The cultural dimension of war traumas in central Mozambique: The case of Gorongosa

 

VICTOR IGREJA, M.A., 

BAS J. N. 

SCHREUDER, M.D., Ph.D.,  

WIM CHR. 

KLEIJN, M.A.

 

« Psychiatry

Introduction

This paper is a preliminary discussion of a more enlarged and longitudinal research project on the prevalence of post-war related symptoms, prevention and intervention strategies in some rural areas of Gorongosa, a District belonging to Sofala Province in central Mozambique. Our purpose in this paper is to explore the ways in which culture influences the perception of trauma in a non-western society. The major constraints and limitations in making correct assessment when applying measuring instruments designed in western countries and for specific western populations will also be examined. The preliminary findings suggest that what can be widely conceived as a traumatic experience is not always transferable from one culture to another. It also suggests that to understand the local cultural dimension of trauma it is necessary to determine (a) the type of relationship that living people establish with their dead loved ones and the ways that the war disrupted these relationships, and (b) the degree to which people believe that their well-being depends on the good performance of established ceremonies and rituals surrounding birth, marriage and death and the ways in which the years of social, political and economic crises inhibited the people from fulfilling these vital obligations.

The recent historical background of Mozambique was characterized by almost three decades of war. The struggle for independence began in 1962 and ended in1974 and the civil war lasted from 1976 until 1992. Although, within these two periods the war spread throughout the whole country, the rural areas were the most affected. At present, the psychosocial magnitude of the effects of these two wars is still unknown. War represents one of the most ancient and the most important forms of man-made violence in terms of the magnitude of its effects (McFarlane and de Girolamo, 1996). In the case of Gorongosa, our demographic data demonstrate that almost 95% of the people lived in the war-zones during the 16 years of war, alongside soldiers from both sides. Furthermore, the populations were living under permanent threat of death in both Renamo and Government controlled areas.

In fact, there were very few studies done in Mozambique regarding the colossal effects of the war (very exceptionally some assessments were made with specific groups of population like children, e.g., Cliff & Noormahomed, 1993; Richman, Ratilal & Aly, 1990; Shaw & Harris, 1994; Miles & Medi, 1994; Gibbs, 1997) and natural disasters (such as drought and floods) on mental health. At the same time, there has been an increasing interest from the Government authorities of post-conflict countries in Africa and from the World Health Organization (WHO), to assess the psychosocial consequences of these conflicts, and to find desirable culturally congruent local therapies to help the people cope with them (Marrato & Wilson, 1995; Mandlhate, 1996; WHO, 1997). This article aims to explore the limitations and challenges posed by the singular application of Western instruments and concepts in a non-western society. The ways in which culture influences and regulates the perception of trauma is also analyzed and discussed.

Trauma concept

In the last two decades there was an increased interest from psychologists, psychiatrists and psychotherapists in the study of ethnocultural aspects of trauma (Lee & Lu, 1989; Summerfield, 1991; Mollica et al., 1996), posttraumatic experiences (Marsella, Friedman & Spain, 1993) and coping strategies or psychotherapies (Kinzie, 1978; Kinzie, Tran, Breckenridge, & Bloom, 1980; Holm, 1982; Boehnlein, 1987b; Krippner & Colodzin, 1989; Silver & Wilson, 1990; Parson, 1990; Morris & Silver, 1992).

Trauma has been conceived of as an event  (of a short or longer duration) that is outside the range of usual human experience and that would be markedly distressing to anyone (APA, 1987). This conception suggests that the individual, regardless of his or her cultural environment can suffer, in some way, negative psychological consequences, when confronted with overwhelming experiences. Such a definition can be problematic when trauma is discussed from a cultural perspective.

This conceptualization of trauma based on Western biomedicine and Western Psychoanalysis becomes too narrow and restricted for the discussion of trauma and posttraumatic experiences from a cross-cultural dimension. This is because they do not embody a socialized view of mental health. Most people exposed to the effects of war and trauma in the non-Western world do not go through these events as a private or individual experience (Summerfield, 1995). By contrast, these events are faced generally as collective experiences in which the traumatic content of the experience is not attached to the event itself but to the pain and negative consequences associated with it.

The Western models have also been criticized for their strict consideration of the person as a self-contained unity, an individual completely independent of others (Bracken, Giller & Summerfield, 1995). In this way, many challenges are raised when research on trauma and posttraumatic experiences has to be done with traumatized people from societies where the individual is conceived as a part of an extended living and a dead family, special group, or community. In addition, the traumatic experiences are not strictly confined to their overwhelming impact on the individual psyche. With few doubts a broader conceptualization of trauma is needed in which the loss or disintegration of cultural beliefs and values should be considered as traumatic experience too.

The need to widen the concept of trauma to adjust it to the local cultural dynamics of the people in our study has led us to take into account in the investigation procedures: (1) the role of culture in PTSD (2) the specificity of the cultural meaning of trauma and its implications to the development of effective strategies to address the individual and collective adaptation to trauma. Our research suggests that these objectives can be better fulfilled when applying a constellation of methodological approaches- methodologies that provide much more freedom for individuals, families and their communities to express what they went through and how these experiences are perceived as being very traumatic in the light of their cultural background. In addition, the use of ethnographic approaches is also of great importance to fulfil these objectives.

  The cultural validation of traumatic experiences has demonstrated that what can be widely conceived as a traumatic event is not always applicable from one culture to another. Research suggests that the characteristics and nature of traumatizing events (Herman et al., 1986; Roth et al., 1990) and their cultural interpretation (Cánive & Castillo, 1997) are very important factors for correct diagnosis.

  The measuring instruments

The research on PTSD in non-western societies raises many challenges, when these investigations are constrained by the singular application of western etiological categories in diagnosing mental health or illness in a different cultural environment such as that pertaining to the study. Although these measuring instruments do give a certain portrayal of some mental health problems across populations, they do not seem adequate to make a complete and correct diagnosis due to the fact that they were developed by westerners for westerners, based upon their own Eurocentric values, assumptions and norms. Even now, there are few published ethnocultural studies of PTSD concerned with assessment issues, in spite of the fact that cultural sensitivity in assessment procedures may be a major factor in the determination of PTSD rates and clinical features (Marsella et al., 1996).

In making a diagnosis of the impact of the war on mental health of people, what is used are interviews, questionnaires, self-reports, scales and other instruments elaborated for specific populations (e.g. the north American or the western Europeans) who have experienced a limited range of traumatic experiences (McFarlane & de Girolamo, 1996). These experiences are completely different from African people who have a different cultural background, and who have suffered the effects of long years of exposure to civil wars and other traumas.

It is also common to use categorisations of mental distress or behavioural problems, following models that do not have the same meaning across cultures. It is important to bear in mind when making an assessment of the psychosocial impact of violence that victims react to extreme trauma in accordance with what it means to them. Interpreting these meanings is an activity that is socially, culturally, and often politically framed (Summerfield, 1995). Despite the attempts emerging with the advent of transcultural psychiatry to respond to the cultural demands in diagnosing and treating mental disorders (Murphy, 1969; Kleinman, 1977; Littlewood, 1990; Weiss at al., 1986), research on the relationships between culture, trauma and posttrauma is still at the very beginning (de Vries, 1996).

Limitations and challenges of measuring instruments

In the light of the recognition that the measuring instruments can not be universally applied across cultures (Eisenbruch, 1991; Bracken, Giller, & Summerfield, 1995) the question to be raised is: What are the real limitations and challenges posed by the use of these assessment instruments during the field work in our research project? The first problem is posed by the language differences. Do translated words mean the same thing? Our research suggests that it is not always possible to translate psychological concepts to the local language. This problem is further complicated when the local languages are not yet written and specificity of meaning need to be minimised by translations and back translations having to be done many times. These in turn are tested and re-tested using as many local people as possible.

The second challenge is related to the conceptual equivalence of items, scales or measures. For instance, concepts like nervous, disturbed, palpitation, unhappy or useless are extremely difficult concepts to translate accurately in the local language.

The third problem is related to the standardized way in which the participants are expected to give their answers to the questionnaires. For example, although there are equivalent translations on the local language to rate items like “not at all”, “slightly”, and more importantly “seriously” and “extremely” are not used as a linguistic resource in the daily language of the people. This means that these distinctions to assess the severity of the symptoms are inappropriate and irrelevant to the people in this culture.  

The fourth problem is the time period used to assess the appearance of different symptoms. For example, some questionnaires use the length of time of “last or previous four weeks”. In most of the cases, the people in our communities do not manage their daily lives by controlling the time in this way. Rather their time is guided by natural phenomenon (e.g., the different phases, or appearance of the moon) or more importantly, the Agricultural Cycle. So for instance, when someone in our sample is asked “did you have bad dreams in the last four weeks?” This question becomes not an easy equation to solve, not because of he or she does not understand the content of the question but because the length or interval of time do not fit with the cultural way of perceiving time.

The fifth problem is related with the way people register and interpret traumatic experiences. For instance, contrary to general perception, the death of a family member may not be as a traumatic experience as the failure to bury appropriately the body of the deceased. This is because of the negative consequences associated with the breaking of the culturally prescribed rituals. Another example is the fact that the main source of mental distress of a woman who spent all her life in the war zone may not be in anyway related with what happens during the war. Although she may have experienced the most fiendish events in the wake of the war, her mental distress may be caused solely from the fact that she cannot give birth. Both male and female infertility, but in particular the latter case, can lead to a deep social stigmatization because in cultural terms, the woman in this condition is classified as still being a child. She will never grow up and she is condemned to live forever under extreme dependence on the goodwill of men. In this case, her infertility may overshadow her high degree of war exposure. Therefore, the items of HTQ do not seem relevant to this category of people even if they reply to all the questions. Gender relations should be carefully understood when trying to apply questionnaires.       

Methodology

a. Participants

The sample is composed of 159 adult individuals, men and women, living in two different communal villages of Gorongosa District, namely Casa Banana (runway) and Mucodza. They fulfilled the following criteria: have lived in the former war-zones (whether of Renamo or former government controlled areas) and have more than four years at the beginning of the civil war in 1976. Both communal villages were artificially created in the middle 80s after the destruction of the Renamo main headquarters, located in Casa Banana (Mussicadze), by the joint forces of Zimbabwe (locally designated “Komeredes”) and Mozambican government soldiers.

The participants belong to a community of countrymen and women where agriculture is the main activity. In general, the families are polygamous and the man is the head of the household having the responsibility to take all the decisions concerning family related issues. Gender relations are markedly evident since men and women have different roles to play both in public and domestic places. These cultural relationships have a vital importance in understanding and developing sensitive measuring instruments because they clearly influence the ways in which the different items of the questionnaires become valid or irrelevant for both men and women.

b. Instruments

These were semi-structured interviews which consisted of four parts with a total of 92 items: (1) demographic data and war circumstances (9 items); (2) data on psychiatric morbidity (SRQ 26 items); (3) data on shocking experiences (HTQ - part 1; 24 items); (4) data on sleep and re-experiencing (NITE 12 items); and (5) data on PTSD (SifP 22 items). The questions from these instruments were applied as semi-structured interviews because the people in the communities in the study cannot read or write. Most of the questions can be answered with "yes", "no" or a question mark. In-depth interviews were also applied to complement data on the war experiences. Individuals were asked specifically to make a list in order of decreasing scale of potency of what they considered to be the major traumatic events they went through during the years of war and the reasons for considering these events traumatic ones.

The validation process of these instruments was carried out in three phases during the pilot study. The first pilot study took place during four weeks (February, 1997) in Boane, a district belonging to Maputo province in the south of the country. The second phase was carried out in Gorongosa during one week (April, 1997). The last phase was also carried out in Gorongosa during two weeks (June, 1997). Linguistic equivalence for each of the items of the questionnaire was established in Portuguese and Chi-Gorongose. All questionnaires were first translated from English to Portuguese and then to the local language by different bilingual members of Gorongosa district. None of them was related to mental health care institutions. The different versions were then translated back “blind” into Portuguese by comparable individuals. The quasi-final version (as long as the study progressed we discovered that some concepts that had been previously translated needed to be redefined) of the questionnaires were applied in this study. 

The validation of the questionnaires confirmed that some items were not valid for our sample either because of semantic or contextual equivalence. They had to be removed. Other items were introduced due to their relevance in relation to what they went through.

On the SRQ, none of the items was removed but the following items had to be explained because they were not clear enough:

(1) Difficult to think clearly and feel disturbed in the thoughts.

(2) Difficult to appreciate the daily activities and daily work damaged (in these two cases the difficulties were not related to psychological or physical complaints but with the weather conditions to practice agriculture).

(3) Not being able to make oneself useful and feeling as a useless person (in this case most of the people would say “I don’t know” because one is not expected to make self assessment. Culturally the good or bad fulfilment of one’s roles and obligations towards the community is made by the other members of the community.

(4) To lose interest in things (it can not be something abstract. It should be concrete things like: kids, wives, fields...).

(5) To think that there are people trying to hurt you (this event could only happen if the person saw, heard or dreamed about, and not just through thinking about it).

(6) Difficult to take decisions. In this case gender relations had to be taken into account because culturally women are not expected to take decisions concerning issues in the household. This would be a sign of alienation, unless women are divorced or widows with no adult sons and brothers).

(7) All the time crying (this event is more relevant for the women and not for the men. In fact the men are not expected to cry which is a sign of weakness unless the man is older than fifty, which culturally represents the beginning of the regression process to the early phases of human development in the ontogenesis, i.e., old people are comparable to children; for this reason, there is room for men to cry like children or women).

On the HTQ, the following items had to be removed due to the content equivalence: brainwash; suffocation; drowning, unnatural death of a family member; and assassination of a friend. The following items were introduced due to their relevance: fall in ambushes; kidnap of a family member; loss of goods. The item torture had to be explained because there was no linguistic equivalence.   

Results

The preliminary analysis of the data was focused on the comparison of the data collected with the semi-structured interviews and the in-depth interviews on war experiences and post-trauma symptoms. Our research suggests that, in some cases, prior to determining the generic dimensions of traumatic stressors defined, for example, by Green (1990) cultural prescriptions, beliefs, and values are also important and should be carefully understood and respected when trying to define traumatic experiences, post-trauma reactions (Raphael, 1996), and development of effective strategies to address mental distress.

The Harvard Trauma Questionnaire considered to represent a singular and most important effort to assess exposure to trauma and its symptoms cross-culturally (Newman et al. 1996) states that the lack of shelters in a war situation is a traumatic experience. Of course, it is very understandable that, in the middle of a war-zone, if one does not have a shelter in which to hide, the risk of being injured or killed is much higher. But the cultural trial of the shelter experience suggests that this is not true at all. In fact, when the people in our sample were asked about experiencing the lack of shelter during the war period, almost 90% of them had experienced this reality anyway.

At first glance and without cultural bias, this fact would clearly mean that the event (lack of shelters) was indeed a traumatic one, as it was for the IndoChinese refugee sample (Mollica et al, 1992). However, in considering the list that people made of the major traumatic experiences that they had undergone through, in order of decreasing priority, the results suggested a different interpretation of this event. This emphasises the very need to carefully examine the way in which people interpret traumatic events, in the light of their cultural background. As a result of this cultural and local categorisation of traumatic experiences, the majority of respondents (95%) considered the use of holes for shelters, the communal villages, gandira and the drought and floods caused by the war as being among the most traumatic experiences.

The holes for shelters as a traumatic experience

This apparently contradicting observations raised questions such as: if these shelters were protecting and saving many lives from the intensity of bombardment, why at the same time were they being considered a traumatic experience? Why the presence and not the absence of shelters, which could result in many more deaths, was considered to be a traumatic event? Do the holes symbolize something bad for the people? What could be the cultural explanation for these unexpected outcomes?

The people used to dig huge holes on the ground which they covered over with wood, mat and grass. Somewhat surprisingly, we found out that, what was saving many people's lives, was considered, at the same time, to be a very traumatic stressor. The cultural explanation for this fact is based on two death principles:

(1)When someone dies, he/she carries, with him/her, a set of symptoms, called Tsanganiko that only the homeostatic mechanisms can prevent from infecting and spreading to the realm of the living; and

(2)After the ceremonies and rituals surrounding loss and grief (e.g. mass on the seventh day, visits to the grave at the cemetery to put flowers on or clean it), there should be no more symbolic contacts with the deceased. These type of practices are not allowed and every action or behaviour, suggesting or symbolizing a proximity with the realm of the dead creates distress, fear, sadness or anxiety because the people believe that they are provoking the dead and therefore they will be contaminated by tsanganiko. Several people, in particular old men, referring to the shelters, told us that:

The pain and grief increased even more when we had to share for almost six months the same place with the dead. Where have you seen living people sleeping on the same house with the dead? We had never seen before living people sharing the same place with dead. Our tradition does not allow such behaviour. The holes are our 'last house’; therefore we can only sleep there when we are already dead. One cannot go there in advance; that's why many people were contaminated by tsanganiko and up to this day, we are still getting sick because of that. It would have been better, if when the attacks began, we had run away to the bush instead of getting inside these holes.

Culturally established norms and standards of behaviour in these communities dictate that there are no rational reasons to justify someone's presence at the cemetery unless strictly to bury a dead person where for that a hole must be opened. Therefore, when the people, during the war, had to open big holes to get inside to protect themselves against the armed attacks, they considered the event a traumatic experience, because they were symbolically sharing the same place (or house) with the dead, instead of standing aloof, which would have been the normal cultural response.  In defining post-traumatic cultural reaction in line with De Vries (1996), "the holes for shelters" can be viewed as an abnormal response to an extraordinary event. 

The experiences of trauma, resulting from the breakdown of cultural beliefs and values, (these types of traumatic experiences are not present in the western measuring instruments to assess trauma exposure) raises the concern to understand two important aspects: (1) the ways that people used to organise the surviving strategies during war and their obligation to preserve and follow traditions in the former war zones and (2) the need to have a very broad view, when asking subjects to respond to questions by simple " true and false" or "yes and no", or rating items from high to low; the responses may not be what we are expecting. The example of the shelters mentioned above is a clear illustration of this fact, i.e., when the people were asked about their experience of lack of shelter, the answers were very clear that they had experienced the event, but at the same time, this event did not mean that it was a traumatic experience. Rather, we could conclude that the presence of shelters had been one of the most war traumatic experiences so much so that even today, people believe that they are facing its consequences.

The traumatic experiences of the communal villages

The social and cultural influences affecting the perception of trauma, should be a prerequisite in classifying a traumatic event and its implications, when doing trauma research in non-western societies. This is because of the range of local peculiarities. The researcher has to define the sources of mental distress during the diagnostic procedures. It would be very difficult to have a comprehensive view of the wide range of traumatic events and post-trauma reactions without considering the organizational system of life in the rural areas and the ways that the political instability tries to destroy these cultural and historical standards of living in the wake of war.

The so-called communal villages, for example, were created, first by the Portuguese soldiers, termed as "Aldeamentos". They consisted of concentrating many people in the same place to use them as a war strategy to prevent contact between the populations and Frelimo soldiers during the struggle for independence. After Mozambique's independence, Frelimo applied the same strategy but using a different political justification, and apparently better rationale, to “facilitate the development of the rural areas”. Then, later on, during the civil war Frelimo used it again (the communal villages) as a military battle strategy to enlarge the control of the war zones. These policies toward the people in the rural areas created dramatically a discontinuity in the social and cultural systems of the Gorongosa populations.

The apparently positive strategy of communalization in name of the “development of the rural areas” disrupted the agrarian way of life and was locally classified as a traumatic experience for several reasons. Two are seen as the principal ones. Without excluding the fact that the impact of the war was more intense inside communal villages, resulting in many deaths every day, and that many families were compulsorily separated from one another (some were living in Renamo controlled areas and others in Government controlled areas), the main reasons to consider that communal villages were a traumatic experience were that:

First, the massive concentration of people forced to live in the same place was against their historical and traditional way of living in a community. Their traditional ways of living are based on the principle of separated households, which means that each family, most of them enlarged or extended ones, should live far from one another. This type of social organisation allows polygamous families to build the houses of the wives and young children in the same yard, to open freely their own fields of production in front of and around their houses instead of having to walk long distances to practise agriculture (i.e., separating the place of living from the place of production). In this way they can also better protect their produce against thieves and animals.

Second, the people rarely congregate except during the ceremonies surrounding grief and loss, or during the healing ceremonies at the traditional healer's house. The people present at these ceremonies can only go back home, when tsanganiko is done, otherwise the person can take it home and contaminate all the family members. Therefore, the communal villages where many people were living, concentrated in the same place (or yard), symbolically carried these moments of grief and loss continuously.

The populations had to be forced under threat of death to leave their “old residences” and go to live inside the communal villages in spite of them wanting to follow their traditions, before and during the war. Several people, both men and women, told me that:

 

  I never wanted to leave my old residence and come to the communal village. Even with the war, I wanted to stay where I had my land and granaries. Ever since a long time ago, we never lived with so many people together in the same place. Everyone must live in his own yard. The Komeredes came to my house and said that I should leave my house and go to the communal village where there were a lot of people. I tried to refuse and then they set fire to my house, my granaries, and my fields. They threatened me with death and they told me and my family to go forward.

  Inside the communal village we lived like pigs. It was like a yard for pigs. We were so many people living close to each other. If someone slept with his wife everyone could listen to what they were doing. When we went to the fields or to the cemeteries to bury the dead, the soldiers had to come behind and in front of us. When the women went to the river to wash themselves, the soldiers had to go too and they usually saw our women naked. Everything was a complete shame inside that corral. Usually to eat, we had to depend on humanitarian aid, but we never knew when it would arrive. It was terrible; that is why many people used to run away from the communal village to their old residences where Renamo soldiers were, although it was also terrible there.  

 

The breaking of cultural values and norms suggests that this can also be a very traumatic experience. Sometimes, even in situations of great instability, the populations would prefer to risk their own lives and make alliances with either side in the conflict which could guarantee, in some way, that these norms and values were protected. Otherwise, it would be difficult to understand the frequent attempts of the populations to run away from the communal villages to the so-called Renamo controlled areas, where the situation in terms of instability was not different.

The daily life in these areas was not a bed of roses. One of the most traumatic events that people used to experience was locally called Gandira which was also closely associated with frequent rapes of women. Gandira was a war management system established to support and guarantee Renamo war efforts in the war zones. The key elements of this system were that the civilian populations were used, without their consent, to perform two main tasks (1) produce and supply the soldiers with food and (2) as a means of transportation of military armament and food from one place to another.

Gandira consisted of forcing the people to carry on their heads boxes of weapons and ammunition, bags of food and meat of hippopotamus. The people were forced to produce food not only to be self-sustaining but also to maintain the war effort, by giving food to the soldiers and they had to travel long distances on foot to transport it. They would walk and be far from home for two to three weeks and in these cases most of the women became easy targets for the soldiers. The soldiers could arrive at any time of the day or the night to do gandira and the women were forced to cook naked and give them food. Even though they knew the reality of the nature of the traumatic events in these areas, the people preferred to live there instead of going to the communal villages. The great movement of the populations from the Renamo controlled areas to the communal villages was only registered during the long years of intense drought between 1987-1988 and 1990 until the end of 1992.

Natural and human-made disasters

The distinction is made, in trauma studies, between human-made disasters and natural disasters. There are claims that the former is more traumatic than the latter, as they provoke a greater sense of being the deliberate victims of one’s fellow human beings (Smith & North, 1993). However, this does not appear to fit with the type of cultural perception in our sphere of study.

Our findings from the research in Gorongosa suggest that the cultural interpretation does not make a distinction between these two dimensions of disasters. Instead, during the periods of social upheavals, such as the sixteen years of civil war, the causes of natural disasters (in particular drought) were attributed to the (1) constant suffering and killings of human lives (2) the disrespect of the ancestors and (3) the violation of the cultural regulating mechanisms of relationship between the living and the loved dead. In addition, the cultural perception is that the drought was an aftermath of the rivers of blood of innocent people that permanently permeated the ground, and the floods were an attempt to clean the red fields. Inside this frame of thinking, there is only room for one dimension of disasters, i.e., the human-made.

Conclusions

This article has attempted to show the limitations and challenges posed by the singular application of Western concepts and measures across cultures using the case of Gorongosa in central Mozambique. Four serious problems were identified when doing our field research namely (1) language differences associated with absence of a written local language (2) difficulties in finding conceptual equivalence to items, scales or measures (3) the standartized way in which we expect participants to answer the questions (4) the time-symptom manifestation to control and assess its severity and (5) the cultural and gender relations when interpreting traumatic events. 

We have also tried to look into the ways in which culture influences and regulates the perception of trauma. By providing a particular system of meanings, prescriptions, and beliefs culture becomes one of the major determinants of human behaviour. Therefore, trauma should not be seen or limited to the extent that it threatens the psychological balance of individuals. But more importantly, it should be recognized that trauma disrupts the adaptive capacity provided by the culture to its members.

In this overview, we suggest that to understand the cultural dimension of trauma it is necessary to determine (1) the type of relationship that living people establish with their dead loved ones and the ways in which war disrupts these relationships, and (2) the degree to which people believe that their well-being depends on the good performance of established ceremonies and rituals surrounding birth, marriage and death, and the ways in which the years of social, political and economic crises inhibit them from fulfilling these vital obligations.

These results are of great importance in the diagnostic process of trauma and post-war symptoms and for adequate assessment of local cultural interpretation of the sources of mental distress. Our findings suggest that a careful understanding of the complex ways in which individuals and their communities register traumatic experiences and socialize their grief are of vital importance to develop sensitive diagnostic instruments. For these reasons future studies across populations will have to translate local concepts of trauma and post-traumatic manifestation and add them to semi-structured questionnaires. This will create the necessary conditions to develop effective and combined strategies to help individual and their communities recover from war traumatic experiences in non-western societies.  

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