Roles of Health Care Providers
Healthcare providers often are the first and only contacts that Native veterans are willing to make for help in healing. Seeking medical care for a physical illness often is more socially and personally acceptable for Native veterans (and their families) than seeking psychological treatment for "mental illness" or addiction. During the routine health and medical history, health care professionals must be alert to the symptoms of PTSD, as well as to a variety of problems that are sometimes associated with PTSD and that warrant further inquiry:
- Anger or hostility
- Social isolation
- Grossly disturbed interpersonal relationships (e.g., violence in intimate relationships, inappropriate sexual behaviors)
- A wide variety of somatic complaints
- Smoking
- Poor nutrition
- Poor self-care
Patients vary greatly in degree of impairment. For example, some individuals may exhibit high levels of interpersonal, social, and vocational functioning, whereas others may be totally incapacitated and may appear to have a mental illness such as chronic schizophrenia.
If trauma or PTSD is suspected, a sensitive and careful exploration is extremely important. Obtaining a trauma history is an essential first step in diagnosing PTSD and distinguishing it from other major mental disorders. Although patients most often welcome the opportunity to talk about their trauma, it can often be stressful for them. At first, the discussion will likely be quite brief; and at that point, the patient can be referred to a psychiatrist or psychologist for further evaluation. Initially American Indian and Alaska Native veterans, like most people, may be more open to meeting with a "stress management" clinician - one who is also a specialist in PTSD, depression, and alcohol or drug abuse - than to be referred to a mental health practitioner.
A four-question, symptom-related paper-and-pencil screening instrument can be used in primary care and other medical settings (Prins and Kimerling, 2004). This PTSD screening instrument has shown promising psychometric properties for detecting those individuals with more severe trauma-related difficulties. A positive response to the screen does not necessarily indicate a problem with posttraumatic stress. However, it indicates the need for sensitive questioning by a helping professional. We recommend that these questions be embedded in a more comprehensive screen used to assess health behaviors, mental health problems, and perceived health difficulties. Further questioning about trauma and its effects would be warranted if a patient responded "YES" to two or more of the following items (all use yes or no response format):
Have you ever had an experience that was so frightening, horrible, or upsetting that, in the past month you...
a. Have had nightmares about it or went out of your way to avoid situations that reminded you of it?
b. Tried hard not the think about it or went out of your way to avoid situations that reminded you of it?
c. Were constantly on guard, watchful, or easily startled?
d. Felt numb or detatched from others, activities, or your surroundings?
In discussing traumatic stress symptoms, it is important to inform patients that traumatic events and the distress they create can have important effects on the body and on health as well as on the patient's psychological functioning. The health care provider can explain that he or she is opening this discussion as part of an effort to provide more comprehensive health care. The patient should be made aware that greater understanding and recognition of symptoms of posttraumatic stress and, if appropriate, help from a professional will be of benefit, both physically and psychologically.
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