Copyright 1990 by the American Psychological Association, Inc. 0022-006X/90/S00.7S

Journal of Consulting and Clinical Psychology 1990, Vol. 58, No. 6, 704-712

Culturally Sensitive Psychotherapy for Puerto Rican Children and Adolescents: A Program of Treatment Outcome Research Lloyd H. Rogler

Robert G. Malgady

Fordham University

New York University and Fordham University

Giuseppe Costantino

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Sunset Park Mental Health Center, Brooklyn, New York and Fordham University Recognition of cultural distance between Hispanic clients and non-Hispanic therapists has prompted efforts to introduce culture into therapy, but there is little evidence that such efforts influence treatment outcomes. This article evaluates treatment outcomes from a program of research on modeling therapy with Puerto Ricans, targeting anxiety symptoms, acting-out behavior, and self-concept problems. Evaluation of outcomes confirmed the impact of culturally sensitive modeling therapy on anxiety symptoms and other selected target behaviors, but negative treatment effects also were evident. Results suggest that new approaches to psychotherapy for special populations, such as Hispanic children and adolescents, should be buttressed by programmatic research oriented toward the comparative evaluation of treatment outcomes and should be attuned to therapeutic processes mediating between culture and outcome.

For several decades processes shaping migration streams from Latin America have deployed large numbers of Hispanic immigrants into major urban centers in the United States. The growth of the Hispanic population exceeds that of any other ethnic group in this country: The 1987 advance census estimated the Hispanic population at 18.2 million, which is nearly a 30% increase over the 1980 census figure. Puerto Ricans constitute about 14% of the Hispanic population in the United States and are geographically concentrated in New \brk City; in addition, there are 3.2 million residents in the Commonwealth of Puerto Rico. Demographically, Puerto Rican families are disproportionately below the national median income and poverty level; Puerto Ricans are a young population with a median age of about 20; and Puerto Rican children and adolescents constitute over 30% of New "York City's public school population (Gurak & Rogler, 1980). Early epidemiologic studies of Puerto Rican mental health reported higher rates of psychiatric symptomatology compared with other ethnic groups, independent of socioeconomic status (SES; see Dohrenwend & Dohrenwend, 1969; Haberman, 1976). More recent data indicate that, controlling for SES, the psychiatric prevalence rate of depression, according to Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. (DSM-III; American Psychiatric Association, 1980) criteria, among Puerto Ricans is twice that of Mexican-Americans and Research reported in this article was supported by Grants RO1MH33711 and RO1-MH30569 from the National Institute of Mental Health, Division of Biometry and Applied Sciences, Minority Research Resources Branch, and by Grant 83-0868 from the William T. Grant Foundation. Correspondence concerning this article should be addressed to Robert G. Malgady, Program in Quantitative Studies, 933 Shimkin Hall, New York University, New York, New York 10003. 704

Cubans (Moscicki, Rae, Regier, & Locke, 1987). Other evidence from sociological studies associates the socioeconomic and demographic profile characteristic of Puerto Ricans with increased risk of mental disorder (Rogler, Malgady, & Rodriguez, 1989). However, studies of psychiatric prevalence rates and symptomatology have neglected Puerto Rican children and adolescents. According to some estimates (Aspira, 1983; Canino, Barley, & Rogler, 1980), school-age Hispanics (largely Puerto Ricans) exhibit the highest high-school dropout rate of all ethnic groups as well as alarming rates of referral for problems such as social and emotional disorientation, conduct and anxiety disorders, adjustment reactions with anxious features, and low self-esteem. Estimates of Puerto Rican dropout rates have ranged from 6880%, and comparative data suggest that New \fork City rates are "as bad or worse" than national averages (National Puerto Rican Forum, 1980). In 1978, the Special Populations Sub-Task Panel on the Mental Health of Hispanic Americans reported to the President's Commission on Mental Health that Hispanic youngsters are especially at high risk of mental disorder, but that the mental health literature had contributed little to the resolution of the problem. More recent reviews bf the literature concur that such neglect persists (Rogler, Malgady, & Rodriguez, 1989). Given the alarming estimates of dropout rates and mental health problems experienced by Puerto Rican children and adolescents, coupled with rapid population growth, there is a compelling need for preventive mental health services for these youngsters.

Culturally Sensitive Psychotherapy Despite considerable attention to problems attending the delivery of mental health services to Hispanics, such as underutilization of traditional resources (Rodriguez, 1987), premature dropout rates from psychotherapy (Sue, 1981), and allegations

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SPECIAL SERIES: CULTURALLY SENSITIVE PSYCHOTHERAPY

of ineffective treatment modalities (Padilla, Ruiz, & Alvarez, 1975; Rogler, Malgady, Costantino, & Blumenthal, 1987), there has been little research evaluating psychotherapy for Puerto Ricans and even less on children or adolescents. The more general literature on Hispanics (usually Mexican-American adults) implicates cultural distance between the typically lower SES bilingual Hispanic client and the middle-class, non-Hispanic therapist as the root of psychotherapeutic calamity. Hence, the recognition of cultural conflict in the client-therapist relationship has prompted considerations of "cultural sensitivity" in the treatment process. Based on a review of the Hispanic mental health literature, Rogler et al. (1987) identified three approaches to providing culturally sensitive mental health services. The first seeks to increase the accessibility of treatments for Hispanic clients, largely by narrowing the gap between the client's and professional's values (e.g., conception of mental illness and treatment) while accommodating what often may be a culturally patterned lay or indigenous referral system. Such efforts, which reportedly result in increased service utilization, involve recruiting bilingual/bicultural staff, coordinating service networks with the Hispanic community, and creating a therapeutic atmosphere in which Hispanic cultural values are accepted (e.g., Acosta & Cristo, 1981; Scott & Delgado, 1979; Trevino, Bruhn, & Bunce, 1979). Once services are used, the second approach involves selection of a treatment modality that is congruent with the Hispanic client's perceived cultural values. This approach has eschewed insight-oriented therapy as both uneconomical and irrelevant to the context of Hispanic life (Ruiz, 1981; Sue & Sue, 1977). Ruiz, for example, recommends screening Hispanic clients according to level of acculturation and then assigning relatively acculturated clients to the "usual" therapies and less acculturated clients to special interventions designed to confront their immediate crises. However, whether such efforts to increase the sensitivity of therapeutic intervention to the Hispanic client's cultural orientation affect treatment outcomes remains largely unevaluated. The third approach to cultural sensitivity introduces the client's cultural values directly into the therapeutic modality. Two premises have guided this approach. One is that the client's values structure should be matched isomorphically by a similar set of therapeutic assumptions, such as focusing on Cubans' strong sense of familism to treat intergenerational and acculturative conflict in family therapy (Szapocznik, Scopetta, & King, 1978). The other does not seek to merely reproduce a culturally congruent ambiance, but takes the client's culture as a point of departure for restructuring therapeutic intervention (Rogler et al., 1987). In this case, therapeutic goals are established that integrate conflicting cultural norms; the bicultural treatment approach shapes behavior by bridging cultural conflict. This article presents an evaluation of treatment outcomes of a program of research consistent with this approach to culturally sensitive psychotherapy for Puerto Rican children and adolescents.

Folktale Therapy With Children In our initial study of cultural intervention with children, Costantino, Malgady, and Rogler (1986) developed a story-tell-

705

ing modality using Puerto Rican atentos or folktales in modeling therapy. In this approach, the characters in folktales were posed as therapeutic peer models conveying the theme or moral of the stories. The nature of such stories motivates children's attention to the models, which is critical to the first stage of the modeling process. Second, the models portray beliefs, values, and behaviors with which children can readily identify and which they can imitate. Third, reinforcement of children's imitation of the models in a therapeutic setting facilitates social learning of adaptive behaviors that are targeted in the story themes. Previous studies have used story telling of fairy tales and fantasy play to treat dysfunctional nonminority (Bettelheim, 1977; Gardner, 1981) and minority children (Freyberg, 1973; Smilansky, 1968), and informal evaluations have suggested favorable outcomes. The cuento study was designed to evaluate treatment outcomes of cultural intervention compared with a standard therapy and with no therapy. Two versions of cuento therapy were developed, one based on stories originating in Puerto Rican folklore, and the other on folktales adapted to bridge Puerto Rican and American cultures. This variation on cultural intervention provided for a test of the two assumptions guiding the third approach to cultural sensitivity. Method Subjects Treatments were implemented in mixed-sex group sessions with 210 Puerto Rican boys and girls (mean age = 7.45 years), kindergarten to third grade, and their mothers. The children were screened for behavior problems in school and at home (by teacher and parental ratings) and were classified in the secondary prevention stage for risk of mental disorder. Children's families were of low SES; the father was absent from 68% of the households; most parents were unemployed (mothers, 88%; fathers in household, 39%) and had not completed high school (mean education = 8.5 years).

Procedure A panel of Puerto Rican psychologists and parents selected 40 cuentos with child protagonists from Puerto Rican folklore on the basis of thematic content embodying cultural values. Development of a therapy modality from these original cuentos was consistent with the approach of isomorphic reproduction of culture in treatment. A second modality, consistent with the bicultural approach, was developed by adapting these cuentos to bridge Puerto Rican and American cultures and to convey more therapeutically the moral of each story. The ethnic identity of the main character remained Puerto Rican in the adapted stories, but other characters were presented as multiethnic (Hispanic, Black, and White) to more naturally reflect inner-city social interactions. The rural Puerto Rico settings of the original cuentos were changed to urban settings similar to the children's community. Original themes were altered to stress themes such as social judgment, control of anxiety and aggressive impulses, delay of gratification, and compliance with parental authority. In conducting cultural intervention sessions, the therapists and mothers of the children read the cuentos aloud bilingually. Sex-role modeling was controlled by presenting in each session two cuentos varying by sex of the child protagonist. Therapists then conducted group discussion of the character's feelings and behavior and the moral of the story. Once the target behaviors of the session were clear, the

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opportunity for imitative behavior was provided as the mother-child dyads dramatized the story and resolved the basic conflict. Reinforcement of imitative behavior occurred both from the consequences attending the dramatic role playing and from the therapist's verbal reinforcement of adaptive behavior consistent with therapeutic goals. A videotape of the drama was reviewed, and the group discussed the adaptive and maladaptive consequences of the players' actions. Two control conditions were used to evaluate treatment outcomes. An art/play therapy control was conducted under similar conditions, using recreational tasks and games in which mother-child dyads interacted under the supervision of a therapist. Mother-child dyads also dramatized common family scenes depicting interpersonal conflict. Videotapes of the role-playing exercises were reviewed by the groups, and the therapist led discussions of members' personal experiences with similar conflict and which solutions were adaptive and maladaptive in terms of reducing family tensions. A second no-treatment control group participated in discussion sessions conducted by a therapist and a school teacher. Children were randomly assigned by sex and grade level to treatment groups, and 20 weekly 90-min sessions were led by male and female Puerto Rican therapists. Sessions were held in a public school within the Hispanic community, and attendance was above 80%.

Measurement of Treatment Outcomes Children were pretested and posttested individually with a battery of measures by bilingual Puerto Rican examiners blind to treatment group assignments. Tests were administered in a child's preferred language or bilingually. A second follow-up posttest administration was conducted 1 year later on 178 (85%) of the children. The screening criteria for inclusion in the study and the targets of the therapy intervention were anxiety symptoms, conduct problems (control of aggressiveness, disruptiveness, inability to delay gratification), poor social judgment, and low self-esteem. Anxiety symptoms were measured by the Trait scale of the State-Trait Anxiety Inventory; mean item response is reported here on a 3-point scale denoting the frequency of a given anxiety symptom including hardly ever (0), sometimes (1), and often (2). Social judgment was measured by the Comprehension subtest of the Wechsler Intelligence Scale for Children—Revised (WISCR); age-appropriate standardized scale scores are reported (M = 10, SD = 3). Observation data were collected in independent experimental situations designed to elicit either aggression (response to a frustrating task provoked by a confederate), disruptiveness (compliance with instruction to maintain silence during a 10-min task), delay of gratification (number of days awaiting increasingly larger monetary rewards after successful task performance), or self-concept (selection of tasks varying in perceived age-level difficulty). Five trials in each situation were administered. Aggressiveness and disruptivenessof children's behavior were rated on a 5-point scale ranging from low aggression/ disruptiveness (1) to high aggression/disruptiveness (5) by independent observers who were trained to at least 80% agreement. Delay of gratification (number of days) and self-concept (age level selected) were objectively recorded.

Results Evaluation a/Treatment Outcomes Given multiple treatment outcome measures, a multivariate analysis of covariance (Treatment x Sex X Grade Level) was conducted with the pretests as covariates and the immediate and follow-up posttests as dependent variables. The overall multivariate analysis revealed a significant main effect due to treatment and a Treatment X Grade Level interaction, account-

ing respectively for 28% and 11% of the generalized variance. Univariate analyses of covariance then were conducted separately for the immediate and follow-up posttests of each outcome measure. Treatment effects were significant in the analyses of anxiety symptoms, social judgment, and aggression observation ratings; however, differential treatment outcomes were not evident in disruptive behavior, delay of gratification, or self-concept. Anxiety outcomes. With respect to immediate posttest anxiety ratings, treatment groups differed significantly only among first graders. Residualized posttest means (adjusted for pretest differences) of the four treatment groups are shown in Figure 1 on a scale ranging from low anxiety (0) to high anxiety (2). The adapted cuento group reported significantly less frequent anxiety symptoms than the other groups, with moderate to large (.63 to 1.22SD) effect sizes (ESs). The original cuento group reported anxiety symptoms significantly less often than the notreatment control group (ES= .33SD), but did not differ significantly from the art/play control group. Analysis of the follow-up data indicated that treatment effects emerged after 1 year for all grade levels. Adjusted 1-year posttest means of the four treatment groups also are shown in Figure 1. The adapted cuento group reported significantly less anxiety than the two control groups (ES= .34 to .685D), but did not differ significantly from the original cuento group. The original cuento group differed significantly and moderately (ES= .48S!D) from the no-treatment control group but did not report significantly less anxiety than the art/play control group. Thus the evaluation of anxiety symptoms as a treatment outcome revealed a complex pattern of findings. Immediate treatment effects were evident only with younger children in the first grade; in this specific subgroup, the cultural modeling intervention based on folktales adapted to bridge Puerto Rican and American cultures had the strongest impact on reduction of anxiety symptomatology. However, treatment differences

MEAN ANXIETY

Immediate Follow-up

1.30 1.26 1.20 1.15 1.10 1.00 0.96 0.90 Original Cuento

Adapted Cuento

Art/Play Control

No-Treatment Control

TREATMENT GROUP

Figure 1. Mean residualized immediate and follow-up posttest scores on trait anxiety for cuento and control treatment groups. (From "Cuento Therapy: A Culturally Sensitive Modality for Puerto Rican Children" by G. Costantino, R. G. Malgady, and L. H. Rogler, 1986, Journal of Consulting and Clinical Psychology, 54, p. 642. Copyright 1986 by the American Psychological Association. Adapted by permission.)

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707

MEAN SOCIAL JUDGMENT were uniform (regardless of grade level or sex) after 1 year. Adaptations of the folktales once again had substantial impact on 10.8 anxiety symptoms relative to the control conditions, but the 10.5 difference between the two cultural interventions was not con10.2 firmed. 09.9 Anxiety reduction achieved by introducing cultural sensitivity into modeling therapy with Puerto Rican children is consis09.6 tent with the treatment outcomes reported in earlier studies 09.3 using social learning techniques with nonminority populations 09.0 • (see Costantino et al., 1986). This treatment outcome is espe08.7 cially prominent because anxiety is a core symptom in many other types of more severe psychopathology. Because Puerto Original Adapted Art/Play No-Treatment Rican children generally may be classified as a high-risk popuCuento Cuento Control Control lation, and because the children screened for participation in TREATMENT GROUP this study already were experiencing behavior problems at school and at home, cuento therapy may serve a preventive mental health function. This conclusion is underscored by the stability of anxiety outcomes for 1 year following the intervention, although the attempt to distinguish more subtle approaches to cultural sensitivity had diminished long-term success. Social judgment outcomes. Treatment effects on social MEAN AGGRESSION judgment (WISC-R Comprehension subtest) were significant only in the analysis of immediate posttests. Adjusted means of 3.68 the four treatment groups are shown in Figure 2. Results re3.60 vealed that both cuento therapy groups, although undifferen3.52 tiated, displayed significantly increased social judgment in comparison with the two control groups. The pooled effect 3.44 sizes were moderate (.54SD) compared with the art/play group, 3.36 and small (.2SSD) compared with no treatment. 3.28 Thus, without qualification by grade level or sex, culturally 3.20 • sensitive intervention significantly increased social judgment 3.12 in terms of children's ability to understand, verbalize, and evaluate socially acquired knowledge in an adaptive manner. This Original Adapted Art/Play No-Treatment finding concords with similar studies of the effects of story Cuento Cuento Control Control telling and dramatic play techniques on minority and disadTREATMENT GROUP vantaged children's cognitive functioning (see Costantino et al., 1986). However, the cognitive outcomes of approaching culFigure 2. Mean residualized immediate posttest scores on social judgment and aggression for cuento and control treatment groups. (From tural sensitivity through isomorphic reproduction of Puerto Ri"Cuento Therapy: A Culturally Sensitive Modality for Puerto Rican can culture versus through adaption to inner-city settings and Children" by G. Costantino, R. G. Malgady, and L. H. Rogler, 1986, American values were not distinct. Journal of Consulting and Clinical Psychology, 54, p. 643. Copyright Reconsidering the potential preventive mental health value 1986 by the American Psychological Association. Adapted by permisof cultural interventions, the lack of stability of cognitive outsion.) comes after 1 year suggests the need for provision of supportive follow-up services. The promotion of adaptive social judgment among children is especially critical for the prevention of the ments significantly reduced children's aggressive behavior reladevelopment of conduct disorders. This is particularly true about minority children who, often lacking adaptive social and tive to the noncultural treatment, with substantial effect sizes (,53SD with adapted cuentos and .3957? with original cuentos). academic role models, instead find themselves exposed to maladaptive models reinforcing delinquency, truancy, and even However, the adaptation of cuentos to bridge cultures had little effect (see Figure 2) and did not have an impact on aggression criminal behavior. Behavioral outcomes. Differences between treatment significantly more than the original cuento modality. Figure 2 groups were not significant with regard to observation ratings also shows that both cuento treatments may have induced agof children's disruptiveness or to the objectively recorded obsergressive behavior by comparison with the no-treatment control condition. Although these comparisons were not statistically vations of self-concept and the ability to delay gratification. significant, the consistent direction of the findings on both the Treatment effects with respect to observation ratings of children's aggressive behavior were found only in relation to art/ immediate and follow-up posttests is alarming. play therapy and only at the immediate posttest. Adjusted One explanation of the findings concerning aggressive behavgroup means are presented in Figure 2. The two cultural treatior is that in the art/play treatment, which had a significant

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negative treatment outcome relative to all other conditions, the therapy was nondirective, permitting children to express and act out their feelings—often aggressively—without reproach by therapists or parents. Similarly, several folktale themes involved punishment of the child protagonist's maladaptive behavior by an adult character, particularly in the original cuentos. Thus, despite children's vicarious experience of punishment through both story telling and dramatic play, the cultural modalities actually may have promoted imitative aggression induced by secondary modeling of aggressive adult behavior. Among inner-city minority children, acting-out behavior, such as failure to control aggression, is a frequently noted problem by parents and teachers (Rogler et al., 1989). The evaluation of aggression outcomes suggests that, if cultural modeling therapy is replicated elsewhere, the modality should be revised by redacting aggressive behavior by either peer or adult models. Such an oversight in the development of cuento therapy may be the reason why the adapted folktale modality did not promote statistically and clinically more favorable treatment outcomes than the original stories. The preventive mental health value of cultural interventions would be enhanced if modalities could be developed to effectively have an impact not only on anxiety and social judgment, but also on children's acting-out behavior.

Hero/Heroine Therapy With Adolescents Interviews with the older (third-grade) children participating in the cuento therapy study, and other small-sample pilot studies with adolescents, revealed their tendency to view the folktales as juvenile and the characters as cartoon-like (Costantino, Malgady, & Rogler, 1988). In conjunction with the anxiety outcomes specific to the younger children in the cuento study, these findings inspired the development of a somewhat different approach to the introduction of cultural sensitivity into modeling therapy. Following the promising treatment outcomes emerging from the evaluation of cuento therapy, the program of research on culturally sensitive psychotherapy was extended to an adolescent Puerto Rican population, basing the story-telling modality on "heroic" adult role models. Adolescence is considered a turbulent period in the psychosocial development of most youngsters, and the weight of evidence suggests that Puerto Rican adolescents may be at increased risk of mental disorder. According to the 1980 Census, 41% of Puerto Rican families are single-parent households headed by females, and estimates specific to Puerto Ricans in New York City are at least this high (44%, reported by Mann & Salvo, 1985). Moreover, according to the National Puerto Rican Forum (1980), about 9% of Puerto Rican households are headed by adolescents and young adults under 24 years old. The frequency of young, single-parent households—typically a result of father absence—indicates that Puerto Rican adolescents often lack appropriate adult role models with whom they can identify and therefore lack adaptive values and behaviors to imitate during adolescence (Lash, Segal, & Dudzinski, 1979). It has also been suggested that the identity crisis of Puerto Rican adolescents is compounded by strong intercultural and intergenerational conflicts (Lewis, 1966). Consequently, Puerto Rican adolescents would appear to be suitable candidates for mod-

eling therapy that fulfills their need for adaptive adult role models in a culturally sensitive way. In our second study, Malgady, Rogler, and Costantino (1990) developed a modeling therapy using biographical stories of heroic Puerto Ricans in an effort to bridge the identity, bicultural, and intergenerational conflicts faced by Puerto Rican adolescents. This modality sought to enhance the relevance of therapy for adolescents by exposing them to successful adult models in their own culture, thus fostering ethnic pride and identity as a Puerto Rican, and to model achievement-oriented behavior and adaptive coping with stress common to life in the Puerto Rican community. The content of the biographies embodied themes of cultural conflict (e.g., expression of cultural pride juxtaposed with the experience of discrimination), and group discussion and imitative role playing drew upon experiences in Puerto Rico and the United States. This approach to cultural intervention represents an attempt to bridge cross-cultural conflict much in the manner of the adaptation of folktales in the previous study. Method

Subjects The therapy was implemented in group sessions with 40 male and 50 female Puerto Rican adolescents in Grades 8 and 9 (mean age = 13.67), who were screened for behavior problems by teacher rating and classified as secondary risk status. All households were of low SES, 64% were receiving welfare benefits, and 71% were female-headed. The major difference from the children participating in the cuento study, apart from age, was that these adolescents all were U.S.-born and English-dominant. Children were randomly assigned to either the hero/ heroine intervention group (n = 70, with 9 dropouts) or an attention control group (n = 40, with 11 dropouts). The intervention group participated in 18 weekly 90-min therapy sessions and the attention control group in 8 monthly discussion sessions, each led by male and female Puerto Rican therapists in a publicschool within the Hispanic community. Attendance at the sessions averaged 68% in the intervention, and 84% in the control group. A research panel selected and compiled biographies of nine male and nine female "heroic" role models, sampling diverse periods of Puerto Rican history. The role models were chosen on the basis of their significant achievements (in politics, sports, arts, and education) and adaptive coping to overcome adversities such as poverty and prejudice. A different male or female biography was presented in each session. Intervention sessions were conducted in three stages. First, group members read the biography, and the therapists led a discussion of the source of stress and behavior reflecting ethnic pride, positive self-concept, and adaptive coping strengths. Second, in order to promote identification with the model, therapists led group discussion through structured questioning comparing group members' experiences with the model's biography. Therapists verbally reinforced group members' sel f-reported behavior that was consistent with the model and explored alternatives to maladaptive behavior. Third, group members dramatized an open-ended skit related to the biography with direction to resolve the conflict posed. Peer reinforcement of adaptive resolutions was encouraged and also verbally reinforced by the therapists. Thus, the intervention sought to promote adolescents' identification with the heroic role models through ethnic and cultural similarity, and also by comparison of stressful experiences. Group discussion and imitative role playing then provided a forum for reinforcement of appropriate target behaviors.

SPECIAL SERIES: CULTURALLY SENSITIVE PSYCHOTHERAPY

symptoms as an outcome of the hero/heroine intervention is consistent with the earlier cuento study but somewhat weaker Adolescents were pretested and posttested individually in English in effect size. However, it is not entirely clear why cultural modwith a battery of measures by Puerto Rican examiners blind to treateling of heroic biographies would be less effective among the ment assignments. The models in the therapy intervention displayed a older group of adolescents. One clue is provided by feedback positive self-concept and strong ethnic identity. Therefore, these outfrom the therapists and informal interviews of the participants comes were targeted using the Piers-Harris Self-Concept Scale, includfollowing the study. After about half of the sessions, the 14- to ing low self-concept (0) and high self-concept (1) and a 17-item Puerto 15-year-old participants were somewhat jaded by what they Rican Identity rating scale ranging from very Puerto Rican (1) to very Anglo (5); Malgady et al., 1990. The models also were selected for emperceived as repetitive themes in the biographies. Thus, as their phasis on adaptive coping with stress; thus, anxiety and symptom disinterest waned they became less responsive to the therapeutic tress also were targeted as treatment outcomes. Anxiety symptoms message. This also may explain the poorer attendance rate in were measured by the Trait scale of the State-Trait Anxiety Inventory, the hero/heroine study compared with attendance in the as described in the cuento study. Symptom distress was measured by cuento study. Nevertheless, this treatment outcome supports the SCL-90-R (Derogatis, 1983), which was scored for the Global the preventive mental health value of cultural intervention for Severity Index across symptom dimensions on a scale ranging from no younger adolescents and invites the development of new culdistress (0) to extreme distress (4). tural modalities that can capture and maintain the interest of an older population. Evaluation ofTreatment Outcomes Self-concept and ethnic identity outcomes. Overall, there was no significant main effect of treatment intervention on selfDue to small cell sizes, it was necessary to conduct separate multivariate analyses: Treatment X Sex x Grade Level or Father Presence in concept, but there was a moderate main effect on ethnic idenHousehold, with the pretests as covariates and the posttests as depentity. The hero/heroine intervention group evidenced signifident variables. The overall multivariate analyses revealed a significant cantly greater Puerto Rican identity than the control group main effect due to treatment, a Treatment X Grade Level interaction, (ES - .54SD). However, rather strong interaction effects involvand a Treatment X Sex X Father Presence interaction. Subsequently, ing treatments were evident with respect to both self-concept univariate analyses of covariance were conducted for each outcome and ethnic identity, as a function of sex and father presence in measure. Treatment main and interaction effects were significant in the household. Residualized posttest means are shown in Figthe analyses of self-concept, ethnic identity, and anxiety symptoms, but ures 4 (ethnic identity) and 5 (self-concept). not in the analysis of symptom severity. Treatments did not differ significantly for girls in fatherabsent families nor for boys in father-present families. HowResults ever, boys from father-absent families showed significantly and Anxiety outcomes. The analysis of anxiety outcomes resubstantially stronger Puerto Rican identity in the intervention vealed a Treatment X Grade Level interaction in which treatgroup compared with the control group (ES =1.15SD), and a ment groups differed significantly only at the eighth-grade similar effect (87SZ>) was apparent among girls from intact famlevel. Residualized posttest means (adjusted for pretest differilies (see Figure 4). ences) of the intervention and control groups are shown as a Consistent with the intention of the cultural intervention, the function of grade level in Figure 3 ranging from low anxiety (0) role models presented in therapy appeared to promote greater to high anxiety (2). The intervention group reported signifiethnic identification in the absence of a male adult in the adolescantly less frequent anxiety symptoms than the control group, cents' household, but only among male adolescents. Female with a modest effect size (39SD). adolescents in female-headed households generally had The grade level specific finding in the evaluation of anxiety stronger Puerto Rican identities than their male counterparts, which were not augmented by the therapeutic role models, perhaps because they already strongly identified with their mothers. Similarly, boys in intact families identified ethnically MEAN ANXIETY with their fathers (i.e., no male identity gap needed fulfillment), .86 but their female counterparts may have experienced intergenerational or cultural conflict with their fathers, which was ame.80 liorated by the intervention. Grade 9 .76 In terms of self-concept (see Figure 5), the interaction was .70 consistent with expectation in the father-absent families. The .66 therapeutic role models promoted increased self-concept, significantly more so for girls (ES = .56SD) than boys (ES = .60 .36SD). Consistent with the ethnic identity outcomes, boys .65 Qrad* 8 from intact families did not enhance their self-image as a result .60 of exposure to therapeutic role models. However, there was a significant and large negative treatment effect (1.29SD) among Control Hero/Heroine female adolescents from intact families. TREATMENT GROUP This unexpected negative treatment outcome may derive from the same source implicated in ethnic identity. Although Figure 3. Mean residualized posttest scores on trait anxiety for hero/ heroine and control treatment groups as a function of grade level. female adolescents from intact families became "more Puerto

Measurement ofTreatment Outcomes

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considering the preventive mental health value of cultural interventions. This implicates the need to investigate both the integrity and quality of intrafamilial relations not only as potential mediators of treatment outcomes but in the development of interventions for populations with special mental health needs.

MEAN ETHNIC IDENTITY

2.70 2.60 2.50 2.40 2.30 2.20

• • • -

Discussion

2.10 • 2.00 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Control

Hero/Heroine

Perhaps the most fundamental question that should be faced by culturally sensitive psychotherapy research is whether or not culture is consequential to treatment outcome. In a recent review of two decades of cross-cultural psychotherapy research on ethnic minority populations, based primarily on Blacks, Sue

TREATMENT GROUP (Father Absent) MEAN SELF CONCEPT .65 .82 .79

.76 .73 .70 .67 .64

MEAN ETHNIC IDENTITY 2.70 2.60

• • • -

2.50 •

Control

2.40

Hero/Heroine TREATMENT GROUP (Father Abaent)

2.30 •

Male

2.20 • Female

2.10 2.00 • Control

Hero/Heroine TREATMENT GROUP (Father Preaent)

Figure 4. Mean residualized posttest scores on ethnic identity for hero/ heroine and control treatment groups as a function of sex and father presence/absence in the household. (From "Hero/Heroine Modeling for Puerto Rican Adolescents: A Preventive Mental Health Intervention" by R. G. Malgady, L. H. Rogler, and G. Costantino, 1990, Journal of Consulting and Clinical Psychology, 58, p. 469-474. Copyright 1990 by the American Psychological Association. Adapted by permission.

Rican," their self-image diminished in the process. A twofold explanation of this process seems plausible. The role models idealized in therapy may have aroused conflict about the girls' parental models and, through identification with their parents, personal inadequacy. This process may have operated only among girls because the therapeutic female role models typically represented nontraditional female sex roles (e.g., professional athlete, politician, lawyer). Thus, ideal-real parental conflict and female sex-role conflict may account for the negative treatment outcomes among female adolescents. The interactions that had an impact on treatment outcomes call attention to the importance of adolescents' social context in

MEAN SELF CONCEPT

.65 .82 .79 .76 73 -\ .70 .67 .64 -

Male

Female

Control

Hero/Heroine

TREATMENT GROUP (Father Present)

Figure 5. Mean residualized posttest scores on self concept for hero/ heroine and control treatment groups as a function of sex and father presence/absence in the household. (From "Hero/Heroine Modeling for Puerto Rican Adolescents: A Preventive Mental Health Intervention" by R. G. Malgady, L. H. Rogler, and G. Costantino, 1990, Journal of Consulting and Clinical Psychology, 58, p. 469-474. Copyright 1990 by the American Psychological Association. Adapted by permission.

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SPECIAL SERIES: CULTURALLY SENSITIVE PSYCHOTHERAPY

(1988) identified two competing conclusions pertinent to this issue. The first is that ethnic or cultural mismatch between client and therapist decreases the likelihood of favorable therapeutic outcome, whereas the second suggests that cultural differences are largely irrelevant to therapeutic outcomes. According to Sue (1988), the research literature on this fundamental issue apparently is equivocal and riddled with methodological flaws. Although studies specific to Hispanics are scant, findings of the cuento and hero/heroine research show that cultural interventions produced generally more favorable outcomes than did no-treatment intervention, lending support to the conclusion that cultural match or mismatch is indeed consequential. The theoretical notion underlying these treatment strategies is that culturally related conflict is at the root of symptomatic behavior among high-risk Puerto Rican children and adolescents. The growing concern for the provision of therapeutic services responsive to Hispanic culture, and with it the need to evaluate the outcomes of such treatments, address Paul's (1967) pervasive question about outcome research: What type of psychotherapy administered by whom is most effective for which type of client with what type of problem under which set of circumstances? The prospect that the outcomes of psychotherapy may be influenced by the surrounding cultural ambiance lends a new perspective to this litany of queries. In the case of a Hispanic client, cultural distance intrudes on the relationship with a non-Hispanic therapist, not only because of differences in ethnicity and language usage, but also as a function of their less ostensible differences in values structure and culturally patterned orientations toward therapy. Cultural distance also arises in the form of incongruity between the client's cultural predispositions and the structure and content of the therapeutic modality itself. Thus, the goal of culturally sensitive psychotherapy, broadly conceived, is to attenuate cultural distance and thereby promote more effective therapeutic gains than would be obtained by standard treatments. Unfortunately, studies of therapy outcomes with Hispanic clients, especially with child and adolescent populations, present a fragmented picture of the extent to which this goal has been realized. In this respect, the cuento therapy research is exemplary in providing a test of the effectiveness of cultural interventions compared with a standard therapy control group. On the other hand, the hero/ heroine therapy research provides evidence that cultural intervention is more effective than no therapeutic intervention, but the more rigorous question of whether cultural intervention promotes outcomes superior to standard treatments remains unanswered. A related but unexamined question is whether culture-specific intervention enhances outcomes in the cultural target population more than in other cultural groups. For example, does an intervention based on Puerto Rican role models, many of whom are Black, produce different treatment outcomes among Puerto Ricans compared with Black Americans? Even more specific than whether culture is relevant to outcome, or whether cultural intervention is more effective than standard therapy, is the question of whether cultural values should be reproduced in therapy or adapted to therapeutic goals consistent with adjustment in the host society. To our knowledge, the cuento study is the only research effort to examine this issue. The evaluation of treatment outcomes provided

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mixed support for the adapted folktale modality. The outcomes of the hero/heroine intervention provide additional support for the therapeutic bridging of cultures in a treatment modality. The biographies presented conflicts experienced by the role models in circumstances similar to the adolescents' personal experiences, and therapists reinforced adaptive resolution of such conflicts within the adolescents' current cultural context. However, the nature of the hero/heroine therapy modality did not lend itself to the development of a comparable therapy condition involving isomorphic reproduction of the native culture alone, because most of the biographies involved cross-cultural themes. Sue and Zane (1987) have provided insight relevant to the complex interaction effects found in our outcome research. They have suggested that cultural factors may have a "distal" rather than a "proximal" effect on therapy outcomes. Consideration of a client's culture in treatment planning may not necessarily have a direct link to outcome but may enhance the process of therapy, which in turn is more proximately linked to outcome. Accordingly, the interaction of the hero/heroine intervention with adolescents' sex and household composition may reflect the operation of culture on outcome indirectly through mediating process variables. That is, culture embodied by the idealized Puerto Rican adult models enhanced the therapy processes of identification and imitation for some participants (e.g., adolescents from single-parent families) but interfered with the therapy process for others (e.g., females from intact families). In light of Sue and Zane's (1987) comments, these findings call attention to the need for process-oriented research in outcome studies of cultural intervention. Cultural adaptations of therapeutic modalities are well intentioned and certainly not misdirected, but an equally important consideration is the client's cognitive response to the therapeutic intent. The pattern of positive and negative treatment outcomes in the hero/heroine study suggests, for example, that clues to differential responsiveness to the therapeutic process may be evident from the Hispanic adolescent's familial context. A final commentary relates to the value of programmatic research on treatment outcomes. Our own program of research currently is focused on therapeutic process variables that may mediate the effects of cultural intervention in a replication of the hero/heroine study with English- and Spanish-dominant adolescents. Research in progress in other cultural settings is replicating cuento therapy with American Indian children (La Fromboise & Fink, 1990) and hero/heroine therapy with Black adolescents in South Africa (Woutres, 1990). Such programmatic efforts provide formative feedback that refines and expands our understanding of the basic triangular relationship between clients' needs, the therapy process, and the assessment of outcome.

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This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

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Culturally sensitive psychotherapy for Puerto Rican children and adolescents: a program of treatment outcome research.

Recognition of cultural distance between Hispanic clients and non-Hispanic therapists has prompted efforts to introduce culture into therapy, but ther...
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