Cultural Formulation: Continued

A Clinical Case presented by Spero M. Manson
THE WOUNDED SPIRIT: A Cultural Formulation of Post-Traumatic Stress Disorder Cultural Formulation

Part 2 of 2

A. Cultural identity

Cultural reference group(s)

J. is a full-blood (4/4's quantum) and an enrolled member of a southwestern American Indian tribe residing largely in Arizona; both of his parents are also tribal members, as are his wife and children.

Language

He speaks and understands English moderately well. J. is fluent in his native language, speaking it most of the time in his home setting and among family and friends. The children also are conversant in his native language, but generally more adept than he in English, which is predominant in school and among their peers.

Cultural factors in development

On his mother's side, J. is a descendant of a family of medicine people, hand-tremblers (diagnosticians) among the women and singers (healers) among the men. Consequently there have been expectations that he would play a leadership role in the cultural and spiritual life of the community. Boarding school interrupted J.'s participation in some of the important aspects of local ceremonial life, but his mother's family worked hard to include him in critical events.

J.'s severe and frequent physical punishment at boarding school was related to issues of identity. He was beaten regularly by non-Indian staff for speaking his native language, for wearing his hair long, and for running away on a number of occasions - all home to his family. J., afraid of ridicule and harassment, attributes his reluctance to share the cultural aspects of his personal background with fellow infantrymen to this experience.

B. Cultural explanations of the illness

Predominant idioms of distress and local illness categories

The pattern of symptoms presented by J. is widely acknowledged as a real problem in his community although it has no consistently specific label in local terms. Until recently tribal members had never heard of PTSD, but now they sometimes refer to it as the "wounded spirit." J.'s culture typically employs etiologic rather than descriptive categories to refer to illness. Here, the consequences of being a warrior and participating in combat have long been recognized. Indeed, a ceremony has evolved to prevent as well as treat the underlying causes of these consequences.

Meaning and severity of symptoms in relation to cultural norms

Cultural dynamics clearly influence J. 's problem drinking and subsequent alcohol dependence. Talking about the traumas that J. experienced poses psychologically and culturally constructed risks for him. Group drinking, most often with other veterans, is one of the few contexts that frees him from these risks in his community. Recognition of the risks of talking about such traumas and the culturally ascribed role of alcohol in permitting such talk helps to explain, at one level, why J. maintained a lifestyle of heavy drinking for 20 years after his return from Vietnam. The resurrection of the agony, fear, guilt, sorrow, and horror associated with combat is done while being "blanked out," to use the local term. Veterans claim to have no memory of what transpired when they were drinking, what they talked about, whether they wept, or who fought. It is this ability of alcohol - to enable one to disclose intimate details about "Nam," and yet at the same time forget it for even a brief moment - that many Indian veterans cite as the most important reason for their drinking.

J's hearing his father's voice years following the death is not considered by his tribal community to be out of the ordinary. However, it is uncommon to talk openly about these experiences or to dwell at much length on the death of a loved one, as doing so may pose a serious risk to the individual and to those around him. Thus, J. who was not able to participate in the brief, intense period of ritual mourning at the time of his father's death, but now is capable of doing so, finds few cultural avenues open to him to resolve this enormous sense of loss.

Perceived causes and explanatory models

J.'s tribal community subscribes to a distinct philosophy of life captured in the phrase sb'a naghai bik'e hozhq. The first half of this phrase (sb'a nagai) refers to spirituality, an individual's goal or quest to attain eternal life and physically to live his mortal life to the fullest extent. Sb'a refers to old age and naghai to the attainment of a goal, specifically the process or effort of getting there. Bik'e hozhq, the second part of the phrase, refers to the beauty of this process. These two main parts of the phrase also embody female and male identity, respectively, which must be balanced in order to maintain a positive, harmonious self. It is this balance that underpins one's personal, physical, mental, emotional, and spiritual health. In J.'s view, the Vietnam War and failure to participate in the culturally prescribed grieving process immediately after his father's death have upset this harmony. The consequences - alcoholism and PTSD - kept him from pursuing its restoration.

Help-seeking experiences and plans

As noted earlier, J. attends a VA- sponsored support group comprised of all Indian Vietnam veterans. This group functions as an important substitute for the circle of "Indian drinking buddies" from whom J. separated as a part of his successful alcohol treatment. The regular summer hiatus in his attendance relates to familial responsibilities, namely sheep- herding at summer camps, and to his pow-wow activities, which bridge his absences from the support group. The same ethnicity composition of the VA support group proved to be important to J. His discomfort with the brief PTSD inpatient experience stemmed from different styles of disclosure, expectations in regard to reflexivity, and therapeutic group membership defined exclusively on the basis of status as a combat veteran.

Until 1991, J. had participated sporadically in the Native American Church. His reimmersion, and now steady involvement, in it provides an understanding of the forces that led to his drinking, ongoing reinforcement of the decision to remain sober, and encouragement to continue positive life changes. The roadman who leads the services that J. regularly attends is himself a Vietnam combat veteran. Thus, much of the symbolism contained in the ritual structure (e.g., an altar shaped as a combat-V; Marine flag upon which the staff, eagle feather fan, and sage are placed) are relevant to this other dimension of J. 's identity.

J. feels that he is ready to benefit from the major tribal ceremonial intended to bless and purify its warriors. His family is busily preparing for that event, which is quite costly and labor intensive.

C. Cultural factors related to psychosocial environment and levels of functioning

Social stressors

Steady employment opportunities are rare in J.'s community. Thus, he has chosen to attend community college to complete his GED and prepare for vocational training. This is not easy but is made possible by the shared resources (food, money, transportation) of the large extended family with which he resides. Work is sporadic for him, but he readily seeks odd jobs.

Social supports

J. received active encouragement from family and the community as he began to work seriously on sobriety and recovery from war trauma. Introduced through Native American Church contacts, members of a local gourd society sought him out and invited him to join them. He did and participates in their activities with increasing frequency.

Levels of functioning and disability

As a consequence of this support, J. just entered a physical rehabilitation program at the VA center, which has helped him to cope better with the handicap posed by his injured hand. Previously the mere mention of this disability sent him into a hostile rage, with a lengthy tirade - not entirely unfounded - about the poor quality and insensitivity of medical care.

J. has begun to visualize social and economic stability in his future. Although challenges remain, notably the successful resolution of remaining PTSD symptoms, his overall functioning has improved and is expected to continue to do so.

D. Cultural elements of the clinician-patient relationship

Upon presentation at the Gallup VA outpatient medical program, J. already had some experience with majority behavioral health services. The primary providers at the program were non-Indian but experienced in working with veterans from J.'s tribe. Hence, after reviewing his case, they recommended the all-Indian support group which has worked well. Moreover, his positive experience with these providers increased J.'s respect for their abilities and has led him to seek periodic counseling from them in an adjunctive fashion. This counseling has focused on cognitive-behavioral strategies for managing his anger and on recognizing situations that consistently prove to be problematic for him. Neither they nor he discuss underlying causes in this regard but focus instead on changing the overt behaviors and how J. thinks about them. J. and his providers have talked about his upcoming ceremonial, for which the latter have voiced support.

E. Overall cultural assessment

This is a complex presentation of an American Indian patient with multiple problems: combat-related trauma, alcohol dependence, a history of childhood physical abuse, and bereavement. Accurate assessment and treatment of his long-term PTSD symptoms initially were precluded by the focus on his alcoholism. This was inevitable given the particular array of services available in his community and the lack of awareness of PTSD in general. Once his alcohol abuse was controlled, J. sought appropriate guidance and treatment for his trauma- related symptoms, first from the VA and subsequently from traditional cultural resources. J.'s bi-cultural identity allowed him to be open to different modalities of help, but it also presented challenges for both Indian and non-Indian providers to understand fully his needs and resources. The restricted nature of culturally prescribed mourning practices in his tribe, coupled with severe drinking at the time of his father's death, may have contributed to still unresolved grief.

J.'s residential alcohol treatment proved effective because it separated J. from his "Indian drinking buddies," addressed issues specific to American Indians, and allowed him to acknowledge possible links between his problems with alcohol and combat trauma. J.'s initial reticence to seek help from local cultural resources may have been compounded by significant insults to his ethnic identity - earlier at boarding school and later in the military - thereby confusing his sense of self. His brief tenure in the PTSD inpatient program underscored the severity of his symptomatology, its relationship to Vietnam, and commonality among combat veterans. However, the alien nature of that treatment experience also emphasized the need for something different, more familiar, which J. initially found in the Indian Vietnam veteran support group.

J's comfort with this support group enabled him to explore his combat trauma more deeply and in a culturally appropriate fashion, and also awakened him to the physical abuse he suffered in boarding school; something shared with many of these veterans. A sense of ethnic pride emerged from the bonding that ensued. Moreover, he felt able to seek more narrowly defined help from non-Indian providers at the Gallup VA program. These gains facilitated his joining a local gourd society, which further reinforced feelings of belonging, connection, and dignity as a warrior.

Cultural values surrounding family and a large extended kin network have kept important resources in place for J., even during times when he severely tested those commitments. He now is drawing upon them as he pursues significant self-improvement.

Involvement in the Native American Church has helped J. to struggle effectively with the reasons for his drinking, to continue self-reflection, and to maintain a life plan. That the roadman also is a Vietnam veteran encourages further attention to shared traumatic experiences and the ways in which one may seek to escape their memory.

J. has a great deal of work before him. His PTSD symptoms are impairing. He looks hopefully to the tribal ceremonial to assist with the resolution of their cause. Continued work with VA counselors, the support group, and the gourd society may have long-term benefits along these lines as well. Perhaps most difficult is the residual grief over the death of is father. The options within his culture by which to process these feelings are less clear.

National Center for American Indian and
Alaska Native Mental Health Research
Department of Psychiatry
University of Colorado Health Sciences Center
4455 East 12th Avenue
Denver, Colorado 80220

NOTE 1. An earlier version of this case originally appeared in Manson, SM. (1997), Cross-cultural and multi-ethnic assessment of trauma. In J.P Wilson & TM. Keane (Eds.), Assessing psychological trauma and PTSD: A handbook for practitioners. NY, NY: Guilford Press. Culture, Medicine and Psychiatry 20: 489-498, 1996.

Reprinted with kind permission from Kluwer Academic Publishers