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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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Beck outlines several frameworks from which to view emotions. Sadness is seen as resulting from a loss of some kind. Conversely, euphoria and excitation arise from a perception or expectation of a gain. Anxiety stems from the real or imaginary threat of danger to safety, health or psychological state of a person. And, anger can be produced by intentional or unintentional transgressions, indirect transgressions, or hypothetical transgressions (Beck, 1979). Intentional transgressions take place when people are deliberately attacked in the form of a physical attack, criticism, coercion, thwarting, rejection, deprivation or opposition. Unintentional transgressions take place when a person perceives that his/her rights are being violated. Indirect transgressions that may lead to anger are characterized by actions that indirectly expose a person to selfdevaluation. Some examples are when people talk about their successes and this angers others, or a man becomes furious when his girlfriend chats in an animated way with another man. Hypothetical transgressions may evoke anger in a person when the person places the same weight on what could happen as if it did happen. One example is when a person becomes angry about a speeding car and thinks “What if I had been crossing the street at that time.” To summarize, Beck writes that different emotions will arise depending on the meaning attached to an event (Beck, 1979).

CBT also makes assumptions about the nature of certain conditions. According to CBT, depression is caused by a sense of loss, which leads to the cognitive triad. The cognitive triad involves the three themes of basic ideation in depression: 1) events are interpreted negatively, 2) depressed individuals dislike themselves, and 3) the future is appraised negatively. Beck views the fundamental ideas in depression as being too

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depressed people. One is the dependent type who is vulnerable to depression after a loss or rejection because they hold schemas such as “I must be loved by others or I’m worthless”. The other is the autonomous type who is vulnerable to depression after a loss of independence or failure because they hold schemas such as “I must be independent or accomplish significant achievements or else I am worthless”.

Beck describes factors underlying distorted cognitions. Beck believes that direct and indirect distortions of reality, as well as, illogical thinking such as overgeneralizations lead to problems (Beck, 1979). One example of distortions of reality

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overgeneralization is when a person states “my whole house is falling apart,” when in reality there are only a few things that need to be repaired.

As Beck’s approach evolved a cognitive model for CBT developed. This cognitive model presents the relationship between a person’s appraisal of stimuli and the resulting emotional, physical and behavioral reactions (Beck, 1964; Ellis, 1962). In other words, a person will react to a situation based on their interpretation of the situation. By

the 1980’s, Aaron Beck’s CBT became a:

system of psychotherapy that consisted of 1) a theory of personality and psychopathology with solid empirical findings to support its basic postulates 2) a model of psychotherapy with sets of principles and strategies that blended with the theory of psychopathology, and 3) solid empirical findings based on clinical outcome studies to support the efficacy of this approach. (Beck, J., 1995, p. vii)

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Beck’s theory of cognitive therapy looks at the interaction between behaviors, cognition and mood. The theory proposes that a change in one will result in a change in the other two in a reciprocal causal association (Persons et al., 2001). CBT is a timelimited, structured therapy that requires the therapist to be active and directive (Beck, 1979). Psychoeducation is a major part of CBT and the therapist plays the role of a teacher (Persons et al., 2001). The therapy involves several interventions that were developed to increase a depressed person’s activity level, change cognitions and change their mood as a result.

The first is activity scheduling, which is a simple intervention where the client and the therapist develop a list of activities for the client to carry out. It is recommended this be one of the first interventions in treatment because “it can help elevate mood by providing direct evidence to disconfirm depressed patients’ negative automatic thoughts and schemas” (Persons et al., 2001, p. 90). An activity scheduling worksheet can be used initially to bring awareness to the client and therapist of problematic times or situations in the client’s daily routine. The worksheet can also be used to record behavioral experiments, increase activity level, increase pleasure and mastery activities, record graded task assignments and schedule behavior plans that support adaptive thinking (Persons et al., 2001).

Teaching clients to identify cognitive distortions is another intervention in CBT that helps clients shift to more reasonable, realistic modes of thinking. The best way to do this is to provide clients with a list of thinking errors and help them identify when they use these thinking errors. The therapist can help normalize thinking errors by using everyday examples of how everyone uses them. Most depressed people find this

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situation that affected their mood adversely; (b) identify and rate the emotions associated with the situation; (c) identify the automatic thoughts that took place as a result of the situation; (d) identify the thinking errors the client is using; (e) evaluate the automatic thoughts by looking at the evidence for and evidence against the automatic thoughts; (f) and develop a more accurate thought about the event based on the evidence identified.

Socratic questioning is the major tool used by the therapist to assist the client in achieving each of these steps. Socratic questioning is questioning that helps clients arrive at a view of a situation that would be useful to them (Beck, 1979). Socratic questioning is more useful than lecturing because most people do not like to be told what they “should” think.

CBT and Depression Beck’s approach to CBT has been studied and shown effective in more randomized clinical trials (RTCs) than any other psychosocial treatments for depression (Agency for Health Care Policy and Research, 1993). Numerous empirical studies have been conducted to examine the efficacy of cognitive behavioral therapy to treat depression. These studies found CBT to be more effective than no treatment and as effective as antidepressant medication (Agency for Health Care Policy and Research, 1993). “Cognitive behavioral therapy is generally recognized as the ‘treatment of choice’ for depression” (Prochaska & Norcross, 2007). Dobson (1989) found cognitive behavioral therapy to be superior to no treatment. Other studies have found it to be efficacious for inpatient samples as well (Prochaska & Norcross, 2007, p. 449). Studies to examine whether CBT is more effective than medications in treating depression have varied findings. Earlier studies which were found to have inappropriate implementation

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administration of medications was appropriately implemented found CBT had no advantage over drugs (Hollon et al., 1992; Murphy, Simons, Wetzel & Lustman, 1984).

The American Psychiatric Association (2000) concluded that CBT is effective in treating less severe depressions but medications are preferred in treating more severely depressed patients.

Persons et al., (2001) concluded the following about CBT from their review of the


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CBT and Mexican Americans There is a paucity of literature on the effectiveness of CBT with Mexican Americans diagnosed with depression. A few studies have been conducted examining the effectiveness of CBT with Hispanics, but with samples that involved Puerto Ricans (Comas-Diaz, 1981; Rossello & Bernal, 1999). One study was found that examined the effectiveness of CBT with panic disorders (Sanderson, Raue, & Wetzler, 1998). Another study evaluated a cognitive-behavioral school based program for pregnant adolescent

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conducted on predominantly White, middle-class, and well-educated patients (Organista et al., 1994).

The Depression Clinic at San Francisco General Hospital has taken the lead in developing CBT interventions for Mexican Americans with depression. As discussed earlier, four major projects were developed at that facility to address depression in their Spanish-speaking population: 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.

All four projects showed positive outcomes in preventing depression or lowering depression scores for the participants.

Another study that was conducted at San Francisco General Hospital sampled 175 low-income and minority, depressed medical outpatients and found that depression scores were reduced from pre to post treatment after using CBT as the intervention (Organista et al., 1994). The sample was comprised of 44.4% Spanish-speaking Latinos, 18% AfricanAmericans and 34.6% Whites. The study involved a retrospective review of clinic charts for a 3-year period. The study conducted by Muñoz and his collaborator (1995) on the effectiveness of culturally adapted CBT for groups in the Depression Prevention Research Project showed that 133 out of 139 participants were depression free after one year. The results of these two studies satisfy the requirement for CBT to be considered a probably efficacious treatment for depression for Latinos (Zane, Hall, Sue, Young, and Nuñez, 2004) Sanderson et al. (1998) conducted a study evaluating the effectiveness of CBT for panic disorder in a clinical setting with an ethnically diverse population. Thirty patients

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12 sessions of CBT. Results showed that 50% of the patients were panic-free at post treatment. There were no significant differences in response to treatment by race.

Another outcome study examined the effectiveness of a cognitive-behavioral school-based group intervention with Mexican American pregnant and parenting adolescents (Harris & Franklin, 2003). The study involved cluster sampling of five high schools that had teenage parent programs. Eighty-five participants were randomly assigned to treatment or control groups and were given a pretest, posttest and 30-day follow-up. The participants underwent an eight-week, task-centered, cognitive-behavioral program using a curriculum called “Taking Charge”. The curriculum was developed to help adolescent Mexican American mothers improve social problem-solving skills, effective coping skills, and success in school. The treatment group showed a statistically significant improvement on all outcome measures at posttest and at the 30-day follow-up.

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impact on how well Mexican Americans respond to mental health treatment. More specifically, the effects of culturally adapted cognitive behavioral therapy (CACBT) for two groups of Mexican Americans with depression who were at different stages of

acculturation were observed. The study was divided into three research questions:

1. Is there a relationship between acculturation level and depression scores among

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2. Is CACBT effective in reducing depression scores among Mexican Americans?

3. Does acculturation level mediate the effectiveness of CACBT treatment?

This chapter outlines the components of the methodology utilized for this study. It includes a description of the study design, the setting where the study took place, and the procedure used for recruiting and screening study participants. In addition, an outline of the criteria used for respondent inclusion and group assignment is provided. A description of the instruments used for data collection is presented, including a depression scale, an acculturation measure, and a demographic client intake form. Finally a description of the culturally adapted intervention is detailed.


This study used a two-group pretest/posttest comparison group design model in order to test within group differences in the effectiveness of CACBT among two groups of Mexican American adults at different stages of acculturation. The sampling consisted of a purposive nonprobability sample of adults diagnosed with depression recruited from

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Family Service of El Paso (FSEP) is a private non-profit organization that was founded in

1893. The demographics of the clients served at this outpatient mental health center are as follows: 75% Hispanic, 17% White, 4% African American and 4% other. Clients served at the agency range from ages 4 to 80. Approximately 50% of clients seeking help at FSEP are in the range of 19 to 43 years of age. FSEP provides therapy services for individuals, couples and families. FSEP provides services for approximately 2,000 clients every year. In addition, FSEP offers weekly parenting classes, marriage groups, and post adoption case management.

Family Service of El Paso is one of five Texas sites that were selected to participate in an initiative titled “Cultural Adaptation: Providing Evidence-based Practices to Populations of Color” sponsored by the Hogg Foundation for Mental Health from The University of Texas at Austin. The purpose of this 3-year, 2.9 million dollar initiative was to identify effective ways to modify evidence-based practices in order to culturally adapt them for people of color. The Hogg Foundation study focused on process evaluation of the implementation of culturally adapted cognitive behavioral therapy at the different sites. The Hogg Foundation study was designed as a phenomenological qualitative study. The investigation for this dissertation, which was conducted independently from the larger study, adds a quantitative component to the Hogg evaluation, in order to study the effects of acculturation when using culturally adapted cognitive behavioral therapy.

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