Social Work Clinical Skills used In Assisting Afghanistan and Iraq
Combat Veterans: Cultural Considerations for Hispanic Veterans
Course Objectives
1. Be familiarized with diagnostic skills used assisting Hispanic
Veterans with Post Traumatic Stress Disorder
2. Learn to identify the PTSD cluster symptoms; Reexperiencing, Arousal and Avoidance
3. Be introduced to evidence-based practices currently used in
the treatment of combat-related PTSD
Rise in Hispanics in the military; more suffer from
PTSD
• 2012: 1.2 Million Hispanic veterans; 39% suffer from PTSD
• 1994 to 2008: Hispanics in the military grew from 6 to 13 %
• 2004: Hispanics in the Army: 12.1% , Hispanics in the USMC:
40%
• 2012: Hispanic Females in the military: 7%, Hispanic Males in
the military 6%
• 2012: 24% Hispanics joined the Army, “ for the desire to serve
my country.”
• 2012: Rand Corporation: 88% Hispanics joined the military to
obtain a college degree
Proud History of Hispanic Veterans in Service to
Our Country
• World War II: Hispanics served in both the European and Pacific Theatres of
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War. 400,000 / 12,000,000 or 4.7% were Hispanic, Full integration into military
units.
200th Coast Artillery from New Mexico and the Bataan Death March
65th Infantry Regiment in France commanded by LTC Juan Cesar Davila
relieved the 442nd RCT
Veteran Dr. Hector Garcia started the American GI Forum in 1948 to stop
discrimination of Latino veterans
• Korea: 147,800 Hispanics served in all branches. 9 received the Medal of
Honor, 100 received the Distinguished Service Cross and Silver Stars for
combat bravery
• Vietnam: 344, 000 Latinos Served, 23 Hispanic Medal of Honor Winners
• Iraq War
• Afghanistan War, 1 Hispanic Medal of Honor Winner
The Cultural Formulation Interview (CFI) of Hispanic
Veterans
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Understanding the cultural context of combat trauma for Hispanic Veterans is
essential for effective diagnostic assessment and clinical management
Focus are four (4) domains of assessment:
1. Cultural Definition of the Problem: Focus on the individual’s own way of
understanding the problem; ( What are your Idioms of distress, Language used to
describe your problems, individual’s ethnic background and developmental
experiences?)
2. Cultural Perceptions of Cause, Context and Support: Focus is on the
meaning of the condition for the individual, and the views of members of the
family, friends and community;(What do you think are the causes of your
problems, and what does your family, community think is causing your problem?)
Stressors and Supports: Elicit information on resilience, social supports and
also stressful aspects of the individual’s environment i.e. discrimination,
difficulties at work, school or relationships ( Are there any kinds of support from
family, friends that make your problem better? Are there any kinds of stressors that
make your problem worse; such as money or family problems?)
*DSM-5
The Cultural Formulation Interview (CFI) of Hispanic
Veterans (Part 2)
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Role of Cultural Identity: Elicit aspects of your cultural identity that make
your problem better or worse (Are there aspects of your cultural identity that
make it better or worse for you?)
3. Cultural Factors Affecting Self-Coping and Past Help Seeking: Elicit
various sources of self-help; (What kinds of help were most useful? Not useful?)
Barriers: Ask about social barriers to seeking help; Stigma, discrimination;(
Has anything prevented you from getting help?)
4. Cultural Factors Affecting Current Help Seeking: Clarify the person’s
cultural network of support including Religion, Spirituality, Older Adults;
(What kinds of help from your family, community, church would be helpful to
you?)
Clinician-Patient Relationship: Elicit concerns about the clinician’s values and
cultural background; ( Do you have concerns with the care I am giving you?)
*DSM-5
The Hispanic Veteran and the Role of Hispanic Identity
• Strong Family Support
• Religion & Spirituality
• Language
• Implications for the Therapist:
• Ask the veteran which aspects of Hispanic identity make
the problem better, or worse?
Strong Family Support; Stressors and Support
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Devotion to the family
Source of Material and emotional support
Reliance on each other
Shame is experienced when roles of proper conduct are not
met
• Implication for the therapist:
• Are there any kinds of support from your family that
makes your problem better, or worse?
Spirituality: Cultural Factors Affecting Self-coping and
Past Help-Seeking
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Maintain strong spiritual beliefs
Most belong to organized religions
Predominantly Catholic
Rituals are interwoven in the lifestyle
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Implications for the therapist:
Ask if your religion, faith, has been helpful to you?
Include the use of rituals to assist in the intervention
For Moral Injury : The concept of seeking forgiveness and
making amends
Language, Cultural Definition of the Problem
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Spanish language has idioms of distress:
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Uncomfortable emotions are expressed somatically- reason for seeking primary care
providers
Panic Attacks can be expressed as “ nervios”
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Tradition of machismo:
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Does not allow for complaints
Treatment is for others
Implications for the Therapist:
How would you describe your problem?
Spanish is primary language of use when one wants to convey different emotions
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To validate the client’s language;“ How would you say that in English,”
Asking for Help: Barriers
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Proud people have difficulty asking for help, due to:
Pride
Loyalty
Machismo
Gender Roles
Treatment Considerations for Hispanic Veterans:
Clinician-Patient Relationship
1. Higher respect for authority; will defer to therapist directives
2. Provide psycho-education on rationale for treatment and
coping mechanisms; which will improve client decisionmaking and increase self-esteem
3. Directive Interventions; Cognitive Behavioral Therapy using
Cognitive Restructuring, Journaling, and homework
assignments
4. Provide Couples and Family Therapy; will help re-connect
and re-vitalize family relationships
5. Ritualize Treatments; integrate treatment with religious
practices and family activities.
Posttraumatic Stress Disorder, DSM- V
A. Exposure to actual or threatened death, serious injury, or sexual
violence:
A.
Direct experience
B.
Witnessing in person as is occurs to others
C. Learning that the traumatic event occurred to a close family member
or close friend
D. Experiencing repeated or extreme exposure to aversive details of the
traumatic event
B. Intrusive, recurrent , involuntary: memories, dreams, dissociative
reactions (flashbacks), Intense or prolonged psychological distress at
exposure to internal or external cues that symbolize or resemble the event,
Marked physiological reactions to internal or external cues
Posttraumatic Stress Disorder -continued
C. Persistent Avoidance of stimuli associated with the traumatic event:
A. Avoidance of memories, thoughts or feelings
B. Avoidance of people, places or situations
D. Negative Alterations in Cognitions and mood associated with the
traumatic event
A. Persistent and exaggerated negative beliefs or expectations about
oneself, others or the world
B. Persistent, distorted cognitions about the cause or consequences of
the trauma that lead to the individual to blame him/herself
C. Persistent negative emotional state ( fear, horror, anger, guilt,
shame)
D. Markedly diminished interest in significant activities
E. Feelings of detachment from others
F. Persistent inability to experience happiness, satisfaction or loving
feelings
Posttraumatic Stress Disorder -continued
E. Marked alteration in arousal and reactivity associated with he
traumatic event
A. Irritable behavior and angry outbursts
B. Reckless and self-destructive behavior
C. Hypervigilance
D. Exaggerated startle response
E. Problems with concentration
F. Sleep disturbances
F. Duration of Disturbance in > one (1) month
G. Significant disturbance or distress in social, occupational or other
important areas of functioning
H. Disturbance is Not related to substance abuse
Types of Stressful Combat Zone or Military
Setting Experiences
 Terrorist Activities
 Exposure to Improvised
Explosive Devices (IED’s)
 Exposure to Vehicle Based
Improvised Explosive Devises
 (VBIED’s)
 Surviving attacks from
explosive devices
 Exposure to suicide bombers
 Ambushes
 Firefights
 House-to-house searches
 Accidentally wounding or
killing civilians
 Being shot at
 Surviving combat wounding
 Exposure to the wounding or
death of others.
 Encountering human remains
 Surviving a vehicle accident
 Difficult living and working
environments
 Poor leadership
 Concerns about relationship,
family and life disruptions
 Sexual Assault or harassment
 Perceived exposure to
chemical, biological or nuclear
weapons
Treatment Focus with Hispanic Veterans
• PTSD – Military Related
• Complex PTSD
• Moral Injury
Moral Injury, Definition
• Moral injury; a construct that describes extreme and traumatic life
experiences, where events are morally injurious if they "transgress
deeply held moral beliefs and expectations"
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The lasting psychological, biological, spiritual, behavioral, and social
impact of perpetrating, failing to prevent, or bearing witness to acts
that transgress deeply held moral beliefs and expectations
*Moral Injury and Moral Repair
Brett Litz, PhD
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www.ncptsd.va.gov
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Moral injury is present when: (1) there has been a betrayal of what’s morally
correct
(2) by someone who holds legitimate authority (3) in a high stakes situation
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Jonathan Shay MD, PHD
Wkipedia.com
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Combat Trauma and the Soldier
• After the trauma,
• SM is preoccupied with the event
• Intrusive memories as a response to
horrific experiences
• Replay the upsetting memories to
modify their feelings and to tolerate
the memories
• If unable to integrate the memories,
they avoid and become hyper-aroused
• Failure of time to “heal the wounds.”
Memories are not accepted as part of
the past
Changes in Belief Systems (STICS)
 Self-esteem. Difficulty believing that life is meaningful , the
assumption that one is a worthy person.
 Trust. Difficulty trusting in one’s own decisions, others, leaders or
governments.
 Intimacy. Questions the belief that people are capable of love and
worth relating to.
 Control and Competency. Distorted beliefs that events are no
longer orderly, predictable, fair and controllable. Feelings of
vulnerability.
 Safety. A persons sense of safety and security is compromised.
The world is a more dangerous place.
RAA Cluster Symptoms of PTSD
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REEXPERIENCING THE TRAUMA: Intrusive memories, nightmares,
flashbacks
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AROUSAL: Irritability and anger, sleep problems, hyper vigilance,
exaggerated startle responses, difficulty concentrating
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AVOIDANCE: Avoiding one’s feelings, avoiding relationships, losing
interest/avoiding activities, being overly detached.
Intrapsychic Factors contributing to PTSD
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Worsening of stress-related symptoms,
new onset of dangerousness to self or others
maladaptive coping to stress,
exacerbation of co-morbid psychiatric conditions,
deterioration in psychosocial functioning
new onset stressors
Co-occurring and Psychosocial Issues related to adapting back
to family/installation/community living
 Recognizing co-occurring
disorders resulting from
combat trauma
 Suicide ideations
 Alcohol and Substance Abuse
 Anger, Aggression
 Grief Reactions
 Physical Health problems
 Chronic Pain
 Sleep Problems, insomnia,
nightmares
 Anxiety
 Depression
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Recognizing psychosocial
issues resulting from combat
trauma
Marital conflict and divorce
Parent-child relationship problems
Domestic violence
Employment problems
Issues in school or education
Financial strain
Homelessness
Primary Life Areas of Functioning for the Returning
Combat Veteran
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Marital, Partner and Family Relationships
Employment
Higher Education, Vocational Training
Peer support and friendships
Housing
Legal
Financial
Community and church involvement
Recreational
Evidence based practices and non-traditional healing
practices for PTSD
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Cognitive Processing Therapy
(CPT) Evidence-Based Practice
Prolonged Exposure (PE)EvidenceBased Practice
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Eye Movement Rapid
Desensitization (EMDR)EvidenceBased Practice
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Family Therapy (FOCUS)
Couples Therapy
Specialized Inpatient PTSD
Programs
Partial Hospitalization Programs
 Complimentary and Alternative
Medicine (CAM)
 Animal Assisted Therapy
(AAT)
 Innovative Outdoor Adventure
Therapy Programs
 Resiliency Skills Training
• Pharmacotherapy
• Anger Management therapy
• Fitness Training
• Stress Inoculation Training
Theoretical Basis for Understanding PTSD
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1. Pre-Trauma Belief Systems of “Self” and “The World”
2. The Traumatic Event: Trauma memories of :
A .Stimulus Elements (Auditory, Visual, tactile triggers)
B. Response Elements ( Fight or Flight)
C. Meaning Elements (“Dangerous” “Incompetent”)
3. Post-Trauma Experiences (Persistent Symptoms, Disruptions in daily
life, negative reactions from others)
• Two negative schemas that underlie chronic psychopathology:
• “ The world is completely dangerous and, the self is totally inept”
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Foa and Kozak (1985)
Core Clinical Assumptions
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Suffering from PTSD for the Hispanic veteran can involve betrayal of/ by
spiritual, moral, cultural and family values
Healing from PTSD requires understanding what belief systems have been
compromised; the Cognitive Dissonance
Clinicians can assist the veteran to emotionally process guilt, shame, sorrow,
and re-evaluate his/her sense of responsibility related to the trauma
There is the need for Making Amends, Forgiveness or Restorative Justice in
order to reattach back to one’s family and community
Spiritual, community, cultural, and family acceptance matters a great deal
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Brett Litz, Moral Injury and Moral Repair
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Mechanisms of change for Trauma-Focused
psychotherapies
 Trauma-focused psychotherapies include:
 exposure techniques that involve repetitive review of traumatic memories and traumarelated situations,
 cognitive techniques that focus on identification and modification of trauma-related
beliefs and meanings, and/or
 stress reduction techniques designed to alleviate PTSD symptoms and assist patients in
gaining control and mastery over the physiological reactivity
 SIT protocols include components of
 cognitive restructuring or in-vivo exposure,
 breathing retraining
 relaxation
 The core components involve combinations of:
 exposure (particularly in-vivo and imaginal/oral narrative),
 cognitive restructuring,
 relaxation/stress modulation techniques, and
 psychoeducation.
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P117 Guidelines
Treating symptoms using Cognitive Behavioral Therapy; for
arousal, avoidance and re-experiencing
 For increased arousal, the goal of treatment is to help the person learn
skills that will reduce overall arousal. relaxation, self-hypnosis, and
physical exercises that discharge tension.
 • For behavior, the goal of treatment is to review a person's most frequent
ways of behaving under perceived threat or stress and help him or her to
expand the possible responses. time-out; writing thoughts down when
angry; communicating in more verbal, assertive ways; and changing the
pattern "act first, think later" to "think first, act later."
 • For thoughts/beliefs, individuals are given assistance in logging,
monitoring, and becoming more aware of their own thoughts prior to
becoming emotionally upset. Give alternative, more positive replacement
thoughts for their negative ideas (e.g., "Even if I am out of control, I won't
be threatened in this situation." . Individuals often role-play so they can
practice recognizing their emotionally-arousing thoughts and apply more
positive thoughts.
Engagement: Initiating trust with the Hispanic
Veterans; Five “Icebreaker” questions
1. Ask : What was the client’s branch of the military? Army / Navy /
Marine Corps / Air Force / Coast Guard?
2. What was service member’s rank? ie SGT/Chief Petty Officer
3. What unit was the service member assigned to? ie 1st Marine Division
4. Where did he/she serve? Iraq/Afghanistan/ USS Enterprise/ Fort McNair
5. What was the service member’s Military Occupational Specialty (military
career)? ie 11B Infantry
Establishing a Therapeutic Alliance with a Hispanic
Service member or veteran
• Compassion, that the military is an honorable but hazardous
occupation
• Empathy; understanding that combat creates the most intense
feelings of grief, fear, anxiety
• Trustworthiness; “ Do what you say you are going to do”
• Acknowledgement of the client’s service to the country,
• Understanding of the military sub-culture
• Provide realistic hope; that the client will learn to live more
comfortably with uncomfortable feelings
• Be open-minded and non-judgmental
• Watch a military documentary or movie
PTSD Screening Tools
• PTSD Checklist
(PCL-M)
• Beck Depression
Inventory
PTSD Checklist (PCL): The PCL has been used
extensively in military and civilian populations, and there
are numerous validation studies, including studies in
military populations (Terhakopian et al., 2008).
• Novaco Anger
Scale
• Assessment for
Suicide
Research supports the utility of brief
screening tools for identifying
undiagnosed cases of PTSD
Questions and Discussion
Gracias, Thank you, for your participation