Posttraumatic Coping and Distress

Abstract

The current body of knowledge related to trauma and posttraumatic stress disorder (PTSD) is primarily based on research conducted in Western nations. Thus, Western clinicians and researchers may know little about whether people from non-Western societies have similar reactions or symptom manifestations to specific traumatic events. Traditional Chinese health beliefs with their roots in Taoism, Confucianism, and Buddhism influence illness perception and affect coping behaviors of Chinese exposed to traumatic events. This article discusses compatible and incompatible aspects of the traditional Chinese health beliefs with Western beliefs about PTSD and examines how culture-based motivations may possibly impact emotional responses to traumatic events between American and Chinese cultures. This article also reviews the literature on the prevalence and applications of Western diagnostic criteria and measures of PTSD in contemporary Chinese populations and proposes suggestions for developing a culturally sensitive framework for clinical management of Chinese trauma survivors.

Keywords

posttraumatic stress disorder coping strategies trauma cross-cultural research Taoism Confucianism Buddhism

As the diagnosis of posttraumatic stress disorder (PTSD) has been grouped with a number of trauma-related disorders in a newly established category—Trauma and Stressor-Related Disorders—in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013), it is particularly important and timely to consider emerging diverse conceptualizations of posttraumatic pathology and innovative approaches to treatment (Gray & Lombardo, 2012). The current body of knowledge related to trauma and PTSD is mainly based on research conducted in Western nations, and its findings are typically published in English, with only 6% in languages other than English (Bedard, Greif, & Buckley, 2004). Thus, clinicians and researchers may know little about whether people from non-Western societies have similar reactions or symptom patterns for specific traumatic events (Tang, 2007). In this article, we examine American conceptualization of PTSD and Chinese conceptualizations of trauma-related distress and consider the applicability of the American PTSD construct in cultural ways to Chinese trauma survivors.

As the largest ethnic group in the world, Han Chinese constitutes about 20% of the entire global human population (Wen et al., 2004). As the most influential group in the Chinese communities in Mainland China, Taiwan, Hong Kong, and Western countries (including Chinese Americans), traditional Han Chinese have showed very similar attitudes and beliefs toward traumatic experiences, regardless of location (Yeung, Xu, & Chang, 2005). Because the overwhelming majority of the population in China and nearly all relevant research has been conducted with them, the present article focuses on the comparisons of American and Han Chinese cultures with regard to the posttraumatic coping and distress. Accordingly, in this article, Americans refer to European Americans living in United States, whereas Chinese refer to Han Chinese people living in Mainland China, Hong Kong, Taiwan, and other regions in the world. Occasionally the term Western is used when literatures or conceptualizations based at least partially on non-American Western populations are discussed. Importantly, these terms—American and Western—are not used interchangeably throughout the article. When specific investigations utilizing only participants from one country (i.e., the United States) are described, we use the narrower, country-specific term in those cases.

The construct of PTSD is indeed a cultural construct, but it is important to evaluate the applicability of this Western construct in Eastern cultures because of the often misguided attempts to study and treat Western-derived disorders in Eastern cultures. The definition of trauma varies cross-culturally, but the universal depictions of trauma have centered on an emotional response to a terrible event like an accident, rape, or natural disaster (APA, 2013). This article discusses compatible and incompatible aspects of traditional Chinese health beliefs with Western beliefs pertaining to the conceptualization of and coping strategies for trauma. Specifically, we examine how culture-based motivations are associated with emotional responses to traumatic events between the American and Chinese cultures, we review the prevalence and applications of Western diagnostic criteria and measures of PTSD in contemporary Chinese populations, and we propose suggestions for developing culturally sensitive conceptualizations and corresponding culturally adaptive treatments for Chinese trauma survivors.

Conceptual Similarities of Trauma-Related Distress Between American and Chinese Cultures

Although there are many differences in beliefs and culture-based values between American and Chinese populations, they share some similar interpretations of traumatic events and utilize some common coping strategies. First, most individuals in Western and Chinese populations believe that trauma-exposed individuals have experienced difficulties moving on with their lives. In both the Modern Western Medicine and the Traditional Chinese Medicine (TCM), the goal of treatment is stabilization of human life.

Second, research findings generally indicate that a population could be dominated by one cultural worldview, but influenced by another culture at the same time, because similar types of value orientation may coevolve in certain historic eras or cohorts. For example, Chinese trauma survivors may not only manifest their problems in a traditional way (e.g., somatic channels) but also be capable of discussing their problems in Western psychological terms (Thiel de Bocanegra, Moskalenko, & Chan, 2005). However, some components of Western coping strategies for traumatic stress (e.g., mindfulness and acceptance) have been borrowed from Taoism or Buddhism, which originated from Chinese culture (Burns, 2010).

Third, the hypothesis of altruism born of suffering has been demonstrated across both individualistic and collectivistic societies (Zhai, Liu, Wu, & Jiang, 2010). Altruism in Western cultures and collectivism in the Chinese culture both emphasize interdependent relationships among individuals. When it comes to individuals’ responses to traumatic events, altruism and collectivism may both demonstrate the characteristics of prosocial behavior toward helping disadvantaged groups (Vollhardt & Staub, 2011).

Finally, in both American and Chinese cultures, the effects of avoidant coping strategies and approach coping strategies may be the same: Avoidance-oriented coping strategies may lead to ineffective long-term adjustment outcome, whereas approach-oriented coping strategies (e.g., seeking connections with others, cognitive processing, and positive self-reinforcement) may lead to greater positive adjustment (Y. W. Wang & Heppner, 2011).

Incompatible Aspects of Health Beliefs Between American and Chinese Cultures on Traumatic Experiences

American and Chinese culture derived from different historic backgrounds and philosophies lead to differing health beliefs related to traumatic experiences. Western medicine, which has been associated with relatively greater dualistic thinking and reductionism, shows a tendency to dichotomize mind and body and to emphasize the parts of the whole rather than the whole when interpreting traumatic stress. TCM, which has been associated with more holistic thinking, tends to conceive of the mind and body as integral parts of the whole human body when conceptualizing emotional reactions to traumatic experiences. The concept of “trauma” has been clearly defined and conceptualized in American psychiatric nomenclature for quite some time. In the DSM-5 (APA, 2013), diagnostic criteria for trauma-related disorders include a history of exposure to a traumatic event that meets specific stipulations and symptoms from each of four symptom clusters: intrusion, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity.

In contrast, no clear definition of “trauma” or “PTSD” can be found in TCM. Grouped with other psychiatric illness or emotional difficulties (e.g., depression), a certain number of PTSD-related symptoms and their mechanisms have been discussed such as Fanzao (agitation, frequently signing, or grief), Ji (uneasiness), or Kong (phobia, forgetfulness, or sleeplessness) in TCM. In addition, these PTSD-related symptoms have been suggested to be treated with acupuncture in the Cannon of Internal Medicine (Liu, 1981), although stressors were not specified or categorized as trauma. From the perspective of modern Western medicine, the concept of trauma-related distress in TCM may be seen today to be primitive and incomplete, but it was an attempt to classify trauma-related mental disorders. In TCM, although description of trauma-related distress has not been systematically and clearly stated as an independent category of mental disorders, treatments have been developed to deal with the array of psychological and physical symptoms likely to manifest in those who have experienced trauma (Sinclair-Lian et al., 2006).

Holistic Thinking in TCM

With its roots in Taoism and Confucianism, the fundamental theoretical framework of TCM exhibits a great tendency toward holistic thinking in the core theories of categorization, diagnostic system, and treatment. Specifically, this tendency can be seen in the TCM conceptualization and treatment of trauma-related distress.

The TCM conceptualization of trauma-related distress

Conceiving the mind and body as integral and inseparable parts of the whole human in understanding disease, the holistic TCM conceptualization is unlikely to consider biological diseases and psychological disorders as two categories of abnormality of the human. This may partially explain why Chinese trauma survivors have been found to be more likely to report more somatic complaints than their Western counterparts (Zhou et al., 2011). In addition, Chinese trauma survivors have been reported to complain predominantly about cardiopulmonary symptoms, vestibular symptoms, and sleep paralysis experiences (Yeung et al., 2005), whereas American trauma survivors have not typically been found to report these symptoms. Even when American trauma survivors express some physical symptoms, their somatic symptoms are not the primary complaint (the lone exception may be the case of panic attacks). One explanation is that some medical descriptions of symptoms of stress-related disorders in TCM are holistic and can refer to both the emotional and physical feelings (Scheid, 2013), such as “constraint” or “stagnation.” The TCM diagnostic approach involves both physical and psychological elements, which may increase the tendency of Chinese respondents with emotional difficulties to report physical symptoms as their primary concern.

The two levels of diagnosis of mental disorders in TCM have determined the treatments for Chinese trauma survivors: disease diagnosis and syndromatic diagnosis (Cai et al., 1995). Disease diagnosis is conceptually the same as that in Western medicine, whereas syndromatic diagnosis, something unique to TCM, is a diagnosis of disequilibrium among the subsystems. Specifically, some Western stress-related disorders are not considered disease diagnoses but rather syndromatic diagnoses in TCM and treated by adjusting disequilibrium. Neurasthenic symptoms, as an example of syndromatic diagnosis for stress-related disorders, have been considered as a culturally sanctioned method to express psychological distress in Chinese populations (Lee & Kleinman, 2007).

PTSD, as defined by Western medicine, is not recognized as an official diagnosis in TCM, although the symptoms of PTSD defined by Western medicine have been noticed and described by Chinese psychiatrists and trauma survivors. Intentionally or unintentionally, perhaps due to the two levels of diagnosis of TCM, Chinese psychiatrists/physicians and/or patients tend to underemphasize the psychological descriptions of trauma-related distress, relative to their Western counterparts. Most Chinese somatizers are not aware of their emotional problems and usually seek help from their physicians rather than mental health providers (Thiel de Bocanegra, Moskalenko, & Kramer, 2006). However, Chinese physicians trained in biomedicine may pay less attention to psychological symptoms caused by emotional difficulties (e.g., trauma-related distress) and do not routinely refer their patients to mental health providers unless they have perceived that their patients have demonstrated signs of serious psychiatric disorders (e.g., schizophrenia). Therefore, Chinese patients reporting somatic complaints, as opposed to those reporting emotional complaints, are more likely to receive a disease diagnosis, treatment, and additional attention from their physicians. Thus, the two levels of diagnosis of TCM may help to explain why somatic expression of distress is so common among help-seeking Chinese trauma survivors.

The TCM treatment of trauma-related distress

The core treatment philosophies of TCM are strengthening and nonantagonistic (Wong, 2000). According to TCM, traumatic experience could disrupt the human body’s harmonious interactions with the environment leading to health-related problems. The treatment goal of TCM is that individuals can rebalance their intrapersonal and interpersonal systems and restore the harmonious dynamic equilibrium of these systems through adjusting their mind–body–spiritual systems. With that in mind, TCM favors a multimodal intervention approach that includes traditional Chinese herbal medicine, acupuncture, nutritional therapy, traditional health exercises (e.g., Tai Chi and Qigong), and a quest for spirituality based on traditional Chinese philosophies (i.e., Confucianism, Taoism, and Buddhism) to attain its treatment goal. According to TCM, every individual (including trauma survivor) is unique and should be assisted by developing an individualized treatment plan to relieve stagnation caused by disequilibrium. In essence, the type of healing for traumatized individuals in TCM is referred to as cultural healing by Kleinman (1978), with the implication that it is the cultural system as a whole that heals.

Chinese herbal medicine and acupuncture are two representative examples of holistic treatments for distress resulting from trauma. Use of TCM has been found to be significantly associated with having a sense of Chinese cultural superiority and believing cultural values and religious beliefs that influence health behavior (Rochelle & Marks, 2011). This may explain why traditional Chinese herbal medicine is so popular among all Chinese populations, including those living in Western countries. Recently, traditional Chinese herbal medicine, as an alternative treatment, has been found to effectively reduce the symptoms of PTSD (Meng et al., 2012). In a randomized clinical pilot trial conducted at the University of New Mexico School of Medicine, 84 individuals diagnosed with PTSD according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; APA, 1994) were randomly assigned to an acupuncture treatment condition, a group cognitive-behavioral therapy (CBT), or a wait-list control. Acupuncture as an intervention for PTSD has shown benefits comparable with CBT for PTSD and superior to a wait-list control condition (Hollifield, Sinclair-Lian, Warner, & Hammerschlag, 2007). Reductions of PTSD symptoms in the acupuncture condition and loss of diagnosis were found to be maintained 3 months after treatment. As a complementary therapeutic option, acupuncture has been approved for use in the conventional treatment-resistant instances of PTSD in German army hospitals (Kowalski, 2013).

These findings suggest that traditional Chinese herbal medicine and acupuncture may be alternative, viable options for improving general psychological well-being in patients with symptoms of trauma-related distress. However, from the Western scientific perspective, the safety of traditional Chinese herbal medicine and acupuncture has not been substantiated by scientific studies, which presently limits their use as regular treatments for PTSD.

In sum, the holistic thinking of TCM has been strongly reflected in categorization, diagnosis, and treatment of PTSD in Chinese populations. Also, the beliefs associated with TCM may have influenced help-seeking behaviors of Chinese trauma survivors and Chinese doctors trained in Western biomedicine.

Dualistic Thinking and Reductionism in Western Medicine

Relatively speaking, dualistic thinking and reductionism infiltrate every aspect of life in Western populations (Abramson, 2003), including diagnosis and conceptualization of PTSD, and correspondingly, Western scientific investigation and treatments for PTSD.

Western conceptualization of trauma-related distress

Western knowledge of mental disorders is largely based on disease diagnosis and a medical model of psychopathology though there is ongoing debate concerning the construct validity and reliability of various disorders in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; APA, 2000). The diathesis-stress model, as it pertains to Western research of etiology and psychopathology of traumatic stress (e.g., McKeever & Huff, 2003), is an example of the tendency toward dualistic and reductionist notions. According to this model, residual (situational) stress, ecological diatheses, and biological diatheses mutually influence each other. Although this model stresses interactions among multiple variables, these interpretations focused more on causality among those variables and temporal ordering of influences than on the holistic system consisting of those variables.

In addition, the tendency to separate mind and body is also associated with help-seeking behavior, healing expectations, and outcomes of PTSD in Western populations. Most Western trauma survivors typically turn to their physicians to treat their physical symptoms and turn to their psychotherapists to treat their psychological problems. By virtue of Western medicine’s focus on illness, according to the DSM-5 (APA, 2013), disease, and deficits, an individual diagnosed with PTSD is viewed as malfunctioning or disabled in Western countries.

Furthermore, Western medicine emphasizes that a scientific method of inquiry must be based on gathering empirical and measurable evidence: systematic observation, measurement, experiment, formulation, and testing and modification of hypotheses. This biomedicine-based approach to understanding psychological distress is prominent and perhaps most evidently differentiates the American and Chinese culture-based approaches to understanding and treating distress. By way of example, compared with the limited neuroimaging studies of PTSD that have been conducted in Chinese populations (Chen & Shi, 2011), a majority of neuroimaging studies of PTSD have been conducted in Western populations (e.g., Mickleborough, 2011).

Western treatments of PTSD

The scientific understanding of psychopathology subsequent to traumatic event exposure has expanded dramatically over the past century in Western countries (McMackin, Newman, Fogler, & Keane, 2012). Therefore, treatments for PTSD that have proven efficacious using randomized controlled trials and dismantling studies are prominent in Western countries, although these reductionist-oriented approaches may lead to a debate regarding the part–whole relationship (Tieszen, 1995). As data-driven decision-making processes are common in many clinical settings in Western countries, evidence-based treatments for PTSD such as prolonged exposure and cognitive processing therapy are recommended in clinical settings (Foa, Keane, Friedman, & Cohen, 2009).

Culture-Based Motivations Influence Emotional Responses to Traumatic Experiences

Cultural understandings of trauma may greatly influence intrinsic and extrinsic motivations of emotional responses to traumatic events in Americans and Chinese. Cultural understandings of human emotions, values of life, the relationship between the self, and the world may interplay with one another. Discussion of these dimensions, explaining detailed relationships between cultural influence and the construct of trauma for each culture, is essential for culturally appropriate conceptualization and treatment of trauma.

Cultural Understanding of Human Emotions and Life

Western understanding of emotions and life

Stemming from ancient Greek philosophies, American culture tends to separately discuss positive and negative emotions. Inappropriate emotions are thought of as an “intruder” of a process of logical reflection in American cultures. By way of example, according to the DSM-IV-TR, one of the symptoms of PTSD—“re-experiencing”—is described as “intrusive distressing recollections of the event” (APA, 2000, p. 468). The notion of consciously being aware of the difference between the self and the environment has been applied to attain the goal of preventing inappropriate emotions from disturbing cognition, appraisal, and judgment. One of the purposes of making unconscious processes conscious is to facilitate self-change and enhance self-control to adjust the relationship between the self and the environment (Prochaska & Prochaska, 2010). One application of this notion in psychotherapy is CBT for PTSD. The emphasis of CBT is to encourage trauma survivors to be aware of their maladaptive behaviors and cognitive processes to facilitate behavioral modification.

Chinese understanding of emotions and life

Chinese understanding of human emotions is based on the notion of a harmonious equilibrium of the seven emotions (joy, sorrow, anger, worry, panic, anxiety, and fear; C. Chan, Ho, & Chow, 2001). These emotions are regulated by reinforcing and prohibiting each other, for example, individuals encountering trauma-related distress may experience more anxiety or fear but less joy because anxiety/sorrow reinforces fear and prohibits joy. According to the teachings of Confucianism and Buddhism, no human emotions are absolutely negative. One needs to fully experience all emotions to be truly alive. However, imbalance of the system of emotions could be triggered by traumatic experiences, which could cause problems relating to emotions. For example, one’s excessive fear could cause the stagnation of one’s well-being. Stated differently, Western approaches to treating pathology have the explicit goal of eliminating or minimizing distress, whereas Chinese approaches tends to be more appreciative of the value of negative emotion provided that emotions are balanced. Specifically, the objective of TCM treatment for traumatic stress is to help traumatized individuals balance their emotions. The teachings of TCM emphasize self-regulation rather than intervention and advocate the belief that the traumatized individuals themselves should gain an inner power to balance emotions with the help from external environment (e.g., social support). In addition, the results of at least one empirical study have indicated that fatalistic voluntarism has shown a significant, positive net effect on life happiness among those Chinese who believe in fate control (Liu & Mencken, 2010). Chinese fatalism-related beliefs not only motivate traumatized individuals to accept what has happened (e.g., traumatic experiences) but also encourage those individuals to move forward in life. Cultural understanding of human emotions and life may inform incorporation of components of cultural, religious, and philosophical belief systems (e.g., concept of sin, belief in fatalism and reincarnation) in tailoring psychotherapeutic techniques for reducing traumatic stress.

Cultural Understanding of Human Values

Cultural understanding of human values may help clarify human emotions in cultural contexts. In American culture, a commonly advanced purpose of human life is to maximize pleasure and minimize pain of individuals. Most Americans believe that individuals have the fundamental right to enjoy freedom, happiness, and relatively pain-free existence. Any obstacles (e.g., traumatic events) diminishing happiness or causing suffering may be reduced or eliminated through coping strategies or psychological interventions (Burns, 2010).

In contrast, the purpose of human life in Chinese culture is to maximize pleasure of all the social members and to be accepted by other social members. Although the traditional Chinese culture encourages people to pursue rational happiness, individuals’ emotions are not central to personal well-being but rather interpersonal relationships and the feelings of social values or moral senses dictate well-being. In a study of recall of autobiographical memories, Chinese participants have been found to focus more on social and historical events and placed a greater emphasis on social interactions and significant others in their stories than their American participants did (Wang & Conway, 2004). In other words, the interdependent framework of the self is more meaningful to most Chinese.

Differing values between Western cultures and Chinese culture could lead to worse mental health outcomes if people from one culture are compelled to accept values from the other culture or if treatments influenced by one cultural tradition are applied indiscriminately to other cultural groups. Disclosure intention has been found to mediate the relationship between culture-based social acknowledgment and stress response syndrome, which suggests that culturally noncompatible values could be linked to worse mental health outcomes (Müller, Forstmeier, Wagner, & Maercker, 2011). Specifically, the reluctance to talk about one’s trauma in China may be seen as a result of one’s own cultural values and therefore would not be stressful, whereas in Germany reluctance to talk about the trauma would more often be seen as a deficiency (Mueller, Orth, Wang, & Maercker, 2009).

Cultural Understandings of the Relationship Between the Self and the World

Culture-based self-construal frameworks provide explanations for individual motivations for coping strategies in the wake of trauma. According to the DSM-IV-TR, one of the symptoms of PTSD is described as “intense psychological distress at exposure to internal and external cues that symbolize or resemble an aspect of the traumatic event” (APA, 2000, p. 468), suggesting the notion of being aware of the internal self and the external world. Most Americans believe that humans need to reduce the threat of harmful events from the external world. In addition, the American dominant culture emphasizes the independent self and the realization of existential aloneness that each person is unique, and that while some experiences can be shared, others must be faced alone (Markus & Kitayama, 1991). In contrast, Chinese culture emphasizes the interdependent self with the concern for significant others, and the concern for one’s relation with his or her external environment, and the dynamic equilibrium of this relationship (Mou, 2005). In Chinese culture, the self and the world in Chinese culture are thought of two inseparable parts of the whole system. As a result, Chinese trauma survivors are expected to make a connection between their life experiences with fatalism and are encouraged to incorporate traumatic events as a part of life.

Comparison of Prevalence of PTSD in American and Contemporary Chinese Societies

Presently, the term PTSD, which has been popularly used in Western populations, has been used increasingly in Chinese societies as well. It has been reported that the lifetime prevalence of PTSD among Caucasians was higher than that among Asians in the United States, including Chinese Americans (Roberts, Gilman, Breslau, Breslau, & Koenen, 2011). Large-scale empirical studies and epidemiological studies that focus on the impact of different trauma types on Western populations have been done in Western countries, particularly in the United States (e.g., Pietrzak, Goldstein, Southwick, & Grant, 2011). In contrast, the bulk of the information about the prevalence, comorbidity, and predictors of PTSD in Chinese societies is mainly generated from studies on limited trauma types. The Western construct of PTSD has been adopted in those studies. Most of the studies of PTSD in Chinese populations focus on mental health impacts of natural disasters on certain subgroups, such as earthquake survivors (Kuo, Wu, Ma, Chiu, & Chou, 2007) and rescuers in natural disasters (Wu, Chan, & Ma, 2005). Other examinations of PTSD in Chinese populations focus on life-threatening illness (Lu, Zheng, Young, Kagawa-Singer, & Loh, 2012), intimate partner violence (IPV; Chan, Chun, & Chung, 2008), and childhood sexual abuse (Luo, Parish, & Laumann, 2008). There is comparatively limited research on traumatized Chinese populations regarding road accidents (Wu, Chan, & Yiu, 2008), terrorist attacks (Thiel de Bocanegra et al., 2005), or other traumatic events. Although a great number of studies related sexual assault/rape have been found among Western trauma survivors (e.g., Elwood et al., 2011), only a few studies on this issue have been found among Chinese trauma survivors (Luo, 2000). In addition, although a considerable number of Western studies of PTSD focus on war-related PTSD, there are no studies of war-related PTSD that focus on Chinese populations, because no substantial Chinese populations have been involved in war for the past 60 years. Thus, compared with Western populations, relatively little is known about impacts of human-made disasters and other life adversities in Chinese populations.

Applications of Western Diagnostic Criteria and Measures for PTSD to Contemporary Chinese Societies

Chinese indigenous concepts of trauma can be considered as a combination of a primitive understanding of stress-related illness in TCM and Chinese understanding of concepts of trauma developed in Western medicine. Western classification and diagnostic criteria of mental disorders, which were first introduced to Chinese societies in the early 1950s, have been translated into Chinese for clinical and research applications (Tang, 2007). The DSM-IV-TR (APA, 2000) and the International Classification of Diseases (10th ed.; ICD-10; World Health Organization, 1992) systems have been widely used throughout contemporary Chinese societies outside Mainland China. Substantially influenced by the ICD-10 and the DSM-IV-TR schemata, the Chinese Classification of Mental Disorders (3rd ed.; CCMD-3, Chinese Psychiatric Society, 2001) has been developed based on cultural considerations and is widely used in Mainland China. Contemporary Chinese psychiatrists have been trained to apply the techniques from Western medicine and TCM to their practice. The results of a survey examining 181 Chinese psychiatrists’ attitudes toward the application of the ICD-10 and DSM in Chinese populations indicated that DSM-IV had limited application (7.7%) in Mainland China (Zou et al., 2008). According to this survey, 75.1% professionals agreed that Western constructs of psychiatric disorders are “useful and reliable regardless of patient ethnicity and culture,” while 46.8% found “sometimes difficult to apply across cultures,” and 35.8% thought classification is “over-embedded in Western cultural concepts and values.” The DSM-5 has adopted a broad definition of PTSD and provided maximal coverage of a range of symptoms seen in the typical clinical presentation of posttraumatic distress. Whether the DSM-5 diagnostic criteria for PTSD will be accepted by the majority of Chinese psychiatrists depends on more empirical evidence in the future (Weathers, 2014).

Most of Western measures of PTSD have been found to exhibit adequate reliability and validity in Chinese samples: the Chinese Version of PTSD Checklist (Wang et al., 2012), the Chinese Version of Posttraumatic Diagnostic Scale (Su & Chen, 2008), the Chinese Version of the Impact of Event Scale–Revised (Zhang, Zhang, Wu, Zhu, & Dyregrov, 2011), and so on.

Some Western measures of traumatic stress reactions have been partially revised to meet the needs of Chinese trauma survivors: The Western 33-item Posttraumatic Cognitions Inventory (PTCI; Foa, Ehlers, Clark, Tolin, & Orsillo, 1999) has been adapted as the Chinese 29-item PTCI (PTCI-C; Su & Chen, 2008). Some Western measures have been fully revised to accommodate Chinese culture, for example, the five-dimension Post-Traumatic Growth Inventory (PTGI; Tedeschi & Calhoun, 1996) has been adapted as the two-dimension Chinese Version of PTGI (PTGI-C (Ho, Chan, & Ho, 2004).

In addition, some indigenous measures of PTSD were developed by Chinese researchers and are currently used in Chinese societies. For example, the Chinese Health Questionnaire (CHQ) is constructed as a short DSM-IV screening scale for PTSD (Kuo et al., 2007). Compared with Western measures of PTSD, the CHQ-12 emphasizes more somatic items as Chinese populations tend to manifest psychological disorders with more somatic discomfort. This indigenous measure demonstrates good reliability and validity and has been widely used in Chinese populations.

In sum, evaluations of the applicability of Western conceptualizations of mental disorders (including measures of PTSD) in Chinese populations, especially in Mainland China, are still in the initial stages. Due to East–West differences in cultural understanding of ethical behavior (Zheng, Gray, Zhu, & Jiang, 2014), some culture-related ethical concerns of using Western measures of PTSD with Chinese populations have been garnering more attention in the area of Chinese mental health, which makes the application of Western measures to Chinese populations controversial and complicated. Whether or not the Western measures of PTSD should be revised when these measures are used in Chinese populations is the question Chinese researchers and clinicians are struggling with. Does the evidence that a Western measure demonstrating good reliability and validity in a Chinese sample necessarily mean that this measure should be used widely in Chinese populations without any revisions? Is there anything unique to Chinese culture but not addressed by Western measures? Stated differently, there is an important difference between proving some items to be reliable and valid in another cultural group on one hand and adequately covering the intended domain on the other. Consequently, indigenous measures of PTSD may be more appropriate in Chinese clinical settings, because such measures more appropriately reflect the Chinese understanding of assessment of PTSD.

Conclusion and Treatment Implications

Different philosophies between American and Chinese understandings of mental health may determine distinctions in exploratory approaches of etiology and implementation of coping strategies of traumatic stress between the two cultures. Regarding dealing with trauma-related mental health issues, identifying and treating problems separately in functional domains through data-driven decision-making processes have been recommended by many American clinical professionals, whereas assisting promotion of total well-being by facilitating the self-healing of individuals has been advocated by Chinese clinical professionals. Cultural understandings of posttraumatic growth and resilience between American and Chinese populations may have greatly influenced intrinsic and extrinsic motivations of individual responses to traumatic events in different ways, although the American and Chinese perspectives have many interpretations of traumatic stress and surviving approaches in common. Although the cross-cultural validity of PTSD is preliminarily supported by available evidence, further research is needed to clarify cross-cultural variability in certain areas (Hinton & Lewis-Fernandez, 2011).

The coping strategies used by individuals in Chinese culture are characterized by Chinese social norms, values, and beliefs. Therefore, when American culture-based treatments for PTSD are applied to Chinese populations, these treatments should be adapted to meet the needs of Chinese trauma survivors. For example, when dealing with Chinese victims of IPV, culturally dominant virtues of endurance, tolerance of suffering and self-sacrifice for familial responsibility, or independently dealing with family issues should be understood, respected, validated, and assisted by clinical practitioners (Chan, Tiwari, Fong, & Ho, 2010).

In addition, some interventions or coping strategies for PTSD may fit Chinese better than Americans (e.g., expressive writing). It has been found that Chinese-speaking Chinese-American trauma survivors showed increased benefits from expressive writing due to the culturally preferred ways of expression (Lu et al., 2012). Americans may prefer to articulate the breadth, depth, and uniqueness of the self through their verbal communication with others, whereas Chinese consider personal narratives as guides for good social conduct and prefer to direct the self to show good social conduct through their context-based communications with others (McAdams, 2011). The differences in culture-related communication styles suggest that clinicians should incorporate culturally adaptive expressions of language and cultural understanding of context into their practice (Zheng & Gray, 2014). In addition, other complementary and alternative approaches, though considered as folk treatments by some Chinese psychiatrists, such as disclosure to peers, mindfulness-based stress reduction, religious counseling, or acquaintance-counseling, have also been used by Chinese trauma survivors.

The implications of this review suggest the development of a culturally informed framework for effective clinical management of Chinese trauma survivors. First, differentiating official diagnostic criteria of PTSD from indigenous concepts of trauma and the resulting distress may be helpful in developing culturally adaptive understanding of the needs of trauma survivors. Second, a combination of selected techniques of TCM (e.g., acupuncture) and Western psychotherapies has been found effective for therapeutic change among Chinese trauma survivors (Feinstein, 2012). This implies that a convergence of effective components of TCM (e.g., acupuncture) and verbal techniques from Western psychotherapies may be helpful in developing new culturally acceptable approaches for indigenous Chinese populations. Third, by taking advantage of the Chinese understanding of TCM in advocating the total well-being and balance of intrapersonal and interpersonal systems, culturally competent professionals may develop trauma-focused psycho-education programs at a community level, facilitating the self-healing of traumatized individuals and providing guidance for seeking help from professionals. Fourth, appropriate incorporation of useful components from Buddhism, Taoism, and even Western religious teachings will be helpful in adapting Western psychotherapy techniques and developing meaningful individualized treatment plans for Chinese trauma survivors. Finally, Chinese indigenization of the Western resources for PTSD into local cultures should be a priority in the field of Chinese mental health for Mainland China, Hong Kong, and Taiwan; Western resources of PTSD should be tailored and individualized to meet Chinese trauma survivors who may not be fully acculturated in Western countries (e.g., Chinese Americans, or Chinese Canadians). Adapting potentially fruitful treatment approaches to different cultures in a manner that honors their cultural beliefs and worldviews will not only be arguably more effective, those treatments will also be deemed more credible and better received by those seeking treatment.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

References

Abramson

R. J.

(2003). The unity of mind, body, and spirit: A five element view of cancer. Advances in Mind-Body Medicine, 19(2), 20-21.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Bedard

Greif

J. L.

Buckley

T. C.

(2004). International publication trends in the traumatic stress literature. Journal of Traumatic Stress, 17, 97-101.

Burns

G. W.

(2010). Happiness, healing, enhancement: Your casebook collection for applying positive psychology in therapy. Hoboken, NJ: John Wiley.

Cai

J. F.

Chao

G. C.

Chen

D. J.

Chen

K. J.

Chen

X. Q.

Cheng

X. Z.

(1995). 传统中医药高级教材 [Advanced textbook on traditional Chinese medicine and pharmacology] (Vol. 1). Beijing, China: New World Press.

Chan

Chun

P. R.

Chung

(2008). Public perception and reporting of different kinds of family abuse in Hong Kong. Journal of Family Violence, 23, 253-263.

Chan

P. S. Y.

Chow

(2001). A body-mind-spirit model in health. Social Work in Health Care, 34, 261-282.

Chan

C. H.

Tiwari

Fong

D. Y. T.

P. C.

(2010). Post-traumatic stress disorder among Chinese women survivors of intimate partner violence: A review of the literature. International Journal of Nursing Studies, 47, 918-925. doi:10.1016/j.ijnurstu.2010.01.003

10.

Chen

Shi

(2011). A review of neuroimaging studies of anxiety disorders in China. Neuropsychiatric Disease and Treatment, 7, 241-249. doi:10.2147/NDT.S10997

11.

Chinese Psychiatric Society. (2001). 中国精神疾病分类及诊断标准第三版 [The Chinese Classification of Mental Disorders (CCMD-3)] (3rd ed.). Shandong, China: Shandong Publishing House of Science and Technology.

12.

Elwood

L. S.

Smith

D. W.

Resnick

H. S.

Gudmundsdottir

Amstadter

A. B.

Hanson

R. F.

. . . Kilpatrick

D. G.

(2011). Predictors of rape: Findings from the national survey of adolescents. Journal of Traumatic Stress, 24, 166-173.

13.

Feinstein

(2012). Acupoint stimulation in treating psychological disorders: Evidence of efficacy. Review of General Psychology, 16, 364-380. doi:10.1037/a0028602

14.

Foa

E. B.

Ehlers

Clark

D. M.

Tolin

D. F.

Orsillo

S. M.

(1999). The Posttraumatic Cognitions Inventory (PTCI): Development and validation. Psychological Assessment, 11, 303-314.

15.

Foa

E. B.

Keane

T. M.

Friedman

M. J.

Cohen

J. A.

(2009). Effective treatments for PTSD: Practice guidelines from the international society for traumatic stress studies (2nd ed.). New York, NY: Guilford Press.

16.

Gray

M. J.

Lombardo

T. W.

(2012). Advances in the conceptualization and treatment of trauma. Behavior Modification, 36, 755-758. doi:10.1177/014544551245220

17.

Hinton

D. E.

Lewis-Fernandez

(2011). The cross-cultural validity of posttraumatic stress disorder: Implications for DSM-5. Depression and Anxiety, 28, 783-801.

18.

S. M. Y.

Chan

C. L. W.

R. T. H.

(2004). Posttraumatic growth in Chinese cancer survivors. Psycho-Oncology, 13, 377-389. doi:10.1002/pon.758

19.

Hollifield

Sinclair-Lian

Warner

T. D.

Hammerschlag

(2007). Acupuncture for posttraumatic stress disorder: A randomized controlled pilot trial. The Journal of Nervous and Mental Disease, 195, 504-513.

20.

Kleinman

(1978). Concepts and a model for the comparison of medical systems as cultural systems. Social Science & Medicine, 12(2B), 85-93.

21.

Kowalski

J. T.

(2013). “Deployment-related stress disorder in German soldiers: Utilization of psychiatric and psychotherapeutic treatment”: In reply. Deutsches Ärzteblatt International, 110(9), 144-144.

22.

Kuo

H. W.

S. J.

T. C.

Chiu

M. C.

Chou

S. Y.

(2007). Posttraumatic symptoms were worst among quake victims with injuries following the Chi-chi earthquake in Taiwan. Journal of Psychosomatic Research, 62, 495-500. doi:10.1016/j.jpsychores.2004.11.012

23.

Lee

Kleinman

(2007). Are somatoform disorders changing with time? The case of neurasthenia in China. Psychosomatic Medicine, 69, 846-849.

24.

Liu

E. Y.

Mencken

F. C.

(2010). Fatalistic voluntarism and life happiness in post-socialist China. Sociological Spectrum, 30, 270-288. doi:10.1080/02732171003635455

25.

Liu

(1981). Psychiatry in traditional Chinese medicine. The British Journal of Psychiatry, 138, 429-433. doi:10.1192/bjp.138.5.429

26.

Zheng

Young

Kagawa-Singer

Loh

(2012). A pilot study of expressive writing intervention among Chinese-speaking breast cancer survivors. Health Psychology, 31, 548-551. doi:10.1037/a0026834

27.

Luo

T. Y.

(2000). “Marrying my rapist?!” The cultural trauma among Chinese rape survivors. Gender & Society, 14, 581-597.

28.

Luo

Parish

W. L.

Laumann

E. O.

(2008). A population-based study of childhood sexual contact in China: Prevalence and long-term consequences. Child Abuse & Neglect, 32, 721-731.

29.

Markus

H. R.

Kitayama

(1991). Culture and the self: Implications for cognition, emotion, and motivation. Psychological Review, 98, 224-253.

30.

McAdams

D. P.

(2011). Narrative identity. In Schwartz

S. J.

Luyckx

Vignoles

V. L.

(Eds.), Handbook of identity theory and research (Vols. 1 & 2., pp. 99-115). New York, NY: Springer Science+Business. doi:10.1007/978-1-4419-7988-9_5

31.

McKeever

V. M.

Huff

M. E.

(2003). A diathesis-stress model of posttraumatic stress disorder: Ecological, biological, and residual stress pathways. Review of General Psychology, 7, 237-250. doi:10.1037/1089-2680.7.3.237

32.

McMackin

R. A.

Newman

Fogler

J. M.

Keane

T. M.

(2012). Trauma therapy in context: The science and craft of evidence-based practice. Washington, DC: American Psychological Association. doi:10.1037/13746-000

33.

Meng

X. Z.

Wei

P-K.

Xiu

L-J.

Shi

Pang

. . . Lao

(2012). A Chinese herbal formula to improve general psychological status in posttraumatic stress disorder: A randomized placebo-controlled trial on Sichuan earthquake survivors. Evidence-Based Complementary and Alternative Medicine, 2012, 1-11.

34.

Mickleborough

(2011). Effects of trauma-related cues on pain processing in posttraumatic stress disorder: An fMRI investigation. Journal of Psychiatry & Neuroscience, 36, 6-14.

35.

Mou

(2005). 中国哲学十九讲 [Nineteen lectures on Chinese philosophy]. Shanghai, China: Shanghai Ancient Book Press.

36.

Mueller

Orth

Wang

Maercker

(2009). Disclosure attitudes and social acknowledgement as predictors of posttraumatic stress disorder symptom severity in Chinese and German crime victims. Canadian Journal of Psychiatry, 54, 547-556.

37.

Müller

Forstmeier

Wagner

Maercker

(2011). Traditional versus modern values and interpersonal factors predicting stress response syndromes in a Swiss elderly population. Psychology, Health & Medicine, 16, 631-640. doi:10.1080/13548506.2011.564192

38.

Pietrzak

R. H.

Goldstein

R. B.

Southwick

S. M.

Grant

B. F.

(2011). Prevalence and axis I comorbidity of full and partial posttraumatic stress disorder in the United States: Results from Wave 2 of the national epidemiologic survey on alcohol and related conditions. Journal of Anxiety Disorders, 25, 456-465. doi:10.1016/j.janxdis.2010.11.010

39.

Prochaska

J. O.

Prochaska

J. M.

(2010). Self-directed change: A transtheoretical model. In Maddux

J. E.

Tangney

J. P.

(Eds.), Social psychological foundations of clinical psychology (pp. 431-440). New York, NY: Guilford Press.

40.

Roberts

Gilman

Breslau

Koenen

(2011). Race/ethnic differences in exposure to traumatic events, development of post-traumatic stress disorder, and treatment-seeking for post-traumatic stress disorder in the United States. Psychological Medicine, 41, 71-83. doi:10.1017/S0033291710000401

41.

Rochelle

T. L.

Marks

D. F.

(2011). Health behaviors and use of traditional Chinese medicine among the British Chinese. Journal of Cross-Cultural Psychology, 42, 390-405.

42.

Scheid

(2013). Depression, constraint, and the liver: (Dis)assembling the treatment of emotion-related disorders in Chinese medicine. Culture, Medicine, and Psychiatry, 37, 30-58.

43.

Sinclair-Lian

Hollifield

Menache

Warner

Viscaya

Hammerschlag

(2006). Developing a traditional Chinese medicine diagnostic structure for post-traumatic stress disorder. The Journal of Alternative and Complementary Medicine, 12, 45-57.

44.

Chen

S. H.

(2008). A three-month prospective investigation of negative cognitions in predicting posttraumatic stress symptoms: The mediating role of traumatic memory quality. Chinese Journal of Psychology, 50, 167-186.

45.

Tang

C. S. K.

(2007). Assessment of PTSD and psychiatric comorbidity in contemporary Chinese societies. In Wilson

J. P.

Tang

C. S. K.

(Eds.), International and cultural psychology: Cross-cultural assessment of psychological trauma and PTSD (pp. 135-168). New York, NY: Springer Science + Business Media. doi:10.1007/978-0-387-70990-1_7

46.

Tedeschi

R. G.

Calhoun

L. G.

(1996). The Posttraumatic Growth Inventory: Measuring the positive legacy of trauma. Journal of Traumatic Stress, 9, 455-472. doi:10.1002/jts.2490090305

47.

Thiel

Bocanegra

Moskalenko

Chan

(2005). PTSD and depression among displaced Chinese workers after the world trade center attack: A follow-up study. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 82, 364-369.

48.

Thiel

Bocanegra

Moskalenko

Kramer

E. J.

(2006). PTSD, depression, prescription drug use, and health care utilization of Chinese workers affected by the WTC attacks. Journal of Immigrant and Minority Health, 8, 203-210. doi:10.1007/s10903-006-9323-0

49.

Tieszen

(1995). Mathematics. In Smith

D. W.

Smith

(Ed.), The Cambridge companion to Husserl (pp.432-462). Cambridge, UK: Cambridge University Press.

50.

Vollhardt

J. R.

Staub

(2011). Inclusive altruism born of suffering: The relationship between adversity and prosocial attitudes and behavior toward disadvantaged outgroups. American Journal of Orthopsychiatry, 81, 307-315.

51.

Wang

Conway

M. A.

(2004). The stories we keep: Autobiographical memory in American and Chinese middle-aged adults. Journal of Personality, 72, 911-938.

52.

Wang

Wei

You

(2012). Application of the Chinese Posttraumatic Stress Disorder Checklist to adolescent earthquake survivors in China. Social Behavior and Personality, 40, 415-424. doi:10.2224/sbp.2012.40.3.415

53.

Wang

Y. W.

Heppner

P. P.

(2011). A qualitative study of childhood sexual abuse survivors in Taiwan: Toward a transactional and ecological model of coping. Journal of Counseling Psychology, 58, 393-409. doi:10.1037/a0023522

54.

Weathers

F. W.

(2014). Posttraumatic stress disorder in DSM-5: New criteria, new measures, and implications for assessment. Psychological Injury and Law, 7, 93-107.

55.

Wen

Song

Zhang

. . . Jin

(2004). Genetic evidence supports demic diffusion of Han culture. Nature, 431, 302-305. doi:10.1038/nature0287

56.

Wong

(2000). Holism and caring: Nursing in the Chinese health care culture. Holistic Nursing Practice, 15(1), 12-21.

57.

World Health Organization. (1992). The ICD-10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines (10th ed.). Geneva, Switzerland: Author.

58.

K. K.

Chan

S. K.

T. M.

(2005). Posttraumatic stress after SARS. Emerging Infectious Diseases, 11, 1297-1300. doi:10.3201/eid1108.041083

59.

K. K.

Chan

S. K.

Yiu

V. F.

(2008). Psychometric properties and confirmatory factor analysis of the Posttraumatic Stress Disorder Checklist for Chinese survivors of road traffic accidents. Hong Kong Journal of Psychiatry, 18, 144-151.

60.

Yeung

Chang

D. F.

(2005). Prevalence and illness beliefs of sleep paralysis among Chinese psychiatric patients in China and the United States. Transcultural Psychiatry, 42, 135-143. doi:10.1177/1363461505050725

61.

Zhai

Liu

Jiang

(2010). What does posttraumatic growth mean to Chinese burn patients: A phenomenological study. Journal of Burn Care & Research: Official Publication of the American Burn Association, 31, 433-440. doi:10.1097/BCR.0b013e3181db5240

62.

Zhang

Zhu

Dyregrov

(2011). Factor structure of the Children’s Revised Impact of Event Scale among children and adolescents who survived the 2008 Sichuan earthquake in China. Scandinavian Journal of Psychology, 52, 236-241.

63.

Zheng

Gray

M. J.

(2014). Telehealth-based therapy connecting rural Mandarin-speaking traumatized clients with a Mandarin-speaking therapist. Clinical Case Studies, 13, 514-527.

64.

Zheng

Gray

M. J.

Zhu

W. Z.

Jiang

G. R.

(2014). Influence of culture on ethical decision-making in psychology. Ethics & Behavior, 24, 510-522.

65.

Zhou

Dere

Zhu

Yao

Chentsova-Dutton

Y. E.

Ryder

A. G.

(2011). Anxiety symptom presentations in Han Chinese and Euro-Canadian outpatients: Is distress always somatized in China? Journal of Affective Disorders, 135, 111-114. doi:10.1016/j.jad.2011.06.049

66.

Zou

Y. Z.

Cui

J. F.

Han

A. L.

M. Y.

Fan

H. Z.

(2008). Chinese psychiatrists views on global features of CCMD-III, ICD-10 and DSM-IV. Asian Journal of Psychiatry, 1, 56-59. doi:10.1016/j.ajp.2008.09.007