Clinician’s Corner: PTSD Treatment Considerations for Asian Indians – Ateka A. Contractor, PhD, and Anu Asnaani, PhD

The South Asian community includes individuals originating from the Indian sub-continent region (e.g., India, Pakistan, Bangladesh, Bhutan, Nepal, Sri Lanka, Maldives). Asian Indians (i.e., individuals of Indian descent) are a subgroup of the South Asian community. This Asian Indian community reports experiences of several commonly occurring traumatic events, including natural disasters, interpersonal traumas (e.g., domestic violence), and racism-based traumas.^1-5 In response to such traumas, Asian Indians endorse posttraumatic stress disorder (PTSD) symptoms (with prevalence estimates reported to be as high as 70% in some studies). ^1,5 Critically, Asian Indians living in other countries face additional unique immigration-related stressors such as acculturative stress, ethnic identity conflicts, lack of social support from extended family members, lack of knowledge about local health care institutions and policies, and discrimination (anti-Muslim sentiment post-9/11, anti-Asian sentiment during the COVID-19 pandemic).^6,7 Also, Asian Indians are less likely to use mental health-related services,⁸ including those for PTSD symptoms. Considering the prevalence of traumatic events and PTSD symptoms, immigration-related factors, as well as community-specific mental health-seeking barriers, it is important to address the issue of appropriate and effective PTSD treatments for this community.

There are several evidence-based treatments for PTSD including prolonged exposure therapy (PE), cognitive processing therapy (CPT), and cognitive-behavioral therapy (CBT), among others.⁹ While there is some preliminary work that examines such front-line PTSD treatments among Indians in their country of origin,¹ we are not aware of work that has culturally adapted existing PTSD treatments or examined their effectiveness among the Asian Indian community living in other countries, such as the U.S., who present with additional complicating immigration/acculturation issues as noted above. This is a huge clinical and research gap in the existing knowledge base.

Toward the larger goal of informing PTSD interventions for this community, we are highlighting a few points and considerations based on our research and clinical work with Asian Indians in their country of origin as well as in other countries:

1. Clinicians would find it helpful to acknowledge that Asian Indians are not a homogenous cultural group—there is tremendous diversity in terms of religion, language, and cultural norms within this community that has implications for PTSD interventions. For instance, an individual who identifies as Asian Indian and Hindu may believe in “karma” and “reincarnation”; such beliefs may help to reduce guilt associated with traumatic events (e.g., ideas of destiny, rebirth and a new opportunity to live life).⁵
2. Clinicians would also be aided by familiarizing themselves with the collectivistic values of the Asian Indian community—which include an emphasis on societal and familial interdependence as well as group/community needs and goals.¹⁰ Thinking about our own clinical work with Asian Indians, such collectivistic values have been shown to influence if and how clients chose to disclose or not disclose traumatic experiences, especially if perpetuated by family members. Further, certain cognitive beliefs that are targeted in CPT/CBT may have to be framed within an interpersonal context (e.g., beliefs of interdependence, beliefs about causing familial shame).
3. Asian Indians utilize family and friends as primary coping resources instead of seeking professional services; familial support is a strength for this community.¹¹ This being said, at times, families choose to isolate individuals with post-trauma distress to avoid societal stigma and shame, contributing to the rising need for institutional care for individuals with serious mental health conditions in India. Thus, PTSD treatments with a familial component may be a strength or disadvantageous depending on the quality and nature of bonds and understanding within an individual’s family. Balancing group-level beliefs/norms with an assessment of the individual’s unique family setup is in line with culturally competent approaches more broadly.¹²
4. Clinicians might also wish to consider that Asian Indians are not socialized and encouraged to express emotions.⁷ Hence, PTSD interventions that involve emotional exposure strategies such as PE may have to be modified or tailored to account for the default tendency for engagement in emotional avoidance and suppression in this community.
5. As another distinct consideration of this community, it would be helpful for clinicians to note that a considerable number of immigrant Asian Indians live in multigenerational households (e.g., ~25% Asian Americans in the U.S.).¹³ Such living conditions may impact privacy and confidentiality considerations, as well as the definition of “family” in PTSD interventions.
6. Language is another important point to consider in PTSD intervention work with Asian Indians. Estimates suggest that, for example, ~30% of American Asians speak only English, and >60% speak a language other than English in their homes.¹³ A question raised in this regard is whether the terminology of “trauma” is appropriate when talking about stressful life experiences as understood in the context of their language/dialect and experiences. Also, there is limited data on cross-cultural validation and psychometric properties of back-translated trauma/PTSD assessments that are needed for therapeutic practice in this community.¹⁴
7. Similar to other communities of color, Asian Indians report cultural stigma on seeking mental health treatment,⁷ which may contribute to under-reporting of trauma experiences and associated distress as well as limited engagement in adaptive coping strategies (e.g., getting a divorce or separating from partner when in an abusive relationship). Additionally, we don’t know whether a treatment labelled as a “trauma intervention” may be stigmatized, and thus avoided, by this community.
8. Another question is whether PTSD is a valid diagnostic construct capturing posttraumatic symptoms among Asian Indians.^5,15 As a clinician working with Asian Indians, it may be important to consider the manifestation of PTSD as somatic symptoms or as idioms of distress within the socio-cultural and psychological framework of the Indian culture.¹⁶
9. Given the collectivistic nature and religious/spiritual orientation of this community, clinicians may want to consider a more holistic approach for PTSD interventions, including community involvement (e.g., religious institutions), indigenous treatments (yoga), and local rituals.⁵ Further, family-based approaches to treatment may provide an opportunity to capitalize on the social support system and strong familial ties. However, such features are yet to be empirically examined for the Asian Indian community living in other countries, who vary in their level of acculturation to ethnic/heritage and mainstream cultural values.
10. Lastly, research does indicate that Asian Indians prefer a more directive, solution-oriented, and structured therapeutic approach (e.g., CBT) that focuses on symptom reduction.⁷ Thus, Asian Indians may be open to structured, manualized PTSD interventions (however, this question also needs to be empirically examined).

In summary, there is an imminent need to develop and examine effects, feasibility, and scalability of both culturally-adapted and culturally-informed PTSD interventions¹⁷ among the Asian Indian community (including immigrant individuals living in other countries) to address health disparities as well as to reduce the health burden of PTSD in this community. Indeed, supporting evidence suggests that immigrant Asians (e.g., those living in the U.S.) may benefit from Western approaches to mental health treatment, especially when they are culturally tailored.¹⁸ Relatedly, conducting nationwide studies on trauma experiences and PTSD prevalence estimates among Asian Indians may provide useful data to inform clinical knowledge and practice. Lastly, there is a need to overcome a range of institutional barriers, especially that of a dearth of clinicians who are culturally responsive to the distinct cultural needs of this community.¹⁹

About the Authors

References

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