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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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physicians rather than from specialty mental health providers such as psychiatrists, psychologists, social workers, psychiatric nurses or other mental health professionals (Vega et al., 1999). The Quality Improvement for Depression project, which involved a sample of Whites (n=994), Latinos (n=200), and African Americans (n=127) ages 18 and older, found that Latinos were less likely than Whites to obtain specialty mental health care even though they reported that their primary care providers recommended depression treatment at rates similar to those of White patients (Miranda & Cooper, 2004). These researchers propose that this may be due to barriers such as language and lack of culturally responsive providers. A relevant limitation is that there was no measure of acculturation in this study that would explore intra-ethnic variations in care.

Alegria and her collaborators (2002) analyzed data from the 1990-1992 National Comorbidity Survey with the purpose of exploring whether there were disparities in the rates of specialty mental health care for Latinos and African Americans compared to nonHispanic Whites. The sample included 695 Latinos, 987 African Americans, and 6,026 non-Hispanic Whites ages 15 to 64. There were no significant differences between ethnic groups when the overall rates of use of any mental health, general health or human services were analyzed. However, when specialty care was examined specifically, Latinos, like African Americans, reported lower rates of obtaining specialty care than did non-Hispanic Whites. Reported rates were 7.2 %, 5.9%, and 11.8%, respectively. Based on the findings from these empirical studies, evidence suggests that Latinos in general are less likely to obtain specialty mental health care when compared to non-Hispanic Whites.

In addition, further probing into the literature yields evidence that there are disparities in the use of mental health care services for people of Mexican descent, more

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people of Mexican descent. The Los Angeles Epidemiologic Catchment Area Study (ECA) conducted by the National Institutes of Health showed that Mexican Americans are less likely to use mental health services than White Americans at rates of 11% for Mexican Americans compared to 22% for Whites (Hough et al., 1987). The ECA looked at prevalence in the past six months and sampled 3,132 individuals from two distinct mental health catchment areas (Burnam et al., 1987). Half the sample was of Mexican descent (Mexico- or U.S.-born) and the remaining half was largely non-Hispanic Whites.

Vega and his colleagues (1999) found that only 9% of their Fresno, California sample of 508 Mexican Americans who had mental disorders in the prior 12 months sought services from a mental health specialist. They also found that Mexican Americans were two times more likely to seek treatment for mental disorders in general medical settings than in specialized mental health agencies (Vega et al., 1999).

Alegria et al. (2007) reported that 1 out of every 10 Mexican Americans reported past-year mental health service utilization. Utilization rates were significantly lower when the differences between U.S.-born and foreign-born Mexican Americans were examined. Vega et al. (1999) found that U.S.-born Mexican Americans were more than twice as likely to seek mental health services as their foreign-born counterparts. These results indicate the utilization rates for Mexican Americans are low, but they are even lower for Mexican Americans who report a foreign-born status. At the same time, Sue, Fujino, Hu, Takeuchi & Zane (1991) documented a dropout rate of 14.6% after one session for Mexican Americans and group averages for length of treatment of 5.1 sessions. Some of the reasons that were identified as contributing to dropout rates were socioeconomic factors, perceptions of mental health, cultural commitment, and lack of

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Services, 2001).

Each study mentioned above indicates the disparity in mental health treatment utilization by Hispanics and more specifically, Mexican Americans. The studies presented here point to the need of examining the factors that contribute to this disparity.

Issues of access and barriers to obtaining treatment must be explored to better understand some of the factors that may play a role in maintaining disparities in utilization of mental health services for Mexican Americans.

Access Lack of access to mental health services is an issue that affects millions of Americans, but for minority groups this issue becomes even more paramount. The Surgeon General’s Supplement Report (2001) defines access as “probability of use, given need for services” and measures it by whether or not a person has private or public insurance to cover some or all of the cost of services. The supplement documents that 37% of Latinos are uninsured mostly due to the lack of employer-based coverage. Alegria et al. (2002) found that Latinos were less likely to have private insurance than non-Latino Whites (62.2% in comparison to 85.4%) and more likely to have Medicaid (11.5% in comparison to 3.5%). Snowden et al., (2006) explored the issue of access for different minorities groups by looking at statewide mental health penetration rates by ethnicity for Medi-Cal recipients in California. Penetration rates were calculated by dividing the number of users of mental health services in each ethnic group by the number of MediCal eligible persons. The California Department of Mental Health’s (DMH) Medi-Cal Paid Claims File was used to gather data on service utilization and the DMH’s Client Service Information System was used to gather client ethnic characteristics. Findings

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Penetration rates for Whites were 11.6% while they were only 3.6% for Latinos.

Barriers Understanding the barriers that lead to lack of access is very complex as it is difficult to isolate any one barrier. The best way to tackle this feat is by focusing on how these barriers intersect and result in underutilization, premature termination and short lengths of treatment for Mexican Americans. The Surgeon General’s Supplement identifies language, lack of Spanish-speaking mental health providers, and lack of insurance, as the major access barriers (U.S. Department of Health and Human Services, 2001). Snowden et al. (2006) list cultural misunderstanding and culture-based alienation, economic barriers, mistrust, stigma, clinician bias and language as important factors to consider when examining lack of access to mental health services. Other reasons that are identified are lower levels of acculturation (Wells, Holding, Hough, Burnam & Karno, 1989), different beliefs about the need for ongoing treatment (Anderson, 1995), a cultural heritage that makes use of different methods of treatment (Rogler & Cortes, 1993), and extensive support systems that may mitigate the acuity of the need for treatment (Briones et al., 1990).


In an effort to address the mental health disparities for people of color, the mental health field responded by moving toward the cultural adaptation of evidence-based practices (Hall, 2001; Lau, 2006). This emerging trend involves understanding three major components: cultural competence, evidence-based practices and cultural

adaptation. Cultural competence is defined as:

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individuals and groups of people into specific clinical standards, skills, service approaches, techniques, and marketing programs that match the individual’s culture and increase the quality and appropriateness of mental health care and

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Cultural competence occurs in mental health service delivery when cultural issues are acknowledged and addressed at all levels of an organization: administration, service delivery and clinician (Hogg Foundation, 2008). Others pose the question of whether cultural competence in mental health services is even necessary being that very little research has been conducted to prove its efficacy (Satel, 2000; Weinrach & Thomas, 1997). Sue (2003) counters that, it is true that there are few efficacy studies on cultural competence, but that the emphasis on efficacy studies instead of other forms of evidence may hinder the understanding of cultural competence. He adds that lack of funding and resources are at the root of the lack of research to support cultural competence. Sue urges that despite these limitations, there is evidence that supports the need for cultural competence and that efforts must continue to uncover the many layers of this phenomena (Sue, 2003).

Evidence-based practice is broadly defined as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual clients (Sackett, Richardson, Rosenberg & Haynes, 1997, p. 2). More specifically, the American Psychological Association’s Division 12 Task Force on Promotion and Dissemination of Psychological defined two levels of evidence-based practices: WellEstablished Treatments and Probably Efficacious Treatments (Hogg Foundation, 2008).

Well-Established Treatments are:

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to another treatment or equivalent to an already established treatment across two or more between-group design experiments or 10 or more single-case design experiments. The studies must have included the use of treatment manuals and a clear description of the client samples’ characteristics, and the treatment’s efficacy must have been demonstrated by at least two different researchers or research teams (Hogg Foundation, 2008)

Probably Efficacious Treaments are:

psychological treatments that research support but not to the extent of wellestablished treatments. Support for probably efficacious treatments may be demonstrated by: 1) two studies demonstrating the treatment’s superiority to being on a wait list; 2) one or more studies that meet all of the criteria for wellestablished treatments except that only one researcher or research team has conducted the studies; or 3) four or more single-case design studies that meet the well-established treatment criteria except for the number of studies conducted (Hogg Foundation, 2008).

Cultural adaptation stems from the work of Sue, Zane & Young (1994) who propose that incorporating the customs, values and beliefs of an ethnic group into the selection, modification or development of psychosocial therapies can increase service utilization, length of treatment, and clients’ satisfaction. Cultural adaptation is the process of making mental health service delivery culturally competent. Whaley and Davis (2007)

define cultural adaptation as:

any modification to an evidence-based treatment that involves changes in approach to service delivery, in the nature of the therapeutic relationship, or in

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and behaviors of the target population. (pg. 570) Although the contemporary belief is that interventions should be culturally adapted, caution should be taken so that the core elements of an intervention are not compromised (Castro, Barrera, & Martinez, 2004; Lau, 2006).

Lau (2006) and Barrera and Castro (2006) move away from the debate of the pros and cons of cultural adaptation to providing frameworks for when and how to culturally adapt evidence-based practices. Lau (2006) proposes a selective and directed framework of cultural adaptation in which she outlines conditions for when cultural adaptation may be warranted. This selective approach focuses on evidence of poor fit and advocates for treatment adaptations that do not change the integrity of the evidence-based practice. The first condition is when “there is evidence that a clinical problem emerges within a distinctive socio-cultural context in a given group” (p. 297). The second condition is when there is “evidence suggesting that certain communities may respond poorly to certain approaches” (p. 299). Barrera and Castro’s framework (2006) supports Lau’s proposal and adds steps that investigators should take in the cultural adaptation process. These steps are: 1) information gathering, 2) preliminary adaptation design, 3) preliminary adaptation tests, and 4) adaptation refinement.

Need for Cultural Adaptation of Interventions The quest to promote the cultural adaptation of psychosocial interventions has been growing in recent years. Bernal et al. (1995), Bernal & Sharron del Rio (2001), Nagayama-Hall (2001), Rogler et al. (1987) emphasize the need to consider culture and contextual aspects in psychosocial interventions. Nagayama-Hall (2001) argues that at times conventional psychotherapies can promote mainstream values such as

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interdependence of some minority groups. Bernal & Saez-Santiago (2006) contend that more research is needed to address disparities in access and that focus should be placed on ethnic minority communities that are often overlooked by NIMH-funded research.

Zane, Nagayama-Hall, Sue, Young and Nuñez (2006) point out that research on psychotherapy with diverse populations is necessary to prevent ethnic minority clients from receiving poor quality of care because they are likely to be treated by White therapists who are unfamiliar with cultural values which may lead to invalid clinical assessments and ineffective psychotherapy. These authors also argue that psychotherapy must be adapted to meet the needs of minority groups by having psychotherapists understand the history of racial/ethnic relations in the U.S. and how these can play a role in mental health issues for individuals.

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