«The Mediating Effect of Acculturation on the Effectiveness of Culturally Adapted Cognitive Behavioral Therapy with Mexican Americans Suffering From ...»
The Dissertation Committee for Griselda Villalobos Certifies that this is the
approved version of the following dissertation:
The Mediating Effect of Acculturation on the Effectiveness of Culturally
Adapted Cognitive Behavioral Therapy with Mexican Americans
Suffering From Depression
Yolanda Padilla, Supervisor
Lori Holleran Steiker, Co-Supervisor
Arthur A. Islas Michael Lauderdale The Mediating Effect of Acculturation on the Effectiveness of Culturally Adapted Cognitive Behavioral Therapy with Mexican Americans Suffering from Depression by Griselda Villalobos, B.S.W.; M.S.W.
Dissertation Presented to the Faculty of the Graduate School of The University of Texas at Austin in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy The University of Texas at Austin May, 2009 Dedication To my sons Andres Emmanuel and Adan Alejandro.
To my mother Maria, my sister Vasti, and my brother Ruben.
Hoping this will pave the way for a better future for you and future generations.… Acknowledgements First, I would like to thank my dissertation chair, Yolanda Padilla, for her guidance, support, and encouragement throughout this process. I always knew that with her on my side I could never go wrong. I would also like to thank my dissertation co- chair, Lori Holleran Steiker, for her encouraging words and support every step of the way. I would like to thank my dissertation committee, King Davis, Ph.D., Michael Lauderdale, Ph.D., and Arthur Islas, M.D., MPH, for their individual and unique contributions to this project. With their guidance I was able to expand my understanding of the important topics addressed in this dissertation. I would like to acknowledge the dedicated guidance and support of Iván del la Rosa, Ph.D., research professor at New Mexico State University, for the countless hours of mentoring, planning, and consultation. A special thanks to Richard Salcido, LPC, and staff at Family Service of El Paso. This project would not have been possible without them. I would also like to extend my gratitude to Donna Cude-Islas, Inez Bañuelas, and Elizabeth Urban, for their unconditional friendship. A special thanks to the entire El Paso social work community for their good wishes. Finally, I extend my gratitude to my mother Maria for being a wonderful example of what it means to be a Mexican American woman with an admirable work ethic, integrity, and never-ending energy.
The purpose of this research study is to explore the role of culture in how Mexican Americans respond to mental health treatment. Cultural background is likely to affect not only the meaning attributed to mental illness, but also help-seeking and responses to treatment. Creating a match between treatment modalities and people’s cultural backgrounds requires consideration of a person’s cultural context. Cultural characteristics can vary not only across cultural groups, but even within groups can change across time.
This study used a quasi-experimental pretest/posttest comparison group design to analyze culturally adapted cognitive behavioral therapy (CACBT) with Mexican Americans diagnosed with depression. A purposive nonprobability sample of 81 adult Mexican Americans diagnosed with depression was recruited from a mental health
which received CACBT, and 33 to a comparison group, which received treatment as usual. Depression was measured using the Patient Health Questionnaire (PHQ-9).
Participant acculturation level was measured using the Acculturation Rating Scale for Mexican Americans-II.
Independent and paired t tests were used to examine the effectiveness of the culturally adapted intervention. OLS regression analyses examined whether acculturation mediated the relationship between the culturally adapted intervention and depression. No direct effect was found between CACBT and depression relative to treatment as usual. The results showed that CACBT and treatment as usual both decreased depression scores. However, the interaction effect between acculturation and group assignment was significantly related to posttest depression scores. Thus, the effect of CACBT varied according to acculturation level.
This study demonstrates the role that acculturation plays in how Mexican Americans respond to mental health treatment. An implication for social work practice is the need to use evidence-based practices that have been tested for their cultural appropriateness with Mexican Americans.
List of Tables
List of Figures
Statement of the Problem
Effects and Costs of Depression
Current Mental Health Practices
CHAPTER 2 13
Need for Cultural Adaptation of Interventions
Previous Cultural Adaptation of Interventions
The Incorporation of Acculturation in Mental Health
CHAPTER 3 28
The Concept of Culture
Theoretical Frameworks of Culture
Culture as a Tool Kit
Culture and the Helping Process
Culturally Grounded Perspective
The Context of Mexican American Culture
viii U.S. Mainstream American Culture
Mexican American Culture: An Amalgamation of Cultures...............42 Cultural Characteristics of the Study Population: Mexican Americans in El Paso
Theoretical Framework of the acculturation process
Modes of Acculturation
Measures of Acculturation
Acculturation of Mexican Americans in El Paso
Cognitive Behavior Therapy
CBT and Depression
CBT and Mexican Americans
CHAPTER 4 63
Participation of Ethnic Group Members in Study Development.........75 Existing Administrative and Service Delivery Adaptations................77 Language
Translation of Written Materials
Aesthetics of the Facility
Adaptations made to Clinical Services
Adjunct to therapy
Data Analysis plan
CHAPTER 5 88
Comparison of Treatment and Comparison Groups
Research Question 1: Effect of Acculturation on Depression...........100 Research Question 2: Culturally adapted CBT and Depression........103 Research Question 3: Mediating Effect of Acculturation on the Relationship between Culturally Adapted CBT on Depression........108
CHAPTER 6 112
Discussion and Implications
Summary of The Study
x External Validity
Implications for Theory and Practice
Appendix A. IRB Approval
Appendix B. Family Service of El Paso Letter of Support
Appendix C. Intake Form
Appendix D. CBT Protocol
Appendix E. Patient Health Questionnaire
Appendix F. Acculturation Rating Scale for Mexican Americans-II.........126 Appendix G. Client Information Form
Appendix H. Initial Assessment Form
Appendix I. List of Mexican Sayings
Table 3-1 Comparison of Cultural Norms and Values
Table 4-1. Variable Table
Table 4-1. Variable Table
Table 4-2: Comparison of CBT and CACBT
Table 5-1. Descriptive Statistics: Demographic Characteristics (n=81 ).............90 Table 5-2 Descriptive Statistics: Cultural Characteristics of (n=81 )................93 Table 5-3. Descriptive Statistics: Clinical Characteristics (n=81)
Table 5-4. Correlation Matrix for Demographic, Cultural and Clinical Variables
Table 5-5. Multiple Regression Analysis of Depression Scores as a Function of Acculturation
Table 5-6. Results of Independent t test on pretest and posttest depression scores
Table 5-7. Results of Paired t test on depression scores from pretest to posttest
Table 5-8. Multiple Regression Analysis of Treatment Effects on Depression Scores
Table 5-9. Multiple Regression Analysis of Treatment Effects on Depression Scores Accounting for Acculturation Level
Figure 1: Model of the Relationship Between Acculturation, Culturally Adapted Cognitive Behavioral Therapy (CACBT), and Depression
Figure 2: Cultural Adaptation Model
Figure 3: Analysis Plan
A major question in determining effective mental health interventions is whether existing practices respond to the unique characteristics of clients, their values and beliefs, their social contexts and backgrounds. Many of these unique characteristics are embodied in cultural background. Because the meaning of mental illness is not universal, cultural background must be taken into account. Cultural background is likely to affect not only the meaning attributed to mental illness, but also help-seeking and responses to treatment.
Creating a match between treatment modalities and people’s cultural backgrounds requires consideration of a person’s cultural context. Yet cultural characteristics not only vary across cultural groups, but even within the groups. They can be fluid and are subject to change due, for example, to co-existence with other cultures (Bernal, Bonilla, & Bellido, 1995; Bernal & Sharron del Rio, 2001; Nagayama-Hall, 2001; Rogler, Malgady, Constantino, & Blumenthal, 1987).
An important development in the understanding of culture and mental health came as a result of the work of national experts in the field, who in their supplement (U.S. Department of Health and Human Services, 2001) to the Surgeon General’s 1999 report concluded that it is critical to consider culture in planning interventions for minority groups. Culture bears upon what people bring to the clinical setting, if they seek treatment and where they seek treatment. In addition, culture influences how people communicate their symptoms. Furthermore, culture influences the meaning people give
and how much stigma is connected to mental illness (U.S. Department of Health and Human Services, 2001).
This study focuses on the significance of culture for mental health services for Mexican Americans. Some Mexican Americans may attribute mental illness to supernatural causes and seek help from faith healers who are familiar with their culture (Altarriba & Bauer, 1998). Mexican Americans may present other culturally appropriate beliefs such as talking with deceased relatives, seeing religious visions, and worrying about hexes (Miranda, Azocar, Organista, Muñoz, & Lieberman, 1996). In addition, studies have found that Mexican Americans may present more somatic symptoms of depression than exhibit sadness or depressed mood (Escobar, Burnham, Karno, Forsythe, & Golding, 1987; Kolody, Vega, Meinhardt, & Bensussen, 1986; Mezzich & Raab, 1980). Furthermore, some Mexican Americans may believe that others will think they are crazy if they are depressed and may view antidepressants and other medications as addictive (Lewis-Fernandez, Das, Alfonso, Weissman, & Olfson, 2005).
As the literature review will show, research has established the significance of culture for mental health treatment. Namely, culturally adapted treatments are more likely to yield positive results (Harris & Franklin, 2003; Muñoz & Mendelson, 2005; Sue, 2003). However, much less is known about how variations within cultural groups come into play. Do all people who share the same cultural background respond similarly to culturally adapted interventions? The purpose of this dissertation is to examine the role of
behavioral therapy (CACBT) for depression is investigated.
In order to address this issue, this study investigated three research questions:
1. Is there a relationship between acculturation level and depression scores among
2. Is CACBT effective in reducing depression scores among Mexican Americans?
3. Does acculturation level mediate the effectiveness of CACBT treatment?
It is hypothesized that higher acculturated Mexican Americans will have higher depression scores than will lower acculturated Mexican Americans. Moreover, it is hypothesized that low acculturated treatment group participants will have a significantly lower posttest depression score as compared to higher acculturated counterparts. The objective of the study was to further understand how culturally adapting evidence-based practices can enhance treatment for Mexican Americans. Figure 1 depicts the research questions and proposed relationships between variables.
The study involved a two-group pretest/posttest comparison group design model, using a purposive nonprobability sample recruited from Family Service of El Paso, an outpatient mental health center located in El Paso, Texas. The treatment group (n=48) received individual therapy using culturally adapted cognitive behavioral therapy, using a structured session protocol. The comparison group (n=33) received treatment as usual.
Depression scores were collected using the Patient Health Questionnaire (PHQ-9). A measure of acculturation was collected using the Acculturation Rating Scale for Mexican
(DSM-IV-TR) (2000) for Major Depression and determined by a clinical assessment.