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

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Figure 2 depicts the cultural adaptation model. First, as part of the Hogg Foundation study, ethnic group participation was obtained through focus groups. Second, the agency included existing culturally sensitive modifications to its operation at the administrative and service delivery levels, as well as, in the delivery of therapy services. Some of the cultural adaptations to the agency were already in place at the time this research study began because of the geographic location of the agency on the US-Mexico border and the largely Mexican American population served. During this study the task at hand became to identify these cultural adaptations and put them in writing.

It is important to note that the extensive existing modifications present at FSEP in order to make it more culturally responsive to its population are a limitation for the study.

Specifically, while only the treatment group received culturally adaptive cognitive behavioral therapy, all participants shared the culturally adapted environment created by the agency.

Participation of Ethnic Group Members in Study Development One of the adaptations in this project was the use of Mexican Americans in the development of the program. The Executive Director and research therapists who developed the adaptations were all Mexican Americans of various acculturation levels. In addition, a focus group was conducted in June 2006 in which therapists conferred about what cultural adaptations should be made. Translation and regional adaptation of all written materials was done by research therapists. A focus group of Mexican American clients was held during year two of this project. Suggestions made by the participants of

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therapists met weekly to share cultural adaptations that were being used in therapy sessions.

Existing Administrative and Service Delivery Adaptations Some of the cultural adaptations at the administrative level of the agency began ten years ago when the Executive Director made the commitment to make the Board of Directors more diverse and representative of the population being served. During a ten year span, the Board of Directors changed from being 75% White to being 75% Mexican American. This was possible due to the active efforts of the Executive Director. In addition, in order to account for issues of access, the agency’s mission statement became “to make services available to anyone in the El Paso area regardless of ability to pay”.

Furthermore, changes in the agency’s by-laws were made to include culturally sensitive language and language that the Board members would be reflective of the community.

Finally, the agency adopted a philosophical approach to target services to the poor and disadvantaged.

Cultural adaptations that were already present, and were solidified during this project were in the areas of language, time, location, financial, client/therapist matching, hiring practices, translation of anything in print, aesthetics of the facility and agency culture.

Language Continued efforts were made at the agency to provide bilingual office staff, as well as clinical staff being that 80% of the clients at FSEP are Hispanic, predominantly of Mexican descent. Of these, 40% prefer treatment in Spanish and a smaller percentage

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therapists, as well as, every employee with responsibility to answer telephones or provide customer service, were bilingual.

Time Being that the availability of evening appointments is critical for this population, FSEP is opened from 8 a.m. to 8 p.m. Monday to Friday to be accessible to those with different needs. All therapists are required to have at least four evening appointments per week.

Location FSEP relocated to a more centralized location in February 2005. This was a conscious decision based on client satisfaction surveys that indicated that the agency was too far west in the city. In addition, FSEP created outreach programs that take its services out to various communities. These services reach primarily Hispanic clients.

Financial FSEP charges clients on a sliding fee scale. Clients are charged 1/10 of one percent of their income. For example, if a client earns $12,000 per year their fee is $12.00. The agency has a policy that no one will be turned away due to not being able to pay. FSEP seeks funding to be able to provide services at no charge to clients.

Client/therapist Matching Eight variables are used when matching clients and therapists for case assignment.

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availability, expertise in problem, payment source, and acculturation level when determining which therapist will be assigned to each client.

Hiring Practices The FSEP administration works diligently in the recruitment and retention of bilingual staff, as well as, of staff from various acculturation levels, in order to meet the needs of the diverse Hispanic population that it serves.

Translation of Written Materials All written material at FSEP is translated into Spanish that is used in the El Paso border region. These translations are a collaborative effort among therapists who are bilingual and familiar with the language from the region.

Aesthetics of the Facility The agency provides a family atmosphere by providing coffee and other beverages to clients. A waiting room equipped with a television that is set to Spanish channels is available with an adjacent playroom for children. The playroom has glass walls so that office staff can supervise children while adults attend therapy. The waiting room is furnished with Spanish materials for clients and family members to read. It is not uncommon for adult clients to be accompanied by their mothers or other family members.

This is considered a common occurrence at the agency and all family is welcomed.

Agency Culture FSEP provides a family-like atmosphere for clients and their families. Everyone is welcome to visit the agency’s kitchen for a cup of coffee or to use the facility microwave

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vendor that visits the agency and to enjoy meals with their families in the agency waiting room.

Adaptations made to Clinical Services The core elements of CBT remained intact during the cultural adaptation of insession delivery of CBT. The cultural adaptations that were made were with the purpose of making CBT more appealing to Mexican Americans. Cultural values were considered in therapy. Therapists for the treatment group received cultural competence training on the history of Mexico, immigration issues, Mexican and Mexican American cultural characteristics, and acculturation. Table 4-2 presents the core elements of CBT and CACBT used in this study.

Familism and the collectivist approach were incorporated into the therapeutic process by not expecting clients to make decisions independently of their family. In addition, the client’s extended family was engaged in therapy if the client requested it.

Therapists were cautious not to emphasize mainstream cultural values when the client had traditional Mexican American values. Clients were encouraged to disclose any religious or spiritual beliefs and these were acknowledged during therapy. Therapists were familiar with Mexican American beliefs regarding the supernatural and were open to discussing this with clients.

Using knowledge of the groups’ acculturation issues was another cultural adaptation used during therapy. Treatment group therapists underwent training on

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Personalismo was incorporated by allowing time for informal chit-chat rather than “getting down to business”. The length of therapy sessions was flexible to meet the more flexible time orientation that some Mexican Americans hold. Time was spent

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decrease the myth that people who seek treatment are “crazy”. Clients’ past experience with therapy and their views of mental health treatment were discussed during the initial therapy session to gain an understanding of clients’ viewpoint.

Therapy sessions were bilingual or monolingual in English or Spanish depending on the client’s preference. Therapists used Spanish that is commonly used in the El Paso area. Code switching was welcomed by therapists and was found to be a bonding factor in the clinical session. Therapists found that clients would help them when they did not know a particular word in Spanish. Therapists were able to assess what level of Spanish their client required and would move from Calo, a slang form of Spanish, to Spanglish, to more formal Spanish when needed (Aguilar Melantzon, 1989; Burciaga, 1993;

Fuentes, 1974). Interventions were simplified and presented in very concrete ways taking into consideration that some clients only attended primary school in Mexico.

Another cultural adaptation was the use of culturally relevant examples in therapy. Therapists understood the dilemma that some Mexican Americans deal with in trying to negotiate between their culture of origin and the mainstream culture. With this in mind, therapists were able to explore with clients whether some of their distorted cognitions were based on trying to find their place in the world. One therapist reported exploring with a client the schema of “what a Mexican mother should be”. This allowed the therapist and the client to explore the evidence for and the evidence against what it means to be a good mother.

Although, CBT requires homework assignments, therapists were flexible with requiring homework for Mexican American women, taking into account that gender expectations for them sometimes impose many responsibilities for caregiving. Women

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during the therapy session to complete their homework.

Mexican sayings and metaphors were used in therapy. The therapeutic use of “dichos” or metaphors is supported by various writers (Bettelheim, 1977; Gordon, 1978;

Littman, 1985). Metaphors are described as infusing life with worth, value purpose and meaning (Lankton & Lankton, 1989). For Mexican Americans and other Latino cultures, metaphors involve cultural beliefs and ideals imbedded in figurative language that describe the human conditions. Using metaphors that are familiar to Mexican Americans can mitigate resistance, enhance motivation and reframe problems (Zuniga, 1992).

Clients were encouraged to use familiar sayings in order to reframe cognitions, which is one of the goals of CBT.

In CACBT, Mexican dichos were used when asking clients to find alternative explanations for events to replace negative or unhealthy schemas. The use of metaphors was useful because it helped clients conceptualize ideas and reframe negative cognitions in terms that were familiar to them. Conversely, Mexican metaphors that conveyed distorted cognitions were used as opportunities for exploration. When metaphors that carry negative cognitions emerged as being part of a client’s automatics thoughts, cognitive restructuring was used by CBT therapists to evaluate and replace the distorted cognitions with accurate ones. For example, at times the therapist would use a Mexican saying to make a point with clients in a way that made sense to them. Such as in the case of a newly diagnosed dialysis patient who was feeling worthless. The therapist for this client used the Mexican saying “hoy por mi, mañana por ti” (today for me, tomorrow for you) and was able to help the client understand that it was his turn to accept help from others without feeling shame. Many other Mexican sayings were incorporated into the

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clients. If a therapist judged that folk healing was part of a client’s belief system, the therapist would discuss this as possible treatment for client. Therapists discussed the impact of folk healing on their clients during weekly meetings. Therapists learned from one another about the different beliefs related to folk healing and curanderismo.

Adjunct to therapy A Masters level case manager was available to meet with clients who were identified by their therapists as needing assistance in accessing other services. The case manager provided assistance with accessing food, clothing, furniture and providing transportation when needed to access medical or psychiatric evaluation services. The case manager accompanied clients who were having difficulty accessing the local county mental health services and helped them navigate through this complex system by providing interpreter services and information. The case manager accompanied clients to medical/psychiatric appointments and served as an advocate for clients. In addition, the case manager conducted home visits and outreach to clients as needed.


Treatment fidelity was increased by having research therapists undergo 56 hours of training in cognitive behavioral therapy using a standardized manual that outlined a protocol of 10 sessions of CBT. Weekly meetings were held with research therapists and the clinical director of the agency to discuss cultural adaptations that were taking place during therapy sessions. Peer supervision was implemented to provide research therapists

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CBT model structure. Research therapists recorded audiotapes of their sessions and submitted them to the CBT expert for review and feedback. Research therapists were blind to the research hypotheses in order to decrease the possibility of researcher bias.

Trained bilingual agency staff obtained consent forms in order to decrease the probability that the therapeutic relationship was tainted by whether or not a client agreed to participate in the study.


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