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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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Research question two explored whether CACBT would be effective in reducing depression scores among Mexican Americans. Results from independent t test analysis showed no statistically significant difference in depression scores at posttest between treatment and comparison groups. Models from multiple regression analysis showed that after controlling for selected demographic and clinical variables, group assignment was not statistically related to posttest depression scores. Thus, CACBT was not more effective in reducing depression scores among Mexican Americans than CBT. This finding is similar to Kopelowicz (1997) who considered a culturally adapted intervention for people with schizophrenia. In contrast, Muñoz et al. (1995) and Organista et al.

(1994) found significant prevention and reduction of depression after culturally adapting treatments. One explanation for the finding of this dissertation study might be that the

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groups were exposed to cultural adaptations at the administrative and service delivery levels. The only difference in the type of intervention was what occurred during the therapy sessions. However, based on results from the independent t test analysis, it can be said that CACBT was at least as effective as CBT.

Research question three examined whether acculturation level mediated the effectiveness of CACBT treatment. Model 4 of the multiple regression analysis showed that after controlling for group assignment, age (40-49), and use of psychotropic medications, acculturation level was associated with depression scores. The final model of multiple regression analysis showed that the interaction effect between acculturation and group assignment is significantly related to posttest depression scores. Thus, the effect of CACBT on depression varies according to level of acculturation.

Although bivariate analyses examined for demographic, cultural, and clinical differences between the treatment and comparison groups, it is conceivable that alternate factors not measured by this study produced the noted change in depression scores. For example, evidence suggests that family support is essential in reducing depression (Skarsater, Languis, Agren, Haggstrom, & Dencker, 2005). In addition, empirical evidence suggests the link between religion, spiritual and mental health outcomes among disadvantaged populations (Levin, Taylor, & Chatters, 1994). Furthermore, people who participate in religious activities also report greater social networks (Ellison & George, 1992; Zuckerman, Kasl, & Ostfeld, 1984).

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Internal Validity As discussed above, a number of factors threatened the internal validity of this study. First, related to research question two which examined the effect of CBT on depression, exposure of the comparison group to some aspects of CACBT cannot be ruled out. For example, both the treatment and comparison groups were exposed to cultural adaptations at the administrative and service delivery levels.

Second, group assignment was vulnerable to biases. The Executive Director who identified and assigned cases considered both the needs of the clients, agency and availability of therapists to determine case assignment. For example, if the client did not meet the income eligibility criteria or there were conflicts in scheduling, they were assigned to the comparison group. To reduce biases, assignment of cases to treatment and comparison groups should have been random.

Third, the internal validity of this study was threatened by instrumentation issues.

According to agency protocol, study group participants were to be administered a PHQ-9 at every therapy session. Although, this practice was not consistently applied, statistically, multiple measures of a given construct, may have introduced testing bias and measurement error (Rubin & Babbie, 2005).

External Validity This study took place in a mental health agency located in a border city that provides services to primarily low acculturated Mexican Americans. Due to the unique setting for this study, caution should be taken to generalize findings to the Mexican American population. In addition, the nonprobability sampling method limits generalizability. The findings of this study are most useful when considering Mexican

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this study consisted of approximately 66% low acculturated Mexican Americans.

The external validity of this study is strengthened by matching between treatment and comparison group. Bivariate analyses indicated no significant difference between treatment and comparison group except on acculturation. Despite this difference the two groups were comparable, thus supporting external validity.


An important theoretical contribution is that this study supports the need to continue examining the role of acculturation in mental health treatment in an effort to develop path models to understand depression for Mexican Americans. Acculturation is key to enhance the knowledge of the link between culturally adapted interventions for depression. One specific area is the culturally-bound understanding of depression. For example, how Mexican Americans view mental illness, the way in which they manifest symptoms, and seek treatment (Altarriba & Bauer, 1998; Escobar et al., 1997; Kolody et al., 1986; Lewis-Fernandez et al., 2005; Mezzich & Raab, 1980; Miranda et al., 1996).

Moreover, culture influences the way Mexican Americans respond to treatment. Evidence suggests the need to further examine ethnic and racial similarities and differences in the client-therapist dyad (Bernal et al., 1995; Gamst, Dana, Der-Karabetian, Aragon, Arrellano, & Kramer, 2002). This study supports the culturally grounded perspective which translates abstract concepts of culture to very specific tasks (Marsiglia & Kulis, 2009).

Results from this study have several practice implications. The finding that acculturation plays a role in how Mexican Americans respond to CACBT reaffirms the social work philosophy that practitioners need to “start where the client is.” Furthermore,

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2003). Because acculturation is key in the helping process, this study supports what has been written in the literature previously on the issue of client matching (Bernal et al., 1995; Gamst et al., 2002). Finally, as social work researchers unravel the acculturation phenomenon, they can begin to map nuances of when culture is a strength or a barrier (Marsiglia and Kulis, 2009).


Some considerations for future research in the role of acculturation in mental health would be to oversample for higher levels of acculturation. This would allow for a clearer picture of whether greater variability leads to an association between acculturation and depression. Second, the findings for research question three resulted in a significance in the interaction effect between acculturation and group assignment and depression scores, after controlling for age (40-49), use of psychotropic medications, and previous therapy, but the nature of this relationship is unclear. Qualitative research to examine what factors play a significant role in how Mexican Americans respond to treatment for depression would add further knowledge. Finally, it would be useful to investigate the relationship between acculturation, CACBT and depression using varied settings. For example, replicating the study using a comparison group from another agency where the service and therapeutic environment had not been saturated with cultural sensitivity may yield different results.

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EL Paso Family Service CBT for Depression Treatment Outline:

Ten week CBT Regimen for Depression Session 1) Establish rapport Psychoeducation on depression (share DSM-IV Dx) & CBT model Outline treatment and rationale for various components of treatment Set goals for treatment Session 2) Generate list of activities for Bx activation (pleasurable, rewarding, high in mastery).

Explain Mood log and assign (for this session, simply assign tracking of mood/activities across the week).

Session 3) Check homework (focus on connection btwn low mood and Bxs) Assign activities from list for next week’s mood/activity log.

Session 4) Check homework Review cognitive distortions Assign recognizing cognitive distortions throughout week Session 5) Check homework Cognitive Restructuring Session 6) Check homework (Restructuring Worksheets [“Thought logs”], as well as Bx activation) Cognitive Restructuring Session 7) Check homework (Restructuring Worksheets [“Thought logs”], as well as Bx activation) Cognitive Restructuring

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Session 9) Check homework (Restructuring Worksheets [“Thought logs”], as well as Bx activation) Cognitive Restructuring Discuss Termination issues Session 10) Review treatment/Acquired skills Discuss Relapse Prevention Process termination issues


Self report measure will be collected throughout as per study’s design. Results of self reports should be used as a clinical tool to track symptom severity/progress throughout the course of treatment, for motivational purposes, and to assess treatment response.

Suicidal assessment will be conducted regularly throughout the course of treatment. Emergent care procedures of the facility will be followed, and responsibility for emergent care issues will lie with the agency, rather than the supervising clinician.

Clinicians may use whichever forms they wish for the specified components of treatment, so long as they adhere to the fidelity of the model. Also, that forms MUST be used in written form for successful treatment outcome and adherence to the model.

For difficult behaviors, add graded task assignments as needed throughout treatment.

Problem solving, assessing for secondary gain, socialization/assertiveness training should be initiated throughout treatment as the need arises. This is a rough outline to follow for the purposes of ensuring that the major components of CBT treatment are followed. Additional sessions can be applied as necessary. However, sessions 1-4 should be applied as standard components of treatment.

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126 1 2 3 4 5

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Our standard rates are $80 for one hour of individual or family therapy. If you have children, your fee may be adjusted based on the above scale. We recognize that therapy requires a significant investment, both emotionally and financially. Due to the high cost of billing, we require payment for services at the time they are delivered.

Income verified by: ______________________________________ Date:


Client/Guardian Signature: ________________________________ Date:



_____ ___________________________________________________________________


Therapeutic Agreement

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Because I/We, _____________________ understand that individual, group and family counseling are (Name of client/legal guardian) not exact sciences, I do not hold the staff and board of Family Service of El Paso in any way responsible for the outcome of my/our treatment.

I accept full responsibility for the value received and the outcome obtained from my/our therapeutic contract with the agency.

I have been informed and do understand the issues of confidentiality, fee schedules/payment, the limits and guidelines of services provided and my responsibilities as a client.

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Some examples of Mexican sayings that were used in CACBT Sessions “Dime con quien andas y te dire quien eres” (tell me who you are with and

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“La esperanza nunca muere” (Hope never dies) “Cada cabeza es un mundo” (Every head is a world) “A boca de jarro”(without any regard) “Fiadas hasta puñaladas” (bargain hunting no matter what) “Me mato el gallo en la mano” (beat me to the punch) “Como lazo de cochino” (being treated like to pig’s rope) “No hay mal que por bien no venga” (There is no wrong that does not

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“Mientras hay vida, hay esperanza” (As long as there is life, there is hope) “Al mal tiempo, buena cara” (To a bad time, give a good face) “El tiempo no pasa en vano” (Time does not pass in vain) “Dios dira” (God will say) “No hay mal que dure 100 años” (There is no grief that lasts 100 years) “El flojo trabaja doble” (The lazy person works twice)

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Aguilar Melantzon, R. (1974). Glosario del calo de Cd. Juarez. NM: Joint Border Research Institute, New Mexico State University.

Alegria, M., Canino, G., Rios, R., Vera, M., Calderon, J., Rusch, D., et al. (2002).

Inequalities in use of specialty mental health services among Latinos, African Americans, and Non-Latino Whites. Psychiatric Services, 53(12), 1547-1555.

Alegria, M., Shrout, P.E., Woo, M., Guarnaccia, P., Sribney, W., Vila, D., et al. (2007).

Understanding differences in past year psychiatric disorders for Latinos living in the US. Social Science & Medicine, 65, 214-230.

Alderete, E., Vega, W.A., Kolody, B., Aguilar-Gaxiola, S. (2000). Lifetime prevalence and risk factors for psychiatric disorders among Mexican migrant farm workers in California. American Journal of Public Health, 4, 608-614.

Altarriba, J. & Bauer, L.M. ( 1998). Counseling the Hispanic client: Cuban Americans, Mexican Americans, and Puerto Ricans. Journal of Counseling and Development, 76(4), 389-397.

Altarriba, J., & Santiago-Rivera, A. L. (1994). Current perspectives on using linguistic

and cultural factors in counseling the Hispanic client. Professional Psychology:

Research and Practice, 25, 388–397.

Alvidrez, D. & Bean, F.D. (1976). The Mexican Family. In C. Mindel & R.Habenstein (Eds.). Ethnic Families in America. New York: Elsevier.

American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (text revision). Washington, DC: Author.

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