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