Post-traumatic stress disorder (PTSD) is a severe, persistent emotional reaction to a traumatic event that severely impairs the individual's life. It is the most prevalent mental disorder arising from combat. As Veteran's Administration faces up to a new generation of combatants and veterans, the existing perspective is to build on the lessons of the past by serving those in present need but also aiming at the future to maximize preparedness and, if possible, prevention. Recently the Institute of Medicine (IOM) Committee on Treatment of Posttraumatic Stress Disorder released the report Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence (2008) concluding that while the evidence was inadequate for most psychological and pharmacologic treatment modalities, there was strong evidence to support the effectiveness of Exposure Therapy for the treatment of PTSD. In addition they noted that although it could be expected that psychotherapies pose special challenges in different cultural groups, they were unable to comment because none of the studies addressed the acceptability, efficacy, or generalizability of treatment in ethnic and cultural minorities. The committee recommended designing specific studies of interventions tailored to these specific subpopulations.
The proposed study focused on the translation, from English to Spanish, and the cultural adaptation of a manual-guided exposure therapy for Spanish-speaking veterans with PTSD. To accomplish this goal, we proposed the following specific aims: (1) To translate therapist and client manuals of an established theoretically-based exposure therapy for PTSD; and, (2) To evaluate the cultural compatibility of the translated manual guided intervention and culturally adapt the theoretically-based, exposure therapy intervention manuals.
Initial activities involved the translation from English to Spanish of manual guided interventions by a professional translator. The second phase involved the cultural adaptation of the manual guided interventions. The CDC model to guide the adaptation of behavioral interventions and the eight dimensions of the culturally centered treatment framework proposed by Bernal and collaborators guided the methods we followed in the adaptation of the Prolonged Exposure (PE) therapist and client manuals. Key informant interviews with mental health providers and administrative personnel were conducted for the assessment of the local community conditions that impact providers and veterans, and the organization's capacity to implement the intervention. Focus groups discussions with OEF/OIF veterans explored the elements of treatment interventions proposed by CDC and Bernal, Bonilla and Bellido.
During the assessment phase we found that it is common for San Juan Veterans Health Administration (SJVHA) to adopt evidence based interventions and conduct patient assessments using the English version of the manual and assessment measures. The framework guiding this project sustains that it is essential that interventions and assessment measures be translated into the patient's population language, placing special emphasis on the attainment of conceptual and cultural equivalence. In examining the cultural equivalence of the language used in the PE therapist manual, we took into consideration the age group (20-50 years), gender (male and female), education (high school or higher), and trauma experiences of OEF/OIF veterans.
Overall, providers, administrators and patients acknowledged that there is a strong interest among the SJVHA in advancing the clinical care for OEF/OIF veterans with PTSD. Focus groups and key informant interviews provided significant information on relevant provider characteristics for providing trauma-focused therapy to veterans. Our findings revealed that patients were in agreement with how PE defines the problem, as well as the goals and the methods of treatment. When discussing their attitudes and views about the proposed PE treatment intervention, participants unanimously endorsed the importance and benefit of talking to professionals about their experiences and traumatic events. The importance of family members was particularly highlighted when discussing their attitudes and views about the proposed PE treatment intervention. To strengthen this dimension within PE we designed an introductory session targeted at participants and their family members explaining the main principles, goals and methods of PE, as well as the relevance of this treatment for veterans with PTSD.
The work proposed to be accomplished in this study, as well as future research efforts grounded in the product of this project, will strongly contribute to address the mental health care of Hispanic veterans with PTSD and advance interventional studies focused on the reduction of health disparities among ethnic minorities, priority topic areas of high relevance for HSR&D. Next re-search efforts will focus on conducting a pilot study to test and further refine the culturally adapted interventions with Spanish-speaking veterans. Future research efforts will focus on the examination of the effectiveness of the intervention with PTSD Spanish-speaking OEF/OIF vet-erans. Our ultimate goal is to make available to VHA a culturally relevant intervention with proven effectiveness that could contribute to increase access to mental health care and to eliminate mental health disparities.
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