Culturally centered psychosocial interventions

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Culturally centered psychosocial interventions
  JOURNAL OF COMMUNITY PSYCHOLOGY , Vol.34, No.2, 121–132 (2006)Published online in Wiley InterScience ( ©2006 Wiley Periodicals, Inc.DOI:10.1002/jcop.20096 Support for the preparation of this manuscript was provided by the International Institute of Mental Health,Division of Services & Intervention Research, Grant ROIMH 67893 (awarded to the first author).Correspondence to: Guillermo Bernal, Department of Psychology, University of Puerto Rico, CentroUniversitario – CUSEP, P.O. Box 23174, San Juan, Puerto Rico 00931-3174. E-mail: CULTURALLY CENTEREDPSYCHOSOCIAL INTERVENTIONS Guillermo Bernal and Emily Sáez-Santiago University of Puerto Rico  Over the last few decades, psychologists and other health professionals have called attention to the importance of considering cultural and ethnic- minority aspects in any psychosocial interventions. Although, at present,there are published guidelines on the practice of culturally competent  psychology, there is still a lack of practical information about how to carry out appropriate interventions with specific populations of different cultural and ethnic backgrounds. In this article, the authors review relevant literature concerning the consideration of cultural issues in  psychosocial interventions. They present arguments in favor of culturally centering interventions. In addition, they discuss a culturally sensitive  framework that has shown to be effective for working with Latinos and Latinas. This framework may also be applicable to other cultural and ethnic groups. © 2006 Wiley Periodicals, Inc. The thesis that cultural and social processes must be considered in treatment, preven-tion, and mental health service delivery has been advanced over the last several decades(Bernal, Trimble, Burlew, & Leong, 2003; Marín & Marín, 1991; Rogler, 1989, Sue &Zane, 1987). A growing number of authors are emphasizing the need to consider cultur-al and contextual aspects in psychosocial interventions (Bernal, Bonilla, & Bellido, 1995;Bernal & Scharron-del-Rio, 2001; Nagayama-Hall, 2001; Rogler, Malgady, Costantino, &Blumenthal, 1987; Sue & Sue, 2003; Sue & Zane, 1987). The field is progressively mov-ing toward recognition of multiculturalism in nearly all aspects of psychology, as evi-denced by the adoption of documents, such as the multicultural guidelines on education,research, training, practice, and organizational change (American Psychological Association [APA], 2003). Nevertheless, there are very few guiding frameworks availableto investigators who are interested in tailoring treatment or preventive interventions to work with specific populations of various cultures and languages. The challenge is todevelop evidence-based, culturally sensitive interventions.  A R T I C L E  Culturally sensitive interventions has been described as a continuum of the followingdimensions: (a) awareness of culture, (b) acquisition of knowledge about cultural aspects(such as norms, customs, language, lifestyle, etc.), (c) capacity to distinguish between cul-ture and pathology, and (d) capacity to integrate the previous three dimensions in theintervention (Zayas, Torres, Malcolm, & DesRosiers, 1996). It is important to note that cultural sensitivity is a dynamic process that changes across time and in different con-texts, in which the cultural hypothesis should be constantly tested against the alternativeones (López et al., 1989).  Various terms have been used over the years to refer to the consideration of culture,including “culturally sensitive,” “culture centered,” “culturally competent,” “multicultur-al competence,” or “culturally responsive.” All of these terms, while perhaps varying indegree of intensity, have in common the consideration of culture and language-relatedissues in any psychosocial intervention. In this article, we primarily use the term “culture-centered” first described by Pederson (1997) and subsequently adopted in the Guidelines on Multicultural Education, Training, Research, Practice and Organizational Change for Psychologists (APA, 2003). In this article, we discuss the need for culturally specific psychosocial interventionsand present an evolving framework for the adaptation of empirically based, culturally sensitive treatment and interventions for ethnic minority populations. While our workhas focused primarily on adapting interventions for Latino populations, the guidingframework presented here is applicable to other populations as well. We will begin withan overview of information pertinent to the circumstances of ethnic minorities (andspecifically the Latino population) in the United States, which will clearly illustrate theneed for culturally sensitive interventions. ETHNIC MINORITIES IN THE UNITED STATES Ethnic minority populations represent a considerable proportion of the entire popula-tion in the United States. According to the 2002 American Community Survey, 24.2% of the U.S. population identified as something other than White (U.S. Census Bureau,2002). Of these, 13.5% identified as Hispanics/Latinos, 12.0% as African American,4.1% as Asian/Pacific Islander, 0.7% as Native American or Alaskan Native, and theremaining 1.2% reported other ethnicities.There is evidence suggesting that ethnic minorities in the United States are current-ly experiencing major mental health problems. Ethnic minorities often have less accessto health care, and the care that is available is frequently of poorer quality than that avail-able to the White population (U.S. Department of Health and Human Services, 2000).Ethnic minorities experience disproportionately higher poverty and social stressors asso-ciated with psychological and psychiatric conditions than do Whites (Mays & Albee, 1992;U.S. Department of Health and Human Services, 2000). In fact, after controlling for vari-ables such as socioeconomic status, educational level, health and mental health history,and attitudes toward health-related issues, there are significant disparities in the use andquality of mental health services among and across different ethnic, cultural, and racialcommunities (National Institute of Mental Health [NIMH], 1999). These disparities inmental health services represent a major challenge to the field (U.S. Department of Health and Human Services, 2000). The goal of decreasing disparities between ethnicminority groups and the majority populations is currently a national effort, spearheadedby the National Institute of Mental Health (NIMH, 1999). 122  •Journal of Community Psychology, March 2006   Journal of Community Psychology  DOI: 10.1002/jcop  Latinos and Latinas Living in United States  In the United States, Latinos and Latinas are currently the largest ethnic minority group.In 2002, the number of Latinos and Latinas living in the United States was estimated at approximately 37.9 million, comprising 13.5% of the entire population (U.S. CensusBureau, 2002). Of these, 63.3% were Mexican Americans, 9.5% were Puerto Ricans, 3.4% were Cubans, and 23.8% were from some other Hispanic/Latin American country. Thecensus projections indicate that by 2050, the Latino population will increase to 102.6 mil-lion, which will comprise approximately one-fourth of the total U.S. population.It is important to note that the Latino population in the United States is diverseand heterogeneous. However, statistics show that all of the various Latino ethnicgroups share certain similarities, among which are: (a) poverty, (b) inadequate hous-ing, (c) high proportion of single-parent families, (d) alcohol/drug addiction, (e)acculturative stress, (f) discrimination (Dana, 1998), (g) relatively low educationaland economic status (U.S. Department of Health and Human Services, 2000), and (h)a history of conquest, oppression, defeat, and struggle for liberation (Garcia-Prieto,1982), particularly for the Mexican Americans and Puerto Ricans. Also, literaturereviews reveal a set of characteristics shared by most Latinos and Latinas, such as theSpanish language and cultural ideals such as  personalismo  (personal contact), simpatía  (social engagement, charm), and  familismo  (familialism) (Bernal & Enchautegui-de- Jesús, 1994; Dana, 1998). Certainly, the family system contributes to the development and maintenance of both health-promoting and health-damaging behaviors (Bagley, Angel, Dilworth- Anderson, Liu, & Schinke, 1995). Thus, familialism could be considered as either a pro-tective factor or a risk factor for the mental health status of Latinos as living in the UnitedStates. One disadvantage faced by many minority groups is the loss of their traditionalcultural orientation, which may lead to family disruption (Bagley et al., 1995). Such dis-ruption is common in Latino families who migrate from their native countries to theUnited States. Given the loss of the extended family resources and the difficulties of keeping in touch across national boundaries, many family ties are broken.  As are other ethnic minority populations, Latinos and Latinas are in need of mentalhealth services. Epidemiological studies (The Epidemiologic Catchment Area Study andThe National Comorbidity Study) have found that Latinos and Latinas—mostly Mexican Americans—have similar rates of mental disorders as Whites, and that the Latino popu-lation is considered to be at high risk for mental health complications. Despite this needfor mental health services, Latinos and Latinas and those belonging to other ethnicminority groups have less access to mental health services than do Whites, and all too fre-quently, these services are inadequate or of poor quality (U.S. Department of Health andHuman Services, 2000). There are a number of factors that impede access to mental health services(Echeverry, 1997). These factors can be grouped into the following broad categories: (a)client variables, (b) client–therapist variables, and (c) organizational and structural vari-ables. Client variables  include demographic characteristics (age, gender, educational level,and legal status in the United States), cultural factors (religious beliefs, degree of accul-turation, national srcin, English proficiency level, resource preference, and beliefsabout mental illness and treatment), and individual factors (presenting problem andpersonality variables). Client–therapist variables  refer to confidentiality concerns and social-ization with clients. Finally, organizational and structural variables  consider the geographiclocation of mental health services, the cost of evaluation and treatment, the scheduling Culturally Centered Psychosocial Interventions• 123   Journal of Community Psychology  DOI: 10.1002/jcop  of services, the type of services offered, and the availability of Spanish-speaking or bilin-gual personnel. It is essential that all these variables be taken into consideration whendeveloping and implementing any mental health services for the Latino population.Nevertheless, the majority of the mental health services provided overlook these impor-tant aspects, causing the disparities in access and acceptance of such services. Barona and Santos de Barona (2003) summarized the status of mental health servicesfor the Latino population by indicating the following needs: (a) to increase the number of bilingual and bicultural mental health professionals who are competent in the carrying out of evaluations, diagnosis, and treatments, (b) to better train primary care service providersand mental health professional so that they can recognize symptoms of emotional distress,and (c) to develop effective and affordable models of mental health services. THE CASE FOR CULTURALLY CENTERED PSYCHOSOCIAL INTERVENTIONS The need for mental health providers to attend to cultural aspects when working withmembers of diverse ethnic minority communities is well documented (APA, 2003; Bernal,Bonilla, & Bellido, 1995; Lopez et al., 1989; McGoldrick, Pearce, & Giordano, 1982; Sue, 2003; Sue & Zane, 1987; Tharp, 1991; U.S. Department of Health and Human Services, 2000). The National Institute of Mental Health Strategic Plan for Reducing HealthDisparities (1999) pointed out several findings from the literature on ethnicity and men-tal health. This report highlighted the following observations: (a) one’s cultural beliefsabout the nature of mental illness influence one’s view of the course and treatment of any condition; (b) there are differences in how individuals from different cultural back-grounds experience and manifest symptoms of mental illness; and (c) diagnoses of men-tal disorders vary across cultures. In a later supplement on culture, race, and ethnicity (U.S. Department of Health and Human Services, 2001) to the Surgeon General’s report on mental health (U.S. Department of Health and Human Services, 1999), the U.S.Surgeon General concludes that culture influences many aspects of mental illness, such asmanifestation of symptoms, coping styles, family and community support, and willingnessto seek treatment, as well as diagnosis, treatment, and service delivery. Subsequently, the American Psychological Association approved guidelines for multicultural counseling(APA, 2003). This document, based on the available literature, provides guidelines forclinical practice, research, organizational change, education, and training in psychology.In general, these guidelines encourage psychologists to increase their awareness of theinfluence of culture on themselves, as well as on their patients, clients, and trainees. Inaccordance with this premise, Pedersen (2003) points out that all behavior is learned anddisplayed within a cultural context, and, therefore, an effective intervention requiresattention to the cultural context in which the client/patient is immersed. Bernal and Scharron-del- Rio (2001) note that because psychotherapy is a culturalphenomenon, culture plays an important role in treatment. Evidence from severalresearch studies supports this idea. For example, studies on service utilization ( Arroyo, Westerberg, & Tonigan, 1998; Cheung & Snowden, 1990; Flaskerud & Liu, 1991; McMiller & Weisz, 1996; Schacht, Tafoya, & Mirabla, 1989), treatment preferences ( Aldous, 1994; Constantino, Malgady, & Rogler, 1994; Flaskerud & Hu, 1994; Flaskerud & Liu, 1991; Penn, Kar, Kramer, Skinner, & Zambrana, 1995; Schacht, Tafoya, & Mirabla, 1989), and health beliefs (McMiller & Weisz, 1996; Penn et al., 1995) have reported that  members of ethnic minority communities tend to respond differently to treatment thando nonminorities. These differences are most likely due to cultural differences. 124  •Journal of Community Psychology, March 2006   Journal of Community Psychology  DOI: 10.1002/jcop  Nagayama-Hall (2001) points out that there may be conflicts between the cultural values of ethnic minorities and the more mainstream values often used in conventionalpsychotherapies. For example, conventional treatment approaches tend to promote indi- vidualistic value systems (i.e., differentiation, individuation, etc.) rather than the inter-dependent value systems (i.e., familialism) within which minority communities are oftensocialized. The role of spirituality in healing processes, which is being increasingly acknowledged in the realm of mental health care, has not traditionally been part of for-mal treatment approaches, and this, too, may have an important intra- and interperson-al role among ethnic minorities. Certainly, the degree of discrimination one experienceshas important implications for treatment. Poverty and lack of access to resources areoften part of the ethnic minority experience, and it is essential to understand how eth-nicity, culture, cultural values, discrimination, community resources, and SES may impact a particular client or family. These dimensions can be considered in intervention proto-cols to work more effectively with ethnic minority groups. Toward Culturally Centered Intervention With Specific Ethnic Minority Groups  To decrease the disparity in mental health services and to be able to provide effective psy-chosocial treatments, we must work to develop new studies. These studies should direct-ly address disparities in access and in the knowledge base by using state-of-the-art research methods and the best practice treatment protocols that focus on mental healthissues in the low income, ethnic minority communities that are often overlooked by NIMH-funded research. In the absence of reliable information on the efficacy and effec-tiveness of mental health treatments for ethnic minorities, there is a need for researchthat can contribute to the knowledge base of what works and how it works. Thus, we must develop studies on the efficacy and effectiveness of treatments that are culturally sensi-tive or that use manuals that have been adapted to include important cultural consider-ations. There is a great need to produce or adapt treatment manuals and instruments,and to test these manuals and instruments in preparation for efficacy trials with ethnicminority communities. In this manner, it may be possible to adequately respond to theNIMH’s call for investigators to move toward more generalizable studies (National Advisory Mental Health Council’s Clinical Treatment and Services Research Workgroup,2000). Particularly necessary are studies that target underserved and underresearchedpopulations that approximate the types of cases seen in community mental health cen-ters. If we conduct clinical trials that consider cultural and language issues as being inte-gral to the treatment itself, we may be able to move more quickly from efficacy to effec-tiveness. Studies that consider ecological validity serve to bridge knowledge gaps andmove the field toward to translational and dissemination studies (National Advisory Mental Health Council’s Clinical Treatment and Services Research Workgroup, 1999). Sue (2003) discusses several positions that have emerged concerning research issuesabout cultural competence. These positions are that: … a) more resources are needed in order to meaningfully address cultural competen-cy; b) the emphasis on randomized clinical trials and efficacy research has, in fact, hin-dered understanding; c) theoretically driven research is needed because of the impos-sibility of studying each significant minority group; d) cultural competency cannot beeasily defined operationally and subjected to testing; and e) despite the lack of defin-itive research, guidelines for policies and practices must be established (p. 966). Culturally Centered Psychosocial Interventions• 125   Journal of Community Psychology  DOI: 10.1002/jcop
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