Toward Culturally Competent Care

The construct of PTSD has been criticized from the perspective of cross-cultural psychology and medical anthropology because it has usually been diagnosed by clinicians from Western industrialized nations working with patients from a similar background. Major gaps exist in our understanding of the effects of ethnicity and culture on the phenomenology of posttraumatic syndromes. Only recently have vigorous ethnocultural strategies been employed to delineate possible differences in cross-cultural impacts of traumatic exposure and its intrapsychic effects and clinical manifestations.

It is important that both psychological and pharmacological interventions be adapted carefully to the cultural and spiritual expectations and realities of American Indian and Alaska Native veterans. The DSM-IV provides an outline for the cultural formulation of a patient's signs and symptoms within the patient's cultural context:

• Ascertain the cultural identity of the individual.
• Consider the extent of involvement in both the culture of origin and the majority culture. Also note language abilities, use, and preference(s).
• Identify and explain the symptoms within the cultural context.
• Identify the predominant idioms of distress through which symptoms or the need for social support are communicated (e.g. "nerves," possessing spirits, somatic complaints, inexplicable misfortune).
• Identify the meaning and perceived severity of the individual's symptoms in relation to the norms of the cultural reference group.
• Identify any local illness category used by the individual's family and community to identify the condition.
• Identify the perceived causes or explanatory models that the individual and the reference group use to explain the illness.
• Identify current preferences for and past experiences with mainstream, alternative, and traditional sources of care.
• Identify social supports and stressors.

Cultural factors related to the psychosocial environment and levels of functioning include culturally relevant interpretations of social stressors, available social supports, and levels of functioning and disability. This would include kinship ties and the role of religion/spirituality in the patient's life.

Facilitate awareness of cultural differences between the individual and the clinician. Consider such factors as:

• Difficulty in communicating in the individual's first language.
• Difficulty in eliciting symptoms and understanding their cultural significance.
• Difficulty in negotiating an appropriate relationship or an appropriate level of intimacy.
• Difficulty in determining whether a behavior is normative or pathological.

Some practical factors to keep in mind

Conceptualize PTSD as a wounding of the spirit. A disturbance has occurred in the connectedness, reciprocity, balance, and coherence of the veteran's world. Start with a full measure of patience and aim for basic human understanding.

Let the veteran know you are interested in his or her well being.

Listen with empathy.

Respect silences; allow long latencies in responses. Do not interrupt the speaker. This may be interpreted as "you're not really listening."

Selectively validate feelings.

Do not expect prolonged "eye contact", as the veteran will likely feel more comfortable looking away from you, rather that at you.

Family and clan are very important. Options may need to be discussed with the group prior to a decision being made. Elders are honored.

American Indian and Alaska Native veterans' culture is based on the sharing of resources.

"Hallucinations" are an important part of the American Indian and Alaska Native spirituality. In American Indian culture, people may "see spirits."

Try to obtain the nature of what the spirit did or said. If the message was bad or evil, then consider pathology.

American Indian and Alaska Native veterans' cultures share a present orientation; therefore memories of trauma often are not "put in the past" and thus may be "brought up" quickly and with as great an intensity as when they happened.

See a table that illustrates traditional Native American values that may clash with dominant society values.