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Attribution License (As the evidence-based practice (EBP) movement has gained dominance in scientific discourse regarding psychotherapy in the United States, so too has its vision of what constitutes scientific evidence. However, there are those who question whether that vision is too narrow. In particular, there has been a debate in the literature as to whether many of the prominent EBPs work equally well for diverse populations, and resolving this controversy has been difficult, in part because of the many methodological challenges involved in the study of cultural meanings. After all, intersectionality theory (Cole, 2009) suggests that culture is not simply a variable, but a large matrix of interrelated variables, too complicated for any quantitative method to truly analyze. We suggest that the best solution to this impasse is to integrate more qualitative research into the evidence base in a meaningful way. Qualitative research can provide an inductive means for the identification of cultural factors, as well as a rigorous means of understanding the real-world meaning of quantitative outcome findings. It can examine cultural factors without the need to reduce their complexity down to isolated variables which lose all meaning because of their de-contextualization.
The Evidence-Based Practice Movement in Trauma Theory
The newly established field of trauma psychology has increasingly adopted evidence-based practice guidelines (Foa, Keane, Friedman, & Cohen, 2009) in an effort to promote the treatment modalities that can best help patients seeking relief from the sequelae of traumatic experiences. Increasingly, federal agencies in the United States are require the use of EBP’s as mandatory prerequisites for funding. The International Society for Traumatic Stress Studies (ISTSS) has also identified several EBP’s for trauma treatments (Foa et al., 2009).
However, the efficacy of some of these evidence-based practices with diverse populations, such as clients from underprivileged groups and non-Western cultures, has been a subject of controversy. Sources in the multicultural literature question whether some of the evidence-based assessment strategies and interventions are suitable for these populations (Sue & Zane, 2006). In particular, Helms, Nicolas, and Green (2010) draw attention to the outcome literature’s oversight of the role of racism and ethnoviolence in their understanding of PTSD symptomatology. Likewise, the emerging field of disaster mental health now recognizes the inadequacy of older disaster intervention models with regard to their lack of understanding of diverse experiences of human suffering (see the Inter-Agency Standing Committee [IASC] Guidelines on Mental Health and Psychosocial Support in Emergency Settings, 2007). Similarly, indigenous and postcolonial social science movements in recent years have adopted new forms of inquiry that challenge the efficacy of traditional methodologies and epistemologies, mainly developed in the Western world (Lincoln & Denzin, 2005). This critique has become more salient with Western psychology’s increasing emphasis on evidence-based practices (EBP’s) and the exclusive use of randomized controlled trials (RCT) to assess efficacy.
One of the primary criticisms of EBP has been that the research community in the United States has tended to ignore cultural variables, and has consequently failed to recognize the distinctive clinical needs of underprivileged groups (Brown, 2006; Levant & Silverstein, 2006; Olkin & Taliaferro, 2006; Sue & Zane, 2006). They have faulted EBP’s for perpetuating cultural inequities in the health care system, and have called for an increase in the use of effectiveness research, with interventions tested in real world settings as opposed to controlled settings, and the use of homogeneous samples (Glasgow & Emmons, 2007). The proponents of EBP in turn have suggested that the proponents of multiculturalism are pursuing a political agenda to the detriment of scientific understanding (Morales & Norcross, 2010), and have criticized the multicultural literature for a lack of scientific rigor.
It is clear that what is needed to bridge this gap is a rigorous methodology, which is capable of examining complex, intersubjective phenomena in a less reductionistic manner. We argue that integrating qualitative research into the evidence base supporting trauma treatments, as a matter of standard practice, can fill this need. Qualitative research can give diverse and neglected populations a voice in the research literature, by using their experience to inductively identify new hypotheses which need to be examined as part of the quantitative evidence basis for determining the efficacy of trauma treatments. This approach has the promise of identifying unmet needs, contraindications, and inconsistencies between theory and experience which are unlikely to be discovered through purely deductive approaches. This would address EBP advocates’ concerns about the unscientific nature of the multicultural literature’s critique, and multiculturalism advocate’s concerns about the lack of contextualism in EBP outcome studies of trauma treatments.
Traumatology and its Context
Psychology, Qualitative Research and Culture: A Brief History
A brief review of the field of psychology’s history with regard to the topic of culture and qualitative methods will show some apparent parallel processes with regard to their acceptance in the field. Both make their initial appearance, at the inception of scientific psychology, in the works of Wilhelm Wundt (Diriwächter, 2004). In Wundt’s folk-psychology, Wundt linked the two by suggesting that culture and other higher-order human mental processes were best studied using qualitative approaches, like those used in cultural anthropology. When psychology turned away from structuralism to functionalism, and then to radical behaviorism, qualitative approaches were discredited and the subject of cultural difference was ignored as psychology focused on finding universal theories of human phenomena.
Historically, it was cultural anthropology that first raised awareness of the need to understand contextual descriptions of meaning and purpose in individual behavior (Geertz, 1979; Kirmayer, Lemelson, & Barad, 2007; Westen, 2006). Franz Boas, the founding father of American cultural anthropology, was the first to recognize that human behavior can only be meaningfully studied in its normal context, particularly the context of its culture of origin (Lewis, 2001). He recognized that a researcher can only come to a useful understanding of a culture different through her own through immersion in that culture, and participating in it over an extended period of time. He acknowledged that the members of any given culture are the true experts on that culture, and that outside researchers need to treat members of the culture as their teachers, as collaborators in the research. He also recognized that researchers are also cultural beings, just as research participants are, and that researchers need to be aware how their own cultural lenses shape their perceptions of their subjects. Finally, Boas was the first to suggest that social scientists must be activists, dedicated to the pursuit of social justice, particularly for the benefit of the populations they study. From its inception in the work of Boas, as well as that of early sociologists like those of the Chicago school (Cavan, 1983), qualitative methods have been used to study the experience of minority, disenfranchised, and stigmatized groups. We would argue that overall, qualitative research has a better track record of service to these groups than quantitative research.
From Boaz onward, anthropology and sociology have recognized qualitative approaches, such as ethnographic fieldwork, as the means to work collaboratively with populations of interest, and through that interaction to develop the researcher’s cultural self-awareness, cultural sensitivity, and social consciousness. These ideas imply that the learning and doing of qualitative research fosters the very skill sets which are needed to address the underlying deficits identified by the cultural competence training literature in psychology.
More recently, the qualitative research of the psychological anthropologist Catherine Lutz on the cultural mediation of emotion has inspired a new body of research and theory in psychology, challenging fundamental assumptions of emotion theory which date back to Darwin (Kitayama & Markus, 1994; Lutz, 1988). Other contemporary cultural psychologists and psychiatrists (Drožđek, 2010; Kirmayer et al., 2012; Kleinman & Kleinman, 1999) have strongly argued in favor of emphasizing the significant role of cultural and contextual factors in mental health, as well as the cultural idioms of distress. Sue (1998), for instance, argued for the importance of including what he termed “scientific mindedness” and “dynamic sizing” in the implementation of culturally competent practice. These skills, also reflected in the American Psychological Association’s Guidelines on Multicultural Education, Training, Research, Practice and Organizational Change for Psychologists (APA, 2003), can enable therapists and researchers to understand the delicate balance that needs to be struck, between generalizing research findings, and recognizing the limitations of these findings when creating treatment guidelines meant to apply to whole populations.
By the end of the 20th century, we can see that psychology is at least making high-level efforts to address cultural diversity, as exemplified by the aforementioned APA best practice guidelines for a variety of diverse populations. APA’s Policy Statement on Evidence-Based Practice in Psychology (APA Presidential Task Force on Evidence-Based Practice, 2006) also highlighted cultural considerations in its definitions of EBPP by defining best practices as “the integration of the best available research with clinical expertise in the context of patient’s characteristics, culture and preferences” (APA Presidential Task Force on Evidence-Based Practice, 2006, p. 273). The EBPP policy statement proposes the incorporation of qualitative research as a culturally sensitive approach. A major challenge in implementing these APA guidelines is determining how cultural competence can coexist with evidence-based practice and how to ensure the cross-cultural validity of the evidence provided by research studies. “Defining evidence, deciding what qualifies as evidence, and applying what is privileged as evidence are complicated matters with deep philosophical and huge practical consequences” (Norcross, Beutler, & Levant, 2006, p. 7). To make matters more complicated, the broad definition of culture defined by the APA Presidential Task Force on Evidence-Based Practice (2006) emphasizes cultural meanings, not simply race and ethnicity, as well as the sociocultural context in which this meaning is created. This conceptualization creates methodological challenges with regard to the operationalization of cultural meanings. The need to account for variables such as power and privilege differentials within and between cultures further increase these challenges (La Roche & Christopher, 2009).
Indeed, over the last 30 years or so, Psychology seems to have reached near-consensus that education, research and clinical work need to better account for the role of cultural factors in human nature. What a meaningful accounting for culture looks like, in practice, is a subject of greater debate. Will psychologists minimally adapt existing approaches to pay lip service to cultural factors? Or will they re-conceptualize their approaches from the ground-up to build a new psychology which is derived from the acknowledgement that human nature is fundamentally culturally mediated? By the same token, as researchers scrutinize clinical practices to make therapy increasingly evidence-based, will they turn an equally critical eye upon the forms of evidence they themselves use, and consider whether they capture the true richness of human diversity?
Trauma Psychology: Cultural Considerations
The aforementioned questions are of particular importance to the developing field of trauma studies. While traumatic experience has been central to clinical psychology from its inception, traumatic studies as a distinct discipline is relatively new, and psychology’s increased recognition of the importance of culture has prompted traumatologists to make efforts to account for culture in their work. The cross-cultural shortcomings evident in some of the early, prominent disaster psychology efforts have also forced the field of traumatology to revise some of the etic assumptions inherent in much of earlier trauma theory (Bhugra & Van Ommeren, 2006; Murray-Law, 2006).
Thus it is imperative that traumatology develop in a manner which is mindful of psychology’s past oversights, both theoretical and methodological. The complexity and the depth with which cultural factors involved in trauma will be addressed in research designs, assessments, therapy, and the training of the next generation of psychologists will determine whether trauma psychology will become a discipline of service to non-dominant communities. The current evidence on racial and cultural mental health disparities in the United States reinforces the need for this critical self-examination (see the U.S. Department of Health and Human Services National Health Care Disparities Report, 2006).
How can psychology go deeper with the subject of culture in both trauma research and clinical training? We would like to propose that the understanding generated by qualitative research, and the awareness fostered by the qualitative mindset applied in clinical and educational settings, can contribute significantly towards building a culturally competent traumatology. We further propose that there are two ways in which qualitative psychology can make such contributions: through the direct contributions of qualitative studies to the research literature, and through the skills fostered in clinicians by training in methods such as ethnography, descriptive phenomenology or grounded theory and the application of qualitative mindsets and skill sets to clinical work (Corbin & Strauss, 2008; Giorgi, 2009).
The process of cultural competence acquisition for therapists is also one that needs to be inductive, to generate ideas about client populations from direct interaction with the members of those populations, while simultaneously recognizing the therapist’s own standpoint relative to them. Also, it is important to interact with client and research populations in an informed and skillful manner. Zayfert (2008) stated that:
a central challenge for culturally-competent treatment of PTSD does not appear to be whether to utilize empirically supported treatments for PTSD, but rather how to effectively engage individuals of various cultures in these interventions and how to address ethnocultural sources of avoidance in the maintenance of PTSD (p. 68).
This supports the contention that addressing cultural mediation is a prerequisite for developing our understanding of PTSD. We already noted some ways in which Boas’ work identified skills involved in qualitative research, which also had apparent utility for clinical training. It is worth noting that training in more recent qualitative research methods can likewise develop distinctive and useful skill sets for clinicians. For example, Giorgi’s (2009) descriptive phenomenological methodology involves procedures for evaluating whether one’s assumptions and biases have intruded into one’s understanding of another person’s words. The technique of axial coding in grounded theory coding teaches a rigorous approach to creating predictive models of complex patterns in human behavior (Corbin & Strauss, 2008). However, the primary focus of this paper is the potential for direct contributions of qualitative findings to traumatology. Before we can address that, we must take a more in-depth look at some of the limitations of the exclusive use of quantitative methodology.
Can Culture be Operationalized?
Culture has traditionally been treated as a nuisance variable in quantitative research, leaving little meaningful accounting for culture in scientific work (Valsiner, 2009). One major reason for this is that culture, from a quantitative standpoint, appears to be a vast array of interrelated and difficult to operationalize variables. The complexity and ambiguity of culture makes the operationalization of cultural factors seem overwhelming, as noted by Sue and Zane (2006):
Because much of the research (with ethnic populations) touches on topics such as disparities, inequities, differential treatment, prejudice and values, investigators may be uncomfortable in initiating studies that systematically examine important ethnic and cultural variations. These problems involving sampling, research difficulties, de-emphasis on external validity, and focus on controversial topics reveal both the major challenges to conducting such research and the complexities in achieving rigorous research designs (p. 332)
Intersectionality theory (Cole, 2009) is probably the most effective theoretical model to describe the complexity of cultural mediation. Intersectionality describes how multiple categories of identity, difference and power depend on one another for meaning, intersecting to create a complex matrix of context-specific manifestations, each dependent upon its unique standpoint. It suggests, for example, that to recognize and understand PTSD symptoms in a refugee population, one would need to examine the interaction of acculturation variables, political affiliation, economic circumstances before and after immigration, the family’s developmental stage, religion, and a number of other factors which might be impossible for researchers to identify deductively. Therefore, to isolate one of the many effects these factors produce through their interaction in the course of research is inherently to distort a correct understanding of how they operate.
The Value of Qualitative Methods for Trauma Psychology
We suggest that quantitative methods, used alone, cannot fully capture the full nature of human suffering, because they cannot encompass the richness and nuance of its meaning. The predominant reliance upon quantitative methods has driven an oversimplified, de-contextualized approach to many research topics (Arnett, 2009; Gergen, 2001), especially those concerning underprivileged groups, who are also at greater risk for experiencing traumatic situations. Quantitative approaches can miss the complexity of traumatic responses, especially when the precipitating stressor is ambiguous, such as in the case of racial and cultural microaggressions (Helms et al., 2010). We also argue that qualitative approaches can remedy several methodological flaws that have caused evidence-based research to insufficiently address cultural factors. While we are not discounting the value of quantitative work, or of mixed-method approaches, we are arguing for the value of free-standing qualitative programs of study which can: suggest directions for quantitative work, enrich the understanding of quantitative findings, and explore phenomena which cannot feasibly be well-studied quantitatively.
The Quality of the Evidence
What factors do qualitative methods address that quantitative methods do not fully account for? First of all, qualitative methods are less reductionistic than quantitative methods (Smith, 2003). It is not accurate to describe them as non-reductionistic, because scientific understanding is inherently reductionistic. It is reductionism which provides the clarity that gives scientific understanding its value. However, in quantitative research, data made up of human meanings which are linguistic or behavioral in their raw form, must be converted to numbers, analyzed in numerical form, and then turned back into meaning-encompassing language in the results section. Often the task of converting the meanings into numbers is foisted upon the participants through the use of rating scales and the like. This approach requires that the researcher have a very thorough prior understanding of the structure of the phenomenon of interest, and thus of all the variables involved in it. The identification and isolation of these variables is often a rather arbitrary and nebulous task. The choice of which variables to study, which to control for, and which to ignore, is often driven by considerations of convenience as much as considerations of scientific value.
In a qualitative method by contrast, language data remains in linguistic form, although the form is altered in the interests of clarity and conciseness (Smith, 2003). Certainly, meanings can be distorted by the qualitative analysis process, just as they can by the quantitative analysis process. However, the original meanings provided by the participants can be compared and consolidated without ever needing to be converted into a non-meaning encompassing form. This allows the researcher to approach the phenomenon of interest without a preexisting model of exactly how it operates, and lets the researcher decide how much to abstract the analysis from the obtained raw data. Thus complexities can be encompassed and described easily, because they do not have to be broken down into specific, irreducible variables, determined in advance. A good example of how the non-reductionist nature of qualitative findings can better capture the complex interaction between trauma and aspects of culture is Weine et al.’s (2006) grounded theory study of how Bosnian refugee familial beliefs regarding child-rearing adapt in the wake of immigration to the United States. Weine et al. were able to model how pre-immigration family beliefs adapted in response to post-immigration contextual factors, producing specific parenting stances which could be adaptive or maladaptive in different contexts. The result is a theoretical model which offers direct guidance to clinicians in the selection of preventative family and child interventions with this population. It would have been exceedingly difficult for a quantitative researcher to have deductively framed a series of a priori hypotheses encompassing these factors, to have operationalized many of these factors, or to have designed a unified study that could track the complexity of the interrelationships between the varieties of pre-immigration attitudes and traumas, the post-immigration experiences, and the resulting adaptations and behaviors.
This brings us to the second value of qualitative research, which is its inductive nature. Qualitative research explores phenomena in an open-ended manner, rather than testing a priori hypotheses. It looks at phenomena, rather than for particular manifestations of those phenomena. To test a hypothesis, one needs to proceed from a thorough and operationalized understanding of the phenomenon of interest. Where culture is concerned, such an understanding is quite difficult to obtain, and regardless of cultural factors, human meanings often do not correspond well to any given point on a Likert scale. When using qualitative approaches, researchers need little pre-existing understanding of the phenomenon of interest, and indeed need to bracket the knowledge they have (Giorgi, 2009). The qualitative researcher discovers an understanding of the phenomenon of interest through her examination of it. Thus, the researcher does not need to know in advance which aspects of the phenomenon of interest are culturally mediated; rather that is precisely what the researcher hopes to discover. The value of this inductive approach for traumatology is exemplified by Henry’s (2012) study of African refugees in Egypt. Henry found that participants experienced an interrelationship between how they mourned the loss of their culture of origin, how they coped with the traumatic circumstances that led to their refugee status, how they coped with political turmoil in their host country, and their acculturation stance towards Egyptian culture. In this way, Henry was able to examine how refugee trauma experiences intersected with the mourning and cultural continuity phenomena addressed by existing theoretical models of immigrant experience (Silverman & Klass, 1996), without needing start from an a priori hypothesis as to precisely how they did so. The relationships Henry discusses are not correlations, but the ambiguous relationships that exist in human being’s attributions of their own experience. A quantitative researcher might easily dismiss these as unscientific in nature, but that would be missing the point. People’s perceptions of relationships between aspects of their experience are the stuff of psychological research; the qualitative researcher is observing the existence of these as perceptions, rather than measuring them as behaviors.
A third value of qualitative research is a product of an interaction between the previous two. Because the original meanings of the participants are maintained to a greater degree, and because the inductive nature of the approach allows participants to express meanings that the researcher had no prior awareness of, qualitative approaches enable participants to have greater voice in how the findings of research reflect them. Too often, the use of deductive approaches, in both theory and research, have created a situation in which dominant culture researchers characterize an underprivileged group without meaningfully consulting its members in any way. While the inclusion of population-community stakeholders in research design and review processes is helpful in this regard, such inclusion does not address the methodological issue of the form which the participant’s contributions take in the study. The isolation of variables in quantitative design, and the reduction of linguistic data to numerical values, both serve to de-contextualize human experiences. In qualitative approaches, the analyzed forms of the data remain experience-near. Consider this passage from Mohatt et al.’s (2008) study of recovery from alcohol abuse among Alaska Natives:
In this active coping stage, many individuals often confronted their experiences with trauma. Participants frequently identified healing from traumatic experience as one of the central features of Stage I sobriety. Although most described healing through finding meaning in their current lives, this process included culture-specific elements. Healing often included discovery of what participants described variously as an identity, a role or a ‘voice’, that was at the same time theirs and also firmly grounded in their culture. Along with this was the experience of new relationships with significant others that did not repeat the past in terms of recurring and repetitive traumatic experience. This process was quite transformative: “Because I had come to, in my recovery—I continually came to realization after realization after realization about the why of things. And I realized that I felt like I was at home. And back at my grandpa’s house and hearing the language. And then I understood that the reason that I am confused about society is that I’m full-blooded Tlingit. I think in Tlingit and it’s okay.” (p. 5).
The qualitative analysis is broadly similar in form to the participants’ original stories; it is a narrative, and typically contains direct quotations from the participant’s stories; it captures the essence of the participants’ unique knowledge of their own experience. Untrained participants are able read the qualitative analysis of their own data, and judge for themselves whether it is a good reflection of what they said.
Thus qualitative methods enable underprivileged groups to portray themselves in a direct way that quantitative methods do not. To do this is equally in the service of social justice and good science, for to represent a group’s view of themselves promotes accuracy as much as fairness. We suggest that this is of particular importance to the field of traumatology, since non-dominant culture populations have historically been at the greatest risk for being misunderstood, mischaracterized, and harmed by social science (U.S. Department of Health and Human Services, 2001)
While not all aspects of trauma are clearly cognitively mediated, it is clear that a variety of the aspects of ascribed meaning do mediate the extent to which experiences are traumatic for individuals; this meaning involves complex, interrelated beliefs which are rooted in core cultural beliefs (Markus & Kitayama, 1998). Beliefs about such things as how much control one does or should have over life are part of the internalized form of culture, and also fundamentally construct the meaning of any traumatic experience. Other social and contextual factors influencing an individual’s responses to trauma include: shame and stigma, notions of family, religion, culture-related stressors, acculturation, histories of trauma and violence and cultural discontinuity, as well as oppression (Ancis, 2008). We would argue that some evidence-based treatments for trauma are rooted in theoretical assumptions about how traumatic experiences are interpreted, that are actually reflections of Western core cultural ideas. For example, a therapist using cognitive processing therapy expects traumatized clients to hold beliefs like the just world theory, and conform to individualistic cultural norms regarding locus of control (Resick & Schnicke, 1993); the highly manualized nature of this treatment encourages a top-down search for such ideas. Qualitative research suggests that the understanding of another person’s meaning inherently needs to be bottom-up, and approached with all assumptions thoroughly bracketed (Giorgi, 2009), or one is at risk for simply seeing one’s own assumptions as the other’s ideas.
The limitations of qualitative methods are generally better understood within psychology than their strengths. Clearly, qualitative results cannot be generalized. That is, predictions cannot be made of the likelihood with which an inference about the population can be made on the basis of the findings in regard to the sample. However, the very recognition of the importance of culture is an acknowledgement that psychology has historically been overly ambitious in its efforts to create universal theories of human behavior. Historically, it has been a tacit assumption of psychology that the virtues of quantitative research are preeminent, but the field must realize that to designate them so is to value external validity to the virtual exclusion of considerations such as ecological validity and relevance (Westen, 2006). If we can value qualitative research’s strengths over its limitations, then in clearly has much to offer trauma psychology.
Towards a Program of Study for Qualitative Research in Traumatology
The specific qualitative studies we have discussed in this paper are good examples of the kind of research that we would like to see more of. To outline a proposed program of study for qualitative research in traumatology is a big task, however we can briefly provide a broad outline of what we would like to see done.
Studies of diverse population’s experience of trauma and its aftermath provide the best starting points for bodies of research looking at trauma in a population-specific manner. The more inductive such studies are the better, so methods such as descriptive phenomenology, (Giorgi, 2009) which uses a non-directive interview, are ideal.
Studies yielding theoretical models of successful coping with trauma by diverse populations can provide building blocks for the creation of new interventions, and the selection and adaptation of existing interventions, to ensure that interventions are culturally syntonic. Grounded theory (Corbin & Strauss, 2008) is most clearly suited to this, although consensual qualitative research (Hill, Thompson, & Williams, 1997) may also be useful for this purpose.
Finally, studies examining diverse client’s experience of existing trauma treatments will provide a more nuanced understanding regarding how EPB’s and other psychotherapies are working, in a culture-specific manner. This may be best done with conventional and directed content analysis (Hsieh & Shannon, 2005), although any of the aforementioned methods may be useful for this sort of clinical utility study. In each case, we would hope that complimentary quantitative and mixed-methods research would be used for follow-up studies.
Conclusion
Attention to culture in clinical research and work is clearly necessary given the increasing diversity and interconnectedness of our world. The challenge that multiculturalism presents to psychological research can best be answered by the increased use of qualitative methodologies, which are emic in nature and can therefore encompass subjective phenomena and contextual understandings that are not well-captured by quantitative designs. Because of these strengths, qualitative studies often do a better job of giving underrepresented groups a voice in research.
As trauma psychology attempts to develop best-practice guidelines, the field must first expand notions of scientific evidence and embrace those methodologies that historically have best addressed the needs of underprivileged, underrepresented and stigmatized groups. Treatment guidelines that do not recognize the cultural differences between groups will ultimately fail with a majority of clients, and endanger the relevance of the field as a whole.