Cultural Values in the Treatment of Depression

(Dr. Lusk) Today we’re going to talk with
a client, Alberto, who is a Vietnam veteran. In this particular case, we’re going to see
an interaction between a Hispanic therapist and a Hispanic client who strongly identifies
as a Mexican, not as a Mexican American. Important to know that we do not mean to imply in any
of these trainings that in order to be an effective therapist or clinical social worker
with a Hispanic client that you need to be Hispanic, not at all. What we’re contending
in our training is that to be a good therapist and to be a good practitioner with any other
group requires that you be culturally competent, and to some extent, we hope, linguistically
competent in the culture and the context of that particular person’s culture and orientation.
In this case, we’ll see some interesting features because not only is he a Hispanic male, but
he’s also a veteran and he’s a decorated veteran, so there’s another cultural theme that permeates
this particular case which is that he is a person who was raised in a Hispanic culture,
but has strong identification with himself as a former military officer and as a veteran.
Alberto has been asked by some of his friends in a church group that he belongs to to come
into being evaluated and possibly treated because his behavior has been changing over
the last few months. Some of the precipitating events may be that his wife died 7 months
ago, which of course we know is associated with grief and loss, so, he’s been experiencing
the consequences of that loss. But, to aggravate the situation, just a few weeks ago his companion animal, a dog, also passed away, so, he’s had a couple of grief related incidents in the
near past. The folks at his church noticed that he had become more socially isolated
and when he came in for his initial evaluation, and now we’re going to go into the second
session, not the initial workup by the intake social worker, who did all of the confidentiality
clarifications about what it is that are his protections. The intake social worker noticed
that he had reported that his drinking had increased over the past few months, to the
point that he was isolating himself socially and drinking alone, which we always know in
clinical work is something to be concerned about. Alberto’s 65 years old. He was born
in Mexico, but was a U.S. citizen with his parents migrated to the United States as a
youth. He attended an inner city school here in El Paso, called Bowie High School. For
those of you not from El Paso, it’s a classic inner city school, highly minority represented
and is only a few blocks from the border. This is an area of town called, Segundo Barrio,
which is one of the most historic parts of our city in that it is a longstanding community
for migrants from Mexico and is a platform for migrants from Mexico and people born here
in El Paso–Americans of Hispanic origin, to move on upward and forward in society from
their more humble upbringing in that context. He, himself, growing up in Segundo Barrio,
faced all of the challenges that youth face in such an environment. Nonetheless, he did
not join a gang. He did not become involved in some of the things that people stereotype Hispanic
barrios about. Indeed, quite the contrary, he graduated from Bowie High School in the
upper half of his class, was a very good student, and knowing that his opportunities were probably
pretty limited given the employment prospects of a young man in the 1960s, he joined the
army, rather than being drafted, because of course at that time, that was a very real possibility.
He joined the army and quickly advanced in a non-commissioned role as a non-commissioned
officer rising to first sergeant where he was a Huey helicopter repair person. He was
deployed to Vietnam and served in Vietnam behind the front line as a technician and
only saw traumatic events indirectly, that is through the people that were coming in
on the Hueys and going into the medivac hospitals and so on. However, because of his aptitude,
he was identified for early career promotion to a warrant officer and was sent to flight
school in the United States and became a chief warrant officer, eventually retiring as a
chief warrant officer 4. What’s important to this case, is that he experienced a series
of traumatic events in Vietnam. One of the most traumatic events was where he was on
a landing zone, as they say, attempting to load injured combat soldiers onto the aircraft
and he received fire at the aircraft. Several of the men that he was attempting to load
into the aircraft were shot. He got out of the aircraft to assist in the loading. He,
himself, took fire. He got back into the helicopter. He noticed that his copilot had been shot
in the head and was dead. He attempted to take the aircraft off. The aircraft failed
and he crashed at the scene. He was rescued along with his fellow soldiers by a medivac,
but that event, having seen all these men killed in combat and then having seen his
copilot shot in the head was very traumatic. That being said, he went on to a successful
career after the Vietnam era and continued to serve with distinction for 20 years. He
also has received a number of combat related medals. All of this is detailed in the case
study that is available on this module so that you can learn a little bit more about
Alberto. After getting out of the army, he had a career in helicopter maintenance and
repair, but for our purposes, now he’s retired. During retirement, he has experienced a lot
of the things that people who are retired experience, and that is increasing social
isolation. The challenge of finding meaning absent of ongoing and productive labor. Over
the past few months, his intake worker said that he had complained of a loss of appetite,
significant change in his sleeping patterns. He sensed that he didn’t feel himself anymore.
His affect was quite flat and depressed. He used the word, that he feels really “weak”
and doesn’t feel so much like a man like he used to. The preliminary assessment made by
the intake worker was that he has chronic post-traumatic stress disorder, but that we’re
now looking at an acute depressive episode. So, he has been referred to Dr. Sam Terrazas
who’s a licensed clinical social worker and clinical supervisor and master clinician who’s
going to take on the role in this next session of his clinician. So, I’ll turn it over to
them. [Knock at door] (Dr. Terrazas) Come on in.
(Alberto) Good morning. (Dr. Terrazas) Good morning.
(Alberto) Dr. Terrazas? (Dr. Terrazas) Yes, Mr. Casas. Very
nice to meet you Buenos dias. Please take a seat.
(Alberto) Thank you very much. (Dr. Terrazas) You’re welcome. Can I get you
some water or coffee or anything? (Alberto) No, I’m good. Thank you.
(Dr. Terrazas) Yeah? Okay, great. What side of town did you come from?
(Alberto) What side of town? Central. (Dr. Terrazas) Okay. So was the traffic okay?
(Alberto) The traffic was a little bit hectic, but not too bad.
(Dr. Terrazas) Yeah, they’re doing a lot of construction–
(Alberto) A lot of construction, yes, making a mess in several places.
(Dr. Terrazas) Yeah, yeah it gets frustrating. Did you have any trouble finding the place?
(Alberto) Not really. They had told me, more or less, where it was, so I was able to walk
right over here. (Dr. Terrazas) Okay, great great. I noticed
that it looked like it was going to rain this morning. It wasn’t raining when you came through,
yeah? (Alberto) It looked like it was going to rain,
but it didn’t. It was just, you know, wind and dust all the usual.
(Dr. Terrazas) That’s good because that does complicate things when we get going, which
I hear (inaudible). How long have you been in El Paso?
(Alberto) Most of my life actually, except for the time that I’ve been in the military. I
was always–this has always been my hometown. I’ve always been an El Paso boy. Yeah, most of my
life I’ve been here. (Dr. Terrazas) Oh, I see. Okay. How much time
did you spend in the military? (Alberto) Oh, I’ve spent quite a few years, quite
a few years. 8 years active duty, and then I did some reserve time as well.
(Dr. Terrazas) Very admirable. (Alberto) Thank you.
(Dr. Terrazas) So, what I want to talk about a little bit is just sort of how this works.
You were referred over here and I got some information about you, so I have kind of a
heads up of what’s going on. (Alberto) Yeah.
(Dr. Terrazas) We’ve already talked about confidentiality in intake, so we’re not going
to go into it a lot–a great deal about that, but you understand the limits of confidentiality?
(Alberto) Yeah, yeah. They told me all about that.
(Dr. Terrazas) Okay, so if you have any questions at that point just let me know about that,
okay? So, tell me, you’re retired? (Alberto) Yes.
(Dr. Terrazas) How long have you been retired? (Alberto) I’ve been retired since ’04, so
it’s been a while now, 11 years. I’m going on 11 years.
(Dr. Terrazas) What do you spend your time doing?
(Alberto) Today? Actually, today? (Dr. Terrazas) Well, just in general, I mean
since you’ve been retired have you found other employment–
(Alberto) Well, I have been doing a lot of volunteer work and I have been spending a
lot of time with people in church and what have you. I kind of stopped doing that, and
right now I’m not doing much of anything. (Dr. Terrazas) I see.
(Alberto) I used to spend a lot of time with my dog, but he died a couple of weeks ago.
(Dr. Terrazas) I’m sorry to hear that. What was your dog’s name?
(Alberto) I just called him puppy. He was just a mutt, but he meant a lot to me.
(Dr. Terrazas) Sure, I understand. (Alberto) Yeah, I spent a lot of time with
him grooming him, walking him, and all of that. Now, that he’s gone there’s really nothing
to do. During the day, I watch a lot of tv, eat a lot of tv dinners, drink a few beers.
I don’t even work on the garden much anymore. (Dr. Terrazas) So, you’ve said about 2 weeks
ago Puppy passed away? So, it sounds like Puppy was very important to you.
(Alberto) Well, he was because that’s kind of all I had left after my wife died. He kind
of kept me busy, kept me occupied. Now, that he’s gone I don’t do much of anything.
(Dr. Terrazas) I see. And your wife passed away some time ago, from what I read, correct?
(Alberto) Yeah, 2 years ago. (Dr. Terrazas) So, you’ve had some significant
losses over the last several years. (Alberto) Well, yeah. The most important person
in my life was my wife. I come from the barrio, I don’t know if you know about that, and I’ve always identified
with the barrio. I grew up in the second (inaudible). When I retired, and even while I was still
working after I left the military, my wife and I spent a lot of time helping out. Down at
the barrio we did a lot of work with the people at la fey over there, helped with the church
and the convent they have down there. When she passed away, I haven’t felt much like
doing that anymore. I don’t have the will, the strength to do that.
(Dr. Terrazas) It sounds like you and your wife were the barrio and your history there
was really important to you and you wanted to give back, I presume.
(Alberto) Yeah, it was because I remember when I was a kid there was a lot of bad stuff
going on in the barrio. I had 2 older brothers and they kind of kept the peace in our neighborhood.
(Dr. Terrazas) Really? (Alberto) Yeah. I still have a lot of distant
cousins there and my mother was the old fashioned type, that she would take in even some of
my friends that didn’t have a good home, didn’t have enough to eat. She would take them in
for long periods of time. My heart is kind of still there
(Dr. Terrazas) So, who you are as a person, your identity really is part of the barrio.
You still have family there it sounds like. (Alberto) Always was. Always was.
(Dr. Terrazas) Can you tell me more about what that is, because I’m not from El Paso,
in particular. I know about it, but I surely don’t have the insight that you would have
about that would mean. (Alberto) Yeah, well, when I still had my dad, my dad
passed away when I was in my teens, but when I still had my dad he taught us a lot of important
things. He taught us the old way. He would give us a cozcarron if we didn’t listen, or
my grandma would give us a peisco, but they taught us to take care of the family, to take
care of friends, take care of each other. My older brothers did that for me, down in
the barrio, and I kind of passed it on to younger kids. That kind of stays with you
wherever you go. I even took that when I was in the army. It really helped a lot. Those
are pretty good values to live by. (Dr. Terrazas) So, it sounds like familia
is really important. Respeto is really important and that translated into other parts of your
life. (Alberto) Yeah. You got to do what’s right,
especially you got to start with your family, your friends, and your relatives. That kind
of takes you a long way. That helps you like in the military to respect authority, to get
along with (inaudible) and that sort of thing. I still see that in the barrio, when I was
helping out at la Fey I still see a lot of folks that even though they’re poor and struggling they
still have those values inside of them. That’s why I never kind of left the barrio. Physically,
I might have left, but my heart is still there, my mind too.
(Dr. Terrazas) That’s great. So, it sounds like the values that your father and the
community itself, or in general, really was very powerful and it was a level of strength
for you. (Alberto) Yeah. It taught me how to be a man.
At 19, I had to leave and go and be on my own. I had to be a man by then. I had to do
what a man does. I had to be strong. I had to earn–‘portase bien’ that kind of thing.
(Dr. Terrazas) So, the idea of machismo, in the sense that you learned the proper ways
of being a man, meaning that you took care of your family, you had to be strong in the
sense of doing what was right for your family and other people, and it sounds like that
in the military that would be an important value to hold.
(Alberto) It was. It really helped me out because during that time we had the Vietnam
War going on so it was really important that you had a sense of value and respect and that
your were strong in a hellacious situation over there. If you didn’t have a good foundation,
inside, you weren’t going to make it. It was kind of–a lot of it I learned and a lot of it
was just thrust on me and I was kind of forced to learn a lot of things over there. But always,
always wherever I was, it was the same thing that drove me–be strong, be loyal, that’s
everything that my dad taught me. (Dr. Terrazas) So, would you say, and it sounds
like you’re saying, that the values of being strong and the respect really worked well
when you were in the military and it sounds like, what I heard as well, was that those
values also helped you survive to some degree. (Alberto) Oh, yeah. I mean, because you had
to respect other people so they would respect you and you needed that because we all depended
on each other. We were all trying to get out of hell together. As it turned out, when I
was growing up in the barrio I didn’t even know a lot of gringos, but in Vietnam we were
all brothers because we had to be. Once we got out of Vietnam we started separating,
you know, gringos are not over here, the rest of us over here, but in Vietnam we had to
band together. So, yeah, it helped me. Those values helped me get along and I moved up
through the ranks. (Dr. Terrazas) Really? I want to make another comment
about the idea of family. So, that idea of family and the strength of family and the
commitment to family ended up really translating well to when you were in Vietnam, it sounds
like, to have this band of brothers because that’s what you spoke about. That value sort
of worked well, and I’m presuming really helped you again get through whatever that was.
(Alberto) Yeah, well what happened in Vietnam is that if you did your job well, if you were
able to survive then you advance. When you advance that meant that you had more responsibility
for other people. So, here you are, if you’re a sergeant you got 12-15 guys underneath you
and you’re responsible for these guys. One of them gets shot out in the jungle and you
carry that weight on your shoulders because he was in your squad.
(Dr. Terrazas) Oh, I see. I wasn’t in the military. I only know very little about what
that means. I certainly wouldn’t understand what that would be like to be in the military
during wartime. So, can you tell me a little bit about what it meant to you to be in the
military? (Alberto) Well, it was–I was proud to be
in the military because like I said, coming up in the barrio a lot of stuff was going
on at that time. It still is. A lot of people my age wound up in jail or dead. I was happy
that I was able to get out there, kind of in an honorable way. I didn’t necessarily
agree with the war over there. I didn’t start it, but my country said they needed me over
there and I’ve accepted this country as mine so I was proud to serve over there. I had
an opportunity to look after troops underneath me and what have you. That’s what a man does.
So, I was proud to serve. (Dr. Terrazas) That’s very admirable. It seems
like the idea of machismo really also supported your progress, and I guess survival in the
military as well because it sounds like that your commitment to the other men and your
commitment to hard work and your– the value of those things really helped
you move up in the ranks. (Alberto) It did. I did fairly well. I did
fairly well. I was, as a matter of fact, in comparison with the gringos over there in
Vietnam, we really did have different values. They were kind of more personal. They looked
out after themselves and not so much the others, where I was kind of the opposite. They complained
a lot. I didn’t because I came up hard. To me it was just like another day at the office,
but those guys though they were just like counting the hours until they could come back.
There was a difference and that’s why I think I was promoted over a lot of those guys.
(Dr. Terrazas) I see. To what degree were you promoted?
(Alberto) I went up–I did several tours. I did 3 tours. When I got in country I was a
corporal, and then I quickly moved to sergeant, and then staff sergeant, and then sergeant
first class, and then they gave me a chance to go to aviation school.
(Dr. Terrazas) Wow. (Alberto) They didn’t have too much of a choice
on the one hand because they were really short on pilots, but on the other hand I was doing
really good work over there so they gave me an opportunity to come back stateside and
go to school and I got my wings, then they made me a warrant officer. By the time I left
over there, I was a chief warrant officer. Some crazy guys at the VA still call me chief,
but that was a long time ago. (Dr. Terrazas) I’m guessing that your aptitude
had a lot to do with your ability to do those things, the values that you learned in the
barrio and your family probably helped you get to where you got I’m presuming.
(Alberto) Yes, all of that and the other thing was that one of the things that you have to
conquer to survive in Vietnam was fear because you were always scared over there. You never knew
who was going to shoot at you. The enemy you had over there, you couldn’t see. Nobody could
ever see those guys until they were right on top of you. A lot of the guys that I worked
with–they didn’t make it because they were just too scared, but in the barrio, if you’re
scared you’re not going to make it there either. I had 2 older brothers and they taught me
to face–if I had a problem they taught me to face it. If that meant that I had to go
toe-to-toe with so and so, I did what I had to do, and I did the same thing over in Vietnam.
So, that helped me a lot because I kind of focused on what I had to do and that helped
me forget about the fear for a little bit. I mean, I was scared, but I didn’t want to
show it. (Dr. Terrazas) One of the things men do is,
Hispanic men maybe or men from the barrio, specifically, is they don’t show their fear.
(Alberto) You don’t show your fear. You don’t show your weaknesses.
(Dr. Terrazas) But, that doesn’t mean that you’re not emotional. It doesn’t mean that
your not fearful. (Alberto) Actually, you are. You’re fearful
and you’re emotional, but you don’t show that because once you do, you become weak and if
you’re weak, if somebody’s after you, they’re going to get to you.
(Dr. Terrazas) Right. I see, I see. The presence of weakness is an important thing for you
in terms of how you identify yourself or how you see yourself. You don’t want to be seen
as weak. (Alberto) No, never, never.
(Dr. Terrazas) Do you think people misinterpret that sometimes–that they see you maybe being
hard or maybe stoic or whatever, but it’s really about the belief that you have related to
not wanting to be seen as weak? (Alberto) Well, I think that’s what’s been
happening to me lately is all of these things–there’s a lot of things going on that I don’t understand
and they do make me seem weak. That’s why I don’t go to the church meetings anymore
with the guys over there, because those guys are strong. The faith they have makes them
strong and that makes them successful and they’re admired by their family and their
friends. The way I feel, the way I feel, I don’t want them to see me like this. I’m not
myself. It is because like–I just don’t feel strong anymore.
(Dr. Terrazas) So, would you say that the thing that bothers you the most right now–or
let me rephrase that. What bothers you the most right now, in terms of how you’re feeling
or what you’d like to change? (Alberto) Well, I guess what bothers me the
most is that I’m not myself. I kind of like to be my old self and my old self is, even
though I’m old and I’ve got these old wounds and everything hurts, I felt strong. For this
place and time, for my particular situation, I felt strong. Lately, I don’t. I feel that
people who look at me they will think that they need to help me out and I need to lean
on them, so I don’t even go to places I used to go because I don’t want that to happen.
(Dr. Terrazas) So, what you’d like to do is feel strong again and that means–maybe one
or two things you could tell me about what that means so I understand it better?
(Alberto) Yeah, right now it’s like I’m always tired and a lot of it is because I’m getting
old, but I know that if I was to do something that was important, that was important to
me, that would help me forget about that. It would help me get out of this funk that
I think I’m in, but I can’t find the–I can’t find the, I guess, forgive my French, but
I can’t find the juevos to do it for right now. I don’t know why. There’s, like I said,
I still felt that way when I had my dog. I sure felt that way when I had my wife, but
right now I don’t have the desire to do much of anything.
(Dr. Terrazas) So, what have you done in the past to sort of get the juevos back, so to
speak? (Alberto) Well, like I said, I used to do
a lot of volunteer work. I still belong to the Lion’s Club. They also were with me when–and
they helped me help out at the barrio at la Fey–we did hearing screenings. We gave out food baskets
in Christmas. We went out and we helped people paint their houses and do basic repairs on
people’s houses and even helped them with their carts sometimes. That made me feel good.
That made me feel like I was helping out, like I was protecting some of these little
older folks that lived down there that needed a hand up. Same thing with the guys at the
church, somebody fell into some bad times we were there to help with whatever we could
whether it was money or food or whatever. When we couldn’t do that we could at least
pray for the guys. (Dr. Terrazas) So, really, what it sounds
like you have been a very giving and very thoughtful person throughout your life and
it sounds like what’s made you get the juevos back or get feel back in line with how you
were was really just helping people. What’s interesting is that the thing that helped
you the most is the thing that you don’t want to do right now, because you’re ashamed–that’s
my word, you didn’t say that, but you feel like you don’t have the strength to go be
in front of those other–of your friends because you don’t want them to see you as weak. Isn’t
that interesting–that you want to help and you’re a good person, you’ve done these amazing
things, you’re an admirable honorable man, you’ve served our country, and yet, I would
presume your friends and people in church know that to some degree or another, but yet,
in your mind kind of, you see yourself as weak and you don’t want to present that to
the people, I’m guessing, care about you, and respect you, and are concerned about you,
because the referral came from them as well. (Alberto) Yeah, I think I agree with that. I kind
of dug myself into a hole. I’ve been drinking a little too much, a little more than usual
and that makes things even worse. If I’m in a funk, that makes it worse, but that cold
beer’s always in the refrigerator. You take a couple of those you think you start to feel
better until it wears off. That’s what I don’t want people to see.
(Dr. Terrazas) Oh, I see. (Alberto) I don’t want people to see that
I don’t have everything under control and I don’t feel like I have everything under
control. (Dr. Terrazas) I think it’s really good insight
that you see that the alcohol isn’t going to be helping you. The other part of that
is that it’s probably not the best thing to do because, you’re right, it just covers up
for a little while, you know this. I don’t have to (inaudible). But, the thing is that
as you think about what you’d like to do to sort of move forward, I think that you’ve
done very well in your life. You have a lot of strengths. It seems like you’ve been very
functional–well, actually, highly functional. So, maybe, it’s about going back to things
that you used to do. The fact that you’ve lost your dog recently, it’s pretty normal to feel
the way you feel. You’ve lost your spouse, you’re maybe feeling lonely is what I’m hearing
a little bit. You’re feeling sad about those things that have happened in your life. I
don’t see that as anything different than what most people would feel. Part of it is
maybe seeing yourself in that light that a lot of people who would be in that situation
would feel that way. You don’t have to sort of feel like you’re not–feel like you’re
not ‘normal’, so to speak–that you have done something wrong, or that you’re less than,
I guess. Is it possible to maybe ease towards those things that you used to enjoy. It sounds
like, given the things that have been important to you in your life, your family, your friends,
your commradery that is it possible to, maybe, start easing back to your social groups, going
back to church a little bit with the idea that you don’t have to just rush into obviously.
You need a little bit of time to grieve and a little bit of time to feel sad.
(Alberto) Yeah, I think I could do it, but it would have to be like you said, kind of
a gradual thing. I don’t think I can just walk into a big meeting with the brothers
in church and say, “I’m back,” sort of thing. I couldn’t do it with the Lions either or
the people at la Fey, but I could–what I could do is, I guess, call a couple of the
guys at the church group and maybe talk to them, just start out doing small things kind
of start from scratch. (Dr. Terrazas) That is a great idea.
(Alberto) Then, maybe I could do the same thing with the Lions. I’m sure those guys
would be able to help me. These guys have helped me a lot more over the years than the
VA or places like that. Those guys have their head up their butt, the way I feel.
(Dr. Terrazas) I think a lot of people feel that way, unfortunately.
(Alberto) Yeah. Yeah, I think I could kind of ease back. I couldn’t do it just cold turkey
like walk into a meeting and say, “I’m back.” (Dr. Terrazas) Exactly. That seems very reasonable.
That seems like a very smart idea. Secondly, maybe, just as a suggestion, is that one of the things
when we’re feeling sad and our appetite is low and that we’re getting tired, we really
have to–it’s important to think about eating right. You’re a fit man. You’ve always been
fit, so maybe getting back to that as well. I know it’s hard and can be difficult, but
you can see where not eating right, not being healthy can also exacerbate being tired and
that can also sort of lead into you not feeling like wanting to do stuff. So, it’s kind of
like a vicious cycle. One thing that you could potentially do is be thoughtful about eating
those meals a little bit, maybe getting out a little bit, but, you know, bit by bit, like
you said. You can’t just turn the page and do everything the next day.
(Alberto) Yeah, I used to hike up at the mountains at the national park over there. I’ve been thinking
about starting to do that again, but the way I’m feeling, I’m afraid I’m going to fall
over there. I would have to get a little stronger before I did that.
(Dr. Terrazas) That’s a great idea, but maybe you could, maybe, just walk around a track
or something. Something–ease into it. Ease back into it. You’ll see, hopefully, you’ll
see that your energy will come back a little bit with your support system, with your brothers
and the different clubs and having you move into that, I think will be useful too. So,
can we agree, we’ll work towards that this week and next week we’ll come back and kind
of see how you’re doing? (Alberto) Yeah, I can come back next week.
I think I can talk to you a lot better than the guys over at the VA. They’ve been trying
to get me to talk for years, but I don’t trust them.
(Dr. Terrazas) Right. That means a lot–that we’ve developed that trust. Fantastic. So,
same time next week and we’ll see you then. (Alberto) Sure.
(Dr. Terrazas) Have a great week and you can call me if you have any questions.
(Alberto) Thank you very much. (Dr. Terrazas) Nice to meet you, Senor. Have a good
day. (Dr. Lusk) Culturally competent social work
in Spanish. After each session we debrief. In this case, we’ve used a practicing therapist
rather than a student, but we debrief so that we can recap some of the themes that we saw
in the interview and frame them for that student and for the rest of the students to see what
things that we learned from it and then also to coach and critique as needed. For the purposes
of this debriefing, we’re going to talk about some of the things that the therapist did
and that the client did that we found particularly illustrative of some of the principles that
we’re trying to develop for this module, most importantly, how the two engaged around cultural
issues because, as we’ve been saying in this module, cultural issues are matters of strength.
They’re sources of resilience. When we work with a person we always have to be cognizant
of their context not only as a member of an ethnic or cultural group, but as a member
of other groups, families, military organizations, professional occupations, and all the various
forms of identity that each of us bring to the therapeutic relationship, but in this
particular case, we’re focusing in closely on the fact that we had a Hispanic veteran
who identifies very strongly with his culture. That was being used by the therapist as a
potential source of resilience and recovery for him which all the evidence points to as
being a very very helpful feature of treatment insofar as we draw on those things that gave
us sustenance in the past and we saw that his culture definitely gave him a great deal
of sustenance in the past. Sam, the therapist, Dr. Terrazas was able to pull out of his past
a great deal of significance around his identity as a Hispanic man. A couple of the things
I’d like to talk about and we’re going to do this as a panel so each of us has an opportunity
to assess what we thought was important, was that when they established a rapport, the
therapist took–actually a fair amount of time, a fair number of minutes to do that.
You may have noticed that that was a longer period of time than you see in a conventional,
sort of Anglo style assessment and intervention. For instance, it is very off-putting to traditional
Hispanic clients for a therapist to enter into the work phase immediately. There is
a tendency in my culture, I’m Anglo-Saxon, person who would likely, in most interactions,
quickly cut to the chase, as we say–get down to business. That’s the style of dominant
American culture. In this particular case, Sam took some time to get to know him. He
spent some time talking about him as a person, and I think, that opened up immediately, for
Alberto, a sense of comfort and that’s really important in establishing the relationship.
He very briefly described the ground rules because, as the intake worker had done that,
but as a clinician then, he began to focus in on some of the client’s losses. He clarified
that there had been a death of his spouse some years back. He clarified that there was
a death of his pet, the client’s pet. He also talked with the client about the process of
disengagement that he had been going through over the past few months, but at the same
time, he was able to bring back this to the individual’s past and was evoking memories
of when Alberto grew up in the Segundo Barrio, which is a traditional low-income Mexican
neighborhood. It was there that the theme of familismo, or the focus on the importance
of the family emerged because Alberto was talking about his mother’s role in the home.
He talked about his dad’s role in the family and how, as a young man, he was taught respect,
loyalty, and the value of helping others. This was real important, I think, in assessing
this interview from that cultural point of view, because it moved on and segued well
into the cultural attributes that he had as being very helpful to him in being resilient
in the military. The loyalty, the sense of duty, the sense of being a proper man, which
could be framed as machismo, and again, we frame, in this module, machismo as a positive
attribute, not as the violent sort of stereotype that some people have of machismo in Hispanic
culture. The therapist referred back to his cultural base. Why? Because he was going to
lead the client, as you saw in the latter part of the interview, back to reconnecting
with that as a potential source of strength in the future. So, while he had disengaged
from activities in his church and with the volunteer work that he was doing, he did recognize
with the expiration that the therapist had done, that these were very important sources
for him. From a clinical point of view, one of things that Sam was able to focus in on
was the issue that Alberto felt weak. He was ashamed of feeling weak. Those were the clinician’s
words not his, but in many respects when he said, “I don’t feel strong,” the client and,
“People will look at me and think they need to help me,” that’s a quote, this is cultural
code for depression. When you talk with a Hispanic male who’s traditional, they’re not
likely to tell you straightforwardly, “I’m depressed,” because that is, in fact, a confession
of weakness and is a confession that they’re not wanting to feel comfortable with. So,
one of the ways in which depression is often expressed in Hispanic clients is somatization
through stomach aches, through head aches, and saying, “I feel lethargic,” and you did
hear him say he felt lethargic, “I don’t have the energy that I used to have,” but what
he was getting at was that he’s depressed and he feels devalued. Then, as the interview
went on, as we saw, this was being set up very well. Sam began to talk about ways that
he could reconnect through volunteering because as a young man, or as a retired man, he had
painted houses in the segundo barrio, he’d fix cars, he protected older folks who needed
a hand up as he said. This was framed by Sam as he was helping people. We know that helping
other people is also a very therapeutic activity. He went on then to begin to move toward closure
by saying that it seemed like he didn’t feel that he had everything under control. He seized
on that when the client noted that. He also reaffirmed in the client his observation that
the client knew that he was drinking too much and that this wasn’t solving the problem.
It was only giving a short term relief. So, he recognized that the client had that kind
of insight. He also normalized the process of grief. Grief is a natural and normal process
of life, especially when you lose a life companion whether it’s your pet or most importantly,
if it’s your spouse. We need to let people know that these kinds of responses and grief
reactions are normal. Sam let him know that these were normal responses, but then brought
it back to the issue of how he might ease back into some of the social institutions
and cultural institutions that had sustained him. A couple of themes that I’d like to conclude
with are familismo. The value of family to this particular person was huge. It framed
everything about him and now he has no wife. He has no immediate family. He’s living alone.
Even his pet is gone. Imagine the sea of isolation that he is swimming in in the absence of having
the fundamental cultural institution that formed him and sustained him through life.
Another is respeto, or respect. His concern about respeto is that he doesn’t want to appear
to feel weak because he respects himself, he respects others to respect him. He can’t
do this if his loss of orgullo or pride, and that threatens his traditional view of the
male role. His fear of being seen as weak. I think that one of the final statements I
could make about this is that this is a really good representation of how you can connect
a person to their cultural identity at the same time connect them with their cultural
groups that can sustain them through the process of recovering from loss, because it seems,
in this particular client, that the PTSD is probably fairly latent. We didn’t see any
references to anger or road rage or hyper arousal or those sorts of things we see with
PTSD, so this is really probably a fairly normal reaction to grief and loss and Sam
framed it very well. What would you like to say in retrospect, having looked back at that
interview? (Sam) I think what was really important in
that interview was the idea that, like you were talking about earlier, that men–Hispanic
men are not going to want to divulge their weakness and depression would certainly be
that way. There’s stigma around mental illness, as we know, across many populations many groups,
but for Hispanic men, they’re there because of this idea of being strong and this idea
of machismo. They’re not going to want to commit to a therapist and say, “I’m depressed.”
So, you have to be very careful in how you frame that kind of language, but also in how
you differentially diagnose, using the idea of culture as a way to understand the language
that they use to sort of explain symptomology. I think that was really important and beyond
that is the idea of engaging the client in where he’s at and know that if you don’t engage,
if there isn’t that respect and that understanding of cultural awareness, you’re going to struggle
to get that client back in for another session. In this case, Alberto said that I trust you
and I can talk to you better and he spoke very specifically saying, “All those people
at the VA, I don’t really trust them,” or whatever. That’s not a dig on the VA. It’s
probably more about speaking to the importance of cultural competency and work with Hispanic
men in general. (Dr. Lusk) Good. Dr. Chavez?
(Dr. Chavez) Well, I just want to add the importance about performing a deep interview
about the immigration, because the reasons of immigration also are going to lead you
about how the people behave and how the people can resolve the issues that happen in their
lives. (Dr. Lusk) In this case, then, you would suggest
that Sam perhaps added some questions or probed a little bit about the migration experience,
because we know the migration experience is a significant factor in becoming an American
and leaving another identity. He seemed to hold on very strongly to his Mexican identity,
but what kinds of things would you have asked? (Dr. Chavez) I’d ask them the reasons of immigration.
If they reason because of the violence, if they migrated to the U.S. because of the violence
or if they migrated because they are looking for this American dream or because they were
looking for feeding their family. (Dr. Lusk) Right. I think that’s an important
point because one of the things that’s lost in the current debate about migration is the
failure to recognize that people migrate here primarily for economic reasons and often–or
actually returning back to their country of origin and identify strongly with their Mexican
identity, but the other is that there’s a recent wave of migrants that’s coming to the
United States over the past 7-8 years who have been profoundly traumatized by the war
on drugs in that country and by the rise of organized crime there. We want to be checking
with that with any type of migrant. Is there anything you’d like to add in conclusion,
Sam? (Dr. Terrazas) Yeah, the final thing that
relates to the migration part is that if folks migrate here because they feel like they’re
being forced then the process of acculturation becomes much more complicated. If they have
children that makes it much more complicated. So, the likelihood or the probability that
psychosocial sort of problems will sort of be more prevalent with those populations.
First is someone who migrates because they got a great job and they’re excited about
it so the acculturation process will be much different. That’s what the importance is,
I think. The secondary importance Dr. Chavez spoke about of assessing the migration process.
(Dr. Lusk) Very good. Well, we hope this has been useful in understanding the source of
strength that being a member of a cultural group can bring to the therapeutic and healing

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