Culture and PTSD
Culture matters in PTSD, from resources that foster social and emotional support to interpretations of symptoms and how to make sense of trauma. Sources of emotional and social support have been linked to positive adjustment following disasters and other traumatic events (Bonanno et al. 2011). Similarly, organizational and economic resources make a difference in how stressful events are interpreted, as something controllable or as something threatening and disruptive (Hobfoll 2002; Miller and Rasmussen 2010). These sources of support and subjective interpretations emerge from cultural and social dynamics (Finley 2012; Panter-Brick and Eggerman 2011). Institutional constructions of “right” and “wrong” as well as the ability to make sense of different cultures and “acceptable” interpretations of combat all play a role in soldiers’ interpretations of what happens to them, their comrades, and enemy combatants (Burnell et al. 2011). As Brewin (2011) shows, the memory disturbances associated with PTSD are shaped by negative appraisals of self and negative interpretations of memory symptoms; in turn, emotions like shame and interpretive frameworks work through sociocultural dynamics (Budden 2009; Finley 2012; Hinton and Lewis-Fernandez 2010).
These types of internalized cultural structures, and their relationship to military policy, are important factors in soldiers’ take on adversity. The military can both help and hinder acquiring the support and understanding that prove a necessary buffer to adversities faced while deployed. Panter-Brick and Eggerman (2011) highlight how deep rooted cultural understandings of stress are always “in play,” and in the context of deployed soldiers, will generally be more important for understanding combat functionality than the military training that service members go through predeployment. The training experienced within boot camp and soldier's subsequent MOS training (their job or occupation within the Army or Marines) often do not have the same influence as the constructed cultural views of trauma, stress, and adversity that military personnel have acquired while growing up.
Cultural models and interpretations acquired in childhood and adolescence frame the ways that individual soldiers interpret combat and adversity and serve as a cipher of how and why some individuals can cope with trauma and combat and some cannot (Hinton and Lewis-Fernandez 2010; Panter-Brick and Eggerman 2011). This point establishes the importance of looking at multiple cultural spheres as influential forces in the development and functionality of soldiers on the battlefield, including recognizing them as people outside the military and embracing the idea that they are not just ``GIs.'' Being thought of as only a soldier with a specific function in combat may serve the military mission at a critical moment, but the aftereffects of trauma can last a lifetime unless the soldier can make some sense of his or her combative actions and losses endured.
This cultural view needs to be augmented by a consideration of the socioeconomic diversity of people coming into the armed forces. A large majority of U.S. recruits come from a low socioeconomic status (Kleykamp 2006). These recruits do not have any other means of going to college and have typically dealt with ranging levels of adversity because of the economic disadvantages that have surrounded them (Kleykamp 2006). This type of economic adversity leaves the military as a last resort option in which young men and women seek to receive education funding via the Montgomery GI Bill. The decision to enlist as a last resort alternative because of economic hardship creates a sense of forced military service in which deep-rooted motives such as patriotism, honor, sense of duty, and an overall true excitement about volunteering for service in a time of war can be artificially present. Such words to describe military service are often seen advertised in low socioeconomic environments as a means of recruitment and enticement for young men and women. Yet, the motives for joining are often fueled by the desire for military benefits; a sense of personal pride and recognition; as well as the constructed and often romanticized view of being a war hero.
Finley (2011), in her ethnography of veterans struggling with PTSD on their return from Iraq and Afghanistan, highlights the adaptive qualities that humans possess that enable them to function in differing environments. These qualities include possessing a sense of service to others as well as increasing social capital postdeployment, and yet go awry in veterans who seek to isolate themselves from others and lack the ability to speak about the overall impact that combative trauma has had on their personal lives. The contrast between civilian life expectations and living a life of war is immense. Recognizing the need for GIs to be with individuals who care and are willing to listen to them reaffirms the positive outcomes that are associated with smooth transitioning between the two identities. The separation and differing expectations between civil society and military combative culture leaves room for confusion that is not navigated easily and almost always calls for strong support systems as a means of reaffirmation of servitude, duty, and justification for trauma suffered.
Dislocation is a central analytical construct in Finley's research (2011, 2012). PTSD is marked by the physical and psychological sense of dislocation; for combat veterans, both the camaraderie with other soldiers and the sense of the person they once were before war are gone. Together, these jarring changes feed into a sense of dislocation in which they feel they are different from others and cannot connect interpersonally. For Finley, forms of treatment, rituals of memory, webs of relationships and social support, and understandings of what trauma means shape veterans’ attempts at making sense of trauma and coping with PTSD.
This ethnographic research highlights the social component of camaraderie and why it is that service members are known to suffer PTSD from enduring the loss of a fellow soldier, although they may have only known their comrade for a short amount of time. It is the strength of social interactions and what soldiers mean to one another, which buttress the ways that soldiers interpret what is going on within the battlefield. These intense relationships and forms of interpreting adversity carry over into civilian life once returning from deployment, and can create difficult situations when trying to adjust back to social norms. No longer are these service members faced with imminent danger; there are no improvised explosive devices (IEDs) lurking underneath a piece of pavement, Taliban snipers waiting to take a fatal shot, or the sound of incoming mortar fire. Rather, soldiers are surrounded with domestic issues (paying the bills, becoming employed, communicating emotions with loved ones), and are expected to deal with such issues with ease and confidence, as if they were never deployed to a combat zone for well over a year.
Identity matters in PTSD. As Berntsen and Rubin (2007) show, the degree to which traumatic memory forms a part of one's personal identity is directly correlated with the severity of PTSD symptoms, even when controlling for mental health problems like depression and anxiety. Furthermore, Jobson and O’Kearney (2008) shows cultural differences in identity that are linked to PTSD through interpretive frames, for example, how self is defined in relation to others and to culturally important goals. Anthropological research has established that for some combat personnel, fostering an identity as “indestructible” or as “Rambo” (as taught in boot camp) can create an identity crisis when faced with trauma and interpreting combat and loss (Finley 2011). This crisis can provoke or worsen mental health issues such as depression, substance abuse, PTSD, domestic violence, and suicide. What needs to be focused on within future resiliency training paradigms is the balance of cultural identities within the service member population. This issue of identity formation requires a closer look into the cultural constructs that are responsible for what stress and trauma mean to each individual soldier.
The cultural influences that young men and women have before going into the military help shape multiple facets to their identity. From the time a young man or young woman approaches a recruiter of the armed forces, they have a culturally constructed meaning of what serving in the military signifies. Through mass marketing campaigns and consistent exposure to governmental influences of how “glorious” military service is, many of these individuals develop a fantasy of military culture and the rewards that combat can bring. These influences are cultural constructs that are not only practiced on a daily basis but also are emphasized by recruiters, politicians, and segments of the U.S. population. They are wooed by the college incentive programs of enlisting, the benefits of a steady paycheck, and the opportunity of international travel. They are exposed to video games and movies that glorify the battlefield as a place of action and excitement, and imagine the characters of such entertainment as themselves operating as a hero as well as a person to be admired. Finally, they are encouraged to be an “Army of One,”“Army Strong,”“All That You Can Be,”“A Global Force For Good,” or “The Few. The Proud,” all service mottos that have cultural interpretations of pride, honor, and servitude.
This cultural construction clashes with the realities of war once these young recruits enter into a theater of operation. Video games and mottos do not accurately depict the true nature of the combative military experience. Resources that might be drawn on to make sense of these experiences are often limited. From the military point of view, there is little room for the clashing of identities or the confusion of what one's place is on the battlefield. Nevertheless, this sort of clash and confusion inevitably happens.
When soldiers are initially trained to do things the “Army way” in boot camp, they are not allowed to build on their own identity as a person outside the military. This neglect can help foster disassociation (Seligman and Kirmayer 2008) and dislocation (Finley 2012), given that the identity and interpretations of an individual cannot be erased in a ten week period. There are tentacles of associations between their identity as a soldier and their identity as a son, daughter, mother, father, brother, sister, friend, and so forth. These associations attach meaning, and become essential when dealing with the vivid presence of death, violence, and dislocation. These expectations about combat and being a soldier, as well as how and even if to maintain a civilian identity, shape how service members interpret the loss, trauma, and adversity they meet once hitting the battlefield.
The contrast between what one thought the battlefield would be like and what it actually is can help produce disjunctures of identity and meaning making and foster soldier dysfunction. This dysfunction in turn can lead to increased levels of adversity for the individual, his or her comrades, and thus increase potential problems for entire units. Soldiers need to know that their loss and adversity mean something (Burnell et al. 2011). They need to feel and be defined by the fact that getting shot, blown up by an IED, or suffering the loss of their best friend in combat has meaning to it. Their ability to define meaning is correlated to their cultural understanding of honor, pride, and sacrifice. This sense of honor and sacrifice exist in contrast to horror and fear, two key components of initial reactions to trauma that can drive the development of PTSD (Finley 2012). We propose that as soldiers’ ability to relate these positive meanings to traumatic experiences on the battlefield suffers a disjuncture, the possibility for PTSD can increase. This neuroanthropological view builds on research that shows that the feeling of loss and not having control of their environment causes a sense of distrust in their surroundings and is known to further increase symptoms of the disorder (Johnson et al. 2011).
The ability to “make sense” of adversity, trauma, sufferance, and loss in combat makes a large difference in how a soldier is going to deal with the inevitable flashbacks and memories after returning from deployment. This interpretive strength allows for a “big picture” to be formed and can help prevent the soldier from being defined by the trauma lived in combat. In making cultural connections with their unit members, Afghani and Iraqi citizens (combatants and noncombatants), family members, friends, as well as their surrounding environments, they will be able to maintain an image of why it is they are doing what they are doing and faced with such adversity on the battlefield.
Culturally specific understandings of trauma, idioms of distress, and the interpretation of trauma-caused symptoms all play a role in reactions to trauma (Hinton and Lewis-Fernandez 2010, 2011; Zur 1996). During deployment, interpretations of war will differ from one soldier to another. For example, if two soldiers are involved in a firefight and are side by side throughout the duration of the engagement, the story of significance that one soldier gives will not be the same exact story of significance that the other soldier gives. Because of differing cultural backgrounds and interpretations of death, killing, previous violence experienced (both within the military as well as a civilian), and motivational factors for voluntary military service, the events lived within that firefight will resonate with different meanings. The idea that an enemy force is actually trying to kill them and their need to respond with such violence of action will have an altering affect in how each soldier describes what took place post engagement. If one soldier had multiple deployments under his belt and had been involved with multiple past firefights over a nine year span, and the other soldier was a first year service member and had never been in a firefight but had been exposed to gang violence and shootings as a civilian, the ways in which they negotiate and describe the transpired events will differ.
These cultural understandings of one's self and one's relationship to his or her environment can depend on age, experience, and maturity. Such maturity is reflected in how individuals handle adversity and combative stress. Many times, this is reflected by life experience, which normally equates to age. According to the National Center for PTSD, veterans from ages 18 to 24 years faced the greatest risk for receiving mental health or PTSD diagnoses in a study of 103,788 veterans returning from deployment in Iraq and Afghanistan (Litz and Schlenger 2009). Neuroanthropology explains such differentiation via the cultural awareness and environmental understanding that the 18–24-year-old age group has versus those who are older. Establishing a soldiers’ cognitive understanding of their surroundings and the institutional constructs that convinced them to go to war is of paramount importance in establishing greater resilience. Being grounded and culturally affluent with one's self outside adversity as well as predeployment is an important way for soldiers to not feel overwhelmed, and allows them to keep trauma and adversity on the battlefield “in check” with the big picture of their complete identity.
Neural Dynamics and PTSD
Previous research has established the close links between the meaning of specific acts and experiences and neural function, for example, in the salience of drug use or the impact of dissociative experience (Lende 2005; Seligman and Kirmayer 2008). Recent neuroanthropological work on memory and knowledge traditions highlights how different medical knowledge practices can drive differential use and organization of memory systems in the brain (Hay 2012). Neuroscience research also shows that established memories can become labile when they are retrieved or reactivated, with subsequent consolidation shaped by the present context and use of the memory (Inda et al. 2011; Schiller and Phelps 2011). Together, this research on memory highlights the strong possibility that memory-related aspects of identity rely both on cultural traditions and present uses, shaping the consolidation and activation of basic memory processes in the brain. This framework shows how soldiers’ lives during deployment will shape how they interpret trauma, from forming invasive memories to fitting experiences into a “big picture” of what trauma means.
Identity is not only related to memory but also to self. The neural correlates of self are found in the midline structures of the brain, including the anterior cingulate, insula, and prefrontal cortex (Medford and Critchley 2010; Modinos et al. 2009; Qin and Northoff 2011). In relation to our discussion of dissociation and dislocation above, the point by Qin and Northoff (2011:1221) on how self emerges in the relation between default-mode functioning and present engagement is particularly pertinent: “our data suggest that our sense of self may result from a specific kind of interaction between resting state activity and stimulus-induced activity.” Dislocations in self, in particular between more resting state and consolidated aspects of self and present challenges to self (such as caused by threats to life or to core aspects of personal meaning), can emerge through these interactions in ways that potentiate the impact of trauma on encultured individuals.
Finally, biocultural connections exist between the interpretation of trauma and how different individuals embody adversity (Kirmayer et al. 2007). Varying allostatic loads and epigenetic modifications can play a significant role in the dysregulation of the hypothalamus–pituitary–adrenal axis (HPA axis; see Yehuda and Bierer 2009), one of the primary systems mediating reactions to stress and trauma. This HPA dysregulation has been linked in part to the 5-HTT (serotonin transporter) gene, which promotes the development of the human stress response system (Gross and Hen 2004). Serotonin matters because the neurotransmitter works as a modulator of emotions and of stress-response hormones in the amygdala (Wang et al. 2011). Allele length variance of the 5-HTT gene is directly linked with an increase in amygdala activity when humans are put in moments of anxiety; this has been linked with greater susceptibility to the development of PTSD (Gross and Hen 2004). These differences can shape how people react to and interpret trauma; for example, experiencing greater or lesser amounts of anxiety will color what a particular event means to a person.
These aspects of neural function play a significant role in the impact of trauma and the overall development of PTSD. As Finley (2012) argues, there is a rewiring of responses to stress and fear in individuals who spend extended periods of time at war, with increases in vigilance and decreased reaction time and an emphasis on less cognitive processing in situations perceived as threatening. This response pattern demonstrates cultural priming, where previous learned experiences provide an instant interpretive frame for stress and trauma, both in the immediate aftermath and over the long term. Using this approach, Finley (2012) reinterprets the core diagnostic features of PTSD—hyperarousal, reexperiencing, and avoidance—through a model of neuroanthropological stress framed by the horror, dislocation, and grief that veterans experience through war.
In sum, the comprehensive lens that is offered through neuroanthropology allows us to connect the psychobiological components of reactions to trauma to individual experiences and interpretations that develop within specific cultural environments and are shaped by local institutional dynamics. This approach also paves the way for applied anthropological research to begin making recommendations for dealing with PTSD in a proactive manner.