Patient and Provider Characteristics
shows the clinician and patient characteristic for the analytical sample. Out of the total study sample, these 31 patients who were diagnosed as having PTSD by both the provider and research clinician formed the analytic sample. Twenty-four clinicians were involved in assessing these PTSD cases. These 24 clinicians served 31 patients, of whom the largest percentage was Latino (68%), followed by non-Latino white (29%), and Black (Afro-Caribbean; 3%).
Below we provide examples of themes reflecting the way clinicians discussed strategies used for diagnosing PTSD. (Clinician and patient dyads are numerically identified to allow comparison across the examples. ID numbers used in this paper are not patient record numbers, but are solely for research classification; some identifying information is obscured to ensure confidentiality).
Theme 1: Assessing Cultural Identity
Cultural Identity of the CFD model was evident in 7 out of the total 31 patient cases (23%) and represents the reflections of seven different clinicians. Clinicians discussed this component of the CFD model in regards to identifying what country the patient comes from, or what larger ethnic group the patient identifies with, in order to help identify the potential mix of socio-cultural influences that has patterned the patient’s world and risk for traumatization. For instance, various providers note the different circumstances of recent immigration for Cubans who came to the US as “political refugees,” or Central American or Haitian immigrants who came to the US for economic reasons, or Italian Americans who have long established cultural enclaves. Some described broadly the risk for a particular ethnic group, rather than specific country of origin, as this Latina clinician described, “I consider culture. [My patient] is Latina, and childhood trauma is so common in Latino groups I need to consider [this possibility] (Clinician #10, Patient #138). In this case, the patient and provider shared gender and ethnic background. In another example, a Black clinician described familiarity with her patient’s cultural background related to trauma diagnosis because of the clincian’s time spent in the Middle East. Specifically, she focused her questioning on how the patient is treated as a woman in a Middle East context and how this may heighten her risk for trauma.
Study clinicians sometimes took into account that cultures are experienced differently by different members according to subgroup characteristics such as gender, class, religion, race, and sexual orientation, among other factors. In the following case, this white female psychiatrist considers how her Latina patient identifies and fits within her cultural origins and current cultural transitions as an immigrant. She considers what impact this has on the risk for PTSD and the consequences of trauma.
She described to me that she’s [from Central America]. And I think it’s a huge part of her presentation. Many of the struggles that she’s dealt with are related to her cultural background but also [in part] to a changing culture. This includes moving when she was [in her late teens] to a new country, and I think it’s a huge part of her story. Her depression and her PTSD feel cross-cultural. It’s independent, but I think her ethnicity and her life story are hugely a part of who she is and how she suffers. (Clinician #46, Patient #423)
Theme 2: Cultural Explanations of the Illness
The heart of the Cultural Formulation is this second section, which examines the cultural factors that affect the experience and interpretation of illness, as understood by the patient, the family, and the social network. Explanations of illness help to create the illness experience by affecting cognitive, bodily, and interpersonal aspects of disease. This includes helping to shape symptom presentations, perceived etiologies, severity attributions, treatment choices, and outcome expectations. This component was reported in only 7 cases with seven different clinicians.
Two examples represent challenges to clinicians regarding symptoms which could be interpreted as psychosis or dismissed as supernatural folklore. As one white male provider describes of his Latina patient:
Well, we talked a bit about her faith and she grew up Catholic and you know when she says: “Oh, I hear”— one of her grandchildren was murdered --, “Oh, I hear this toddler playing in the hallway, when in fact there’s no one there.” Well, is that psychotic or is that sort of culturally appropriate for Hispanics. It could go either way. (Clinician #45, Patient #409)
By entertaining the possibility that cultural beliefs (ethnicity and religiosity) are a lens through which to explore a PTSD diagnosis and its symptoms, this clinician is then subsequently able to extract extended information about the trauma history. Without extended exploration of contextual background the clinician might be drawn to assumptions of delusional thinking. However, this clinician relied on the patient’s “explanations of how traumatic experiences have affected and continue to affect her” in order to determine a diagnosis. Similarly, a white female psychiatrist described a Haitian patient who reported recurring “flashbacks of his mother’s death and that “the cause of his mother’s death was related to voodoo.” (Clinician #64, Patient #608) Although the clinician was unable to get more detailed information from the patient, she was primed to pay attention to “a big cultural component” of the patient’s expression of loss and trauma during the intake.
In addition, clinicians described cultural explanations for illness that were explicitly related to the cultural background of the patient and commonly understood as such in the patient’s community. For example, a Latina psychologist described “padece de nervios” (suffers from nerves) that she observed and heard from her Latina patient:
For example, I know that in El Salvador it’s important to ask whether “someone suffers from nerves? “Do you suffer from nerves?” This is a term that is used a lot diagnostically to describe a picture very similar to PTSD.] (Clinician #2, Patient #125—Translated from Spanish)
A more subtle example is that of a Latina psychologist describing her Latina patient’s presenting complaints: “The person came to me because she had [suffered] a long period of headaches. [These were] headaches that wouldn’t go away, and [she had] nightmares, and the nightmares gave her nausea” (Clinician #8, Patient #131—Translated from Spanish). This clinician emphasized the patient’s somatic expression of illness to identify that the patient was experiencing both emotional and physical distress related to her trauma history.
Theme 3: Cultural Factors Related to the Psychosocial Environment and Levels of Functioning
This section of the CFD model allows the clinician to examine how culture influences the stressors patients are exposed to and their reactions to these situations. The clinician can also consider the social supports available to patients and the contexts against which their functioning should be measured. This component of the CFD model was evident in 12 out of the total 31 patient cases (39%) and represents the reflections of 12 different clinicians during post-intake interviews.
In some cases, the evaluation of trauma is based on what the clinician believes is the “meaning” of a particular trauma for a patient given the developmental and social norms of his or her culture. This includes a consideration of the psychosocial supports, and competing stressors at the time of the experienced trauma, for instance a white female patient is “struggling financially” but the white male provider who evaluated her also pointed out the importance of exploring “religious background and current level of spiritual involvement the client uses as part of her recovery process” both for substance abuse and mental health (Clinician #30, Patient #301)
Another level of use for this CFD component is in reflecting how current psychosocial supports and stressors exacerbate preexisting PTSD symptoms. One Latino psychiatrist reflected on how immigration and risk of deportation brings to light other underlying PTSD symptoms and stressors in the area of psychosocial support for his Latina patient,
She has suffered a lot of trauma in her life. The incident that occurred a week ago (her friend telling her that she was going to report her to the immigration agency) was a trigger that brought her back to this state of trauma. She describes her problem as PTSD. She has been feeling well for some time, but this incident put her again in such a condition. (Clinician #7, Patient #120)
Consideration of psychosocial supports and social status (such as education and employment) in identifying risks for PTSD or how traumatic environments have affected patient psychological and social outcomes were evident.
Well with people coming from developing countries now, there is often neglect and abuse. Those countries have gone through civil war. There’s extreme poverty there, and also the parents, out of economic necessity, leave the children with other relatives and they have to go to the US to get jobs and make money and try and bring the kids over. But the people they leave them with, they don’t have control over how their kids are treated. And often they aren’t nurtured and are physically abused and are made to work, hence, I’d say that’s [a] cultural, socioeconomic [risk]. (Clinician 18, Patient 172).
However racial/ethnic considerations were not as primary among some clinicians, as this white female provider goes on to say that, “in terms of being Spanish, I didn’t really notice-I mean, I just know the deprivation that he’s coming from” (Clinician 18, Patient 172). In this example the socioeconomic vulnerabilities of trauma are considered although not articulated specifically in the context of culture.
Theme 4: Cultural Elements of the Clinician–Patient Relationship
This CFD component allows the clinician to consider how his/her own interaction has affected the disclosure of the patient’s illness experience, including symptom expression and treatment response (Lewis-Fernandez & Diaz, 2002
). Cultural Elements of Clinician-Patient Relationship were described by 4 different clinicians across four different cases. One Latina provider emphasized the importance of having experience working with diverse cultures in order to better understand their experiences. This clinician also mentioned the additional gendered connection she had with her Latina patient who thus found it easier to reveal a history of sexual abuse to a Latina female provider in a shared language. (Clinician #8, Patient #131)
Just as important to noting shared connections was having the insight to realize one’s limitations. For instance, a Latina provider described her historical knowledge of her Latino patient’s country of origin and his exposure to political violence, but at the same time admits, “I’ve never lived in anything like that. I think that somebody who’s lived through that would understand it much better. If I had better firsthand knowledge I would have been able to “formulate question[s] in a different way thereby getting richer information about his trauma history” (Clinician 15, Patient 158).
In contrast to these deeper reflections on the cultural elements of the patient provider relationship, a white female provider discounted the importance of shared ethnic background of her white male patient: “Well, frankly, what difference would it make?” She goes on to say that while the patient might feel that “there’s a kinship” and maybe “feel more comfortable” it is not an important consideration for her (Clinician #36, Patient 332). Similarly, a Black female provider chuckles about the fact she was able to “make a little connection” with a Middle Eastern patient by speaking “some Arabic” (Clinician #76, Patient #726). Although the connection is identified as positive for the patient in each of these cases, there is little attention to how this enhancement to the patient-provider relationship might increase diagnostic capability or in the formulation of the clinical presentation. There was no mention across any of the clinicians regarding how patients from different cultures perceive authority figures (such as clinicians) when specifically discussing trauma.
Theme 5: The Overall Impact of Culture on Diagnosis and Care
The final component of the CFD model summarizes the information in the previous sections, focusing on cultural material that contributes to diagnosis and treatment. The role that cultural features have played in determining overall illness outcome is particularly emphasized. This CFD component was described by 10 different clinicians across ten different cases in discussing patients with trauma histories. Several examples centered on interpretation of the patient’s recollection of witnessing or experiencing domestic violence. For instance, providers had to assess patient reports that downplayed histories of violence, as in this example of a Latina provider describing her intake with a Latina patient: “There are cultural-gender roles that include machismo or male dominance but [what this patient] described [is] physical, verbal, and sexual abuse”. This clinician had to consider the context of a potentially traumatic experience by assessing the boundaries between culturally based gender role expectations and trauma (Clinician #2, Patient #125—Translated form Spanish).
In another case, a white female provider presented the patient’s recollection of traumatic childhood events (“when his uncles were physically abusing him”), as well as physical evidence (“he said he still has the scar he got when he was seven”), and then placed this in a larger cultural context: “I’ve worked with a lot of people from the Dominican Republic. And they had a terrible revolution and a lot of them at a certain age saw a lot of violent things, murders and terrible things.” (Clinician #18, Patient #172). The childhood abuse was a primary trauma but by taking into account the larger context of political violence the clinician feels she gains a clearer picture of how these experiences “interfere with relationship capacity” and can become cumulative. Delving into the patient’s cultural background, specific to this patient’s experience of living through a revolution, she notes, “that affects people too, if you ask them about it.”
For this theme, two of the clinicians stated that culture was not relevant to the diagnosis. When asked outright if social, cultural, or racial background influenced the diagnostic assessment of her Latina patient, a Black female clinician said that “It didn’t” (Clinician #76, Patient #721). In the second example, a Black clinician stated that she would not say her patient is “a white woman so I give her ‘X’ diagnosis – it’s really just about history of trauma and abuse” (Clinician #21, Patient #209).
Theme 6: Other Diagnostic Strategies and Concerns
The CFD components, when used, were usually used together with other strategies in assessing PTSD in this diverse patient population. In 25 out of the 31 patient cases (81%), when clinicians discussed PTSD they reported using other diagnostic strategies, which were not related to the CFD model. These strategies most commonly included: (1) previewing patient records to ascertain a history of trauma and previous clinical assessments; (2) prioritizing substance abuse as a focus in dual diagnosis cases; (3) delineating DSM-IV PTSD symptom criteria in the interview. The most common reported barriers to more fully assessing the context of trauma included needing to streamline inquiry about trauma because of time concerns and limiting discussions of trauma in the first meeting in order to limit distress in the patient.
In summary, the most frequently coded CFD model component related to trauma and PTSD was assessing cultural factors related to the psychosocial environment (39%). The least frequently coded CFD component was cultural elements of the patient-provider relationship (13%). In 30% of cases there was no reference to any of the CFD components, 37% of cases noted one component, 7% of cases noted two components, 23% of cases noted three components and in 1 case the clinician named four components. No clinician named the CFD or reported systematic use of the full CF. (However, we should note that CFD components may have been discussed in other sections of the interview not related to trauma and PTSD, and a more general analysis of cultural aspects of the patient-provider encounter is underway (Alegria et al., manuscript under preparation). Other diagnostic strategies (reviewing old charts, asking PTSD DSM-IV criteria, deciphering dual diagnoses or multiple diagnoses and time limitations for discussing multiple issues) were more often discussed by clinicians (81% of cases).