The Relevance of Hispanic Culture to the Treatment of a Patient with Posttraumatic Stress Disorder (PTSD)

Abstract

Cahill, et al.¹ discussed the importance of psychotherapy and psychotropic medications in the prevention and treatment of acute stress disorder and posttraumatic stress disorder (PTSD) in the September, 2005, issue of Psychiatry. In this article, we will specifically explore PTSD in the Hispanic population and present a composite case to demonstrate several clinical issues to consider when treating this population. This topic is timely and highly relevant to the practice of psychiatry as the Latino population continues to grow at a pace that far exceeds the capability of both current Latino/bilingual psychiatrists and the number of Latinos in the mental health provider pipeline. Given this great disparity, all psychiatrists need to be equipped with knowledge that will enable them to provide culturally sensitive care² that will result in better Hispanic patient outcomes.

Hispanics and PTSD

Hispanics as a population may be more prone to the development of PTSD. In a study of Vietnam Veterans, it was found that roughly 28 percent of Hispanic soldiers had PTSD at some point in their lives compared with approximately 21 percent non-Hispanic African-american American soldiers and 14 percent non-Hispanic White American soldiers.³ Latinos were also likely to have worse PTSD symptom severity when compared to these ethnic groups.^4,5 Symptom severity in Hispanics appears to be correlated with experiencing greater perceived racism in the workplace, and is associated with greater peritraumatic dissociation and less familial/social support.^5–7 This may be explained socioculturally, as a result of Hispanics' endorsement of fatalistic beliefs (events are inevitable and beyond their control),^5,7 their tendency to normalize stress,⁷ and the underreporting of distress, in combination with diminishing resources.^5,7 These Latino cultural characteristics may encourage the development of coping practices such as avoidance, peritraumatic dissociation, and self-punitive coping.⁵ Unfortunately, many Latinos in the US encounter stressful situations, such as discrimination and economic hardship, and have lost the strong familial, religious, and social network that made their learned coping mechanisms effective.^5,7 While these coping mechanisms may still work for day to day stress, they are likely to be ineffective in the context of extreme trauma.⁷

Case Presentation

Juanita is a 64-year-old Hispanic woman without past psychiatric history who is brought in by her family for psychotherapy. She has been experiencing increasing symptoms of sadness, with frequent crying spells and increasing religiosity. Her family reports that she has become more withdrawn and has been unable to perform her daily household activities.

At the initial interview Juanita reports crying spells, difficulty sleeping and focusing on tasks, and irritability. Several times she tearfully states, “Es mi culpa,” (It's my fault), but does not elaborate. She has been spending approximately three hours per day praying either at church or at home to the “Virgencita” (the Virgin Mary), who often comforts her. There is no evidence of psychotic or manic symptoms. She denies vehemently any thoughts of hurting herself, as that would be “un pecado grave” (a grave sin). She has never seen a psychiatrist before and only comes now at her children's insistence. Her husband and children are present at this interview, and her children are very concerned about the change in her behavior. Treatment strategies are discussed, and she and her family decide that weekly therapy is the treatment of choice and decline any use of antidepressants. Juanita and her family feel that she is proficient enough in English to participate in therapy with an English-speaking provider.

Over the next several sessions, it becomes apparent that at least one family member will come to every session with Juanita. The therapist feels uncomfortable broaching most sensitive topics. When the therapist asks to speak with Juanita alone, the family becomes visibly upset and it is obvious that the patient desires their continued participation in the therapy.

For the next several months, Juanita comes to all her sessions with the exception of several cancellations to visit with her grandchildren. Initially, she is quiet in sessions while her children do much of the talking. Juanita continues to appear withdrawn and dysphoric during these appointments without much improvement in her activities at home. She often reports feeling guilty about not being useful to her family.

Practice Point: Familism

An essential component of Latino culture is the family unit.^8–10 This unit is often larger than the Anglo family unit, often comprising several generations of extended family.⁹ Unlike Anglo culture, it is very common for the youngest generation to live with their parents well into their adulthood.⁸ Latinos place a lot of importance on the family and emphasize each member's interdependence on the family, and the family's responsibility is to provide not only material support but emotional support to its members. Therefore, Latinos are raised knowing that they have a constant, reliable source of support.^8–10 In therapy, this support may present itself as a highly involved Hispanic family, like the one depicted in the case here. While in some ways, such involvement may feel like a hindrance to the therapist, studies have shown that Hispanics with good familial and social support appear to be protected from the more debilitating symptoms of psychiatric illnesses such as PTSD.⁶ Therefore, it is very important for therapists to elicit patients' wishes regarding their family's involvement in their treatment.¹¹ It is also important that the therapist understand when patients desire to discuss treatment options with family before making any decisions.⁸ In fact, many authors recommend educating and involving the Latino family in therapeutic considerations.^8,10 The importance of a Latino patient's family as a positive source of support should be emphasized throughout the course of therapy.⁸

The symbiotic relationship that develops among members of the family often leads to the development of an allocentric identity, or identifying oneself by how one relates to others, which is a reflection of the Hispanic culture's collectivistic values. Many Latino patients will derive more comfort from imagining themselves interacting with someone else than from imagining themselves individually,⁹ such as going shopping with a daughter versus sitting on the beach alone.

In the last sentence of the case presented so far, we see that Juanita's mental health has begun to affect her identity with regard to her place in the fabric of her family. Throughout therapy, the therapist will likely notice the Latino patient's tendency to phrase personal issues in the frame of the family, as Juanita does when relating her guilt for not being useful to her family. It is, therefore, often important to study family functioning to understand the patient. It also may be helpful for the therapist to frame therapeutic goals and plans in a collectivistic manner, using the term we more than you.⁹ Given the Latinos' view of themselves as a reflection of their place in the family, it is easy to understand that they will often prioritize family time over therapy time, as Juanita did; this is not an indication that they are uncommitted to therapy.

Practice Point: Spirituality

Juanita's case demonstrates the powerful psychic relief she derives from her religion. Spirituality, or a sense of interconnectedness with life (which, interestingly, parallels the Latino familial philosophy) is highly valued in Latino culture, and is usually practiced through Roman Catholicism.^2,8,12 Three-fourths of Latinos, with female Hispanics outnumbering males, attend a weekly religious activity. Older Hispanic women, such as Juanita, are particularly active in worship-related activities, and often wish they could be more involved. They not only derive a sense of life fulfillment from attending church, but also seem to cope better than Latinas who are not as involved. Older Hispanics, as well as less acculturated Hispanics, feel that religion is more important to them than do European Americans. Thus, religious activity as a source of support may be especially important to older Latinas. This may stem from the church's major role as a sole source of support for recently immigrated Hispanics, who must adjust to an entirely different way of life while being separated from the unconditional support of their family.¹²

Latinos will also frequently express their spirituality through their own personal ideologies and folk religions, even while paradoxically being highly active in the organized Catholic faith. This reconciliation of very different ideologies is a result of the blending of Catholicism with native African and native American religious rituals and beliefs. The resulting folk religions are Curanderismo (Mexican American), Espiritismo (Puerto Rican), and Santeria (Cuban American).^8,13 Hispanic veterans suffering from PTSD have been found to frequently seek the advice/healing powers of a Curandera.⁸ The therapist should assess the importance of these different ideologies to patients as well as their degree of participation,^8,12 and may even individualize therapy based on the patient's emphasis on religion as a support system. The therapist could do this by involving the patient's priest, minister, or curandero/a in the treatment plan¹² if this is desired by the patient, or by performing symbolic rituals such as burning a representation of a traumatic event (a picture or description) as a way of “cleansing the soul.”⁸ The therapist should also elicit any religious interpretations Latino patients may have regarding their current suffering.⁹ It is very important to Hispanics that their physicians treat their ideologies with respect,¹² so a therapist must not simply dismiss these beliefs, no matter how implausible the patient's explanation seems.

Practice Point: Typical Attitudes and Beliefs Regarding Mental Health Among Hispanic Persons

In Juanita's case, she and her family choose psychotherapy as her primary mode of treatment. In general, Hispanics find psychotherapy to be a more acceptable form of treatment for depression than antidepressant medications.¹¹ They also value psychotherapy in conjunction with pharmacotherapy, and prefer this to antidepressant medication alone.¹⁴ This may stem from negative Latino beliefs regarding medication. Compared to Caucasian people, Latino and African-American people are more likely to believe that antidepressant medications are ineffective and addictive.¹¹ Some of these beliefs may relate to experiences Latinos may have had with medication. Racial and ethnic groups, other than Caucasian, will often have higher plasma levels of medications at lower doses than Caucasian people; Hispanics, in particular, not only respond to lower antidepressant dosages, but also report more medication side effects at lower doses than Caucasian people.¹⁵ This is an important consideration when initiating a medication trial with a Latino individual. A psychiatrist may want to start at very low doses and titrate very slowly to avoid poor adherence due to side effects.

Unlike Juanita, Latinos will often seek services only during emergency/crisis settings due to socioeconomic difficulties and possibly secondary to cultural beliefs that seeking aid is a sign of weakness. These issues also make them less likely to continue their treatment⁹ once the crisis is resolved. While they are more likely to receive mental healthcare in an emergency or primary care setting than in a specialty setting^2,11 they still receive less mental healthcare in primary healthcare settings than Caucasian people.¹⁶

Case Example Continued: The “Secret” is Revealed

During the third month of therapy, Juanita asks her family to wait in the waiting room. While describing her feelings of guilt, she becomes tearful and hesitantly reveals something about her past that she has never disclosed to anyone. Thirty years ago, shortly after having immigrated to the US and while working as a housekeeper, her male employer sexually assaulted her at work on two separate occasions. In the session, she shares that she has been feeling increased guilt and anxiety due to reemerging nightmares and recollections of the events. Juanita attributes the re-occurrence of her symptoms to the knowledge that her daughter began working as a housekeeper approximately 4 or 5 months ago.

Although the session appears to be a breakthrough in some aspects, it is also frustrating for the therapist. Just as the therapist sees a glimmer of understanding, Juanita switches to Spanish and says, “Por años yo mantenía este íntimo secreto. Solamente mi Virgensita y Diosito me escuchaban noche tras noche, y el padresito cuando me confesaba. Cuando mi esposo se immigro a los estados, por mucho tiempo yo le negaba sus propias necesidades íntimas que los hombres se merecen de sus esposas. Al momento que se ponian las cosas íntimas me causaban dolores de estómago, dolores de cabeza con los horribles imagines del hombre que me desgracio, ¡Madre Santisima! Me causan angustias, mis pesadillas tan horribles que he tenido por miles de noches. Ahora, ahora mi pobre hija…temo que a ella tambien la vallan a desgraciar. Por favor Dios mio, proteja mi hija. ¡Ay! ¡Es mi culpa, es mi culpa!”

The therapist feels confused and alarmed, not knowing the content of what is spoken but aware that the patient is very emotional. Though unsure of the meaning, the therapist continues to listen empathetically and when it appears that Juanita is done speaking, the therapist states, “It seems as though you have been through a lot, and I know this must be difficult for you, but I don't want to miss anything you have told me. Do you think you can try to tell me what you just said in English?” Juanita expresses her gratitude to the therapist for listening and being patient as she explains her circumstances in English:

“For years I've guarded this very intimate secret. Only my dear Virgen de Guadalupe has heard my anguish night after night, and my priest when I have confessed my sins. Long after my husband immigrated to the US, I denied him the intimacies that were justly due him from his wife. Every time he tried to become even remotely sexual with me I would suddenly get a stomache ache, my head would hurt from the ugly, horrible images relived in my mind. Images of the man who raped, ruined, and disgraced my life. Holy Mother of God! These horrible images have caused me anguish and nightmares for thousands of nights, night after night. Now I fear that my daughter will be disgraced in the same way. Please, my Lord, protect my daughter. Oh! This is all my fault, this is all my fault!”

Practice Point: The Spanish Language

The Spanish language is very important to Hispanics, irrespective of their level of acculturation or desire for assimilation. From first to third generation Hispanics, 87 to 65 percent, respectively, identified themselves as Spanish speakers. Most Latinos share the desire to preserve not only their culture but their language as well, indicating that language plays a key role in Hispanics' cultural identity.² In this case, Juanita finds it very difficult to express her emotional turmoil in English and reverts back to her native tongue. This is very common in Latinos and can lead to frustrated therapists and thus, impaired therapy. This oscillation between two languages can also lead to higher ratings of psychopathology due to the appearance of an illogical thought process.⁸ It is, therefore, very important for the therapist to clarify any confusion the language barrier may create, using an empathic approach that does not demonstrate frustration or irritation.

Practice Point: Confianza (Trust)

In the case scenario described here, it takes Juanita several months to open up to her psychiatrist about her personal issues. Many Latinos will need more time in therapy to build a trusting relationship with their provider. This is not only true in therapy, but for all clinical relationships, from primary care physicians (PCPs)¹¹ to psychiatrists. This can be explained by their culture's emphasis on confiding personal and emotional issues in family members rather than in strangers.^8,17 Anticipating the discomfort that a Latino may experience when seeking mental health services and discussing it beforehand may prove to be helpful.¹⁸ The therapist can establish confianza, or trust, by instituting a style that incorporates personalismo, or personalism, when dealing with Hispanics.¹⁰ This may require more therapist self-disclosure¹⁰ and a more relaxed atmosphere in the therapeutic interaction.⁸ Hispanics will likely develop a quicker therapeutic alliance with a therapist who is more emotionally interactive, and they tend to take on a more submissive and aloof role with anyone deemed to be an authority figure (a reflection of their familial values).⁸ The therapist must realize that Hispanics will avoid disclosing any family information that might cast the family in a negative light, as they will often feel as though they are betraying their family unit by disrespecting its privacy. It may initially be best to avoid pressuring patients to disclose personal family information until a strong enough rapport has been established⁹ using the aforementioned techniques.

Case Example Continued

Juanita misses the next session of therapy. Her family calls to say she has been to the emergency room due to a bout of excessive nausea and vomiting that morning that left her weak and dehydrated. The following week in therapy, the reasons for the missed session are explored further. Juanita notes a long history of intermittent diarrhea, stomach pain, nausea, and vomiting over a period of several years requiring many tests, ER visits, and even a few hospital admissions. Her family attests that she has frequent stomach problems that limit her activities several times a month. She has always believed the symptoms were caused by “nervios” (nerves). The family sought care from the American healthcare system and she was diagnosed with irritable bowel syndrome and prescribed a low dose of Elavil in combination with Aciphex. Although hesitant to take medications, she agreed to try the regimen, but after an adequate trial did not find it helpful.

Over the next few sessions, the therapist begins to notice a change in Juanita's demeanor. She often avoids eye contact and seems preoccupied. When the therapist brings up the change in her behavior, Juanita reveals that she has started going to a curandera (a folk-healer). When asked why she has not felt comfortable sharing this with the therapist earlier, she states that she was afraid the therapist would not understand, and might even be upset. The therapist explores her reasons for seeking help from the curandera and discovers that the patient's difficulties with “nervios” have continued to create significant difficulty in her functioning and frequent gastrointestinal upset. When asked what she believes is causing such distress, Juanita tells the therapist that she had been contemplating telling her husband about the assault. She is frightened about his response as she knows he will be upset that she has kept this secret from him for 30 years, but she also knows that he will probably feel responsible. She does not explain why.

Practice Point: Somatization

This excerpt demonstrates a common finding in PTSD, that of somatization.^19–21 Patients meeting PTSD criteria will endorse more somatic manifestations than those no longer diagnosable with PTSD.²⁰ In addition, somatization is the most common manifestation of psychic stress in Latinos.⁸ South America has a somatization rate 10 times higher than other comparable regions. This high rate of somatization could possibly be explained by Hispanics' approach to illness. They view their mental and physical health with an attitude of wholeness; that is, they do not make a distinction between the health of their mind versus their body, but rather, view them as intimately connected.²² Therefore, when Latinos are in psychic pain, the connection between mind and body may lead to physical manifestations.

Practice Point: Idioms of distress/Perceived Cultural mismatch

While somatization is the most common idiom of distress in Latinos, they often use several other explanations of illness.⁸ One of these is “nervios” as stated by Juanita in the case scenario. This is a vulnerability to stress that can result in irritability, impaired focus, lightheadedness, and dizziness. Latinos will also explain illness using supernatural means.^8,9 For example, “susto” (fright) occurs when a frightful occurrence leads to the separation of the soul from the body. They may also speak of being “embrujado”⁸ or having “mal de ojo,”⁹ both of which explain illness in terms of being hexed or cursed.^8,9 Some Carribean Latinos may report auditory, visual, and tactile hallucinations that are commonly regarded as “celajes” in their culture.²³ Hispanic patients may be reluctant to share these beliefs with their psychiatrists due to cultural differences and the fear of being misunderstood or ridiculed.^9,13 These explanations may also be misinterpreted by culturally insensitive physicians as psychosis.²³ Latinos may seek help from folk healers who share their same cultural beliefs, as Juanita does. They may avoid disclosure of such practices because they feel it is irrelevant or want to avoid being viewed as unsophisticated by the therapist.¹³ It is therefore important for the therapist to actively solicit patients' explanatory models and alternative treatments in a nonjudgmental, culturally sensitive manner.^8,13 Therapists should also describe their explanatory models,⁸ remembering that many mental illness concepts, such as depression or psychosis, may be difficult for some Latinos to comprehend, as these concepts have not even fully evolved into common use in the Spanish language.²

Case Example Continued

Juanita arrives to the next session looking very distraught. She begins crying early in the session and states that she should never have told her husband. She reports that he became very upset and has been very quiet ever since. He has not been himself and has become very depressed—not eating or sleeping well and not seeming to find joy in anything. After exploring the potential consequences, the therapist asks Juanita to bring her husband to the next session.

At the next session, Juanita and her husband, Pedro, arrive for the session and the therapist notices an obvious strain between them. When the therapist begins to explore Pedro's feelings about Juanita's revelation, he is initially very cold and states that he does not discuss such private matters with strangers. The therapist respects Pedro's wishes and continues the explore Juanita's feelings regarding the current situation. After a while Pedro begins to slowly open up to the therapist and his wife. Over the next few sessions, he reveals that he feels that he failed to protect Juanita, and that if he had provided a better life for her she never would have had to work as a housekeeper. It is obvious throughout the sessions that he has difficulty expressing emotions of sadness, and when he does cry, he often states, “Yo soy el hombre. No debo llorar” (I am the man. I am not supposed to cry).

Practice Point: Machismo

This portion of the case illustrates the importance of the Hispanic male's role as his wife's protector and provider in the construction of his personal identity. Whether a Latin male is a laborer or an architect, he is a provider and protector first, which speaks to the importance of the concept of machismo in the Hispanic patient's life and mental health. Machismo can be described as the “complex interaction of social, cultural, and behavioral components forming male gender-role identity in the sociopolitical context of the Latino society.”¹⁷ There are many misconceptions about the concept of machismo, including that Hispanic males view themselves as superior⁸ or dominant² over their wives; first generation Hispanics were actually found to prefer an egalitarian method of decision making in their relationships. This preference increased in second and third generation Latinos. The machismo construct, therefore, should not be viewed as inflexible roles that are thrust upon Latino men and women, but rather as guidelines for interaction between Hispanic men and women.^2,17

Hispanic males may view seeking assistance for mental health issues as a sign of weakness and may therefore underreport.^5,7 They might also be reluctant to participate in therapy, as they may perceive this as a position of vulnerability.¹⁷ It may be especially difficult for them to participate in therapy with a female psychiatrist as Hispanic males are often taught that it is disrespectful to discuss certain topics, such as aggression or sex, with women.⁸

Therapists should use the multiple positive qualities of machismo, such as fairness, responsibility, respect for self and others, strength of will, and self-assertiveness, to further therapeutic understanding and alliance with Hispanic males. These qualities should be recognized and emphasized throughout the therapeutic process.¹⁷

Case Example Continued

The couple continues to come together to the therapy sessions for the next several months. Pedro continues to describe his destroyed fantasies of protecting Juanita and the dismay of letting her down. Juanita reveals her fears of disappointment and rejection to her husband. As they work with the therapist over time, both are able to more completely open up about the incident and their resultant feelings. The therapist helps the couple to explore their fears, frustrations, and fantasies about each other more fully. Eventually, they work through the difficulty. Both Juanita and Pedro express definite relief of their depressive symptoms and increased confidence in one another. This process helps Juanita feel more emotional support from her husband at home and alleviates her fear of abandonment.

After several months of coming together, Juanita begins to again come to therapy alone. She finds that her gastrointestinal difficulties have decreased significantly in intensity and frequency to the point that she no longer requires the prescription medications. Juanita feels that she has attained her goals in coming to therapy. She expresses much appreciation for the efforts of the therapist and even brings the therapist some homemade baked goods. The therapist spends several sessions reviewing the therapy they have completed and working through termination issues. As Juanita has returned to fulfilling her household duties and is no longer suffering from the stomach problems, crying spells, or depression, the therapy is terminated.

Acknowledgment

The authors would like to thank Dr. Gillig, Dr. Coleman, and Dr. Dyer for their help and support throughout this project. Dr. Fierros would like to thank Raul Gonzalez, Jr for his assistance with translation and his support.