to neurobiological processes, e.g., inflammation, high blood pressure, which might vary across different cultural contexts, Interpretation occurs at yet another level, which may result in different outcomes or syndromes. He suggested decomposing the process and examining each step to create some kind of integrated system. Interviews in and of themselves are powerful processes that can be subject to looping effects. Ultimately, people may construct stories that may or may not be reflected in their physical symptoms. These narratives can be therapeutically beneficial, but not answer the causal questions.

Part 1 [25:01 mins]

Returning to Gendron and Trang’s immediate concerns, Gendron noted Sally Seraphin’s chat comment: “Inflammation and its various bodily manifestations (pain, psoriasis, arthritis) seem like a cross-cultural universal that links trauma survivors (of disparate forms of violence).” For Gendron and Trang, it is important to understand heterogeneity in outcomes from the same level of exposure. Gendron said the idea of conceptualizing your own experiences, understanding and labeling them may help organize social support and response to trauma in the West, and data suggests low alexithymia is associated with lower PTSD symptoms. But that may not be a source for resilience for the individuals that Gendron and Trang are studying, who seem far more reticent just talking about emotions in the abstract, let alone revealing their vulnerability through personal stories. Resilience may be more closely tied to social connection and interpersonal forms of emotion regulation. Another point of tension, starting with exposure, what kind of exposure matters for predicting health outcomes (trauma or something larger?), which will most likely be multiply determined (link to VHAS biomarkers and health outcomes).

Seinenu Thein-Lemelson said she had long conversations with Trang about Trang’s work with Rohingya refugees for her Bangladesh project because of Thein-Lemelson’s deep ethnographic research involving political prisoners in Burma. Thein-Lemelson encouraged multi-year ethnography rather than brief interviews, saying there are complexities and different layers of meaning, behaving, and aspects of ritual life, asking, What do symptoms really mean within that community? The dissidents she studies seem to channel what we would consider their psychological trauma into political activism and rituals. Thein-Lemelson mentioned the cyclical nature of the rituals versus the Western, more linear representations of time. She also suggested looking at history of psychiatry within the local setting, whose ideas about trauma and PTSD have evolved (particularly South vs. North Vietnam). Gendron said she recognizes the superficiality of measurement, that there may be limits to doing this kind of work, e.g., survey studies on emotion. Referring to the trauma book, Kirmayer reminded us that most people recover from exposure to terrifying experiences; if not, there are usually other mitigating factors affecting responses.

Kitayama said psychosocial variables, e.g., personality, are missing in Gendron’s project. Kitayama said that he initially thought such variables would not be predictive in the MIDUS study [Midlife in the United States], but he was wrong. Many socio-personal variables (via questionnaire) do predict biological markers; they’re very good predictors and can be considered intermediate variables between exposure and a biomarker, say. Kitayama also said some of the socio-personality variables might be predictive in one country, but not another. He said ethnography can help here. Gendron said her team’s role on the (VHAS) project is precisely at this entry point, to provide this level of analysis. Snodgrass said we don’t have to choose between using questionnaires and interviews.

Kitayama mentioned Kohrt and Worthman’s research on gene expression related to inflammation among child soldiers in Nepal, finding that eudaimonia predicted gene expression. Kohrt said he was skeptical of using psychological resilience measures. But he found that they were more predictive of CTRA response than trauma exposure. Kohrt said measurement of daily stressors was the best predictor of current mental health, not just the prior trauma exposure. He also said it would be useful to measure (1) the impact of the traumatic event (loss of livelihood?), and (2) the reaction to it. Network analysis might be useful to determine where best to intervene (see Jayawickreme, 2017, Fig. 1 below). He also noted the use and misuse of idioms of distress, and the importance of ethnopsychology in trying to see how these fit into models of wellbeing.

Part 2 [41:38 mins; coming later today]

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