Hispanic Veterans Diagnosed With PTSD: Assessment And Treatment Issues
By Jose M. Canive, M.D. and Diane Castillo, Ph.D.
NCP Clinical Quarterly 7(1): Winter 1997
American psychotherapists tend to depart from an ethnocentric or Western-centric point of view. According to Kinzie (1), "Mental health professionals are dominated by value systems of clinical humanistic psychology which promote self-aggrandizement and self-satisfaction, autonomy and rejection of authority, relativity in values, situational ethics, apology (rather than restitution), and avoidance of long-term relationships and responsibility." These values, which can be construed as American therapists’ cultural countertransference, often differ from the values of Hispanics or other ethnic minorities, and can pose major treatment obstacles.
This article begins by establishing the relevance of the topic and follows with a brief description of the salient features of Hispanic cultures, as a basis for discussing important considerations in the assessment and treatment of Hispanic veterans. A warning about generalizations and the pitfalls of cultural stereotyping concludes the discussion.
Topic Relevance
Hispanics are the fastest growing minority group in the United States. In 1993 they constituted 10% of the total population. It is expected that by the year 2000 the Hispanic population in the U.S. will increase to 40 million, becoming the largest minority group. Ethnic minorities were overrepresented in all the wars. Hispanics were the second largest American minority in Vietnam, with over 19% killed or wounded (2). Furthermore, according to the National Vietnam Veterans Readjustment Study (3), 29% of the Hispanic Americans who went to Vietnam at some point in their adult lives met the full diagnostic criteria for PTSD, in comparison to a lifetime prevalence rate of 20% and 14% for African Americans and White European Americans, respectively.
Salient Features Of Hispanic Culture
Culture refers to the customs, shared beliefs and social organization of a people. More colloquial, and paraphrasing Bock (4), culture is what makes us strangers in a foreign country. Culture is what constitutes a people’s world of meanings. Hispanics’ worldviews derive from three main sources: Spanish-European, Native groups from North and South America, and from Africa, mostly from the Yoruba tribe (today’s South Nigeria [5]). Differences in worldviews are increased by a number of factors, including patterns of migration, age of migration, level of acculturation, socioeconomic status, education and occupation (6). In spite of the heterogeneity of Hispanic minorities in the United States, there are similarities in the organizations of their local worlds. Language, familism and spirituality are facets of Hispanic culture which may affect the clinical encounter.
Language
Community studies have found that 70% to 83% of Hispanics preferred to be interviewed in Spanish (7). Furthermore, 47% of the Mexican American respondents to the National Institute of Mental Health (NIMH) Epidemiological Catchment Area Survey (ECA) completed the interview in Spanish (8). Several studies have shown that Spanish-speaking patients with limited English proficiency are rated as having greater psychopathology when interviewed in English (9). The patient’s general attitude towards the clinician, his motor activity, speech, affect and sense of self are strongly influenced by the degree of language compatibility. For example, Hispanic veterans oftentimes abruptly switch from English to Spanish when anxious or when expressing strong emotions. This "language mixing" can not only annoy the inexperienced clinician but may make the patient’s speech appear confused and his thinking illogical.
Familism
Another common characteristic of Hispanic culture is the individual's reliance on the family. Marin and Van Oss Marin (10) include under the characteristic, familism, three types of value orientations: 1) family members are expected to provide material and emotional support to each other; 2) family members expect to rely on others in the family; and 3) family members perceive their relatives as examples of proper conduct and good attitudes. In the clinic setting, this family interdependence may be interpreted as a sign of lack of motivation for treatment when the patient expresses the need to consult with his family prior to making a treatment decision (11). Similarly, 40 and 50 year old Hispanic war veterans, who live with their elderly parents, may be labeled as dependent and weak, when they are only adhering to traditional family values. Appointments canceled to attend family functions appear unjustified and are often interpreted as resistance to treatment, unless the values inherent in the Hispanic extended family system are considered. Given the typical lack of geographic mobility and the large size of many veterans’ families, the loss through death of family is multiplied. Thus, PTSD symptomalogy in Hispanic veterans is sometimes triggered by their relatives deaths, which sometimes leads therapists to question the veracity of veterans' stories. Mothers, worried about the suffering of "mi hijito" (my baby), may inadvertently enable their son to self-medicate or otherwise sabotage treatment efforts. This family overinvolvement can be a hindrance to treatment when not addressed appropriately; however, the benefits of unconditional family support also can not be ignored. Educating and involving parents and significant extended family members in treatment decisions, if not in therapy itself, is of great clinical importance.
Spirituality
Another commonality among Hispanics is the value placed on spirituality, defined as a sense wholeness, inner peace, interconnection and reverence for life (12). These values may be expressed through organized religion and belief in a higher power, particularly through Roman Catholicism, but also through personal ideologies and folk religions. Spirituality summarizes the ideals that family life must fulfill. The clinical relevance of this religious orientation can be seen in the impact that numerous Catholic rituals have throughout the life cycle: baptism, confirmation, First Holy Communion, marriage and death. These religious events are occasions to strengthen family relationships and to extend family boundaries by including close friends, in the role of "compadres," within the "bosom of the family." Outside the Catholic religion, Hispanics often express their beliefs in a Higher Power through their reliance on folk healers (curanderas among Mexican Americans, spiritualists among Puerto Ricans and santeras among Cuban Americans). These traditional healers represent the fusion of American Indian or African spiritual beliefs with Catholic faith. Hispanic veterans attending our PTSD program often seek the support and remedies of the curanderas, although mostly in secret. This strong cultural-spiritual orientation has led us to include some quasi spiritual rituals in the treatment program. Patients oftentimes are encouraged to light candles on anniversary dates. During the last week of intensive treatment, they are led on a pilgrimage to the Angel Fire Vietnam Veterans Memorial and instructed, prior to the journey, to write letters expressing feelings about their traumatic events. At the Memorial Chapel they light candles and read their letters and eventually burn them at the end of the ceremony, symbolizing the cleansing and purification of their inner beings.
Assessment Issues
Among many issues cited in the literature the following seem particularly important to address when evaluating veterans: self-disclosure; idioms of distress and the cultural validity of structured interviews, self-rating scales and psychological tests.
Self-Disclosure
Traditional Hispanic cultures socialize the individual to confide in family members and to not disclose intimate emotional problems to strangers (11). In addition, men learn that issues and concerns related to sex and aggression should not be discussed with women. Therefore, veterans’ common reticence to disclose details of their military history is heightened among Hispanics. A longer period of time to establish "confianza" (trust) is required prior to disclosure of traumatic events (6). Moreover, Hispanic veterans may not disclose significant details of their traumas to women therapists due to shame and because traditional Hispanic male socialization patterns emphasize male superiority and its responsibilities as financial and emotional providers and protectors of family members, especially women.
Cultural Explanations Of Illness
Conceptions of illness and symptom expression are culturally bound (13). Hispanic veterans with PTSD may express their symptoms and social support needs through a number of idioms of distress. Perhaps the most common idiom of distress invoked by Hispanics is somatization (14-16). A number of our Hispanic patients present with a variety of somatic complaints which sometimes mask their PTSD symptomatology or at least raises questions about their correct diagnosis. Another frequently utilized idiom is "nervios" (17) a state of vulnerability to stress characterized by irritability, inability to concentrate and dizziness among other symptoms. Hispanic patients often seek illness explanations in the supernatural. For example, it is not uncommon for Hispanics to attribute their illness to "susto", a frightening event which causes the soul to separate from the body (18). Similarly, being hexed or "embrujado" serves to explain a wide variety of symptoms (19). Patients seldom reveal their explanatory models of illness spontaneously, instead they need to be elicited by the clinician. Understanding the patients idioms of distress and explanatory models may be crucial to arriving at a correct diagnosis and to establishing a therapeutic relationship which includes the patient’s conception of the clinical reality.
Cross-Cultural Validity Of Assessment Measures
No assessment measure or psychological test is absolutely culture free (20). Standardization of PTSD structured interviews and self rating scales with Hispanic populations is clearly needed, since most measures have been developed in Anglo society with a theoretical base anchored in a Western viewpoint of psychopathology. Further, idioms of distress and conceptions of illness frequently invoked by Hispanics are not included in the existing questionnaires (21). Prior research with the MMPI indicates that ethnic minorities score as more pathological on several clinical scales (22). Nonetheless, retrospective data from our clinic reveal no significant differences between Anglos and Hispanics on the MMPI 2, except for attenuated PTSD scale scores among Hispanics with current alcohol abuse (23). However, conclusions made with non-standardized measures should be made with caution.
Following Hinton and Kleinman (24) we propose the following guidelines to arrive at diagnosis and at a culturally appropriate formulation: 1) be empathic from the beginning and elicit the veteran’s ideas about his suffering; 2) assess the patient’s illness experience within his socio-cultural context: Family, Work, Health Care System, and Local Community; and 3) arrive at a diagnosis utilizing not only DSM-IV categories but the veteran’s cultural idioms of distress. In addition, clinicians’ diagnostic consensus, following a thorough review of testing results, self-rating scales and structured interviews, is paramount.
TREATMENT CONSIDERATIONS
Crisis Orientation
Hispanics tend to seek services during crisis periods and may abruptly discontinue treatment when the emergency abates. This crisis orientation is not resistance to treatment but may be related to socioeconomic difficulties (6) and the Hispanic male belief that seeking help denotes weakness. It must also be noted that low-acculturated Hispanics are not psychologically minded (25). This common problem may be partially addressed through patient and family education and assertive case follow-up, hoping to establish a therapeutic alliance. A more comprehensive approach would include the development of alternative treatment strategies more compatible with Hispanics’ world view and socioecological realities (26).
Direct Advice
The scientific literature also describes Hispanics as being more amenable to advice and counsel rather than insight-oriented therapy. Thus, cognitive behavioral therapies which provide specific instructions on "how to" may be better suited than individual insight oriented psychotherapy for this population.
Negotiation of Explanatory Models
Therapists need to negotiate treatment with their veterans based on the explanatory models veterans and their families adhere to. It is senseless to expect patients to accept therapists' models of causality and embrace "scientific" conceptions of illness when they have been socialized to believe that their illness may be caused by being "embrujado" (hexed), suffering from "susto" or being punished for their sins. Instead, it is important to elicit and respect their beliefs while describing professional explanatory models and openly considering referral to religious authorities and folk healers, if deemed appropriate.
Cultural adaptation of program content and context
The service delivery format can be enhanced to attract and keep Hispanic veterans in treatment through providing a casual atmosphere in the clinic geared to facilitate the development of "confianza" (trust) and by including extended family members in treatment. In general, mental health professionals can accentuate emotional responsiveness to faciliatate therapeutic engagement, since interpersonal distance may be increased by those Hispanics who believe in submissiveness to authority. Showing Hispanic veterans "respeto" (respect), "dignidad" (dignity) and "carino" (caring) are essential to the therapeutic process.
Similarly, adaptation of the program content needs to be considered. For example, folk explanations of illness should be discussed during the psychoeducational phase of treatment. Family overinvolvement may be reframed as devoted concern for the patient and not labeled as treatment intromission. Powerful metaphors to utilize in therapy may be found in the often colloquially used Spanish sayings or proverbs ("dichos o refranes") (27). Also, commonly used skill training modules should be scrutinized and adapted for use with Hispanic veterans. Finally, it is recommended that clinical team members engage in simple cultural sensitivity exercises, as those proposed by Pinderhughes (28), to increase awareness of their cultural heritage and to better understand cultural differences.
In closing, the heterogeneity of Hispanics should be recognized by therapists working with combat veterans. The information presented here can be a useful framework by which to formulate hypotheses to be tested in actual clinical work.
References
1. Kinzie, D. (1985). Cultural aspects of psychiatric treatment with Indochinese patients. American Journal of Social Psychiatry 1, 47-53.
2. Pina, G. (1985). Diagnosis and treatment of PTSD among Hispanic Vietnam veterans. In S.M. Sonnenberg, A.S. Blank Jr. & J.A. Talbott (Eds.), The trauma of war: stress and recovery in Vietnam veterans. Washington D.C.: American Psychiatric Press, pp. 389-402.
3. Kulka, R.A., Schlenger W.E., Fairbank, J.A., Hough. R.L. Jordan B.K., Marmar C.R. & Weiss D.S. (1990). Trauma and the Vietnam war generation: Report of findings from the National Vietnam veterans readjustment study. New York: Brunner Mazel.
4. Bock, P.K. (1970). Culture shock: a reader in modern cultural anthropology. New York: Knopf.
5. Ramirez, M. (1991). Psychotherapy and counseling with minorities: A cognitive approach to individual and cultural differences. New York: Pergamon Press.
6. Rosado, J.W., Jr. & Elias, M.J. (1993). Ecological and psychocultural mediators in the delivery of services for urban, culturally diverse Hispanic clients. Professional Psychology: Research and Practice, 24, 450-459.
7. Lang, J.G., Munoz, R.F., Bernal, G., & Sorensen, J.L. (1982). Quality of life and psychological well-being in a bicultural Latino community. Hispanic Journal of Behavioral Science, 4, 433-445.
8. Karno, M. (1194). The prevalence of mental disorder among persons of Mexican birth and origin. In C. Telles and M. Karno (Eds.). Latino mental health: Current research and policy perspectives (pp. 3-16). Washington, D.C.: U.S. Department of Health and Human Services.
9. Marcos, L.R., Alpert, M., Urcuyo, L., & Kesselman, M. (1973). The effect of interview language on the evaluation of psychpathology in Spanish-American schizophrenic patients. American Journal of Psychiatry, 130, 549-553.
10. Marin, G., & Van Oss Marin, B. (1991). Research with Hispanic populations. Applied Social Research Methods Series, 23. London: Sage.
11. Koss, Chioino, J.D. & Canive, J.M. (1996). Cultural issues in relational diagnosis: Hispanics in the United States. In F. Kaslow (Ed.). Handbook of relational diagnosis and dysfunctional family patterns (pp. 137-151). New York: John Wiley and Sons, Inc.
12. Cervantes, J.M., & Ramirez, O. (1992). Spirituality and family dynamics in psychotherapy with Latino children. In L.A. Vargas & J.D. Koss-Chioino (Eds.). Working with culture (pp. 103-128). San Francisco: Jossey Bass.
13. Huges, C.C. (1993). Culture in clinical psychiatry. In A.C. Gaw (Ed.). Culture, ethnicity and mental illness (pp. 3-42). Washington, D.C.: American Psychiatric Press, Inc.
14. Kleinman, A. (1986). Social origins of distress and disease.. New Haven: Yale University Press.
15. Escobar, J.I., Burman, A., & Karno, M. (1987). Somatization in the community. Archives General Psychiatry, 44, 713-718.
16. Escobar, J.I., Canino, G, & Rubio-Stipec, M. (1992). Somatic symptoms after a natural disaster: A prospective study. American Journal of Psychiatry, 149, 965-967.
17. Jenkins, J.H. (1988). Ethnopsychiatric interpretations of schizoprenic illness: The problem of nervios within Mexican American families. Culture, Medicine and Psychiatry, 12, 301-329.
18. Rubel, A. (1964). The epidemiology of a folk illness: Susto in Hispanic America. Ethnology, 3, 268-283.
19. Koss-Chioino, J.D. & Canive, J.M. (1993). The interaction of cultural and clinical diagnostic labeling: The case of Embrujado. Medical Anthropology, 15, 171-188.
20. Westermeyer, J. (1993). Cross-cultural psychiatric assessment. In A.C. Gaw (Ed.). Culture, ethnicity and mental illness (pp. 3-42). Washington, D.C.: American Psychiatric Press, Inc.
21. Marsella, A.J., Friedman, M.J., & Spain, E.H. (1993). Ethnocultural aspects of Posttraumatic Stress Disorder. In. J.M. Oldham, M.B. Riba, & A. Tasman (Eds.), Review of Psychiatry, Volume 12 (pp. 157-181). Washington, D.C.: American Psychiatric Press, Inc.
22. Gynther, M.B. (1972 ). White norms and Black MMPIs: A prescription for discrimination? The Journal of Psychological Bulletin, 78, 386-402.
23. Weaver, D.D., Castillo, D.T., Howard, R.A., & Canive, J.M. (1995). MMPI-2 profiles of Hispanic Vietnam combat veterans. Paper presented at the annual meeting of the International Society for Traumatic Stress Studies, Chicago, October, 1995.
24. Hinton, L., & Kleinman, A. (1993). Cultural issues and international psychiatric diagnosis. In J. Costa e Silva & C. Nadelson (Eds.). International Review of Psychiatry (pp. 111-129). Washington, D.C.: American Psychiatric Press.
25. Acosta, F.X., & Evans, L.A. (1982). The Hispanic-American patient. In F.X. Acosta, J. Yamamoto, & L.A. Evans (Eds.), Effective psychotherapy for low-income and minority patients (pp. 51-82). New York: Plenum Press.
26. Rogler, L.H., Malgady, R.G., Constantino, G., & Blumenthal, R. (1987). What do culturally-sensitive mental health services mean? The case of Hispanics. American Psychologist 42, 565-570.
27. Zuniga, M.E. (1992). Using metaphors in therapy: Dichos and Latino clients. Social Work, 37, 55-60.
28. Pinderhughes, E. (1989). Understanding race, ethnicity and power: The key to efficacy in clinical practice. New York: Free Press.
Jose Canive is Coordinator of the Post-Traumatic Stress Disorder Clinical Team at the Albuquerque VAMC and Assistant Professor of Psychiatry at the University of New Mexico Health Sciences Center. Dr. Canive is also the President-Elect of the American Society of Hispanic Psychiatry. As a Board Member of the Society for the Study of Psychiatry and Culture (SSPC), he will chair the SSPC 1997 meeting "Migration, Politics, Social Policy and Mental Health." He received his M.D. from the Universidad Complutense de Madrid (Spain) and trained in cross-cultural psychiatry at McGill University in Montreal.
Diane Castillo is Coordinator of the Emotional Disorders Clinic at the Albuquerque VAMC and holds an adjunctive Assistant Professor position at the
University of New Mexico Health Sciences Center. Dr. Castillo specializes in cross-cultural counseling and post-traumatic stress disorder with sexual trauma victims. She received her Ph.D. from the University of Iowa and has taught cross-cultural counseling at the University of Texas at Austin.
|
