Posttraumatic Stress Disorder and Specific Ethnocultural Groups

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Before we begin to look at the various ethnocultural factors of some specific groups, a disclaimer needs to be made. Certainly, a discussion of all the various ethnocultural groups in the United States (and elsewhere for that matter) would by encyclopedic. The groups discussed in this section were chosen for a couple of reasons. Studies with these particular groups constitute the largest proportion of studies. Further, these three groups constitute the largest ethnic minority groups in the United States. It is not my intention to communicate that other groups' experiences are not as important. For more information on various other groups and an in depth discussion of ethnocultural factors and PTSD, please see Ethnocultural Aspects of Posttraumatic Stress Disorder: Issues, Research, and Clinical Applications (2001), edited by Anthony Marsella, Matthew Friedman, Ellen Ger-rity, and Raymond Scurfield. What is important to get from this section is that depending on historical factors, certain ethnocultural groups may be at increased risk for exposure to traumatic events and subsequent development of PTSD. For now, these groups have been identified, but these groups' statuses as high-risk groups are not frozen in time or carved in stone. Traumatic stress does not respect cultural or national boundaries, and for now our focus is on these groups, but nobody knows the fates of other groups.

Posttraumatic Stress Disorder and African Americans

The African American community has an unmistakably unique social and cultural history in the United States. The ethnocultural approach requires that such uniqueness be treated with the utmost importance when approaching PTSD within the African American community. In essence, the African American experience is one of stress—historically and contemporarily. This experience of heightened stress has been viewed to have a unique effect on both the occurrence and prevalence of traumatic stressors within the African American community and the epidemiology, manifestation, and treatment of PTSD.

The legacy of slavery, past and ongoing racism, high rates of poverty, high rates of incarceration, and high rates of violent death among male adolescents and young adults are considered critical stressors in the African American community. Moreover, Allen (1996) proposes that such an adverse and challenging environment has created life circumstances requiring a constant search and struggle for meaning, purpose, and pressure within the African American community. These circumstances serve as moderating variables that may lead to greater or more long-lasting effects of traumatic stress than in other groups.

Research seems to suggest a positive relationship between being African American and an increase in the frequency and degree of PTSD. However, Allen (1996) again goes on to state that we should be cautious against a bias that views African Americans as living more pathological lives than others and adds the following caveat: "The majority of African Americans do not suffer from PTSD nor do they consider themselves traumatized as individuals. . . Many have learned to cope and survive despite difficult life experiences" (p. 210). Or, as W. Nobles (1991) states,

African American psychology is something more than the psychology of so-called underprivileged peoples, more than the experience of living in ghettoes or having been forced into the dehumanizing condition of slavery. It is more than the "darker" dimension of general psychology. Its unique status is from the positive features of basic African psychology which dictate the values, customs, attitudes, and behavior of Africans in Africa and the New World. (p. 47)

Despite both of these positive and powerful positions, some investigators and researchers still struggle with the question of whether the African American experience in the United States is inherently traumatogenic. Racism and its expression in social and political policies create circumstances that make trauma and deprivation "endemic facts of life" (Allen, 1996, p. 216). Hacker (1992) has identified numerous circumstances or factors: higher unemployment rates than European Americans; social problems, such as higher rates of teen pregnancies, higher rates of single-parent households, higher rates of incarceration, lower life expectancy, higher rates of low birth-weight newborns, higher rates of postneonatal mortality, higher rates of tuberculosis, hypertension, stroke, diabetes, and heart disease; and inequality in education and schools. This is certainly a daunting list and in as much as these factors can be viewed as traumatogenic or increasing one's risk for developing PTSD, the answer to the question of whether the African American experience in the United States is traumatogenic is a resoundingjes. Irving Allen (1996, p. 221) states, "racism is the ideological foundation for excessive stress in the lives of African Americans."

Research from an ethnocultural perspective with African Americans is typically divided into research with African American Vietnam veterans and research with civilian populations.

African American Vietnam veterans have been consistently found to have higher rates of PTSD than those of European descent. As soldiers, they were 12 percent more likely to be assigned to combat duty and, therefore, had higher rates of combat exposure. The National Vietnam Veterans Readjustment Study of 1990 (Kulka et al., 1990) found that 20.6 percent of African American soldiers suffered from PTSD, compared to 13.7 percent for European Americans and 27.9 percent for Hispanic Americans.

Civilian studies have found that African American children reported higher rates of symptoms following Hurricane Hugo than European American children (Lonigan et al., 1991). Norris (1992), in a study of four Southern cities in the United States, found that African Americans showed higher levels of trauma-related distress. Researchers have cited that SES was a significant confounding factor in these studies, however.

Now that we know that African Americans are at increased risk for exposure to PTSD and of developing PTSD, what issues are important in treatment? To begin with, it is extremely important to keep in mind that African American clients or patients don't leave their experience at the door when they enter treatment. Conflicts and issues that occur in the broader society can be played out in any treatment setting (clinic, therapy office, or hospital). Reenactments of such conflicts have the potential to retraumatize patients or, at the very least, add to their disillusionment. As we have been warned by Allen (1996) and Nobles (1991), there is the risk of overpathologizing behavior or of failing to recognize symptoms by being quick to label hostility or a sense of being entitled.

African American clients and patients may be less open with non-African American professionals and professionals working in settings identified with the larger, conflict-ridden society and culture. Therapist neutrality is contraindicated as patients or clients may expect some acknowledgment of their background and unique experiences. There has been some suggestion that group therapy is a preferred modality for psychotherapy (Prothrow-Stith, 1991). For a more in depth discussion of treatment, see Elaine Pinderhughes' 1989 book, Understanding Race, Ethnicity, and Power.

Posttraumatic Stress Disorder and Southeast Asians

Abueg and Chun (1996) cite that the body of literature studying PTSD with Asians and Asian Americans is relatively small and is focused primarily on Asian refugees in the United States. The region of Southeast Asia including Vietnam, Cambodia, and Laos is considered a highly war-torn area, and the peoples of this region have been extensively exposed to traumatic events and stressors. Abueg and Chun (1996) have developed a schema for understanding stress and traumatic stress in Southeast Asian refugees. They identify four distinct periods of stress: premigration, migration, encampment, and postmigration stress.

Premigration stressors include exposure to war, brutalization, death of family and friends, and loss of property. Migration period stressors include separation from family, travel barriers, and assaults by border police and guards. Encampment stressors include detainment in unsafe, overcrowded and unsanitary conditions plus high levels of uncertainty about one's future. Postmigration stressors include having to learn a new language and skills, loss of loved ones, and loss of cultural and social familiarity.

Vietnamese refugees have been exposed to all such stressors in their experience of war and migration to the United States following the Vietnam War. There were long periods of refugee encampment in Thailand, Hong Kong, Indonesia, Malaysia, and the Philippines. Research has continued to show high levels of vulnerability to depression, anxiety, and poor general health in the general Vietnamese refugee population. Groups that are considered particularly at risk are divorced or widowed female heads of households, individuals older than

46 years old, individuals younger than 21 years old, and women between the ages of 21 and 45 years old. (For more on PTSD and women, see the last section of this chapter.)

Prevalence rates for PTSD vary from study to study but are still considerably higher than the general non-Vietnamese population: 11 percent at a refugee clinic (Mollica, Wyshak, & Lavelle, 1987), 8.1 percent at a psychiatric outpatient clinic (Kroll et al., 1989), and 54 percent at another psychiatric outpatient clinic (Kinzie et al., 1990).

Cambodian refugees have experienced horrendous premigration stress with the political terror and genocide of Pol Pot's Khmer Rouge regime. These people have experienced mass executions, forced separations of family members, confinement to work camps, forced labor, torture, beatings, starvation, and disease. Cambodians have consistently shown higher levels of anxiety and depression than even Vietnamese refugees. They have also been found to see themselves as more different than Americans than do Vietnamese, Laotian, and Hmong refugees (Mollica, 1994; Nicassio, 1983). The following prevalence rates for PTSD have been found: 57 percent in a psychiatric outpatient clinic (Mollica et al., 1987), 22 percent in a clinic population (Kroll et al., 1987), and 92 percent in another clinic population (Kinzie et al., 1990).

Abueg and Chun (1996) argue that understanding that Cambodian, Hmong, and Mien refugees have the highest rates of traumatization among Southeast Asian refugee groups is a crucial factor in effective clinical work, especially in the establishment of empathic connections and encouraging help seeking and disclosure.

Posttraumatic Stress Disorder and Hispanics

Hispanics in the United States represent the largest ethnic minority group. Immigration from Mexico, Central America, and South America continues at an unprecedented pace, with the consequence of people bringing their traumatic experiences with them, not to mention their experience as immigrants and the stressors that come with such. There is also a substantial group of Hispanic Americans whose presence in what is now known as the United States far out-dates most European Americans. Just as the groups discussed so far, their history and ongoing experience is unique to them and are important variables with respect to PTSD.

Immigrants and refugees from Latin America have experienced high rates of political repression in the latter half of the twentieth century. Children from both Chile and Argentina have shown increased levels of withdrawal, generalized fear, increased startle response, increased levels of depression, an increased sense of impotence, and an increased sense of vulnerability, for example.

Hispanics living in the United States, whether recent immigrants or long-time inhabitants, may have experiences that add to their vulnerability to PTSD. Disadvantaged sectors of even developed nations may have higher prevalence rates of trauma. This group has higher rates of exposure to crime, exposure to violence, immigration issues, prejudice, discrimination, fewer social resources, and language barriers (Hough, Canino, Abueg, & Gusman, 1996).

Research with nonimmigrant Mexican Americans has shown increased risk for PTSD. Following the San Ysidro McDonald's Massacre in the early 1980s, Hough et al. (1990) found general vulnerabilities significant in predicting later onset of PTSD, such as old age, low income, and medical illness. These researchers suggest that in tightly knit Hispanic communities, trauma may spread throughout the social network.

From the positive side, research shows that in the case of disaster, the strong focus on social and family support within Mexican American communities has proven to provide a stress- or trauma-buffering effect. On the negative side, however, social networks can also place demands or burdens that have shown to be related to a higher number of posttraumatic symptoms (Solomon, the Federman Foundation, & the Israeli Ministry of Defense, 1993).

Although variation in symptom expression can been seen, Guarnaccia, DeLa-Cancela, and Carrillo (1989) found a significant dissociative feature to ataques de nervios (a cultural label for stress reactions) However, research has failed to find an increased level of dissociation than in other populations.

Numerous studies have shown that Hispanics tend to report significantly more somatic symptoms than non-Hispanics. There are also higher levels of unexplained physical symptoms. In the case of comorbidity, PTSD is more typically seen in conjunction with a host of other DSM-IV-TR diagnoses even though Hispanics with PTSD have been found to be less likely (8.4 percent compared to 37.3 percent for European Americans and 13.6 percent for African Americans) to be diagnosed with a Mood Disorder than individuals from other groups.

When it comes to treatment with the Hispanic ethnocultural group, keep in mind that this population does not use mental health services as much as other groups. When they do seek formal treatment, they may have had experiences that have left them feeling that treatment programs, clinics, and professionals are culturally insensitive. These factors increase their risk for chronicity of PTSD and other mental disorders as well.

Posttraumatic Stress Disorder and Women

It may at first seem out of place to be discussing gender issues as they relate to PTSD in this chapter, but consider the following story from Amy Goodman, infamous journalist and radio talk show host on Pacifica Radio. Amy was speaking of the defense of her dissertation for her PhD in anthropology, stating that she conducted a study of health care delivery for women in the Southern region of the United States. A member of the committee asked her if she knew that anthropology was the study of cultures other than one's own and questioned why she would conduct a study within the United States. Amy's response was powerful;

she stated that as a woman in a male-dominated society, she did not typically think of the United States as her "own culture" and, therefore, was not violating the tenets of anthropology. The committee member responded, "Carry on."

This story is not to arouse the reader's political sensibilities but simply to illustrate the point that within the context of considering the importance of ethno-cultural factors and their relation to PTSD, gender and, certainly, being a woman is a cultural factor worth discussing.

The exploration of PTSD and the other groups within this chapter has revealed that certain groups are at increased risk for being exposed to traumatic stressors or stimuli and for developing PTSD. This is also the unfortunate case for women but in a more specific sense. Maria Root (1996) makes the powerful point that women are at a considerably higher risk for exposure to violence. As the other groups in this chapter are at greater risk for natural disaster, refugee stressors, and racism, women are exposed to disproportionate levels of interpersonal violence. Consider the following statistics from Root (2001):

Annually, 2,000 women are murdered by their husbands.

Each year, 1.8 million wives are physically battered by their husbands.

One woman is raped every 60 seconds.

One out of four adult women report being the target of sexual abuse as a child.

These statistics are serious and daunting and make a powerful argument that women are virtual victims of a war consisting of murder, assault, sexual assault, and many other forms of violent trauma. Many, if not most, women are acutely aware of these risks and find themselves altering and adjusting their everyday lives in order to protect themselves. These circumstances have led to very real pragmatic limitations on women's freedom. The cumulative effects of abuse of power, male domination, economic inequality, and sexism have been powerful. Researchers (Ho, 1990; Sorenson & Siegel, 1992) have argued that the roots of the traumatogenic nature of being a women stems from a larger cultural endorsement of violence and ultimately results in impacting women's well-being physically, psychologically, and spiritually.

Women are raped more than men. Koss (1992) reports that one out of five women have experienced a completed rape. The trauma of rape is therefore more likely in women than men. Herman (1981) found that one out of three to one out of five women has had a sexual encounter as a child with an adult male. In a large study, Straus and Gelles (1986) found that 28 percent of women and men reported physical violence within their intimate relationships, but 75 percent of the incidents were male perpetrators to female victims.

Even with these shocking statistics, the mental health community has been relatively slow to acknowledge the psychological and psychiatric effects of such experiences in women. Researchers have found that a significant number of women admitted to emergency psychiatric facilities have histories of sexual assault (Carmen, Rieker, & Mills, 1984), ranging from almost half to 81 percent (Beck & van der Kolk, 1987; Jacobson & Richardson, 1987). It has been proposed that the common nature of violence against women and girls has been suppressed and denied in the United States. Such denial may have led many women to seek mental health treatment for trauma-related problems and symptoms without a direct acknowledgment of their traumatic experiences. Certain psychiatric diagnoses that are more commonly given to women than to men have been associated with higher incidences of violence and sexual violence, such as Eating Disorders, Dissociative Disorders, and Borderline Personality Disorder.

Perhaps one of the more infamous scandals with regard to this phenomenon came from the work of Sigmund Freud. Some critics have argued that Freud's Oedipal complex was invented as a cover-up to hide the fact that many of his female patients' discussions of sexual encounters with their fathers were in fact real and did actually occur. Given that many of Freud's patients were the daughters of his colleagues and the powerful members of Viennese society at the time, it is alleged that Freud concocted the notion of fantasized encounters rather than expose the epidemic of sexual abuse. Of course, this has never been actually proved or substantiated, but it is very interesting in light of the current discussion.

There are numerous clinical issues related to the high risk of women to the traumatic stimulus of violence. Women may be more reluctant to seek treatment for PTSD secondary to violence or sexual assault, instead presenting for treatment for depression, panic attacks, or relationship problems instead. This situation is fraught with the risk of misdiagnosis and the possibility of failing to form an empathic clinical relationship. From this situation, treatment drop out may be more common. Cross-gender treatment situations may also lead to difficulties. Feminist therapists have long argued about the unique nature of conducting psychotherapy with women. As with ethnicity, the larger society is never left at the clinic door. Gender stereotypes and sexist beliefs can be significant barriers to effective treatment.

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