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«The Mediating Effect of Acculturation on the Effectiveness of Culturally Adapted Cognitive Behavioral Therapy with Mexican Americans Suffering From ...»

-- [ Page 1 ] --

Copyright

by

Griselda Villalobos

2009

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

Committee:

Yolanda Padilla, Supervisor

Lori Holleran Steiker, Co-Supervisor

King Davis

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.

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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

–  –  –

Introduction

Statement of the Problem

Effects and Costs of Depression

Current Mental Health Practices

CHAPTER 2 13

Literature Review

Treatment Issues

Access

Barriers

Cultural Adaptation

Need for Cultural Adaptation of Interventions

Previous Cultural Adaptation of Interventions

The Incorporation of Acculturation in Mental Health

CHAPTER 3 28

Conceptual Framework

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 Culture

Mexican American Culture: An Amalgamation of Cultures...............42 Cultural Characteristics of the Study Population: Mexican Americans in El Paso

Acculturation

Theoretical Framework of the acculturation process

Modes of Acculturation

Measures of Acculturation

Acculturation of Mexican Americans in El Paso

Cognitive Behavior Therapy

Major Assumptions

Main Interventions

CBT and Depression

CBT and Mexican Americans

CHAPTER 4 63

Methodology

Study Overview

Setting

Procedure

Participants

Data Management

Instruments

Depression Scale

Acculturation Measure

Demographic Data

Intervention

Participation of Ethnic Group Members in Study Development.........75 Existing Administrative and Service Delivery Adaptations................77 Language

ix Time

Location

Financial

Client/therapist Matching

Hiring Practices

Translation of Written Materials

Aesthetics of the Facility

Agency Culture

Adaptations made to Clinical Services

Adjunct to therapy

Treatment Fidelity

Data Analysis plan

CHAPTER 5 88

Results

Descriptive Analyses

Comparison of Treatment and Comparison Groups

Demographic Characteristics

Clinical Characteristics

Correlation Analysis

Multivariate Analysis

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

Limitations

Internal Validity

x External Validity

Implications for Theory and Practice

Future Directions

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.



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