Recognizing Historical Trauma’s Role in Cross-Cultural Psychiatry

As a first-generation Singaporean American, I sometimes think about the stark contrast in richness between the age-old historical narratives of Asian countries and of acculturated Asian Americans. Identifying more with the latter, I realize how the absence of an inspiring historical narrative among us has left some of my second and third-generation peers susceptible to internalized prejudice and reduced self-esteem. My parents, even as immigrants, may have an unconscious boost to resilience from feeling tied to a Chinese historical-cultural tradition with millennia of achievement. Yet, many of my Asian American peers, who only remember life in the states, are unaware of positive role models and absorb their own stereotyped misrepresentations in media and literature. Collective historical identity obviously need not define a person; however, it can subtly erode at one’s mental wellbeing. 

Stress resulting from historical consciousness is by no means isolated to Asian Americans. In Black Skin, White Masks (1952), Frantz Fanon described psychiatric stresses specific to citizens of African ancestry in the West at the time. He noted how collective memory of African culture and achievement had long disappeared, but historical trauma and cruel portrayal by media within the “mother country” insidiously ravaged one’s self-esteem. Even today, even ignoring ongoing injustices that cause stress, it should surprise none that repeatedly hearing, starting from elementary school, about the horrific enslavement of and discrimination towards one’s ancestors could contribute to mental trauma. 

Joy DeGruy proposed a term for the results of such historical trauma: “post-traumatic slave syndrome” (PTSS). According to DeGruy, and which may seem intuitive, a collective memory of centuries of slavery, Jim Crow laws, and unwarranted mass incarceration aggravates maladaptive behaviors among many African Americans. Acute racism against African Americans has subsided markedly since the last century, but widespread sentiments of being victimized persist despite this reduced context of racism. Older generations, who experienced and vividly remember acute racism, may indoctrinate their children into anti-authority cynicism and aggression. Despite policy and sociology’s roles in perpetuating PTSS, there exists an enormous opportunity for psychiatrists to help patients identify and defuse their maladaptive mechanisms. 

At times, psychological impacts of historical consciousness are so strong that cultures have well-established terms for them. Such terms abound today for Korea, which historically had little power to resist brutal interference from militaristic giants. Connecting all this to psychiatry, palja denotes a sort of fatalistic, helpless attitude: an acceptance of lack of control over one’s life’s course that stems from folk memory of both those invasions and the historical caste system that dictated individual Korean status. Even more prominent, han describes an unresolved, distress-inducing—often strong enough to elicit somatic pain—and collective feeling of unjust victimization among Koreans, to this day. A lifelong internalization of memories of unavenged foreign humiliation no doubt contributes immensely. 

All of these examples relate to Arthur Kleinman’s term “cross-cultural psychiatry,” which first described a tendency towards somatization of depression among patients of native Chinese cultural background. Fanon’s observations, PTSS, and han could be categorized into a new 

“collective history-bound” subfield within cross-cultural psychiatry. Much of psychiatry and, especially, psychoanalysis tries to alleviate latent tension in part by bringing buried, uncontemplated stressors into conscious processing. These stressors arise not only from a person’s life events, or events involving their close friends and family, but also from their ethno-cultural community. Discussing historical traumas relevant to an entire culture could benefit certain patients. 

A more immediate priority, however, is public awareness of cross-cultural psychiatry. In 2016, some psychiatric morbidities allotted the greatest federal funding for research included acquired cognitive impairment ($1.132 billion) and depression ($410 million). Few would argue against such conditions receiving major attention in research, due to their conspicuousness and universality across demographic lines. Yet, mental stress arising from historical collective memory, even if a culture-specific source of burden, receives very little attention from American psychiatric research. 

The gap in research funding for cross-cultural psychology has two causes. First, the US is relatively young among civilizations. In turn, the dominant historical narrative we do have about our last 241 years almost close-mindedly emanates optimism. The national narrative is easily replete with heroic George Washingtons and Abraham Lincolns and achievements like our contribution towards an Allied victory in both world wars. However, it may not show a rounded picture with darker undertones, such as fairly recent, extensive de facto racism as depicted by Fanon. Thus, researchers may not perceive historical consciousness as a stressor. 

Second, there is a lack of diversity among academicians. Trends at any academic center will likely be influenced by issues its researchers feel most aware of. More ethno-cultural diversity among research psychiatrists would likely lead to increased academic interest in the impact of culture on mental health. Inadequate representation in academic psychiatry alienates ethnic groups that have unique culture-bound and minority status-related psychiatric stressors. Hence, advocates for psychiatry and other mental health care training programs should intensify thir current academic diversity initiatives. When demographic diversity among trainees may not be easily obtained, more psychiatry residency programs should adopt training initiatives surrounding culture-bound mental illness, such as those that at Yale and George Washington University. Furthermore, more programs could train all residents to show awareness of and sensitively screen for history-bound conditions such as PTSS and han, especially in and near large cities. 

Finally, cross-cultural psychiatry as a whole deserves stronger advertising among medical students and psychiatry residents. Long-term solutions include the addition of several pertinent lectures to medical school curricula and the creation of clinical rotations in cross-cultural psychiatry. Immediately, psychiatry clerkship preceptors could encourage trainees, when giving psychiatric evaluations among diverse patients, to ask about cross-cultural concerns. Advocates can also write and speak about cross-cultural psychiatry’s relevance not only to academic centers, but also to community practice. In turn, more attention can be paid by psychiatrists to distress specifically related to historical trauma. 

Identifying with one’s cultural history may enhance resilience but may also generate distress. A traumatic collective history can certainly aggravate the latter, justifying a greater awareness of historical narrative’s effect on mental health when evaluating diverse patients. Mental health advocates can promote awareness of and encourage research on culture-bound psychiatric stressors. In turn, by also acknowledging the limited attention thus far on historical trauma’s role as a stressor, we can promote a new “collective history-bound” field of discussion within psychiatry. Such a field would help psychotherapy patients transcend trauma from not only their individual pasts, but also from a far larger collective past. 

This article was written by Richard Zhang, Sidney Kimmel Medical College Class of 2020


The Case for Spirituality and Medicine

Effective medicine requires developing meaningful relationships with patients. As students, we are taught to start conversations with patients with open-ended questions. Without a simple "yes" or "no" for an answer, the patient shares their story and is able to decide what is important to tell the physician. Clinicians can then ask follow up questions to fill in any gaps in the patient's narrative. Not only is this efficient in terms of diagnosing and treating the patient, but it also facilitates an environment of trust. The patient’s concerns are easily conveyed to the physician and the physician can focus their therapy based on this conversation. Although this is an excellent technique, including spiritual histories could enhance the standard patient interview.

Readily focusing on patient values, spiritual histories allow patients and physicians to connect on a deeper level. They also facilitate planning of advance directives, end of life care, and other spiritually-sensitive medical treatments. By talking about spirituality, patients are able to share, in their own words and in a way that they can understand most, what gives their lives meaning and how this can be applied during difficult times. Physicians have a spiritual role in terms of caring for others and physicians could use this role to their advantage by acknowledging it and using it during patient care.

One method that can be used by residents and physicians to take a spiritual history includes the HOPE acronym:

H: Source of meaning, hope, strength, and connection

O: Organized religion

P: Personal spirituality and practices

E: End of life issues and how spirituality affects medical care

For example, in terms of “H: Source of meaning, hope, strength, and connection”, a physician could ask, “What are the sources of hope in your life?” Alternatively, one could ask, “I understand that religion and spirituality can help people find strength and meaning in their lives; is this true for you?” This step in the spiritual history opens the door to the rest of the questions. If the answer is yes, then the physician could ask about “O: organized religion.” When asking about organized religion, a physician should ask how important the patient’s spirituality is to him or her and what role it has in his or her life.

“P: personal spirituality and practices,” has two sides. One side focuses on the patient’s beliefs independent from an organized religion or the patient’s belief in God and what that relationship looks like. The other, and equally valuable, side looks at the patient’s spiritual practices, such as prayer, meditation, or other practices that helps the patient find motivation and comfort throughout the day. Finally, as it especially pertains to medical practice, a physician should address “E: end of life issues and how spirituality affects medical care.” For example, a physician can ask the patient if there are any spiritual restrictions health care professionals should know about, such as dietary restrictions, that could change the patient’s treatment plan.

So what can physicians do after they have received this information? There are many different options depending on the circumstances and patient’s desires. Firstly, the physician can take no further action with this information if that is what is desired. Even if no further action is taken, the patient will feel a connection with the physician after speaking about his or her spirituality and the physician will gain a better understanding of the patient’s values and what they find meaningful in life. On the other hand, if desired, the physician can incorporate the patient’s spirituality into the patient’s health care. For example, if a patient is dealing with anxiety related to his or her illness, the physician can try to encourage the patient to use spiritual practices such as prayer or meditation to get through difficult times. A physician could also help find resources that the patient could use to find motivation during an illness, such as speaking with a spiritual leader or spirituality-focused support groups.

Incorporating a spiritual history into patient care is important because not only does it open the dialogue, but it also creates a safe space for discussion. This helps to create a meaningful relationship between the physician and the patient that can facilitate trust. In addition, the spiritual history helps the physician to understand where the patient’s desires and values come from. This enables them to be advocates for their patients by making sure that the care that the patient is receiving is in line with his or her values and motivations in life. Considering these advantages, the argument can be made that a spiritual history can be a valuable add-on to a medical history that helps to create a trusting environment between the patient and the physician where open dialogue can be facilitated, patient concerns can be addressed, and care that aligns with the patient’s beliefs can be offered.

This article was written by Michelle Evans, Sidney Kimmel Medical College Class of 2019






The Case For Needle Exchanges

The Case For Needle Exchanges

Needle exchanges are organizations that allow injection drug users to receive free or reduced cost hypodermic needles with no prescription. To the dissenters, the first word that comes to mind when discussing these programs is “enabling.” It is often hard to define the line between support and collusion, but the best way to do so is to look at the overall pros vs the cons.

The Virtue of Patience: Medical School Admissions & The Waitlist

The Virtue of Patience: Medical School Admissions & The Waitlist

For patients, actually being patient can be the most difficult part of receiving healthcare. For some, this ends in the waiting room, but others, unfortunately, anxiously await insurance approval, test results, surgery, transplants, and sometimes—even death. The list of things patients wait for is long, but in medicine, patients aren’t the only ones who need patience.

Can Physicians Also Be Political Advocates?

Can Physicians Also Be Political Advocates?

As medical students, we are torn: can we express political opinions? Will it affect my residency application? Will future patients see it and decide to seek out a second opinion with a physician who is opinion-less on political issues? We take an oath to be inclusive, to treat everyone equally regardless of race, gender or religion. How do we defend that oath but still remain neutral?

Doubting Modern Medicine through Memes

Doubting Modern Medicine through Memes

Conspiracy theorists like the “anti-vaxxers” spread a dangerous strain of anti-intellectualism, and their efforts are rewarded by outbreaks of previously obsolete diseases (and preventable deaths). We need to analyze and fully understand their methods.

Deep Freeze: Why residency programs should pay for trainees’ egg freezing

Deep Freeze: Why residency programs should pay for trainees’ egg freezing

As women make up more of the physician workforce, it’s becoming more evident that women in their training years are also in their prime reproductive years. And residency programs need to recognize that.

High-Yield Lecture Hacks for Professors

High-Yield Lecture Hacks for Professors

The former high school teacher in me says there is room for improvement in medical school pedagogy. In fact, I have noticed some high-yield and easy-to-implement teaching “hacks” that would improve overall instructional practice and student understanding if they were consistently instituted by each professor during every lecture.

Making Health: The Future of Medicine

Making Health: The Future of Medicine

Designing and making with patients would flip the current dynamic of medical education, making us feel empowered to solve problems in healthcare even at this early stage in our career. Fueled by patient engagement and creativity, medical making could produce many dividends for the future of high-quality, patient-centered care.

Pre-Med Internship Mirage

Pre-Med Internship Mirage

Summer “break” has become a well-known critical time for students to strengthen and polish their applications to medical school. The question is: Is the competitiveness of medicine forcing more and more students to do internships that are unpaid, unproductive, and unhelpful just to check that last box on their resume?