The explosion burst across the field, spreading a dust cloud toward Justin Bernal and Anthony Cumpian. The two combat veterans toted rifles as they inspected the blast site they had set up for a morning of gunplay at a South Texas shooting range.

After the target shooting and pyrotechnics, conversation turned to war stories, and from there to post-traumatic stress disorder.

Bernal and Cumpian, who are Hispanic, said their upbringing affected how they viewed mental health. For Bernal, who said he has struggled with PTSD, the lack of Hispanic psychiatrists is one barrier to getting help. Another barrier, said Cumpian, a Purple Heart recipient, is that he, like other Hispanic vets, learned early on to bottle up his emotions.

A person’s background may have a larger effect on minority veterans and their mental health than once thought. Two studies published this year reveal how African-American and Hispanic veterans face unique challenges with mental health.

“Service members from diverse cultures, ethnicities and racial groups may experience or cope with war-related events differently and thus may be at greater risk for PTSD,” Brittany Hall-Clark, an assistant professor of psychiatry at UT Health San Antonio, wrote in an article published this year.

Not only do minority veterans tend to have greater PTSD symptoms, they also face those unique mental health challenges. Internal barriers include learned machismo and fear of weakness. External barriers include distrust of institutions, racism and difficulty accessing treatment, Hall-Clark said.

In another study published this year, one’s race and ethnicity were found to be among the biggest predictors of whether a combat veteran will be diagnosed with PTSD. The research by the NYU Langone Medical Center followed 699 Vietnam veterans over 25 years.

Minorities are a growing segment of the veteran population, making up 22 percent as of 2014. In 2040, around a third of all vets will be minorities, according to the National Center of Veterans Analysis and Statistics.

In a nation that has been at war since 9/11, taking care of all veterans may mean acknowledging differences in how people view mental health.

“It’s essential to think about cultural competence,” Hall-Clark said. “We need to be mindful of how people see their world.”

Internal barriers

Cumpian, a cavalry scout, was serving in Paktia province in Afghanistan in December 2012 when he was shot. He recalled one day burning some feces and eating half a ration before helping a fellow soldier wall up their base. A gunman waiting in the bushes must have spotted him, Cumpian said.

The shot of an SPG 9 recoil-less rifle, normally used against tanks, burst 60 feet or so away. Cumpian saw one fragment whistle by his head. Another fragment hit his left arm.

He didn’t think the wound was a big deal. Then on the operating table, he saw his doctor’s eye through the hole in his arm. After getting patched up, he was back on patrol clearing mines two days later. He cried tears of pain, which he hid behind dark glasses as he gritted through the mission. He learned this while growing up: Grin and bear it.

Cumpian said he learned this lesson during a rough childhood: a parent in prison, foster care until his grandparents adopted him. Emotions stayed hidden. He recalled that his grandparents brought him to a funeral in Mexico, and he bit his tongue, holding back tears, because like many other Hispanic men, he was told men don’t cry.

The Army taught the same mindset. In fact, it encouraged it. Then, once he was wounded, people all of a sudden began asking him to open up and share his feelings. “You’re introducing a new concept to people,” said Cumpian, who now works at a mental health clinic.

Avoidance of traumatic thoughts can lead to self-destructive and dangerous behaviors. Blanca Torres, a Hispanic female veteran of the Iraq and Afghan wars, described how the need to be seen as tough and unemotional in the face of PTSD led to problems self-medicating with alcohol. “You didn’t want to be a crybaby,” Torres said.

Hall-Clark studied active-duty service members at Fort Hood as part of the STRONG STAR Multidisciplinary PTSD Research Consortium. She found that minority active-duty soldiers had more negative thoughts about themselves, more self-blame and more numbing when compared with their Anglo peers. A multitude of social, economic and other factors can contribute to mental health, and the stigma against asking for help among minorities may actually worsen the symptoms of PTSD.

“Machismo and the importance of being strong and not showing emotions, that can prevent people from accessing their emotions in the process of healing,” Hall-Clark said.

Of all the symptoms of PTSD, numbing and avoidance of traumatic thoughts are seen to be the most tied to culture. Researchers believe that the more a given culture teaches avoidance of emotion, the higher the levels of PTSD symptoms. In 2006, researchers at a California Department of Veterans Affairs Center tested this prediction in a study of 668 police officers.

The paper explored why Hispanic police officers tended to have higher rates of PTSD. The researchers found that Hispanic officers had similar levels of trauma in the line of duty to other officers. What was different was that they were more likely to suppress their emotions during the moment of trauma and they were more likely to blame themselves afterward.

Hispanic service members similarly suffered at higher rates than their peers. A National Vietnam Veterans Readjustment Study found that among male combatants, 28 percent of Hispanic vets had PTSD, compared with 21 percent of African-American vets and 14 percent of Anglo vets.

Cumpian said that when he began referring fellow soldiers to mental health resources, the stigma of asking for mental health applied to everybody, but especially for minority soldiers. Cumpian has not been diagnosed with PTSD and does not think he has it. Still, he said he believes that many combat vets come home damaged in some way.

“You see a lot of people who grew up without a support system, who should be jumping at the chance to get help, (but) don’t,” Cumpian said.

External barriers

Disparities in health care aren’t just in mental health, but across the medical field overall, said Cynthia Macri, who serves on the Japanese American Veterans Association and while in the Navy assisted senior leaders on diversity issues.

“There is now an abundance of research highlighting disparities in treatment — and, indeed, in death/survival rates — among majority and minority patients who present for care in emergency rooms for any disease or condition,” Macri said.

The Veterans Health Administration chartered a health care equality work group in 2011. Veterans provide a unique window into differences among races and ethnicities in health. The VA system eliminates many of the financial factors present in the civilian marketplace, yet in its latest report, the work group found greater proportions of minority vets reporting barriers to care.

While there may be a variety of reasons, Marci said one of the biggest barriers is when there is a mismatch in the way patients and providers perceive each other. Cultural barriers, or the fear of them, can prevent minority soldiers from seeking doctors or psychiatrists.

For Bernal, a Marine vet, going to the hospital was not seen as an option when he grew up. Like Cumpian, he had an upbringing that taught him to be strong and stoic in the face of wounds both physical and mental.

Bernal said deploying to Afghanistan as a combat engineer meant weeks of clearing routes and waking up to mortar rounds and mayhem. He recalled how he once saw a good friend blown up, but there was no time to think about feelings then. Only the mission.

When he did want to talk about his experience, Bernal said he found it difficult to connect to his non-Hispanic squad members. They would ask “touchy-feely” questions tangential to what he cared about, and he said he spent a lot of time explaining himself.

His Hispanic friends, however, understood what was important to him. It wasn’t just that his friends could speak Spanish, but that they had grown up the same way he did. Because he was around people who had similar childhood experiences, Bernal said, he didn’t have to waste time explaining what he meant.

He could say the words, “You know how it is.” And they did. His non-Hispanic friends always asked about bullets and bombs, and although those issues mattered somewhat, Bernal said, his Hispanic friends knew that family troubles back home mattered just as much, if not more.

“Family is really important to me. … Other guys, I’d have to explain it, but Hispanic guys I wouldn’t have to explain it, I could go to the next point,” Bernal said.

After his deployment, Bernal said he was ushered before an older Anglo doctor for a checkup. Rote questions from someone he didn’t relate to led to rote answers. He decided that going at that point to psychiatrists would be pointless, a choice he would uphold even as he struggled with PTSD back home. If there were more Hispanic doctors, he said, he might have reconsidered.

“If I go to a white doctor, he wouldn’t understand,” Bernal said. “Why would I talk to someone who wouldn’t understand?”

Minority vets are more likely to drop out of mental health treatment early, according to a 2017 report on views of VA mental health care. The National Center for PTSD report found that minority vets were more likely to have “lower-quality relationships with their primarily white mental health care providers,” with less communication, more emotional distance and shorter appointments.

“People of color are less likely to seek and receive mental health care,” said Lindsay Bira, assistant professor of psychiatry at UT Health San Antonio. “Part of that might be cultural, distrust of services, some may be less access to care. … It can be hard to get someone in the door if they feel the therapist isn’t a good match.”

The field of psychiatry is predominantly Anglo and male, which leads to difficulties serving minority veterans, psychiatrist Mrudula Rao said. Rao runs a PTSD clinic in San Antonio and has treated veterans for PTSD. She said therapists should tailor treatment to a person’s specific cultural values and beliefs, which may mean including a patient’s family or faith.

“There’s such a stigma to pursue mental health,” Rao said. “And then when you come across a clinician who’s not aware of your cultural needs, then that’s another step back.”

Talking about what’s going inside one’s brain can be a frustrating and sensitive process. Eddie Bell, an African-American veteran, said he served in Vietnam and was assigned to a morgue. Decades later, Bell said, he found himself in front of an Anglo VA doctor, talking about how he was feeling and wondering why he and the doctor seemed to be talking past each other.

For Bell, there seemed to be a disconnect between his doctor and him, but he couldn’t deduce a reason. Was it because of differences in race, or in age or experience? The racism he faced growing up in the Jim Crow-era South was blatant. Now, racism is more subtle, Bell said, and he retains the wariness he learned years ago, on whether he can trust another person not to judge him unfairly.

“‘Are you really hearing me?’ You’re trying to figure it out,” Bell said.

Hispanic veteran Albert Mireles felt the same way when he first went to therapy — which notably was the first time he stormed out of therapy at the VA. “When you seek help, it’s anything that turns you off. If the person doesn’t show much concern or much interest,” said Mireles, who served as commander of VFW 76 and now directs veterans to seek help.

People may vary in how much they identify with one identity over another as well, researcher Hall-Clark said. Not all studies consistently found that race and ethnicity had significant effects on PTSD.

Kat Cole, an Asian-American vet, is now director of the Steven A. Cohen Military Family Clinic at Family Endeavors. Cultural barriers and stigma against mental health are real, Cole said.

What is needed is not special treatment but consideration for veterans of all backgrounds.

“It’s very important for practitioners, nurses, doctors to be very culturally competent with their clients, so they can build rapport,” Cole said, “so they can identify any kind of resistance or barriers.”

jlawrence@express-news.net