Abstract
The scarcity of accessible culturally competent service providers and a general sense of mistrust in Eurocentric-based mental health settings exacerbate the lack of help seeking and effective therapeutic engagement for Latinos. Thus, clinical interventions that account for diverse values and worldviews may be an important step in the helpful treatment of U.S. Latino populations. Behavioral activation (BA), an evidence-based intervention for the treatment of depression, was recently evaluated through a preliminary clinical trial study in a community clinic primarily serving Spanish-speaking Latinos, and the results were promising. A culturally adapted version of BA was developed for Latinos, which took into consideration the cultural value of familismo (a collectivist worldview and preference for maintaining close connections to family); however, BA has not been previously applied to Latino families. The current case study presents the clinical treatment of a Mexican American family living in the southwest of the United States experiencing numerous stressors resulting in depressive symptoms. Specifically, this family sought therapy having experienced many negative life events, including stressors associated with institutionalized racism, their financial situation, and acculturation process. This led to a disruption of the family hierarchy, anger, unhappiness, fear, and isolation among family members. Outcomes of the intervention include a decrease in depressive symptoms and improved family communication and relationships by their involvement in activities such as attending cultural events in their community, family outings, and the children’s participation in extracurricular activities.
1 Theoretical and Research Basis for Treatment
It is well recognized that the unprecedented growth of the U.S. Latino population (Pew Research Center Hispanic Trends, 2016) in the last two decades has prompted considerable interest in learning about their overall physical and psychological well-being. Specifically, there is substantial interest in understanding the impact of their experiences and life circumstances associated with poor mental health outcomes. Environmental stressors encountered by many U.S. Latinos (e.g., acculturative stress, underemployment or unemployment, separation from family members, financial hardship; Hiott, Grzywacz, Arcury, & Quandt, 2006; Miranda, Siddique, Der-Martirosian, & Belin, 2005) contribute to depression and depressive symptoms (e.g., Cabassa, Lester, & Zayas, 2007; Martinez-Pincay & Guarnaccia, 2007; Santiago-Rivera, Arredondo, & Gallardo-Cooper, 2002). Despite the challenges that can lead to psychological problems, Latinos seek mental health services at significantly lower rates than Whites and other ethnic minority groups (Sue & Sue, 2016), and end treatment prematurely (e.g., Fortuna, Alegría, & Gao, 2010). It has been argued that Latinos, as well as other ethnic groups, tend to underutilize mental health services because treatment modalities often do not take into consideration cultural factors that are unique to this ethnic group (e.g., Santiago-Rivera et al., 2002). This is further complicated by the lack of culturally and linguistically competent service providers (Verdinelli & Biever, 2013) and a general mistrust of a Eurocentric-based mental health setting (Sue & Sue, 2016) that contribute to underutilization of services. More importantly, those who do seek mental health care may stop attending therapy because of cultural misunderstandings and language barriers (e.g., Castaño, Biever, González, & Anderson, 2007; Santiago-Rivera, Altarriba, Poll, Gonzalez-Miller, & Cragun, 2009). To address these concerns, it is recommended that clinical interventions need to consider cultural values, beliefs, traditions, and worldviews to improve treatment engagement, retention, and outcomes (Kanter, Dieguez-Hurtado, Rusch, Busch, & Santiago-Rivera, 2008).
Behavioral activation (BA) is an evidence-based intervention for depression (Mazzucchelli, Kane, & Rees, 2010) that has been proposed as a treatment that is “effective, easy to teach, scalable and acceptable to providers and patients across settings and cultures” (p.361) (Kanter, Puspitasari, Santos, & Nagy, 2012). The theoretical premise of BA is that symptoms of depression result from insufficient contact with diverse, stable sources of positive reinforcement (Kanter, Busch, & Rusch, 2009). Based on Peter Lewinsohn’s earlier behavioral treatment of depression (e.g., Lewinsohn & Graf, 1973; Zeiss, Lewinsohn, & Muñoz, 1979), the goal was to help clients increase rates of positive reinforcement in their lives through scheduling pleasant activities. In essence, the approach focused on external factors rather than internal phenomena such as cognitions as an explanation for depression. More recently, the model was expanded and described by Santiago-Rivera and colleagues (2008):
. . . current BA adds an idiographic, functional approach that explores both the clients’ needs and goals and the environmental contingencies that support depressive behaviors and moods. This assessment leads to activation strategies and assignments to target inertia and avoidance, improve quality of life, address environmental factors that caused depression, and increase pleasant events. (p. 177)
Santiago-Rivera et al. (2008) also proposed that an effective treatment approach for Latino adults using the BA framework is to identify culturally appropriate activation targets (e.g., activities that take into account cultural practices and tradition such as the celebration of Dia de Los Reyes, specific religious holiday; Quinceañera, celebration of a girl’s 15th birthday; Cinco be Mayo, a celebration of the May 5, 1862, Mexican victorious battle with the French in Puebla; traditional music and dance), as well as incorporate family, social, and community resources into treatment. Because BA focuses on environmental causes of depression and “action steps” (Spanish: “Pasos de acción”), it is practical and concrete. Moreover, clients work with the therapist to identify meaningful activities and schedule them early in the treatment process.
In sum, the main focus of BA is to identify the negative life events that contribute to depression and to identify ways to help the client come in contact with personally meaningful activities that are reinforcing (i.e., “get the client active again”). Equally important, BA considers relevant contextual factors and balances rapport building with a problem-solving approach that appears to fit well with Latinos who may be unfamiliar with therapy and its process, or prefer concrete, action-oriented approaches. Latinos value connectedness and having feelings of closeness with therapists. In addition, there may be a preference for an active therapist role, providing direct answers and psychoeducation regarding therapy (Chang & Berk, 2009; Sue & Sue, 2016), which is typically part of the BA Latino treatment modality.
A recent randomized controlled trial (Kanter et al., 2015) sought to examine the efficacy and effectiveness of BA with a sample of primarily low-income, Spanish-speaking Latino adults with depression Behavioral Activation Latino (BAL). BAL was compared with treatment-as-usual (TAU), in a community mental health clinic setting. Latinos who received BAL attended more sessions and showed a significant reduction in depression symptoms (Kanter et al., 2015). Last, BAL also produced significant improvements in quality of life and mental health functioning (Kanter et al., 2015; for a complete explanation of the treatment model, see Kanter, Santiago-Rivera, et al., 2014).
2 Case Introduction
Although the BA model has been tailored for Latinos by taking into account various cultural values such as familismo (a collectivist worldview and preference for maintaining close connections to family), to our knowledge, previous case examples have not shown its application with families. The following case study is an illustration of how BA may be culturally adapted and implemented to a Latino family. We present the clinical treatment of a Mexican American family living in the southwest of the United States. The family experienced numerous stressors leading to depressive symptoms, and these had the most impact on Ernesto Jr. (Identified Patient [IP]). The Pérez family received therapy in a community mental health center. Upon beginning treatment, the immediate family consisted of the parents, Ernesto Sr. and Juana, who were in their mid-40s, and their children Julia (12 years of age), Ernesto Jr. (10 years of age), and Manuelito (4 years of age). All names have been changed to conceal the clients’ identities.
3 Presenting Complaints
Ernesto Jr., the middle child, was initially referred for individual therapy by a primary care physician. This subsequently led to a referral for family therapy. Ernesto Jr. originally displayed behavior problems at school and home. These included a lack of concentration at school, homework noncompletion, and arguing with his older sister and parents. Furthermore, Juana reported Ernesto Jr. had been isolating from friends and family and crying often. Factors affecting Ernesto Jr.’s psychological well-being comprised acculturation gaps, language barriers, financial strain, and Ernesto Sr.’s problematic alcohol consumption. Upon starting family therapy, Ernesto Jr. disclosed feelings of hopelessness and frustration thinking that his father would be unable to reduce his alcohol abuse and the family would be able to improve their financial situation. Last, Ernesto Jr. began treatment with clinically significant scores on interpersonal relationships characterized as family wellness, and depression assessment measures administered throughout the treatment of the family. The aforementioned problems affected the entire family unit, which, in turn, further added to Ernesto Jr.’s symptoms. Specifically, all members of the family expressed feeling stressed out, although this was having the most impact on Ernesto Jr. There was no reported previous history of depression or mental health problems in the Pérez family.
4 History
The parents were born and raised in the state of Sonora in Northern Mexico. They crossed over the Tijuana, Baja California, Mexico border into San Diego, California, over 15 years ago without legal documentation with the help of a coyote (human smuggler). They moved to the state of Arizona a few years later to start a family, attracted by the lower cost of living and the presence of extended family members living nearby. The father was employed as a part-time construction worker, and the mother worked at home caring for the children. The three children were born in the Phoenix metropolitan area and were being raised there. The family’s uncle Raimundo (Juana’s brother) was recently deported to Mexico after a workplace raid by the U.S. Immigration and Customs Enforcement revealed his undocumented status forcing him to be separated from his family living in Arizona.
The Pérez family was residing in Arizona during a time when some of the harshest anti-immigrant legislation in the history of the United States had recently been implemented, resulting in very unfriendly living conditions. Legislation such as Senate Bill (SB) 1070 and others led to discrimination and the separation of a shockingly high number of families and instilled fear in many communities (Santos, Menjivar, & Godfrey, 2013). This external stressor negatively affected the Pérez family as the parents were of undocumented status and a family member (Raimundo) had been recently deported. The children were fearful that their parents might be deported as evidenced by crying in therapy sessions when the topic arose.
The difference between the parents’ more traditional Latino values and their children’s values was causing family problems. The parents were born and raised in Mexico and spoke primarily Spanish with limited English proficiency, whereas the children were fully bilingual in Spanish and English and were adopting more Mexican American values. In addition, Juana’s score on the Short Acculturation Scale for Hispanics (SASH) indicated low levels of acculturation (described below). The parents may have been disempowered in their attempts to access many societal and communal resources and were experiencing challenges in effectively communicating with their children’s school system. Often, the children translated for the parents when accessing systemic resources and in other public domains. This contributed to the acculturation gaps between the children and parents, disrupting the family roles and hierarchy as the children were empowered in these instances. This may have led the children to misbehave in some instances, which the parents labeled as falta de respeto (lack of respect and undermining of the family hierarchy). Ernesto Sr. and Juana were both raised to believe the parent’s authority should not be questioned and that their children should obey the family rules. As Ernesto Jr. and Julia became more immersed in the U.S. mainstream individualistic society through schools, friends, and media, their parents felt that some of their important family values and respect were being lost. The children complained that their parents could not fully understand their experiences as first-generation Mexican Americans, and similarly, the parents felt some frustration that the children were not fully aware how challenging life was for them having immigrated to the United States. Taken together, these factors further accentuated the acculturation gaps.
5 Assessment
Outcome Rating Scale (ORS)
The Spanish version of the ORS (Miller & Duncan, 2004) is an overall wellness assessment. Scores for the total ORS can range from 0 to 40, with the cutoff score of 25 or below indicating low levels of overall wellness. The measure includes a family and close relationships subscale labeled as the “Interpersonal” scale. The Interpersonal and/or Family-Related subscale of the ORS score ranges from 0 to 10, with higher scores indicating more positive family relationships. This instrument was used in the initial session and throughout treatment to measure progress.
Center for Epidemiological Studies Depression Scale for Children (CES-DC)
The Spanish version of the CES-DC (Faulstich, Carey, Ruggiero, Enyart, & Gresham, 1986; Weissman, Orvaschel, & Padian, 1980) is a 20-item measure where higher scores indicate increasing levels of depression. A cutoff score of 15 or higher is suggestive of depressive symptoms in children and adolescents. Scores from the CES-DC range from 0 to 60. This instrument was also used at intake and throughout treatment to measure progress.
SASH
The Spanish version of the SASH (Marin, Sabogal, VanOss Marin, Otero-Sabogal, & Perez-Stable, 1987) is a 12-item instrument that measures level of acculturation of Latinos. Items are summed and then divided by 12 to calculate an overall average score. Thus, scores on this measure fall between 1 and 5. The measure’s cutoff score is 2.99, where scores between 1 and 2.99 correspond to less acculturated respondents. This instrument was used at intake to estimate family’s level of acculturation.
6 Case Conceptualization
There seemed to be a power struggle amplified by the acculturation gap between the father and oldest son Ernesto Jr. In one of the early sessions of treatment, Ernest Jr. stated, “my father is dumb because he only speaks one language and drinks too much alcohol, not spending enough time with the family.” The children and mother often blamed the family financial stressors on the father. Ernesto Sr. was frustrated by the challenges of finding more work hours with his undocumented status due to the recent anti-immigrant legislation. Ernesto Sr. was coping with the family issues by drinking alcohol excessively with coworkers after completing his daily work. These practices are consistent with negative aspects of machismo (traditional Latino male gender role). His abusive drinking behavior is in contrast to caballerismo, an aspect of machismo that is related to the positive qualities of Latino male gender roles such as loyalty and other gentlemanly characteristics (Arciniega, Anderson, Tovar-Blank, & Tracey, 2008). Juana complained that Ernesto Sr. consumed alcohol in front of the children and felt that he was not supportive of her idea of seeking part-time employment. Juana stated that her potential part-time employment could alleviate some of the financial stressors and also provide a positive example for Julia. The therapist recast the family as the client, rather than Ernesto Jr., and deemed the family was a good candidate for BA. Specifically, the therapist hypothesized activating the family toward reducing Ernesto Jr.’s symptoms of depression, improving overall family relationships and well-being, and coping with external institutionalized racism and discrimination would be helpful to the family.
BA-Specific Case Conceptualization
Identifying negative life events
The events that were causing the Pérez family the greatest number of problems were identified and discussed to help establish treatment goals. As mentioned in the previous section, the negative events included many psychosocial stressors. These involved experiences of racism and discrimination through sociopolitical anti-immigrant policies (SB 1070), acculturation gaps in the family, marital dissatisfaction, living in impoverished conditions and having financial concerns, fear of deportation due to undocumented status, child arguments, and child misbehavior with the parents. The significant negative events were followed by common emotional and behavioral reactions.
Identifying natural emotional and behavioral responses
The Pérez family displayed a wide range of typical emotional and behavioral responses to the many negative events. In response to the fear of deportation, the children cried throughout many of the beginning sessions whenever the topic was discussed. Ernesto Jr. and his older sister, Julia, were afraid that they would arrive home from school and not find their mother, Juana or their younger brother, Manuelito, in fear that they had been taken away by immigration enforcement officers. The parents were angry and stressed about the recent anti-immigrant legislation, and Juana mentioned that she wanted to find a part-time employment, but local hiring agencies began checking for documented status and immigration raids of workplaces were common after the recent laws were passed (Santos et al., 2013). This amplified the financial stressors in the home causing marital problems. Ernesto Sr. displayed characteristics of machismo (Latino gender roles) as the father felt vergüenza (shame) that Juana was looking for work. He perceived this as an insult to his manhood and evidence that he was not fulfilling his role as the family breadwinner and provider. Consequently, Ernesto Sr. began yelling at Juana and his children in treatment sessions and at home. This resulted in increased marital problems, family stress, and frustration as the father stated that Juana or his children did not understand his concerns. Ernesto Jr. was most negatively affected by the enhanced stressors and reacted by misbehaving and imitating his parents’ yelling by calling his older sister names, punching her, and not completing his homework or household chores. Instead of confronting these family emotional problems, they were avoided, thus increasing depressive symptoms.
Family avoidance patterns
The Pérez family’s avoidance patterns exacerbated their emotional and behavioral problems. Ernesto Sr. began withdrawing from family activities by drinking alcohol with coworkers and coming home late many nights. He would also sleep more than usual on days when he was not working instead of interacting with Juana or the children. This limited his positive interactions and potential family outings and activities especially when the children were not in school. Ernesto Jr. imitated his father’s behavior by isolating himself and spending more time in his room away from family members after school. Juana reacted to the family avoidance patterns by lashing out verbally and yelling at Julia and Ernesto Jr. The family was able to confront some of these avoidance patterns by taking action steps or pasos de acción as the BA Latino model was presented and explained to the family in their native Spanish language. This included the therapist and family collaboratively establishing treatment goals, which were accomplished through the scheduling of culturally relevant and purposeful activities (Kanter, Santiago-Rivera, et al., 2014).
Action steps to break the cycle of family depression
The family became aware of the depressive spiral of which they were a part of and became activated by the BA Latino treatment. As part of the activity scheduling, Ernesto Sr. spent more time with the family by reducing his alcohol consumption. Julia and Ernesto Jr. improved their communication through extracurricular activities. Safety planning activities were incorporated in case one or both parents were detained or deported. The family engaged in helpful family outings when Ernesto Sr. was not working and continued to attend family therapy. The youngest member of the family, Manuelito, started preschool, and this allowed Juana time to find part-time employment. They were also able to reconnect with extended family members in Mexico via phone calls including contacting uncle Raimundo. These specific activities and their outcomes will be explained in more detail as they were scheduled and occurred throughout treatment.
7 Cultural Adaptations to Treatment
The therapist conducted a careful analysis to understand the family’s adherence to traditional Latino cultural values along with specific sociocultural factors influencing their worldview. The integration of these values followed an ecological validity model that included a language and ethnic match between the family and clinician and are described in more detail in subsequent sections of this article (Bernal & Domenech Rodríguez, 2012). In addition, the culturally adapted BA framework allowed the therapist to make a careful analysis of possible activities that were sensitive to the client’s context (i.e., institutionalized racism, community involvement, sociopolitical stressors, acculturation gaps).
8 Course of Treatment and Assessment of Progress
Baseline Clinical Scores
Ernesto Jr. began treatment with an ORS score of 15, which was clinically significant and indicated low levels of overall wellness. The Family-Related subscale of this measure (score = 2) indicated interpersonal difficulties within the family unit. In addition, he scored well above the cutoff score on the CES-DC (score = 30) indicating significant symptoms of depression. This score coincided with family’s report that Ernesto Jr. was isolating himself from family and friends and would oftentimes cry in his room after school. Last, Juana’s SASH score was 1.67 out of 5, which corresponds to low levels of acculturation (see Figure 1 for a graph of scores at baseline and through treatment).
Scores on the Spanish version of the ORS and Family subscale and CES-DC.
Treatment Components and Clinical Progress
Establishing rapport
After the therapeutic alliance including confianza (trust) was established, the BA Latino/a model was explained and presented to the family. The model was applied to conceptualize the sociopolitical stressors, acculturation gaps, and family relationship problems that led to symptoms of depression for Ernesto Jr. and the family. The initial therapy sessions focused on creating a therapeutic alliance with the family and included the entire immediate family with the exception of the father Ernesto Sr. It was important to listen and validate every member of the family and their experiences. This was especially important with Juana, due to her undocumented immigrant status. By engaging in plática (small talk) and by demonstrating personalismo (engaging in a warm and personal interaction) along with simpatía (friendliness and openness to discussing shared interests) during the conversation in the information-gathering session, a safe and therapeutic environment started to form. Establishing confianza was particularly important with this family given the discriminatory sociopolitical context mentioned above. The treatment provider was a male doctoral-level Latino bilingual (Spanish/English) therapist, and the sessions were in the native language (Spanish) of the family. Therefore, an ethnic and language match between the therapist and family was present, and this helped to enhance the therapeutic alliance (Cabral & Smith, 2011).
The therapist was also able to culturally empathize with the Pérez family’s Mexican and Mexican American worldview. This was accomplished by listening to their unique experiences along with the knowledge of important cultural and contextual factors having provided therapy services in this specific Latino community for numerous years. A mutual respeto (respect and understanding) between the therapist and family was enhanced by reinforcing the confidential nature of therapy. This was also created by therapist self-disclosure of his relevant personal and professional background to help ease the typical anxieties associated with help seeking that was particularly important given the anti-immigrant context where therapy took place.
After the family was able to describe their presenting problems, the therapist continued the alliance building by normalizing the Pérez’s family issues. The normalizing helped to address some of the stigma associated with seeking therapy. The family, especially Juana, expressed relief knowing that they were not the only family experiencing similar stressors and were not all loco (crazy or mentally unstable). The therapist instilled hope in the family by informing them that other Spanish-speaking Mexican American families had benefited from therapy employing the BA Latino treatment modality. Inviting all family members to participate in the therapy emphasized the importance of familismo (a collectivist worldview and preference for maintaining close connections to family) and led to Ernesto Sr. participating in subsequent treatment sessions. The therapist also provided role induction, explaining the therapy format in detail including what to expect in later treatment sessions as none of the family members had been involved in any type of previous counseling or therapy. These were all important aspects of the first few sessions to help create a safe, friendly environment and alliance with the Pérez family so they could begin to heal multiple family wounds.
The Pérez family displayed many characteristics labeled as strengths throughout treatment, which were acknowledged by the therapist. These included the resiliency demonstrated by the family and the many positive coping strategies such as seeking treatment and other important community services. Despite the multiple stressors, the children, especially Julia, were achieving good grades in school. The meaningful activities and community events that the family was already engaging in were incorporated into the BA Latino activity scheduling.
Explaining the BA model and activity scheduling
The BA Latino model was used to help identify the initial goals of treatment that were collaboratively formed between the Pérez family and the therapist. The therapist explained the BA Latino model including weekly activity homework sheets to be used to take pasos de acción and the activating process through scheduling began. The majority of Session 3 was spent identifying the purposeful activities that the family was already engaged in and setting specific short- and long-term goals. The Pérez family agreed to bring the weekly activity homework sheets to every session and review how successful each activity had been throughout the previous week before scheduling new ones. Potential challenges to completing the goals were also discussed; however, the Pérezes were very motivated to begin the activities. In addition, Julia agreed to remind the entire family the day before the treatment session to ensure their attendance to the appointment. Upon completing the first three sessions, the family’s overall wellness showed slight improvement and Ernesto Jr.’s depressive symptoms showed improvement (see Figure 1).
Activation and family behavioral problems
Juana stated that she desired the Pérez children improve their behavior at home and at school. As a reaction to the symptoms of depression and stress in the home, Ernesto Jr. was displaying behavior issues at school. Thus, a goal of treatment was to improve communication with the children’s school system. This presented a challenge to the parents, especially Juana. She felt that they were not able to effectively navigate and communicate with their children’s schools. Numerous unsuccessful attempts to make contact led to feelings of frustration and of general mistrust of the school. The parents were relying on information provided to them by Ernesto Jr., which was not always complete nor accurate. Hence, the therapist confronted this communication barrier by connecting the family to a reliable Spanish-speaking case manager who was able to connect the family with a school psychologist and teachers. This allowed the family to receive accurate information and helped to reduce some added responsibilities and pressure placed on the children. Moreover, weekly phone conversations with the case manager were scheduled on the activity homework sheets. This helpful scheduled activity allowed the parents to be better informed regarding the children’s progress and reduce family stress.
Meaningful extracurricular activities and events helped to activate the children and reduce stressors associated with negative life events. One of Julia’s cousins was planning a Quinceañera (15th birthday celebration and rite of passage for some Latinas) of which she was very excited to be a part. Her parents allowed her to participate in weekly practices to prepare for the dance routine to be performed at her cousin’s Quinceañera. Julia stated that this activity helped her become closer to her cousin and served as a positive outlet. Ernesto Jr. and Julia joined a track team, which was free-of-charge to the family and was facilitated by the improved communication with the school. This physical exercise helped the children improve their positive interactions and led to less arguments and an overall better sibling relationship. It also allowed them to form a stronger sibling bond as their communication improved, and they were able to support each other. This activity had the added benefit of increasing Julia’s self-esteem as she excelled on the team and also prevented Ernesto Jr. from isolating himself after school. Ernesto Jr. also joined a neighborhood soccer team. This important activity was planned by dedicating a portion of the fifth session discussing how this could be accomplished given the family’s lack of financial resources. The family was able to reconnect with a neighborhood friend, who happened to be the soccer coach, who was able to purchase the required shoes and uniform for Ernesto Jr. By attending his weekend soccer matches, the family was also able to spend quality time together. These important events for the Pérez older children, which helped to reduce stress within the home, were added to the weekly activity schedule as part of the BA Latino treatment.
The Pérez family members were able to improve their communication at home by addressing acculturation gaps and sociopolitical stressors in treatment sessions. Juana and Ernesto Sr. expressed their dissatisfaction with their children’s misbehavior at home as they complained of falta de respeto. The children were also frustrated with their parents believing that they did not fully understand their experiences as Mexican Americans being born and raised in the United States. The family resided in a predominately Spanish-speaking Latino neighborhood, and the parents spoke primarily Spanish. In addition, Juana’s low score on the SASH acculturation measure indicated the parents’ stronger adherence to their cultural values of Mexican origin. In contrast, the children’s worldview was bicultural as they spoke mostly English outside of their home while attending public schools that emphasized individualistic values. The therapist and family members discussed these acculturation differences, and the parents were able to share their immigration experiences during a therapy session. This allowed the parents and children to culturally empathize and understand each other’s unique perspectives. Activity scheduling using the homework sheet was used to reconnect with the parents’ extended family in Sonora, Mexico, via weekly phone calls. This helped the children become better connected with their Mexican heritage and served as an important aspect of ethnic socialization that has been found to enhance the development of a psychologically healthy ethnic identity (Neblett, Rivas-Drake, & Umaña-Taylor, 2012). The parents also benefited from this increased communication as they were not able to take frequent trips to Mexico due to financial problems and the strict anti-immigrant laws that made travel to visit extended family more difficult.
Many activities were scheduled to help the family overcome sociopolitical stressors. The therapist helped the family to externalize some of the societal discrimination they encountered living in an anti-immigrant environment. Psychoeducation regarding their human rights and advocacy groups in the community was provided. To help plan for the potential detainment and/or deportation of the parents, a safety plan was created for the family. The children were provided important contact information of extended family and friends in case Juana and Ernesto Sr. were not home when they arrived from school. Discussing these sociopolitical issues was a way of taking action steps to confront them. The family was also encouraged to talk to friends and community members instead of avoiding this stress-provoking topic. This was especially helpful for the Pérezes as Raimundo, with whom they had a close relationship, had been recently deported and many other families in their community had been separated. At the end of each session, potential obstacles to completing activities were discussed and problem solved in the sessions. The positive progress upon completing session treatment was confirmed by the improvement in the results of the assessment measures (see Figure 1).
Ernesto Sr. and family relationships
The treatment shifted focus to include Ernesto Sr. as the family therapy sessions were scheduled in the early evening to accommodate his work schedule. The therapist made sure that the other family members updated Ernesto Sr. about the topics discussed after every previous therapy sessions and to include him in the activity scheduling. As the oldest child, Julia had more responsibilities in the home, and she volunteered to report the details of the previous sessions and activities to the father to supplement Juana’s summary. Attending the therapy sessions was not easy for Ernesto Sr. as he displayed some aspects of machismo; he reported that he had not been socialized as a Mexican Latino male to express his emotions. He went on to say that attending therapy was Juana’s parental responsibility as she spent more time raising the children. Contemporary theory reveals that Mexican and Mexican American men desire to be involved and approach fathering with egalitarian attitudes toward shared parenting responsibilities (Roubinov, Luecken, Gonzales, & Crnic, 2016). However, parental engagement is often lower when fathers are less acculturated, as was the case with Ernesto Sr. (Roubinov et al., 2016). Thus, confidentiality was restated by the therapist, and extra support and attention were given to establish rapport with Ernesto Sr. so that he did not feel scapegoated for the family’s depression. He stated that the family did not understand his work-related stress. However, his participation in the sessions allowed him to listen to how his heavy alcohol consumption was negatively impacting his children and marriage. As Ernesto Sr. became more comfortable in the sessions, he was able to express how much he cared for the family and listen to how these feelings were reciprocal. Juana mentioned that she had to aguantar (to endure or to suffer in silence, an aspect of marianismo, traditional Latina gender roles) his excessive drinking and was fed up with this behavior. Supported by the children’s insistence, Ernesto Sr. agreed to make efforts to reduce his alcohol consumption. This resulted in a better marital relationship with Juana, although the couple mentioned this being secondary to the importance of the overall family well-being.
The inclusion of Ernesto Sr. in the treatment was a significant action step to overcome the family depressive symptoms. The Pérez planned many activities on the activity homework. These involved trips to the public library and renting movies to watch together twice a week in which Ernesto Sr. agreed not to drink alcohol. The family began attending Ernesto Jr.’s soccer matches on Saturday, which also allowed them to connect with other families in the community. They also scheduled la comida semanal (weekly family dinner) after Catholic church services on Sunday as well as weekly trips to the nearby park. The Pérezes identified these activities as meaningful and realistic given their financial difficulties. As a result of these multiple action steps, Ernesto Jr.’s scores on the assessment measures improved drastically to clinically significant healthy levels (see Figure 1).
Termination
The Pérez family approached the end of therapy as many of the treatment goals were accomplished. The family celebrated Manuelito’s fifth birthday and shortly after he was enrolled in preschool. Because the children were outside of the home for part of the day, Juana was able to find part-time employment to help with the family financial problems. Although Ernesto Sr. was initially opposed to her working outside of the home, he realized that this would be beneficial for the family. The therapist reviewed the progress of the family goals and activities and by using the Behavior Activation Goals and Values Assessment Sheet introduced in the final session. Through the use of this assessment, the Pérez family was able to review how they improved in many areas, including relationships with family, spouse, friends, and community; spirituality; physical well-being; safety; education; and cultural roots. The Pérezes were encouraged to continue the pleasant and meaningful activity scheduling through the BA Latino Staying Active Guide. This guide helped to remind the family how to stay active and overcome potential obstacles to continue their important activities. Ernesto Sr. reported benefits to treatment; specifically, he began to feel more appreciated and respected by the family as he spent more meaningful time with the family. The Pérez family also received information about Spanish-speaking support groups in the community. As the treatment came to an end, Ernesto Jr.’s overall ORS score improved to a 37 out of a total of 40 and the Family-Related subscale score was a 9.5 out of 10 indicating positive wellness. His depressive symptoms reduced to 5 out of 60 on the CES-DC. The results of the assessment measures were provided as feedback to the family. The Pérez family was grateful for having received the BA Latino treatment that resulted in many positive changes.
Posttreatment Outcomes
Reliable change index (RCI) scores (Jacobson & Truax, 1991) were calculated for outcome measures (i.e., ORS total score and CES-DC) to identify the presence of clinically meaningful improvement across time (i.e., from baseline to last session). Results indicate that on the ORS total score, Ernesto Jr.’s increase from 15 to 37 resulted in a significant RCI value, thus indicating clinically relevant improvement in the area of overall well-being. Last, on the CES-DC measure, a decrease from 30 to a score of 5 out of 60 also resulted in a clinically significant RCI, suggesting there was a clinically relevant improvement. Furthermore, Ernesto Jr.’s parents’ self-report included a subjective “feel” that their son was much better following treatment.
9 Complicating Factors
Medication management was a topic that was included in the course of family treatment. Ernesto Jr. was prescribed medication by the family primary care physician for symptoms related to lack of concentration. The Pérez family was not interested in Ernesto Jr. taking medications and disclosed to the therapist skepticism regarding their use and effectiveness. Consequently, psychoeducation was provided to the family and an appointment was made with a psychiatrist as an option for the family to receive more information about the potential benefits and harm of medication use. As Ernesto Jr.’s overall behavior and well-being improved without medication, the family did not follow up with the psychiatrist appointment.
10 Access and Barriers to Care
There were noteworthy barriers to treatment that were overcome by the Pérez family. Ethnic minorities have been found to prematurely terminate from treatment at high rates after only a few sessions (Sue & Sue, 2016). Therefore, special attention was given to establish a positive therapeutic rapport with this Spanish-speaking Latino family. Meeting the language and cultural needs of the family as the therapist was a Latino bilingual and native Spanish speaker may have helped build confianza. This was particularly important given the anti-immigrant climate and the parents’ undocumented status. The stigma associated with receiving help outside of the family was present, especially with the parents. Juana mentioned that she thought that people would think her family was loca for seeking services. Thus, normalizing the therapeutic experience and psychoeducation by way of culturally competent role induction was important to include early in treatment. Ernesto Sr. did not participate in the initial therapy session and attended later sessions only because he was pressured by his family. After agreeing to participate, special arrangements were made by the therapist to accommodate his work schedule, and the sessions were changed from afternoon to early evening meeting times. Confidentiality was restated, and rapport building was reemphasized with the addition of Ernesto Sr. in the family treatment. Also, the therapist accentuated the family resilience and their many strengths including the importance of the entire family showing up for treatment. The Pérezes were unable to attend two scheduled sessions throughout the course of treatment due to transportation issues. The therapist made sure to follow up on the missed sessions by contacting the family via phone calls and checking on the progress of the activity scheduling. Overall, this family was very motivated, and the BA Latino treatment modality was an excellent fit for them.
11 Follow-Up
After a few months had passed upon completing treatment, the therapist called the Pérez home as part of the follow-up procedure. The Staying Active Guide was reviewed with Juana, and she was pleased to report that the family was well and continued to engage in helpful family events.
12 Treatment Implications of Delivering BA in a Family Context
Practical Considerations
There are several factors that ought to be taken into account when considering utilizing BA in a family context, as BA was developed as a treatment for use in individual therapy settings. Therefore, one of the first steps is to select the IP, as this might differ based on the specific circumstances of the family. The IP in the present case was a 10-year-old boy. Over the course of treatment, it became apparent the family of the IP could benefit from engaging in meaningful activities, a tenet of BA. As treatment progressed, family members were added to the treatment until eventually the entire family attended therapy sessions.
When considering the function of bringing in family members into treatment, it is important to discern the short- and long-term consequences of their involvement in treatment. If a specific individual is the IP, it is imperative to have a conversation about the value of bringing in other family members into treatment. In general, it is appropriate to bring family members into treatment after the IP has agreed to do so. However, if the IP is a minor, the parents have the legal right to be involved in the treatment and request joint sessions.
In the case where the family as a whole is the IP, it is important to identify which family members will be present in treatment and for what reason. To that end, values and goals must be identified to schedule activities that are meaningful for the family. In the case presented herein, one of the primary values of the family was to be spend quality time and to have positive communication. Several obstacles were present such that it was difficult for the family to behave in accordance with these values. Thus, the work of therapy was largely spent on identifying and planning activities that increased the amount of meaningful time family members spent with each other (e.g., parents attending children’s extracurricular activities), as well as rearranging the environment to facilitate communication, primarily between the father and the son.
In most trials examining the efficacy of BA, the standard number of sessions has been 12 (e.g., Dimidjian et al., 2006; Kanter et al., 2015). However, it is possible that when additional individuals are brought into treatment, the progress of treatment may be slowed. That is to say, it might take longer to orient other family members to BA’s theoretical framework and rationale, as well as to decide on the activities to be scheduled. Generally speaking, treatment should end when patients have met the goals they have set for themselves. However, several limiting factors might be present that might impact the length of treatment (e.g., financial instability, insurance coverage).
13 Recommendations for Clinicians and Students
Delivering the BA Rationale
Asking depressed clients to change ingrained, depressive ways of behaving can be difficult (Martell, Addis, & Jacobson, 2001). Thus, it is extremely important for the client to understand the rationale for activation from the outset. Providing the BA rationale early in treatment will allow the clinician to assess the level of buy-in and enthusiasm for the treatment (Kanter, Puspitasari, Santos, & Nagy, 2014). Arguably, one of the most important aspects of BA is understanding and communicating depressive behaviors in context (Martell et al., 2001). Specifically, the BA clinician ought to be able to distinguish between negative life events (triggers), emotional responses to those events, and subsequent avoidance behaviors, to present the function of activation assignments as a component that will break the cycle of depression (Kanter, Puspitasari, et al., 2014).
Activity Scheduling
When conducting activity scheduling, several factors need to be considered. First, when identifying activities for the client to engage in, the clinician ought to pay careful attention to the case conceptualization to assign activities that fit the client’s values and goals. Clinicians will spend time with clients gathering input regarding the type, amount, and intensity of scheduled activities (Kanter, Puspitasari, et al., 2014). Encouraging the client to develop, with help from the clinician, treatment goals will enhance the therapeutic relationship and effectiveness of the treatment. Furthermore, the clinician can be a source of positive reinforcement following assignment completion if he or she is validating, empathic, caring, understanding, and patient (Kanter et al., 2009).
Second, activation assignments should be challenging enough for the client so that he or she feels a sense of mastery and accomplishment. Yet, they should be easy enough so as to ensure completion of the assignment. For that reason, it is important to recognize that depressed individuals often have great difficulties completing tasks they were able to successfully complete before they became depressed. Thus, at times, the clinician will need to break activities down into smaller, more manageable chunks, and increase their frequency, duration, or amount through the course of treatment (Martell et al., 2001).
Providing Culturally Competent BA
Conducting good BA does not necessitate the use of jargon. In fact, it is recommended that clinicians utilize the words and notions the client uses, as well as language the client will understand (Kanter, Puspitasari, et al., 2014). Doing so will increase the client’s buy-in to BA. In addition, it is important for the clinician to have a good understanding of what the client views as the factors that have caused and maintained their depressive behaviors (López, 1997). Moreover, it will be important for the clinician to not assume what the client needs but rather ask the client what he or she wishes to gain from therapy (López, 1997). Achieving this will require the clinician to balance clinical judgment with curious, open, and empathic approach that facilitates the client sharing his or her perspective.
Although it is important for the clinician to consider adherence to traditional cultural variables, such as the ones discussed in this case (e.g., familismo, personalismo, respeto), it is equally important for the clinician to not perpetuate cultural stereotypes and recognize the heterogeneity of Latinas/os and uniqueness of every family (López, 1997). In the case presented herein, BA was carried out as a treatment for Ernesto Jr. and the Pérez family as it was important for all members to improve their relationships with each other. However, this was done after a careful assessment. Thus, in carrying out BA treatment, it is important for the clinician to keep in mind and ascertain the applicability of cultural variables, especially as they relate to activation assignments and case conceptualization (Kanter, Santiago-Rivera, et al., 2014). The BA clinician not only assesses the client’s values to give activation assignments that are indeed aligned with them but also takes care to be sensitive and not contradict them (Kanter, Santiago-Rivera, et al., 2014).
It is essential for clinicians to understand the harmful psychological impact that institutionalized racism and other environmental stressors can have on individuals and families. Anti-immigrant legislation and other forms of societal racism perpetuate a xenophobic and discriminatory environment that has harmful consequences for marginalized communities (Santiago-Rivera, Adames, Chavez-Dueñas, & Benson-Flórez, 2016). The symptoms of depression displayed by the Pérez family were intensified by these external stressors. Thus, it is imperative for clinicians to assess sociocultural contextual stressors and victimization of racism. This will lead to the inclusion of meaningful social justice–related activities as part of the treatment to help families confront these issues.
BA has promise as a treatment that is applicable to a broad range of populations (Kanter et al., 2012). To increase BA’s relevance to clients from diverse backgrounds, it may be appropriate to use cultural metaphors in the spirit of activation. For example, the idiom “al mal tiempo, buena cara” (during hard times, put on a good face and continue on) can be used as a metaphor for perseverance of activation goals, despite its difficulty (Kanter, Puspitasari, et al., 2014). It may be appropriate to ask the client directly if any cultural metaphors or idioms come to mind while discussing BA concepts.
A last important recommendation for professionals and students is to be aware of local resources and the community of the client when identifying activation goals. For example, for the client who faces financial hardship, it will be important for the BA clinician to be creative to find free or low-cost activities for the client (Kanter, Santiago-Rivera, et al., 2014). On a related note, it is important for the clinician to ask the client about activities that are common in his or her community, and for ideas on meaningful and relevant activation assignments.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.