Trauma and Violence: From Liberia to Katrina

The debate surrounding the importance of mental health is complicated by personal experience and the aggregate prevalence of mental disorders. In America, we focus on treating mental health on a case-by-case basis through psychiatric services that utilize therapy and prescription medication. Individuals who have the resources and information can seek out treatment from health care providers to unpack traumatic experiences or other sources of emotional stress.

But what happens to our conception of trauma and the treatment of mental illness when conflict arises, and a thousand people in Monrovia are killed in less than a month? What, if anything, can be done to assess and “diagnose” the experience of trauma on a population level?

Abramowitz examines the experience of Liberians after the nation’s second civil war, and explains the struggle for people to regain, reconstruct, and reconfigure their identities in the aftermath of extreme violence. She defines trauma as “a rupture of the self,” and describes the need for people to cope with their experiences in order to build new lives in the midst of pervasive cultural and social uncertainty (Abramowitz). The collective memory of thousands of people who were witness to the most horrid acts of violence committed against their family members and communities now had to negotiate social values and terms of peace whilst dealing with immense emotional suffering.

To understand the mental health needs of this “traumatized nation” using the western model of a per person, by request basis would be a mistake. Health care services provided by NGOs and government agencies must be proactive in recognizing symptoms of mental illness and recommending treatments.

Yet, these solutions are complicated by the link of trauma and violence to poverty and socioeconomic disparity. It is often asserted that mental illness requires resources that low-income nations cannot afford, and usually conflict torn places do not have secure institutions to deliver services anyway. Additionally, social stigmas associated with mental disorder discourage people to question or report their emotional states, and diminish the opportunities of the mentally ill in employment, education, and marriage (Farmer 217). Not only that, but co-morbidities between mental illness and communicable disease mean that the burden of all disease is compounded on those worst off in the world.

Socioeconomic disparity can also serve as a lens to understand the parallels between the experience of trauma in post conflict countries and the trauma from natural disasters. Violence and disaster both produce conditions that affect people on a mass scale, especially poor people, and lead to the deprivation of torn communities. The stress from disaster and violence are both characterized by uncertainty and existential crisis – not knowing where your family is, not knowing if they are okay, not knowing what will happen to you tomorrow.

For example, in the aftermath of a devastating earthquake in Nepal in April of 2015, the rate of suicide increased by 41% over a period of three months since the event, according to police data (“Suicide Rate Surges Post Quake: Report”). It has been studied that in places where disasters occur, the initial shock and trauma usually subsides within a year. This has the implication that the suicide rate will normalize in Nepal soon after the earthquake. However, the case of hurricane Katrina conveys that different chronic problems persist long past the initial disaster event. A recent survey reports that ten years later 47.7% of participants were living with PTSD in New Orleans (Kelley). Though many studies done in the past of survivors of previous hurricanes “showed quicker and more complete recovery from mental disorders,” the high rate of PTSD in Katrina victims stands out as a failure of services to return to New Orleans (Kelley). Additionally, the survey validates the need for consistent mental health treatment beyond the first years that follow a disastrous event.

The relationship between violence and disaster reveals the complexity and extensive domain of trauma experienced by large populations. Paul Farmer points to one solution that can address this trauma by singling out successful, low cost programs in Ecuador and Colombia that train primary care workers in the recognition and treatment of mental disorders (Farmer 219). He quotes Arthur Kleinman about the standard practices of mental health that can be utilized across cultures, “serious psychiatric disorders such as schizophrenia and depression are recognizable around the world, even if they differ in their course and convey different meanings depending on the local context” (Farmer 224). This offers some hope for the abilities of communities to incorporate mental health testing into their current routines in a way that is practical and substantive. If the world is going to continue to see large-scale violence and natural disasters, and we know that it will, then mental illness is not just a nation-state issue; it is global issue and should be included in the determination of the UN’s Millennial Development Goals.

 

Discussion Questions:

  1. Are western practices of therapy and psychiatry appropriate blueprints from which to model mental health services in low-income, post-conflict nations?
  1. As world temperatures rise and the effects of climate change continue to impact populations, the rates of violence are expected to increase. In the case of Syria, it is claimed that drought led to the insurrection and political instability that has produced millions of IDPs and refugees. And in the case of Nigeria, it has been argued that drought created the conditions of instability that were exploited by Boko Haram (Shockman). Do you think climate change will have a role in the violence and rates of trauma-related illnesses of the future?

Outside Sources:

Kelley, Kendra. “10 Years After Hurricane Katrina, Mental Trauma Remains.” Mississippi News Now. WorldNow and WDAM, 31 Aug. 2015. Web. http://www.wdam.com/story/29837949/10-years-after-hurricane-katrina-mental-trauma-remains

Shockman, Elizabeth. “Is Global Warming Contributing to the Current Refugee Crisis?” Pri.org. Public Radio International, 28 Sept. 2015. Web. <http://www.pri.org/stories/2015-09-27/global-warming-contributing-current-refugee-crisis>.

“Suicide Rate Surges Post Quake: Report.” The Kathmandu Post, 9 Sept. 2015. Web. <http://kathmandupost.ekantipur.com/news/2015-09-15/suicide-rate-surges-post-quake-report.html>.

17 thoughts on “Trauma and Violence: From Liberia to Katrina”

  1. The connection between climate change and trauma-related illnesses is so interesting to me. Violence has definitely been connected to warmer temperatures and since we cannot stop global warming (only try to decrease its impact), the only way to move forward seems to build up our mental health resources and funding around the world. One of the reasons this is hard is because of the invisibility of mental health. Infectious diseases are more physically visible than mental disorders. Prevention initiatives, treatment, and therapy for infectious diseases are definitely better funded (and made easier to donate to because of a clear picture of the disease in the donors’ minds?). Therefore, I think the first step is to increase the visibility of mental illness in general society. This could easily be done with a government-, NIH-, or WHO-sponsored information campaign about the prevalence of mental disorders and how to get help. After that, it seems more reasonable to work on how to better deal with the impending increase in mental disorders and raising the funds (or getting the government to allocate the right funds) to do so.

  2. – I think that Westernized countries should be a basic model that developing countries should aspire to do. The more programs they have, the better off they will be. According to The Guardian’s recent post on Syria, approximately 80% of the people are living in poverty. As we discussed in class, poverty and high rates of anxiety and depression have a direct correlation. Although Westernized countries are a good example to replicate, Syria may not be in a good financial position to implement it. That being said, NGO’s can help fund for these operations and ask for donations in hopes to help a developing countries needs.
    The Guardian. “Syria’s War: 80% in Poverty, Life Expectancy Cut by 20 Years, $200bn Lost.” Associated Press, 12 Mar. 2015. Web.
    http://www.theguardian.com/world/2015/mar/12/syrias-war-80-in-poverty-life-expectancy-cut-by-20-years-200bn-lost
    – I think your points regarding the different temperatures are really interesting. I have heard of this before, but I didn’t even think to connect the two in this situation. I do believe that temperatures have a role in violence rate of trauma-related illnesses. Weather causes aggression, aggression causes violence, and violence causes catastrophic events, which can lead to mental illnesses. It truly is a spiraling effect. I definitely think more research could be done on this issue. Do you propose any suggestions as to how it could be examined and measured?
    – I think you brought up some really interesting and unique points. I thought you mentioned some intriguing statistics about earthquakes and hurricane Katrina and how issues are still prevalent today. This demonstrates how mental illnesses are an ongoing issue that desperately needs to carefully monitored. Like I said on Sarah’s blog, it is extremely hard to “unsee” horrific events. I think your statistics also show that the US (a Westernized country) still has flaws considering nearly 50% of Katrina victims reported having PTSD symptoms.

    1. Hi Samantha,

      Thanks for your thoughtful comment. There may be present research that attempts to predict periods of violence based upon weather patterns, though I think the pursuit of this kind of data is maybe less useful than the acknowledgement that while we cannot necessarily predict violence, we know that as global warming produces more severe conditions, communities will face impending suffering, populations will be migrating, and that violence tends to accompany these shifts. Very likely there will continue to be large scale refugee crises resulting from changing weather patterns, so maybe we should think about preparing for them now. Here are a couple articles that suggests many people will look to Canada as a place that is particularly climate safe:

      http://globalnews.ca/news/1750950/scientist-predicts-mass-exodus-of-climate-change-refugees-to-pacific-northwest/

      http://www.nationalobserver.com/2015/10/30/exodus-climate-refugees-has-just-begun-where-will-they-go

      The idea being that Canada or other places might begin to think about climate refugee policies. We can see with the current crisis in Syria that displaced people suffer incredible injustices, and health being a major problem that is difficult to fix with emergency aid services. Accepting refugees is a health issue, and I think governments need to reimagine national boundaries as permeable in order to share the immense health burden that these crises produce. Mental health services are an important aspect of this problem but are services that are typically not offered through emergency aid groups, so the only way to help conflict or crises displaced people is to accept them first and expand mental health programs after.

  3. Elena,

    Firstly, I enjoyed your post immensely and thought the comparison you drew between natural disasters and violent conflict to be fascinating and well argued. I particularly liked the approach you took to natural disasters as a form of environmental injustice caused by climate change, as we generally view natural disasters to be outside of human control or influence. I liked how you also noted that while both environmental circumstances—such as natural disasters—and violent conflict may individually lead to traumatized populations, the two situations can be related as environmental events themselves may lead to societal instability and possible conflict.

    In response to your third question, I think it is very likely that climate change could have a role in increasing the rates of trauma-related illness in the future. It has been established that natural disasters themselves can be traumatic experiences and lead to the manifestation of trauma-related illness (as you pointed out in the cases of the earthquake in Nepal and Hurricane Katrina) and unfavorable climate conditions can be a contributing factor to the eruption of violent conflict. As climate change is causing more severe climate conditions (stronger storms, longer droughts, etc.) it is likely that we will witness increasingly worse environmental disasters that will precipitate greater rates of trauma related illness. With this in mind—and knowing that climate change is largely caused by developed nations but has a global effect—should climate change be considered a form of environmental injustice? If so, what could be done about it?

    1. Hi Sabrina! That is an excellent point that I think is well worth arguing and which I did not fit into my post. If developed nations, like the US, can understand their disproportionate contribution to climate change, than it can be argued that the kinds of disasters and conflicts in the world that were potentially sparked by global warming are in part our doing. This kind of argument I think can be used to assert that we too have an obligation to help resettle people displaced by these events and afford them access to health services particular to them. Its about seeing the world as a global community in order to give better distribute health services to those who need them, and mental health services are only going to become viewed as more vital to one’s right to health in the future.

  4. Hi Elena! Thanks for your post! To respond to your first question as well as some of what you wrote, I want to point out that while I wouldn’t say that Western practices surrounding mental illness can be exported and applied to every other population, neither would I single out the individualistic approach as what defines my reasoning. Western diagnosis and treatment of mental illness does use an individualistic approach, but it also includes many other idiosyncrasies, such as specific ways of describing symptoms or specific methods of diagnosis. With trauma specifically, DSM diagnoses of PTSD need to be linked to a specific traumatic event in the person’s past. But what if what has caused their trauma is not a very personal event, and not even a thousand people being killed in a month, like you give as a counter example, but is just constant stress, danger, and fear in daily life? What if violence has become ordinary? What, then, is trauma? To provide another example, the piece on nightmares showed just one way in which post-trauma symptoms can vary by culture; the DSM symptoms are thus proved culturally-specific as well. These differences become further problematic not just for diagnosis but also for treatment. Meanwhile, I wouldn’t be so quick to dismiss the importance of looking at individual cases, provided they are also taken with the social context. I agree that when trauma becomes a characteristic of a particular society or population, mental illness needs to be assessed and dealt with on a population level; however, mental illness can be a complicated concept, and both collective and individual methods of analysis can provide more information that can be used to help people. Context matters, and that includes individual context as well as environmental and social context.

    1. Hi Allison!

      I think you have made a good argument here, and looking back on my post I would agree that we cannot diminish the individual when considering how to manage mental health. I think my original intent was to imagine the huge need for mental health services after major conflicts or disasters, especially when funding for them is negligible. In the US our mental health care system is not constructed around the events of state emergency, so for places where thousands of people have been impacted by violence and suffering, what can be done immediately to help them? Is there a way to imagine a kind of emergency response to mental health needs, one that could impact whole communities? Perhaps I should have articulated that there could be the development of a first response kind of mental health initiative, that would accompany more standard practices of individual-centered care.

  5. Hi, I really enjoyed your post and agree entirely that the need to treat mental illness is absolutely a global issue and not just an American or Western one. That said, it is very costly to treat mental illness and trauma, and that’s proven to be so just in the U.S. alone. As it is, health insurance doesn’t always fully cover adequate mental health care, if at all. So to remedy this in foreign countries via an NGO style mental health care delivery system would be a fine way to go. It’s easy to be critical of the care these NGOs can provide, or the quality of those doing the treating, but if it’s between that and nothing, I can’t see how the former could ever go wrong.

    1. Additionally, I wanted to take a stab at your first question. I do believe that western style practices of therapy and psychiatry are appropriate blueprints from which to model mental health services in low-income, post-conflict countries because it seems to yield positive results. Mental health care has come a long way since just 60 years ago when the U.S. government thought it was okay to lobotomize psychiatric patients. I think Western medicine has evolved and improved for the better and it only stands to reason that it would have improve the mental health of those living in low-income, post-conflict countries. That said, I do agree that whoever is offering their services should be very cognizant of the context of the conflict, and perhaps be proficient in the language in order to be accessible. As we saw in that one reading where the word “nightmare” didn’t translate, there could be a problem with communication if the health care provider isn’t well-versed in the lexicon.

      1. And why not take a stab at the second question.

        Yes, and it will be over water. Speaking from someone from LA, water is a scarce resource and has added to the tension between socal and norcal, where we get a significant portion of our water. I am not projecting a violent uprising to take place in California, but it is clear that whenever a basic necessity’s availability is compromised, people fight, and people die. Perhaps a more proactive approach, like curtailing the right to emit a certain amount of CO2 in order to combat global warming would be a step in the right direction.

  6. Hi Elena,
    I think the connection you brought up between climate change and rates of violence was incredibly interesting and thought provoking. I had never heard of that correlation it almost sounds biblical. However, I can see how that connection is more than plausible. In regards to answering your question I definitely see how drought itself any extreme weather can affect one’s mental well being. For instance, it is well known that California is experiencing a drought however in Los Angeles that drought is experienced differently than someone living in Central Valley. The emotions and stress associated with drought I believe would vary by region, and I would be interested to see how data would follow the mental health of inhabitants who live in areas more susceptible to the heat. For instance, would violence rates increase at the same rate in the Silicon Valley/Beverly Hills area as in cities such as South Central Los Angeles? And if they did how would the U.S. government address the mental illness increase, we have talked about how clinical interventions would be a possibility even if it only helped one person, but what part of the population would be left out?

    1. Hi Florisel,

      I think you point to an interesting juncture between health, the environment, violence, and socio-economic status (and of course other issues related to these). If the kind of increase in violence that global warming causes mainly impacts poorer communities, then we will continue to see the burden of all issues placed upon the most vulnerable people, and at an accelerated rate. This stresses the importance of recognizing inequality as something that those who live outside of poverty should feel complicit in.

  7. Hi Elena,

    Thank you for your post. Im having a lot of difficulty with tackling your first question. On the one hand you are right in that Western practices of therapy and psychiatry do not translate exactly in different societies. However, I am having a difficult in thinking of an alternative. I believe that the face to face model of Western therapy is the most effective in treating the individual, but when dealing with whole populations that are suffering will this approach make a difference? There is also the question about electing to receive this care. Will those from a place were suffering is normal feel that their own warrants special attention? These are difficult questions that I don’t feel capable of answering, but this will certainly be a predominant theme in the upcoming waves of foreign aid objectives. In regards to your second question, it is clear from the information you have provided that climate change will definitely affect future violence and rates of trauma-related illness. This is an interdisciplinary problem and thus would require and interdisciplinary approach to fix. Climate will prove to be the battle of our generation as we fight to reverse the damage done by generations before us. This however is no small feat as it will require totally renovation of our economic, political and cultural systems to accomplish. Due to the complexity, if the issue is ever solved, I doubt it will be for many years, and for this reason I am assured that we will see further climate related violence in the world.

  8. Elena,

    Thanks for that though provoking post! You brought up some really interesting points about the nature of Trauma and metal illness. I enjoyed the example of the long lasting impacts of the trauma hurricane Katrina had on New Orleans and how it really highlights deeper more chronic problems that face a location after a traumatic event. I definitely agree that there need to be continued services made available past the first few years following the trauma. Mental Illnesses, such as PTSD do not simply go away and the metal health services should reflect that, helping people live with and get over their PTSD.
    To try to answer your second discussion question, I believe that climate change will definitely affect trauma-related illnesses in the future. We are looking at a future in which natural disasters and hardships are going to more and more commonplace. When these awful climate related events are happening the underlying socio-economic and political problems tend to come to the surface as in the example given such s Syria and Nigeria. With more climate problems more of these problems will come to the surface, a lot of the time the result of this more violence which results in trauma related illnesses that need mental health professionals and resources in order to address.

  9. I find your discussion of the “initial period of trauma,” which is believed to subside after a certain timeline, as a fascinating chance to discuss how culturally-imposed visions of normality and abnormality directly shape the field of mental health as well as mental healthcare intervention efforts. The DSM (as discussed in class as we looked at social suffering and local biologies (Lock) as strong examples of biosocial contingencies of human health) is highly symbolic of the boxes we create along lines of perceived normality, perceived instances of severe or threatening difference in behavior and affect, etc. We reach a very interesting problem when we think about the discrepancies in the ways that trauma and mental wellbeing are treated in discussions of suicide following the Nepal disaster and PTSD following Hurricane Katrina. We are forced to confront the truth of health interventions in our current world, that there is no “quick fix” for problems that hinge on both the biological and the social, and the inextricability of the personal biology from its social body.

    In an effort to answer your first question in regards to all this, I think delivering proper psychotherapy-based or psychiatric care to a population which has endured major stress and grapples with residual trauma must begin with the understanding that the boundaries of “normal” and “abnormal” under which Western mental healthcare workers are trained (from DSM-defined periods of ‘normal’ grief to officiated protocols for screening for a person’s basic “functionality”) will not sufficiently guide care that makes a long-term change for the individual, let alone the population. The expectation of a “normal” timespan in which trauma should subside is a concern when thinking about the intensive patient-doctor engagement that is necessary for high-quality and deeply productive mental healthcare. Individual patient narratives become increasingly important in treating not only the individual, but diagnosing the pain of social suffering shared by entire populations.

  10. Hi Elena,
    I really enjoyed your post. The connection you made between climate change as a possible propellant of violence is one I’ve never considered before. You made some really good points and to answer your first question, I don’t think it’s appropriate to use the western model for treating mental illness in low resource settings especially areas facing disasters. The stigma associated with mental illness in certain areas make seeking treatment in the form of therapy or counseling much more difficult. Also in these places there is usually lack the necessary numbers of primary care physicians, so there is most likely not nearly enough psychiatrists for populations experiencing mental illnesses like PTSD. I think one way to counteract this, might be to train the already existing primary care physicians to diagnose and treat mental illnesses. Additionally the pharmaceuticalization of illnesses make giving drugs one of the simpler ways of treatment in low resource settings. Like the use of anti-depressants in Chile, it might be worthwhile for NGOs or these governments to give out anti-psychotics to treat PTSD. This will probably result in any unanticipated consequences like the price of drugs sky rocketing in Chile also these areas typically have high risk o f drug abuse, so introducing more drugs into these areas might be dangerous if they aren’t monitored carefully.

  11. Hi Elena,

    Your post was a great read, thank you!
    To answer your first question, I do not think that western practices of psychiatry are appropriate blueprints from which to model mental health services in low income countries. Primarily because of the fascinating topic of ‘local biologies’ that we discussed in class. It seems to be that social and cultural environments can interact with genes to influence our mental health, and thus I think that ultimately the best way to approach global mental health is to have mental health care tailored to each and every country. Additionally, psychiatry isa field that is still very much in its infancy so I just don’t think that western psychiatrists have the right to say that their approach is without a doubt the approach that will yield the best results.
    Your second point was fascinating to me because I had never heard of/read of the relationship between climate change and the rates of violence, but it does indeed make sense. So thank you for bringing that to my attention. Certainly, given your example with Boko Haram I do think that climate change will have a role in the incidence of trauma-related illnesses. I just hope that the politicians at the Paris Climate talks right now are just as aware about this association as you are!

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