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 **
