«The Mediating Effect of Acculturation on the Effectiveness of Culturally Adapted Cognitive Behavioral Therapy with Mexican Americans Suffering From ...»
Previous Cultural Adaptation of Interventions Bernal et al. (1995) used their Ecological Validity Model to culturally adapt several interventions for Puerto Ricans (Rossello & Bernal, 1999). The Ecological Validity Model (Bernal et al., 1995) has seven components of adaptation: (a) language, (b) persons, (c) metaphors, (d) content, (e) concepts, (f) goals, (g) methods, and (h) context. The language component involves, knowledge of emotional expression, mannerisms and verbal style. The persons component involves considering the role of ethnic and racial similarities and differences in the client-therapist dyad. Thirdly, metaphors involve knowledge of the symbols and concepts that are shared by a particular cultural group. Content refers to knowing the values, customs and traditions of an ethnic group. Concepts refers to the importance of conceptualizing and communicating the presenting problem to the client in a way that makes sense to him/her. The fifth
knowledge. The sixth component, methods, involves incorporating procedures for goal attainment congruent with the client’s culture. The seventh component, context, involves the consideration of broader social, economic, and political contexts, as well as, acculturative stress, phases of migration, developmental stages, availability of social support and the person’s relationship to his or her country or culture of origin (Bernal & Saez-Santiago, 2006).
Kopelowicz (1997) culturally adapted a program to work with Hispanics diagnosed with schizophrenia and their families. The cultural adaptations involved translating the trainer’s manual and patient workbook, as well as, dubbing the program videos into Spanish. Skills trainers for the program were all Mexican American and bilingual. Trainers modified their in-session activities by allowing more time for each participant to answer questions. The most relevant adaptation was allowing family members into the skills training process. Family members attended thirteen group sessions in which they were taught how to be collaborating participants in the treatment process of their relative diagnosed with Schizophrenia. Ninety-four participants were assigned randomly to either the culturally adapted program and customary outpatient care or customary care alone. Participants were assessed at baseline and after receiving thirteen weeks of services on measures of skill level and skill utilization, symptoms, level of functioning, and quality of life. There were no significant improvements from baseline in any of these areas. There was some question as to whether the small sample size or the short time allowed for the intervention played an important role in the outcomes.
Another example of cultural adaptation is the Guiando a Niños Activos (Guiding Active Children, or GANA) program. This project culturally adapted Parent Child
(McCabe, Yeh, Garland, Lau, & Chavez, 2005). One of the cultural adaptations included administering a comprehensive assessment protocol at the first session that assessed for how parents viewed the problem and seeking treatment. Another adaptation was to move away from some of the stigmatizing terms of “therapy”, “therapist”, and “mental health” and use terms such as “teacher” and “expert in child behavior”. A third adaptation was to engage fathers and other extended family in the treatment process from the onset of contact. In addition, increased attention was given to explaining the program and process, as well as, in rapport building to include checking with families periodically about their satisfaction with the program. And finally, all handouts were translated and written in simple language. No outcome studies have been conducted on the effectiveness of this culturally adapted program.
Muñoz and Mendelson (2005) wrote about several culturally adapted interventions that were developed at San Francisco General Hospital. These projects included the Depression Prevention Research Project, CBT Group Treatment Manuals for Depression, the Mood Management Intervention for Methadone Maintenance Patients, and the Mood Management Intervention for Psychiatric Inpatients. The cultural adaptations made in all of these programs were to include ethnic minority involvement in intervention development and to consider cultural values, religion and spirituality, acculturation, racism, prejudice and discrimination in the program design. Members of the Latino group were involved in the writing of the treatment manuals for each one of these projects. Special care was paid to language issues, as well as, issues of level or education and income. Manuals were written at less than high school reading level and exercises were simplified. Cultural values such as familism and collectivism were
Racism, prejudice and discrimination were talked about openly.
One outcome study showed that after one year, 133 of the 139 participants of the Depression Prevention Research Project were depression free (Muñoz et al., 1995). A study on the CBT Group Treatment Manuals for Depression found significant reductions in depressive symptoms, no differences in effectiveness between individual or group formats, and higher drop-out rates in patients who were younger, minority and treated with group therapy. The Mood Management Intervention program for Methadone Maintenance Patients study showed a significant reduction in depression symptoms after a 10-week mood management course (Organista, Muñoz & Gonzalez, 1994). The Mood Management Intervention for Psychiatric Inpatients program used and adapted a version of the Depression Clinic CBT manuals for Latinos. To measure outcomes, a sample of 44 patients was followed 60 days after discharge. Those who underwent the intervention were found to be significantly more likely to attend outpatient appointments and less likely to return for psychiatric emergency services.
THE INCORPORATION OF ACCULTURATION IN MENTAL HEALTHIn addition to studies focusing on the impact of culture, other studies have specifically focused on the influence of the acculturation process on mental health for Mexican Americans (Escobar et al., 2000). Research exists that examines the association between an individual’s place of birth (whether U.S.-born or foreign-born) and prevalence of mental disorders, as well as, mental health treatment utilization (Burnam et al., 1987; Escobar et al., 1998; Vega, Gil & Wagner, 1998). Other research examining these same issues focus on an individual’s level of acculturation as measured by an acculturation scale (Burnam et al., 1987). It is difficult to identify a pattern of association
differences. Moreover, a linear association between acculturation and mental illness has not been established, given the complexity of the association.
There are several major studies that examine the relationship between place of birth, acculturation and psychiatric disorders for Mexican Americans. Some of these studies report findings about psychiatric disorders in general, while others present findings on depression specifically. All of these studies point to U.S.-born Mexicans being at higher risk for the development of psychiatric disorders including depression than their foreign-born counterparts (Burnam et al., 1987; Escobar et al., 1998; Vega, Gil & Wagner, 1998). In addition some studies show that as Mexican individuals become more acculturated they tend to experience more psychiatric disorders. Escobar, Nervi & Gara (2000) conducted an appraisal of three major studies. The Epidemiologic Catchment Area Study conducted by the National Institutes of Health included five different sites. In Los Angeles, a representative sample of 3,132 was obtained 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. The analysis conducted in this study included using a measure of acculturation (26-item inventory that appraised primary language use and ethnic identity) and a place of birth measure. The Diagnostic Interview Schedule was used to assess Diagnostic and Statistical Manual diagnoses. Results showed that rates for diagnoses of alcohol abuse and dependence, drug abuse and dependence, phobia, and antisocial personality increased significantly as the level of acculturation increased. Place of birth was also found to be strongly associated with the presence of psychiatric disorders, including Major Depression. When looking at Major Depression, Mexico-born immigrants had a lifetime
prevalence of 6.9 per 100.
The National Comorbidity Survey was conducted between 1990 and 1993 with a total sample size of 8,098 (Escobar et al., 2000). Hispanics comprised 9% of the sample, 70% of which were of Mexican descent and the rest were Puerto Rican, Cuban or “other Hispanic”. The Composite International Diagnostic Interview (CIDI) developed by the World Health Organization was used to assess DSM diagnoses. The results of this study showed Hispanics were more likely than non-Hispanics to have met criteria for a diagnosis of any affective disorder within the previous year. Secondary analysis of this study showed revealed that Hispanics born in Mexico had a significantly lower prevalence of several psychiatric disorders, including depression, than those born in the U.S.
The findings of the Mexican American Prevalence and Services Survey (MAPSS) (Vega et al., 1998) showed that U.S.-born Mexican Americans were two times more likely to have psychiatric disorders than Mexico-born immigrants. The MAPSS used a Spanish translation of the CIDI instrument adapted for use with less acculturated people of Mexican descent to assess psychiatric disorders. No measure of acculturation was collected for this study. Findings showed that Mexico-born individuals had a prevalence of 8.0 per 100 while U.S.-born individuals had a prevalence of 18.7 per 100 for affective disorders which included depression.
The University of California-Irvine Study of Mental Disorders in Primary Care (Escobar et al, 1998) sampled 1500 patients from four ethnic groups, 600 were classified as Mexico-born immigrants and 200 as U.S.-born and found that Mexican and Central
disorders than U.S.-born people of Mexican descent.
This chapter set the stage for the development of this study. It provided a review of literature on treatment, access and barriers associated with mental health services for Mexican Americans. Literature on previous culturally adapted interventions was presented. In addition, previous studies using acculturation as a variable in examining mental health for Mexican Americans were presented. The studies reviewed here provided the foundation for this research and guided the development of the methods for this dissertation study.
This chapter provides a detailed description of the concept of culture including the theoretical frameworks of culture and the various approaches to understanding culture.
The chapter then outlines the context of Mexican American culture by describing the U.S. mainstream culture and Mexican culture. The discussion then focuses on the specific cultural characteristics of the study population. This discussion is followed by an examination of acculturation, including the theoretical framework used for this study.
The chapter ends with a section on the major assumptions and main interventions of cognitive behavioral therapy, its effectiveness in treating depression in general and for Mexican Americans specifically.
THE CONCEPT OF CULTURECulture is a concept that is used to explain individual behavior, a set of beliefs, norms and values (Gordon, 1964). The concept of culture has evolved from being understood as an
intangible construct to being operationalized into specific
study of culture (Winkelman, 2005). Most recently the study of culture has broadened to include the intersectionality of ethnicity, gender, sexual orientation, social class, religion and ability status (Marsiglia & Kulis, 2009). In addition, there is an emerging field of study in culturally adapting interventions for specific populations (Bernal et al., 1995;
Bernal & Sharron del Rio, 2001; Castro et al., 2004; Nagayama-Hall; 2001; Rogler et al., 1987).
Theoretical Frameworks of Culture Two dominant theoretical frameworks of culture provide the foundation for the study of culture and mental illness: the evolutional/ecological theories of culture and the ideational theories of culture (Keesing, 1974). Each brings an important perspective to the understanding of how culture impacts a groups’ definition of mental health, methods for seeking mental health treatment, and ways of engaging in the treatment process. At the same time, the two frameworks can help practitioners understand why it is important to tailor interventions to the cultural group that is being served.
According to the evolutional/ecological theories, culture is an adaptive process.
It is considered a strength, not a barrier, as well as, an obvious background in any therapeutic endeavor. The evolutionary/ecological perspective has several assumptions.
First, cultures are systems of socially transmitted behavior patterns that serve to relate humans to their physical and social ecology. This assumption includes the idea that individual behavior might be determined by modes of economic organization, settlement patterns, social grouping, and contact with other social groups or political organization.
change in order to maintain equilibrium with the ecosystem. Because cultural groups have developed certain cultural characteristics as a way of adapting to their environment (e.g. as survival mechanisms), it is important to consider culturally adapting interventions. According to this perspective, economies and their social correlates should be considered as primary when looking at cultural change, while ideational systems such as religion, ritual and world view should be considered as secondary. Finally, ideational elements of cultural systems may have adaptive consequences such as controlling populations or maintaining the ecosystems.