References for Culturally-Sensitive Treatment of PTSD Annotated Bibliography

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Culturally Competent Trauma Care

Allen, B., Wilson, K., & Armstrong, N. (2014). Changing clinicians' beliefs about treatment for children experiencing trauma: the impact of intensive training in evidence-based, trauma-focused treatment. Psychological Trauma: Theory, Research, Practice, and Policy, 6(4), 384-389.

Despite a recent push towards more structured treatment protocols, many clinicians have taken an unstructured approach to the treatment of trauma in children, based upon a belief that children may be unable to verbalize or otherwise express their feelings about a trauma. This study focuses on whether training can change a clinician's approach in practice and suggests that intensive training can influence clinicians in their choice of therapeutic approach and guide them to use evidence-based therapies (EBT) that are highly structured. This research fails to discuss the impact that cultural upbringing may have on the willingness or ability of children to discuss trauma early in the treatment process. As a result, it may be that these EBTs have applications limited to the cultural groups in which they were developed.

Bernal, G., Jimenez-Chafey, M. & Domenech Rodriguez, M. (2009). Cultural adaptations of treatments: a resource for considering culture in evidence-based practice. Professional Psychology: Research and Practice, 40(4), 361-368.

The use of evidence-based practice in psychology and the broader practice of medicine has been gaining momentum. However, there are questions about the cross-cultural applications of therapies developed in specific cultural contexts. Most of these questions are posed based on ethnic differences in culture and look at diagnosis as well as treatment. On the other hand, there is resistance to challenges to evidence-based therapies because of the established success of those therapies. The authors suggest cultural adaptations to existing therapies that would allow the therapies to be utilized cross-culturally, but with culturally-specific modifications.

Brady, K. & Back, S. (2012). Childhood trauma, posttraumatic stress disorder, and alcohol dependence. Alcohol Research: Current Reviews, 34(4), 408-413.

The exposure to childhood trauma is positively correlated to the development of alcohol dependence in later life. Generally, the trauma precedes the development of the alcohol dependence, which is suggestive of a cause and effect relationship. Of course, common cultural factors that lead to exposure to childhood trauma could be responsible for the development of later alcohol dependence. Moreover, the role of neurobiological changes that occur as the result of trauma and increasing alcohol dependence may impact the ability to recover from either.

Couineau, A. & Forbes, D. (2011). Using predictive models of behavior change to promote evidence-based treatment for PTSD. Psychological Trauma: Theory, Research, Practice, and Policy, 3(3), 266-275.

This study focuses on the differences in proven EBT practices and the approaches that clinicians actually used when treating trauma. One reason that clinicians may not implement EBT is that they have concerns about treatment outcomes. These concerns may be reasonable and may reflect their awareness of cultural differences in the populations being served. However, the study focused on encouraging implementation rather than on exploring why clinicians felt like it might not be successful.

De Young, A., Kenardy, J., & Cobham, V. (2011). Trauma in early childhood: a neglected population. Clin Child Fam Psychol Rev, 14, 231-250.

This study looks at childhood trauma and the interaction between development stage and the development of post-traumatic stress disorder (PTSD). One of the things the researchers highlight is that the diagnostic criteria for PTSD is not developmentally-sensitive. As a result, diagnosis in children may be over-inclusive because a normal reaction to trauma at different developmental stages may look like PTSD in adults. On the other hand, it could be under-inclusive, because children experiencing PTSD may not exhibit all of the maladaptive hallmarks one would anticipate in an adult patient.

Eisenhruch, M. (1991). From post-traumatic stress disorder to cultural bereavement: diagnosis of Southeast Asian refugees. Soc Sci Med, 33(6), 673-80.

Not only do cultural differences impact treatment, but they may also impact diagnosis, because normative behaviors differ across cultures. In this study, Eisenhruch examines a phenomenon he refers to as cultural bereavement among the Southeast Asian refugee community. The hallmarks of this phenomenon match the diagnostic criteria for posttraumatic stress disorder. However, Eisenhruch suggests that, culturally, those behaviors are adaptive rather than maladaptive. As a result, treatment or intervention may have long-term negative consequences rather than the intended positive consequences.

Hall, R. (2005). Childhood posttraumatic stress disorder: a comprehensive analysis of recognized treatment options considering the neurobiological impact of trauma (Doctoral dissertation). Chicago School of Professional Psychology, Chicago.

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Retrieved from ProQuest. (UMI 3239722).

In this work, Hall examines neurobiological changes that occur as the result of childhood trauma, resulting in possible alterations in neural circuitry. These changes have the ability to impact functioning on multiple levels: behavioral, cognitive, emotional, and social. Because all four of these components are influenced by cultural norms and guidelines, it seems clear that potential changes will interact with cultural background in individual patients. Furthermore, Hall looks at the impact of socioeconomic background, a component of culture, on normal development, and suggests that because schools are expected to serve multiple roles for these children (counselors, nurses, referees, meal providers, parents) that schools have a compromised ability to educate (2005, p.4), suggesting that the impact of trauma and a culturally competent approach to the treatment of trauma might naturally extend beyond the traumatized individual.

Henry, J., Sloane, M. & Black-Pond, C. (2007). Neurobiology and neurodevelopmental impact of childhood traumatic stress and prenatal alcohol exposure. Language, Speech, & Hearing Services in Schools, 38(2), 99-108.

This study examines the impact of the combination of childhood traumatic stress in the form of abuse, neglect, or sexual abuse, and prenatal alcohol exposure on childhood development. It finds that they are negatively correlated with intelligence scores and positively correlated with neurodevelopmental deficits and some behavioral disorders. The research suggests that teachers or speech pathologists have to change their approaches to work with these students. While an atmosphere of abuse may not be a typical cultural hallmark, this research does indicate the important role that environment plays in development.

Murray, L., Cohen, J., & Mannarino, A. (2013). Trauma-focused cognitive behavioral therapy for youth who experience continuous traumatic exposure. Peace and Conflict: Journal of Peace Psychology, 19(2), 180-195.

While there has been much research on EBTs used for children with history of trauma, much of it has ignored the role that continuing trauma plays in the outcomes for these children. While some of this continuing trauma can be classified as abuse, other elements of it are culturally normative and help define the role of culture in these children's lives. Therefore, this research looks at four different strategies that are commonly used to deal with continuing trauma. The conclusion is that trauma-focused cognitive -- behavioral therapy (TF-CBT) can be used successfully by children coping with continuing trauma.

Trautman, R., Tucker, P., Pfefferbaum, B., Lensgraf, S.J., Doughty, D. Buksh, A., & Miller

(2002). Effects of prior trauma and age on posttraumatic stress symptoms in Asian and Middle Eastern immigrants after terrorism in the community. Community Mental Health Journal, 38(6), 459-474.

This paper focused on different immigrant groups living in Oklahoma in the wake of the Oklahoma City bombing. Many of those immigrants had a history of trauma prior to immigrating to the United States. If earlier trauma was linked to the development of PTSD or exhibition of PTSD-like symptoms, the victims were more likely to develop PTSD after the bombing. This suggests the possibility of a cumulative impact of prior trauma.

How to Provide Culturally Relevant Care

What the research makes clear is that application of previously effective EBTs may be unsuccessful if those EBTs are not tailored to specific-cultural groups. To provide culturally relevant care, it is critical to understand what behaviors are considered normative in that culture, and which behaviors signal maladaptive behavior. Without having that knowledge, it is impossible to diagnose PTSD, much less to treat PTSD. In addition, it is important to look at the culture to see if there is an expected history of prior trauma, like one would expect in refugee groups, or even a likelihood of continuing trauma, which might otherwise interfere with treatment.

How to Assess Treatment

Assessing treatment for different cultures may involve an inspection of normative behaviors from the framework of that background culture. Is the person able to interact as a normal and healthy member, from the perspective of his or her own cultural norms and expectations? However, this assessment plan has weaknesses. Just because something is considered normal within a culture does not mean that it is healthy, even when viewed from the context of culture. For example, there are a number of practices that are documented as being unhealthy that are considered normal parts of culture. It may be a better goal to discuss with the patient which cultural practices he or she wants to continue post-treatment and then assess treatment by examining.....

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