University of Freiburg, Switzerland Department of Psychology Traditional ways of coping with consequences of traumatic stress in Acholiland Northern Ugandan ethnography from a Western psychological perspective By Thomas Harlacher Dissertation zur Erlangung der Doktorwürde an der Philosophischen Fakultät der Universität Freiburg (Schweiz). Genehmigt von der Philosophischen Fakultät auf Antrag der Professoren Prof. Dr. Meinrad Perrez (1. Gutachter) Prof. Dr. Andreas Maercker (2. Gutachter). Freiburg, den 9.10.2009 Pof. Dr. Thomas Austenfeld, Dekan Contents Foreword and Acknowledgements................................................................................................vi Overview of content........................................................................................................................ix Introduction......................................................................................................................................1 Use of the PTSD concept in complex emergencies across cultures.................................................................. 2 Research questions ........................................................................................................................................... 6 Part One: Local background...........................................................................................................8 1 The Northern Ugandan War .................................................................................................9 1.1 Brief outline on the history of the conflict ............................................................................................. 9 1.2 The impact of war on the population.................................................................................................. 10 1.3 Widespread psychological traumatization.......................................................................................... 12 1.4 Attempts to foster healing: The Psychosocial Support Program of Gulu Archdiocese....................... 14 2 History and General Traditions of the Acholi...................................................................15 2.1 Acholi Identity from an Historical Perspective .................................................................................... 16 2.1.1 The pre-colonial era ...................................................................................................................... 16 2.1.2 The colonial and post-colonial eras............................................................................................... 20 2.2 Socio-political Organization ............................................................................................................... 22 2.2.1 The pre-colonial era ...................................................................................................................... 22 2.2.2 The colonial and post-colonial eras............................................................................................... 25 2.3 Patterns of Daily Life.......................................................................................................................... 29 2.3.1 The pre-colonial era ...................................................................................................................... 29 2.3.2 The colonial and post-colonial eras............................................................................................... 33 2.4 Cosmology: Safeguarding the Rules of Social Life and Dealing with Evil......................................... 34 2.4.1 The pre-colonial era ...................................................................................................................... 34 2.4.2 The colonial and post-colonial eras............................................................................................... 38 2.5 Literature on traditional ways of coping and healing in Acholi............................................................ 42 Part Two: Western clinical perspective on traumatic stress......................................................44 3 Posttraumatic Stress Disorder (PTSD) .............................................................................45 3.1 Diagnostic criteria .............................................................................................................................. 45 3.1.1 Diagnostic criteria according to DSM-IV........................................................................................ 46 3.1.2 Diagnostic criteria in the ICD-10.................................................................................................... 49 3.2 Epidemiology ..................................................................................................................................... 49 3.2.1 Prevalence of exposure to traumatic events ................................................................................. 49 3.2.2 Conditional risk and prevalence of PTSD...................................................................................... 50 3.2.3 Risk and protective factors............................................................................................................ 51 3.2.4 Phenomenology and longitudinal course ...................................................................................... 54 3.2.5 PTSD and functioning ................................................................................................................... 55 3.3 Etiological models.............................................................................................................................. 56 3.3.1 Understanding symptoms of hyperarousal and active avoidance ................................................. 57 3.3.2 Understanding flashbacks and traumatic memory ........................................................................ 58 3.3.3 Integrative models......................................................................................................................... 61 3.3.4 Implications for recovery and treatment ........................................................................................ 64 4 Other disorders related to traumatic stress .....................................................................66 4.1 Acute stress disorder ......................................................................................................................... 66 4.2 Complex PTSD .................................................................................................................................. 67 4.3 Disorders frequently comorbid with PTSD ......................................................................................... 68 5 Early intervention ...............................................................................................................70 5.1 Frontline treatment............................................................................................................................. 70 5.2 Psychological debriefing .................................................................................................................... 71 5.3 Psychological first aid ........................................................................................................................ 74 5.4 Early intervention with cognitive behavioral approaches.................................................................... 75 6 Treatment of PTSD .............................................................................................................77 6.1 General treatment issues................................................................................................................... 78 6.2 Exposure............................................................................................................................................ 79 6.3 Cognitive therapies ............................................................................................................................ 82 6.4 Eye movement desensitization and reprocessing (EMDR) ................................................................ 85 6.5 Anxiety management and stress inoculation training......................................................................... 86 6.6 Contentious issues and limitations of current knowledge................................................................... 88 6.6.1 Contentious issues........................................................................................................................ 88 6.6.2 Limits of current knowledge .......................................................................................................... 89 Part Three: Cross-cultural considerations on mental health and posttraumatic stress .........92 7 General theoretical and methodological considerations ................................................93 7.1 Universalism versus Relativism ......................................................................................................... 93 7.2 Definitions of culture .......................................................................................................................... 95 7.3 Postulated pathways of cultural influence on mental disorders.......................................................... 96 7.4 Cross-cultural issues in assessing mental disorders.......................................................................... 97 7.4.1 Ethnocentricity..............................................................................................................................