Reconceptualizing Culture as Resilience in Hispanic Mental Health - Griselda Villalobos

By: Culturally Competent Mental Health Practice with Hispanic Clients

(Dr. Lusk) My name is Mark Lusk and I'm a professor of social work at the University of Texas at El Paso. Our next presentation is reconceptualizing culture as resiliency in Hispanic mental health. The presenter is Dr. Griselda Villalobos. She's the director of Social Services at the Ysleta Del Sur Pueblo, a Native American reservation here in the El Paso/Socorro region. Dr.

Villalobos is a graduate of New Mexico State University, where she received her bachelor and master of social work. After that, she received the PHD in social work from the University of Texas at Austin. She's practiced in a variety of settings including CPS, Child Protective Services of the state of Texas, and also Family Service of El Paso.

Dr. Villalobos is pursuing a second doctorate in neuropsychology at the Fielding Institute. She is one of the most gifted clinicians that I've had the opportunity to work with and she's going to present today on reconceptualizing culture as resiliency in Hispanic Mental Health.

(Dr. Villalobos) Hello. The title of this presentation is, "Reconceptualizing Culture as Resilience in Hispanic Mental Health." The objectives of today's presentation are to define culture in a broad sense, to define resilience, to outline the reasons to consider culture in social work and mental health interventions, as well as to identify predominant cultural characteristics of Mexican Americans, and the fifth objective is to identify how culture can be seen as a factor of resilience in how Mexican Americans cope with adversity. Before I begin the presentation, I would like to quote a renowned author by the name of Melvin Delgado who wrote, "Culture, I believe, functions like an anchor on a ship. It provides stability during turbulent seas, or provides a sense of security because it is readily available if needed. Culture as represented through values and beliefs, as a result, is as much a part of life as an anchor is part of a boat's equipment. No experienced sailor would think twice about casting off without an anchor, no human being can expect to navigate his or her way through life without a firm embrace of culture in all its manifestations." So, to begin with a definition of culture, it's important to talk about what Marsilgia and Kulis wrote in 2009.

Reconceptualizing Culture as Resilience in Hispanic Mental Health - Griselda Villalobos

Their definition of culture in the culturally grounded social work perspective is that culture must be understood as the intersectionality of ethnicity, gender, sexual orientation, social class, religion, and ability status. In the beginning, when we first began to study the concept of culture, we looked at culture as being the basic idea that culture involved beliefs, values, and customs. As our understanding of culture has evolved, we now understand that it involves many more concepts than just beliefs values and customs. What is culture? We know that for many of us, culture has been presented as an abstract intangible construct. However, one of the dangers of conducting research using this definition of culture is that sometimes culture has become a variable of intervention rather than a descriptor.

Max Weber described culture as values that motivated people to ideal and material interests. Swidler's framework, in 1986, moved the understanding of culture to that of a tool kit which involves stories, rituals, and world views, which people may use in varying configurations to solve different kinds of problems. In the mid-80s we begin to see that culture begins to take a different shape. When considering culture, we must always remember to distinguish between ethnic culture, family culture, individual personality traits. We must always look at culture as a descriptor and not as a variable for intervention. By doing so, we begin to look at culture as a strength rather than a weakness or limitation.

Similarly, when considering interventions, we must look at the universal principals that apply to all people, group adaptations which involve similarity among groups of people, and also the individual application of interventions, both in social work and mental health. Now, let's move on to a definition of resilience. In general terms, resilience can be defined as the "capacity to spring back, rebound and successfully adapt in the face of adversity and develop competence despite exposure to severe stressors or simply to the stress inherent in today's world." This is the definition presented by Henderson and Milstein in 1998. As we talk about culture, it's important to talk about cultural resilience.

This builds up our understanding as we move towards the understanding that culture can be seen as resiliency in Mexican American mental health. What is cultural resilience? Many human cultures have come and gone, others have survived; the longer surviving cultures can be said to be resilient. Cultural resilience refers to those cultures who have the capacity to maintain and develop cultural identity and critical cultural knowledge and practices. Despite challenges and difficulties, a resilient culture is able to maintain and develop itself. A resilient culture engages with other challenges such as natural disasters and encounters with other cultures, and manages to continue. Some examples are the Jewish culture which was able to be resilient to the challenges of World War II, Native American who have survived years of oppression, African Americans who survived slavery, and Mexican Americans who survived a history of conquest, repatriation, oppression, and discrimination. At the center of the resiliency wheel is culture surrounded by spirit, the person, family, and community. The resiliency wheel provides a way for helping professionals to link individual client strengths while drawing from factors related to person, family, community, spirit, and culture.

Understanding that culture acts as the hub of the resiliency wheel, the context for each of the other aspects is mediated through culture. So, why talk about culture? We provide interventions in social work and mental health. Many of these evidence based practices are found to be effective so why do we need to talk about culture? When we don't attend to culture, a number of things happen--a number of things that are very serious to populations. If we don't talk about culture, we don't adapt our system to respond to the diversity that is out there. We expect diverse communities to respond to us.

If we don't attend to culture we limit our ability to engage families in a meaningful way. If we don't attend to culture we enforce our own views of the world and do not respect or respond to the cultural worldview represented by a community or a set of individuals. If we don't attend to culture in social work and mental health we make harmful decisions for populations, we don't understand what's normative in the context of a culture and what's unacceptable in the context of the culture, and therefore, we make decisions based on the majority world view. If we don't attend to culture we don't build on the strengths of families, we don't build on the strengths of communities, we don't even look for these strengths, and then we blame the victims for their failure. One response to the inability of majority populations to address the needs of minority groups is the cultural adaptation movement that began in the mid 80s.

Cultural adaptation is a process of making interventions culturally competent with the understanding that culture is a strength. Whaley and Davis, in 2007, gave us a very broad definition of cultural adaptation. This definition is as follows, "Cultural adaptation is any modification to an evidence-based treatment that involves changes in approach to service delivery, in the nature of the therapeutic relationship, or in components of the treatment itself to accommodate the cultural beliefs, attitudes, and behaviors of the target population." With this idea of cultural adaptation, we can begin to look at culture as a strength and begin to adapt our social work interventions as well as mental health interventions to address the particular needs of specific populations.

In terms of, the cultural adaptation that can be done with Mexican American populations, it's important to understand what some of these cultural characteristics are in order to be able to infuse these cultural characteristics and adaptations into our interventions. The cultural adaption movement is driven by the idea that cultural characteristics can be used to help people overcome adversity. For example, predominant cultural characteristics in the Mexican American culture are familism which is the promotion of strong family bonds among family members, collectivism which is the emphasis on mutual interdependence, religion and spirituality which is respect for a sense of the personal meaning that each person has, respeto and simpatia, which is respect and congeniality, the idea of fatalism which in this case is, in the positive sense, the acceptance of fate, present orientedness which is a focus on the present rather than the past, personalismo which is personalism or gentle treatment of others. Of course, we must always consider acculturation level in understanding how these cultural characteristics are playing a role in the person's everyday life.

Let me give you several examples on how culture can be used to help individuals with depression, medical conditions, traumatic events, and forced migration. One example in the late 1990s took place at the San Fransisco General Hospital where a group of psychiatrists came together and decided that they were going to culturally adapt a group intervention for Mexican Americans and Hispanics with depression. They got together and they looked at the cultural characteristics of this population and said, "How can we make this group intervention," which included cognitive behavioral therapy, "to be more appealing to this population?" They focused on acculturation and cultural values like familism, collectivism, religion, and spirituality to create a program that was appealing to the population. What they found was that by adapting this cognitive behavioral therapy--group cognitive behavioral therapy to Hispanic populations, they were able to see depression scores lower at higher rates than they had previously. Another extensive review of the literature by Padilla and Villalobos in 2007 found that support for using culture as a strength and a protective factor was very meaningful in understanding cultural adaptation interventions for Hispanic populations.

They noted, "To provide services in a way that is meaningful to the populations we serve, we need to offer choices and counsel in a way that culturally makes sense to them." What these 2 authors did was they did an intensive or extensive review of the literature and they looked at different research studies that had looked at various cultural components and how these played out in either helping or hurting Hispanic populations. What they found was that familism and social support are related to Mexican American immigrant women birth rates. This is called the Hispanic paradox, which they weren't able to really understand why these underprivileged women who many times had difficult circumstances tended to have babies that had higher birth weights than the general population. What they found was that family support was instrumental in helping mothers with their prenatal care and take care of themselves for the good of their babies. Familism has a direct impact on elder health and well-being.

These 2 authors looked at various studies that looked at how well people do with home health or in nursing homes. What they found is although these 2 seem to be last resorts for Hispanic families, that when there's family support there's greater victory or success in how elders do with these 2 programs. They also looked at studies that looked at how well families supported individuals with depression, brain injury, and heart disease. What they found was that in terms of recovery, individuals did much better when there was family support helping them through these circumstances. They also found other research studies where many cultural adaptations were based on the idea that taking care of self for the good of the family helped Hispanic and Mexican American families adhere to medical and mental health programs at higher rates. They looked at programs that focused on reaching children because they knew that if they were able to reach the children, it would eventually be able to reach the families. They also looked at a prenatal care program for Hispanic women which emphasized respeto and simpatia through unhurried interactions, social gatherings, and gentleness techniques. What they did was that they brought in Hispanic women who were pregnant and rather than having them go through their prenatal visits as usual, what they did was that they did group prenatal education and they did prenatal care examinations individually while others attended group.

They made it more of a social event rather than an event where they were coming into the medical system and being treated as everybody else. When we look at how well Hispanic populations do in the eyes of adversity, there is one particular research study that examined 20 individuals who fled Mexico due to violence. The results were interesting. At the beginning, Lusk, Villalobos, and McAllister set out to understand the journey of people who had fled Mexico due to the violence in 2010.

Originally, they thought they would find a lot of trauma, a lot of depression, a lot of impaired functioning in this population, and what they found was astonishing. Although many people did score high on the PTSD scales and the depression scales, that was the minority. Many of the participants did not score as high on trauma and depression scales as would have been expected. Some cultural factors that were identified as protective factors were familism in the sense that family support was key to helping individuals survive and have resilience despite the traumatic experiences they had endured, personalism which helped people keep a positive attitude no matter what they had been through in the new country, fatalism which helped people keep a sense of acceptance of, "This is what we have to endure," present orientedness which helped the survivors of this trauma keep their focus on the here and now and not focus on the past.

We can see how these cultural characteristics served as protective factors for these individuals who had endured, many of them, severe violence, some torture, kidnappings. Some had been held hostage for many weeks. One quote that really hits home and is relevant to this presentation is the quote that states, "This manifested primarily through engagement with the migrant expatriate community, where they found solace and social relationships. Because extended families in the order region often are arrayed across both sides of the border, many found economic and social support among relatives." We see the concept of familism as a very important factor in the survival of these individuals. Another study that looked at migration and loss was conducted by Moya and her collaborators in 2015. What this study found was that culture was a protective factor against mental illness, despite traumatic events and many losses. What they found was that family support was key. When asked, "What helped you survive this migration experience?" many of the participants, in fact, most of the participants said, "My family, my children. Everything I did was for my children." Fatalism was also a cultural characteristic that helped these immigrants accept their reality and take steps to improve it, as well as present orientedness, which helped them focus on the here and now and survive and adapt to their new surroundings.

I'd like to finish the presentation with the presentation of a case study that took place in the border region. This was a 25 year old Mexican American transgender female to male client, Hispanic, Mexican American, who had experienced severe sexual abuse by the mother's boyfriend from the age of 14 to the age of 16. He wanted to teach her to be a "girl". This client presented to therapy with severe PTSD symptoms, bipolar disorder with psychotic features. The interesting thing was that these concepts of culture as resiliency and protective factors was in the background as this therapist worked with this particular client. Let me tell you how culture was seen as a strength and was used in the mental health intervention with this client. First of all, the acculturation level of the client was considered to see how traditional the client was in terms of her Mexican American cultural characteristics. It was found that the client was bicultural and bilingual and therefore the mental health intervention was tailored to these characteristics. As a result, sessions were conducted in English and Spanish and there was a lot of code switching done throughout therapy where the therapist would follow the lead of the client in terms of language preference at whatever section of the therapy was being conducted.

The family was involved and the client was encouraged to explore how her decisions impacted family members as well as involving family members and understanding that the client needed family support as well as support in her recovery. Respect was shown in this intervention by the acceptance of her being transgender and the issues related to this were explored, as well as an openness to understand that her symptoms were not related to her sexuality. Her symptoms were related to the trauma she had endured during her adolescence. Simpatia was demonstrated by gentleness in speech and the use of humor in therapy sessions all while following the client's lead. The client was encouraged to seek spiritual guidance to help her cope as well and her faith was respected as a strength to help her with her recovery.

In conclusion of the therapy, the client engaged well in the therapeutic alliance, had not had any psychotic episodes in many months, and the bipolar disorder symptoms were stable. a lot can be said to the idea that using culture along with an evidence based practice, which in this case was prolonged exposure and cognitive behavioral therapy, together, the two made it possible for her to do better in therapy. In summary, I have discussed culture in the broad sense as well as defined resilience. I've talked about the reasons to consider culture in social work and mental health interventions and the dangers of not doing so. I described some of the predominant cultural characteristics of Mexican Americans that we need to keep in mind when we tailor interventions to meet the needs of this population. I've also talked about the issue of how culture can be seen as a protective factor in resilience of how Mexican Americans withstand adversity.

I reviewed several programs, research studies, and presented a case study that illustrated how culture emerges as a component of resilience for Mexican Americans. I thank you very much for your time and I hope you will consider culture as a a way to increase and identify resiliency in your clients and be able to tailor your interventions to address their very specific and particular needs. Thank you.

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