International Society for Traumatic Stress Studies

Importance of Considering Culture – Final Installment: Intervention and Treatment

Posted 7 October 2014 in StressPoints by Stefanie F. Smith, PhD, Bita Ghafoori, PhD, Yael Caspi, ScD, MA, Erika Felix, PhD, and Ateka Contractor, MA on behalf of the Diversity and Cultural Competency SIG

The importance of addressing culture in the definition of traumatic stressors (Caspi, Ghafoori, Smith, & Contractor, 2013) and in the understanding of their short and long-term impact (Ghafoori, Caspi, Contractor, & Smith, 2014), is further accentuated in the cross-cultural examination of help-seeking practices, barriers to health-care, and the appropriateness and effectiveness of trauma treatment methods.  

While cultural groups are defined in many different ways, this article will talk about racial/ethnic culture as an example of how culture is important to consider, and we encourage readers to keep in mind the interplays of other cultural groups. Culture influences the decision to potentially seek help (Wilson, 2007) and from whom help is sought. Help is often sought initially from more culturally-acceptable figures such as shamans, traditional healers, spiritual leaders, or primary care providers (Moodley & West, 2005). Culture can also influence treatment choices and engagement (Lester, Reisnick, Young-Xu, & Artz, 2010; Pole, Gone, & Kulkarni, 2008; Wilson, 2007).

One barrier to help-seeking, especially from traditional mental health providers, is stigma and shame regarding emotional problems within some cultures (Kinzie et al., 1990; Roberts, Gilman, Breslau, Breslau, & Koenen, 2011). These issues can be compounded by low mental health literacy prevalent in some cultures, including culturally diverse communities in the U.S.  (Ghafoori, Barragan, Tohidian, & Palinkas, 2012; Ghafoori, Barragan, & Palinkas, 2014), accentuating the role of education as a necessary precursor to interventions in multicultural communities. Finally, help seeking is further compromised by access issues (Bandeira, Higson-Smith, Bantjes, & Polatin, 2010; Ghafoori, et al., 2012; Roberts et al., 2011).

The cross-cultural relevance and effectiveness of standard trauma treatment modalities is another imperative concern. Emerging research suggests that culture influences response to different treatments and that different therapies may be more effective with different cultural groups and situations (Fantuzzo et al., 2005; Marsella, 2010; Neuner, Schauer, Klaschik, Karunakara, & Elbert, 2004; Stein et al; 2004).

Furthermore, empirically validated treatments may need to be modified. For example, a shortened CBT was found to be effective and more feasible for earthquake survivors in Turkey (Basoglu, Livanu, Salcioglu, & Kalender, 2003).

The wider cross-cultural literature indicates that cultural sensitivity and knowledge is a necessary component of effective treatment (Wilson, 2007). Moreover, integration of Western and culture-specific healing practices may prove to be effective therapeutic modalities (Wilson, 2007), and several variations have become more known in recent years, such as Transcendental meditation (Rees, Travis, Shapiro, & Chant, 2013) and the use of mindfulness in trauma treatment (Omidi, Mohammadi, Zargar, & Akbar, 2013).

More research is necessary to increase the understanding of culture specific healing practices and culturally embedded barriers to treatment access.  

About the Authors

Stefanie F. Smith, PhD, is an Associate Professor at the California School of Professional Psychology at Alliant International University and maintains a private practice. Her main research interests include neurophysiological and sensorimotor impacts of complex trauma and corresponding interventions, cultural impact on trauma symptomatology, and complex trauma's impact on health and risky health behaviors.

Bita Ghafoori, PhD, is a Professor of Counseling at California State University Long Beach (CSULB) and the Director of the CSULB Long Beach Trauma Recovery Center. Her current research focuses on mental health disparities in traumatized populations, cultural considerations in the assessment and treatment of traumatic stress, and the dissemination of evidence-based, trauma focused therapies.

Yael Caspi, ScD, MA, is a clinical psychologist and a researcher. She is the director of the veterans' psychiatric outpatient services at the Rambam Medical Health Center, in Haifa, Israel. Yael received her ScD degree from the Harvard School of Public Health in Boston, where she investigated the impact of refugee trauma in a community sample of Cambodian refugees. During the past few years she has been writing and advocating for increased awareness of war trauma and its impact on Bedouin servicemen in the Israel Defense Forces and their families.

Erika Felix, PhD, is an Assistant Professor in the Department of Counseling, Clinical, and School Psychology at the University of California, Santa Barbara (UCSB). Her research focuses on promoting adaptive recovery for youth following disaster or terrorism, youth victimization and its consequences, and research and evaluation to improve community-based services.

Ateka Contractor, MA, is currently a predoctoral psychology resident at Warren Alpert Medical School of Brown University and a doctoral student (clinical psychology) at University of Toledo. She has obtained her masters degree in clinical psychology at Eastern Illinois University. Her main research and clinical interests are the interaction between PTSD and culture, and PTSD's comorbidity with depressive and impulse-based disorders using structural equation modeling techniques.


Başoğlu, M., Livanou, M., Salcioğlu, E., Kalender, D. (2003). A brief behavioral treatment of chronic post-traumatic stress disorder in earthquake survivors: results from an open clinical trial. Psychological Medicine, 33(4), 647-54.

Bandeira, M., Higson-Smith, C., Bantjes, M., &Polatin, P. (2010).  The land of milk and honey: a picture of refugee torture survivors presenting for treatment in a South African Trauma Centre.  Torture, 20(2), 92-103.

Caspi, Y., Ghafoori, B., Smith, S., Contractor, A. (2013). On the Importance of Considering Culture When Defining Trauma.Traumatic StressPoints, 27(5).

Fantuzzo, J., Manz, P., Atkins, M., & Meyers, R. (2005). Peer-mediated treatment of socially withdrawn maltreated preschool children: Cultivating natural community resources. Journal of Clinical Child and Adolescent Psychology, 34, 320–325.

Ghafoori, B., Barragan, B., & Palinkas, L. (2014).  Mental health service use after trauma exposure: A mixed-methods study. Journal of Nervous and Mental Disease, 202(3), 239-246.

Ghafoori, B., Barragan, B., Tohidian, N., & Palinkas, L. (2012). Racial and ethnic differences in mental health outcomes among urban survivors of trauma and violence. Journal of Traumatic Stress, 25, 106-110.

Ghafoori, B., Caspi, Y., Contractor, A., Smith, S., (2014). Importance of Considering Culture Series: Culture and Traumatic Symptoms. Traumatic StressPoints, 28(2).

Kinzie, J., Boehnlein, J. K., Leung, P. K., Moore, L. J., Riley, C., & Smith, D. (1990). The prevalence of posttraumatic stress disorder and its clinical significance among southeast Asian refugees. The American Journal of Psychiatry., 147, 913-917.

Lester, K., Artz, C., Resick, P. A., & Young-Xu, Y. (2010). Impact of race on early treatment termination and outcomes in posttraumatic stress disorder treatment. Journal Of Consulting and Clinical Psychology, 78(4), 480-489. doi:10.1037/a0019551

Marsella, A. J. (2010). Ethnocultural aspects of PTSD: An overview of concepts, issues, and treatments. Traumatology, 16, 17-26. doi: 10.1177/1534765610388062

Moodley, R., & West, W. (2005). Integrating traditional healing practices into counseling and psychotherapy. Thousand Oaks, CA: Sage Publications Ltd.

Neuner, F., Schauer, M., Klaschik, C., Karunakara, U., Elbert, T. (2004). A comparison of narrative exposure therapy, supportive counseling, and psychoeducation for treating posttraumatic stress disorder in an african refugee settlement. Journal of Consulting and Clinical Psychology, 72(4), 579–587. doi: 10.1037/0022-006X.72.4.579

Omidi, A., Mohammadi, A., Zargar, F., Akbari, H. (2013). Efficacy of mindfulness-based stress reduction on mood States of veterans with post-traumatic stress disorder. Archives of Trauma Research, 1(4), 151-154. doi: 10.5812/atr.8226

Pole, N., Gone, J. P., & Kulkarni, M. (2008). Posttraumatic stress disorder among ethnoracial minorities in the United States. Clinical Psychology: Science and Practice, 15, 35-61. doi: 10.1111/j.1468-2850.2008.00109.x

Rees B, Travis F, Shapiro D, Chant R. (2013). Reduction in posttraumatic stress symptoms in Congolese refugees practicing transcendental meditation. Journal of Traumatic Stress, 26(2), 295-298. doi: 10.1002/jts.21790

Roberts, A. L., Gilman, S. E., Breslau, J., Breslau, N., & Koenen, K. C. (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

Stein, B. D., Jaycox, L. H., Kataoka, S. H., Wong, M., Tu, W., Elliott, M. N., et al. (2003). A mental health intervention for schoolchildren exposed to violence: A randomized controlled trial. Journal of the American Medical Association, 290 , 603–611.

Wilson, J. P. (2007). The Lens of Culture: Theoretical and Conceptual Perspectives in the Assessment of Psychological Trauma and PTSD. In J. P. Wilson & C. S. Tang (Eds.), Cross-Cultural Assessment of Psychological Trauma and PTSD (pp. 3-31). New York, NY: Springer Science + Business Media, LLC.