Ethnocultural Aspects of PTSD in Vietnam War Veterans
by Anthony J. Marsella, Ph.D., Claude Chemtob, Ph.D., and Roger Hamada, Ph.D.
NCP Clinical Quarterly 1(2): 9-10 (Fall 1990)
As the Vietnam War approached its slow and painful end, American society became acutely aware of the tragic consequences of its struggle to bring freedom and democracy to Vietnam. One of these consequences was the many veterans whose battlefield experiences proved to be so traumatic that they were no longer able to function effectively in society. Their minds were scarred with tragic and brutal memories which remain an omnipresent background for virtually all they do. They are victims of PTSD.
At a recent meeting of the National Center for PTSD, attention was directed to the needs of ethnocultural minority veterans suffering from PTSD. The National Vietnam Veterans Readjustment Study (NVVRS 1988) reported significantly higher rates of PTSD among Hispanics and Blacks. Unfortunately, the study did not include findings from any cross©cultural or transcultural research. Those attending the meeting at the Center concluded that understanding and treating PTSD veterans from ethnocultural minority groups requires more specialized knowledge about ethnocultural variations in the nature, experience, and care of PTSD.
We have identified four factors which may have predisposed ethnocultural minorities to additional risk and vulnerability under battlefield conditions. First, ethnocultural minorities were subject to racial stereotyping, ridicule, and inequitable treatment. Second, they were asked to fight a non-white people on behalf of a country which many of them considered racist. Third, the Vietnamese enemies often reminded soldiers of color of their own non-white status, increasing guilt and conflicts. Fourth, ethnocultural minorities' personality temperaments were often different from those preferred by the military. Lower military social status and ambivalent feelings towards the white-dominated military may have acted in concert to increase minorities' risk and vulnerability to stress.
In addition, many ethnocultural minority traditions idealize the masculine role and encourage endurance and silence in the face of distress rather than complaining about the problems. Many ethnocultural minority veterans felt complaining to the Veterans Administration about PTSD-related problems would make them feel shame and humiliation. This was compounded by the reluctance of many ethnocultural minority veterans to pursue assistance from the Veterans Administration because of their distrust of the white©dominated institutions. Lastly, ethnocultural minorities are reluctant to seek assistance because of language and communication differences. Frequently, they speak street or pidgin English dialects which are difficult to understand. In some instances, English may be their second language. It should be noted that communication difficulties also apply to a spectrum of non©verbal and paraverbal ethnocultural differences which are non-redundant communication channels.
While there has been only limited research on variations in PTSD among ethnocultural minority veterans, considerable anecdotal experience has been accumulated at Department of Veterans Affairs clinics and hospitals across the country (eg. Abueg, 1990, Hamada, Chemtob, Sautner & Sato, 1988). In addition, there is an extensive body of published research regarding cultural determinants of psychopathology and psychotherapy that bear directly upon the needs of ethnocultural minority veterans with PTSD. This research addresses virtually all aspects of psychopathology and psychotherapy that are relevant to PTSD. This includes the ethnocentricism and bias associated with current psychiatric and psychological knowledge regarding: (a) standards of normality and abnormality; (b) expression, course, diagnosis, classification, clinical assessment, and outcome of mental disorders; and (c) cultural appropriateness of various therapy procedures and techniques (eg. Kleinman & Good, 1985; Marsella, 1980; Marsella & Kameoka, 1989; Marsella & White, 1984).
There has been considerable research demonstrating ethnocultural variations in the expression and manifestation of certain anxiety and depressive disorders (op. cit.). This research has shown that individuals from non-Western cultural traditions often fail to present classical symptoms of these disorders and are misdiagnosed as suffering from somatic disorders. Thus, it is quite possible that ethnocultural minority veterans suffering from PTSD and related disorders may be wrongly diagnosed and inappropriately treated. This problem requires developing clinical assessment procedures which are sensitive to ethnocultural variations in the expression of PTSD. Clinical assessment of PTSD relies on a battery of psychological and psychiatric tests and interviews. Many questions used in clinical tests and interviews, however, are inappropriate in content for assessing ethnocultural minorities and thus do not accurately index problems that may be present. Many of the tests and interviews are based on norms which do not include ethnocultural minority group reference data. Yet these norms are being used as the standards for evaluating ethnocultural minorities.
Every ethnocultural tradition has therapy forms which seek to resocialize patients according to expected and preferred standards of behavior. In addition, every culture uses therapy forms consistent with its own view of the nature and cause of disease and of the procedures presumed necessary to reestablish normal functioning. Thus, all aspects of therapy and counseling reflect cultural influences. This includes: (a) the patient's conception of the nature/cause of his disorder; (b) the patient's expectations of therapy and of the therapist; (c) the patient's definition of the role; (d) the patient's motivation to comply with therapy; and (e) the patient's personal/social resources and skills.
In response to the gradual recognition of ethnocultural variations in both therapy process and outcome, the field of cross-cultural psychotherapy and counseling has gained increased popularity (eg., Marsella & Pedersen, 1982; Pedersen, Draguns, Lone & Trimble, 1988). Some authors have raised serious ethical questions about the implications of therapists conducting therapy with patients from different ethnocultural backgrounds. In recent years, there have been efforts to introduce indigenous healers and non-Western alternatives into Western clinical settings. These therapies differ from traditional Western "talk" psychotherapies in that they frequently involve strong spiritual, tactile, and family components. There can be no doubt about their effectiveness. Many of them have been in use for centuries. Increasingly, clinics and hospitals are beginning to work collaboratively with indigenous healers in providing care to ethnocultural minority group members who are still heavily identified with traditional cultures.
There is a growing body of research regarding ethnocultural variations in the use of psychoactive drugs and medications. This has given rise to reported ethnocultural variations in responsiveness to tranquilizers, anti-depressants, and stimulants among patients. While research in this area is new, results suggest care must be taken in the prescription of psychoactive medications to ethnocultural minorities. A major limitation on much cross cultural research is the assumption of homogeneity among subjects from different ethnocultural groups. this assumption is incorrect. While it is reasonable to assume there are similarities among members of an ethnocultural group, there is growing recognition of the considerable variations in ethnic identify that exist among members of a particular ethnocultural group. As a result, within group variation among sample members may distort or hide actual cultural differences that exist.
Ethnic identity can be defined as the extent to which an individual or group is committed to both endorsing and practicing in a set of values, beliefs, and behaviors associated with a particular ethnocultural tradition (Marsella, 1990). By assessing a veteran's ethnic identity, the therapeutic program can be adjusted to the ethnocultural traditions of the veteran. This increased sensitivity could result in more accurate diagnosis and more appropriate therapeutic efforts. The assessment of ethnic identity has assumed a number of forms including behavior checklists, attitude questionnaires, self-nominations scales, and cultural comparison profile techniques. Each of these approaches have proven easy to use for both clinical and research purposes. The authors strongly recommend that all veterans' programs concerned with PTSD develop ethnic identification scales to augment their existing assessment methods.
Dr. Chemtob is Director of the PTSD Research Laboratory, Department of Veterans Affairs, Honolulu, Hawaii
Dr. Marsala is Professor of Psychology, University of Hawaii
Dr. Hamada is currently in private practice in Honolulu, Hawaii
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