The Role Culture Plays in Veterans with PTSD

Abstract

Experiencing traumatic events can take a toll on an individual, both mentally and physically. The effects can be devastating to one’s quality of life and may even be associated with an increase in a variety of psychiatric symptoms. However, even when two people experience the same traumatic event, the reactions present can be vastly different. A number of variables may contribute to the array of reactions that may occur following the witnessing or experiencing of a traumatic event. The main variable that was examined in this paper was culture and the role it plays in the development of symptoms associated with posttraumatic stress disorder. Knowing the influence culture may have on the mental and physical health of individuals from diverse backgrounds can help to design and tailor assessment and treatment plans for a multicultural client population.

The Role Culture Plays in Veterans with PTSD

            Upon witnessing or being involved in a traumatic event, there are a number of reactions that take place. These may include both mental and physical effects that can have a lasting impact on one’s life. This paper will examine the role one variable, namely the cultural background of individuals  may play in the development, experience, and treatment outcomes of military members who have been diagnosed with posttraumatic stress disorder. Through gaining a deeper understanding of the role culture plays in the life of members from various cultural backgrounds, diverse populations within the military, as well as in the civilian population, can be better served. However, first, it would be helpful to identify the diagnostic criteria for posttraumatic stress disorder, as well as define what exactly culture is in regards to the influence it may have on psychiatric conditions such as posttraumatic stress disorder.

What is PTSD?

            The American Psychiatric Association has provided ample guidelines when it comes to diagnosing and treatment options for individuals who may meet the diagnostic criteria for posttraumatic stress disorder. According to the Diagnostic and Statistical Manual of Mental Disorders (APA, 2013), individuals who witness, hear about, or directly experience a traumatic event can develop symptoms of posttraumatic stress disorder, which may greatly impact the quality of life that is able to be achieved. Research into the impact traumatic events have on the population indicates that individuals can experience vicarious symptoms of posttraumatic stress disorder through watching the events on the news or other media outlets (Kilpatrick et al., 2013). As technology improves, so does the reach it has; the ability for it to permeate society through outlets such as cell phones and social media has allowed the impact to spread further than in previous generations.

Additional symptoms for diagnostic purposes include intrusive thoughts, flashbacks, nightmares, avoiding certain locations or thoughts that may trigger a reminder of the event, and negative thoughts (APA, 2013). Hyperarousal may also be present, which can manifest in symptoms of irritability and a low threshold for the startle response (APA, 2013). Within the military, posttraumatic stress disorder can mean an end to one’s chosen profession due to the emotional impact that the symptoms can have on one’s life (Steenkamp, Litz, Hoge, & Marmar, 2015). This may not only be limited to one’s military career, as veterans who have been deployed to a war zone may experience functional impairments, including higher rates of unemployment and income disparities, with some of the impacts of these impairments being present for several decades after the initial traumatic event (Steenkamp et al., 2015).

What is Culture?

            Culture can be a difficult thing to pinpoint, as it has the potential to influence just about every aspect of one’s life. For the purposes of the current review, culture will pertain to one’s ethnic background. Even that small section of culture can be quite vast, and when it comes to the military population, there may be an additional aspect of culture, namely the military culture, which, at times, can appear as a culture within a culture (Hajjar, 2014). Ethnicity can have a significant impact on the mental health of members from a variety of cultural backgrounds for a number of reasons (Ojeda & Bergstresser, 2008). Understanding the role culture plays in the mental health of military members will be one of the focuses of the current research paper.

Research Question

            In order to identify the role that culture may play in the development of posttraumatic stress disorder, as well as the treatment outcomes, the research question that guided the review of literature consisted of the following: “How do cultural variables affect the experience, assessment, diagnosis, and treatment of military veterans who have been diagnosed with posttraumatic stress disorder (PTSD)?” This research question helped in the collection of studies and research that has been conducted with aims to determine the potential sources of influence that culture plays in the development of symptoms that are consistent with posttraumatic stress disorder among military veterans.

Background and Significance

            Within the military population, as the number of wartime conflicts rise, so do the rates of posttraumatic stress disorder. This increase has been found to be present in both male and female military members, in active and reserve statuses. Research into the prevalence of posttraumatic stress disorder has suggested that the overall lifetime incidence in veterans may be as high as 30.9% (Richardson, Frueh, & Acierno, 2010). This high rate of symptoms associated with posttraumatic stress disorder that has been observed in military populations continues to remain one of the most frequently identified and treated psychiatric conditions in both male and female veterans (Ramsey et al., 2017). Due to the makeup of the military consisting of a population that comes from diverse cultural backgrounds, it is important to identify the role culture plays in the susceptibility, experience, diagnostic, and treatment stages of mental health care.

            The American Psychiatric Association (APA) has provided guidance for identifying the symptoms that are associated with numerous psychiatric conditions, including posttraumatic stress disorder. The guidelines that have been published in the Diagnostic and Statistical Manual of Mental Disorders (APA, 2013) are quite helpful for mental health professionals, however, the diagnostic criteria may not be adequately sensitive enough to account for some of the differences that may be attributed to the culture of the client. Although overlooking the role culture plays in the manifestation of various symptoms has not been done purposefully, the risk of not accounting for cultural influences in psychiatric conditions can, ultimately, place members of various cultural backgrounds at risk for missing out on quality mental health care and, thus, resulting in a lower quality of life.

Rates of PTSD Among Ethnic Minority Military Veterans

            Research into the variations that exist within the posttraumatic stress disorder diagnosis among different cultures has revealed that there is indeed a difference in regards to the race of the individual and the likelihood that he or she will develop symptoms that are associated with posttraumatic stress disorder. It has been found that members of ethnic minority groups often experience a greater level of posttraumatic stress disorder attributed to serving in combat positions (Ruef, Litz, & Schlenger, 2000). Thus, these military members and veterans may be at an increased risk for developing a number of psychiatric conditions, including posttraumatic stress disorder.

Some insight that has been gleaned from studying Vietnam era military veterans indicates that within this population of veterans, African American military members were more likely to develop symptoms of posttraumatic stress disorder when compared to Caucasian or White cohort veterans (Ramsey et al., 2016). Similar findings have been revealed when comparing Caucasian and Hispanic military veterans; Hispanic veterans have a rate of posttraumatic stress disorder diagnosis that is twice what is observed in Caucasian or White veterans (Ramsey et al., 2016). Additionally, it has been suggested that ethnic minorities may be more conflicted when it comes to participating in wartime activities. According to Penk et al. (1989), minorities who served during the Vietnam era had less to gain from participating in combat and military missions, while also being more likely to be incorrectly identified as the enemy, depending on the cultural background of the military member.

            Within the general, civilian population, the lifetime prevalence of posttraumatic stress disorder has been observed to be between 6.8 and 12.3% (Alegria et al., 2013). However, within this range, there are stark differences when the prevalence is broken down by race and/or ethnicity, with some members of the population being more prone to develop symptoms that are consistent with posttraumatic stress disorder. This difference observed when analyzing by race and/or ethnicity has been found to remain even after adjusting for a number of variables such as sociodemographic and social support (Alegria et al., 2013). When it comes to members of the military population, similar inconsistencies in the prevalence of posttraumatic stress disorder have been observed.

            The differences that have been noted in the rate at which posttraumatic stress disorder is diagnosed within various cultures, as well as the cultural interpretation and experience of the symptoms associated with the psychiatric condition will be discussed in the following section. Areas that will be explored further in respect to the diagnosis and treatment of veterans with posttraumatic stress disorder consist of African American, Asian American and Pacific Islander veterans, Hispanic Veterans, American Indian veterans who served during the Vietnam era, as well as Native Hawaiian and Japanese American veterans who served during the same time period. It should be noted that Caucasian and White cultures will not be discussed due to the overrepresentation of this ethnicity and cultural background in research on the topic of posttraumatic stress disorder and other psychiatric conditions.

African American Veterans

            Epidemiological studies have found that, even after adjusting for factors such as the extent of one’s combat experience and exposure to a traumatic event, African American military veterans have been found to have a greater incidence of posttraumatic stress disorder when compared to White or Caucasian veterans (Frueh, Elhai, Monnier, Hammer, & Knapp, 2004). One of the main differences in regards to the way in which the symptoms are experienced by African American veterans has been found to occur when utilizing the Minnesota Multiphasic Personality Inventory (MMPI-2) to clinically assess the symptoms present associated with posttraumatic stress disorder. African Americans were more likely to identify the experience of bizarre mentation as indicated on the MMPI-2 (Frueh et al., 2004), which corresponds to symptoms such as hallucinations and strange thought patterns (Hill, Pace, & Robbins, 2010).

            There have been a few theories that have attempted to provide a reason to why African American veterans are more likely to experience symptoms associated with posttraumatic stress disorder when compared to the rate observed in White or Caucasian military members. One such study took place in the aftermath of one of a traumatic natural disaster. In the wake of Hurricane Katrina, Davis et al. (2012) found that the rate of posttraumatic stress disorder symptoms was significantly higher in African American veterans (40%) versus Caucasian veterans (27%) who had experienced the same traumatic event. In studying the potential reasons for this difference in prevalence between the two groups of veterans (African American and Caucasian or White), it has been suggested that previous exposure to traumatic events, both prior to and during military service, contributes to the high rate of posttraumatic stress disorder that has been observed in African American military veterans (Davis et al., 2012).

Other theories have postulated that minority groups, such as African Americans, may experience a higher rate of traumatic events, with some of the trauma not being easily recognized such as discrimination and a lack of access to services (Davis et al., 2012). Experiencing discrimination is not just relegated to the pre-military service, as racism has been found to be present within the ranks of various military branches. Among Vietnam era African American veterans, the experience of racism during one’s military service, followed by a limited opportunity after the war in the civilian sector has been linked to an increased level of symptoms associated with posttraumatic stress disorder among this population of veterans (Allen, 1986; Ghafoori & Hierholzer, 2010). The experiencing of discrimination, traumatic events, and the sense of stigma surrounding seeking help for psychiatric disorders within the African American veteran community appears to be some of the main cultural-bound influences when it comes to the experience of the symptoms associated with posttraumatic stress disorder.

Asian American and Pacific Islander Veterans

            Although Asian Americans and Pacific Islanders make up a small percentage of the military population, it has continued to grow over time. Studies have indicated that approximately 1.5% of military veterans identified as being from an Asian American or Pacific Islander background, which is over one percentage point higher than it was in 2004 (Tsai, Whealin, & Pietrzak, 2014). Within the Asian American and Pacific Islander cultural label, there are more than 60 different ethnic groups that are commonly lumped together for the purposes of multicultural health research (Tsai et al., 2014). The Asian American culture consists of Chinese, Japanese, Korean, Taiwanese, Vietnamese, Thai, and Mongolians, among other groups, each of which has traditions and values that may influence the experience and risk factors for developing psychiatric disorders.

Likewise, there are several cultures under the heading of Pacific Islander, with many of them identified as traditionally warrior cultures. The cultural traditions held by Hawaiian, Samoan, Tongan, Chamorro, and Filipino cultures can serve as barriers to seeking care for mental health conditions (Chang & Subramaniam, 2008). This amalgamation of cultures can result in inaccurate data when it comes to some of the risk factors that members of these cultural backgrounds may possess in regards to psychiatric conditions such as posttraumatic stress disorder. Some culturally-based reasons for the higher rate of posttraumatic stress disorder among Asian American and Pacific Islander military veterans include racism, cultural norms and beliefs, and socio-histories (Yoneda, Whealin, & Tsai, 2015).

Asian American and Pacific Islander military veterans who served during Vietnam have been found to experience unique events when compared to their White or Caucasian service member cohorts. According to research, Asian and Pacific Islanders reported that the majority of service members had been mistaken for being Vietnamese by both their fellow military members, as well as Vietnamese residents (Loo, Singh, Scurfield, & Kilauano, 1998). This likeness to Vietnamese residents have been mentioned by Asian and Pacific Islander military members as influencing the way they were treated by both fellow military members and their commanding officers (Loo et al., 1998).

The race-related stress of being mistaken for the enemy during the Vietnam War makes this population of military veterans at risk for developing stress- or trauma-related psychiatric conditions, including and not limited to posttraumatic stress disorder. The “anti-gook” movement that occurred following the Vietnam war helped to fuel the racial prejudice towards Asian Americans who served during this time (Loo, 1994). The cumulative racism following serving in the military during the Vietnam War, as well as the bicultural identity held by members of the Asian and Pacific Islander cultures have been identified as a source of trauma, which can lead to the development of symptoms that are associated with posttraumatic stress disorder.

Hispanic and Latino/a Veterans

            Within the United States, the Latino and Hispanic sections of society are one of the most rapidly growing populations, accounting for 16.3% of the total population (Pittman, 2014). As the population of Latinos and Hispanics continues to grow, so does their representation within the various military branches. Recent reports have found that within the military population, Hispanics and Latinos comprise 12.3% of active duty members and 18% of the troops who have been deployed during Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn (Pittman, 2014). However, when it comes to the rate and severity at which Hispanic and Latino combat military members experience symptoms of posttraumatic stress disorder, the prevalence is disproportionate when compared to non-Hispanic Caucasian combat military members (Duke, Moore, & Ames, 2011). With the number of Hispanic and Latino military members being deployed and serving over the decades, as of 2010, over 1.3 million Hispanic and Latino individuals are military veterans (Pittman, 2014). However, the rate of various psychiatric disorders, including cluster A personality disorders, have been observed to be higher in this population of military veterans when compared to Caucasian or White military veterans (Pittman, 2014; Ghafoori & Hierholzer, 2010).

            Some theories to why Hispanic and Latino military veterans experience higher rates of posttraumatic stress disorder highlight the increased vulnerability that may be present in this population of veterans (Pittman, 2014). Additionally, some cultural factors may also contribute to the elevated rates of posttraumatic stress disorder that has been observed in Hispanic and Latino military veterans. According to Pittman (2014, p. 321), “wishful thinking and self-blame coping, low social support, perceived racism, expressive style and acculturation level, partially explained the higher prevalence of PTSD in Latinos.” Other research has indicated that the severity and type of symptoms present may differ from what other cultures experience. Duke et al. (2011) found that Latino veterans were more likely to report cognitive and sensory perceptions, which include flashbacks and hypervigilance, at higher rates than what is reported in non-Hispanic White military veterans. This would suggest that there are some culturally-bound vulnerabilities for this population of military veterans in regards to developing symptoms associated with posttraumatic stress disorder following exposure to a traumatic event.

            Due to the unique characteristics of the Hispanic and Latino culture that serve as an increased vulnerability, it can be difficult to accurately assess for the presence of symptoms that may be present in veterans who may have posttraumatic stress disorder. However, an additional challenge when it comes to the diagnostic process is that the cultural factors that may place a service member at risk of various psychiatric disorders is not shared across the number of Hispanic and Latino groups that fall under this cultural category (Pittman, 2014). This should serve as a reminder to treat each veteran as an individual that just happens to belong to a Hispanic or Latino cultural background. Despite these differences in the Hispanic and Latino cultural background, there are some shared experiences, including exposure to racism and discrimination during service, as well as the presence of fatalism that is a part of the Hispanic and Latino culture (Pittman, 2014).

            In addition to fatalism, there are a few other culturally-bound aspects that may place Hispanic and Latino at an increased risk for developing symptoms associated with posttraumatic stress disorder. The stress responses unique to the Hispanic and Latino culture include ataques de nervios, nervios, and susto, however, it should be noted that not all cultures that fall within the Hispanic and Latino cultures recognize these culture-specific stress responses (Center for Substance Abuse Treatment, 2014). Within the general population, Hispanics that were from a Dominican or Puerto Rican background were more likely than Hispanics from other backgrounds and non-Hispanic groups to experience symptoms of posttraumatic stress disorder following the terror attacks of September 11, 2001 (Galea et al., 2004).

The difference within the various cultures found within the Hispanic and Latino groups may be due to the presence of ataques de nervios, which has been associated with an increase in the rates of panic disorders, depression, and posttraumatic stress disorder and is often associated with Caribbean Latinos, but has been found to occur in other Hispanic and Latino populations (Galea et al., 2004; Guarnaccia et al., 1989). Ataques de nervios is characterized by a feeling of reduced control over one’s expression of emotions (Lewis-Fernandez et al., 2002). This symptom, in addition to crying, suicidal ideations, and episodes of verbal and/or physical aggression may be mistaken for some of the diagnostic criteria that are associated with posttraumatic stress disorder, which may place this population of veterans at risk for an incorrect diagnosis due to the similarities in both conditions (National Institute of Mental Health, 2001).

            In regards to racism, 11% of Hispanic veterans who served during Vietnam reported experiencing discrimination while serving (Reuf et al., 2000). Of those who affirmed that they were the target of discrimination or racism, over 7% of these veterans stated that they felt that they were placed into harm's way and selected for dangerous duty positions while serving in Vietnam due to their cultural background (Reuf et al., 2000). Although the rate of reported discrimination was higher among African American military members (26%), the impact of discrimination based on having a Hispanic or Latino cultural background can be far reaching and impact every aspect of one’s life, including the physical and emotional safety while serving in the military (Reuf et al., 2000).

Some research has suggested that when discrimination is experienced, Hispanic and Latino Vietnam veterans were found to have higher rates of posttraumatic stress disorder when compared to African American Vietnam veterans who also experienced discrimination (Reuf et al., 2000). This would support the concept that greater exposure to combat, in combination with unequal treatment and the presence of discrimination, places Hispanic and Latino veterans at a higher risk of developing symptoms that are associated with posttraumatic stress disorder when compared to non-Hispanic White military veterans.

American Indians (Vietnam Era)

            Similar to the differences that have been identified when it comes to various cultural backgrounds and the experience and treatment challenges associated with posttraumatic stress disorder, members of the American Indian population who served during the Vietnam Era also have had a unique experience when it comes to this, and other, psychiatric conditions. In a study highlighted by Holm (1995), 80% of American Indian Vietnam veterans reported that they experienced symptoms of depression on a frequent basis, with nearly the same number of veterans experiencing sleep disturbances, rage, and flashbacks, with many of these veterans developing substance abuse disorders as a way to cope with their symptoms. Other studies have identified one in three American Indians who served during the Vietnam War era still experienced symptoms associated with posttraumatic stress disorder, even decades after leaving the service (McMurray-Avila, 2001). These symptoms can greatly influence the quality of life that is able to be achieved by this population of veterans through the difficulty they present during the adjustment back to civilian life.

            During the Vietnam War era, Native Americans comprised a disproportionate number of military members, particularly within combat positions (Holm, 1995). This is thought to be due to the fact that during this period, the Native American population was relatively young, and thus, were recruited by the military service. Serving in the military was also lucrative to the Native American population, particularly due to the high levels of unemployment experienced by this population, which was, in part, influenced by the low level of educational attainment achieved by the young members of the Native American tribes (Holm, 1995). The lack of education also meant that Native Americans were more likely to serve in non-technical, combat positions, exposing them to traumatic events that could serve as a trigger for the symptoms associated with posttraumatic stress disorder.

In addition to having an increased exposure to traumatic combat experiences, Native American service members also experienced discrimination from the commanding officers who were tasked with overseeing combat exercises. This type of behavior aimed at Native Americans during the Vietnam War, which was not directed towards other minority groups, at least to the extent that was experienced by Native American service members, also increased their likelihood of becoming wartime casualties (Holm, 1995). This additional stress experienced by this population of service members also served as a reminder to the conflict that occurred between the ancestors of the Native American service members and Whites when they first arrived in the United States.

Many Native American service members turned to their tribal traditions in order to cope with the symptoms that they experienced due to the traumatic events that they were exposed to during wartime combat. However, in a clinical setting, the traditions that Native American veterans engage in may not be recognized as being appropriate since they differ from some of the evidence-based practices that serve as the backbone to mental health treatment (Gone & Trimble, 2012). This can result in treatment disparities in the areas of substance abuse, suicide prevention, and posttraumatic stress disorder for Native American veterans (Gone & Trimble, 2012). Culture-bound barriers to care, such as the stigma and public perception about mental illness and help-seeking for psychiatric conditions within the Native American veteran population have also hampered sufficient treatment and care for mental health needs (Vogt, 2011).

Native Hawaiian and Americans of Japanese Backgrounds (Vietnam Era)

            The final cultural group that will be reviewed in this current paper consists of the Native Hawaiian and Americans of Japanese cultural backgrounds who served during the Vietnam War era. Research that has been conducted in an attempt to understand the unique aspects that these cultural groups experience revealed that both Native Hawaiians and Americans who are of Japanese backgrounds may be prone to some unique experiences during their service (Schnurr, Lunney, Sengupta, & Waelde, 2003). With the help of the Matsunaga Vietnam Veterans Project, a large amount of data has been collected in regards to the relationship between culture and posttraumatic stress disorder among military veterans (Schnurr et al., 2003). Similarly, the Hawaii Vietnam Veterans Project has highlighted the unique military experiences and cultural influences experienced by Native Hawaiian veterans.

            Some of the key points that were discovered when examining the unique experiences, cultural influences, and barriers experienced by Native Hawaiians who served during the Vietnam War era have helped to shape the treatment, assessment, and evaluation processes that are in use today. For example, research has indicated that Native Hawaiians experienced high levels of combat exposure while serving during the Vietnam War, which resulted in high levels of posttraumatic stress disorder, with the prevalence greater than what was observed in White/Caucasian and Japanese Americans (Friedman, Schnurr, Sengupta, Holmes, & Ashcroft, 2004). It has been found that over half of the Native Hawaiians who served at least one tour in Vietnam experienced trauma that was directly related to being deployed in a war zone (Friedman et al., 2004). The emotional and mental turmoil that occurred during first deployments was severe enough, for some Native Hawaiians, to desire to return for a second tour with a wish to die while in combat (Friedman et al., 2004). The toll of combat was, in essence, severe enough for some military members who came from a Native Hawaiian background, among others, where death in a combat setting was more lucrative than the thought of living as a civilian back home.

            When it comes to Japanese American veterans who served during the Vietnam War era, the number of veterans who developed symptoms of posttraumatic stress disorder were on par with the White/Caucasian veteran population, which is lower compared to the rates of posttraumatic stress disorder observed in the Native Hawaiian community of veterans (Hamada, Chemtob, Sautner, & Sato, 1988). This might be due to the lower level of exposure to traumatic events while serving in the military during the Vietnam War era, which was contributed, at least in part, to the higher level of education and placement in military officer roles, which was not common among the Native Hawaiian veteran population. However, this is not to say that Japanese Americans who served during the Vietnam War era were able to escape combat unscathed, as many experienced discrimination and racial prejudice due to the fact that they were Asian (Hamada et al., 1988). The fear associated with not knowing if your fellow soldiers truly “had your back” led to a near constant fear for one’s physical safety for those who were not placed into military officer roles.

            When it comes to culturally-bound symptoms that might mirror some that are present in posttraumatic stress disorder, the interpersonal fear known as taijin kyofusho, which is characterized by symptoms associated with anxiety, including avoidance behaviors (Center for Substance Abuse Treatment, 2014). The American Psychiatric Association (APA) recognizes this culturally-bound condition and has included it in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). However, it should be kept in mind that taijin kyofusho is a separate diagnosis from posttraumatic stress disorder, but the overlapping symptoms can make it difficult to accurately diagnose in Japanese American Vietnam War veterans.

Multicultural Considerations and the PTSD Assessment Process

            The military population is continuing to grow as a diverse population within a population, where both men and women from a variety of cultural backgrounds come together for the support of a single mission within the armed services. When working with a multicultural population, whether within the military or veteran population, as well as within the civilian realm, there are a number of challenges that may exist in utilizing a uniform approach in the assessment process for posttraumatic stress disorder diagnostic purposes. Using a “carbon copy” approach, ignoring the culturally-bound symptoms, unique experiences, and challenges to treatment-seeking behavior can place a large population of clients at risk of incurring further mental distress due to such a homogenous approach. Ignoring the cultural background of a client can greatly affect the quality of life achievable, which can also influence the health of society on a larger scale.

The Surgeon General has recognized the need for utilizing culturally appropriate assessment tools within the mental health field (Spendlove, Jackson, & Borrego, 2009). When there is a lack of culturally appropriate screening and assessment tools, it has been shown that minority populations are less likely to have access to psychiatric and counseling services, will be less likely to obtain interventions, receive a lower quality of care when they are able to obtain treatment, and they may experience stigma that is attached to receiving or seeking treatment of mental health needs (Spendlove et al., 2009). In response to the recognition of the various considerations that should be taken during the assessment process, a number of tools have been developed to use in a multicultural military population.

Challenges

            There are several challenges that have been noted in the literature when it comes to the assessment process in a multicultural setting in regards to accurately identifying and diagnosing posttraumatic stress disorder in military veterans. For instance, in the Hispanic and Latino culture, the help- or treatment-seeking behavior of this population of veterans, the cultural barriers in place may prevent many, particularly Latino veterans who reside in rural locations, from obtaining help for the symptoms being experienced (Duke et al., 2011). Additionally, when the veteran resides in a rural location, regardless of his or her cultural or ethnic background, there may be structural or socio-cultural barriers that work to reduce the likelihood of the veteran from obtaining mental health counseling services when compared to their urban dwelling cohorts (Duke et al., 2011).

            It appears that simply belonging to an ethnic minority may place some veterans at a higher risk for having the symptoms of psychiatric conditions, including posttraumatic stress disorder, go untreated. Research conducted by Roberts, Gilman, Breslau, Breslau, and Koenen (2011) found that African American males and Hispanic females were more likely to experience war-related traumatic events than White/Caucasians, but were less likely to seek out treatment for their symptoms, even if they impaired their daily activities. The lack of treatment seeking behaviors for minority groups highlights the need for culturally-sensitive assessment and treatment options to be developed and utilized when working with multicultural populations, such as that present in the military.

            For some clients who come from ethnic minority backgrounds, it can be difficult for them to open up and discuss personal information, such as the experiences they had while in the military and the symptoms and distress that are currently impairing their ability to enjoy life. One method that has been suggested to help in this issue is through matching cultures between the veteran client and the clinician working with them during the assessment and treatment phases of care (Rosenheck, Fontana, & Cottol, 1995; Lester, Resick, Young-Xu, & Artz, 2010). Research has indicated that when there is a discordance between the client and counselor ethnic backgrounds, there is a greater likelihood that the client will not complete the course of treatment when receiving care for symptoms associated with posttraumatic stress disorder (Lester et al., 2010). This was found to be true even after income and education levels were assessed. Similar findings were presented by Rosenheck et al. (1995), with the largest effect occurring when the veteran is an African American who is working with a White/Caucasian clinician. This should serve as a reminder for mental health professionals who work with veterans during the initial screening and assessment steps to be cognizant of the perceptions held by some veterans regarding race and ethnicity when there is a discrepancy between the culture of the veteran client and the mental health professional conducting the screening, assessment, and treatment.

            A mismatch between client and counselor race and/or ethnicity can also affect the ability to build a therapeutic alliance during treatment for posttraumatic stress disorder, particularly among racial and ethnic minority veteran populations (Koo, Tiet, & Rosen, 2016). It can also lead to a lower level of treatment expectancies, which can greatly influence the outcome of treatment (Koo et al., 2016). During the assessment process, steps should be taken to match race or ethnicity between the client and the counselor, as this can help to improve the likelihood that the veteran will continue on with treatment for their symptoms associated with posttraumatic stress disorder. However, it may not always be possible, depending on the demographics of the staff members, but steps should be taken to ensure that the facility is capable of working with a diverse multicultural population of veterans.

Making Assessments Sensitive to Multicultural Populations

            One step that has been taken to better understand, thus increase the likelihood of making accurate assessments of mental disorders, was through the Matsunaga Vietnam Veterans Project, which aimed to examine the unique challenges faced by the multicultural population of the military. The focus of the Matsunaga Vietnam Veterans Project was to gain a better understanding of the challenges experienced in regards to readjusting after being deployed to a combat mission, as well as examining why minority groups, specifically American Indian, Japanese American, and Native Hawaiian veterans, experience higher rates of posttraumatic stress disorder (Keane, Marshall, & Taft, 2006). Studies, such as the Matsunaga Vietnam Veterans Project have helped to bring about an increase in the understanding of the challenges faced by certain minority populations in regards to mental health needs within the military.

            When taking the steps required for ensuring that the assessment process is sensitive to the cultural backgrounds of the clients, the cultural beliefs of clients, including complications that may arise due to culture-specific issues, as well as treatment resistance, should be kept in mind due to the influence these aspects can have on treatment, including the initial assessment and screening steps (Spendlove et al., 2009). Spendlove et al. (2009) highlights the tendency for some clients who fall within an ethnic minority category are more likely to be overdiagnosed or incorrectly diagnosed with certain conditions, such as a substance abuse disorder and alcoholism within the Native American and African American populations, which might be a symptom of posttraumatic stress disorder rather than strictly a substance abuse condition.

The APA has taken notice to the influence that culture can have on the assessment process for clients with posttraumatic stress disorder. However, as pointed out by Rosen, Spitzer, and McHugh (2008), there is still a tendency within the mental health field to medicalize symptoms that may be better explained as a normal reaction for an individual who has experienced or witnessed a traumatic experience. Despite this “criterion creep” of symptoms, there have been some meaningful gains in regards to assessment tools that are sensitive to the needs of a multicultural client base. Two assessment approaches have been indicated as being effective when working with a multicultural population who may meet the diagnostic criteria for posttraumatic stress disorder.

The Cultural Formulation Model (CFM)

            In order to provide a culturally sensitive assessment for the purposes of identifying symptoms that may indicate the presence of posttraumatic stress disorders, a framework has been outlined that aim to improve clinical assessments. The Cultural Formulation Model has been proposed as an effective method for assessment when using the Diagnostic and Statistical Manual for diagnostic purposes of posttraumatic stress disorder in a multicultural client population (Fortuna, Porche, & Alegria, 2009). The previous assessment tools have not been adequately sensitive to the unique issues experienced by veterans who fall within minority categories, such as discrimination based on one’s skin color (Fortuna et al., 2009).

The CFM, which was developed by the National Institute of Mental Health, asks mental health professionals to take five key components into account when assessing clients who may have symptoms that are consistent with posttraumatic stress disorder. These aspects include the cultural identity of the client, how his or her culture may explain the symptoms and disorder, the cultural factors that may influence the level of functioning within his or her psychosocial environment, the cultural factors that are present in the client-counselor relationship, and finally the role and impact the culture of the client can have on both the diagnostic and treatment realms (Fortuna et al., 2009). Despite the appearance and research supporting the use of the CFM for use in a multicultural environment, it remains underutilized in mental health settings for assessing for the presence of symptoms associated with posttraumatic stress disorder.

Harvard Trauma Questionnaire (HTQ)

            During the early 1990s, there was a lack of assessment tools that took client cultural backgrounds into account when assessing clients for posttraumatic stress disorder. As a result, the Harvard Trauma Questionnaire, or HTQ, was introduced to the toolbox of assessment procedures to address this lacking aspect of assessment and treatment care planning (Mollica et al., 1992). The HTQ has been described as a “simple and reliable screening instrument that is well received” when working with a multicultural staff and client population (Mollica et al., 1992, p. 111). A more recent study examining the use of the HTQ in Iraqi refugees provides additional support for the use of this culturally sensitive screening assessment tool when working in a multicultural environment (Shoeb, Weinstein, & Mollica, 2007).

            The HTQ consists of five parts that have been shown in research to be effective in identifying symptoms of posttraumatic stress disorder with clients from diverse cultural backgrounds (Shoeb et al., 2007; Mollica et al., 1992). The concepts that are included in the HTQ include a review of the traumatic events, the description of the event by the client, the assessment for any brain injury that might be present as a result of the traumatic event, the symptoms present that are associated with the diagnostic criteria for posttraumatic stress disorder, and the scoring of the assessment (Shoeb et al., 2007). Since the inception of the HTQ, several versions, including Cambodian, Laotian, Japanese, Vietnamese, and Croatian translations have been found to be effective at identifying the symptoms of posttraumatic stress disorder (Shoeb et al., 2007). The effectiveness of the HTQ in different cultures highlights the applicability of this key assessment tool in a multicultural setting, such as the population seeking mental health services within the veteran population.

Treatment for PTSD in Multicultural Populations

            Many cultures have traditions and ceremonies that can be traced back for generations as ways to cope with the symptoms that are currently associated with various psychiatric conditions. For example, Native Americans have utilized a number of ceremonies to assist Vietnam Era veterans who returned from combat with symptoms that are recognized as being consistent with posttraumatic stress disorder within the mainstream mental health community. A number of ceremonies and rituals Vietnam Era Native Americans have pursued as alternatives to more traditional treatment options have been shown to be helpful, but are not viewed as effective therapies within the mainstream mental health realm.

Four ceremonies that have been a part of the Native American tradition, specifically within the Vietnam Era veterans include the homecoming ritual, the ceremonial fire, tree planting, and attending a sweat lodge ceremony (Johnson, Feldman, Lubin, & Southwick, 1995). Other ceremonies include the Gourd Dance and the Red Feather ritual, both of which are highly respected practices within the Native American community (Johnson et al., 1995). However, due to the culture-specific nature of these rituals, there is a lack of evidence-based studies and protocols for carrying out these types of interventions for veterans from other cultures for the treatment of symptoms associated with posttraumatic stress disorder.

Within the realm of modern, mainstream mental health treatments, there are a number of therapeutic interventions that have been indicated as being effective at addressing the symptoms of posttraumatic stress disorder across a variety of cultures. For example, prolonged exposure has been shown to be effective when used for veterans from African American, Spanish-speaking Hispanic and Latino, as well as Japanese Americans who have been diagnosed with posttraumatic stress disorder (Williams et al., 2014; Vera et al., 2011; Asukai, Saito, Tsuruta, Kishimoto, & Nishikawa, 2010). Likewise, cognitive processing therapy has also been recommended as an effective method of treatment for use in a multicultural setting (Laska, Smith, Wislocki, Minami, & Wampold, 2013). However, these two approaches for treatment in no way are the only two that have been found to be effective when working in a multicultural veteran population.

Prolonged Exposure

            When there is a discordance between the counselor and the client, treatment outcomes have been shown to be impacted, often to the detriment of the client’s mental health. Some studies have indicated that the presence of discrimination and/or racism, either prior to or during the event that served as the trigger for the symptoms of posttraumatic stress disorder, can increase the severity of the symptoms experienced by the client (Williams et al., 2014). However, when cultural adaptations to treatment are utilized, it can lead to a successful treatment outcome, even when there is a mismatch between client and counselor (Williams et al., 2014).

Adaptations can help to make cognitive behavioral approaches, including the evidence-based prolonged exposure intervention, more effectively in a multicultural patient environment. Some of the adaptations to the prolonged exposure intervention include the use of additional sessions at the beginning of treatment which can help to establish rapport, inquiring directly about culture-related themes during the course of the assessment and treatment stages, as well as speaking openly about any race-related events or discrimination that the client has experienced when appropriate in regards to the event or events that may have triggered the development of symptoms that are associated with posttraumatic stress disorder (Williams et al., 2014).

Cognitive Processing Therapy

            In addition to prolonged exposure, cognitive processing therapy has been shown to be an effective method for addressing the symptoms of posttraumatic stress disorder when working with a multicultural population. When cultural adaptations are made, cognitive processing therapy has been shown to be an effective intervention in diverse client populations, including Bosnian refugees (Schulz, Huber, & Resick, 2006), African American, and Hispanic and Latino cultural backgrounds (Horrell, 2008). However, even when adaptations are made to make the treatment appropriate for various cultures, it is still important for the counselor to be culturally competent in order to increase the likelihood that the client will experience a beneficial and positive treatment outcome.

Conclusion

            As indicated by the body of research that has been covered in this paper, it is evident that working with the military population in regards to mental health, appropriate cultural adaptations need to be taken to adequately care for this multicultural population. Many cultural groups have unique experiences during their military service, both veterans of the most recent conflicts, as well as those who served during the Vietnam War era. If these adaptations are not made to the screening and assessment processes, many cultural groups run the risk of being misdiagnosed, leading to an ineffective treatment approach.

            Research has supported the use of various treatment options for the purposes of addressing the symptoms of posttraumatic stress disorder in a multicultural patient population, such as that found within the military. However, clinicians working with a diverse group of veterans need to keep in mind the role culture plays in the assessment, diagnosis, and treatment aspects of mental health, including posttraumatic stress disorder. Based on the material that has been published on the unique experiences encountered by African American, Asian American, Pacific Islander, Hispanic, American Indians, Native Hawaiian, and Americans of Japanese backgrounds who served during various times in the military, mental health professionals need to be truly culturally competent in order to identify and address the mental health needs of this diverse population of veterans.

** References Available Upon Request **