MENTAL HEALTH CLINICIANS PERSPECTIVES ON THE ROLE OF

ACCULTURATION IN THE PROVISION OF SERVICES

TO LATINOS: A GROUNDED THEORY EXPLORATION

by

GABRIELA SEHINKMAN

Submitted in partial fulfillment of the requirements for the degree of

Doctor of Philosophy

Social Welfare Program

Jack, Joseph, and Morton Mandel School of Applied Social Sciences

CASE WESTERN RESERVE UNIVERSITY

May, 2020

i

CASE WESTERN RESERVE UNIVERSITY

SCHOOL OF GRADUATE STUDIES

We hereby approve the dissertation of

Gabriela Sehinkman

candidate for the degree of Doctor of Philosophy*.

Committee Co-Chair

Dr. David Hussey

Committee Co-Chair

Dr. Anna Maria Santiago

Committee Member

Dr. Elizabeth Tracy

Committee Member

Dr. Susan Painter

Date of Defense

December 9, 2019

*We also certify that written approval has been obtained

for any proprietary material contained therein. ii

Table of Contents

List of Tables ...... vii

List of Figures ...... viii

Acknowledgments ...... ix

Abstract ...... xi

Chapter 1 : Introduction ...... 1

The Role of Acculturation in the Mental Health of Adult Latinos in the United States .... 1

Explanatory Models: The Immigrant Paradox and the Acculturation Hypothesis ...... 7

Incorporation of Knowledge of Acculturation to Mental Health Interventions ...... 9

Social Relevance of Incorporating Knowledge of Acculturation into Mental Health

Practice with the Latino Population ...... 11

Proposed Study ...... 14

Formal Statement of Research Aims ...... 15

Chapter 2 : Relevant Cultural Competence and Culture Exchange Frameworks and

Theories...... 17

Introduction ...... 17

Relevant Cultural Competence Frameworks in the Social Work Field ...... 17

Ethnic-sensitive generalist social work practice ...... 18

Multi-ethnic cultural awareness-based approach ...... 20

Process stage approach ...... 24 iii

Competing Constructs in Related Fields ...... 26

Cultural safety ...... 27

Cultural humility ...... 28

Cultural attunement ...... 30

Theory of Acculturation...... 32

Early theories of culture change: Assimilation and cultural pluralism ...... 32

Contemporary theories of culture change ...... 34

Berry’s theory of acculturation ...... 34

Critique of Berry’s Theory of Acculturation ...... 45

Conclusion ...... 49

Chapter 3 : Review of the Literatu ...... 50

Introduction ...... 50

Culturally Modified Mental Health Interventions for the Latino Population: Current State of the Research...... 50

What Constitutes a Cultural Adaptation? ...... 52

Randomized-controlled Trials ...... 54

Interventions for depression ...... 54

Interventions for schizophrenia spectrum disorders ...... 57

Interventions for posttraumatic stress disorder ...... 58

Quasi-experimental Design...... 59 iv

Researcher-driven cultural adaptations ...... 59

Participant-driven adaptations ...... 63

Qualitative Studies ...... 66

Summary and Critique ...... 71

Chapter 4: Research Methodology ...... 77

Introduction ...... 77

Description of the Present Study ...... 77

Rationale for the Use of Qualitative Methodology ...... 81

The Grounded Theory Tradition of Qualitative Inquiry ...... 82

Constructivist Grounded Theory Approach ...... 83

Data Analysis ...... 84

Constructing the Theory ...... 89

Reflexivity ...... 90

Position of the Researcher ...... 92

Chapter 5 : Results ...... 94

Introduction ...... 94

Sample Description and Final Codebook ...... 94

Research question 1: How do mental health practitioners conceptualize the concept and process of acculturation? ...... 95

Substantive-level Theory: Conceptualization of Acculturation and How it Takes Place108 v

Research Question 2 ...... 108

Substantive-Level Theory ...... 114

Research Question 3 ...... 115

Substantive-Level Theory ...... 130

Research Question 4 ...... 131

Substantive-level theory...... 161

Integration of Substantive-level Theory into a Grounded Theory Formulation ...... 161

Postulate 1 ...... 161

Postulate 2 ...... 162

Postulate 3 ...... 163

Chapter 6 : Discussion and Conclusions...... 167

Introduction ...... 167

Conceptualization of Acculturation and Sources of Knowledge ...... 167

Ways in Which Acculturation Knowledge Informs Clinical Practice and Variation Based on Clinician Level of Acculturation ...... 172

How does Acculturation Inform the Different Phases of the Helping Process? ...... 176

Study Strengths and Limitations ...... 184

Credibility ...... 185

Originality ...... 186

Resonance ...... 187 vi

Usefulness ...... 187

Implications for Social Work Practice and Education ...... 189

Suggestions for Future Research ...... 192

APPENDIX A ...... 194

Interview Guide (English Version) ...... 194

Interview Guide (Spanish Version) ...... 198

Appendix B ...... 203

Final Codebook ...... 203

References ...... 205

vii

List of Tables

Table 5.1 Acculturation Definition ……………………………………………………...96

Table 5.2 Acculturation Mechanisms ……………………………………………….....103

Table 5.3 Acculturation Knowledge Sources…………………………………………...109

Table 5.4 Culture-unrelated and Culture-related Clinician Factors……….………….116

Table 5.5 Culture-related and Culture-unrelated Clinician Factors by Nativity Status……………………………………………………………………….130

Table 5.6 Assessment Codes……………………………………………………………132

viii

List of Figures

Figure 2.1 Orthogonal Model of Acculturation (Berry, 2001)…………………………….36

Figure 2.2 Acculturation and Stress (Berry et al., 1987)………………………………...41

Figure 5.1 Grounded Theory of Clinician Views of Acculturation and how

they Inform Practice with adult Latino Clients………………………………………...165

ix

Acknowledgments

My sincerest gratitude to Dr. Anna Maria Santiago, co-chair of my committee, for her unrelenting support, wealth of academic knowledge and rigor, cultural insight and kindness that have been a true inspiration throughout the process. To Dr. David Hussey, committee co-chair and academic advisor, who cheered me on and reminded me that the research topic was relevant when I needed it the most. To Dr. Betsy Tracy, for her willingness to see this process through and stay on board as committee member after retirement. And to Dr. Sue Painter, for so willingly accepting to serve as external committee member late in the process.

To the doctoral faculty at the Mandel School of Applied Social Sciences, my deepest gratitude for opening the doors to a program that would forever change my understanding of how scientific knowledge develops and evolves. Most of all, my gratitude for taking on a non-traditional student like myself, who took longer than planned to make it to the finish line.

To the hundreds of Latino individuals I have had the pleasure to work with since arriving in the United States in 2001, thank you for the privilege of walking next to you in your journeys. This work is a small way in which to give back to a community that has taught me so much about resilience, hope, and dignity in the face of injustice and discrimination. My eternal gratitude also goes to the amazing clinicians who willingly took time out of their busy schedules to share their personal and professional experiences.

I also hope you find the findings from this study helpful in your clinical practice.

Finally, I cannot express enough how much I owe to my family and close friends who always stood by me in steadfast support. You know of the many times I expressed x dismay in this lengthy process and you kept me going with words of encouragement and by taking care of the many things I had to delegate to get this work done. To my parents,

Carlos and Alba, thank you for your unrelenting support of a lifetime and for being models of stability, optimism, and sound ethical standards. To my brother Charly, for always showing up with unconditional love. To my beloved children, Juan Manuel and

Matías, thank you for putting up with a mother who was always working and “still in school.” Last but not least, to Mark – I love you more than words can say! I could have never done it without you.

xi

Mental Health Clinicians Perspectives on the Role of Acculturation in the Provision of

Services to Latinos: A Grounded Theory Exploration

Abstract

by

GABRIELA SEHINKMAN

The present study uses in-depth interviews conducted with licensed mental health clinicians (N = 10) with experience serving Latino clients in Cleveland, Ohio. Utilizing a constructivist grounded theory approach, the study explores the views held by participants about the acculturation process, their sources of acculturation knowledge, how acculturation knowledge informs their approach to practice, and how this knowledge is incorporated throughout the helping process. Findings from the study suggest that clinicians’ understanding of the concept of acculturation and how it transpires was consistent with the extant literature despite the fact that this knowledge is largely drawn from personal experience with acculturation as well as from clinical practice with acculturating individuals. Clinicians recognized the following clinician attributes as useful in their work with Latino clients: flexibility (eclectic approach), being Latino and bilingual, being directive, understanding that Latino clients at times see the therapist as expert, and being comfortable with a closer interpersonal space (“being called family”).

During the assessment phase, several psychosocial variables were identified as mitigating factors that could help or hinder mental health outcomes, such as whether the individual migrated voluntarily or not; whether they have sources of family/social support in the xii

United States; and their views of the help-seeking process. Clinicians did not endorse specific treatment approaches but emphasized the importance of delivering mental health interventions keeping Latino values in mind, tailoring some strategies to Latino culture, using present-focused and behaviorally-oriented interventions, and allowing time for clients to tell their stories. The study corroborates the central role of acculturation in the lives of Latinos in the United States and that this group of clinicians was attuned to the mental health challenges posed by acculturation. It also illuminates the importance of emphasizing the role of acculturation in social work education and the need to continue to advance the field of culturally appropriate interventions.

Chapter 1: Introduction

The Role of Acculturation in the Mental Health of Adult Latinos in the United

States

Rates of psychiatric disorders for Latinos in the United States increase the longer individuals live in the country (Alegría, Sribney, Woo et al., 2007; Burnett- Zeigler,

Bohnert, & Ilgen, 2013; Cook, Alegría, Lin & Guo, 2009; Erving, 2017; Lewis-

Fernández et al., 2016; Salas-Wright, Robles, Vaughn, Córdoba, and Pérez-Figueroa,

2015). However, this relationship between exposure to life in the United States and the mental health outcomes of the Latino population is not fully understood. Moreover, the empirical literature offers a mixed picture of the relationship between psychiatric disorders and the effect that living in the United States has on Latinos, commonly referred to as the acculturation process. Acculturation reflects the changes that individuals experience as a result of engaging in constant exchanges with a different culture (Berry, Kim, Minde, & Mok, 1987). According to Berry and colleagues (1987), this complex phenomenon may affect individuals in five domains: physical (e.g., geographic relocation); biological (e.g., nutrition, exposure to new diseases, intermarriage); cultural (e.g., new political, economic, linguistic, religious and social institutions); interpersonal (e.g., new patterns of ingroup-outgroup relations); and psychological (e.g., behavior changes and/or alterations in mental health status as the person adjusts to a new environment) (Berry et al., 1987). The authors do not provide a definition of mental health status but they use it interchangeably with mental health problems such as anxiety or depression (Berry et al., 1987). For the purposes of this study, mental status is defined as a person’s level of psychosocial, intellectual, and 2 emotional functioning (Barker, 2013) that can be evaluated using different methods, such as observation, structured questions, or screening tools, to name a few.

From a unique perspective as a Latino scholar and family therapist, Jaes-Falicov

(1998) likens acculturation to an uprooting of meaning that takes place in three domains:

(1) the physical uprooting that comes with the change of geographic place, such as new smells, new sounds, or new flavors; (2) the social uprooting that occurs when someone extricates themselves from human networks that used to contain and define them; and (3) the cultural uprooting that introduces drastic shifts in the ways a person’s views of reality were informed by their life experiences. Personal narratives are viewed by Jaes-Falicov as anchored at the intersection of one’s gender, race, ethnicity and social class, all of which can be dislocated by the exposure to a new cultural reality, triggering emotional distress. Jaes-Falicov concurs with the concept of acculturative stress advanced by Berry as a state of anxiety, depression, feelings of marginality and alienation, heightened psychosomatic symptoms, and identity confusion (Berry et al., 1987) that can happen during acculturation when the individual does not have adequate coping resources. Jaes-

Falicov hypothesizes that acculturative stress manifests with such prevalence of psychosomatic complaints perhaps because the type of stressors derived from poverty and/or migration are difficult to articulate for the individual who is barely surviving.

Another plausible explanation is that perhaps somatic symptoms are easier to talk about to a stranger (i.e., clinician) than emotional struggles (Jaes-Falicov, 1998).

Looking at aggregate data of Latinos as a group compared with non-Latino White subjects, Latinos showed lower lifetime prevalence for all the disorders examined

(depressive disorders, anxiety disorders, and substance abuse), except agoraphobia 3 without panic disorder, with 43.2% of non-Latino Whites reporting any lifetime disorder, compared to 29.7% of Latino individuals (Alegría, Canino and Shrout, 2008). However, differences emerge when disaggregating Latinos into ethnic subgroups. Examining subgroups (Mexican, Puerto Rican, Cuban, and “other Latino”), the authors reported that

U.S.-born individuals presented higher lifetime and past-year rates for most psychiatric disorders than their immigrant counterparts. For instance, in the same study, the rate for lifetime depressive disorder, anxiety disorders, and/or any substance abuse disorder was:

37% for Puerto Ricans, 29.5% for Mexicans, 28% for Cubans, and 27% for “other

Latino” (Alegría, Canino and Shrout, 2008). Initial differences were further accentuated when looking at subgroup differences by nativity status, with rates for any of the disorders being significantly higher for Mexicans and the group including “other Latino”

(Alegría, Canino and Shrout and 2008). These results for individuals of Mexican descent were confirmed by a systematic review that examined the status of mental health in

Mexican-Americans, concluding that evidence continues to support a negative effect of acculturation for people of Mexican descent specifically (Escobar, Hoyos-Nervi & Gara,

2000). They noted that previous studies suggest a protective effect of traditional culture retention on various health indexes (e.g., infant mortality rate, diabetes, coronary artery disease) as well as overall mental health in more recent immigrants (Escobar, Hoyos-

Nervi & Gara (2000).

These differences by nativity status also were confirmed in a study that examined the effect of nativity and age at time of immigration on risk of onset of psychiatric disorders (Alegría, Sribney, Woo, et al., 2007). The authors found that U.S.-born Latinos and immigrants arriving in the country between the ages of birth through 6 had higher 4 rates for every psychiatric disorder than those who immigrated after age 6, adding that

U.S.- born immigrants and immigrants who came during early childhood (ages 0 to 3) had similar lifetime and previous year rates of depressive and anxiety disorders (Alegría,

Sribney, Woo, et al., 2007). The authors hypothesized that some cultural values may be difficult to maintain after leaving the country of origin (Alegría, Sribney, Woo, et al.,

2007). These results have been partially replicated by Breslau et al. (2006), who conducted a secondary data analysis to examine variation in nativity differences in mood and anxiety disorders. Breslau and colleagues found that the protective effect in lifetime risk for mood and anxiety disorders applied to immigrants who had entered the United

States at age 12 or older (except Puerto Ricans, who have similar levels of risk as the

U.S.-born, regardless of how old they were when they entered the country).

Stressors related to the process of acculturation have been identified as risk factors for negative mental health outcomes of Latinos living in the United States. The detachment from extended families and social support networks negatively affect the traditional Latino value of familismo, potentially contributing to negative mental health outcomes (Alegría, Mulvaney-Day, et al., 2007; Grant et al., 2004; Lewis-Fernández et al., 2016). Familismo –which loosely translates to English as familism– is a key value, part of the collectivistic orientation of Latino culture, that emphasizes nuclear and extended familial ideals over the interest of the individual (Adames and Chávez-Dueñas,

2017). A progressive loss of the protective role of culture with the ensuing decrease in family connectedness and ambivalence between traditional and mainstream values may contribute to acculturative stress, both of which have an association with depression and anxiety (Hovey & Magaña, 2002; Lewis-Fernández et al., 2016). The connection to 5

Latino culture is believed to provide a buffer for individuals with moderate levels of depression (Torres, 2010), but the literature does not uniformly support this perspective.

The cumulative exposure to adverse experiences related to the immigration process, such as racial and ethnic discrimination, lower socio-economic status, and relationship disruption, also may lead to increased depression and anxiety (Lewis-Fernández et al.,

2016). Additionally, Breslau et al. (2006) found that immigrants who entered the United

States after age 12 had lower risk for depression of anxiety, but they offered a different explanatory hypothesis. They argued that, if acculturation were the culprit, then older immigrants would be the ones suffering from greater cultural loss and more severe mental health symptoms, as opposed to younger migrants who experience more of their socialization in the United States. Their alternative explanatory hypothesis is that differences by nativity status stem from cross-national differences in disposition to mood and anxiety disorders, something that is acquired in childhood (Breslau et al., 2006).

Different relationships between Latino mental health and acculturation were examined in a meta-analysis of 30 empirical studies conducted by Rogler, Cortés, and

Malgady (1991). They found evidence to support both a negative and a positive relationship. The inverse relationship occurred for individuals with low levels of acculturation who grappled with the social uprooting and had not had time to reconstruct such bonds in the new society. This scenario often was compounded by a lack of instrumental skills, such as speaking English, all of which impinged on their ability to control the new environment. A positive relationship, on the other hand, was found in cases of increased acculturation because the individual became alienated from their support networks and internalized norms from the broader society, which often included 6 negative stereotypes of Latinos. This scenario leads to further weakening of an already struggling mental health status. In the opinion of the authors, the third option proposed by some of the studies of a curvilinear relationship was poorly supported by evidence and could not be firmly endorsed.

Some researchers have advanced a typology of acculturative stress among Latino immigrants to the United States (Salas-Wright, Robles, Vaughn, Córdoba, and Pérez-

Figueroa, 2015). In their study with over 1,600 participants, the authors used latent class analysis and logistic regression to analyze the different ways in which acculturation- related stressors impact this population in a variety of domains. The resulting model consisted of four groups. Individuals with low levels of acculturative stress across domains (roughly 2 in 5) tended to be males of relatively higher socioeconomic status who immigrated to the U.S. as minors. The second group (1 in 3 individuals) was comprised of participants with low levels of acculturative stress across most domains, but moderate-to-high stress stemming from friends/family and low English proficiency. This group tended to be older, less educated, and to have immigrated as adults. Finally, about a third of respondents showed substantial levels of acculturative stress in multiple areas.

This group was further divided in two: people with general acculturative stress but no concerns regarding deportation and a smaller subtype with elevated levels of acculturative stress and fears of deportation. The authors also confirmed an association between acculturative stress and mental health disorders. In particular, the group with deportation-related fears was 3.5 times more likely to meet criteria for generalized anxiety disorder in comparison with the group with relatively low levels of stress, as well as more likely to be diagnosed with major depressive disorder. 7

In summary, despite empirical evidence suggesting a relationship between acculturation-related variables and negative mental health outcomes in Latinos living in the United States, this topic of study continues to fuel controversy because of the methodological challenges posed by a population with such a high degree of intra-group diversity.

Explanatory Models: The Immigrant Paradox and the Acculturation Hypothesis

Two not mutually exclusive perspectives emerged over time offering different explanatory frameworks to account for Latino mental health outcomes: the immigrant paradox and the acculturation hypothesis. Both of these frameworks are summarized below.

Immigrant paradox. Proponents of this hypothesis argue that Latino immigrants appear to have better mental health than U.S.-born counterparts and non-Latino Whites, even after controlling for socioeconomic status (SES) (Erving, 2017; Keyes et al., 2012;

Ortega, Rosenheck, Alegría, & Desai, 2000; Vega et al., 1998). In other words, while the myriad stressors that accompany the immigration process would lead to assume worse mental health outcomes for Latinos, data depict the opposite scenario.

Acculturation hypothesis. This perspective was informed by research showing that, despite the apparent advantage of the immigrant paradox, as exposure to the United

States culture increases, the overall psychological wellbeing of foreign-born Latinos may decrease (Alegría, Canino, Shrout, et al., 2008; Alegría, Shrout et al., 2007; Grant et al.,

2004; Cook et al., 2009; Ortega, Rosenheck, Alegría & Desai, 2000; Vega et al., 1998).

The acculturation hypothesis acknowledges that Latinos in the United States are not a monolithic group, presenting significant intra-group diversity that is not restricted to 8 ancestry but includes other variables, such as place of birth, length of stay in the United

States, and age of arrival in the United States. It is believed that the aggregation of

Latinos in earlier studies as one group may have contributed to the formulation of the immigrant paradox hypothesis (Alegría, Canino, Shrout, et al., 2008; Erving, 2017;

González, Tarraf, Whitfield & Vega, 2010). In an effort to correct this problem, more recent research has started to look at mental health outcomes in Latinos taking intra- group diversity into account.

Seeking to understand the relationship between Latino mental health outcomes and acculturation, proponents of the acculturation hypothesis identified the following key variables:

Foreign-born status. Alegría, Shrout et al. (2007) found that being foreign-born exerted a protective effect on individuals’ mental health for some subgroups (Mexicans) but not for others (Puerto Ricans) as well as producing differences by mental health disorder. U.S.-born Latinos were significantly more likely than Latino immigrants to meet lifetime criteria for depression and/or anxiety (Alegría, Shrout et al., 2007).

Length of residence in the U.S. A longer length of stay in the United States was associated with increased prevalence rates of lifetime and past-year psychiatric disorders

(Alegría, Mulvaney-Day et al., 2007). Cross-generational comparisons suggest that lifetime and past-year psychiatric disorder rates were higher among third generation individuals than for first- and second-generation (Alegría, Mulvaney-Day et al, 2007).

Breslau et al. (2006) showed that, with age, lifetime prevalence of anxiety, mood and impulse-control disorders increased in a sample of Latinos, compared to non-Latino

Whites. Consistent with the acculturation hypothesis, they hypothesized that ethnic 9 identification, which occurs early in life, operates as a protective factor and that, as exposure to the dominant culture increases, this protection is eroded. Torres (2010) conducted a cross-sectional study on the effects of acculturation, acculturative stress, and coping on depression, in 148 low-income, predominantly Mexican Latinos. Half of the sample had lived in the U.S. for 8 years or less. Findings supported that immigration- related stressors and feeling that the main culture invalidates one’s ethnic group, increased the chance of mental health problems. Active coping style (i.e., learning

English, trying to understand and/or adopt cultural norms) acted as protective factor for those with high symptom severity. For participants with depression of moderate severity, keeping key aspects of Latino culture may also have a protective effect (Torres, 2010).

Age of arrival in the U.S. Breslau et al., (2006) studied immigration to the

United States and risk for depression and anxiety, finding that the immigrant advantage in risk for depression and anxiety was limited to those individuals who had immigrated after age 12. Yet, Breslau and colleagues found no relationship between nativity status and risk for mood disorders for South- or Central-American immigrants although this group of immigrants had lower risk for anxiety than U.S.-born counterparts, regardless of age at time of migration. Alegría, Shrout et al. (2007) found that Mexican immigrants who arrived after age 6 had lower risk of depressive disorders than counterparts who had arrived prior to that age. They also noted that Cuban immigrants who came to the United

States as children had a lower prevalence rate of depressive disorders than Mexican counterparts, after controlling for age and gender.

Incorporation of Knowledge of Acculturation to Mental Health Interventions 10

In spite of burgeoning evidence in partial support of the acculturation hypothesis

(Breslau et al., 2006; Burnett-Zeigler, Bohnert, and Ilgen, 2013; Torres & Rollock, 2004), a review of the mental health intervention literature with Latinos reflects a mixed picture of the incorporation of the extant knowledge of acculturation theory to practice. In a systematic review of Latino outcome studies in social work, Jani, Ortiz, and Aranda

(2009) identified a common failure to take the level of acculturation of participants into account in sample calculations and/or in the discussion of their findings. The authors call for more attention to acculturation when creating or evaluating interventions for Latinos

(Jani, Ortiz, & Aranda, 2009). Further, great variance in the quality and extent of cultural adaptations of interventions with Latinos becomes apparent when reviewing the literature. Cultural adaptations take many different forms: simple translation of materials into Spanish and/or the use of bilingual/bicultural providers (Heinssen, Liberman, &

Kopelowicz, 2000; Miranda, Chung, et al., 2003; Liberman & Coitigan, 1993; Liberman

& Kopelowicz, 2009; Miranda, Duan, et al., 2003); cultural training of clinicians

(Miranda, Azocar, Organista, Dwyer, & Areane, 2003); incorporation of Latino values into interventions, such as personalism, familism, and respect (Aguilera, Garza, &

Muñoz, 2010; González-Prendes, Hindo & Pardo, 2011; Interian, Allen, Gara & Escobar,

2008; Méndez & Cole, 2014; Pérez-Benítez, Zlotnick, Gómez, Rendón & Swanson,

2013; Ramos & Alegría, 2014; Tran et al., 2014; Valdez, Abegglen & Hauser, 2012;

Valdez, Padilla, Macardell-Moore & Magaña, 2013; Zayas & Torres, 2009); and/or incorporation of issues related to migration and/or acculturation (González-Prendes,

Hindo & Pardo, 2011; Piedra & Byoun, 2012; Ramos, 2005; Tran et al., 2014; Valdez,

Abegglen & Hauser, 2012; Valdez, Padilla, Macardell-Moore & Magaña, 2013). Among 11 the studies reviewed, those that used qualitative or mixed methods were the ones exploring clinician perspectives on the need for cultural adaptation (Aguilera, Garza, &

Muñoz, 2010; Barrio & Yamada, 2010; González-Prendes, Hindo & Pardo, 2011;

Méndez & Cole, 2014; Zayas & Torres, 2009), although in most cases this was done secondary to the analysis of the content of the intervention and clients’ response to it.

It can be argued that, with empirical evidence pointing to acculturation as a potentially important variable to incorporate in our assessment and treatment of mental health disorders in Latinos, the inconsistent role it has in informing cultural adaptations of mental health interventions may pose a challenge to the cultural competence of such interventions. Cultural competence is defined as a “set of congruent behaviors, attitudes, and policies that come together in a system or agency, or among professionals, and enable the system, agency, or professionals to work effectively in cross-cultural situations” (NASW, 2001, p. 11). Cultural competence has been proposed as a strategy to appropriately intervene with diverse client systems, thus reducing mental health disparities (Brach & Fraserirector, 2000) and has been adopted by the NASW Standards for Cultural Competence in Social Work Practice (NASW, 2001). The absence of a culturally informed lens in practice can have dire consequences, such as those conveyed by research findings that show that members of racial/ethnic minority groups are given more severe diagnoses than White counterparts (Hays, Prosek, and McLeod, 2010).

Social Relevance of Incorporating Knowledge of Acculturation into Mental Health

Practice with the Latino Population

It is important to understand the inconsistent incorporation of the acculturation experience into treatment within the systemic problem of mental health disparities. A 12 disparity is defined as a difference in the treatment provided to a member of a racial/ethnic minority that is not justified by the underlying condition or treatment preference of the client (Institute of Medicine, 2002). Overall, Latino participation in mental health services is lower than in the general population (Alegría et al., 2002). One of the reasons for this underutilization stems from lack of access, such as having no insurance. To date, Latinos have the highest uninsured rate of any racial/ethnic group in the United States (Department of Health and Human Services, 2019).

There are two more issues that contribute to the disparity. One is the underrepresentation of U.S. demographic diversity in the research literature (Aisenberg,

2008; Sue & Zane, 2006; Whitley, Rousseau, Carpenter-Song & Kirmayer, 2011). Some researchers have posited that the specific ways in which the cultural contexts of racial/ethnic minorities shape their mental health outcomes seldom inform the process of developing evidence-based practices (Aisenberg, 2008; Kirmayer, 2012). They have further noted that this may pose a limitation to the cultural validity of the extant evidence-based practice literature and its application with racial/ethnic minorities

(Aisenberg, 2008; Carpenter-Song, Nordquest-Schwallie & Longhofer, 2007). The other problem is the underrepresentation of Latinos among mental health providers. A shortage of culturally competent clinicians also has been proposed as contributing to

Latino underutilization of mental health services (Schwarzbaum, 2004). This problem is not exclusive to mental health; it extends to healthcare, where the diversity of providers does not mirror that of the general population (Betancourt, Green, Carrillo & Ananeh-

Firempong, 2003; Clark, Sleath & Rubin, 2004). 13

Mental health services access and utilization can be affected by cultural factors, such as ethnic identity, language use and preference for social interaction within the same ethnic group (Berdahl & Torres-Stone, 2009; Malgady & Zayas, 2001; Norris & Alegría,

2005; Keyes, 2012).

Keyes et al. (2012) found that disparities in access to health services remained after controlling for health insurance status, income, and mental health services resources, concluding that cultural factors play a role in the disparity. The disadvantages that Keyes et al. found at the time of their study publication unfortunately remain in place. Latinos in the United States have the highest uninsured rates of any racial/ethnic minority

(Department of Health and Human Services, 2019). As recently as 2018, Latinos had much lower median household income than White non-Hispanic households, $51,404 to

$67,937, respectively (U.S. Census, 2018) and poorer resources for mental health services (Cabassa, Zayas & Hansen, 2006; Lara et al., 2005) than non-Latino Whites.

The social relevance of the factors discussed above (inconsistent application of culturally appropriate interventions for Latinos, disparities in access and utilization of mental health services, and the underrepresentation of Latinos in the provider role) is augmented when examined in light of the fact that Latinos are the largest racial/ethnic minority in the United States as well as one of the fastest-growing ethnic groups in the country. Pew Research Center reports that Latinos reached a record 59.9 million in 2018

(18% of the population), up from 47.8 million in 2008 (16% of the population), which accounted for over half of the total population growth in the country (Pew Research

Center, 2019) and the projections think Latinos will reach 24% of the population by 2065

(Pew Research Center, 2017). 14

The central role of acculturation-related factors in the life of Latinos in the United

States, specifically its potential impact on mental health outcomes, and the importance of incorporating extant knowledge of acculturation into assessment, treatment planning and intervention appears important in order to fulfill the ethical standard of cultural competence that social workers are called to realize by the NASW Code of Ethics.

Proposed Study

In light of the variability with which acculturation factors are incorporated to interventions and practice with Latinos in general, this study will examine the perspectives on acculturation held by mental health clinicians working with the adult

Latino population. The study will aim to gain a deep understanding of how clinicians believe the culture exchange process impacts their clients’ mental health outcomes, their formal knowledge of the concept of and theories of acculturation (from professional literature), their informal knowledge of the culture exchange process (personal experience), and the extent to which they incorporate this knowledge into practice.

The study will advance the field of cultural competence in social work practice, which is relevant vis-à-vis the continued growth in Latino population in the U.S. and the shortage of culturally competent practitioners. Practitioners working with Latino clients need to be cognizant of the impact of acculturation on mental health outcomes because:

(1) the acculturating individual may present with various levels of distrust in formal help systems, and with culturally-specific views of mental illness and help-seeking that will require tailoring of engagement strategies; (2) there are circumstances during the acculturation process that may function as protective or risk factors in terms of mental health that need to inform the case conceptualization; and (3) clinically sound treatment 15 planning and intervention flow logically from a sound assessment and need to incorporate culturally congruent ways of understanding symptoms and coping to heal. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), a risk factor is defined as characteristics at the biological, psychological, family, community, or cultural level that precede and are associated with higher chances of negative mental health outcomes (SAMHSA, 2019). Conversely, a protective factor is defined as characteristics associated with a lower likelihood of negative mental health outcomes or those that reduce a risk factor’s impact (SAMHSA, 2019). Finally, it will be pertinent to define what constitutes the helping process. In the present study, the helping process comprises the following phases: (1) assessment; (2) treatment planning; (3) intervention; and (4) termination. The assessment phase is the data-gathering portion of the process, that aims to establish the nature, cause, progression, and prognosis of a given presenting problem (Barker, 2013). Treatment planning follows the assessment and is conceptualized the identification of specific goals and objectives, evaluating the means for achieving them, and making choices about the best course of action (Barker, 2013).

The intervention phase includes the many activities clinicians use to solve or prevent problems or achieve goals for the client’s betterment, such as various psychotherapy approaches, advocacy, psychoeducation, to name a few (Barker, 2013). Finally, termination is conceptualized the conclusion of the clinician-client intervention process.

It entails a process to disengage the therapeutic relationship and occurs typically when goals are reached, when the stipulated time frame has been met, or when the client no longer wishes to continue services (Barker, 2013).

Formal Statement of Research Aims 16

This study explores the extent to which mental health practitioners working with

Latinos:

(1) Are familiar with the concept of acculturation and acculturation research;

(2) Have knowledge of the impact of acculturation on mental health outcomes; and

(3) Purposefully incorporate the extant knowledge of acculturation research and its effects on mental health outcomes during the assessment, treatment planning, intervention, and termination phases of treatment.

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Chapter 2: Relevant Cultural Competence and Culture Exchange Frameworks and

Theories

Introduction

This chapter provides the historical context to understand the evolution of cultural competence in social work practice and theories of culture exchange. It does this by presenting relevant cultural competence frameworks developed over time in social work and related fields. These frameworks are representative of the most significant conceptualizations of cultural competence by social work scholars and authors in related fields, providing a description of the evolution of the construct in social work practice.

Each framework is summarized and followed by a discussion of its strengths and weaknesses. The second half of this chapter introduces Berry’s theory of acculturation, highlights pivotal concepts within the theory, provides a summary of empirical support as well as a critique of strengths and weaknesses. Finally, the chapter identifies gaps in the theories discussed that the present study is designed to address.

Relevant Cultural Competence Frameworks in the Social Work Field

The 1980s brought a renewed emphasis on client-worker cultural exchanges and the need for cultural competence to the forefront of social work practice. Early conceptualizations of cultural competence emerged in the social work literature include the multi-ethnic approach to cultural awareness (Green, 1982), and the ethno-sensitive approach (Devore & Schlesinger, 1981), to name a few. Similar developments took place in other helping professions. For example, counseling psychology scholars formulated cross-cultural counseling competencies (Helms, 1984; Pedersen & Marsella, 1982; Sue et al., 1982). Nursing (Campinha-Bacote, 1994; Culhane-Pera, Reif, Egli, Baker & 18

Kassekert, 1997) and education (Banks, 1994; Bennett, 1986) also made early contributions to cultural competence and intercultural communication. Pivotal cultural competence frameworks in social work literature as well as competing theoretical constructs are discussed below.

Ethnic-sensitive generalist social work practice. Devore & Schlesinger (1981) introduced ethnic-sensitive generalist social work practice to highlight the influence of ethnic factors and social class on social work practice. This approach encourages practitioners to pay attention to both individual and systemic factors as they emerge from the needs presented by the client and the practitioner’s evaluation. The assumptions underlying this approach are that ethnicity and social class help shape the problems that individuals experience and that the practitioner must approach problem-solving with the client with a dual focus on both micro and macro problems (Lum, 2004). Their approach proposed viewing each client system through seven “layers of understanding” (Devore &

Schlesinger, 1981, p. 176), namely: (a) social work values; (b) basic knowledge of human behavior; (c) knowledge of agency policy; (d) self-awareness, particularly regarding practitioner’s own ethnicity and how that may influence practice; (e) the impact of ethnic reality on the client’s life; (f) the route through which the client came to the social worker and the impact this has on how services are perceived and delivered; and (g) adaptation of strategies for ethnic-sensitive practice (Devore & Schlesinger, 1996). In a later edition of their classic work, the authors incorporated an ethnic assessment proposed by Fandetti

& Goldmeir (1988) (cited in Devore & Schlesinger, 1996, p. 327) for social workers as culture mediators. It explores the client’s ethnic reality (cultural orientation, language spoken, religion, generational status) and ethnic disposition to problem identification and 19 resolution at the individual, family, and community levels. The ethnic assessment by

Fandetti & Goldmeir (included in Devore & Schlesinger, 1996) identifies three levels of assessment: the person, the family/client group, and a macro level including the local and non-local community. The first two levels are divided in three subsections: (a) cultural orientation, language spoken, religious identification, and generation of immigration; (b) ethnic/cultural dispositions to problem identification and solution; and (c) social class membership.

Strengths and limitations. A strength of this framework is that it breaks down practice behaviors to be completed prior to the encounter with the client (such as acquiring basic knowledge about the specific racial/ethnic minority) and understanding the community and the organization well. Through case studies, the authors present the model applied to scenarios, with particular emphasis on how to adapt to the ethnic reality of a given client. Although no more specific details are offered by Devore & Schlesinger on how to implement this assessment, another strength of this tool as it relates to the topic of culture exchange is that it elicits information on processes related to acculturation. In this sense, it would ensure that the clinician gathers data on acculturation and incorporates that information into planning and intervention. While Devore &

Schlesinger may not necessarily use the term acculturation frequently, their concept of social workers as culture mediators denotes that they are paying close attention to the culture exchange process. A limitation is posed by the fact that the layers of understanding proposed by the authors as original contribution are not specific to ethnic- sensitive practice, but rather to social work in general. 20

Multi-ethnic cultural awareness-based approach. The multi-ethnic cultural awareness-based approach was developed by Green (1982) to address the needs of racial/ethnic minority clients, which he considered to be neglected by the social work field at the time. It introduced an important distinction between categorical and transactional explanations of ethnicity, pivotal in Green’s conceptualization of cultural awareness. Categorical models of ethnicity describe ethnic traits and assume a high level of cultural homogeneity for members of certain ethnic groups. The author maintains that categorical approaches to ethnicity have been dominant in American popular culture for decades, consistent with the melting pot ideology, which try to look past ethnicity and into assimilation. Melting pot was the popular term used to refer to the assimilationist view, the first theory that tried to account for race relations in the United States

(Hirschman, 1983). Assimilation theory posited that, by virtue of contact with the larger society, cultural traits of ethnic minorities would over time recede, culminating in the adoption of cultural traits of the dominant society (Hirschman, 1983). This construct will be further developed later in this chapter.

Thinking categorically about ethnicity results in descriptions of traits that describe the cultural make-up of a particular racial/ethnic minority group, which often gives way to stereotypical depictions of ethnic groups. For instance, following categorical thinking,

Latino women would be expected to be submissive to men and sacrificial, prioritizing their roles as mothers and wives before their role as workers or professionals. A Latino woman who is driven to advance professionally and delays, or is not interested in, maternity may be seen as “atypical.” Another problem that Green highlights in categorical models of ethnicity is that the categories are created by members of the 21 dominant society, who have the power to dictate the standards of what constitutes being different. This compounds the stereotyping potential with risk of reinforcing oppression and discrimination of the racial/ethnic minority group (Green, 1999).

Transactional models of ethnicity, on the other hand, see ethnicity as a result of the way individuals interact to maintain a sense of cultural distinctiveness (Green, 1982).

Transactional frameworks, then, expect changes in the surface manifestation of ethnic traits within groups (Green, 1982). Green states that “ethnicity resides in the boundaries between distinctive cultural communities” (Green, 1999, p. 24), suggesting that difference, rather than uniformity, reigns within a given ethnic group. Contrary to categorical views of ethnicity, the ethnic boundaries of a group are considered flexible.

Individuals vary in the degree to which they adhere to cultural traditions of their group, they engage in transactions with other members of the group, as well as other ethnic groups, and it is through these transactions that the ethnic boundaries are being reconfigured.

Another important concept in Green’s model is his definition of care as a cultural system where emotional distress is viewed as both a personal and a communal experience

(Green, 1999). This concept is informed by ethnographic methodology, where the focus of study is on a community as a culture-sharing group (Creswell, 2007). When a client comes to the professional for help, he/she has already come up with a hypothesis of what is normative within that cultural community and what has gone wrong (Green, 1999).

The author cautions clinicians against “culture-free” diagnoses. The author expresses concern that the American Psychiatric Association’s Diagnostic and Statistical Manual of

Mental Disorders (DSM-IV at the time of Green’s publication) only provides a small 22 section of culture-bound syndromes and, in spite of cautioning clinicians about cultural variations in the presentations of different disorders, clinicians may adhere to the strict diagnostic criteria and ignore or minimize the cultural underpinnings of mental health diagnoses.

In this framework, the culturally competent professional is someone who can

“deliver professional services in a way that is congruent with behavior and expectations normative for a given community and that are adapted to suit the specific needs of individuals and families from that community” (Green, 1999, p. 87). The culturally competent practitioner is one who has learned and tested their awareness of the normative and proscribed values and behaviors of a community as well as one with awareness of their own limitations. Green recommends learning about clients through direct observation and participation in everyday routines in naturalistic settings, something that social workers are capable of doing by the nature of their jobs (Green, 1999). The author also advocates for the use of “cultural guides”. Cultural guides are well informed insiders, individuals who are part of the racial/ethnic community and can explain in an articulate way what is going on in that community (Green, 1999).

The framework. Adopting a transactional view of ethnicity and drawing from ethnographic methods, Green proposed one of the early ethnic competence models in social work (also referred to as the cultural competence model) (Green, 1999). The author cautions that becoming culturally skilled is an ongoing process, not an end in and of itself. Overall, his model should be understood as a “system of learning” (Green,

1999, p. 38) about others and self. There are four key elements in the model. First, an ethnographic knowledge-base of the client’s ethnic group, i.e., the ability to recognize 23 what is salient in the client’s culture for the specific presenting problem he/she brings to the worker through observation, participation in client’s life, use of cultural guides. This constitutes a “systematic learning style” (Green, 1999, p. 93).

The second element is professional preparedness, which entails a self-assessment regarding personal views about racial and cultural differences, as well as language and learning skills, to avoid “expressions of (cultural) insensitivity” (Green, 1999, p. 37). As an example of cultural insensitivity, the author cites workers’ acceptance of surface knowledge about their clients’ cultural reality as adequate, or cultural insights that are communicated using complicated jargon or buzzwords (Green, 1999).

Third, a comparative analysis to identify salient cultural aspects of the client’s presenting problem, not following the categorical tradition of listing cultural traits, but rather understanding different world views and framing client’s individuality in those differences. The fourth element, and logical culmination of the model, is to decide what is the appropriate intervention to implement.

Strengths and limitations: The distinction between categorical and transactional perspectives of ethnicity is Green’s original contribution and one of the strengths of his approach, later cited by other social work scholars who built on this distinction, such as

Devore & Schlesinger (1996), Weaver (2005) and Lum (2004). It allowed the field of cultural competence to move past surface listing of ethnic traits, with its potential for stereotyping, and to acknowledge the complex interplay of cultures shaping each other.

Another original contribution of this early framework was to emphasize the importance of identifying the client’s cultural understanding of the presenting problem and problem- solving criteria, as well as the mobilization of indigenous community resources (when 24 available) to facilitate a resolution (Lum, 2004). Finally, Green strives to apply a systematic learning style informed by qualitative inquiry (ethnography), which entails engaging specific skills in cross-cultural learning. This renders the approach more robust than a mere enumeration of aspirational cultural competence standards. Conversely, the thoroughness of Green’s approach is what could also introduce potential limitations. The use of ethnographic methodology, while appropriate in the academic realm, is not necessarily feasible in a practice setting where resources are scarce and social workers are subjected to the rules of medical insurance companies who will not recognize these important steps as a service.

Process stage approach. Lum (1996) published the first edition of his process stage approach to social work practice and people of color in 1986, with the main assumption that all people of color (i.e., ethnic minority) hold common values —e.g., collective orientation, family unity and mutuality of family members, leadership of elders, etc.— at the same time as it acknowledges each group’s distinctive cultural history (Lum, 1996). He introduces the concepts of cultural commonality and cultural specificity —etic and emic aspects— to reflect these assumptions. The etic perspective refers to generalized patterns that emerge from cross-cultural knowledge, whereas the emic view refers to patterns that are specific to a certain cultural community (Lum,

2004). The use of the term “people of color” is intentional to motivate the field to move past the concept of ethnicity and include the identities of people who think of themselves beyond an ethnic label, such as multicultural individuals (Lum, 2004).

Lum (2004) argued that social work values rooted in Western tradition have an individualistic orientation and that, when working with racial/ethnic minorities, social 25 work should incorporate the collective values of other cultures (Lum, 2004). The framework for culturally diverse social work practice has four components: practice process stage, client-system practice issues, worker-system practice issues, and worker- client tasks. The process stages are: contact, problem identification, assessment, intervention, and termination (Lum, 2004). Awareness of the impact of racism and discrimination on the client-system permeates every stage (Lum, 2004). Some of the key issues identified include the exploration of the client’s ethnicity, degree of acculturation, client’s ethnic-community identity, and delivering services to meet cultural needs (e.g., bilingual/bicultural workers, outreach, etc.) (Lum, 1996).

Strengths and limitations. This framework emphasizes the importance of exploring the client’s ethnic background and ethnic community identity during the contact process stage, with particular focus on the client’s degree of acculturation. The author acknowledges that the dominant culture imposes pressure on the racial/ethnic minority individual to conform, which often results in varying degrees of acculturation even within the same family system (e.g., younger generations acculturate faster than the parental subsystem, which may cause conflict).

In summary, the models presented were among the first efforts to contribute to culturally competent practice, taking into consideration key elements of the culture exchange process between client and worker. All models pay specific attention to work with racial/ethnic minorities, acknowledging important factors such as discrimination and oppression, workers’ ethnic bias, the perils of reductionist (i.e., categorical) views of ethnicity. The incorporation of acculturation processes is not always made explicit by the authors, but even in such instances it can be gleaned from the material. Devore and 26

Schlesinger discuss evaluating the client’s cultural orientation and encourage clinicians to use the ethnic assessment, defining the role of the worker as a culture mediator. The author places great emphasis on how help-seeking behaviors may vary across ethnic groups. Taking this further, it could be argued that help-seeking behavior also will vary as a consequence of the acculturation reality of a particular individual and, in order to engage in culturally competent practice, this element needs to be acknowledged. Lum also sheds light on the contrast between individualistic-oriented societies, a dominant value in the United States, and collectivist-oriented minority groups, acknowledging the pressure exerted by the dominant society on minority groups to conform, something that lies at the heart of the acculturation experience. Lum specifically talks about the importance of evaluating the acculturation reality of the client during the initial contact stage of the helping process. In sum, the examination of relevant cultural competence frameworks in social work practice literature reinforces the link between culturally competent practice with racial/ethnic minorities and the importance of incorporating acculturation theory to practice.

Competing Constructs in Related Fields: Cultural Safety, Cultural Humility, and

Cultural Attunement

In the 1990s, several authors responded to early formulations of cultural competence with conceptual alternatives, such as cultural safety (Papps & Ramsden,

1996), cultural humility (Tervalon & Murray-García, 1998), and cultural attunement

(Hoskins, 1999).

Through a postmodern lens, they embraced difference, relativism of meaning, and a “not-knowing” stance (Dean, 2001; Williams, 2006). These postmodern theorists 27 responded to the modernist view of the 1970s and ‘80s, rooted in ethnographic and anthropological studies. Postmodernists were critical of the modernist perspective which, they posited, had a more static understanding of ethnicity and culture (Dean, 2001). This view saw ethnic groups as having identifiable traits that distinguish them as a stable entity which, in turn, gave way to the assumption that clinicians can competently interact and intervene with racial/ethnic minority groups (Dean, 2001), in line with Green’s description of the categorical view of ethnicity.

The postmodern perspective, thus, argued against cultural competence formulations that implied that cultural content could be mastered and competence ultimately achieved (Hoskins, 1999; Papps & Ramsden, 1996; Tervalon & Murray-

García, 1998). These theorists urged clinicians to approach others from a not-knowing stance, where the client is the expert. Some have called this an informed not-knowing stance, insofar as the clinician must be aware of his or her own cultural baggage in order to effectively get to know others (Laird, 1999).

Cultural safety. This perspective originated in the field of nursing, in New

Zealand, shining a light on the political and historical contexts of healthcare (Papps &

Ramsden, 1996). The approach was developed after a public health report exposed the disadvantaged cultural, economic and social state of New Zealand’s racial/ethnic minority groups (mainly of Maori descent), after over a century of European dominance in that country (Papps & Ramsden, 1996). The nursing field had to acknowledge that their traditional oath mandating that they nurse people regardless of color or creed was no longer effective. In other words, not recognizing difference in the delivery of services had turned into a disservice to racial/ethnic minority groups, contributing to their 28 disadvantaged situation, i.e., an “unsafe” practice. Cultural safety, thus, required nurses to treat people mindful of those aspects that made them different and unique (Papps &

Ramsden, 1996).

Another core assumption of cultural safety is that it views the healthcare relationship to be “power-laden and culturally dyadic” (Papps & Ramsden, 1996, p. 494).

It assumes that, when clinician and patient meet, two cultures converge, of unequal power. Such power imbalances need to be considered, so that the clinical encounter remains safe (Papps & Ramsden, 1996).

Cultural humility. This approach originated in the medical education field in response to the increasing cultural, racial, and ethnic diversity of the United States

(Tervalon & Murray-García, 1998). The authors called attention to the generalized lack of knowledge on the part of medical professionals of patients’ health beliefs and life experiences, as well as of their own racial, class, and gender biases (Tervalon & Murray-

García, 1998). They called to avoid what they considered “the pitfall of narrowly defining competence” (Tervalon & Murray-García, 1998, p. 118). The authors posited a view of cultural competence as a lifelong process, not an endpoint, proposing a terminology change from cultural competence to cultural humility.

Cultural humility, thus, requires an ongoing commitment to self-reflection and self-critique, and to check power imbalances in the physician-patient dynamic (Tervalon

& Murray-García, 1998). Cultural humility requires for practitioners to remain flexible and humble enough to approach the realities of their patients anew and to admit when they don’t know (Tervalon & Murray-García, 1998). It also requires a commitment to accept that patients have perspectives that may be both biomedical and non-biomedical, 29 and facilitate communication so that patients tell their “own illness or wellness story”

(Tervalon & Murray-García, 1998, p. 121).

The authors caution against approaches to cultural competence that are merely descriptive of the other, in the tradition of medical anthropology (Tervalon & Murray-

García, 1998). Instead, service providers should be engaged in an ongoing and honest process of self-critique and self-awareness that examines their intentional and unintentional bias patterns (Tervalon & Murray-García, 1998). In implementing the approach, interviewing and care should be patient-focused. The authors supported this suggestion with research on patient-physician communication showing physician bias against patient-initiated questions, minority patients receiving less information regarding their conditions, in spite of wanting similar amounts of information than non-minority patients, and less talk, overall (Tervalon & Murray-García, 1998).

Ortega and Coulborn-Faller (2011) brought cultural humility into the social work conversation proposing that child welfare workers be trained in cultural humility as a complement to cultural competence. The authors critiqued the shortcomings of cultural competence as a perspective that assumes that workers can become cultural experts.

Ortega and Coulborn-Faller posited that, while the concept of cultural competence emerged to emphasize respect for cultural diversity, it had the unintended effect of emphasizing cultural similarity and neglecting individual differences. Cultural humility departs from viewing culture as monolithic and embraces multiculturalism and intersectionality (to acknowledge the different positions that people assume within the broad sociopolitical context). A cultural humility approach, thus, acknowledges the diversity of the whole person, interpersonal power differentials (particularly between 30 worker and client), different life experiences (including microaggressions), and resources gaps. Ortega and Coulborn-Faller see this approach as “freeing” for the worker who no longer has to be the cultural expert and puts the in the learner’s role, as opposed to being the person in power.

Cultural attunement. This perspective was borne out of social work education, but its assumptions were considered transferrable to other fields (Hoskins, 1999). Like other postmodernists, Hoskins critiques views that promote surface knowledge of cultural differences of different racial/ethnic groups, devoid of the meaning that each individual ascribes to their own ethnicity. She argues that people are both individual and collective beings, actively making sense of reality and reacting to those meanings they generate.

Hoskins proposes the term cultural attunement in response to the concept of multiculturalism as knowledge of ethnicity (Hoskins, 1999).

Cultural attunement engages five processes: (a) acknowledging the pain of oppression and how, when the worker is part of the dominant culture, he or she must acknowledge that their actions may have inflicted pain on minority individuals; (b) engaging in acts of humility by understanding the helping professional is not the protagonist of the encounter, so that the client can take a subject position (this is also referred to as “de-centering” the professional); (c) acting with reverence, i.e., to honor the other person; (d) engaging in mutuality to counter the isolation that oppression imposed on minorities, i.e., to allow for a sharing of experiences that develop a sense of connection; and (e) to enter into the relationship from a “not knowing” stance rather than seeking certainty; the helper must be tentative and open-ended (Hoskins, 1999). 31

This section would not be complete without mentioning how the field of cultural competence continues to evolve expanding beyond racial/ethnic minorities to encompass diversity of backgrounds, such as age or sexual orientation/gender identity, intersectionality, and the incorporation of power differentials in relationships that contribute to cultural alterity (Azzopardi and McNeill, 2016). The authors advance a cultural consciousness framework that rests on three main assumptions: (1) discrimination and inequality are seen as social injustices (i.e., individuals are often discriminated against because they are different from the majority culture, becoming

“othered” by those who are in a privileged position); (2) history, colonialism, and neoliberal ideology (how globalization and capitalism prioritize individual over social responsibility, augmenting the barriers that disproportionately impact diverse individuals, e.g., the push towards small government and dismantling of safety net programs); and (3) postmodernism and intersectionality (reality is co-constructed and truths may be multiple, thus all cultural perspectives are valid; individuals may identify with multiple identities).

The authors propose specific interventions for conscious practice. First, to individualize through clinical empathy as a tool that facilitates cross-cultural engagement. Second, to deindividualize to break down oppression. This complements the first intervention and goes beyond the individual to effect change on structural factors (e.g., linkage to resources, advocacy, access to services). Third, an examination of policy and processes at the agency level in order to advance social justice. Finally, an ongoing critical self- awareness of our own cultural lens, privilege and other biases, similar to the cultural humility framework.

32

Strengths and limitations of postmodernist perspectives. Among the strengths, these perspectives acknowledge the importance of awareness on the part of the professional as well as the influence of macro level forces, such as oppression and discrimination, shaping the helping relationship. This helps the practitioner be mindful of the need for self-evaluation to identify how his or her own privilege may inadvertently oppress a minority client. While these perspectives don’t make explicit mention of theory of acculturation, they do address the culture exchange process. They offer valuable insights and can meaningfully inform culturally competent practice with minority clients. On the other hand, the extent to which they may readily lend themselves to the fast-paced reality of social work practice is questionable. In a hypothetical community mental health agency setting, often characterized by urgent demands from clients and where practitioners manage vast caseloads, it may not be plausible to engage in the kind of complex and deep exploration of self and other, as this may take away from the pressing need to respond to immediate needs with which clients present.

Theory of Acculturation

Early theories of culture change: Assimilation and cultural pluralism. The concept of acculturation evolved from the cultural pluralism perspective and its precursor, assimilationist views. Cultural pluralism developed as a consequence of the unrealized aspiration that assimilating new racial/ethnic minority groups into the dominant society would result in a unified American social identity (Green, 1999;

Weaver, 2005). Cultural pluralism challenged prevailing assimilationist views from the early 20th century, which proposed that incorporation of immigrants into the main society 33 was a linear process, with full integration into the mainstream as the desired outcome

(Hirschman, 1983; Lum, 1996; Park & Burgess, 1969; Weaver, 2005). Assimilation, once the prevailing sociological concept that explained social relations in the United

States, has been challenged as obsolete and seen as ethnocentric and even patronizing of racial/ethnic minorities, as it ultimately pressured the immigrant person to conform to the dominant society (Alba & Nee, 1997). Indeed, assimilation was built on a linear model of culture change that assumed that minority individuals would follow a straight progression resulting in full incorporation to the dominant society. Progressive views of some scholars at the time assimilation theory was prevalent promoted the idea that racial/ethnic divisions would in time vanish, or at least diminish significantly from

America’s industrial society, earning this perspective the popular label of “melting pot” theory (Hirschman, 1983). Melting pot theory gained quick popular appeal and, although it has long been discredited in academic circles, it is still active in popular ideology

(Green, 1999; Weaver, 2005).

Cultural pluralism went beyond assimilation theory in trying to understand the processes involved in culture change. It operated on the assumption of acculturation, not assimilation, and tried to transcend linear assimilationist views considering new factors, such as the level of access to opportunity, and the degree of conflict between minority and majority groups (Kallen, 1924, cited by Robbins, Chatterjee & Canda, 1998, p. 121).

Among the critiques of cultural pluralism was the assumption that the culturally different person could coexist within the dominant society by keeping some core distinctive traits while assimilating others. Several authors counter that this process is presented in a way that appears to be deliberate on the part of the acculturating individual, a view they 34 considered simplistic (Green, 1999; Lum, 1996; Weaver, 2005). The critique also argues that, although this view tried to move past assimilationist shortcomings, it still views ethnicity through a categorical lens, identifying “traits” that make each element in the plurality distinct, as if ethnic identities were permanent and unchanged over time (Green,

1999). In this regard, cultural pluralism did not capture the transactional aspect of ethnicity, failing to see ethnicity as something that is shaped in interactions with others and, thus, capable of changing over time. Following this line of criticism, Green pointed out that categorical thinking pigeonholes individuals in certain groups, and that these categories are created by members of the dominant society (Green, 1999). The obvious risk of this categorization is the power imbalance that drives categorical thinking close to prejudice and stereotyping.

Contemporary theories of culture change. Several theories started to emerge in the late 1970s, offering different explanatory frameworks to account for the complex phenomena involved in the culture exchange process. Among some of the most relevant to social work practice are: Dual Perspective (Norton, 1993), Ethnic Identity (Phinney,

1990), Social Cognition (Padilla & Pérez, 2003), Bicultural Competence (LaFromboise,

Coleman & Gerton, 1993), and Acculturation Theory (Berry, 2001, 2009; Berry, Kim,

Minde & Mok, 1987; Sam & Berry, 2010). From a cultural psychology perspective,

Berry’s theory of acculturation offers good conceptual alignment with the topic of study of this dissertation, focusing on socio-emotional changes that occur during acculturation.

An in-depth discussion of Berry’s theory of acculturation will now follow.

Berry’s theory of acculturation. Acculturation was originally defined by anthropologists as a group-level phenomenon, involving changes that occur as a result of 35 groups of different cultures coming into continuous, first-hand contact (Redfield, Linton

& Herskovits, 1936). Berry defines acculturation as the process of change resulting from the encounter of two cultures and focuses on individual psychological processes that result in affective, behavioral and cognitive changes for each intervening party (Berry et al., 1987; Berry 2001, 2009).

Berry (1997, 2001) describes two group-level phenomena critical to understanding the process of cultural and psychological acculturation. He maintains that, in a cross-cultural situation, a group can penetrate or ignore the other group, and a group can maintain its cultural identity or merge with the other. He counters the argument that high levels of contact between groups will inevitably lead to low cultural maintenance of the minority group and, over time, to the merger of the two. Berry cites as examples the persistence of indigenous groups in Africa and the Americas after European migration, as well as the maintenance of Spanish and French immigrant groups in North America

(Berry, 2001).

Berry also discusses what occurs at the psychological level during acculturation.

He suggests that individuals have different attitudes toward the group-level aspects

(intercultural contact and cultural maintenance) discussed in the previous paragraph. He calls these acculturation attitudes (Berry, 1997; Berry, 2001). In the encounter of two cultures, the acculturating individual has to contend with both challenges, whereas the receiving society is concerned with only the first one (i.e., how much contact is needed).

A mutual process ensues, where acculturation attitudes and the perceptions about the acculturating individual by those in the receiving society interplay (Berry, 1997; Berry, 36

2001). This is illustrated in Figure 2.1, where each one of these aspects is defined by

Berry as the “intercultural contact space” (Berry, 2001, p. 619).

Figure 2.1

Orthogonal Model of Acculturation (Berry, 2001)

Each box contains a depiction of possible combinations. The possible acculturation strategies are: assimilation, separation, integration, and marginalization

(Berry, 1997; Berry, 2001; Sam & Berry, 2010). Assimilation occurs when individuals, in their interaction with other societies, do not want to maintain their own cultural heritage. Separation, on the other hand, occurs when individuals avoid interaction with other societies and firmly hold on to their native culture. In cases when the acculturating individual wishes to both maintain some degree of integrity of the original culture and interact with other societies, the likely outcome is integration. Finally, marginalization occurs when there is low interest in cultural maintenance (frequently in situations of 37 coerced cultural loss) or little interest in interactions with other societies (frequently in situations of discrimination or exclusion) (Berry, 1997; Berry, 2001).

This description of attitudinal orientations suggests that the acculturating individual has the freedom to choose how to approach the culture exchange process. The ideal scenario would be an open, culturally plural receiving society, willing to engage in the culture exchange process with the acculturating individual (Berry, 2001). However,

Berry pointed out early in his development of the theory that this is not always the case

(Berry, 1974). The process of integration is one of mutual accommodation: acculturating individuals adopt basic values of the new society, and the receiving society needs to adapt its institutions (such as education, health, labor, etc.) to accommodate new groups of people (Berry, 2001). Berry (2001) emphasizes the importance of the disposition of the receiving society to engage in this mutual accommodation and posits this is a precondition to integration. Kim (1988) reports that it is not uncommon for individuals to explore different strategies before engaging in one that is more effective than the others (as cited by Berry, 1997).

So far, the basic aspects of intercultural contact and cultural maintenance have been discussed from the vantage point of the acculturating individual. However, the author argues that both intervening parties would eventually become acculturated. He introduces a third aspect to the theory: the influence the receiving society exerts on the direction mutual acculturation would take (Berry, 2001). This third dimension produces a “mirror” intercultural contact space, illustrated by the right hand-side circle in Figure

2.1. As depicted in Figure 2.1, the four acculturation strategies are mirrored by four strategies in the receiving society. The strategy where the dominant group seeks to 38 assimilate the acculturating individual, is termed “melting pot”; when the receiving society pressures acculturating individuals to remain separate, it becomes segregation; when the receiving society rejects and discriminates the marginalized individual, it becomes exclusion; finally, when the larger society seeks cultural plurality and diversity, mutual accommodation will ensue and the strategy is known as multiculturalism (Berry,

1997; Berry, 2001).

Psychological acculturation in Berry’s theory. It’s important to remember that acculturation does not per se lead to negative social and psychological outcomes (Berry

& Kim, 1988). He sees the psychological consequences of acculturation as a progression, linked to the varying levels of difficulty that the acculturating individual may encounter in the process. In situations of mild intercultural conflict, acculturation is seen as a process of culture learning and social skills acquisition (Brislin, Landis, and Brandt,

1983). The author points out that this requires some “culture shedding” (Berry, 1997, p.

13), in order to unlearn aspects of the previous culture that may not be effective in the new environment, which could be accompanied by mild to moderate culture conflict

(Berry, 1997). However, in situations where serious conflict occurs, individuals may experience “acculturative stress” (Berry et al., 1987).

Acculturative stress. This phenomenon comprises stressors that are unequivocally related to the process of acculturation and contribute to a reduction in the health status of the acculturating individual (Berry et al., 1987). Berry uses an already established stress and coping model (Lazarus & Folkman, 1984) that conceptualizes stress as a relationship between individual and environment that the person deems taxing because it overwhelms his/her coping resources. The person engages in a cognitive 39 appraisal to determine whether a given transaction with the environment poses a threat to their wellbeing. If it does, then the individual decides what type of coping is needed in order to deal with the problem and/or regulate emotions (Lazarus & Folkman, 1984).

However, as it was mentioned before, acculturation doesn’t inevitably lead to negative mental health outcomes. Sometimes, it can enhance the individual’s life, as the person will learn new cultural ways that will build on his/her existing cultural repertoire

(Berry & Kim, 1988; Berry et al., 1987). Individuals engage in the experience of acculturation in varying degrees, exposing themselves to stressors of different intensity, which, in turn, may lead to varying levels of acculturative stress (Berry et al., 1987).

When acculturative stress occurs, common stress behaviors are anxiety, depression, feelings of marginality and alienation, heightened psychosomatic symptoms, and identity confusion (Berry et al., 1987).

Empirical testing of Berry’s model. Berry, Kim, Minde and Mok (1987) analyzed results from several studies conducted in Canada between 1965and1985, using a sample of just under 1,200 individuals and a common index of stress and a similar set of predictors to compare five acculturating groups within Canada and how they varied in terms of acculturative stress. Holding the larger society constant, the following acculturating situations were represented by the participants: voluntary vs. involuntary, immigrants vs. refugees, ethnic groups vs. native peoples, and sojourners (temporary immigrants). The authors hypothesized that greater levels of acculturative stress would be observed in groups that face the acculturation experience involuntarily (refugees and native peoples) and lowest levels of acculturative stress experienced by those in voluntary contact (ethnic groups and immigrants). They also hypothesized that sojourners would 40 present rather high levels of acculturative stress. The authors measured acculturative stress creating an index, using items that measured psychosomatic symptoms, anxiety, depression, and irritability in the Cornell Medical Index (Brodman, Erdman, Lorge &

Gershenson, 1952, cited by Berry et al., 1987). The description of the index used in the study was limited to listing the item numbers from the original index that they used and a range of internal consistency coefficients of the subscales. The authors did not provide information about scoring in order for the reader to understand what constitutes low or high levels of acculturative stress.

They hypothesized that the relationship between acculturation experience, stressors and acculturative stress was moderated by several factors, e.g., the nature of the receiving society, type of acculturating group, mode of acculturation, as well as demographic, social and psychological traits of the acculturating individual (Berry et al.,

1987). This acculturation framework is depicted in Figure 2.2.

The authors discuss these factors providing empirical support for some, but not for others, as follows:

Nature of the receiving society and type of acculturating group. The authors cited evidence provided by Murphy (as cited by Berry et al., 1987, p. 494) that pluralist or multicultural societies have higher tolerance for cultural diversity, resulting in less mental health problems in acculturating individuals, but do not discuss what this evidence entails. However, they did not provide any empirical evidence from the study to support the moderating effect of this variable. Similarly, authors discussed the varying levels of voluntariness, permanence of contact, movement, etc. in different acculturating groups, such as refugees, immigrants, sojourners, ethnic groups, or native peoples, and how this 41 may impact the mental health status of individuals, but don’t provide evidence that their results support this relationship.

Figure 2.2

Acculturation and stress (Berry et al., 1987)

Mode of acculturation. This refers to the four acculturation strategies

(assimilation, integration, separation, and marginalization). They found that, for native peoples, those favoring integration and assimilation had lower stress, while those preferring separation had higher stress (Berry et al., 1987). Also, a similarity in social structure between the original society and the host society was predictive of lower acculturative stress.

Demographic, social, and psychological traits of the individual. Here, the authors referred to variables such as level of education, age, gender, cognitive style, prior 42 intercultural experiences, and quality of the experiences with the receiving society (Berry et al., 1987). As far as gender differences, the authors reported a pattern showing females having higher acculturative stress than males (Berry et al., 1987). Unfortunately, the authors didn’t provide further detail about these differences.

The study found that education was a consistent predictor of low stress. When tests of cognitive ability were given to native peoples, and education was controlled for in the model, cognitive ability correlated negatively with acculturative stress (Berry et al.,

1987).

The nature of the contact experiences was also related to stress. This was measured by an acculturation index constructed for the study, that reflected the individual’s general contact with, and participation in, the larger society (Berry et al.,

1987). Unfortunately, no psychometric information is provided about this instrument.

They authors found that, the higher the participation in society, the lower the stress. They also hypothesized that this relationship was driven by education, as individuals with higher education tend to be better equipped to participate in the larger society more extensively (Berry et al., 1987). This also was consistent with results in another other study (Berry, Wintrob, Sindell, and Mawwhinney, 1982, as cited by Berry et al., 1987), where education, wage employment, language skills, and media use correlated negatively with acculturative stress.

Social support was found to mediate the acculturation-stress relationship for groups of sponsored Korean immigrants, Christians (rather than non-Christians) and those with close Korean friends had lower levels of stress, but no statistic results were provided to support this finding (Berry et al., 1987). 43

Schwartz & Zamboanga (2008) empirically tested Berry’s model to evaluate the extent to which the four acculturation categories emerged from continuous measures of heritage and receiving cultural practices. They used latent class analysis to test Berry’s model of acculturation, a clustering technique that extracts categories as they emerge from patterns in the data, without making a priori assumptions about them (Schwartz &

Zamboanga, 2008). The authors tested external construct validity (i.e., how acculturation orientations can relate differently both to indices of cultural identity and other established correlates of acculturation). Also, they tested if the categories related differently to similar theoretical constructs, such as familial ethnic socialization, acculturative stress, and perceived ethnic discrimination (Schwartz & Zamboanga, 2008). The study was conducted in Miami, a Latino enclave for several generations. The study was divided in three sections: (a) using latent class analysis to test whether the four acculturation categories would emerge; (b) evaluation of the categories that emerged in their relationship to ethnic identity and indices of cultural identity, such as individualism- collectivism, independence-interdependence, and familism; and (c) evaluation of the classes as far as how they differentiate in terms of three important cultural identity correlates, such as familial ethnic socialization, acculturative stress, and perceived ethnic discrimination (Schwartz & Zamboanga, 2008). The authors chose a six-class solution that offered the best fit with the data and had high reliability and classification accuracy

(Schwartz & Zamboanga, 2008). In order to validate the six-class solution, they used multivariate analysis of variance and cross-tabulated the clusters against gender and immigration generation. The classes that emerged were labeled: undifferentiated, assimilation, partial biculturalism, American-oriented biculturalism, separation, and full 44 biculturalism. They clarified that the undifferentiated class appeared consistent with marginalization as far as their scores on heritage and American cultural orientation scales used, but at the same time these participants had endorsed all four acculturation categories, leading the authors to hypothesize that these participants could have been confused about their cultural identities (Schwartz & Zamboanga, 2008).

The study results provided partial support for Berry’s model. The six categories that were extracted, instead of four, led them to believe that some of Berry’s categories, at least for the sample they used, may have multiple subcategories. Three of the acculturation categories emerged from the latent class analysis: separation, assimilation and biculturalism (called integration by Berry), although the separation class also had some degree of biculturalism. The authors pointed out that the mixing of categories

(biculturalism mixed with assimilation and separation) was consistent with prior research

(Berry et al., 1987), as categories may not be as independent from each other as once thought. The categories that emerged in the study were different enough, suggesting that they could be differentiated by Berry’s categories (Schwartz & Zamboanga, 2008). The lack of a marginalization cluster, they argued, echoes prior critiques that found it improbable for somebody to not incorporate neither their heritage nor the receiving cultural contexts (Schwartz & Zamboanga, 2008). The authors also recognized that

Berry advanced this idea in later work (Berry, Phinney, Sam & Vedder, 2006), where a

“diffused” category similar to the undifferentiated class that emerged in the study was described, suggesting maybe a sense of discomfort or confusion about cultural identity.

It should be noted, though, that the Berry et al. study (2006) referenced by the authors was a study of youth, not adults. 45

In summary, Schwartz & Zamboanga (2008) provide partial empirical support for

Berry’s model of acculturation using an approach that did not assume any a priori acculturation categories. The authors noted that their findings lent support to a position midway between Berry’s model and some of the criticism in the literature (e.g., Rudmin,

2003, 2009).

Critique of Berry’s Theory of Acculturation

Berry’s theory helped advance the field of acculturation studies from its original conceptualization as a unidimensional phenomenon, to the formulation of acculturation as a transactional process of the exchange between cultures (Berry et al., 1987). In essence, Berry’s model was the first one to reflect the transactional nature of the acculturation process, recognizing that it effects changes not only in the acculturating individual, but on the receiving society as well (Berry, Kim, Minde & Mok, 1987; Berry

2001, 2009). His acculturation model has been empirically tested, obtaining partial confirmation for its conceptual categories (Berry, Kim, Minde & Mok, 1987; Schwartz &

Zmboanga, 2008).

Berry’s theory has shed light on the link between acculturation-related stressors and psychosocial outcomes, with the concept of acculturative stress being another original contribution (Berry & Kim, 1988; Berry, Kim, Minde & Mok, 1987). Another strength of the concept of acculturative stress is that it was modeled after an empirically tested stress and coping model (Lazarus & Folkman, 1984).

Acculturation theory has also informed scale development. The use of acculturation instruments helped advance our knowledge of the impact of acculturation in different fields of study (e.g., health, mental health, public health, psychology, education, 46 etc.), and also within specific cultural groups. Results of two systematic reviews of acculturation scales designed for Latinos exemplifies how acculturation theory has been widely used in studies of the Latino population. One review yielded 26 scales (Wallace,

Pomery, Latimer, Martínez & Salovey, 2010), and the other one a total of 32 scales designed for use with Latinos (Yamada, Valle, Barrio & Jeste, 2006), that attempted to measure acculturation by quantifying variables such as cultural and social knowledge, behaviors and attitudes towards the main culture, language preference, health beliefs.

Berry’s model has informed research on acculturation in several ethnic groups

(Berry, 2003). It has particularly been widely applied in studies of the Latino population in the United States, given the preponderance of this group in the country (Salant &

Lauderdale, 2003; Schwartz & Zamboanga, 2009), such as research on the impact of acculturation on health (Andrews, Bridges & Gómez, 2013; Wallace, Pomery, Latimer,

Martínez & Salovey, 2010); acculturation and Latino social identity (Padilla & Pérez,

2003); acculturative stress (Rudmin, 2009); acculturation and depression in Latinos

(Ramos, 2005; Torres, 2010), and has also informed research on mental health interventions (González-Prendes, Hindo & Pardo, 2011; Piedra & Byoun, 2012; Valdez,

Abegglen & Hauser, 2012; Valdez, Padilla, McCardell-Moore, Magaña, 2013; Tran et al.,

2014).

There are also weaknesses with this theory. Arguably, one of the more apparent weaknesses is a lack of consensus on the definition of acculturation in the literature

(Berry, 2009; Horevitz & Organista, 2012; Rudmin, 2009; Salant & Lauderdale, 2003;

Weinreich, 2009). Rudmin (2009) defines acculturation as the acquisition of a second culture, which appears closer to the idea of assimilation than to the process of negotiating 47 native and dominant culture at the same time. LaFromboise, Hardin, Coleman & Gerton

(1993) make a distinction between acculturation and second-culture acquisition. They identify different models of second-culture acquisition, acculturation being one of them.

There is also a conceptual debate between proponents of acculturation and enculturation

(Weinreich, 2009). Enculturation is the process of identification with a culture (e.g., one’s culture of origin). Weinreich (2009) favors the concept of second enculturation in exchanges between cultures, when a second culture is being transmitted. However, Berry

(2009) defended his perspective and argued that, when a second culture is involved, then the classic definition of acculturation applies, stressing that the transactional nature of the process is better captured by the concept of acculturation. It can also be maintained that unidimensional views of acculturation view a progression towards agreement and conformity with the dominant culture as the desirable outcome (Andrews, Bridges &

Gómez, 2013; Padilla & Pérez, 2003; Horevitz & Organista, 2012) and do not allow for simultaneous acculturation to both cultures to occur (Andrews, Bridges & Gómez, 2013).

Problems with conceptualization translate into concrete consequences. For instance, views of acculturation as a unidimensional process (similar to assimilation) have informed the widely used Acculturation Rating Scale for Mexican Americans

(Cuéllar, Arnold & Maldonado, 1995), which calculates acculturation scores for native and new culture, and a total score subtracting the first from the second one. It appears that the results captured by this scale reflect degree of assimilation, more so than what acculturation stage the individual is in.

Other measurement inconsistencies in the acculturation literature include: use of different proxy variables, e.g., English language proficiency (Alegría et al., 2007; 48

Alegría, Canino, Stinson & Grant, 2006; Finch & Vega, 2003), or length of stay in the

U.S. (Alegría et al., 2007; Ortega, Feldman, Canino, Steinman & Alegría, 2006), and a lack of widely accepted scales (Horevitz & Organista, 2012; Hunt, Schneider & Corner,

2004; Rudmin, 2009; Zane & Mak, 2003).

Arguing that universal scales of acculturation do not work well because they have to inquire about cultural aspects that vary by ethnic group (Berry, 2006), Rudmin (2009) calls for better integration of the literature, in order to make extant scales better known and reduce the need for creating new ones. Measurement inconsistencies should not come as a surprise, though, provided the lack of consensus on the definition of acculturation.

Lastly, Berry’s preference for the use of the term “cultural group” over “minority” has been criticized by others (Padilla & Pérez, 2003). Critics argue that acculturation is a key variable in the minority experience, as minority groups with more power will tend to accommodate less to the dominant culture (Padilla & Pérez, 2003). Berry offered a response to this criticism recognizing that power imbalances do occur as a result of individuals of different backgrounds living together in a diverse society (Berry, 1997).

However, Berry defends his choice of the terms “cultural group” to refer to all groups involved in the process of acculturation, and the terms “dominant” and “non-dominant” to refer to their relative power when such a power imbalance exists. Berry presents this as an attempt to sidestep political and social assumptions that a minority group will inexorably become a part of the mainstream culture (Berry, 1997). Berry does not see this process exclusively as oppressive. He acknowledged that, although the incorporation into the mainstream culture can and does occur, it is also true that this assimilation is 49 resisted by one or both groups, which over time increases cultural diversity (Berry, 1997).

These different viewpoints may be driven by a different theoretical focus, namely the psychological focus of Berry’s theory, as opposed to a sociological focus of the criticism.

Notwithstanding the divergence, it is a valid point to raise, as oppression is a part of the acculturation experience of many ethnic groups in the United States.

Conclusion

The review of cultural competence models reveals that the phenomenon of acculturation and its central role in the lives of ethnic groups is not consistently taken into consideration. This puts the field of social work practice with the Latino population at a risk of ignoring such a critical aspect of these clients’ lives and, in so doing, providing services that are not culturally competent.

Attempts to capture the complex process of acculturation, acculturative stress, and how it affects individuals’ mental health status continue to be challenging due to the high levels of disagreement about the construct and its measurement in the social sciences.

Therefore, it is not surprising that not much attention has been paid to intervention research to help us understand how mental health clinicians can incorporate extant knowledge of acculturation in a meaningful way to their practice.

This study will contribute to social work practice by exploring the knowledge that mental health clinicians have about the phenomenon of acculturation, acculturation theory, and how it informs their clinical practice with Latino clients.

50

Chapter 3: Review of the Literature

Introduction

This chapter synthesizes the extant practice literature of cultural adaptations of psychosocial interventions implemented with adult Latinos with special attention to how acculturation-related factors inform such cultural modifications. Studies are presented organized by research design (randomized-controlled trials, quasi-experimental design, and qualitative studies). The randomized-controlled trials section is further sub-grouped by the targeted diagnosis. The quasi-experimental design segment classifies cultural adaptations in two groups: (a) researcher-driven cultural adaptations that are informed by the researcher’s understanding of the problem, and (b) participant-driven adaptations that seek to include feedback from participants. The final section presents data from qualitative studies.

The timeframe of the literature review search was from 2000 to 2019 in order to assess the current state of the empirical evidence. The studies reviewed in this chapter span from 2000 to 2018. A critique of the literature will follow, identifying methodological issues and gaps that will help frame the need for the present study in the context of the extant practice literature.

Culturally Modified Mental Health Interventions for the Latino Population:

Current State of the Research

There is a paucity of practice research that examines cultural modifications of interventions with adult Latinos. In an extensive meta-analytic review of mental health intervention studies with racial and ethnic minorities, Griner and Smith (2006) reviewed 51 experimental and quasi-experimental studies of culturally adapted mental health interventions published between 1974 and 2004, yielding a total of 76 studies, including both youth and adults. Of the totality of studies reviewed only one-third (31%) included participants of Latino descent. Jani, Ortiz and Aranda (2009) conducted a review of the social work literature on Latino outcome studies between 1995 and 2005, finding only 10 mental health studies that reported interventions with various levels of cultural modification. Benish, Quintana, and Wampold (2011) conducted a meta-analysis of quantitative studies published between 1989 and 2009 of culturally adapted psychotherapy to comparison treatments for racial/ethnic minorities. Their search for cultural adaptations used with racial/ethnic minorities, not exclusively Latinos, yielded a total of 21 studies that met their inclusion criteria with less than one-third (26.7%) of the study participants identifying as Latino/Hispanic.

In a more targeted systematic review of psychotherapy for depression among Latinos,

Collado, Lim and McPherson (2016) searched publications between 1981 and 2015, resulting in a total of 36 studies. Of these, Latino representation in study samples varied greatly, from 8 to 100%. More recently, Rathod et al. (2018) conducted a practice- focused review of meta-analyses of culturally adapted mental health intervention studies with racial and ethnic minorities published between 2006 and 2016. Their search yielded a total of 12 meta-analyses, some of which have been cited in this chapter because of not having an adult Latino mental health focus and one that was a dissertation. While Rathod and colleagues did not focus specifically on adaptations to Latino culture, it highlighted the lack of standardized cultural adaptation frameworks and ran into the problem of diverse criteria for cultural modifications cited in studies. 52

What Constitutes a Cultural Adaptation?

What constitutes a cultural modification of a mental health intervention is not clearly delineated. A cultural adaptation straddles the line between proponents of testing evidence-based practices across all groups before deciding on an adaptation (Elliot and

Mihalic, 2004) to those who call for creating novel, culturally-derived treatments that take cultural contexts into account, such the case of Latino healing (Comas-Díaz, 2006).

One way to organize the diversity of adaptations is to divide them into surface-level versus deep structure adaptations (Resnicow, Baranowski, Ahluwalia, and Braithwaite,

1999). Surface-level modifications address observable cultural traits of the population, such as language, music, or clothing. Materials translated to Spanish, assistance with transportation to the treatment site or employing bicultural and/or bilingual clinicians are examples of surface-level adaptations. The fact that these modifications are called surface-level should not result in a dismissal of the concept. Aside from the obvious advantage of receiving services in one’s own native language, there is evidence that therapist-client ethnic match facilitates rapport (Kim and Kang, 2018), trust-building, and decreases stereotyping (Ertl, Mann-Saumier, Martin, Graves, and Altarriba, 2019), although there is some evidence to suggest that, in the long-term, client-therapist ethnic match does not necessarily translate to better outcomes (Cabral and Smith, 2011; Kim and Kang, 2018). There is also some evidence in support of the ethnic match based on research that shows that minority clinicians reported higher levels of multicultural awareness (Berger, Zane, and Hwang, 2014).

On the other hand, deep structure modifications involve changing the intervention protocol in ways that are informed by the sociocultural, historical, and environmental 53 factors that influence the client’s view of both problem and solution. These types of adaptations seek feedback from members of the target population prior to changing the intervention protocol. Deep structure modifications also often involve providing extensive cultural training to the therapists delivering the intervention.

Cultural modifications often are referred to in terms that are similar but do not necessarily reflect the same concept. In a review of the literature to determine what types of interventions are sensitive to Latino culture, Benuto and O’Donohue (2015) examined the terminology used to refer to treatment that has been modified to reflect cultural values. They found that the most frequently used terms are: cultural adaptation, cultural attunement, culturally tailored, and culturally targeted. A cultural adaptation is defined as the “systematic modification of an evidence-based treatment (EBT) or intervention protocol to consider language, culture, and context in such a way that it is compatible with the client’s cultural patterns, meanings, and values” (Bernal, Jiménez-Chafey, &

Domenech-Rodríguez, 2009, p. 362). Cultural attunement involves changes made to improve reach and engagement, maintaining core treatment components. Treatment that is culturally-tailored involves deciding how to modify interventions after assessing the specific cultural needs of an individual. On the other hand, culturally-targeted treatment is defined as modifications made to the interventions based on group-level cultural traits in the target population (Benuto & O’Donohue, 2015).

Griner and Smith (2006) also offered a categorization of cultural modifications based on whether the following elements are present in treatment: (a) explicit discussion of culture; (b) client-therapist ethnic match; (c) use of client’s preferred language; (d) incorporating cultural values and worldview in the sessions; (e) collaborating with key 54 community members (e.g., healers); (f) adequate physical location of services; and (g) including culturally relevant discussion of spirituality.

The argument for ecological validity of interventions emerged out of this debate, calling for a need to “increase the congruence between the experience of the client’s ethnocultural world and the properties of a particular psychotherapy” (Bernal, Jiménez-

Chafey and Domenech-Rodríguez, 2009, p. 363) also has been seen as an important model to follow in the process of culturally adapting an intervention. An example of this approach is known as the Cultural Adaptation Process Model (CAPM), by Domenech-

Rodríguez and Wieling (2004), that delineates 3 phases in the process of a cultural modification: (1) weighing community needs and scientific integrity to decide who needs to participate in the adaptation; (2) selection and adaptation of evaluation measures, data gathering, revision and adaptation of the intervention; and (3) integrating the data gathered into a new intervention that will, in turn, be tested with the target population.

As it can be gleaned from this review of what is considered a cultural modification, terminology and classifications are not adhered to consistently in the literature. The terms adaptation and modification are used interchangeably in the present study.

Randomized-controlled Trials (RCTs)

Interventions for depression. These constitute the focus of the majority of the

RCTs reviewed that included a cultural adaptation (Foster, 2007; Miranda, Duan, et al.,

2003; Miranda, Azocar, et al., 2003; Miranda, Chung, et al., 2003; Alegría et al., 2014).

An intervention to improve quality of care and outcomes of depressed individuals of racial/ethnic minority background randomized African-American (n = 93), Latino (n =

398) and White (n = 778) participants to CBT or treatment as usual (TAU) in primary 55 care practices in managed care organizations (Miranda, Duan, et al., 2003). TAU consisted of medication and follow-up by nurses to support adherence to treatment, for 6 months. The intervention consisted of 8-12 sessions of CBT and medication, if needed.

Cultural adaptations included materials in Spanish, minority providers featured in training materials, and minority researchers supervising local investigators throughout the study. While all participants receiving the intervention showed significantly higher rates of symptom improvement compared to TAU, the intervention was particularly helpful for racial/ethnic minorities, at 6- and 12-month follow-up. Under TAU, minorities continued to receive less appropriate care than Whites. The authors hypothesized that this could be reflecting a disparity in access to care and quality of care received previously by racial/ethnic minorities as opposed to Whites, and stated their results had relevance particularly for Latinos, who are at greater risk of not receiving appropriate care and having worse outcomes.

At a community hospital depression clinic, Miranda, Azocar et al. (2003) randomized a diverse sample of low-income African-American (n = 56), Latino (n = 77), and White

(n = 67) participants to a CBT intervention enhanced with over-the-phone case management or CBT alone. Cultural adaptations of the intervention for Latinos included fully translated materials as well as cultural training of clinicians, to show respect and a congenial attitude (consistent with Latino values), and to allow for warmer interactions than are usual with English-speaking patients. The enhanced intervention resulted in fewer depressive symptoms at 6-month follow-up than CBT alone, for all participants.

Latino participants who received the enhanced intervention showed greater symptom reduction (30%) than those receiving CBT alone (18%). Authors, however, caution that 56 there were differences across groups, such as Latinos receiving more home visits, that could have influenced these results.

Miranda, Chung et al. (2003) randomized a sample of female welfare recipients to three groups: 6 months of antidepressants, 8 weekly CBT sessions (individual or group, depending on participant’s availability, at the community mental health center or in the home), or TAU (at a community mental health center). The sample’s ethnicity composition was as follows: African-American (n=117), Latina (n=134), and White

(n=16). Cultural adaptations of care included bilingual providers for the Spanish- speaking women and materials translated to Spanish. The authors reported they included pre-treatment outreach (an average of 7.8 phone contacts with staff prior to the intervention) following their literature review that indicated this was necessary in order to engage low-income minorities (including Latinos). Significant decrease in depressive symptoms and social functioning for both the medication and CBT groups were recorded at 1-, 3-, and 6-month follow-ups. Participation in TAU was low for all participants; 83% of women offered TAU failed to attend even 1 session. With relatively few cultural accommodations, authors concluded EBP intervention appeared effective for diverse groups.

Foster (2007) recruited Spanish-speaking women with depressive symptoms at a homeless shelter and at a community hospital psychiatric clinic. Participants were randomly assigned to 16 weekly sessions of either CBT group for depression or a supportive/exploratory group for depression conducted at both sites. The cultural adaptation at the Hispanic Clinic consisted in interventions delivered in Spanish, by

Spanish-speaking therapists, Spanish language manuals and outcome measures (Foster, 57

2007). Contrary to results reported by other RCTs reviewed here, the author’s hypothesis that the outcomes of the CBT intervention would be enhanced was not supported, as both conditions showed a significant decrease in depressive symptoms. The author discusses explanatory alternatives to account for the result, such as Latina participants exhibiting higher levels of depression at all times during the study, particularly higher levels of somatic symptoms, possibly leading to a heightened subjective experience of depression

(Foster, 2007).

Alegría et al. (2014) tested a short CBT intervention for depression in primary care settings serving high numbers of Latinos. The objective was to determine whether a culturally adapted CBT intervention would: (1) be effective in decreasing depression with this population; and (2) increase patients’ follow-through with a referral to mental health treatment by a primary care physician. Participants were randomized to three conditions:

CBT by phone, CBT in person, or TAU. The cultural adaptation included the use of bilingual staff, inclusion of visual aids, and reduction of number of materials used (to match low literacy level of the population), as well as inclusion of culturally relevant metaphors, proverbs and values. At 6-month follow-up, CBT patients in both modalities showed reduced depressive symptoms than controls and significantly more participants had initiated mental health services at the primary care facility than when referred to a mental health center.

Interventions for schizophrenia spectrum disorders. Family-assisted social skills training to increase illness self-management in clients diagnosed within the schizophrenia spectrum is a newer EBP approach (Heinssen, Liberman, and Kopelowicz, 2000;

Liberman and Coitigan, 1993), also tested with Latinos (Liberman & Kopelowicz, 2009). 58

Liberman and Kopelowicz (2009) recruited 92 schizophrenia-spectrum Latino patients from different countries of origin and their 92 key relatives from a community mental health center. Participants were randomized to group skills training with family members included in weekly sessions aimed at using relatives as skills generalization agents or

TAU, which consisted of case management and monthly pharmacological management visits. The cultural adaptation included translation and back-translation of materials

(material is translated to Spanish and then back to English, to test for accuracy) for

Spanish-speakers through focus groups of bilingual patients to determine the appropriateness of the translation. They also employed indigenous bilingual and bicultural staff at the center as trainers, and emphasized the importance of communicating an “informal personal style,” reflecting the Latino value of personalism, as well as other customs such as sharing of food and the sharing of small talk before and after sessions. The purpose was to convey warmth in staff-participant interactions to increase retention and effectiveness. These modifications, together with the involvement of relatives in treatment, led the authors to conclude that they resulted in better outcomes than TAU in symptom reduction, relapse, re-hospitalization, and social functioning at 6- months post-treatment.

Interventions for posttraumatic stress disorder (PTSD). A culturally adapted

CBT protocol for Latino women with treatment-resistant PTSD was pilot-tested comparing it to an applied muscle relaxation intervention (Hinton, Hofmann, Rivera,

Otto, and Pollack, 2011). Women were randomly assigned to either a manualized CBT intervention for treatment-resistant PTSD or applied muscle relaxation. Both interventions had a duration of 14 weeks and were delivered in Spanish. The authors 59 provided examples of the cultural adaptations they introduced to the CBT techniques prescribed by the manual, such as the use of culturally-specific imagery to guide meditation exercises, addressing cultural syndromes such as ataque de nervios (which loosely translates as nervous attack in English), as well as inclusion of emotion- regulation methods traditionally used by Latinos (e.g., reading biblical passages, praying with a rosary, etc.). While their results showed that both treatments were efficacious for several outcomes tracked, the culturally adapted CBT was more effective than relaxation training alone. However, they could not determine the extent to which the cultural adaptation of the CBT intervention accounted for those differences (Hinton et al., 2011).

In a meta-analysis of culturally adapted mental health interventions, Griner and

Smith (2006) reviewed experimental and quasi-experimental studies that included a cultural adaptation of a mental health intervention targeting racial/ethnic minority groups, controlling for variables such as publication bias, research design, demographic characteristics (including acculturation), and type of outcome measure. The authors reported a moderate average effect size of d = .45 (SE = .04, p < .0001), concluding that a cultural adaptation of a mental health intervention that targets a racial/ethnic group is beneficial (Griner & Smith, 2006).

Quasi-experimental Designs

Researcher-driven cultural adaptations. In a pre- and post-test pilot study,

Interian, Allen, Gara, and Escobar (2008) piloted culturally adapted CBT for low-income adult Latinos in primary care settings delivered in 12 individual sessions, as opposed to the group format used in trials, such as the ones cited in this review thus far. The cultural adaptation included assessment and interventions conducted in Spanish, the incorporation 60 of common expressions of emotional distress used by Latinos, as well as Spanish dichos

(sayings). The authors also incorporated some fundamental Latino values. Respeto

(respect) was conveyed by the therapist by helping participants generate assertive statements while conveying respect for others. The value of simpatía (congeniality) was incorporated by demonstrating a warm and positive interpersonal style. The authors also used an “ethno-cultural assessment” (Interian et al., 2008, p. 70) to generate a culturally informed case formulation. This assessment included inquiring about the length of stay in the United States, adaptation to the migration (if applicable), relationship with and location of extended family, changes in social support. The full ethno-cultural assessment was not provided by the authors. Significant decrease of symptomology at termination and at the 6-month follow-up was reported. Given that, due to study design limitations, the role of the cultural adaptation can’t be ascertained, the authors recommended complementing CBT therapy with an ethno-cultural assessment to fully understand the cultural variables at play for each individual client and to use this information to guide subsequent adaptations. Further, they found the 73% retention rate encouraging as it was significantly higher than their review of the literature. In particular, they cite the importance of understanding the individual variations of level of acculturation and to explore how this may impact treatment.

Heilemann, Pieters, Kehoe, and Yang (2011) reported significant decrease in depressive symptoms and significant increase in resilience in a pre/post pilot test of schema therapy, motivational interviewing and collaborative-mapping for depression in

Latinas (N=12). This study represents the first attempt at researching the impact of schema therapy with Latinas. The cultural adaptation consisted in having a principal 61 investigator who was bilingual and “well acquainted with the life situations of the sample” (Heilemann et al., 2011, p. 476), which was supported by the author’s self- disclosed extensive experience as a qualitative researcher with the population.

Driven by their literature review of relaxation technique scripts that showed that most common scripts included idiocentric imagery (i.e., tendency to define self in isolation from others), La Roche, Batista and D’Angelo (2011) modified a relaxation intervention for anxiety to match Latino allocentric orientation (i.e., tendency to define self in relation to others). The authors examined cultural match theory, that posits that patients tend to adhere to and benefit from interventions that match their cultural background. They implemented a culturally competent relaxation intervention to target anxiety symptoms that included allocentric rather than idiocentric relaxation interventions. The authors also wanted to test whether the intervention had an effect on depression, given the commonly found correlation between anxiety and depressive disorders. In a content analysis of guided imagery scripts in psychotherapy journals, the authors found that the idiocentric orientation is reflected in the use of guided imagery congruent with such orientation (e.g.,

“imagine yourself in a beautiful beach”). The cultural adaptation proposed included the use of “allocentric imagery” (e.g., “imagine yourself surrounded by loved ones”). Of importance, the authors didn’t assume that all Latinos share the same allocentric orientation and tested self-orientation as part of the pre-test measurements. Participants reported statistically significant reductions in intensity of anxiety (38%) at time 2 post- test measurement, and this reduction remained significant at time 3 (three months after completion of treatment). The intervention did not have a significant effect on depressive symptoms. The authors found a significant positive relationship between Latinos’ levels 62 of allocentrism and treatment adherence, supporting one of their hypotheses. They posited that the culturally competent ingredients of the treatment (the allocentric imagery and strategies) were effective in treating anxiety, but it should not be assumed that such a modification will be effective on other disorders. The finding was discussed in the context of: (1) the limitations of the study design, (2) the possibility that the results were related to other variables they didn’t control for, such as acculturation and perceived discrimination.

Tran et al. (2014) conducted a pre-test/post-test study to pilot an intervention using bilingual/bicultural lay health outreach workers (promotora, in Spanish) to decrease depression and acculturative stress, and increase social support/coping in immigrant

Latinas living in areas deprived from culturally-sensitive resources (N=58). The intervention was culturally tailored from its inception. The authors used a culturally tailored curriculum for recently immigrated Latinas by Corbin-Smith et al. (2010) and pointed out that immigrants in these settings faced pressure to acculturate quickly related to living in areas deprived of culturally-sensitive resources, which in turn may heighten the risk for negative mental health outcomes. The original curriculum was developed with the input of the community and experts in the areas of health and mental health services to the Latino population, was delivered by bilingual/bicultural promotoras and incorporated cultural adaptations such as the inclusion of active learning experiences.

Promotoras received training and monthly supervision. The study had a 55% retention rate and authors reported a significant post-test decreases in depression (50% reduction), perceived stress (15%), and acculturative stress (12% reduction) as well as significant increase in social support (a 6-point increase, p < .01, percentage of increase values not 63 provided) and positive coping, including increases in distraction techniques (19% increase), active coping (17% increase), emotional support (16% increase), and positive reframing (15% increase). Results showed the intervention significantly reduced depression and acculturative stress and increased social support and coping.

Participant-driven adaptations. Piedra & Byoun (2012) piloted a CBT group intervention for depression in Latino mothers (N=19). Depressive symptoms were measured using the Center for Epidemiological Studies Depression Scale (CES-D).

Results showed significant decrease in post-test symptom severity with a reported large effect size (r = .67), with almost no variation in scores 3 months after treatment completion for the whole sample (CES-D scores were 12 and 11.3 at post-test and 3- month follow-up, respectively). Guided by their literature review, they modified the original manual, which resulted in fewer sessions, orienting subjects to the intervention and the therapeutic process, and included 3 sessions with focus on the acculturation process in immigrants and its impact on relationships). Also, they added focus groups post-intervention to explore participants’ satisfaction and perceived benefits.

Valdéz, Padilla, Macardell-Moore, and Magaña (2013) examined an intervention for

Latino families facing maternal depression (N =16) in a pilot study, incorporating an iterative process of cultural adaptation of an intervention program originally design for non-Latino, English-speaking families, many of which were long-term urban residents, unlike the Latino families that the cultural adaptation hoped to assist. They started out identifying key cultural elements described in the literature and also added those which emerged as a result of conducting focus groups. Community partnerships were promoted, providing input in the design and facilitating dissemination into the wider 64

Latino community. The pilot study yielded positive outcomes in terms of psychological functioning, perceived social support, coping and family functioning, with a high completion rate of 90%. The intervention’s acceptability was measured by questionnaires and focus groups. Two of the twelve sessions were adapted to include four sociocultural themes that emerged from qualitative data: (1) discussion of immigration and acculturation-related stressors; (2) parental involvement and monitoring of children’s activities outside of the home; (3) marital relationships in the context of the acculturation experience and maternal depression; and (4) cultural assets that the families possess, such as traditions, extended family support, ethnic socialization (e.g., cultural pride, coping with discrimination). The intervention’s acceptability was measured by satisfaction questionnaires and by conducting focus groups. Overall, participants stated that the intervention helped them normalize some of their problems through the process of group sharing but, more specifically, the intervention’s focus on culture, immigration-related losses, and acculturative stressors helped them connect as a family, and frame and understand their struggles as immigrants. The authors cautioned that, since their sample consisted of families of Mexican descent and all parents in the sample were foreign-born, it should not be automatically assumed that the intervention will have similar results with other Latino subgroups. The authors emphasize the importance of tailoring the content to the different levels of acculturation and contextual factors of different Latino subgroups.

Pérez-Benítez, Zlotnick, Gómez, and Rendón (2013) conducted a pilot study to test

CBT for PTSD and somatization, delivering 10-14 culturally adapted sessions of CBT to adult Latinos at a community clinic. The cultural modification sought to understand the needs of the participants by conducting pre-trial focus groups that explored the stigma 65 associated with the word “trauma”, as well as how they labeled their traumatic experiences. Post-test focus groups were also conducted, where participants shared their appreciation for having a therapist that showed simpatía (congeniality) and conveyed genuine interest in the participant as a person (value of personalism). The intervention was delivered by Spanish-speaking therapists. The authors point out the importance of being informed about historic events in Latin America, as well as legal and immigration issues, by way of establishing rapport with the population. While the researchers attempted to incorporate daily stressors related to immigration, such as lack of basic resources, unemployment, poor family support, intergenerational conflict, they also noted that this posed a challenge in the context of a brief manualized therapy. At the end of the pilot, the authors found that the intervention was well-accepted and feasible (indicated by strong therapeutic alliance, and high satisfaction and retention rates), as well as a potentially beneficial effect of treatment (50% of those who completed treatment no longer met criteria for PTSD).

In a mixed methods pilot study, Stacciarini, Smith, Wilson-Garvan, Wiens, and

Cottler (2015) investigated rural Latinos’ mental wellbeing exploring links between family, environment, and social isolation. The authors were interested in identifying risk and protective factors associated with the mental wellbeing of Latino immigrants living in rural areas. They recruited immigrant mothers and their adolescent children. The pilot findings indicated that family, rural, and social environments could protect or impair wellbeing, processes that were hypothesized to be mediated by level of acculturation and language skills. They also identified how exposure to racism and discrimination, lack of geographic mobility, and undocumented status were identified as ever-present stressors, 66 heightened by higher visibility of these minority communities in rural areas. While the aim of this pilot was not to deliver a mental health intervention, it illuminated the importance of understanding the ecological context of the population that an intervention will target, with particular attention paid to variables connected to participant immigrant status.

Qualitative Studies

Qualitative methods have been used to explore cultural adaptations of mental health interventions, such as CBT for depression (Aguilera, Garza, & Muñoz, 2010;

González-Prendes, Hindo, & Pardo, 2011; Hayden, Connelly, Baer-Ericzen, Hazen, &

McCue Horwitz, 2013; Martínez, Interian, & Guarnaccia, 2013), working with families of people with schizophrenia (Barrio & Yamada, 2010; Hackethal et al., 2013), engagement of Latino families in treatment (Méndez & Cole, 2014), explorations of the intersection of culture and masculinity in a male client/male therapist context (Zayas &

Torres, 2009), and understanding the clinicians’ perspectives on what constitutes culturally competent practice with Latinos (Gelman, López, and Foster, 2006), to name the more salient topics covered.

The ways in which theory of acculturation informs the cultural adaptation varied.

Sometimes it is implied, as in the study conducted by Aguilera, Garza, and Muñoz

(2010). The authors delivered manualized group CBT for depression in Spanish, and used a case study to demonstrate how they applied a standard CBT manual in a culturally-sensitive manner. They discussed their incorporation of traditional Latino values, such a familismo (a value that reflects the centrality of the family in Latino culture) and simpatía. While this study made no mention of acculturation, this appears to 67 be implied in their incorporation of the value of familismo. The intervention did so by encouraging participants to share their experiences of separation from their families during immigration or to discuss their struggles managing inter-generational conflict with their U.S.-born children. Both these circumstances are intricately connected to the process of acculturation. In processing these life events, participants gained insight into how these issues were connected to their depression.

Other studies acknowledged the role of acculturation in their literature review or the topic emerged as an important factor in the participants’ responses. In an exploration of experiences of maternal depression during the perinatal period among a sample of women of Mexican origin, Hayden et al. (2013) identified in their literature review that Latinos face barriers to mental health services utilization due to, among other things, immigration and legal status, as well as cultural values, such as stigma associated with mental health service use. Using content analysis, the authors gained in-depth understanding of participant understanding of maternal depression and the role of social support in mediating risk and onset of depression (which they found consistent with past research on the topic).

Two studies presented findings from cultural adaptations for family psychoeducation on schizophrenia, Barrio and Yamada (2010) and Hackethal et al. (2013). Barrio and

Yamada documented the process of developing the cultural adaptation, prior completion of an ethnographic study with a Mexican-American sample, to explore the perspectives of consumers diagnosed with schizophrenia, their family members and service providers.

Results of this study revealed five cultural resources that function as protective factors, namely: (1) central role of the family, (2) central role of spirituality and religiousness, (3) 68 nonjudgmental cultural attributions that convey warmth, (4) biculturalism, and (5) “cross- border living” (Barrio & Yamada, 2010, p. 490). The first three factors are illustrated in- depth by the authors. However, biculturalism and cross-border living, of more relevance to this dissertation, are mentioned as background themes that participants identified. The authors suggested that service providers have an awareness of issues of biculturalism and cross-border living in order to competently identify them and include them in group process but they did not provide any further elaboration on the subject. The other study conducted by Hackethal et al. (2013) used content analysis with three focus groups of consumers diagnosed with schizophrenia, their family members and service providers, where acculturation-related factors also emerged during the discussion of barriers to the utilization of mental health services. Interestingly, it was providers, more so than family members and consumers, who expressed concern about barriers to the program implementation stemming from mistrust in the system by immigrants escaping countries with severe political corruption, or the trauma of civil war, or how acculturation can influence choice of language spoken. Consumers and families focused more on the importance of traditional Latino values, such as familism and respect, in the clinical encounter. Another interesting finding was a diverging viewpoint between family members and providers about etiology of the mental illness. Family members adhered to a sociocultural cause while providers endorsed the biological model. This study illuminated the importance of engaging key stakeholders prior to embarking on a cultural modification.

In a case study of interpersonal therapy sessions conducted by a male Puerto Rican therapist with a male Puerto Rican client, Zayas and Torres (2009) explored the 69 adaptations made to standard interpersonal therapy in order for the treatment to be culturally sensitive. The authors pay special attention to how masculinity is defined within Puerto Rican culture and how the therapist balanced the client’s unique qualities and the person’s culture. While acculturation theory per se is not mentioned, there appears to be working knowledge that the therapist has about acculturation and that informs his interventions. In effect, the authors bring up acculturation in the discussion section, stating that therapy occurred against the “backdrop of the culture of an acculturated, second-generation Puerto Rican” (Zayas & Torres, 2009, p. 301), finding it critical to possess knowledge about the client’s cultural heritage.

Martínez, Interian, and Guarnaccia (2013) looked at the role of the family in antidepressant treatment adherence. Acculturation was indirectly alluded to in their literature review. The authors discussed evidence in support of immigrant Latinos having lower rates of depression than U.S.-born counterparts and Whites, being less likely to seek mental health treatment but more prone to seeking informal sources of help first, including family members. Using grounded theory methods, they explored the role of familism in treatment adherence and found that this role was nuanced: it could exert an either supportive or interfering influence. The authors emphasized that cultural constructs such as this one are not unidimensional and recommend researchers and practitioners to take this into account during the development and implementation of cultural modifications.

Other studies articulated more clearly how theory of acculturation informed their cultural adaptation in their literature review (González-Prendes, Hindo, and Pardo, 2011;

Méndez & Cole, 2014) and used knowledge of acculturation to frame a case study’s 70 history and inform case conceptualization (González-Prendes, Hindo, and Pardo, 2011).

In a case study that exemplifies how cultural values are integrated to CBT for depression with a Latino client, González-Prendes, Hindo, and Pardo (2011) describe culturally effective strategies. When providing the case study social history, the authors incorporate

Berry’s theory of acculturation, highlighting that the client appeared to have chosen the acculturative strategy of integration, engaging both Mexican and American cultures. In so doing, the authors identify the high value the client ascribed to the family and “doing for the family” (González-Prendes, Hindo, and Pardo, 2011, p. 380) as a key element for the case conceptualization. They posit that in CBT-style case conceptualization, the clinician identifies factors that may have contributed to emotional vulnerability, in turn leading to the development of the presenting problem (in the case study, depression that was triggered by unemployment and the inability to provide for his family). The authors note the importance of an accurate case conceptualization, particularly when working with Latinos, given the high rates of premature treatment termination in this population, something also identified by other studies (Interian, Allen, Gara, and Escobar, 2008;

Ríos-Elliot et al., 2005).

Another case study that included a discussion of acculturation in their literature review reported findings on the use of an art intervention as a culturally-sensitive strategy to engage Latino families in therapy (Méndez and Cole, 2014). The authors portray the

“tree of life” activity as a culturally sensitive intervention informed by cultural values, level of acculturation, and client self-disclosure. The authors used Berry’s acculturation strategies to inform their understanding of Latino families in therapy. They illustrated this point by saying that oftentimes parents will seek services when their children’s 71 acculturation strategies do not align with the parental strategies. The tree of life intervention discussed here consists of an art activity where the person draws a tree as a metaphor that symbolizes six aspects of their life: roots (cultural identity, family history, ancestry), ground (location the person currently lives in), trunk (skills and strengths the person possesses), branches (hopes, expectations for oneself, dreams for their future), leaves (people in the past or present who had a significant role in their lives, such as family, mentors, friends, etc.), and fruits (internal gifts the person has received over time from him/herself or others, such as kindness, love, patience, etc.). The strategy can be incorporated as a group activity with the family by way of evaluating the different acculturation levels of different family members, different values, as well as to increase self-disclosure. In the case study, the activity uncovered the tension between mother and children in terms of different acculturation strategies. The mother depicted a strong connection with her Mexican heritage by drawing one solid root, while the children felt also connected to the American culture, symbolized as two roots next to their names on the tree drawing. The activity was reported as culturally sensitive and effective, as mother and children engaged in problem-solving to develop new solutions that incorporated values held important by all of them.

Summary and Critique

RCTs reported generally positive results of evidenced-based interventions for depressed Latinos (as well as the other ethnic groups included) of both genders in low income, ethnically diverse community settings (Alegría et al., 2014; Miranda, Azocar et al., 2003; Miranda, Chung et al., 2003; Miranda, Duan et al, 2003), family-assisted educational approach for schizophrenia was also found effective with Latinos in a 72 community mental health settings (Liberman & Kopelowicz, 2009), and intervention for

PTSD (Hinton et al. 2011). One study of culturally adapted CBT for depression didn’t confirm the previous findings (Foster, 2007). Researchers incorporated some form of cultural adaptation aiming to increase engagement, retention, and outcomes of Latino participants, but the kind of cultural adaptation varied greatly by study. At a minimum, all studies included surface-level adaptations, such as Spanish translation of materials and bilingual staff. Other studies involved cultural training of the providers to reflect traditional Latino values (Alegría et al., 2014; Miranda, Azocar et al, 2003) and various cultural customs such as meals and socialization activities (Liberman & Kopelowicz,

2009). Some modified imagery and emotion regulation strategies to make it culturally- specific as well as incorporating cultural syndromes, such as ataque de nervios (Hinton et al., 2011), and use of popular sayings and proverbs (Alegría et al., 2014). Other studies, such as Liberman & Kopelowicz, (2009), chose a deep structure adaptation by using qualitative methods (focus groups) to ensure accuracy of translations and the inclusion of relevant Latino customs.

While it’s encouraging that these adaptations were put in place, the great variance among them makes it difficult to establish a standard protocol of cultural adaptation, let alone identify which aspect of the adaptation may have carried more weight in engagement, retention or outcome improvement. The majority of the cultural adaptations were researcher-driven. The intended recipients of the intervention had not been engaged in the development of the cultural adaptation, which may negatively affect the cultural goodness of fit of the intervention. Another widespread limitation was that sample sizes were relatively small, with the consequent challenges to generalizability. Another 73 limitation related to the study design entailed the type of control groups used, which did not allow for an examination of the sole effect of the cultural adaptation. Most studies reviewed had a treatment condition including the cultural adaptation versus TAU (Foster,

2007; Hinton et al., 2011; Liberman & Kopelowicz, 2009; Miranda, Azocar, et al., 2003;

Miranda, Duan, et al., 2003). Two studies assigned participants to three conditions

(Alegría et al., 2014; Miranda, Chung et al., 2003), but neither study included the same condition with and without cultural adaptation. The relative efficacy of a culturally modified intervention against an unmodified intervention was not answered by the RCTs.

In essence, these studies show that the culturally modified interventions are, in most cases, effective but they are unable to parse out their specific contribution.

In regards to the incorporation of knowledge of acculturation to the intervention, none of the RCTs reviewed used theory of acculturation to inform the cultural adaptation.

Most of the quasi-experimental studies (except for Heilemann et al., 2011) included a discussion of acculturation theory or acculturation-related factors. In order to compensate for problems intrinsic to the design (i.e., selection bias introduced by the lack of random assignment), some of these studies used qualitative data analysis to strengthen their results, such as post-test focus groups to further explore the validity of the modification (Pérez-Benítez et al., 2013). Aside from study design weaknesses, perhaps the next concern in this set of studies is that six of them were pilots with small sample sizes (Heileman et al., 2011; Interian et al., 2008; Pérez-Benítez et al., 2013; Piedra &

Byoun, 2012; Tran et al, 2014; Valdez et al., 2013). On the other hand, these pilot studies contained a rich breadth of cultural components to their interventions, including acculturation-related factors. 74

Acculturation knowledge was woven into the intervention in a variety of ways. One study used an ethno-cultural assessment that included immigration and acculturation factors as part of the case conceptualization (Interian et al., 2008). The ecological context of depressed Latino immigrant mothers was addressed during the intervention with Latino families (Valdez et al., 2013). The importance of addressing acculturative stress in order to increase social support was recognized (Tran et al., 2014). The recognition of acculturation-related stressors resulted in the addition of specific sessions to talk about acculturation and relationships in CBT group treatment for depression

(Piedra & Byoun, 2012). Also, discussion of historic events in Latin America, as well as legal and immigration problems was deemed relevant and incorporated to a cultural adaptation of CBT to treat PTSD (Pérez-Benítez et al., 2013).

Qualitative studies provided a thicker description of cultural adaptations, with in- depth understanding of key cultural variables, which allows the reader to “hear” participant voices through the data. The way in which theory of acculturation or acculturation-related factors informed qualitative studies varied but it was present, directly or indirectly, in all the studies reviewed. Acculturation was raised as an issue by participants discussing their immigration journey, their adaptation to the United States main culture, or conflict with their United States-born children (Aguilera, Garza &

Muñoz, 2010), biculturalism and cross-border living (Barrio & Yamada, 2010), and barriers to service access/utilization due to immigration status or mistrust of providers

(Hackethal et al., 2013). Acculturation theory was also used by study authors in their literature review to identify barriers clients faced to service utilization (Hayden et al.,

2013; Martínez, Interian & Guarnaccia, 2013). It also appeared as “working knowledge” 75 the authors used to inform their conceptualization of a clinical case (Zayas & Torres,

2009). In-depth discussion of acculturation was also observed in the literature review section with specific mention of theory of acculturation and acculturation strategies (most specifically, Berry’s theory) and this knowledge informed the study intervention

(González-Prendes, Hindo & Pardo, 2011; Méndez & Cole, 2014).

As it can be gleaned from the review of different study designs, there is some evidence that: (1) some evidence-based practices can be effective with Latinos, even with minimal adaptations (such as basic translations and language accommodations, as shown in RCTs reviewed) and (2) adding a tailor-made cultural adaptation to an evidence-based practice increases effectiveness of the intervention for Latinos (as shown by the meta- analysis conducted by Benish, Quintana, and Wampold, 2011). However, the review offers a mixed picture regarding the use of theory of acculturation in the design of culturally modified interventions. In spite of being acknowledged as an important factor in the lives of Latinos in the United States, the presence of any theory of acculturation informing cultural adaptations is inconsistent. A point can be made that, while the incorporation of participant feedback on “what works” from a cultural standpoint is uneven, it does nonetheless happen. What is rather absent in the literature are the voices of mental health clinicians working with Latinos.

In order to address this gap, the present study aims to give voice to mental health practitioners who work with adult Latino clients and elicit their views on the following:

(1) The extent of clinician knowledge of the concept of acculturation in the lives of

Latinos and of theories of acculturation; 76

(2) Clinician main acculturation knowledge sources (e.g. personal history, higher education, practice literature, clinical experience);

(3) The role that clinicians’ ethnic background plays in their use of acculturation theory in their practice with Latinos; and

(4) The ways in which knowledge of acculturation informs practice throughout the phases of the helping process.

This study implements a constructivist approach to grounded theory to gain an in- depth understanding of how clinicians incorporate acculturation-related variables to form a clinical case conceptualization, to identify the clinical decision-making processes that guide the clinician from assessment to termination, and to articulate the culture-specific practice behaviors considered important in order to be effective with this population.

77

Chapter 4: Research Methodology

Introduction

This chapter begins by describing the study and providing support for the use of the chosen tradition of qualitative inquiry. Following, I offer a description of the process of data collection, a detailed account of the data analysis plan and process, as well as the rationale for the chosen qualitative methodology. The chapter wraps up with an explanation of how theory is derived and constructed from the conceptual categories that emerged from the data.

Description of the Present Study

In order to explore the research questions, I used qualitative data obtained through conducting in-depth, semi-structured interviews with licensed mental health professionals with experience working with adult Latino clients in the city of Cleveland, Ohio, between

May 2018 and March 2019.

Data collection and interview guides. A semi-structured interview (Appendix

A) created for the study was administered to 10 clinicians. Participants also were invited to take part in a focus group once the individual interviews had concluded. One individual participant provided further elaboration on one of her answers and two participants agreed to participate in a group session where the emerging themes from the open coding analysis were presented to them for feedback.

The duration of the interviews ranged from 40 to 80 minutes. As anticipated, there were some follow-up questions that were not part of the interview guide, since the interviewing process is not a rigid event and often times participant responses warrant further exploration. 78

Demographic data were gathered as part of the interview. The first two interviews conducted in the study served as a pilot in order to test out the interview guide.

As a result of this, I strengthened follow-up questions to elicit clinicians’ understanding of the connection between acculturation and mental health outcomes, as well as follow- up questions referring to cultural adaptations used in practice. For instance, many clinicians identified social support as something that would favor the process of acculturation, but needed to be prompted in order to articulate how social support would impact mental health outcomes in the acculturating individual.

All interviews were audio-recorded and transcribed by the researcher (bilingual in

English and Spanish). There was a proposed plan that allowed for conducting interviews solely in Spanish, but this was not necessary as all participants were fluent in English (the

Spanish version of the interview guide can be found in Appendix A). All study documents, including the flyer advertising the study, were available in English and

Spanish.

The semi-structured interview consisted of open-ended questions that aimed to explore participant views of acculturation and their incorporation of acculturation knowledge to clinical practice. The interview started with a fictional practice scenario involving a Central American client that served as clinical footing for participants, aiming to put the interviewee at ease by starting in their area of comfort. The scenario opened by saying:

Suppose you are meeting with a Latino client for an assessment. He is an adult

from a Central American country and has lived in the United States for 2 years.

What information related to his experience as an immigrant in the United States 79

do you think is relevant to obtain in order for you to understand this person’s

mental health concerns?

This portion of the interview explored what aspects of the migration experience the participant considered to be relevant to assess in order to understand the mental health status of the client as well as what variables in the immigrant experience they thought would contribute to the client’s mental health outcomes as protective or risk factors.

The interview then moved away from the fictional vignette and shifted into an exploration of how participants conceptualized acculturation, by asking questions such as: “Can you tell me what acculturation means to you?”; how (if at all) they incorporate this knowledge into their practice with Latino clients, “In what ways does your knowledge of acculturation inform your work with clients?”; whether their knowledge source was personal experience with acculturation, higher education, or both, such as

“How did you acquire your professional knowledge of acculturation?”. The final portion of the interview focused on if and/or how they incorporated acculturation factors into their clinical practice, as well as questions that explored if and/or how their knowledge of acculturation informed their practice throughout the helping process (from assessment to termination).

Recruitment and sampling. Participants were recruited from community and private mental health settings in Cleveland, Ohio. The initially proposed number of participants was between 25 to 30, following recommendations by Creswell (2007).

However, the shortage of licensed clinicians who work with the Latino community in

Cleveland impeded this. There are very few licensed clinicians with experience working with Latino clients in the city and, once the snowball process was initiated, participants 80 struggled to provide referrals. In order to avoid a direct conflict of interest or coercive influence, I did not include any participants that I supervised at the time or in the recent past at the community mental health agency where I worked at the time of the study.

This further limited the options of potential participants. All this notwithstanding, the study sample was representative of the scarcity of mental health clinicians with expertise working with Latino clients in the Cleveland area.

Community agencies were approached by the researcher via an informational letter describing the study. Agencies willing to participate were provided a “letter of cooperation” and agreed to posting a flyer describing the study, including ways to get in touch with the researcher for those who are interested, and/or allowing the researcher to announce the study at a staff meeting. The researcher followed up with a personal phone- call or visit to those interested, using a study recruitment script. Participating agencies did not recruit participants on behalf of the researcher. Snowball sampling was used to obtain referrals through participants already recruited. Participants recruited via snowball sampling were approached by email (provided by referring participant) while adhering to the recruitment script.

In order to be eligible, participants had to meet the following criteria: (1) licensed to practice psychotherapy in the mental health field (social work, mental health counseling, psychology, psychiatry) and (2) having past or current experience working with the Latino population in the United States. Participants who agreed to participate signed an informed consent document prior to the beginning of the interview.

Client data confidentiality. Client confidentiality was maintained during interviews with clinicians by requesting that no client names be used. There was a plan 81 to change any names potentially mentioned into pseudonyms during the transcription of the interviews. However, this extra step was not needed as no client names were mentioned.

Compensation. Participants did not receive any compensation for participating in the study. Agencies and individual participants were given the option to receive a summary of the study findings and conclusions.

Storage of audio-files and other study documentation. All study records remained confidential. Participants were identified by pseudonyms that bore no resemblance to their given names. Audio-files were downloaded immediately onto a password-protected computer. Hard copies of study documents were kept in a locked cabinet at the researcher’s home.

Rationale for the Use of Qualitative Methodology

Qualitative research uses inductive data analysis, allowing the researcher to arrange and interpret the data from the bottom up in order to achieve increasingly higher levels of abstraction (Creswell, 2007). It focuses on elucidating the meanings that participants hold about the problem of study, not the understanding that the researcher gleaned from the literature review (Creswell, 2007). The qualitative research process doesn’t start with a clearly prescribed research plan; rather, it allows for changes after the researcher enters the field. It is this progression that allows for the research design to be informed by what is learned through data collection and analysis, a process known as

“emergent design” (Creswell, 2007, p. 39).

A qualitative inquiry approach is recommended when there is a problem that needs to be explored, so that key variables can then be identified and measured, or when 82 silenced voices of stakeholders need to be heard (Creswell, 2007). Also, qualitative methods are appropriate to develop theories when existing theories are fragmented or inadequate for certain populations or when they do not fully capture the depth and complexity of the phenomenon (Creswell, 2007), such as in the case of the theory of acculturation and its incorporation to mental health practice with Latinos, as discussed in the literature review chapter.

The present study used Kathy Charmaz’s constructivist approach to grounded theory, which grew out of the original work of Barney G. Glaser and Anselm L. Strauss, known as objectivist grounded theory (Charmaz, 2014). An overview of grounded theory follows.

The Grounded Theory Tradition of Qualitative Inquiry

Glaser and Strauss developed grounded theory as a means to construct theory that was grounded in data. When they published their seminal work, The Discovery of

Grounded Theory: Strategies for Qualitative Research in 1967, qualitative research in sociology was falling out of favor as quantitative approaches were gaining ground and sophistication (Charmaz, 2014). Glaser and Strauss placed great emphasis on crafting a way of knowing that was rigorous and systematic enough to challenge the prevailing view of qualitative research as “impressionistic, anecdotal, unsystematic, and biased”

(Charmaz, 2014, p. 6). In this approach, theory is derived from the data collected, not chosen beforehand, which gives the approach its name (Corbin & Strauss, 2015).

Data collection and analysis are conceived as interrelated processes. The researcher collects initial data, analyzes the data, and the concepts that emerge from the analysis, in turn, inform subsequent data collection (Corbin & Strauss, 2015). This 83 strategy is known as theoretical sampling. The authors say it clearly by stating that data collection is “controlled by the emerging theory” (Glaser & Strauss, 1967, p. 45). Also specific to this approach is the notion that the researcher samples concepts, not people

(Corbin & Strauss, 2015) in a process that gathers pertinent data that helps the researcher refine categories in the emerging theory (Charmaz, 2014). The process continues until no new material emerges, “all categories are developed, show variation and are integrated”

(Corbin & Strauss, 2015, p. 135), commonly referred to as saturation. Theoretical sampling helps the researcher sample to develop the properties of conceptual categories until no new properties emerge (Charmaz, 2014).

Constructivist Grounded Theory Approach

With the advent of postmodern thinkers in the 1990s, Glaser and Strauss’s approach was criticized as rooted in a positivistic tradition that ultimately strived for objectivity and a neutral depiction of reality. The authors were further criticized for fragmenting the stories of the participants and heavily relying on the voice of the researcher (Charmaz, 2014). While Charmaz’s approach maintained many core principles postulated by Glaser and Strauss, such as the use of inductive logic, the comparative method, theoretical sampling, emergent design, development of theoretical categories, to name a few, it departed from them in her conceptualization of the role of the researcher. Constructivism assumes multiple social realities that coexist and are constructed by many participant actors, which leads Charmaz to postulate that the researcher’s position, perspective, privileges and interactions during the research process must be considered (Charmaz, 2014). In the next section, I will provide detail about the constructivist grounded theory methodology as it was applied during data analysis. 84

Data Analysis

Data were uploaded to Atlas.ti (version 8), a qualitative data software program that was used to organize text files (interview transcripts), identify significant passages and label (code) them, compare data, and create and store memos with ideas that emanated from the data analysis process. The program does not perform any analyses per se, but helps the researcher organize and sort through the raw data through the analytical process.

Following the loading of the transcripts into Atlas.ti, the text files were assigned to a Hermeneutic Unit (HU), which can be thought of as a central storage location for the study material within Atlas.ti. The different transcripts contained by the HU are called

Primary Documents, or P-Docs. The P-Docs manager functionality in Atlas.ti allows the analyst to assign P-Docs to “families”, which facilitates certain analyses where it’s important to make comparisons by certain characteristics. For example, in the study, part of the analysis required to separate clinicians in two groups, using place of birth as a proxy of level of acculturation, in order to analyze differences in their responses. Once the documents were uploaded, the process of coding and memoing began.

Memoing and coding. Memos are notes that reflect the researcher’s thinking while analyzing the raw data. They are a written note the researcher keeps of analyses (Corbin

& Strauss, 2015) and help the analyst to stop and think about ideas about the codes as well as relationships between these ideas (Charmaz, 2014). Each memo is dated and has a title, usually signifying a concept. For instance, in a memo entitled “The telling of the story,” I captured the following:

The telling of the story is important, how things are said is important; Latino clients 85

are more detail-rich in their reports. Good cultural attunement on the part of the

clinician entails that they understand the importance of that, that they are flexible and

adjust their intervention approach and/or style to fit the need that the client has of

telling the story.

While there are no prescriptions about how to write memos, there are some useful guidelines set forth by Charmaz for the analyst to follow when writing early memos.

Among the guidelines are that memos try to capture what is going on in the field or within the interview account; such as what participants are doing and/or saying or what connections can be made about the information gathered.

Coding is the delineation of concepts in the process of interpreting the meaning of the data and provides the scaffolding for the analysis (Charmaz, 2014). Coding, in essence, is labeling the data in order to describe it. There are two phases in the coding process, known as open (or initial) coding and focused coding (Charmaz, 2014). The next section explains the coding procedure and describes how it occurred in the analysis process.

Open coding. This type of coding is the initial phase of the coding process. It can be done word-by-word, line-by-line, or incident-by-incident. Word-by-word coding focuses on subtle nuances, such as choice of words, images, meaning, and flow. According to

Charmaz (2014), this type of coding could be useful when analyzing documents of a certain time period, and therefore not particularly meaningful in the present study. Line- by-line coding is useful in early coding, as it can help identify explicit and implicit statements or concerns, and could also prove useful to refocus later interviews as the research process progresses (Charmaz, 2014). Incident-by-incident coding is related to 86 line-by-line coding, but labels larger portions of the data. Incident-by-incident coding is helpful for situations that line-by-line coding cannot capture, such as a behavioral depiction of people’s actions.

Codes in qualitative research are created inductively. I started without preconceived conceptual categories and followed a recommendation by Charmaz to stay close to the data and capture participants’ behaviors, attitudes, and understanding of phenomena.

One useful strategy to pursue this was to do in vivo coding by labeling the data using the participants’ own words to preserve “participants’ meanings of their views… in the coding itself” (Charmaz, 2014, p. 134). In vivo codes are grounded in the data but are not meant to remain in this initial state. While, in fact, many of these initial codes may evolve and several may be eliminated, they serve the fundamental purpose of organizing the data in segments that may later be refined as conceptual categories that explicate views and behaviors. Some helpful questions to ask at this stage of analysis to help move the process forward are: “What process is at issue here? How can I define it?”; “How does the process develop?”; What are the consequences of the process?” (Charmaz, 2014, p. 127).

Another important part of the analytic process is to develop and organize the codebook. The codebook is the way in which Atlas.ti stores codes as they are created.

After the first round of open coding, some codes were combined because they were similar in essence, for example “feeling despair” and “feeling powerlessness” were merged into “feeling despair”. The codebook was further organized in categories where codes were assigned to groups. This takes the analysis a conceptual step above in vivo coding because it requires that open codes be organized according to themes or ideas that 87 they represent. For example, some of the initial code groups created were related to how participants conceptualized acculturation. The code group “acculturation definition” contained open codes that captured participants’ understanding of acculturation as a phenomenon. I also created subgroups in cases where it was important to structure the data within a code group to ensure that some subcategories were easily distinguishable.

By assigning prefixes to the code name, I took advantage of Atlas.ti’s alphabetical sorting default setting and ensured the necessary subgroupings. For example, I structured the code group “assessment” that contained some codes referring to both risk and protective factors for mental health outcomes by adding the prefix “Risk” and “Prot” in front of the codes that participants had indicated as important to assess in order to determine risk or protective factors.

Focused coding. This phase in the coding process was achieved after completion of open coding and restructuring the codebook. Focused codes are derived from the examination of both the most frequent and/or significant codes of the earlier phase and serve the purpose of determining which of the open codes make the most analytic sense; i.e., fit the data best (Charmaz, 2014). Some of the questions Charmaz suggests as helpful to define focused codes are: “In which ways might your initial codes reveal patterns?”; “Which of these codes best account for the data?”; “What do your comparisons between codes indicate?” The process that goes from open to focused coding is by no means linear and it is not uncommon to revisit earlier open codes and data, as newer statements and incidents will help uncover meanings that were not evident earlier in the process (Charmaz, 2014). Examples of focused coding in the present study were conceptual categories “culture-specific clinician factors” and “culture-unrelated 88 clinician factors” that emerged from initial codes that described what behaviors and attitudes participants viewed as helpful in their clinical stance with Latino clients.

Second coder. To add robustness to the analytic process, my dissertation co-chair, who has extensive experience as a qualitative researcher, functioned as a second coder.

As such, she reviewed the first three interview transcripts and provided feedback on the emerging themes as well as on the overall flow of the interview process. This process occurred before I completed the coding of the rest of the interviews independently.

Member-checking. Once the first round of open coding was completed, I used the strategy of member-checking to elicit feedback from participants about emerging themes.

Member-checking is a process that allows the researcher to go back to participants to gather their feedback about ideas that develop in the process of data analysis, as well as to gather further material to refine conceptual categories (Charmaz, 2014). Participants were made aware during informed consent of the possibility of taking part in this practice and agreed to it at that time. I reached out to the whole group of participants by email and invited them to participate in the process of member-checking individually or in group.

Constant comparative method. Finally, another important strategy in the analytic process is the comparison of emerging codes and conceptual categories across interviews and not only within each individual interview transcript. Constant comparisons allow the inductive method to proceed through comparing “data with data, data with code, code with code, code with category, category with category, and category with concept”

(Charmaz, 2014, p.342). It is this process that allows the researcher to decide when data saturation occurs, i.e., when no further properties or new ideas emerge from the data 89

(Charmaz, 2014).

Constructing the Theory

Following Charmaz (2014), the result of the proposed analytical process will be the elaboration of a theoretical framework or substantive-level theory. As the theory emerges and solidifies, major modifications become fewer. More advanced modifications are mainly about clarifying a logical order, eliminating properties that appear to be irrelevant, adding detail to an outline of interrelated categories and, reduction. Reduction is the process by which theoretical concepts are distilled, such as in instances where underlying commonalities in the original categories or their properties are discovered (Glaser & Strauss, 2008). Also critical at this stage is the notion of theoretical saturation. After coding incidents for the same category repeatedly, the analyst recognizes whether the next incident adds anything new to the category. (Glaser

& Strauss, 2008).

Through each phase of the coding process the inductive method produces fully saturated conceptual categories, and relationships and links between categories are postulated and come together in an interrelated explanatory model. The substantive-level theory (also referred to as middle-range theory) aims to reflect the problem studied in an accurate way (Glaser & Strauss, 2008).

In this study, this approach to theory building was used to develop an explanatory framework to understand how clinicians who work with the Latino population use knowledge of acculturation to inform their clinical practice. Use of a graphic depiction of conceptual categories and their dynamic interaction and linkages was a useful strategy that I employed which allowed me to identify relationships between concepts as I 90 conducted my analysis. Diagramming is also recommended as a strategy by Charmaz

(Charmaz, 2014, p. 218). Useful questions to ask in the process of constructing the theory are suggested by the author, such as: “How does the researcher observe the explicatory processes emerge?”, “How do participants’ actions construct those processes?” and “What are the different meanings that participants assign to the processes?” (Charmaz, 2014, p. 34). These guidelines were employed in the process of theory development.

Reflexivity

In qualitative research, reflexivity is the process by which the analyst scrutinizes how he/she brings their own selves into the process of research. It involves examining one’s assumptions about the inquiry, one’s interests and positions, and being aware and explicit about how they influence the inquiry (Charmaz, 2014).

The practice of memo-writing was employed throughout the analytic process.

This key strategy in qualitative research straddles the line between data collection and drafting the research report (Charmaz, 2014). As I conducted the analysis, memo-writing was a welcomed opportunity to capture my thoughts about the data, elaborate on possible connections between concepts while it helped illuminate what direction to take. The analytic process would not be otherwise possible without the spontaneity of memo- writing that allowed me to engage in a dialogue with myself about the data. It also gave me the opportunity to step back, observe and explore preconceptions, values, judgment, and even emotional material that was activated by my interaction with the data. For example, early on in the process of coding, the category of being “the other” in Latino 91 clinicians’ experience started to emerge. I wrote a memo titled “Otherness” that captured a commonality in the experience of these clinicians:

For foreign-born Latino clinicians, the experience of acculturation appears to be

more striking and of a sudden nature; they are not used to seeing themselves as

‘the other’ outside of the United States. It’s important to explore whether

clinician's own stage of acculturation may also impact his/her own ability to

understand where clients may be in their own process. Clinician's self-assessment

could be important.

Another strategy I used throughout the process was journaling. Journal entries can be used to jot down methodological dilemmas and decisions, as well as be used as a tool for personal reflexivity. Keeping a journal is recommended as a way to avoid

“preconceiving” the data (Charmaz, 2014). Charmaz offers an interesting take on the problem of adhering to the old axiom of “starting where you are at” because it may skip over the examination of where one really is in terms of assumptions about the data. As I am part of that group of foreign-born clinicians talked about in memo on “Otherness”, I journaled about that commonality of experience. I captured the observation of how my journey as an immigrant and foreign-born clinician could bias my interpretation of the data, which increased my awareness and allowed me to put that personal experience to the side to focus on what my participants were saying about their experience. I approached journaling with a spirit of curiosity and strived to keep what mindfulness meditation calls a “beginner’s mind,” observing and describing my own process through the research, non-judgmentally. While it is certainly not possible to excise my own subjectivity from the analytic process, journaling and memo-writing helped ensure that 92 previous assumptions and preconceptions did not dominate the analysis. Charmaz also recommends that a way to “test” whether a certain interpretation of the data is not supported by it is to go back to the data and see if the preconception is grounded in it.

Position of the Researcher

I entered the field with an awareness of my personal and professional proximity to the subject of study, as a foreign-born clinician of Latino descent myself. I was born in

Buenos Aires, Argentina, to parents of European descent and different religious backgrounds. My first experience being “the other” goes back to a religious affiliation dilemma. I was offered religious freedom by my parents but, like most children, I wanted to “fit in,” which led to a period of religious identity struggle before I came to my own decision. I can relate to the experience of being different in this sense. Being different often meant not being able to participate, being left out. I often hear from my Latino clients today how being different has resulted in oppression for them. While I did not experience oppression due to my ethnic or religious background growing up, oppression was present for me as a gender issue. Latino culture, even in a large, cosmopolitan city like Buenos Aires, assigned clear gender roles consistent with traditional male/female role expectations.

The different intersecting identities that shaped me both helped and hindered my acculturation process in the United States. I gained in the realm of gender oppression.

The United States felt freeing with a more egalitarian and flexible distribution of gender expectations. In terms of cultural identity, I distinctly remember walking into my first clinical job in a naïve state of “cultural blindness,” assuming that being from Latin

America and speaking Spanish was all I needed. It quickly became apparent that my way 93 of being a Latina didn’t have much in common with the Latino subgroup I was assigned to work. It is possible that being an educated Latina of European descent served as common ground for me to enter into the mainstream. The paradox was that, while I did not feel immediately othered by the mainstream because of my ethnicity, I felt different from the first Latino clients with whom I worked. I had very little in common with the

Caribbean culture they mostly came from and I had to learn about it. It was unexpected and perplexing. It taught me to use the common language as a bridge with my clients, to keep my assumptions about their cultural background in check, and to adopt a curious attitude.

All of these personal and professional variables helped me relate to the interviewees and build an early rapport during the interviews. I was not surprised by the extent to which clinicians did not recall having much exposure to the concept of acculturation in higher education and had to figure out in practice what to make of it, as that was also my experience in higher education in the United States. On the other hand,

I was truly surprised by the emerging trend within foreign-born clinicians that indicated the possibility that they were aware of cultural factors in the therapeutic relationship, as that has not been my professional experience as a foreign-born clinician.

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Chapter 5: Results

Introduction

This chapter begins with a description of the demographic composition of the sample, followed by a presentation of the results organized by research question.

Comparisons between subsets of the participants are also included, when relevant. The presentation by research question includes the conceptual categories (codes) that emerged in the analytical process, description of the main findings illustrated by data (quotes), as well as their integration into a substantive level theory. A description of the member- checking strategy with examples is presented after the main findings. The chapter concludes with the presentation of the conceptual categories integrated into a grounded theory on the clinical use of acculturation in practice.

Sample Description and Final Codebook

The sample consisted of 10 licensed clinicians with experience working with adult Latino clients. Eight of the 10 were female. All but one reported Latino ethnicity.

Among clinicians of Latino ethnicity, two-thirds reported Puerto Rican descent and the remaining third were of Central or South American descent (33%). Seven participants self-identified as “Multiracial” and three as “White.” Seven of the respondents were born in the United States and the rest in Puerto Rico, Guatemala and Peru. For foreign-born clinicians, the age of arrival to the United States ranged from 12 to 42 years old (M = 20).

Nine participants were bilingual in English and Spanish. Of them, three identified

Spanish as their primary language. As for their clinical practice status at the time of the interview, all but one were active in direct practice, with four individuals dividing their time between direct practice and administration. While both community and private 95 practice settings were represented in the sample, the majority of the sample practiced in a community setting. Eighty percent of participants held social work licensure and all had completed at least the master’s level of training. Years in practice ranged from 5.5 to 40 years (M = 24). Of the active clinicians, roughly half had caseloads with a majority of

Latino clients and the rest provided estimates that ranged between 1 and 15% Latino clients on their caseloads. Of note, the majority of the clinicians with a small percentage of Latino clients at the time of the interview reported having had caseloads with majority

Latino clients in the past.

Final codebook. At the end of the coding process, the codebook consisted of a total of 52 codes grouped in 9 code families, with the exception of 2 standalone codes.

The complete codebook including a brief description of each conceptual dimension can be found in Appendix B.

Research question 1: How do mental health practitioners conceptualize the concept and process of acculturation?

Several codes emerged that captured participants’ views of acculturation, organized in two code groups: “acculturation definition” (explored through a direct question about how they defined acculturation) and “acculturation mechanisms” (how participants thought acculturation happened).

Acculturation Definition. There was a total of 7 conceptual dimensions retained in this code group (depicted in Table 5.1). Each code will be presented separately using quotes from participants that lent support to the conceptual dimension. This format will be followed throughout the chapter.

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Table 5.1 Acculturation definition Code # of quotes linked Used by to code (% participants) Adapting to a different environment 24 100

Keeping cultural core and learning to negotiate 20 70 new environment Learning about differences 17 80 Deciding whether to embrace the culture 2 20 Assimilating to the main culture 2 20 Making bridges 2 20 Finding balance between cultures 2 10

Adapting to a different environment. Environment was referred to as a multifaceted concept, encompassing physical, social, and normative dimensions:

Oh, that’s a big word! It’s basically adapting to a host society, a host country. It’s

where you have moved to an environment that’s not your natural environment, a

different language is spoken, it’s not your native culture. Acculturation is being

able to adapt to a different environment.

As an immigrant you are exposed to a lot of different things and you start

identifying what are these things you need in order to feel more adjusted to this

environment and you start incorporating things you feel are going to shape the

way you are going to function in this new environment.

I think it means what it takes for someone to acclimate to a new environment, to

become one with that environment, usually from another country, where the 97

language is different, customs are different, the attitudes are different. It’s getting

used to that and adapting to it, so that they can fit in, be part of the group, part of

this new world.

The next quotation conveys the multidimensional nature of the adaptation process: “Acculturation is being able to adapt to a different environment. That means the language, being able to communicate, being able to adapt to other norms, resources, the different family roles, family structure, employment, basic needs.”

The next two participants discuss more obvious aspects of the process of acculturation, such as adjusting to different clothing or foods, but also other subtle facets, such as the concept of time and driving etiquette:

Some families that come from Puerto Rico to the United States, they tend to be

acculturated in that they live a fast-paced life. They become more attuned to time,

this is the way Americans do it, be always on time, because that’s a fact with

Hispanics that they are always late. They realize how important it is in the

American way of living, how important time is, they become more sensitive to it.

Acculturation is identifying with the culture that you are adapting to. So,

American culture, living the American lifestyle, they are doing things that most

people are doing here in the United States, the acculturation of foods, dress wear,

the way people drive, just the way of life, you become more similar to the

mainstream. 98

The voice of another participant expressed a sense of critical urgency as part of the process of acculturation: “Survival, I guess. Because you want to be accepted, it’s that critical. You have to adapt to what’s the norm to be accepted.”

Keeping cultural core and learning to negotiate new environment. A U.S.- born Latino participant described what she saw as the essence of acculturation:

I look at acculturation as the salad bowl, and that is to be able to come here and

still hold on to the core of who you are, which, for Latinos, is our Latinoness, but

at the same time maneuver the system… you still have your own identity, you

don’t lose your identity. I look at that as acculturation. And I don’t think it only

happens to people who are immigrants, I think as Latinos, period, we go through

acculturation. There’s no one way to try to hold on, against all odds, against the

stares when you speak Spanish, against the negativity, discrimination. You learn

how to maneuver in this American society but at the same time you hold on to

who you are. To me, that’s what acculturation is.

In the next excerpt, a foreign-born clinician highlights that acculturation is not an achievable outcome but rather an ongoing dynamic process:

But even then there would be times when I felt like I hadn’t reached, it kind of

feels like you never reach that part when you say “Yes, I am acculturated and I

can say I’m American,” because there are all these pulls that happen between your

heritage, people, your family, there’s this pull that you want to still be connected

to your own roots and not forget about that, as well. So, it’s like this dance back

and forth. 99

Another U.S.-born Latino participant extends this concept and adds the dimension of problems that may arise if individuals depart from their “cultural core” too drastically:

I think you might not even realize it happens, just by being forced to face

situations. I think that problems arise when you want to keep doing things the

same way. And finding a balance, how much do you keep of where you came

from and how much do you have to adapt to. Because, also, letting go of

everything puts you more at risk of being vulnerable, fragile, not having your

foundation.

The process of acculturation also entails being open to the experience and a level of trust that the process will be beneficial, as expressed by a foreign-born participant:

Again, it has to do with the degree of openness that the person has. Openness and

strength, and to not feel threatened that you are going to lose yourself by learning

new things. Those are the seeds. And then go out, learn, go to school, take

classes, make friends with people from the host culture, go to the church, the

community center, where they have parties and religious services in English. You

can go to the ones in your own language because it may touch you more, but be

open to learn other things and actively pursue them.

Learning about differences. The process was frequently viewed as one of

“learning about differences.” In all the incidences coded, clinicians noted an intentional aspect of the acculturation process on the part of the acculturating individual. Discovery and learning were emphasized in these quotations: 100

It is a process, you learn this along the way, you are discovering new things and

you start realizing there are some things you need to incorporate in order to

function well or succeed;” “You see the differences and you educate yourself on

the differences, you know your culture and the mainstream culture and you sort of

make a blend.”

Another participant expanded this concept by adding how an intentional openness to the culture can result in personal enrichment: “The person that’s more open, that comes to the host country and wants to learn from that country, borrows from his country and borrows from the new country and mixes it, creates something richer”

One participant provided a rich example from his own experience that speaks to this process of “learning about differences” in a cultural exchange:

…somehow getting a read of how things appear to work around here. I had an

experience that reminded me of acculturation. I was in North Carolina for a

wedding recently and, most of my life, if I hear a conversation within earshot, I

sometimes join in, and usually people are okay about it and sometimes people are

kind of, you can see something going on, but here I was, at this wedding, and I

said something when two women were talking, they kind of looked at each other,

smiled, and they went back to talking to each other. And I said, “That’s not

allowed here.” And then I had another angle on it. I was talking to somebody

and this man… was off to the side and, when we got to kind of a natural

conclusion with this, I looked and kind of invited him in, and he spoke. And I

realized he waited to be invited in and I thought, “I’ve had very little exposure to

the Southern part of the country.” Those are little subtle acculturations that any 101

one individual coming in may pick some of them up and be oblivious to the

others. And we never know when one is going to be so significant that it throws

you or it rules you out for something.

Assimilating to the main culture; finding balance between cultures; and deciding to embrace the culture. These codes had fewer incidences but were retained because they contributed new layers of meaning to the overall conceptual category. The characterization of acculturation as assimilation emerged in two quotes that contradicted each other:

I think acculturation is the process of learning the know-how of a new culture

without losing your own, without losing your identity. I want to make the

distinction between acculturation and assimilation. When you assimilate, you

give up your background, you give up your practices. You become one with the

host culture. But, acculturation, I could be wrong, is the process of learning that

new culture and learning how to navigate, know the know-how, how to act, how

to navigate, how to function in a new culture without losing your identity, without

losing your cultural practices.

It has something to do with culture, like assimilating to the main culture where

you live… Maybe your view of the culture, whether it’s a culture you want to

embrace or not… I think it depends on the person and their view of their culture

versus the view of the dominant culture, but I think it’s also based on their

experience, whether they want to assimilate or not.

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Participants conceptualized the idea of “finding balance between cultures.” This participant emphasizes an intentional aspect of this search for balance:

[There are] things that I don’t want to change. I am Latino forever. I want to be a

Latino, no matter how long I will remain here. I think how I found a balance is

that I try to enjoy what I’m doing right now, I mean personally. I try to be part of

a lot of activities from this culture, but also at the same time I try to keep my own

traditions, even with my friends or people from the same culture I am. But I’m

also curious about being part of the new things or people I meet.

In the words of this participant, working on finding balance between cultures can have positive and negative aspects:

Being from a different culture, coming here and learning day by day different

things, it gave me a sense of confidence and a sense of belonging. Of course, that

made me feel good. It is not easy, I still question some things. When I go back

home and I come here, it’s hard to switch, sometimes is which country do I

belong in? I try to find the balance between both cultures. I think emotionally it

has been very challenging.

The next quote was linked to “deciding whether to embrace the culture.” This code captures the decisions the acculturating individual has to make about embracing the other culture − the intentional element of the process. This participant expands on the positive and negative aspects of the process and emphasizes how complex it can be to know how much of a given culture a person may need and even how much to pass on to younger generations: 103

One of the difficulties, the dangers of acculturation, is how much and where you

find the balance, because if you cut the connection to your past and your culture,

that affects then the ability to provide stability to your kids and your own sense of

self-esteem and who you are. How can you find a balance of trying to raise kids

in English limits then how you can communicate, what you pass on to them, what

you understand from them, so is it okay to speak to them in Spanish and have the

kids who are learning to speak Spanish speak back to you because, if they are not

speaking back to you, are you understanding everything? So, it’s finding the

balance of how much you adapt to the new culture and how much do you keep

and how much you pass on.

Acculturation Mechanisms. In response to the question of how they thought the process of acculturation took place, seven concepts were identified, as shown in Table 5.2.

Table 5.2 Acculturation mechanisms Code # of quotes linked Used by to code (% participants) Through time 15 100 Through being between two worlds 9 50 Through osmosis 8 60 Through strong connection to family of origin 4 30 Through incorporation of new language 3 30 Through blending in 3 30

Through time; through being between two worlds; and through osmosis. The temporal dimension of acculturation as a process was raised by all participants. The following quotes illustrate the temporal dimension of the process: “Well, it happens through time, you know, it happens through blending in, understanding that you live in two societies, your own cultural background and the mainstream.” In the words of 104 another participant: “I think it is a process, something that happens little by little, you know, the experience the person has here and how much they want to adapt or assimilate, trying to find another word, conform, to the new culture.” The next quote expands on this concept:

I don’t think there’s one way in which acculturation happens, it happens at

different levels, over time, you gradually learn the system and you take on pieces

and there are pieces you don’t take on. I think there are different levels because

some people take on more pieces than others and some people take on the whole

piece. I don’t think there is a formula for acculturation, it’s a very individually-

based process.

Another facet of the process was captured by the code “through living in two worlds,” as expressed by this participant: “Understanding that you live in two societies, your own cultural background and the mainstream. You see the differences and you educate yourself on the differences.” Another participant used the example of acculturation in children to illustrate this mechanism:

We can see this a lot in children, when they go to school, for example. They

discover the food is different and they prefer to have, you know, the food that

his/her peers are eating. At home, they can have the typical dishes, but when they

are at school it’s a different story. The way they dress, for example, idiomatic

expressions they start using. So, they are, you know, between two different

worlds. I think for kids it is more noticeable, we can see it in kids more often than

in adults. 105

The idea that acculturation also happens in an unintentional way, “through osmosis,” is conveyed by these excerpts:

You see the differences and you educate yourself on the differences, you know

your culture and the mainstream culture and you sort of make a blend, make it

work through osmosis almost, through learning, through interactions, through

explorations, it’s a life-span process.

It’s like a kid learning how to ride a bike or how to walk. They need to learn a

new language, new streets, how to get (to) places, how to negotiate, how to get

their needs met, how to ask for things, probably with a lot of help from other

people that came before them.

So, they become more aware and suddenly make those changes, very subtle, and

then they start realizing those changes in themselves when they go back home to

visit, hey this is different, it’s supposed to be this way, subtle changes throughout

the years.

I think it happened as a process, I don’t think there was one point where I said

“I’m acculturated, I know about acculturation.” I think it’s in bits and pieces,

different stages of my life where sometimes I have felt that I have been able to

feel like I fit in, I feel comfortable, that these are my roots and I identify with

certain things or feel that sense of community. I guess also seeing how

comfortable I am with other people who are predominantly from the U.S. and that

have been born here has been an indicator for me. 106

Through a strong connection with family of origin. Three of the participants viewed a strong connection to the family of origin, as a conducive part of the process:

In my family. My parents moved from Puerto Rico to Cleveland for a better life.

I was very young so I was able to pick up my native language and the English

language. So, I learned through my personal experience that we were different

from mainstream society, we were very different in the language, in the culture, in

family, kinship, roles… But, the foundation for success in any acculturation, I

think, is family, family connectedness, family bonding, which is the critical point

in our Latino culture, the kinship.

… because if you don’t have roots, as humans we need to know where we came

from and to have that sense of self, that’s where you came from, that’s where you

got your initial message of what’s important, who you are, how to function in the

world.

Through incorporation of new language. The acquisition of English language was mentioned as a valuable tool in the process of acculturation:

One thing could be the use of language, even if they are (inaudible) to English

they interchange, you know, they speak in English and sometimes they go back to

Spanish. Some people sometimes, even if they live in a neighborhood that is

predominantly Hispanic, they try to move for social things out of that area… in

order to become more knowledgeable about the new culture, for example. The

same thing with children, you know, the way they start introducing idiomatic 107

expressions in their language, things that help them get to know the other culture

and become more, not adjusted, but trying to be more comfortable in a different

environment.

The person that’s more open, that comes to the host country and wants to learn

from that country… is the one that fares better. The one that isolates and wants to

stay only with his culture, speaking his language, doing only the cultural practices

of their country, are the ones that don’t fare that well.

Through blending in. This concept was retained as a code, even though it had low frequency of coded incidences, because it captures an important facet of the process.

Blending in entailed being open to the cultural exchange, both intentionally and not, as conveyed in the following quotations:

… it happens through blending in, understanding that you live in two societies,

your own cultural background and the mainstream. You see the differences and

you educate yourself on the differences, you know your culture and the

mainstream culture and you sort of make a blend…

We can see this a lot in children, when they go to school, for example. They

discover the food is different and they prefer to have, you know, the food that his

or her peers are eating. At home, they can have the typical dishes but, when they

are at school, it’s a different story. The way they dress, for example, idiomatic

expressions they start using.

108

One participant expressed a view that suggested the process of blending in could go as far as to conform with the new culture: “I think it is a process, something that happens little by little, you know, the experience the person has here and how much they want to adapt or assimilate, trying to find another word, conform to the new culture.”

Substantive-level Theory: Conceptualization of Acculturation and How it Takes

Place

Acculturation for Latino individuals is viewed as a process that entails an exchange between Latino (cultural core) and mainstream U.S. culture (new environment).

Acculturation is viewed as a process of a learning nature (acquisition of mainstream cultural norms and language) whereby the individual is seeking to reach a balance between cultures, something that happens both on voluntary and involuntary levels. The process of acculturation is viewed as taking place along a longitudinal temporal dimension and rooted in the individual’s connection to the culture of their family of origin. Voluntary and involuntary aspects of the process also play a role in how the individual transacts with the other cultural system and uses cultural tools, such as learning the new language or reaching different degrees of blending in.

Research Question 2: What are the Sources of Clinicians’ Knowledge of

Acculturation? Which Sources of Knowledge are Engaged more often? and Why?

The majority of the participants endorsed having gained knowledge of acculturation through combinations from three sources: higher education (undergraduate and graduate education), clinical practice, and their own personal experience. These most quoted sources were grouped into 3 codes and labeled as “acculturation knowledge sources” (Table 5.3). An analysis of the code co-occurrence within this code group 109 showed that clinical practice and personal experience co-occurred in 7 quotes, followed by 4 co-occurrences between higher education and personal experience, and 2 occurrences between higher education and clinical practice.

Table 5.3 Acculturation knowledge sources Code # of quotes Used by linked to (% code participants) Learning about acculturation in higher education 14 70 Learning about acculturation in practice 13 70 Learning about acculturation through own experience 13 70

In their descriptions of learning about acculturation in higher education, the majority of the clinicians in the sample, regardless of nativity status, highlighted they had not been aware of the concept prior to that point in their lives:

When I was growing up Latina, it was nothing that my parents talked about. To

them it was: “You speak Spanish in the home and you speak English outside.” We

definitely kept all our traditions, which we still keep, but the whole concept of

acculturation, that’s an American-made name, American terminology, maybe

social work terminology. I probably saw it at the college level.

No specific theory or framework of acculturation was recalled, but often times participants presented the topic of cultural competency as something they had exposure to in undergraduate or graduate programs, as described in the next three quotes:

A few classes that talked about acculturation in grad school. There wasn’t too

much emphasis. Undergrad I had some, but I don’t think a lot, not enough 110 emphasis… I think more general… I think they put more emphasis on cultural competency, to be more aware of somebody’s culture before providing services.

It started with the sociology course and, then, it was learning it from the work with the families. Oh, very important, when I started practicing… this issue of acculturation and doing culturally competent therapy was unavailable. That concept was not present in everyday life. Therapy was done according to some therapy standards, but not taking into consideration the process of acculturation or including culture. At that point, I was working exclusively with Latinos. So, in their struggle, I learned. But we were not thinking in these terms. It wasn’t until I got to Ohio, thirty years ago, that we then had cultural models and conceptualizations, professional, educational, systemic concepts to understand this.

I think it goes back to college, that’s when I think I was awoken, being Latino and identifying as American, what that was, and having that privilege of having resources to go to college versus seeing friends who didn’t have an easy ride to go to school and they had to pay for all of their schooling… I think I learned a lot more about acculturation once I started my concentration in social work and how you learn that, in order to be successful helping others, you have to be able to understand where they are coming from, learn about their culture, so that you can be able to understand what their barriers are.

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The responses that reflected learning about acculturation through clinical practice and personal experience, as mentioned above, were often intertwined, as this clinician eloquently describes:

Oh my God, years ago, when I started working with Latino families, and I learned

more when I had to teach it, when I had to give workshops, and when I started

evaluating my own acculturation, my own struggle, my own path. And the person

who really, really helped me with the process was Isabel Allende, who is not a

therapist… but she talks a lot about the process of migration, acculturation, and

how she dealt with it. And when she talked about her own process it was like

doors opened for me, because then I could verbalize, I could put words to my own

process.

The combination of the personal and the professional as sources of knowledge was also conveyed by these participants:

Well, it’s hard to say. It just happened through my own personal evolution. I’ve

always lived in both worlds, the Anglo and the Hispanic/Latino culture, I’ve

naturally been acclimated to both worlds. Professionally, I’ve been with this

agency for a long time. As you know, we specifically serve the Latino/Hispanic

population, we are all bilingual here.

I think in the practice, it’s a way of living. In my experience, I learned that when I

came here because, back home, I didn’t have any idea about it… I used to never

think about it back home. Even though my country… is a very diverse, vast 112

country, but we didn’t see, we didn’t talk, probably there are of course

differences, but we didn’t talk about it, it is not a big issue.

I think it’s a mixture of both, because my experience is in the room, too, and you

don’t want that to get in the way, but it’s there, and I think it’s a bit of both,

knowing what I went through plus what I learned from school. I try to balance

both.

I’d say a little bit of both. I carry myself in a way that’s more sensitive and more

aware of people’s culture, because I always feel culture is so important for each

individual and each individual’s experience and history is different, being aware

of that is important when delivering services.

Six clinicians endorsed relying on their personal experience of acculturation as the preferred source of knowledge that informs their clinical practice. While clinicians may not disclose to their clients explicitly that they are drawing from their own experience as source of knowledge, they value this way of knowing because it entails a commonality of experience with their clients, facilitating a genuine connection. Here’s a quote by a participant who identified his preference unequivocally: “The personal knowledge, not even close. You have to give yourself, because they recognize that.

They have to see that you are invested in who you are to help people. Genuineness counts”

Another participant raised doubts about the extent to which practitioners use formal knowledge and was concerned with how often practitioners are not open to new information: “I think I use the personal experience more and I really value that I 113 happened to have that developed in me… Unfortunately, when schools do the diversity stuff… I hear people complain about it. I don’t mean stop doing it, what I mean is that our confirmation bias is such that, no matter what we say, people will find a way to negate it.”

This Latino clinician relies on the commonality of personal experience with her clients as a privileged way of fostering connection:

Personal, for sure. I mean, it’s good to know, but I’d say personal… Because

that’s my experience and I think that my experience is their experience. I think

that’s what makes us good clinicians, that we are Latino. I think that is part of

being good clinicians, that we are Latino and we know the experience, as opposed

to somebody who just knows Spanish. Don’t get me wrong, I appreciate people

who are not Latino and know Spanish and work with the community, but I think

that when you talk about your personal experience, when you’ve been through it,

been there done that, it’s much different. I know a lot of book knowledge and I

probably apply both, but the one I most use is personal. I think that, if I use the

professional, we wouldn’t be who we are as a program and I think we are a very

good program that really is in tune and adheres to our clients’ needs. If we went

strictly by book knowledge, I don’t think we’d be the program that we are.

This next clinician’s answer was in partial agreement with the previous quote in regards to the value of using personal experience. Her own experience was viewed as instrumental in making a connection with the client’s experience and in helping the client make sense of their own process, but with stricter boundaries around self-disclosure: 114

Both. But, I often use my own personal experience but I don’t label it as such. I

reveal very little about my personal life and my personal journey, but I might use

it, talk about it, without ever identifying where it comes from.

Finally, this Latino clinician reflects on how she engages personal experience to promote engagement and understanding:

I think I go with my gut and use a little more of my personal (story) in dealing

with Latinos… Because I think there’s a lot of similarities, there’s things I’ve

gone through or I’ve seen friends and family members go through, so it’s a lot

easier to empathize, understand or help them understand when they are going

through situations.

Substantive-Level Theory: Sources of Acculturation Knowledge and their Role in

Informing Clinical Practice

The culture exchange process that clinicians experienced in their personal lives is viewed as the preferred source of knowledge. Clinicians use the knowledge of acculturation acquired in practice serving as a second privileged source of knowledge.

Clinician’s own experience is prioritized because it is perceived as genuine and it provides a direct empathic connection with clients who are going through the process of acculturation themselves. The clinician’s personal experience with acculturation, in turn, interacts with the clients’ experience, a process that takes place in the therapeutic space.

Finally, knowledge of acculturation acquired through higher education is often the first point of contact with the subject matter, particularly for Latino clinicians who straddled two cultures. This source of knowledge is incorporated to practice to a lesser extent. 115

Research Question 3: In what ways does knowledge of acculturation inform clinical practice and how does this vary based on clinicians’ acculturation level?

In order to explore this question, participants were asked to articulate how they incorporate knowledge of acculturation to their practice with Latino clients. Participants of Latino descent, in particular, were asked to expand on their views and to build on previous answers about the use of personal versus academic knowledge sources. The original plan was to compare Latino clinicians versus non-Latino clinicians. However, due to Latino ethnicity being over-represented in the sample, a meaningful comparison between Latino and non-Latino clinicians was not possible. Responses were first analyzed for the sample as a whole, followed by a comparison based on clinicians’ nativity status (U.S-born vs. Foreign-born), which is one of the commonly used proxies for acculturation level.

When looking at the sample as a whole, answers coalesced around what participants considered to be effective clinical practices in their work with Latino clients with varying levels of acculturation and how clinicians’ own ethnic background intersected with these practices. These initial codes were further refined into 2 conceptual categories or code groups: “culture-related clinician factors” and “culture- unrelated clinician factors.” The first code group captured clinical attributes conducive to building a strong therapeutic relationship that were not uniquely tied to Latino culture, such as “approaching client with cultural sensitivity,” “approaching client with dignity and respect,” “interest in learning about the client’s culture,” “approaching client with unconditional positive regard,” and “promoting trust” (Table 5.4). The latter group included codes that captured culture-specific attributes viewed as important to build 116 therapeutic rapport with Latino clients along the acculturation spectrum, such as “being

Latino helps therapeutic connection,” “being bilingual helps,” “being directive,” “being flexible,” “being seen as the expert,” and “having no problem being called family” (Table

5.4).

Table 5.4 Culture non-related and culture-related clinician factors Code Name # of quotes Used by linked to (% code participants) Culture non-related clinician factors Cultural sensitivity 8 50 Interest in learning about the client’s culture 5 30 Approaching client with dignity and respect 2 20 Approaching client with unconditional positive regard 3 20 Promoting trust 3 20 Culture-related clinician factors Being flexible 11 60 Being Latino helps therapeutic connection 9 50 Being bilingual 6 40 Being directive 4 30 Being seen as the expert 3 20 Having no problem being called family 3 10

Culture-unrelated Clinician Factors

Participants conveyed the importance of taking a culturally-sensitive stance, which meant having an awareness of how culture can be a factor impacting other domains of a client’s life. One participant reflected on staying mindful about culture and conveying dignity and respect in practice. She provided an example of how she transferred her clinical stance with former clients to a different area of practice, such as research, and how she thought this stance fostered engagement:

I feel that, when you deliver services to somebody, you have to be culturally

sensitive to their experiences, the patients respond so much better… the way I 117

approached them, with sensitivity, respect, with dignity, that comes back to you…

it is the approach I took with my people in general. When we finished the exit

interview, one of the questions is what kept you engaged in the study and the

majority of the participants said because I felt somebody cared about me. So, I

think it really works.

Another participant thought that having a culturally sensitive lens resulted in a broader understanding of how cultural factors could have contributed to outcomes in other domains, such as school dropout:

Several of them truncated their education and I don’t know whether that was, I

mean, in the case of one guy I think he probably had some issues, but I think it

was also a cultural issue that I think the schools failed to see. This kid had a

bunch of absences and, when he came back to school, his teacher said “don’t you

realize you’ve been removed?” and I thought “but he showed up,” so that would

have been a time to kind of start working with him on that rather than saying

“sorry, the door shut.”

Four participants reflected on the concepts of respect and of going beyond simple awareness by cultivating an “interest in learning about client’s culture.” The first individual discussed the importance, even for Latino clinicians, of taking a stance of curiosity:

You have to take more of a stance of learning from the culture, even though we

are all Hispanic, it may be a culture I’m not familiar with. Taking the stance of

learning, having the client tell me what their experience has been. 118

Another participant added that, while having Latino background might have offered an advantage, it may not be sufficient:

I think that it’s important to convey an interest in learning about them. I had a

little head-start, but I don’t think that somebody who isn’t from that background

can’t work with a Latino client or any immigrant… and empathy and respect for

where they are coming from, knowing that you don’t know about something and

not coming from “I know all about it,” being humble, I guess, in your approach.

Intra-group diversity within the Latino community was acknowledged by the focus group participants. Clinicians expanded on what it meant to be open to learning about Latino culture, with awareness of how the culture varies among the different Latino subgroups and how it also intersects with socioeconomic variables:

Also, the experience of different groups within the Latino community. Working

with Puerto Ricans can be different from working with South Americans, Central

Americans, Cubans. When I started working at (agency name) it was different for

me. The Puerto Rican experience was very different from what I experienced in

my family, so that was a whole learning experience. With that, I then learned

from working with Mexicans, Cubans, who is on the hierarchy, who’s preferred

and who is not.

The other group participant concurred with this view:

Yes, it’s a learning process. Not just the different nationalities but the different

educational level of the community we work with. Even within the Puerto Rican

community, there are different levels, people from rural areas, from cities. For 119

me, it’s a learning process, day by day you incorporate knowledge you didn’t

have.

The concept of learning about the client’s culture was thought of as conducive to building rapport and facilitating disclosure of information that otherwise would be difficult or painful to talk about. This clinician furthered this idea by suggesting that doing so may lead to a more accurate problem identification:

I think it was very important in the beginning to be able to learn about my client’s

culture so that they would feel that we can start building that rapport early on and

the assessment will be less daunting and less of a threat, to be asking them

difficult questions. And it was easier to get a lot more information, so that I can

give a diagnosis if they felt comfortable with me and they felt I was able to

understand their culture.

“Promoting trust” in the therapeutic relationship emerged as another conceptual category. While participants identified that trust can be impeded by cultural factors, this code was included in the culture-unrelated clinician factors group because promotion of trust is essential to establishing any therapeutic relationship. This quote conveys one aspect of what’s entailed in the trust-building process with Latino clients:

But with the Latino population, they recognize genuineness because they’ve been

through the ropes, they’ve been trying to access services and doors are closed

because of the language barriers, cultural barriers. But when they come to your

office, you have to assume that they’ve had failures before as far as accessing

services. The traditional Hispanic view on mental health is different from 120

mainstream… you have to be genuine and honest with them because they respect

that, you have to have eye-to-eye contact, above all being empathetic, I think.

This other participant agreed with the previous quote in regards to the importance of understanding the person’s views of the helping process and building connection through speaking their language as a way to gain trust:

I guess it just helped me to be more aware of how culture affects our clients,

specifically in the trust that needs to be built initially, and seeing how they view

the process of getting help, acknowledging that there is something they need to

work on… Mainly speaking in their language, that helped build the trust, also

getting their view of what they think is going on, what they’d like to see different

from the process of getting help from a mental health agency.

Another participant contributed that being personable and genuine was an important aspect of what helped solidify rapport and foster trust, even in the context of a standalone assessment interview:

Being personable was kind of my thing, being silly sometimes, finding something

to grab them with some laughter, just being genuine. Being genuine made a huge

difference with all of my clients. I was even flabbergasted during intakes about

how much people would share. They would say things and say “I have never said

this to anyone.”

Culture-related Clinician Factors

Participants often described the importance of being flexible in their approach with Latino clients. Flexibility entailed not working exclusively within one treatment 121 approach and attending to other areas of need before moving onto an intervention informed by a specific treatment approach:

From my experience, it requires a lot of flexibility, there is not a model. You have

to adjust the model to people’s needs, and not just that, but also adjust to the

resources we know are available. So, the plan would include to support the

person in the beginning to feel comfortable, to satisfy basic things they need and

then moving into the professional intervention itself.

This clinician described the experience of being a program for Latino clients within a larger organization, the pressure to fit a mainstream model as well as feeling judged by the larger organization for their holistic approach with Latino clients:

…we are the only Latino (program) and we are very loud, very boisterous, you

can tell the difference in how we operate. Sometimes, I think (the other

programs) have a difficulty with that and sometimes I think they make judgments

about that. It’s always a fight, never-ending, to try to maintain, to make people

understand, to stay true to your culture… And it’s so different, like we celebrate

Christmas, it’s very big for Latinos, for Puerto Rico the joke is that Christmas

begins at Thanksgiving and finishes in February. That’s just how we are. We

have clients who come with guitars, maracas, we celebrate, so (other programs)

hear this and they are like “they are making too much noise, I can’t concentrate,

I’m trying to talk to my client.” You know, you are going to accept the fact of

who we are, it’s always a fight to keep whole. Our style is different. (Staff name)

is an LISW, a therapist, but we also do case management. The mentality is that,

for us, it’s the whole person, there isn’t a division of “I’m therapist, I’m 122

considered skilled, so I’m not going to do the menial job of doing case

management.” So, for us, that’s part of the whole person.

The same participant expanded on this flexibility as being willing to go outside of the traditional therapist role:

…we are still professional with them, we are still their counselor, we are not their

aunt or their uncle, but we are more personable with them than I think traditional

counselors are. I doubt that [other programs] go to any of the functions that any

of their clients have, I think that they would be very uncomfortable if they got

invited, they would see that as transference and countertransference… they may

think that they have to push the client away. So, we still see ourselves as

maintaining professionalism, but we also see ourselves as more community and

more like them in terms of personal relationships. Not personal in the sense that

we are going partying or drinking with them, but personal in the way that we are

not here for an hour and we never see you again, especially in the community,

because we live in the same community, we run into them all the time.

The idea of challenging what’s viewed as a more traditional therapist role was also conveyed by another participant:

One of the things that was funny in grad school or at work [is that] we would talk

about gifts, clients giving gifts and you don’t take them and all of that. And with

the Hispanic clients the way they like to give is [by giving] food. So, if you make

a home visit, they would make a lunch or they would bring something. Accepting

that or that little trinket during the holidays made a huge difference. To be able to 123

say: “Yes, I will have the cup of coffee that you are offering me” because it is

very insulting to say no.

Flexibility also entailed an understanding of how diagnoses may present differently in different cultures, whereby rigid adherence to diagnostic criteria may result in misdiagnosing a client. This clinician discusses a common emotional reaction in

Latino culture, ataque de nervios, which loosely translates into “nervous attack,” as something that may be mistaken for a psychiatric disorder:

The traditional Hispanic view on mental health is different from mainstream…

I’ve heard that, in the past, clinical psychology would misdiagnose certain

characteristics of the Latino population, where…“ataque de nervios” is something

common, it’s okay, it’s a way to reacting to external forces. So, there’s a lot of

considerations when you are working with Latinos to not follow traditional

clinical social work.

Having a Latino background was identified by many participants as something that helped the therapeutic connection: “I know that, with Puerto Rican clients, they cling on to you, they feel that big connection, they want to give you a hug.” Another participant stated that the connection “…just happened, it wasn’t something I thought I had to be aware of, it was kind of ‘Oh, yeah, I know what you are talking about’… it was very helpful in making the connection, for them to know.”

Latino background also was identified as a key element of being effective as a clinician:

Because that’s my experience and I think that my experience is their experience.

I think that’s what makes us good clinicians, that we are Latino. I think that is 124

part of being good clinicians, that we are Latino and we know the experience, as

opposed to somebody who just knows Spanish. Don’t get me wrong, I appreciate

people who are not Latino and know Spanish and work with the community, but I

think that when you talk about your personal experience, when you’ve been

through it, been there done that, it’s much different.

Another participant illuminated the importance of remaining self-aware because having Latino background and having gone through acculturation may result in minimizing or not seeing your client’s struggles in the process of acculturation:

I think there are some things I’ve always struggled with, trying to find treatment

modalities that have those acculturation pieces integrated. Because I’m Latina

and I’ve gone through some acculturation I don’t know if those are some things

that should be explored more.

Speaking Spanish alone also was considered important but not sufficient, highlighting that a practitioner who is also Latino is better positioned to establish strong rapport with clients, as conveyed by these clinicians:

I think it’s very important to have a Hispanic background in the helping role, it

makes it easier, being able to speak their language. Not that someone who learns

the language can’t do it, but you have your experience, too, of what you have

been through, and I think it helps.

Because I think there’s a lot of similarities, there’s things I’ve gone through or

I’ve seen friends and family members go through, so it’s a lot easier to empathize,

understand or help them understand when they are going through situations.

125

Further elaborating on her answer of why a Latino clinician is better positioned to build a strong therapeutic connection, this participant reflected on her experience at a new organization that didn’t exclusively serve the Latino community:

Having changed jobs into a different setting and not working so much with

Hispanics, I went a little bit back into being Latina and what it means and how,

when you have to constantly remind people of the fact that they have to be aware

(of cultural differences and needs) and constantly reminding people that, if they

are providing services to the Latino community, things need to be translated,

always bringing that, putting your voice in the room to remind people, “What

about the Latinos?”

The advantage of being bilingual as something that helps foster a strong therapeutic connection was also mentioned by several participants. The alternative of having an interpreter was often considered an ineffective option: “That’s not adequate. I mean, for very serious cases an interpreter is okay, but to get effective therapy, you really have to have that one-to-one, (have to have the) language.” Another participant concurred: “It makes it easier, being able to speak their language. Not that someone who learns the language can’t do it, but you have your experience, too, of what you have been through, and I think it helps.”

This participant sees bilingualism as critical from the beginning of the helping process because it gives the client the power of exercising choice of language: “When we do assessments, the first piece is that we are bilingual, so we can choose to do it in

English or Spanish.” 126

The next quote confirmed the advantage of being bilingual in terms of rapport and empowerment. It also extended this advantage to being able to switch between languages when clients need to access specific words or idioms in either language to convey their emotional experience. The other element highlighted by this quote is the importance of being fluent in the nuances of language that communicate respect, such as the distinction between “tú” (informal treatment pronoun) and “Usted” (formal treatment pronoun):

So, let me start with assessments. I always ask whether they want to speak

English or Spanish. They may feel more comfortable in English. Just because

they have a Hispanic name it doesn’t mean they are not, so I often joke that we

can speak Spanglish if that’s what they are the most comfortable with. I find that

first generation, even if they speak English perfectly, there are certain words that

they want to say in Spanish because they have more meaning, they connect more

with, so I let them know they can do that… The use of “tú” and “Usted,”

especially when it’s an older person, I think that’s a sign of respect and it’s

something they are used to and it’s an important signal you are giving to them,

that they are respected.

The next 3 conceptual categories of “being directive,” “being seen as the expert,” and “having no problem being called family” often appeared intertwined when clinicians shared their views of specific cultural factors that helped advance clinical work with

Latino clients. The following quotation offers a vignette of an intervention during a home visit that aimed to facilitate the cultural adjustment of this individual in a directive manner: 127

I visited one woman in the middle of the winter who was complaining that she

didn’t have a lot of money to pay her bills and she was very stressed out and I said

“Well, you probably have a very high energy bill because you are wearing shorts

and it’s the middle of winter, and you are you wearing flip-flops. We are not in

Puerto Rico anymore and you have to wear a sweater, you have to put on socks

and you have your heat at 90 degrees. You can’t do that, you are in the States

now”. And she was like, “It’s that I feel good when I’m wearing my shorts and

my flip-flops.” And I said “So do I, but if we don’t have enough money to pay

the high bills it’s very stressful, (you can) put on a sweater, lower your heat and

then you will have money.” Those interventions that dealt with what they are

doing in terms of social adjustment have a great impact on their level of stress and

on their mental health and they also provide little seeds of acculturation.

The following quotation communicates the clinical struggle between “being seen as the expert” and trying to empower the client to access their own knowledge about themselves. It also adds another culturally-specific way in which Latino clients express respect towards the professional by calling them “Doctor,” even if the person does not hold that degree:

You know, what their expectations are, how they are going to be treated, that

sense that professionals know better than they do, so there’s that huge thing with

“Usted,” the professional is the expert. So, trying to help them feel they are the

experts on themselves, is a whole different way of interacting with professionals

here than there. I try to make it a pleasant experience so that they don’t feel

talked down to, that’s just not who I am. I don’t practice that way and I’m not the 128

expert. They may look up to you, they call me “la doctora,” doctor, anybody in

that position is a doctor… I explain I’m not a doctor, I’m a social worker. We are

going to work on this together, but sometimes it doesn’t sink.

This other clinician shared her view of “being seen as the expert:”

We never thought about Freudian… I mean, (clients) didn’t care, they were like

“Look, I can’t pay my gas, I can’t pay my light.” All they cared about was the

here-and-now, what are you going to do for me here and now, you are the expert.

That’s the other thing… Latinos see you as the expert, “If I’m coming to you for

help… I’m coming to you for help, so you need to know what you are going to do

with me.”

Another culturally-specific concept that was communicated by participants was the importance of being comfortable being considered family while being in a professional role:

…because you are a trusted individual for them, you are family, even the whole

concept of family, we have no problem being called family, being invited to

baptisms, being invited to weddings, graduations, we do those things, because we

are that to them. We keep a boundary, there’s still professionalism there, but we

are that to them and that’s okay, it’s not a role we shy away from. It’s a role that

we understand that, in working with Latinos, we need to do that, because it’s not

easy to trust, many of them have been through experiences where they don’t trust,

they don’t trust other organizations.

129

This quote also speaks to how this clinician conceptualized professionalism with

Latino clients as something that involved being comfortable within a closer personal space, such as coming in contact with your clients more often because of living in the same community:

So, we still see ourselves as maintaining professionalism, but we also see

ourselves as more community and more like them in terms of personal

relationships. Not personal in the sense that we are going partying or drinking

with them, but personal in the way that we are not here for an hour and we never

see you again, especially in the community, because we live in the same

community, we run into them all the time.

Finally, responses were analyzed by nativity status. Two main findings emerged.

One is that there are several categories in which foreign-born participants had no coded incidences. In the culture-unrelated clinician factors code group, the conceptual categories with no representation from foreign-born clinicians are: “approaching with dignity and respect,” “approaching with unconditional positive regard,” and “promoting trust.” The conceptual categories with no representation from foreign-born clinicians in the culture-related clinician factors code group are: “being seen as the expert” and

“having no problem being called family.” The second finding is that there are conceptual categories where the number of clinicians represented in the answers was either equal or close. In the culture-unrelated clinician factors group, “approaching client with cultural sensitivity” and “being interested in learning about client’s culture” are mentioned equally, regardless of nativity status. In the culture-related clinician factors group, “being 130 directive” and “being flexible” are endorsed by both clinician groups, although not equally. The results of the comparison by nativity status is depicted in Table 5.5.

Table 5.5 Culture-related and culture-unrelated clinician factors by nativity status U.S.-born (# Foreign-born clinicians clinicians (# linked to code) clinicians linked to code) Culture-unrelated clinician factors Approaching with cultural sensitivity 2 2 Approaching with dignity and respect 2 0 Interest in learning about client’s culture 2 2 Approaching with unconditional positive regard 2 0 Promoting trust 2 0 Culture-related clinician factors Being Latino helps therapeutic connection 3 1 Being bilingual 3 1 Being flexible 3 2 Being directive 2 1 Being seen as the expert 2 0 Having no problem being called family 2 0

Substantive-Level Theory: Clinicians’ incorporation of knowledge of acculturation into practice and differences by clinicians’ acculturation level

Attributes viewed as important in practice with Latino clients can be divided into two conceptual categories: attributes not specifically related to Latino culture (culture- unrelated) and attributes specifically related to Latino culture (culture-related). Culture- unrelated attributes are essential to establishing any therapeutic environment. They include unconditional positive regard, approaching clients with dignity and respect, being culturally sensitive, being interested in learning about clients’ culture, and using the data gathered about the client’s cultural preferences and past experiences with helping systems to inform the trust-building process. 131

Culture-related attributes that facilitate a positive therapeutic experience include being Latino (seen as important in promoting therapeutic connection); being bilingual

(increased advantage over using an interpreter; being flexible (not adhering strictly to one treatment approach and attending to psychosocial stressors often considered a case manager’s role); being directive; being seen as the expert; having no problem being called family.

A higher degree of acculturation in U.S.-born clinicians versus lower level of acculturation of foreign-born clinicians appears to increase clinicians’ awareness of cultural factors in the therapeutic relationship.

Research Question 4: How does acculturation knowledge inform the different phases of the helping process (assessment, treatment planning, intervention, and termination)?

This question was explored at different times during the research interview.

Initially, the fictional client vignette encouraged participants to focus on the experience of a foreign-born immigrant, identifying assessment areas viewed as important to form a clinical impression. Later, clinicians were asked to expand beyond the fictional scenario and expand on other areas in order to assess mental health risk and protective factors and how they may be linked to the acculturation experience. Finally, participants also were asked to elaborate on how they incorporated their understanding of the acculturation experience into the remaining phases of the helping process, i.e., treatment planning, intervention, and termination. 132

The variables that participants deemed important in order to form a diagnostic impression of a given client will be presented divided by assessment area. A summary of all the codes related to the assessment phase is presented in Table 5.6.

Table 5.6

Assessment codes

Codes by assessment area # of quotes Used by (% linked to participants) code Migration-related variables Type of migration [voluntary (+) or involuntary (-)] 15 90 Trauma during migration (-) 20 90 Biopsychosocial variables Social/family supports in the U.S. (+) 29 100 Social/family supports in country of origin (+) 8 70 Isolation, exclusion, not belonging (-) 17 70 Work status/work experience (+) or (-) 8 70 Financial struggles (-) 9 60 Immigration status (+) or (-) 7 60 Education level (+) or (-) 6 50 Barriers in access to care (-) 7 50 Previous physical or mental health conditions, previous 5 40 traumas (+) or (-) Fears due to being in the U.S. (-) 5 40 Living in adverse neighborhoods (-) 3 30 Cultural variables Openness to mental health treatment (+) 4 50 Importance of religion and/or faith in client’s life (+) 8 50 Assimilation to mainstream culture (-)/openness to 8 40 learning mainstream culture (+) Views of mental illness and the help-seeking process (+) 4 30 or (-) Acculturation Length of stay in the United States 4 30 English proficiency level (+) or (-) 14 100 (+) denotes protective factor status; (-) denotes risk factor status. (+) or (-) denotes variable may be protective if present or risk factor if absent or poor.

Assessing migration-related variables. When working with clients who are foreign-born, all participants indicated the importance of exploring type of migration 133

(voluntary or involuntary), as well as whether the person endured traumatic experiences during the migration. In both instances, participants portrayed these variables as contributors to the person’s presenting problems and overall cultural adjustment.

Voluntary migration was conceptualized as more empowering for the individual, and thus, as a possible facilitator of cultural adjustment, as articulated in the following quotes:

What was the motivation of this person to come here? If he made that choice, I

believe the adjustment would be easier. If he was forced to do that, there are a lot

of things that are unknown for him or her and it will take probably, it’s a different

process, he or she would need more help in order to adjust.

Yes, because you got a choice, you thought it through, even though it’s hard and

not necessarily what you’d want to do if everything was okay, but you were able

to plan for it, you had more control over it. One situation is when you leave

because the gangs are trying to recruit your kids and a different one is when you

leave because there’s no food on the table.

Conversely, involuntary migration was linked to a more difficult cultural adjustment and, potentially, poorer mental health outcomes, as articulated by this participant:

If it’s involuntary, the reasons that made them take this journey and how that

affected them… In the involuntary, I picture more clients that are younger or

people who can’t make those decisions for themselves, or it could even be human

trafficking, so there are more factors that could affect one’s mental health.

134

Another important category related to the migration experience that emerged was to assess traumatic events both prompting the migration as well as during the migration process itself, due to their potential mental health impact on the acculturating individual, as reflected by these quotes:

I’d explore a variety of issues. The first one is how did he come to the States and

why did he decide to leave his country and how did he come here. I’m not that

much interested in finding out whether they are legal or illegal. However, I do

like to know that too, because that gives me an idea of the level of stress that they

are experiencing and that is going to impact your mental health… If they had to

flee their country because of violence, that tells me a lot about the level of stress

they had before, which already sets the first step. And, then, how did they come

here? Did they come here through a process that was easy or did that add another

level of stress on top of the first one? And, then, how are they received here, are

they legal or illegal? That’s a third step.

I think the actual physical aspect of coming over is important, the experiences

coming over. Some people get in a car and drive and there’s no problem. Some

other people are caught, robbed, threatened. So it depends how treacherous the

crossing over was, if they had somebody to come over with, if they came by

themselves. Also, was it a planned exit or were they threatened by gang

members? I worked with somebody who was raped by a gang member and in 2

days she was out because he threatened to rape her daughter.

135

Assessing biopsychosocial variables. Participants identified several biopsychosocial areas as potential contributors to mental health problems. While the majority of these assessment areas are not exclusive to Latino clients, clinicians emphasized the importance of assessing these variables as they can result in protective or risk factors for the acculturating individual. Social/family supports in the United States was primarily identified as a protective factor and its counterpart of social isolation identified as a risk factor. To a lesser degree, social and family support in the country of origin was also perceived as protective. Social and family support was emphasized due to the centrality of family connection or familismo, as a key value in Latino culture:

“…the foundation for success in any acculturation, I think, is family, family connectedness, family bonding, which is the critical point in our Latino culture, the kinship.” The following quotes expand on the importance of social and family support:

You connect with people who are similar to you and then, from there, you go on.

Because those people will expose you to other things because they already know

the culture if they have been here before. If not, those people who are similar to

you help you walk the journey together. Connecting with others, doing things

with others, laughing with others, playing, crying with others who are similar to

you, those are protective factors.

I think that if he had family here, support, coming to somebody here, that would

play a big, important part. Was it smooth coming here? What did he get through

coming here? and what is the support system he has now that he is here? I’d look

at protective factors in terms of who he has here or is he by himself. Did he come

to family who were able to get him a job right away? Is he employed? Is he 136

struggling? What is his language? Most likely he is not going to know a whole lot

of English, but he may know English, it depends on where he comes from.

Family connections, issues of coming here, political concerns back in their

homeland. Do they have family connections here? If they have more family

support people tend to do better… Explore isolation issues, if they left their

family back home, are they in communication with them? If they have a good

connection with them or somebody here, because the family tie is really strong in

the Hispanic community, maintaining those strong family values.

Participants also emphasized the importance of assessing the reverse side of social support, captured in the code “isolation, exclusion, not belonging”. The lack of social connectedness and problems fitting into the mainstream culture were viewed as a risk factor for mental health outcomes, particularly depression:

Oh, yes. I just did a training, but we’ve known for years, and Latinos fit so well

in this, they talked about social connectedness and its impact on mental health.

So, I think that, in some ways, it affects their mental health when they are cut off

completely from something that is such a core part of them. I do think they go

through depression, they have issues with their children because they don’t have

that support of their family.

There’s more of a sense of isolation, finality, not knowing when they may go

back. They miss important family functions, they may have kids who their

parents will never meet. That can add to their sense of isolation, loneliness, being 137

cut-off to your past. If you don’t have that foundation, if you don’t have that

support, it can be very isolating and depressing.

Clinicians stressed the importance of exploring socioeconomic variables such as financial struggles, immigration status, work status and experience, and education level.

These factors were viewed as possible facilitators or hindrances in the acculturation process, thus impacting the person’s mental health. These variables often were cited together. The next two quotes expand on how some of these factors are linked together and may pose a mental health risk to acculturating individuals:

I think (acculturation) is a process, life-long process, and sometimes if feels like

things come full-circle and there’s these, I guess, identifiers of goals you have to

meet in order to feel like you have crossed over emotionally… They have to do a

lot with your socioeconomic status and having gone to school, having a job, being

able to have social supports, having stability, you know, financial and housing

stability, feeling like you are part of a group. There’s all those pieces that form a

foundation of not feeling like you are a stranger to where you live.

If they have education, usually, that provides them with a buffer in terms of how

they can deal with stress. The higher the level of education, the more skill usually

a person has to handle stress. Also, the higher the level of education, the greater

the ability or the possibilities of getting a job. With a job, also, the stress lowers.

While most clinicians stated they would not necessarily inquire about immigration status per se out of respect for the individual, this variable was considered important because of the added stress it causes due to feeling unsafe as well as how it curtails access to resources, as conveyed by the next two clinicians: “I don’t usually ask their 138 legal status unless they bring it up; I think that’s respectful. But I think that also plays a role in their mental health, that adds anxiety, fears, if they don’t have legal status.”

Some clinicians also expressed awareness of this variable particularly in the present sociopolitical environment of the United States. The next quote articulates awareness of the heightened sense of threat for Latino individuals:

I think that living at the margins, both financially and in their case culturally,

especially with the demonization in the last few years, I think that’s so sad. I

mean, I’m in my sixties and I grew up here and still heard foreign accents in

mainstream movies. But I think now, would we have even the patience to listen

to somebody with a little tinge of an accent? And then, if it’s somebody from a

culture other than the one we perceive to be our own, forget what literally is our

own, we criticize it. The tools you (acculturating individual) have for dealing

with that are limited when you are at the margins, you have a sparse support

network, very little money to patch things over, I’m making it seem more like it’s

financial, but financial really does tie in. Especially when you don’t have a legal

status, it’s another area of vulnerability that maybe a person of Appalachian

heritage doesn’t have.

Other risk factors viewed as relevant for the Latino population included previous medical or mental health conditions and/or trauma history, barriers to care, living in an adverse neighborhood environment, and experiencing fears due to being in the United

States (e.g., discrimination, feeling unsafe). The next two quotes discuss the importance of understanding some of the sociocultural issues that a new immigrant may have left behind and how they can shape their mental health presentation: 139

I’d also like to know if what brings them to me [as a mental health provider] is

something that started here because of the immigration process or something they

were dealing with in their country, if they ever had medications… I know that

most people who come from Central American countries are usually poor in their

countries, so they don’t have access to the same medical and mental health

treatment as they do here, so this is like a whole new scenario for them, too.

I’d want to ask if he has suffered any kind of traumas in his country related to

gang violence, access to resources here, if he has had access to medical care back

in his country… Because gang violence is something that is prevalent in some of

those countries. Being from Central America myself, there are lots of issues with

gang-related violence and it is unavoidable. I have had experiences with clients

and with friends that have all very similar issues with trauma related to that. And

the question about accessing healthcare it’s because I know that healthcare in

those countries is very close to non-existent, and there’s no such a thing as mental

health services. If you don’t have money, a lot of things go unseen.

Neighborhood-level factors were also viewed as important to assess and linked to the importance of social connectedness and presence of resources as protective factors:

Also, the neighborhood where they live. If they came to a place where there is no

connection with others, it’s more difficult for them to know about services or how

to navigate the system. But, if they are in an environment where the neighbors are

more welcoming, more willing to provide information, help them, it would be

manageable.

140

Fears of being in the U.S. were also viewed as important to explore, as they compound emotional distress:

If he is open to it, I’d like to get details as to whether he feels safe, comfortable,

any issues with finances, any concerns with any threats or things like that. I think

it’s more prominent now with the new administration in government, that people

seem to be more afraid to verbalize those concerns.

Whether he is experiencing racism, rejection in different arenas, I’m assuming

there may be a language barrier, which (there) often is… so, how the language

barrier has impacted, how looking different, different color, and with politics the

way it is right now there’s so much racism. I’d also want to know any

posttraumatic stress that they might have, which is often the case, which is why

they fled, and how that affects them today.

Assessing cultural variables. Clinicians emphasized the importance of the individual’s “openness to mental health treatment,” which was viewed as a protective factor. Males were perceived as somewhat losing privileged status (consistent with

Latino value of machismo) when entering mainstream American culture, where there is an emphasis on gender equality. This shift con cause distress in the individual and in their close relationships that can escalate to the point of needing services. Traditional

Latino males were perceived as being less open to mental health treatment for these reasons. The following quotes convey these views:

I noticed throughout the years, working with family members, the role of a male

figure in a house changes in a way here. Back in the homeland the father figure is

the strongest, he is the leader of the family. But when they come to the United 141

States, that changes and it becomes more of a partnership. And if the male figure is not able to adapt to that, there is a lot of friction, he could become more resistant, more violent. Those are subtle changes that may hurt the family. It causes huge amounts of stress. I’ve seen that throughout the years, how it changes family dynamics. Now, if the male figure is open to the change, it could be blossoming of the relationship, they share responsibilities, living as a unit. I think that changes a lot and it can go both ways, good or really bad.

I notice more difficult adjustment between the men and the women. For example, if the men are very machista and traditional and think that women need to do things a certain way and women say “wait a minute, there’s a different way of doing this and it’s not so bad,” so how do you adapt to the expectation that “I can work, it’s okay to go out of the house, it doesn’t mean I’m looking for another man.” So, being able to figure that out as a couple or finding a man who will not fight it. A lot of times, the women would call for their partners, they look for the help, make the appointments, the guys would come but it’s kind of like the women are the secretaries, all the messages go through them.

I think more so if the person, I think I see a pattern with men of having a harder time seeking services from those countries, so I would try to not be too invasive…

I think there’s a lot of taboos of a lot of issues. Feeling like they are victims can be very tough and even health-wise I’ve seen with clients a pattern of kind of neglect and invalidation and not wanting to seek services, go to the doctor, get themselves checked.

142

The second most important area to explore was the “importance of religion and/or faith in the person’s life,” particularly in its ability to be a source of spiritual and social support and connection. One participant articulated the social support aspect of participating in religious activities: “Supports, yes. When I think about what kind of activities people are doing, you know, sometimes there are groups for las damas (the ladies) at church, things like that, that’s a huge support for women.” Places of worship were viewed sometimes as a a replacement for the lack of a family network, fulfilling a stabilizing purpose: “If they have more family support, people tend to fare better… they are more at ease. But even if they didn’t have family support, if they have some church, usually churches locally give a lot of support, financial, spiritual, the support they need to stabilize.”

Often, religious organizations were cited as informal social service agencies that assist individuals in need. When asked to clarify whether such organizations were viewed as important because of the concrete support or the spiritual support, this participant viewed them as serving a dual purpose: “Really, both. I’m sure the churches would love for the people to become part of their congregations, but yeah, if that’s needed too, absolutely.”

Another important cultural variable to explore was “assimilation to mainstream culture/openness to learning mainstream culture.” This code captured two ends of the acculturation process. Assimilation was seen as a rejection of the native culture in favor of the mainstream and viewed as a risk factor for mental health outcomes. Openness to learning the mainstream culture was seen as a protective factor in cultural adjustment process and in terms of mental health outcomes. 143

The next quote conveys the importance of assessing assimilation because this process entails a drastic loss and, as such, it may have negative mental health consequences:

You can have the Latino client that comes here and they do hold on to their

values, language, the traditions, but at the same time they know how to play in the

larger world... And then you have those who completely, and I’ve seen this in

clients, where they don’t want Spanish spoken in their homes, they don’t want

their children to speak Spanish, they don’t want to identify themselves as being

Latino… They’ve totally given up… They’ve assimilated, not acculturated. And I

think there are conflicts around, that they have totally cut a piece of themselves

completely out to be able to be part of the mainstream…A definite loss.

In the tension between assimilation and openness to learn, the theme of finding balance reappeared as important for mental health:

I think that the healthiest acculturation for mental health is when you can find the

right balance, not letting go completely of where you came from, but not 100%

just taking on everything else, finding a balance of the things that can be helpful

and can translate to where you are now.

Participants also discussed the importance of assessing “views of mental illness and the help-seeking process.” Exploring views of mental illness and of the help-seeking process was considered important and often linked to gender expectations and how these change in the acculturation process. Males are considered culturally more reluctant to recognize emotional struggles in themselves, let alone seek help, particularly during the initial phases of acculturation, which needs to be assessed if treatment is to succeed: 144

I predominantly worked with people who had not come from Central America,

but being myself from Central America and having friends, I do see that pattern of

being this macho type and if you validate the fact that you are sick, that there may

be something wrong with you, that is a weakness, and you have to always have

this persona of being really strong, being the supporter… I would try to be very

gentle and not make things sound very judgmental, try to open up conversations

about things, make it matter-of-fact, part of the paperwork.

As acculturation takes place, views of mental illness and help-seeking may evolve and modify these initial gender-specific attitudes, as described by this participant:

Early on in the practice I noticed… it was very hard to get men, it was very taboo.

And I noticed in the course of the years that changed a lot and they started hearing

from others that it was okay and they started to become more vulnerable. But

early on it was very taboo, men did not share anything personal outside of the

family. So, the work became very female-male equal, it was great. I think that is

a part of acculturation. Probably it may never be heard of in Puerto Rico that a

man would go see a therapist and here there are very many men who do it.

Another important aspect of assessing views of mental illness and help-seeking is the understanding that a foreign-born client may come from a social reality that is deprived of healthcare services, therefore the person may not have a negative attitude towards the process as much as a need for being educated on it:

I think that if they have better education and they are better able to communicate

in English, they will have fewer barriers to access treatment and services. And 145

also to buy the idea of treatment, to understand why they need help. Also, the

system. The system is totally different from where they come. We are talking

about a person from Central America. Some of those countries have political and

social problems, there’s a lot of violence. How can he understand that the

environment here is different and how to adjust without generalizing the situation

from where they are coming from.

I think also the fact of being aware that (services) might exist and not have the

mindset of “Well, this is life and I just have to tough it out, I can’t expect more.”

If you have more access to language you can hear what’s going on, what’s

available here, they may have more knowledge about “I don’t have live this way,

I can feel better.”

Assessing acculturation. Clinicians did not mention the use of any specific acculturation instruments to assess acculturation level. However, they discussed other variables that they routinely assess, such as “length of stay in the United States” and

“English proficiency level.” While participants did not label these variables as acculturation proxies, they are widely used as such. Moreover, participants emphasized the importance of assessing mental health in the context of acculturation. A client’s mental health is to be approached not as a separate entity but rather as something to be understood within the context of the acculturation process. This clinician discusses how he explores this with a new client: “My first job is to measure where they are with their acculturation… How long they’ve been acclimated to the United States determines a lot of what I do with them…“ The assumption is that individuals who are new to the culture will require more concrete support: “As opposed to the new arrivals to this country, 2 or 146

3 years ago, the assumption is that they are still struggling to acclimate and that there are still major barriers, language barriers, transportation, inability to access resources because of the language barrier, mobility issues.” Another quote from a different participant concurs with this conceptualization:

With somebody who is new, we need to start with basics. They may need more

community resources, basic things like connecting them with a case manager,

someone who can help them navigate access to healthcare, transportation,

interpretation, basic things.

This evaluation informs the diagnosis and level of care needed, as expressed by this participant: “The first thing will be to provide this type of support and then move to something specific, like a professional intervention to treat the emotional disorder they are experiencing” and confirmed by this other clinician:

Then, I determine my level of involvement with them based on their mental health

diagnosis. You know, their mental status could by anything from grieving to

severe depression, the level of impairment could be any varying degree. If they

are severely depressed, I need to get them psychiatric care. So, I have to measure

their impairment versus their acclimation. Those things are critical because they

tell me how much work I have to invest to get this person stabilized, if that makes

sense.

Another assumption when exploring length of stay in the United States is that somebody who has been exposed to the mainstream culture for a while may already have some knowledge of how to navigate the broad healthcare system and, consequently, need less support: 147

People who have been here for many years, even if they never sought a mental

health professional, never had an emotional problem, they probably have been in

contact with the healthcare system, so they know better how to navigate the

system. Somebody who came recently, it’s different if they had a mental health

history in their own country or if they never did.

English proficiency level was considered an indicator of degree of acculturation, as well as a something that could serve as protective or risk factor, depending on the level of proficiency. It was consistently identified as an important factor to assess because of two main processes: it impacts a person’s ability to exert control over their external environment (accessing resources, experiencing socioeconomic advancement) and it leads to social connectedness (which facilitates learning the mainstream culture). In turn, these two processes were viewed as contributors to mental health outcomes.

This clinician articulates the link between low English proficiency and mental health, as mediated by having some control over the external environment:

Those who don’t speak the language they seem to be more in a state of despair,

more, feeling more powerless to be able to control their environment, as opposed

to those who have mastered the English language, they are bilingual, they can

access services, you know, they don’t need as much help as the ones who do not

speak the language. So, it matters. Those who cannot speak the language need a

lot more help, you have to do more for them, as opposed to those who speak the

language, their native and English, they can, uhm, they have a larger sense of

empowerment.

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The following 2 quotes discuss this link by focusing on socioeconomic advancement (job opportunities) and also noting how this affords the person opportunities to learn the mainstream culture and incorporate new coping tools:

The people who don’t learn the language, who can only function in menial jobs,

that don’t have enough money to live in a decent home, that don’t have enough

money or resources to have adequate healthcare, the ones who become isolated,

those are the ones that are going to fare really poorly.

Finally, the language. A person who doesn’t know the language will not be able to

get a good job. A person that’s more fluent will be able to get a job and will also

be exposed to different ideas from the culture that will help them cope.

This other clinician articulates the link between English proficiency and mental health, as mediated by social connectedness:

If a person has the language, the person will be less isolated and, you know,

isolation plays a big part in mental health problems. So, the more the person can

connect, either with people from their own culture or from the main culture, the

better. And then, on top of that, I ask are you married, do you have kids, that

provides another buffer, but I think these five steps are very important in how the

person will land in the new place.

Treatment planning, intervention, and termination. In the final portion of the research interview, clinicians were invited to articulate how their understanding of the process of acculturation informed clinical practice after their initial assessment. When exploring interventions, clinicians also were asked to elaborate on whether they intervened differently with different Latino subgroups. Participants focused most of their 149 answers on interventions. There were no specific mentions of how termination is informed by knowledge of acculturation, except for one clinician who referred to her experience in community mental health with Latino clients and termination in these terms: “Termination is a little bit complicated, because with the Latino community I worked with there wasn’t a whole lot of planned termination; some were, but the majority were either lifers or they dropped out.” This will be further discussed in Chapter 6.

Treatment Planning. Generally, this phase of the helping process was not a category that clinicians addressed in great detail. In clinical practice, the areas of need identified in the assessment will inform treatment planning and, largely, clinicians identified important areas to explore during the assessment as they relate to acculturation.

There were, however, some specific answers that were retained into a “treatment planning” code because they specifically captured aspects of treatment planning that clinicians found relevant in their work with Latino clients. The need to prioritize treatment goals in order to stabilize socioeconomic needs is emphasized: “So, the plan would include to support the person in the beginning to feel comfortable, to satisfy basic things they need, and then moving into the professional intervention itself.” Another clinician concurred with this view:

With treatment planning, it needs to be something attainable, reachable, so if it’s

something very concrete, like obtaining benefits, that’s going to happen. But with

goals that are more related to emotions and working through past trauma, those

were more of a challenge.

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Agreeing with the focus on stabilization of basic needs first and then planning for higher-level interventions, this clinician expresses her approach to planning:

I think the more I feel my clients are acculturated, the more I feel there’s an open

way to doing interventions that might be considered a little more sophisticated,

like being able to teach them skills and for them to practice them and to engage

them in the process of therapy. Whereas with less acculturation, I think, there’s a

lot more barriers they have to cross and it’s harder to engage them in session

because there’s so many things happening, it could be financial hardship, housing

hardship or immigration hardships.

In contrast, a clinician in private practice, working with a less vulnerable subset of

Latino clients than community practitioners, shared how her understanding of the person’s acculturation process will be incorporated into treatment:

And then, when I do treatment planning, and in private practice we don’t do much

treatment planning as in agencies where you have to write and all that, but I have

a framework that I discuss with the patients, and there I might begin to

incorporate, I also think that we need to talk about where you are in the process of

acculturation, or what does it mean to you to be an immigrant.

Intervention. The conceptual category with the most coded incidences was

“intervening with Latino values in mind.” While this category did not refer to a specific mental health intervention, it stressed that, in order for treatment to be effective, interventions had to occur within a Latino value framework. In the words of a participant: 151

I carry the basic values of a traditional Latino male, which is dignity, respect for

others, empathy. I immersed that into my interactions with the clients.

Connectedness, you have to connect with them. Traditional American techniques

sometimes go counter to the culture… For example, sometimes you have to show

empathy by patting them, even the first time… You get close to them and that

goes counter the traditional social work field, you know, “don’t touch the client,”

“maintain appropriate boundaries,” you know. That goes counter sometimes, I

think.

The centrality of family in Latino culture and the cultural expectation that personal matters should be resolved within the family system, not outside, needs to be acknowledged. Failing to understand this may heighten the conflict the individual may be already experiencing when stepping outside of cultural expectations to seek professional help. This clinician discusses her challenges as a trauma therapist serving the Latino community:

In my professional experience, I’ve seen how difficult it is to approach the Latino

community to get services for their trauma because of all of these stereotypes and

taboos (such as) not sharing your problems with professionals, keeping things in-

house. There are different ways we need to consider in being able to serve them

because it is hard to get people to open up, coming to you, and I think it’s easier

to go to a doctor and talk to a doctor about it. There’s a misconception that these

are things I should discuss with these professionals but I’m not crazy, so I’m not

going to go to a therapist.

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While variations exist across Latino subgroups, there is commonality of core values seen as the foundation of culturally appropriate treatment:

Puerto Ricans are (…) citizens, whether they are born on the island or in the

States, as opposed to Colombians or South Americans, their citizenship status is

different. That tells you that they cannot access services, depending on

citizenship status. I don’t treat them differently because I use the basic concepts

of Latino cultures, familismo (familism), personalismo (personalism), I believe in

that… It’s a common ground. Respect is important, very critical for the

Hispanic/Latino. You have to treat them with respect, above all else, or you are

not going to get anywhere. And being heard; sometimes you don’t have to say

anything, just hear them, because for the longest they’ve been trying to get help

and nobody is listening. So, when they can come to your office and you can

speak in their language and really listen to what they are saying, half the work is

done already if they can connect at that level.

Another conceptual category that emerged was to “tailor interventions to the culture.” While clinicians did not identify any validated cultural adaptations of interventions they used in practice, they discussed how often interventions that may be effective with non-Latino clients failed with Latinos. Assigning homework, a common aspect of many therapeutic approaches that helps solidify and generalize coping skills learned in session, was viewed as not conducive. Clinicians hypothesized that the many stressors Latino clients often contend with pose barriers to homework adherence: “There were usually crises most weeks, so usually it was crisis-oriented and very little focus on following through with homework. Let’s say it didn’t work very well.” 153

Clinicians shared strategies to tailor interventions to make them more culturally congruent. In the next quote, the therapist engaged her knowledge of the culturally- prescribed role of women as family-oriented caregivers to present an anxiety- management technique in a way that is not only relevant to the client but also maximizes the chances that the client will practice this skill outside of session:

Some of the techniques I try to adapt. For example, when I talk to clients about

any type of relaxation techniques, for some of them it’s difficult, they are used to

being on the go, always doing something. It’s hard for them to find a specific

time to do that, so I try to find other ways or activities they can practice. We may

not call it relaxation, maybe we call it “your time”, doing something they like

when they are cooking. It’s hard for them to fall into a structure, so I try to help

them understand there are things they can do, even though we don’t call them

those names, so we use things that many times they are doing but are not aware of

them.

The next quote depicts a creative way in which interventions are tailored to Latino culture. It describes how the format of culturally-accepted spiritual practices was used to encourage Latino clients to practice something that may be foreign to the culture, such as mindfulness practice:

…encouraging them to have a little corner, an altar, for them, not just religious,

they connect to that. So, telling them that, when they go to that corner, if they are

going to pray, which is also a form of meditation, I notice that is something

people connect with.

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Another important distinction made by clinicians was the concept of interventions having a “here-and-now focus.” Clinicians viewed the present focus as necessary due to the multiple stressors Latino clients present with that are largely linked to the acculturation process. A quote presented earlier linked to ”being seen as the expert” also describes the importance of the here-and-now focus of intervention:

We never thought about Freudian because we didn’t care if they peed at two years

old… (laughter)… I mean, they didn’t care, they were like “look, I can’t pay my

gas, I can’t pay my light,” all they cared about was the here-and-now, what are

you going to do for me here-and-now, you are the expert.”

Another quote cited earlier in connection to “being directive” also relates to the here-and-now focus and the need to intervene to facilitate a basic cultural adjustment before any higher-order interventions can take place:

I visited one woman in the middle of the winter who was complaining that she

didn’t have a lot of money to pay her bills and she was very stressed out and I said

“Well, you probably have a very high energy bill because you are wearing shorts

and it’s the middle of winter, and you are you wearing flip-flops. We are not in

Puerto Rico anymore and you have to wear a sweater, you have to put on socks

and you have your heat at 90 degrees. You can’t do that, you are in the States

now”. And she was like, “It’s that I feel good when I’m wearing my shorts and

my flip-flops.” And I said “So do I, but if we don’t have enough money to pay

the high bills it’s very stressful, (you can) put on a sweater, lower your heat and

then you will have money.” Those interventions that dealt with what they are 155

doing in terms of social adjustment have a great impact on their level of stress and

on their mental health and they also provide little seeds of acculturation.

As the process of acculturation progresses and the person is more adept at managing challenges, then here-and-now focus is not so critical. At this stage, higher- order mental health interventions are more likely to occur, as this clinician expressed:

I think the more I feel my clients are acculturated, the more I feel there’s an open

way to doing interventions that might be considered a little more sophisticated,

like being able to teach them skills and for them to practice them and to engage

them in the process of therapy. Whereas with less acculturation, I think there’s a

lot more barriers they have to cross and it’s harder to engage them in session

because there’s so many things happening. It could be financial hardship, housing

hardship or immigration hardships.

Another category that emerged was “allowing the client to tell the story” which aligns with a cultural trait of communicating through detail-rich language and vivid depictions of events and emotions. Telling the story was viewed as closely linked to

Latino culture and the importance of personal connection (personalismo). This clinician discusses how she uses specific interventions, such as Eye Movement Desensitization and

Reprocessing (E.M.D.R.) or Somatic Experience (S.E.) and, while the client is not required to focus on anecdotal information while they go through the therapeutic experience, most of her Latino clients needed to tell their story:

I learned E.M.D.R. and S.E., so I keep thinking how to make this work for the

Latino community, because first they have to buy into it, it has to be something

that they can connect with… because you have to express the process a little 156

more, (the clinician) needs to stop at certain points because they (Latino clients)

want to talk a lot. E.M.D.R. is more of an internal thing, where you look at what

you are noticing and you don’t have to necessarily share, and my experience is

that Latino clients want to talk and tell you every single detail. So, it’s about

being able to be patient with the story because, for them, being able to tell the

story, is important. So, there’s that adaptation when you are talking to the client,

that you may have to sit through something you heard, but allow it.

The following quote underscores the importance of telling the story as a way of solidifying the therapeutic relationship:

Participant: I’m thinking about the Latino clients I have, they are so descriptive

and so talkative, that you can’t say “ok, just let me ask this question” because it

doesn’t work that way, there’s a story behind each question.

Interviewer: The narration is important.

Participant: Yeah, yeah. They need to say it and that’s one of the ways in which

you build a relationship with them, by listening and allowing them to say what

they need to say.

When working with a foreign-born Latino client, allowing the telling of the migration story may be necessary in order for the healing process to proceed, as this clinician expressed:

I do gather information. I have found that people tell me, they want to be able to

unload, to vent about how the journey here was. I haven’t worked with a lot of

people who have had a very difficult journey. Most of the people I worked with

are Puerto Ricans and they don’t have that experience. But the people from 157

Central America who are here illegally because they have to escape violence,

persecution, etc., they want to tell the story, they want to use the sessions as a way

of unloading and come to terms with that experience.

Lastly, other categories of low density emerged that were retained as part of one conceptual category named “other common interventions”. Clinicians discussed the importance of intervening by providing psychoeducation, something that typically occurs in the early stages of treatment and is also informed by where the client may be on the acculturation process.

Providing psychoeducation about the culture exchange process and how it impacts, not only the individual, but also the extended family was identified as important.

This clinician discusses her experience with Latino clients –and other cultures with similar collectivistic orientation– explaining how this intervention helps acculturating clients understand the changes that are taking place in them and in their relationships:

I do multicultural interventions. I don’t only work with Latinos… With my Indian

families and Israeli families, I bring this up right away in treatment planning and

in the interventions. And we formulate and talk about, how was it for you to

leave India, how is it that you have your mom in India. And they talk about them

becoming different from their families, the struggles and conflict that develop

because they are becoming more acculturated and their families don’t need to

acculturate because they are in their own countries. We make it a treatment issue:

“How do you deal with your family now that you are different?”

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The next quote discusses the importance of using psychoeducation about the mental healthcare system. The intervention is informed by the clinician’s knowledge of

Latino culture (exploration of attitudes about seeking help) and what to expect in the therapeutic process:

Key is education, you know, information about the system, how the system

works, what it means to go and look for mental health services, but I would also

explore how they feel about this, what it means for them to come to my office. I

will get a sense of where they are and try to educate them about what he or she

needs at that moment. Listening would be the first skill, and then provide

information, orientation, and education.

Psychoeducation in the treatment of an acculturating individual is not necessarily unidirectional, i.e., information that the clinician provides to the client. Rather, it can become a bidirectional process, in which the clinician helps the client understand their new cultural reality, problem-solve effectively and, in turn, the client is encouraged to provide feedback about their cultural background, to educate the clinician. The next excerpt describes this aspect of providing psychoeducation through a comparison where the clinician engages in this mutual process, not just with Latino clients, but with other clients who are also going through the course of acculturation:

I tell them right away, you have to educate me about your culture because I don’t

understand. I do that a lot with the Jewish families, especially the orthodox

families, and I tell them, you have to educate me about your religious practices, so

that I don’t recommend that you do something that isn’t congruent with your

religion or your family practices. And they teach me and then it becomes a very 159

rich, interactive process, where they want to learn about me and my culture, and

then I have to say, okay, teach me about yours so that we can do something that is

combined. And that’s also my way of helping them acculturate, because some of

the orthodox families live in their own country, isolated. I use what I know about

acculturation to help them problem-solve.

Clinicians also discussed the importance of linking to resources within “other common interventions,” particularly in the early stages of treatment. It was viewed as a key intervention due to the vulnerability that Latino clients present with and that clinicians associated with both low-income status and/or being new to the mainstream culture. The next quotation distinguishes how this intervention would be different with clients with different degrees of acculturation:

Their needs would be different. With somebody who is new, we need to start

with basics. They may need more community resources, basic things like

connecting them with a case manager, someone who can help them navigate

access to healthcare, transportation, interpretation, basic things. The first thing

will be to provide this type of support and then move to something specific, like a

professional intervention to treat the emotional disorder they are experiencing.

Decreasing the initial vulnerability that a client with a low degree of acculturation may have is considered a necessary step in order to move onto treating the mental health disorder as such, as expressed by this clinician: “Because there was so (many) problems,

I basically found myself providing more resources, helping them to a place where they can even start to do therapeutic work.”

Member-checking 160

The feedback provided by two participants who took place in the member- checking process confirmed the themes that emerged during open coding as well as some of the emerging conceptual categories. Next, I include examples to illustrate the way in which participants corroborated emerging themes. Here is a quotation where I shared with these participants that the data suggested that cultural factors were not sufficiently explored during the assessment phase:

Participant 1: I don’t think so.

Participant 2: No. I think it’s so diverse that we tend to, what I experience

usually, no matter how much you want to do that, it’s difficult, because they came

from so different environments, different cultures.

Participant 1: Even if we are Latinos it doesn’t mean that we understand what

they experienced in their countries.

Participant 2: Exactly. And I think (Participant 1) made a good point when she

mentioned trauma, for example, that they are not aware even of that, they didn’t

see that as trauma. So, the cultural piece gets often times overlooked.

Another example from the member-checking process pertained to the emerging theme of “allowing the client to tell the story.” When I sought their view on this emerging theme, participants corroborated it:

Participant 1: Yeah, yeah. They need to say it and that’s one of the ways in

which you build a relationship with them, by listening and allowing them to say

what they need to say.

Participant 2: For most of them this may be one of the few opportunities they

have to express themselves. 161

Substantive-level theory: Ways in which Acculturation Knowledge Informs

Different Phases of the Helping Process

The therapeutic process is informed by the client’s acculturation level, an appraisal that is done indirectly –and often unintentionally– by using acculturation proxies such as length of stay in the United States or English proficiency. Assessment is guided by an understanding of: (a) socioeconomic and emotional variables that can act as risk or protective factors that can be heightened by acculturation-related stressors; (b) migration-related variables, such as voluntary versus involuntary migration or experiencing trauma during the migration; and (c) key Latino culture values as well as intra-group diversity.

Individuals with lower level of acculturation are considered more likely to need an initial preparatory phase with linkage to social supports and basic resources to stabilize their situation before they can effectively engage in receiving a mental health intervention. This initial acculturation level appraisal, thus, determines initial treatment goals. The clinician often serves a dual role of case manager and therapist that is congruent with the values of connectedness and personalism.

Integration of Substantive-level Theory into a Grounded Theory Formulation about

Clinician Views of Acculturation and how it Informs Clinical Practice with Latino

Clients.

Postulate 1: Clinicians who work with adult Latino clients define acculturation in ways that are congruent with extant theory of acculturation but derive that 162 knowledge primarily from experiential sources, such as their own experience as acculturating individuals or clinical practice.

Acculturation-related factors inform clinical practice with Latino clients in several ways. Clinicians engage two types of knowledge of acculturation in practice. One reflects knowledge acquired in academic and professional training settings while the other source is experiential and draws from the clinician’s own process of acculturation as well as from clinical experience. Clinician perspectives on acculturation are informed by a transactional view of the culture exchange process where the individual strives to maintain their cultural core while adapting to a new environment. The process is conceptualized as occurring both intentionally and unintentionally in an iterative fashion over the course of time. While acculturation is seen as something that can lead to personal growth, clinicians are aware that it taxes individual socioemotional resources and this may lead to emotional distress. Clinicians privilege the experiential source of knowledge because it helps foster therapeutic connection with Latino clients through a commonality of experience. This constitutes a working knowledge foundation that, in turn, informs the clinical stance that is viewed as effective when working with adult

Latino clients.

Postulate 2: An effective clinical stance is comprised of culture-unrelated and culture-related clinician attributes. Key clinical attributes viewed as effective include client-centered practice behaviors that are congruent with Latino values of personalismo and respeto and promote engagement, as well as culture-specific practice behaviors. Culture-specific skills include clinical flexibility and being 163 directive, which are also congruent with Latino values of respeto, personalismo, and the centrality of the family.

Foundational clinical skills include being interested in learning about the client’s culture and client-centered principles, such as unconditional positive regard, conveying respect and dignity, and building trust. While not culture-specific, these clinical behaviors are identified as therapeutic rapport facilitators. It is hypothesized that client- centered principles are appropriate because they resonate with Latino values of personalismo and respeto. On the other hand, culture-specific clinician factors are identified as important in order to move treatment effectively past the engagement phase.

Ethnic and linguistic client-therapist match are key variables that facilitate engagement.

Effective practice also requires flexibility. Described as a multi-faceted stance, flexibility involves a willingness to step outside of the traditional therapist role when a client’s basic needs are not fulfilled as well as the ability to borrow from different treatment approaches to do “what works” and not only what is prescribed by a treatment protocol. Flexibility also entails being fluent in idioms of distress and cultural presentation of symptomology in order to form an adequate clinical conceptualization. Another important clinical attitude requires feeling comfortable being directive in the sense of offering concrete strategies to overcome difficulties as opposed to a process- or insight-oriented approach.

This stance corresponds with the deferential respeto that Latino clients often display towards professionals.

Postulate 3: Working knowledge of acculturation informs the different phases of the therapeutic process inconsistently. 164

Acculturation level is estimated using acculturation proxies, such as length of stay in the United States or English proficiency. The assessment process focuses primarily on mental health symptoms and identifying needs for resources in other areas of the client’s life. Level of acculturation and, if pertinent, migration-related variables, may be considered if deemed as causing emotional distress or impeding access to resources. For instance, clients with a lower acculturation level may require stabilization interventions that will enhance their ability to navigate the mainstream culture and get linked to resources before mental health interventions can be effective. Mental health interventions are adapted to fit aspects of Latino culture in an individualized manner, not following standardized cultural adaptations of treatment approaches. Interventions are informed by an informal appraisal of the client’s acculturation level, Latino subgroup affiliation, traditional Latino values, and gender roles, with an understanding that these variables are dynamic and will continue to be shaped by the culture exchange process.

The conceptualization of the adult Latino client past and present socio-emotional history as shaped by the acculturation process would result in acculturation-informed care. Acculturation-informed care as a practice framework incorporates both experiential and research-based knowledge of acculturation and its impact on the mental health of

Latino clients. Acculturation level is assessed by administering a validated acculturation scale or by using research-supported proxy variables and informs the level of care needed by the acculturating individual. Psychosocial assessments include questions that explore mental health symptoms in the context of level acculturation and, if pertinent, aspects of the migration experience that impact emotional wellbeing (such as forced versus voluntary migration or traumatic experiences during the migration). The assessment also 165 explores the client’s familial and social functioning struggles that are impacted by the acculturation experience (for instance, lack of social connection, family conflict related to struggles with the mainstream culture or decrease in social status due to inability to navigate mainstream culture). Whenever feasible, interventions are informed by validated cultural adaptations of mental health interventions that incorporate acculturation-related variables. If cultural adaptations are not possible, interventions should include practice behaviors shown to be effective with Latino clients with the understanding that acculturation level will change over time and may need to be reassessed in order for treatment to be tailored to the person’s acculturation level. A visual depiction of this grounded theory can be found in Figure 5.1

Figure 5.1

Grounded Theory of Clinician Views of Acculturation and how they Inform Practice with adult Latino Clients

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Chapter 6: Discussion and Conclusions

Introduction

This chapter is organized in three sections. First, I examine what findings from this study convey about how acculturation-related variables are incorporated in clinical practice by clinicians and discuss the findings within the broader context of the extant acculturation and practice literature. Following the structure of Chapter 5, this discussion of findings is organized by research question. Second, I examine study strengths and limitations vis-à-vis grounded theory research guidelines. The final section provides a summary of the overall findings, implications for social work practice, implications for social work education, and suggestions for future areas of research.

Conceptualization of Acculturation and Sources of Knowledge

Initial assimilationist views of the culture exchange process as one that should result in a unified cultural identity between the acculturating individual and the host society have long been abandoned (Green, 1999; Weaver, 2005). These earlier ideas conceptualized cultures as possessing stable traits that, during the culture exchange process, individuals would shed in order to incorporate the traits of the new culture. The theory of acculturation postulated by Berry (1997, 2001) advanced a dynamic model of the culture exchange process that describes changes taking place at the group- and individual-level. The attitudes exhibited by two cultural groups coming into contact with each other (i.e., the value to be open to the other group versus the value to keep their own cultural identity) result in four possible acculturation strategies: integration, assimilation, separation, and marginalization (Berry, 2001). Berry also posited that stressors specific to the acculturation experience interact with other factors, such as the individual’s 168 sociodemographic and psychological disposition, the nature of the larger society

(accepting or rejecting), the reasons for the migration, among others, and can sometimes result in what is known as acculturative stress (Berry et al., 1987). Moreover, it should be noted that the process of acculturation may result in outcomes that are enriching and promote individual growth, such as the instances when the person is open to the new environment and to the acquisition of new cultural skills (Berry and Kim, 1988; Berry et al., 1987).

When discussing their understanding of the process of acculturation, the study findings suggest that the majority of participating clinicians held transactional views of the process of acculturation whereby the individual strives for balance in the intercultural contact space. In this transaction, the challenge identified by participants was to

“maintain their cultural core” while “negotiating the new environment.” Also, acculturation was frequently referenced in terms of “adaptation.” The code “adapting to a new environment” was comprised of adapting to a new physical environment as well as adapting to new norms and to a host country/society.

In the present study, acculturation also was described often as a process of a learning nature in which the acculturating individual learns about cultural differences.

Participants also referred to this aspect by using words that conveyed an intentionality on the part of the person, such as “you see the differences and you educate yourself on the differences” and a willingness as in “the person that (…) comes to the host country and wants to learn from that country.” These findings are consistent with definitions of acculturation in the literature that conceptualize the process as one of culture learning and social skills acquisition (Brislin, Landis, and Brandt, 1983). 169

The other codes that emerged, albeit less frequently, also conveyed positive aspects of acculturation in the use of words like “bridges,” “embracing” the new culture and “blending in.” Responses emphasized aspects of the process of acculturation that are related to what Berry would identify as an integration strategy. Findings suggesting that clinicians were aware of other, more negative acculturation outcomes will be discussed later in this section.

In addition, clinicians were asked to articulate the processes through which acculturation takes place. Findings revealed great emphasis on the temporal dimension as a process that happens over time, that cannot be rushed, and takes place incrementally.

In the words of a participant, “it happens at different levels, over time, you gradually learn the system and you take on pieces and there are pieces you don’t take on.” In fact, this is consistent with the observations of another acculturation scholar, Kim (1988), who reports that is rather common for acculturating individuals to try different acculturation strategies before reaching a more stable cultural identity, a process that happens over time.

The reverse side of intentional learning was identified by participants when they described processes that occur unintentionally or “by osmosis.” Acculturation requires exposure to the new culture so that new information can penetrate. The process identified as “blending in,” albeit with few coded incidences, amalgamated the intentional and unintentional aspects of the process. The result is a cultural blend, similar to Berry’s integration strategy.

Another key finding was the idea that acculturation takes place through a strong connection to the family of origin. At first glance, this may seem contradictory. 170

However, acculturation does entail a process of comparison between what is known and familiar and what is different and foreign. It is from within the stability of the primary support system that the person can venture into the unknown. One of the participants stated eloquently that “if you don’t have roots (you don’t have) a sense of self.” These words resonate with how Jaes-Falicov (1998) conceptualized acculturation as uprooting of meaning. The author uses the plant metaphor to exemplify how the acculturating individual has to plant roots in new soil and, in so doing, there is often residual soil from the place of origin that remains attached to the roots. The residual soil may find a way to integrate with the new soil and thrive.

This finding also needs to be seen through the lens of the centrality of Latino family connections embodied in familismo. A drastic departure from family connection during the process of acculturation may place undue stress on the individual. Lewis-

Fernández and colleagues (2016) found a direct association between higher acculturation and mental health disorders and hypothesized that one of the factors at play is the general progressive loss of the protective effect of culture, principally family unity and support from family of origin and other relatives. There is also evidence that supports that, while psychological acculturation is an individual phenomenon, the process takes place in the context of a family with cohesive family dynamics promoting a positive acculturation outcome for young people (Ward and Geeraert, 2016).

As for from where clinicians drew their acculturation knowledge, higher education, clinical practice, and personal experience were cited equally as sources of acculturation knowledge. However, when it came to prioritizing which type of knowledge clinicians engaged in their practice more, the majority chose their own 171 personal experience with acculturation. Clinicians were not familiar with any theory of acculturation but they did mention the concept of cultural competence often. Clinicians with 20 or more years of experience reported that they learned about the concept of cultural competence post-graduation, through professional continuing education or their own readings. Even though participants were more familiar with the concept of cultural competence, they were not able to reference any specific frameworks. Chapter 2 of this dissertation contextualized the evolution of the concept of cultural competence in social work across time, dating back to the 1980s and the postmodern perspectives that started to evolve beginning in the 1990s. While it is true that cultural competence as a concept has continued to evolve to reflect current views on how to engage diversity in social work practice, broadening its scope beyond ethnic minority groups to include individuals of diverse backgrounds (Azzopardi and McNeill, 2016), the historical review of the theoretical literature shows that there is no shortage of cultural competence frameworks to use in practice. The finding that clinicians primarily favor their experiential knowledge of acculturation warrants further exploration.

Commonality of experience was viewed as a key factor that fosters rapport, as this clinician eloquently put it: “…I think that my experience is their experience. I think that’s what makes us good clinicians, that we are Latino (…) as opposed to somebody who just speaks Spanish.” The evidence in support of therapist-client ethnic match in regards to establishing rapport and building trust was mentioned in the literature review chapter (Ertl, Mann-Saumier, Martin, Graves, and Altarriba, 2019; Kim and Kang, 2018).

However, research findings offer a mixed picture indicating that although clients of racial/ethnic minority groups tend to prefer clinicians of similar racial/ethnic background, 172 client outcomes do not seem to show significant improvement (Kim and Kang, 2018).

Hence, while relying entirely on experiential knowledge is valuable because it helps build trust, it can also offer a sense of false reassurance that may preclude an objective assessment of the client’s needs and the most culturally adequate ways to intervene.

Ways in Which Acculturation Knowledge Informs Clinical Practice and Variation

Based on Clinician Level of Acculturation

Building on a series of interrelated questions, clinicians were asked to articulate the different ways in which their knowledge of acculturation informed their clinical stance with clients. These factors were organized into two categories. One category coalesced around clinical behaviors that were specifically related to culture. The other one included clinical behaviors viewed as generally conducive to establishing a strong therapeutic alliance and engagement regardless of cultural background. Among the clinician factors that are not culture-specific, clinicians identified the importance of having cultural sensitivity and conveying interest in learning about the client’s culture.

These two behaviors are considered foundational competencies needed to engage in any type of cross-cultural practice. The other three categories related to approaching clients with dignity and respect, unconditional positive regard, and promoting trust, all of which are in line with the client-centered approach to psychotherapy founded by Carl Rogers.

While these practice behaviors can be considered basic skills of cross-cultural practice and psychotherapy, it should be noted that they also resonate with Latino values of respeto and personalismo.

The most frequent factors cited within the culture-specific clinician category were being of Latino ethnicity and being bilingual, both seen as facilitators of the therapeutic 173 connection. There is partial support in the literature for these views. For instance, ethnic minority therapists were found to have higher multicultural awareness relative to White counterparts (Berger, Zane, and Hwang, 2014) and people of color express a preference for therapists of their own race/ethnicity (Cabral and Smith, 2011). However, this match did not necessarily translate in better clinical outcomes (Cabral and Smith, 2011).

Racial/ethnic match between therapist and client appears to make sense vis-à-vis a shared worldview, this is not guaranteed with all members of the same racial/ethnic group. The other downfall of racial/ethnic matching is that it may increase consensus bias, i.e., the assumption that there is greater commonality than there really is (Cabral and Smith,

2011). In summary, while racial/ethnic match may be useful, it may not be needed for all therapeutic relationships.

The next culture-related clinician factor identified was “being flexible.”

Flexibility presented many facets, such as using different treatment modalities, being willing to act in a dual manager/therapist role, and being comfortable within a closer interpersonal space in the therapeutic relationships (for instance, accepting a cup of coffee at a client’s home because not doing so would be offensive). Flexibility also entailed understanding the different idioms of distress and how diagnoses may present differently outside of mainstream culture. There is evidence in favor of the appropriateness of a flexible approach to treatment. Berger, Zane, and Hwang (2014) found that an eclectic (flexible) orientation was positively correlated with knowledge about communities of color and multicultural counseling competencies.

Research findings showing that members of racial/ethnic minority groups are given more severe diagnoses than White counterparts (Hays, Prosek, and McLeod, 2010) 174 were reflected in an observation by a study participant. This clinician stated that the lens through which Latinos see mental health problems may be different from the mainstream:

“I’ve heard that, in the past, clinical psychology would misdiagnose certain characteristics of the Latino population (such as pathologizing) ataque de nervios (which) is something common, it’s okay, it’s a way of reacting to external forces.”

Another clinician attribute considered important when working with Latino clients was being “directive.” This quality was viewed as a willingness to provide clients with concrete strategies to manage emotional distress as opposed to process-oriented interventions. There is support in the literature for this finding. Berger, Zane, and Hwang

(2014) found that a behavioral treatment orientation (directive), as opposed to a psychodynamic or humanistic approach, was positively correlated with multicultural counseling competency.

Among others clinician factors seen as culturally appropriate, clinicians identified the importance of being comfortable with the role of expert and with being called family. These factors need to be understood within the framework of Latino values, such as respeto and the centrality of the family. Clients convey respect for the clinician by deferring to their clinical opinion. One of the social work practitioners who participated in the study highlighted the dissonance she experienced the first time she was called doctora by clients despite her due diligence to clarify her credentials. The expert role that Latino clients may project is out of respect. It neither undermines the client right to self-determination nor does it mean that the clinician makes decisions on behalf of clients. By the same token, feeling comfortable being called family should not be interpreted as a professional boundary breach. Rather, it represents the trust that the 175 client bestows on the clinician. These types of situations may present an opportunity to engage the client in psychoeducation about other styles of clinician-client relationships, so that the client can be empowered to navigate those systems with increased mainstream cultural knowledge.

An unexpected finding emerged when comparing clinician answers by nativity status. Foreign-born clinicians had lower frequencies of coded incidences on both categories within this code group (culture-unrelated and culture-related clinician factors).

One possible explanation of these differences may be that these clinicians have an overall lower level of acculturation than U.S.-born clinicians. U.S.-born clinicians often struggled growing up with a strong sense of being different and even discriminated against –an experience that indelibly shaped their worldview. U.S.-born clinicians also were educated in the United States. It is possible that their personal experience with oppression and discrimination, combined with being exposed to discussions of cultural competence in higher education, equipped this group of clinicians with clinical tools that they use in an intentional way. On the other hand, foreign-born clinicians came to the

United States shaped by the experience of being part of the mainstream culture in their countries of origin, something that could have both sheltered them here from feeling oppressed in the United States and at the same time constitute a “blind spot” to their clients’ experience. Their educational background may also be significantly different from U.S.-born counterparts. In fact, foreign-born clinicians stated they were not exposed to ideas of acculturation or cultural competence in their countries of origin.

These ideas are speculative in nature and will be addressed again in this discussion when

I present the limitations of the study. 176

How does Acculturation Inform the Different Phases of the Helping Process?

Acculturation in the assessment phase. While it is widely recognized that assessment is an ongoing process, the focus here is on the initial mental health assessment that is conducted at the point of intake. It is also recognized that there is great variation in the format of an assessment depending on the setting where the client is seen

(e.g., community mental health center, private practice, hospital setting), what type of data the assessor is required to gather in order to satisfy regulatory agencies, insurance companies paying for services or funders, and the specific focus that the organization may have (for instance, vocational rehabilitation, workforce development, or behavioral health). These are some of the variables over which the assessor has limited or no control. Notwithstanding this, when asked about what acculturation-related variables would be important to assess in order to form an adequate conceptualization of the mental health status of a Latino client, clinicians listed a number of variables that find support in the literature.

Migration-related variables. When pertinent, participants pointed at the importance of exploring migration-related variables because they understood that voluntary versus involuntary migrations may impact mental health differently. In addition to the stress and losses entailed by the process of moving away from their home countries, forced migrants are at a higher risk of severe trauma. Participants were keenly aware of how victimization and exploitation are dire realities that many migrants suffer, thus emphasizing the importance of exploring trauma during the migration. Choosing to migrate, while not a guarantee of a trauma-free migration process, affords the individual 177 some control over the process, which was hypothesized to result in less emotional distress.

Biopsychosocial variables. The array of biopsychosocial variables identified as important to assess was not surprising as a finding given that participants were skilled assessors and well aware of key areas to explore. Some of these variables stood out because they were conceptualized as potential protective or risk factors for mental health outcomes in the context of acculturation. Primarily, participants referred to the need to explore whether the client has social/family support systems in the United States and, to a lesser degree, in the country of origin, both of which were viewed as protective factors, linked to the centrality of the family in Latino culture. There is support in the literature for the negative impact on wellbeing of Latinos in the United States resulting from decreased or severed contact with family members in their country of origin or the experience of being left out and discriminated against based on their ethnic status (Salas-

Wright, Robles, Vaughn, Córdoba, and Pérez-Figueroa, 2015). The reverse side of family/social support was captured by the category of “isolation, exclusion, not belonging.” It is not sufficient to ask a close-ended question about whether a client has family or social support but to explore how the person feels about the support they have in the process of their acculturation. Open-ended questions may yield more meaningful information, such as “Could you tell me how you go about establishing new connections here?” because they invite a conversation about social connectedness and the tools the person has or needs in order to reach out to others.

The importance of exploring socioeconomic variables, such as financial struggle, immigration status, employment status and work experience, and education level, was 178 also recognized in connection to acculturation. Clinicians recognized the stress that ensues when somebody is facing instability in any of these areas. One of the participants articulated the linkage by stating that, in order for a Latino person to effectively manage the mainstream culture, they need basic skills that often come from having education, which in turn may translate into job and financial stability, as well as lower stress.

Having higher educational attainment also was viewed as buffering somebody against some of the acculturation stressors because the person was thought to be better equipped to make sense of adverse situations and problem-solve more effectively. Clinicians added that, while immigration status is not something they would inquire about, if this information is volunteered by the client it helps conceptualize what resources may be available to the client and what other fears may be impacting their emotional wellbeing

(e.g., fear of deportation). These findings echo what the extant literature status about the connection between acculturative stress and financial status, English language proficiency, and education (Salas-Wright, Robles, Vaughn, Córdoba, and Pérez-Figueroa,

2015).

Other risk factors viewed as relevant, albeit with fewer coded instances, included assessing previous medical or mental health history, barriers to care, living in an adverse neighborhood environment, and experiencing fears related to being in the United States.

Clinicians were aware of how often Latino clients (particularly foreign-born ones) come to the United States with untreated physical and mental health conditions that could be exacerbated by acculturation stressors. Barriers to care were linked to both a lack of service providers that Latino clients can feel comfortable with (due to language and cultural differences) as well as issues of accessibility due to lack of insurance. It was also 179 recognized, in connection to the socioeconomic variables discussed above, that individuals with low levels of acculturation may be more likely to struggle and to live in disadvantaged neighborhoods, which further augments the stress of acculturation.

Finally, the current sociopolitical situation of the United States with marked anti- immigrant sentiment, and fear of deportation in some cases, was mentioned as something clinicians should be sensitive to because of how it compounds the existing discrimination and oppression that Latinos may already face. These findings also confirm results from other authors (Salas-Wright, Robles, Vaughn, Córdoba, and Pérez-Figueroa, 2015).

Assessment of cultural variables. There was no uniformity in the approach to assessing relevant cultural variables. Once again, clinicians mentioned that the various assessment forms they use in practice do not always require an in-depth cultural exploration. A client’s “openness to mental health treatment” was viewed as a protective factor. Males were perceived as having more difficulty relative to female counterparts accepting treatment, something that was linked to traditional gender roles and machismo.

The acculturation process at times introduces an imbalance in the traditional role expectations. It is not uncommon for women who might have been in a domestic role prior to entering the mainstream culture to be the ones who join the workforce when males struggle to adjust. Traditional machista views may equate needing mental health services to weakness, something that needs to be explored in cases where male clients struggle to accept treatment and not necessarily label as resistance.

The importance of religion or faith in the person’s life also was mentioned as an important area to explore. The link to acculturation here is two-fold. On the one hand, spirituality is a central value in Latino culture and being disconnected from a place of 180 worship during acculturation can deprive the person of an important part of their identity and coping. On the other hand, participating in activities as part of a faith community increases networking opportunities and exposure to others with different levels of acculturation. This serves the purpose of learning about the mainstream culture and about resources. Participants identified the importance of religious organizations as informal social service agencies that are often the first point of contact for an individual in need.

In resonance with how clinicians discussed the person’s willingness to learn the new culture as key in acculturation, they also identified the importance of exploring two ends of a cultural continuum: degree of assimilation and openness to learning the mainstream culture. Assimilation was viewed as having a potential negative impact on mental health due to the cultural loss that it entails. One participant described cases of assimilation as “they have cut a piece of themselves completely out to be able to be part of the mainstream…a definite loss.” Finding balance between assimilation and learning the new culture was seen as the ideal to strive for, as this quote conveys:

I think that the healthiest acculturation for mental health is when you can find the

right balance, not letting go completely of where you came from, but not 100%

taking on everything else. Finding a balance (between) the things that can be

helpful and can translate to where you are now.

These views are consistent with Berry’s integration acculturation strategy as one that can lead to growth as the person augments their socio-emotional repertoire by learning new behaviors and new problem-solving strategies (Berry & Kim, 1988; Berry et al., 1987). 181

Participants also emphasized the importance of exploring views of mental illness.

While this category had fewer coded incidences, it was retained because it seems like the logical precursor of the openness to mental health treatment. Once again, traditional

Latino males were seen as more reluctant to seek help because of equating emotional distress to weakness. In light of this, clinicians need to be sensitive to the fact that, if a

Latino male with a low level of acculturation finds himself in front of a mental health professional, he may struggle to accept the need for help because that would imply seeing themselves as weak or as a failure. Another participant reflected on how she saw changes over time in the openness of Latino males to services and connected this to the effects of acculturation. Finally, another facet of views of mental illness underscores how individuals with low levels of acculturation who were born in resource-deprived countries may not have a basic working understanding of what the services entail.

Therefore, the assessor needs to be sensitive to this possibility and offer clear information so that the client can be better equipped to make an informed decision.

Acculturation assessment. There were no mentions of acculturation measurement tools or of systematic use of acculturation proxy variables as part of the assessment process. However, clinicians do think it is important to estimate the English proficiency level or know the length of stay in the United States in order to decide how much concrete support the person may need before they might be ready for mental health treatment. The assumption is that individuals with low level of acculturation will need more concrete sources of support, such as help finding jobs, housing or assistance with transportation. In other words, individuals with low levels of acculturation need help fulfilling these basic needs areas more frequently than clients with a high level of 182 acculturation who have had more exposure to the mainstream culture and have learned about these resources.

Acculturation in treatment planning, intervention and termination. I will start with the last phase of the process because it was the one about which the least was said. Clinicians reported a high rate of unplanned terminations and viewed this part of the process as something they had less control over. The majority of participants worked in community settings, which may suggest that the socioeconomic barriers faced by low- income Latinos may interfere with reaching an agreed-upon termination. The other consideration is that clients and clinicians may have differing views on what constitutes improvement. A client may leave after initial improvement but the clinician may consider that there were more areas to address in treatment. The role of acculturation in this phase of the treatment process remains unclear at this time.

Treatment planning. The main distinction that clinicians in community practice made about the role of acculturation in planning was to evaluate the degree to which the client needs stabilization of basic needs before mental health treatment per se can start.

While private practice clinicians were not particularly represented in this study, it was noted that, in this setting, treatment planning is not as regulated as in community practice.

Planning was described as a conversation about where the client may be in the process of acculturation or an exploration of what it means to be an immigrant as this relates to the presenting symptoms. The focus in private practice is different because the socioeconomic status of the clientele tends to be different than in community settings.

Thus, there is less focus on the case management needs. 183

Intervention. Participants discussed the manner in which they intervene effectively with Latino clients more so than cultural adaptations or interventions within a specific treatment approach. There was strong emphasis on intervening within the framework of Latino values, such as dignidad (dignity), respeto, personalismo, the centrality of the family and the importance of spiritualism. The value framework should be thought of as the context that informs any intervention. In Latino culture, problems are first addressed within the family system. Going outside of the family presents great cultural dissonance for somebody with a low level of acculturation and needs to be acknowledged and validated by the practitioner in order for treatment to take place. Also, interventions need to be tailored to be culturally accepted. The way in which interventions are modified by clinicians was not systematic. For instance, interventions that have been proven to be effective in managing anxiety, such as relaxation strategies, may not have great chances of success with a low-acculturation female client with a high value in sacrificing her own needs to take care of others first (a value often referred to as marianismo). Finding creative ways to incorporate a brief breathing or mindfulness practice to a house chore that this client does for others may increase her chances of adhering to the therapeutic recommendation. Similarly, another clinician offered an example of how to use the format of culturally-accepted religious practices to maximize chances of adherence to a self-care activity: creating a self-care corner akin to an altar where the client can retreat to breathe or pray, which is also a form of meditation.

Another consideration viewed as culturally relevant was the need for a here-and- now focus as opposed to approaches that incorporate past developmental or interpersonal history, such as insight-oriented therapies. The present-focused and behaviorally-based 184 approach is congruent with the stance of being directive with Latino clients discussed earlier in this dissertation.

The category “allowing the client to tell the story,” while not showing many coded incidences, was retained in the intervention code group because of its relevance to

Latino culture. This category reflects the anecdotal and florid style of communication common in Latino culture. A low-acculturation individual may be more likely to display this style and will, therefore, have a need to be heard. Oral transmission of information is often preferred over written materials, particularly for individuals with low levels of acculturation and reflects the value of personalismo. Allowing the telling of the story also may serve a cathartic purpose for people who have been oppressed or have felt excluded due to language barriers and discrimination.

Finally, interventions with few coded incidences were grouped as “other interventions,” such as linkage to resources and psychoeducation. Linkage to resources has been discussed earlier as part of the assessment phase and also as an important step to take in order to fulfill basic needs. While typically a case management function, it falls under the non-traditional role of the therapist who needs to be comfortable serving in a dual role as case manager and therapist. Psychoeducation can have an empowering effect on a client with a low acculturation level, helping them understand basic mainstream cultural rules, helping them label their own acculturation experience and the impact that it has on their emotional wellbeing and their relationships.

Study Strengths and Limitations

Clinician views of acculturation and how they inform clinical practice with

Latinos emerged as an understudied area in the extant literature despite evidence that 185 suggests acculturation can lead to negative mental health outcomes (Alegría, Sribney,

Woo et al., 2007; Burnett- Zeigler, Bohnert, & Ilgen, 2013; Cook, Alegría, Lin & Guo,

2009; Erving, 2017; Lewis-Fernández et al., 2016). The literature on cultural adaptations of mental health interventions with Latinos depicted an inconsistent incorporation of acculturation to inform the adaptations. The present study gives voice to clinicians working with Latinos and attempts to reconstruct how they acquired knowledge of acculturation, what they understand to be the most appropriate clinical stance to work with acculturating Latino clients, and how they incorporate both knowledge and stance throughout the therapeutic process. The relative value of this grounded theory will ultimately be judged by fellow practitioners who work with the population of interest.

However, there are some criteria to guide us in the process of evaluating a grounded theory: credibility, originality, resonance, and usefulness (Charmaz, 2014).

Credibility. Charmaz suggests some questions to ask in order to ascertain whether a grounded theory meets this criterion: has the research achieved intimate familiarity with the topic? Are the data sufficient to merit the claims? Has the research provided enough data for the claims to allow the audience to reach their own conclusion? In this case, the data were gathered for the specific purpose of this study by the researcher using an interview guide developed for the study, after conducting a literature review to form an understanding of the scope of the topic of study within the extant research. In this sense, a level of familiarity with the topic was achieved. The proposed study and analytic plan followed Charmaz’s methodological guidelines, as outlined in Chapter 4. As for whether the data were sufficient to merit the claims, this is arguable. There is no qualitative power calculation akin to what exists in quantitative studies. Instead, the concept to 186 reach is data saturation, where the existing categories are well defined and no new data emerge. This may take 20-30 interviews in some cases or 50-60 in others (Creswell,

2007). Ten interviews do not constitute a high number. Moreover, this study described instances where some coding categories had few coded instances. It is possible that, with a larger number of interviews, those categories could have reached saturation. Or it is possible that the opposite could have happened. My dissertation co-chair acted as second coder at the beginning of the analytic process (first 3 transcripts). The emerging open codes were discussed and her feedback about how the interviews were conducted was incorporated to the analytic process of the remainder interviews. Member-checking was also employed in order to seek feedback from participants about the emerging categories and their feedback confirmed the interpretation of the data, as discussed in Chapter 5.

The present study presents the rationale for the study of the problem, a detailed literature review, a methodical account of all the steps involved in the research process, and a detailed summary of the results, all of which should allow the intended audience to form a conclusion about the credibility of the grounded theory.

Originality. This criterion is concerned with whether the categories are fresh and offer new insights. It is also concerned with how the analysis contributes new information about the data, as well as how the theory challenges, extends, or refines current ideas and practices. In the process of developing categories, I stayed close to the data and tried to capture key words used by participants that conveyed the spirit of the conceptual category or process. The use of gerunds aided in that process (“being directive,” “having no problem being considered family,” etc.). Some of these categories had already received support in the extant literature (such as the client-centered practice behaviors or 187 assuming an attitude of cultural sensitivity) but others were surprising, such as the value of experiential knowledge of acculturation in practice and the reverse side of this represented by the inability to recall any theory of acculturation or cultural competence framework. This study lends support about the gap that exists between the association of acculturation and mental health outcomes and the incorporation of this evidence to practice.

Resonance. Some useful questions to ask to evaluate this criterion are: Do the categories portray the studied experience in all its fullness? Have taken-for-granted meanings been uncovered? And, most of all, does it make sense to the clinical community and offer them deeper insights into their practice? The categories that emerged from the data depict a rather comprehensive picture of the experience of acculturation that was elicited through questions that prompted participants to think not only about their clients but also about themselves. Several participants pointed out at different times of the interview that they had never paused to think about many of the issues discussed, which I took as validation that we were delving under the surface and asking them to think about the rationale of why they practice the way they do. This grounded theory resonates with practitioners because it gives voice to their experience as clinicians treating Latinos, which is under- represented in the literature. It also resonates with clinicians because community practice pushes the clinician to meet high productivity standards and there is little to no opportunity to reflect on their clinical experience.

Usefulness. This criterion is concerned with questions such as: how can the results from the grounded theory be applied to practice? Do the categories suggest generic processes at play? Can the results stimulate further research in other areas? Overall, how does the 188 study contribute to knowledge? Aside from emphasizing the importance of informing clinical practice with Latinos with knowledge of acculturation, the analysis encourages practitioners to supplement their experiential understanding of “what works” with their clients with research on existing cultural adaptations that may result in better treatment outcomes. An intriguing finding that grants further research is the apparent difference in the way practice behaviors were endorsed depending on practitioner nativity status. The number of coded incidences were not sufficient enough to ascertain whether this distinction in fact exists or was an artifact produced by the small sample. Overall, this grounded theory contributes to practice knowledge because: (1) it validates that some of the conceptualizations and practice behaviors have support in the scientific literature; (2) it illuminates the importance of being intentional about incorporating a well-known variable in the lived experience of Latino clients and provides evidence of why this is relevant throughout most phases of the therapeutic process (the termination phase remains unexamined at this point); and (3) sets the stage for continued research on the topic of clinician views of acculturation and how they inform practice with Latino clients.

Finally, as with any qualitative study, caution should be exercised when transferring these findings to other populations and/or settings. Findings are contextualized within the time, space, and setting of the research, and therefore may not be transferrable outside of these contexts. The limitations of the sample size were discussed above vis-à-vis conceptual saturation. While it is true that there is a shortage of licensed mental health professionals who are bilingual and bicultural and can work with the Latino population, 10 clinicians offer limited representation of the problem of study.

One idea to be considered in future studies for increasing participant recruitment is the 189 use of incentives. Also, my advertising of the study in person and through the snowball method limited recruitment to clinicians immediately available in the Cleveland area. A strategy that could overcome this limitation is to outreach clinicians through online platforms such as Psychology Today. This type of online platform allows the user to search for clinicians applying filters, which would facilitate reaching clinicians who meet the study inclusion criteria. The use of videoconference platforms to conduct long- distance interviews would facilitate the process. It should also be noted that the results of this study and how they are integrated into a grounded theory are to be considered tentative and not conclusive. These findings should not be taken as guidelines of how to practice with acculturating Latino clients or any other racial/ethnic minority.

Implications for Social Work Practice and Education

Results from the present study confirm the role that the process of acculturation has in the lived experience of adult Latinos living in the United States and how it can lead to growth or emotional distress. Findings from this study also corroborate that Latino clinicians participating in this study were sensitive to their clients’ experience in the mainstream culture, are attuned to the challenges entailed by the acculturation process, and that they strive to incorporate this knowledge to treatment, all of which contributes to a good therapist-client match. This last finding, however, requires further exploration.

Indeed, Latino clinicians in the study have the obvious advantage of speaking Spanish and sharing aspects of the same cultural background as their clients. On the other hand, study participants could not cite any cultural practice frameworks that inform their practice. This could have given the Latino clinicians who participated in this study a sense of false reassurance that they are “competent” in their Latino clients’ culture and 190 that they hold no pre-existing assumptions that may be inaccurate. Postmodern perspectives of cross-cultural practice discussed the notion of “competence” as illusory and running the risk of emphasizing similarity at the expense of neglecting individual differences (Ortega and Coulborn-Faller, 2011). Being of Latino background does not exempt clinicians from engaging in an exploration of their own cultural assumptions, just as any other clinician who wants to work effectively with diverse client systems would.

When it comes to a client-therapist system that is ethnically matched, the stance of cultural humility would open up possibilities of learning about parts of the client’s experience that the clinician may not be aware of due to different lived experiences, power differentials, social class or gender. One of the main challenges in fast-paced and funding-challenged community mental health settings is to find time to devote to issues such as cultivating cultural humility. This is a practice that could be incorporated to weekly supervision, staff meetings or in-service training without great expense. It requires firm commitment from leadership and from clinicians who can become advocates of adherence to this way of practicing.

In regards to knowledge of acculturation, most clinicians in the study demonstrated adequate working knowledge of the process and how it can impact mental health outcomes in spite of not being able to cite specific theoretical frameworks or recalling learning about it in academic settings. Most clinicians also mentioned the challenges in community mental health practice settings where there is limited autonomy to depart from specific assessment forms and struggles to engage in a conversation about the acculturation experience due to limited time and competing crises. These two apparent limitations present opportunities. It is possible that, with adequate 191 organizational supports, clinicians working with Latinos may be able to incorporate this experiential knowledge to practice in a meaningful fashion. One way in which this can be done is by having mental health assessment forms that include a section on culture that contributes meaningful information to the clinical conceptualization of the case. The culture section in mental health assessment forms commonly used by agencies can be rather generic (e.g., “Are there any cultural considerations in the case?”) and lacking in relevant questions that can offer clinical guidance. Whenever possible, the use of acculturation scales could offer valuable information that would allow clinicians to frame the presenting symptoms taking level of acculturation into account. If this option were not feasible, acculturation proxy variables could be incorporated to the assessment to estimate the level of acculturation and tailor treatment accordingly.

The part of the treatment process that offers the most opportunities for improvement is the intervention phase. Study findings concur with the extant research on cultural adaptations with respect to the need to make changes that are congruent with the culture. Study participants could not cite any cultural adaptations of mental health interventions tailored specifically to Latino culture. It is quite possible that many clinicians do not have access to academic databases or peer-reviewed journals in order to stay abreast of the latest cultural adaptations. It is also possible that the dissemination of these adaptations beyond academic circles has not been undertaken in effective ways.

There is no reason to suspect that clinicians who work with the Latino population would not want to have well-researched interventions to help their clients achieve their potential. 192

While there is no immediate way to remedy these gaps in practice, new cohorts of social work students will benefit from learning about effective strategies to practice with diverse client systems impacted by acculturation. Doing so will further strengthen the development of multicultural awareness in students. Cultural competence as a concept still exerts a gravitational pull because the field of social work was organized around it for decades and because it seems to offer a convenient way of describing a complex concept. Indeed, multicultural practice requires an ongoing exploration of one’s own cultural assumptions and biases. Yet, social work practice continues to evolve and we have to remain aware of the contexts that shape practice.

The way in which mental health interventions are taught in social work practice courses would be enriched through the incorporation of the data that show that these interventions were not developed with adequate representation of racial/ethnic minorities and by emphasizing the importance of cultural adaptations.

Suggestions for Future Research

This study provided an initial insight into clinician views of acculturation in mental health practice with adult Latino clients. Some study findings were consistent with the extant literature, such as the understanding of the process of acculturation, key assessment areas vis-à-vis level of acculturation, and some of the practice behaviors identified as effective in work with Latinos. Overall, study findings indicate that incorporating knowledge of acculturation to practice is important when working with acculturating Latino clients, albeit this is done in inconsistent ways. The small scale of the present study warrants a continuation of this research in order to gather a larger sample of clinicians to further test the applicability of this grounded theory. An area that 193 could not be adequately explored due to the small sample size was the emerging differences in clinician factors by nativity status. Another comparison that remains unexplored due to insufficient representation in this sample is the one between clinicians with and without Latino descent. These comparisons could help better understand the ways in which clinicians incorporate knowledge of acculturation to practice and what role the clinician’s cultural background may play.

Finally, the need for continued research on interventions that have been found to be effective with the adult Latino population remains critical. More specifically, incorporating extant knowledge of the process of acculturation and its impact on mental health in the development and implementation of interventions remains woefully understudied.

194

APPENDIX A

Interview Guide (English Version)

Thank you for agreeing to take part in this study. Today, we will talk about your views on acculturation, the role it has had in your life and specifically in the life of your Latino clients, and how it informs your practice as a clinician. I will ask some questions, but I want you to have complete freedom to express any other thoughts on the topic that you think are relevant or related. You can do this at any time, even if it was not part of the question. Please, do not mention any names of clients.

As I mentioned in the informed consent, the interview is being audio-recorded so that I can capture all the information, transcribe it and analyze it. The only people who will have access to the recordings and/or the transcripts are the responsible investigators, Dr. David Hussey and Dr. Anna Maria Santiago, and myself.

Thank you again for your valuable participation in this study.

1) I’d like to start by asking you what your current/last position at work is: Direct practice clinician ___

Supervisor (no direct practice) ___

Supervisor (some direct practice) ___

Administrator (no direct practice) ___

Administrator (some direct practice) ___

2) What setting do you practice in right now?

Community mental health agency/hospital ____

Private practice____

Both____

3) What is your licensure type? ______

4) What degrees do you hold?

Bachelor’s degree___(major) ______Master’s degree___ Type______Doctorate___ Type______195

5) Years in clinical practice: ___

Still in practice? Yes __ No __ (if no, how many years ago ___ )

6) What percentage of your caseload do you estimate is Latino? _____

(If retired or no longer doing clinical work, percentage of last caseload of Latino origin

_____)

7) Let’s start with a practice scenario. Suppose you are meeting with a Latino client for an assessment. He is an adult from a Central American country and has lived in the United States for 2 years. What information related to his experience as an immigrant in the United States do you think is relevant to obtain in order for you to understand this person’s mental health concerns?

7.a) Would you ask details about the migration experience? (e.g., why the person came to the United States; was the migration experience traumatic [how did they enter the United States?], who did they leave behind?), was the migration voluntary or involuntary? Ask the participant to give a rationale for both a YES or NO answer. 7.b) What else would you ask about the migration experience that will help you understand the client’s mental health concerns? 7.c) What aspects of the migration experience do you think could protect the person from having negative mental health outcomes? (e.g., higher education level, English proficiency, extended family support in the United States, access to mental health/health services; participation in community activities that promote integration with the mainstream). 7.d) What aspects of the migration experience do you think could contribute to the development of negative mental health outcomes? (e.g. lower education level, poor English proficiency, poor/no extended family support in the United States, poor/no access to mental health services, poor/no knowledge of where to go for mental health services, isolation within his/her own ethnic enclave).

8) Can you tell me what the term “acculturation” means to you?

8.a) How would you describe acculturation? 8.b) Can you give me some examples of acculturation in the lives of Latino clients that you observed in your practice? 8.c) Where did you learn about acculturation? 8.d) When did you learn about acculturation? 8.e) How do you think acculturation happens?

9) What does acculturation mean to you personally (in your personal life experience)? 196

9.a) (If applicable to the participant) How would you describe acculturation in your personal life experience? 9.b) Could you give me some examples of acculturation occurring in your personal life? 9.c) (If applicable to the participant) How do you think your own acculturation experience influenced your own emotional wellbeing?

10) How did you acquire your professional knowledge of acculturation? (in school, post-grad trainings, professional readings).

11) When did this knowledge evolve in your career?

11.a) Early in your career? 11.b) Mid-to late career?

12) In what ways does your knowledge of acculturation inform your work with clients? (Flesh it out very extensively with the Latino service providers)

12.a) What does it mean in different phases of the helping process: assessment, planning, intervention? 12.b) What would be some me examples of how acculturation informs your practice in each one of these phases? (assessment, planning, intervention). 12.c) Do you implement this knowledge of acculturation differently, depending on what Latino subgroup your client belongs to? • How so? • Can you provide some examples of this in your practice? 12.d) Which one do you think you use more in practice: the professional/academic knowledge or the personal knowledge of acculturation? • Why?

13) Is there anything else you would like to add about the role of acculturation in informing your clinical practice that we haven’t covered in this interview?

DEMOGRAPHIC INFORMATION

Gender:

Female__ Male__ Transgender __

Year of birth:

Race:

White __ 197

Black __

Native American __

Asian/ Pacific Islander __

Multiracial ___

Latino Ethnicity:

Puerto Rican __

Mexican __

Central American __

South-American __

Other __

Not Latino ___

Where were you born? (City and Country): ______

If foreign-born, age of arrival in the U.S.: ______

Primary language: ______

Secondary language: ______

I also wanted to ask if you would be willing to be part of a group discussions with clinicians later in the study. That group may also take between 60 to 90 minutes and the purpose will be to check with participants of the study whether the analysis I’m conducting of the data is accurate. Your feedback will be very valuable and critical to the study.

___ NO ___YES

198

Interview Guide (Spanish Version)

Gracias por acceder a participar en este estudio. Hoy hablaremos acerca de sus perspectivas sobre la aculturación, el rol que ha tenido en su vida y específicamente en la vida de sus pacientes latinos, así también sobre cómo ha influido su práctica clínica. Yo le haré unas preguntas, pero quiero que Usted se sienta con libertad de expresar otras ideas sobre el tema que Usted piense pueden ser relevantes o estar relacionadas. Puede hacerlo en cualquier momento, incluso si no es parte de la pregunta. Por favor, no mencione el nombre de ninguno de sus pacientes.

Como he mencionado en el consentimiento informado, la entrevista será grabada para poder capturer toda la información, transcribirla y analizarla. Las únicas personas que tendremos acceso a la información son mi asesora de tesis, la Dra. Anna María Santiago, y yo.

Nuevamente, gracias por su valiosa participación en el studio.

1) Me gustaría empezar por preguntarle cuál es su posición actual/última posición laboral:

Posición clínica __

Supervisor (no atendía pacientes) __

Supervisor (atendía algunos pacientes) __

Administrador (no atendía pacientes) __

Administrador (atendía algunos pacientes) __

2) En qué tipo de práctica trabaja/trabajaba?

Salud mental comunitaria/hospital __

Práctica privada __

Ambos __ 3) Qué tipo de licencia posee? ______

4) Qué títulos académicos posee?

199

Bachillerato ___(concentración) ______Maestría___ Tipo ______Doctorado___ Tipo ______

5) Cantidad de años de práctica? ___

Aún trabaja? Sí __ No __ (si no, cuántos años atrás terminó ___ )

6) Qué porcentaje de sus pacientes estima que es de origen Latino?___

(Si se ha retirado o ya no hace trabajo clínico, qué porcentaje de sus pacientes mientras hacía práctica clínica estima eran de origen Latino? ______)

7) Vamos a comenzar con un scenario clínico. Supongamos que se encuentra con un paciente Latino para una evaluación. Es un adulto de Centroamérica y lleva viviendo en los EE.UU. 2 años. Qué información relacionada con su experiencia como inmigrante en los EE.UU. cree que sea relevante obtener para poder entender los problemas de salud mental que esta persona presenta?

7.a) Le pediría detalles acerca de su experiencia de migración? (e.g., por qué vino a los EE.UU.; fue la migración traumática? [cómo entraron a los EE.UU.?], de quiénes se separaron?); fue la migración voluntaria o involuntaria? Pedir que explique tanto respuestas por SI como por NO. 7.b) Qué más preguntaría acerca de la experiencia de migración que lo ayudaría a entender los problemas de salud mental de la persona? 7.c) Qué aspectos de la experiencia de migración cree Usted que podrían proteger a la persona de experiencias de salud mental negativas? (e.g., mayor nivel educativo, mayor nivel de idioma inglés, apoyo familiar en los EE.UU., acceso a servicios de salud mental; participación en actividades comunitarias que promuevan la integración con la sociedad en general). 7.d) Qué aspectos de la experiencia de migración cree podrían contribuir al desarrollo de experiencias de salud mental negativas? (e.g., bajo nivel educativo, pobre nivel de idioma inglés, poco o ningún apoyo familiar en los EE.UU.; poco o ningún acceso a servicios de salud mental; poco o ningún conocimiento de dónde obtener servicios de salud mental; aislamiento dentro del enclave étnico).

8) Podría decirme qué significa el término “aculturación” para Usted?

200

8.a) Cómo describiría la aculturación? 8.b) Podría darme algunos ejemplos de aculturación que haya observado en las vidas de pacientes Latinos con los que ha trabajado? 8.c) Dónde aprendió acerca de la aculturación? 8.d) Cuándo aprendió acerca de la aculturación? 8.e) Cómo cree Usted que ocurre la aculturación?

9) Qué significa aculturación para Usted personalmente (en su vida personal)?

9.a) (Si se aplica al participante) Cómo describiría Usted la aculturación en su vida personal? 9.b) Podría darme algunos ejemplos de aculturación ocurridos en su vida personal? 9.c) (Si se aplica al participante) Cómo cree que su propia experiencia de aculturación ha influido su bienestar emocional?

10) Cómo adquirió su conocimiento professional acerca de la aculturación? (en la universidad, capacitación post-graduación, lecturas profesionales).

11) Cómo evolucionó este conocimiento a lo largo de su carrera?

11.a) Al principio de su carrera? 11.b) En el medio o el final de su carrera?

12) De qué manera influye su conocimiento sobre la aculturación en el trabajo con pacientes? (Flesh it out very extensively with the Latino service providers)

12.a) Qué significan esto en las distintas fases del proceso terapéutico: evaluación, planeamiento, intervención? 12.b) Qué ejemplos podría dar de cómo el conocimiento sobre la aculturación influyó en las distintas fases del proceso terapéutico? (evaluación, planeamiento, intervención) 12.c) Implementa Usted este conocimiento sobre la aculturación de manera diferente, depende de a qué subgrupo Latino pertenece el paciente? • Cómo así? • Podría dar ejemplos de esto en su trabajo clínico? 12.d) Cuál cree Usted que usa más en su trabajo clínico: el conocimiento professional/académico o el conocimiento personal del fenómeno de aculturación? • Por qué?

13) Hay algo más que quisiera agregar acerca de cómo la aculturación influye su trabajo clínico, que no hayamos ya cubierto en esta entrevista?

INFORMACION DEMOGRAFICA

201

Género:

Femenino__ Masculino__ Transgénero __

Año de nacimiento:

Raza:

Blanco __

Afroamericano __

Nativo Americano __

Asiático/Islas del Pacífico __

Multiracial ___

Etnia Latina:

Puertorriqueño __

Mejicano __

Centroamericano __

Sudamericano __

Otro __

No Latino ___

Dónde nació? (Ciudad y país): ______

Si no nació en los EE.UU, edad de arribo.: ______

Idioma primario: ______

Idioma secundario: ______

Quisiera también preguntarle si aceptaría participar de un grupo de discusión junto con otros profesionales, más avanzado el studio. El grupo puede durar entre 60 a 90 202 minutos y el propósito será corroborar con los participantes del estudio si el análisis de los resultados que estoy hacienda es correcto. Su opinión al respecto es valiosa e importante para el estudio.

203

Appendix B

Final Codebook

Conceptual Dimensions (Code Supporting Dimensions (codes in group) Groups) with Description Acculturation Definition Participant conceptualizations of Adapting to a different environment the phenomenon of acculturation. Assimilating to the main culture Deciding whether to embrace the culture Finding balance between cultures Keeping cultural core and learning to negotiate new environment Learning about differences Making bridges Acculturation Mechanisms Participant understanding of the Through being between two worlds process through which Through blending in acculturation occurs. Through incorporation of new language Through osmosis Through strong connection to family of origin Through time Acculturation Knowledge Sources Sources through which Learning about acculturation in higher education participants acquire knowledge of Learning about acculturation in practice concept and process of Learning about acculturation through own acculturation. experience Culture non-specific Clinician Factors Clinical attitudes and behaviors Approaching client with dignity and respect that are effective in clinical Approaching client with unconditional positive practice with Latino clients. regard Cultural sensitivity Interest in learning about the client’s culture Promoting trust Culture-specific Clinician Factors Clinical attitudes and behaviors Being bilingual that are effective in clinical Being directive practice exclusively with Latino Being flexible clients. Being Latino helps therapeutic connection Being seen as the expert Having no problem being called family Assessment • Migration-related variables Trauma during migration Type of migration (voluntary or involuntary) Barriers in access to care 204

• Biopsychosocial Education level Fears due to being in the U.S. Financial struggles Immigration status Isolation, exclusion, not belonging Living in adverse neighborhoods Previous physical or mental health conditions/ previous traumas Social/family supports in country of origin Social/family supports in the U.S. Work status/work experience • Cultural variables Openness to mental health treatment Importance of religion and/or faith in client’s life Assimilation to mainstream culture/openness to learning mainstream culture Views of mental illness and the help-seeking process • Acculturation English proficiency Length of stay in the United States Treatment Planning* Intervention Intervening with Latino values in mind Intervening with Latino values in mind Tailor interventions to the culture Here-and-now focus Allowing the client to tell the story Other common interventions • Psychoeducation • Linkage to resources Termination* *Standalone code

205

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