Copyright 1990 by the American Psychological Association, Inc. 0022-006X/90/$00.75
Journal of Consulting and Clinical Psychology 1990, Vol. 58, No. 4,469-474
Hero/Heroine Modeling for Puerto Rican Adolescents: A Preventive Mental Health Intervention Robert G. Malgady
Lloyd H. Rogler Hispanic Research Center, Fordham University
Program of Quantitative Studies, New York University and Hispanic Research Center, Fordham University
Giuseppe Costantino
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.
Sunset Park Mental Health Center, Brooklyn, New York and Hispanic Research Center, Fordham University Culturally sensitive treatments of the special mental health needs of high-risk Puerto Rican adolescents are lacking. The hero/heroine intervention was based on adult Puerto Rican role models to foster ethnic identity, self-concept, and adaptive coping behavior. 90 nonclinical Puerto Rican 8th and 9th graders were screened for presenting behavior problems in school and randomly assigned to an intervention and a control group. After 19 sessions, the intervention significantly increased adolescents' ethnic identity and self-concept and reduced anxiety. Treatment outcomes varied as a function of grade level, sex, and household composition. Self-concept was negatively affected among girls from intact families. The study supports the effectiveness of the culturally sensitive modality as a preventive mental health intervention for high-risk Puerto Rican adolescents, especially from single-parent families.
Hispanics may be at higher risk of mental disorder than their nonminority and other minority counterparts, and among them, Puerto Ricans in particular reveal a high-risk socioeconomic and demographic profile (Rogler, Malgady, & Rodriguez, 1989). Puerto Ricans are markedly below the national median income and poverty level, undereducated and underemployed, living in substandard housing, and confronting linguistic and cultural barriers (Mann & Salvo, 1985). Psychiatric epidemiological models defining a high-risk population in terms of increased stress and higher prevalence of symptomatology coincide alarmingly with the social and demographic characteristics of the Puerto Rican population (Canino, Barley, & Rogler, 1980). More direct evidence of high-risk status is the tendency of Puerto Ricans to report more psychiatric symptoms than Whites or Blacks (Malgady, Rogler, & Costantino, 1987,1988) and, among Hispanics, more depressive symptoms than either Mexican-Americans or Cubans (Moscicki, Rae, Regier, & Locke, 1987). Critics of the mental health delivery system have argued that the contrast between Anglo and Hispanic cultures creates a sociocultural distance between therapist and client that requires bridging through culturally sensitive treatment (e.g, Cohen, 1972; Padilla & Ruiz, 1973; Rogler, Malgady, Costantino, This research was supported by Grants RO1-MH33711-07 and 2RO1-MH30569-12 from the National Institute of Mental Health, Division of Biometry and Applied Sciences, Minority Research Branch to Fordham University's Hispanic Research Center. We gratefully acknowledge the cooperation of the students, principal, and dean of students at Intermediate School 136 in Brooklyn, New York and of two anonymous reviewers for comments on a draft of this article. Correspondence concerning this article should be addressed to Robert G. Malgady, Program of Quantitative Studies, 933 Shimkin Hall, New York University, New York, New York 10003.
469
& Blumenthal, 1987; Ruiz, 1981). Three approaches to cultural sensitivity have been identified: increasing the accessibility of mental health services to the Hispanic community, selecting treatment modalities that are most congruent with perceived cultural traits of Hispanics, and embedding cultural traits directly in treatment modalities (Rogler et al, 1987). Because of the need for special mental health interventions with Puerto Ricans, we investigated innovative, culturally sensitive treatment modalities for high-risk children and adolescents. In an earlier study (Costantino, Malgady, & Rogler, 1985, 1986), young Puerto Rican children were treated by "cuento" therapy, a form of story-telling that is based on Puerto Rican folktales as a modality. The children discussed and enacted folktales selected to foster cultural values and adaptive behavior. The results of this effort were promising: Children in cuento therapy demonstrated increased social judgment and reduced anxiety relative to a control group. In the present study, we developed and evaluated a new treatment modality, hero/ heroine modeling, which exposes Puerto Rican adolescents to achievement-oriented adult role models fostering ethnic pride and identity, self-concept, and adaptive behavior for coping with the stresses of poverty, discrimination, and urban life. Of critical importance to the lives of Puerto Rican adolescents is the integrity of adult role models within the anomic social environment of inner-city life. In 1980, for example, 44% of New York City's Puerto Rican households were femaleheaded (Mann & Salvo, 1985). This signifies not just the absence of a singular male parent but the absence of all patterns of social interaction enmeshing the father role. Puerto Rican adolescents in such families lack comprehensive parental role models with whom to identify and, therefore, may be denied adaptive values and behaviors to emulate as they mature toward adulthood. Thus, the hero/heroine modeling intervention uses biographical stories about prominent Puerto Rican historical figures as a therapeutic vehicle not only to bridge a cultural gap
470
R. MALGADY, L. ROGLER, AND G. COSTANTINO
experienced by adolescents, but also to provide for their need for adaptive role models. Method
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.
Participants All Puerto Rican eighth and ninth graders (N = 418) at a public school in Brooklyn, New \brk were screened for behavior problems by their homeroom teachers using the Conners Teacher Rating Scale (Trites, Blouin, & Laprade, 1982). Students presenting the most severe behavior problems (below the median teacher rating) were solicited for the study, and 110 who were not undergoing mental health treatment volunteered to participate with parental consent. Students were randomly assigned to an intervention group (n = 70) and a control group (n = 40),' but 9 intervention members (13%) and 11 control members (27%) dropped out. The 90 students who completed the study ranged in age from 12 to 15 years (M = 13.67, SD = 0.79); all were U.S. born and English-dominant; 50 were eighth graders (29 male, 21 female) and 40 ninth graders (11 male, 29 female). Seventy-one percent of the students' households were female-headed, and 64% were receiving welfare benefits. Employed mothers and fathers were in the three lowest SES occupations (menial service and unskilled and semiskilled workers) on the Hollingshead Index of Social Position.
Intervention The hero/heroine intervention was based on a social learning, modeling approach to treatment. The rationale was to expose adolescents to successful adult role models, often lacking in their own environment, with whom they could identify by virtue of ethnic and cultural similarity; to focus adolescents' attention, first, on the similarity of their own stressful experiences to the models' experiences and then on how the models coped adaptively with stress; and to reinforce adolescents' behavior that was consistent with the models' by discussion and imitative role-playing exercises. The content of the intervention targeted cultural conflicts, emphasizing the need for a strong sense of personal and ethnic identity, and ways of overcoming stressful life circumstances. The intervention was conceived as preventive rather than actively therapeutic because although the adolescents were socioeconomically and demographically defined as a high-risk population and were already experiencing behavior problems in school, they were not diagnosed as psychiatrically disordered. The target outcomes of the intervention were to increase ethnic identity and self-concept and to reduce stress and its symptoms. In this sense, the intervention did not target specific DSM-IH-R disorders of childhood and adolescence but rather presumed antecedents of psychopathology. A panel of Puerto Rican psychologists, educators, and sociologists and a specialist in Puerto Rican literature and history selected "heroic" role models for the intervention on the basis of their significant achievements and adaptive coping to overcome adversities such as poverty, sickness, and prejudice. Biographies were compiled on nine male and nine female models in diverse areas of achievement (e.g., sports, education, art, and politics), sampling Puerto Rican history from the 16th century to the present time. The intervention sessions were conducted in small groups of 3-5 students led by a schoolteacher and a graduate psychology intern (under supervision of Robert G. Malgady, Lloyd H. Rogler, and Giuseppe Costantino). After rapport was established, each group member read aloud a portion of the biography, and the group leaders analyzed selected anecdotes taken from the biography, identifying the source of stress and the behavior reflecting ethnic pride, positive self-concept, and adaptive coping strengths. The group leaders then asked a series of
questions of the group members designed to focus attention on the model's concerns, feelings, obstacles faced, and the resources used to surmount them. The ensuing discussion prompted members to volunteer similar experiences from their own lives, which were compared with those of the model through another series of questions (e.g., The person faced poverty. How have you faced this problem?) in order to reinforce identification with the model. The discussion evoked examples of positive and negative experiences, feelings, and behaviors; the group leaders intervened to verbally reinforce members' self-reported behavior that was consistent with the model's and explored alternatives to reports of behavior they judged as maladaptive. Sessions ended with unstructured role playing in which members enacted an open-ended skit that was based on the story they discussed. The group leaders closed the session by verbally reinforcing adaptive resolutions of the skit's conflict or seeking alternatives to maladaptive resolutions.
Procedure An introductory intervention session was conducted to present an overview of the history of Puerto Rico and some of the famous people the members would be learning about. The intervention was portrayed as an educational program about famous men and women in the history of Puerto Rico. Eighteen 90-min modeling sessions were conducted in the school on a weekly basis, with a male or female biography presented alternately. One group leader was male and one female in each intervention session. Regardless of students' sex, they were exposed to male and female biographies, as opposed to same-sex modeling, because a significant degree of diversity would have been lost by creating separate male and female intervention protocols. The sequence of biographies was arranged chronologically in order to provide historic continuity to the intervention. Eight 90-min control group meetings were conducted for comparability with the intervention group and to maintain student interest in order to minimize attrition at the posttest. The control group also met in small groups with a psychology intern and a teacher (one male and one female) leading group discussions of current events, school activities, and topics of student interest. Control group meetings were held at the testing sessions and on a monthly basis between testings. Students were paid $7 per session for their participation. Different group leaders conducted the intervention and control group sessions. The students in both groups were formed into single-sex groups because pilot work indicated that groups of mixed-sex adolescents were distracted by members of the opposite sex and were more likely to misbehave, resulting in interference with the intervention. By conducting single-sex group sessions, the leaders were better abie to manage students' behavior and focus their attention on the biography, discussion, and role-playing themes at hand. The comparability of the intervention and control groups is shown in Table 1. The students in the two groups were distributed very similarly by grade level, age, father presence/absence in the household, and welfare status. However, a notable source of discrepancy was amount of contact. There were more than twice as many intervention sessions as control sessions, and the attendance rate was much higher in the control group (M= 84%) than in the intervention group (M= 68%).
Outcome Measures In order to assess the effects of the intervention, participants were pretested and posttested with a battery of instruments to measure 1
By design, the intervention and control groups had unequal samples sizes to accommodate the participating public school officials who wanted as many students as possible to participate in the intervention.
471
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.
HERO/HEROINE MODELING ethnic identity, self-concept, trait anxiety, and symptom distress. These measures were chosen for several reasons. First, the models to be emulated demonstrated a positive self and ethnic image, and the intervention was specifically targeted toward enhancing the participants' ethnic identify and self-concept. Second, because the biographies to be modeled and the criteria for reinforcing imitative behavior emphasized adaptive coping with stress, an effect on indicators of stress (anxiety and symptom distress) was expected. Third, the instruments selected have acceptable reliability with Puerto Rican examinees. Ethnic identity was measured by a 17-item version of the Cuellar, Harris, and Jasso (1980) acculturation scale for Mexican-Americans, which was adapted to measure identification with Puerto Rican versus Anglo-American ethnicity. Items composing the scale referred to behavior and feelings associated with pride in being Puerto Rican (e.g., not proud at all to extreme pride), ethnic affiliation (e.g., Anglo-American to Puerto Rican), language preference in family, peer, and media interactions (e.g., English only to Spanish only), and ethnic self-classification (e.g, very American to very Puerto Rican). Items were rated on a 5-point scale such that low scores reflected high Puerto Rican identity and high scores, high Anglo identity, whereas intermediate scores reflected a bicultural identity. Self-concept was measured by the 80-item Piers-Harris Self-Concept Scale. Items were rated dichotomously ind icating endorsement (or not) of statements indicative of positive or negative self-concept. The scale was scored such that high scores reflected a positive self-concept. Trait anxiety was measured by Spielberger's 20-item trait scale of the
Table 1 Comparison of Intervention and Control Groups by Grade, Father in Household, Welfare, Age, and Attendance Group Variable Grade Eighth n Percentage Ninth n Percentage Father presence Present n Percentage Absent n Percentage Welfare n Yes n Percentage No n Percentage Age M SD Total sessions Attendance M Percentage SD
Intervention (n=61)
Control (» = 29)
34 56
16 55
27 44
13 45
18 30
8 28
43 70
21 72
38 62
20 69
23 38
9 31
13.61 0.63
13.79 0.64
19 12.93
68 2.27
Table 2 Internal Consistency (Alpha) Reliability of Outcome Measures Outcome measure
No. of items
Pretest alpha
Posttest alpha
Ethnic identity Self-concept Trait anxiety Symptom distress
17 80 20 88
.76 .91 .89 .97
.84 .93 .92 .98
State-Trait Anxiety Inventory for Children. Items were rated on a 3point scale representing frequency with which a given anxiety symptom was felt: 0 (hardly ever), 1 (sometimes), 2 (often), and were scored such that high scores reflected high trait anxiety. Symptom distress was measured by the 90-item Symptom Check List (SCL-90-R; Derogatis, 1983), which is appropriate for adolescent nonpatient populations.2 Symptoms were rated on a 5-point distress scale from 0 (no symptom distress) to 4 (extreme distress). The Global Severity Index, a measure of overall distress across nine symptom dimensions, was used in the data analysis. Although raw scores on some of the outcome measures can be converted to norm-referenced scores, scaled scores were not used in the data analysis because the norms were not established for Puerto Rican adolescents. Because of occasional missing data on some items, mean item scores were used in the data analysis. All students were tested in small groups by bilingual psychology students before and after the 19-week intervention period in two 1-hr sessions for each administration. Internal consistency (alpha) reliability estimates of the pretests and posttests are reported in Table 2. As Table 2 shows, all instruments demonstrated an acceptable level of internal consistency reliability.
Results The data were analyzed by three-way multivariate analysis of covariance of posttest scores (anxiety, identity, self-concept, distress), with the corresponding pretests serving as the covariates. The independent variable of main interest was treatment group; sex, grade level, and father presence/absence were of interest as potential qualifiers of treatment effects. However, a four-way analysis could not be conducted because of small cell sizes. Therefore, 2 three-way analyses were conducted: Treatment X Sex x Grade Level and Treatment X Sex X Father Presence/Absence. In both versions of the multivariate analysis, Box's M test was not significant (ps > .15), indicating that the within-group variance-covariance matrices were homogeneous. Significant multivariate effects were due to Treatment, F(4, 75) = 2.99, p < .025; Treatment X Grade, F(4, 75) = 2.53, p < .05; and Treatment X Sex X Father Presence/Absence, F(4, 75) = 3.29, p < .025. The multivariate analysis was followed by univariate analyses of covariance for each outcome measure. In each univariate analysis, homogeneity of variance and of within-group regression of posttests on pretests were satisfied (ps > .20). There was no significant main effect of treatment, nor interactions involving treatment, in the analysis of the
8 6.74
84 0.86
2 Two items on the SCL-90-R were deleted, at the request of school officials, because of their reference to sexual behavior.
472
R. MALGADY, L. ROGLER, AND G. COSTANTINO
Table 3 Adjusted Posttest Ethnic Identity and Self-Concept Means and Standard Deviations of Intervention and Control Groups as a Function of Sex and Father Presence in Household Father present
Father absent
Outcome group
Male
Female
Male
Female
Identity Intervention M SD
2.19 0.36
2.15 0.27
2.14 0.46
2.10 0.47
2.15 0.41
2.51 0.46
2.61 0.48
2.19 0.28
0.73 0.14
0.67 0.17
0.73 0.13
0.76 0.13
0.72 0.18
0.85 0.17
0.67 0.17
0.68 0.16
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
M SD Self-concept Intervention At SD Control
M SD
symptom distress.3 A significant main effect of treatment was found on ethnic identity, F= (\, 81) = 3.96, p < .05. The intervention group had significantly greater Puerto Rican identity (M= 2.14) than the control group (M = 2.36). The mean difference between groups represented a moderate standardized effect size (Cohen, 1977) of 0.54 SD units (pooled within-group SD = 0.41). Another covariance analysis conducted on a global rating of pride in being Puerto Rican, from 1 (not at all proud) to 5 (extremely proud), revealed a significant main effect of treatment, F(l, 81) = 4.23, p < .05, and a significant Treatment X Grade interaction, F([, 81) = 4.36, p < .05. Overall, the two groups had high mean ratings, but the intervention group expressed significantly more pride (M= 4.75) than the control group (M = 4.48), corresponding to a moderate effect size of 0.45 SD units (SD = 0.60). Tests of simple main effects indicated no significant difference at Grade 8, F(l, 81) < 1, and a significant difference at Grade 9, F(l, 81) = 12.19, p < .001. The mean rating of the intervention group (4.81) was significantly higher than the mean of the control group (4.23), which corresponded to a large-effect size of 0.97 SD units. The analysis of trait anxiety revealed a significant Treatment X Grade interaction, .F(l, 81) = 4.37, p < .05. Tests of simple main effects within grade levels revealed no significant difference between the intervention and control groups at Grade 9, F(l, 81) < 1, and a significant difference at Grade 8, F(l, 81) = 4.98, p < .05. At Grade 8, the intervention group had significantly lower trait anxiety (M = 0.54) than the control group (M = 0.65), representing a small-to-moderate effect size of 0.39 SD units (SD = 0.28). The significant multivariate Treatment X Sex X Father Presence/Absence interaction was evident in the univariate analyses of ethnic identity, F(l, 81) = 4.14, p < .05, and self-concept, F(\, 81) = 5.96, p < .025. Table 3 shows the ethnic identity and self-concept means and standard deviations of the treatment groups as a function of sex and father presence. Tests of simple interaction effects revealed significant twoway (Treatment X Sex) interaction effects within father-present
and father-absent families for ethnic identity and self-concept (.01 < all ps < .05), except for father-absent families in the self-concept analysis. These interactions are illustrated in Figures 1 and 2. Analysis of simple main effects on ethnic identity indicated that treatment was not significant for girls in father-absent families nor for boys in father-present families, Fs(l, 81) < 1. However, there was a strong treatment effect for boys in father-absent families, F(l, 81) = 14.34, p < .001, and for girls in fatherpresent families, F(l, 81) = 11.91, p < .001. Figure 1 shows that the intervention group had greater Puerto Rican identity, corresponding to a large effect size of 1.15 SD units in the father-absent group (boys only) and 0.87 SD units in the father-present group (girls only). Analysis of simple main effects on self-concept revealed a significant treatment effect for boys, F(l, 81) = 4.01, p < .05, and girls, F(l, 81) = 5.44, p < .025, in father-absent families, and for girls in father-present families, F(l, 81) = 14.06, p < .001. Treatment was not significant for boys in father-present families, F(\, 81) < 1. Figure 2 shows that boys and girls in father-absent families had a higher self-concept in the intervention group, corresponding to a small-to-moderate effect size of 0.36 SD units (within-group SD = 0.14) and a moderate effect size of 0.56 SD units, respectively. On the other hand, girls in father-present families had a lower self-concept in the intervention group. This negative treatment effect was large, corresponding to 1.29 SD units.
Discussion A culturally sensitive modality that was based on modeling heroic Puerto Rican biographies was evaluated as a mental health intervention for high-risk Puerto Rican adolescents. Features from the client's culture were incorporated into the intervention in compliance with one approach to cultural sensitivity discussed by Rogler et al. (1987). A more rigorous test of cultural sensitivity, however, would be a demonstration that the intervention enhances the functioning of Puerto Ricans more than non-Puerto Ricans. For example, biographies of Black Puerto Rican role models also may be relevant to Blacks and other ethnic groups who face stress induced by poverty, discrimination, and inner-city life. The effect of the intervention on anxiety, specific to grade level, is consistent with our earlier findings with young Puerto Rican children (Costantino et al, 1985,1986), but we know of no similar studies that have treated Hispanics' ethnic identity or self-concept. When the role of anxiety as a precursor in the development of psychopathology is considered along with the importance of ethnic identity and self-concept in psychosocial development during the adolescent years, these outcomes testify on behalf of the secondary preventive mental health value of the hero/heroine intervention. Although the adolescents did 3
In addition to scoring the SCL-90-R on the Global Severity Index,
two other global indices were examined: (a) the Positive Symptom Total, a count of positive symptoms, and (b) the Positive Symptom Distress Index, a ratio of severity/number of symptoms. However, scoring
distress for severity, number, or severity/number of symptoms did not alter this finding.
473
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time and not necessarily to cultural sensitivity and role model fulfillment in the nature of the treatment. An unexpected finding of this research was the variation of treatment effects on self-concept as a function of the presence or absence of the father in the adolescent's household. In addition to the implementation of cultural sensitivity, the intervention focused on the frequent lack of intact parental role models in Puerto Rican households. Self-concept was enhanced among adolescents whose fathers were absent from the household; however, among adolescents from intact families there was no treatment effect for boys, and there was a negative self-concept outcome for girls. One explanation of negative outcomes is that the heroic figures in the biographies may have induced feelings that parents were inadequate. The lofty standards of accomplishment portrayed in the biographies presented idealized role models; by comparison, the adolescents' own role models— their parents—may have fallen short of such standards. The perception of discrepancy between ideal adult models and real parental role models could have increased psychological conflict, and by identifying with their own parental models, the children may have felt personal inadequacy as evidenced in their more pejorative self-concept.
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Journal of Consulting and Clinical Psychology 1990, Vol. 58, No. 4,469-474
Hero/Heroine Modeling for Puerto Rican Adolescents: A Preventive Mental Health Intervention Robert G. Malgady
Lloyd H. Rogler Hispanic Research Center, Fordham University
Program of Quantitative Studies, New York University and Hispanic Research Center, Fordham University
Giuseppe Costantino
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.
Sunset Park Mental Health Center, Brooklyn, New York and Hispanic Research Center, Fordham University Culturally sensitive treatments of the special mental health needs of high-risk Puerto Rican adolescents are lacking. The hero/heroine intervention was based on adult Puerto Rican role models to foster ethnic identity, self-concept, and adaptive coping behavior. 90 nonclinical Puerto Rican 8th and 9th graders were screened for presenting behavior problems in school and randomly assigned to an intervention and a control group. After 19 sessions, the intervention significantly increased adolescents' ethnic identity and self-concept and reduced anxiety. Treatment outcomes varied as a function of grade level, sex, and household composition. Self-concept was negatively affected among girls from intact families. The study supports the effectiveness of the culturally sensitive modality as a preventive mental health intervention for high-risk Puerto Rican adolescents, especially from single-parent families.
Hispanics may be at higher risk of mental disorder than their nonminority and other minority counterparts, and among them, Puerto Ricans in particular reveal a high-risk socioeconomic and demographic profile (Rogler, Malgady, & Rodriguez, 1989). Puerto Ricans are markedly below the national median income and poverty level, undereducated and underemployed, living in substandard housing, and confronting linguistic and cultural barriers (Mann & Salvo, 1985). Psychiatric epidemiological models defining a high-risk population in terms of increased stress and higher prevalence of symptomatology coincide alarmingly with the social and demographic characteristics of the Puerto Rican population (Canino, Barley, & Rogler, 1980). More direct evidence of high-risk status is the tendency of Puerto Ricans to report more psychiatric symptoms than Whites or Blacks (Malgady, Rogler, & Costantino, 1987,1988) and, among Hispanics, more depressive symptoms than either Mexican-Americans or Cubans (Moscicki, Rae, Regier, & Locke, 1987). Critics of the mental health delivery system have argued that the contrast between Anglo and Hispanic cultures creates a sociocultural distance between therapist and client that requires bridging through culturally sensitive treatment (e.g, Cohen, 1972; Padilla & Ruiz, 1973; Rogler, Malgady, Costantino, This research was supported by Grants RO1-MH33711-07 and 2RO1-MH30569-12 from the National Institute of Mental Health, Division of Biometry and Applied Sciences, Minority Research Branch to Fordham University's Hispanic Research Center. We gratefully acknowledge the cooperation of the students, principal, and dean of students at Intermediate School 136 in Brooklyn, New York and of two anonymous reviewers for comments on a draft of this article. Correspondence concerning this article should be addressed to Robert G. Malgady, Program of Quantitative Studies, 933 Shimkin Hall, New York University, New York, New York 10003.
469
& Blumenthal, 1987; Ruiz, 1981). Three approaches to cultural sensitivity have been identified: increasing the accessibility of mental health services to the Hispanic community, selecting treatment modalities that are most congruent with perceived cultural traits of Hispanics, and embedding cultural traits directly in treatment modalities (Rogler et al, 1987). Because of the need for special mental health interventions with Puerto Ricans, we investigated innovative, culturally sensitive treatment modalities for high-risk children and adolescents. In an earlier study (Costantino, Malgady, & Rogler, 1985, 1986), young Puerto Rican children were treated by "cuento" therapy, a form of story-telling that is based on Puerto Rican folktales as a modality. The children discussed and enacted folktales selected to foster cultural values and adaptive behavior. The results of this effort were promising: Children in cuento therapy demonstrated increased social judgment and reduced anxiety relative to a control group. In the present study, we developed and evaluated a new treatment modality, hero/ heroine modeling, which exposes Puerto Rican adolescents to achievement-oriented adult role models fostering ethnic pride and identity, self-concept, and adaptive behavior for coping with the stresses of poverty, discrimination, and urban life. Of critical importance to the lives of Puerto Rican adolescents is the integrity of adult role models within the anomic social environment of inner-city life. In 1980, for example, 44% of New York City's Puerto Rican households were femaleheaded (Mann & Salvo, 1985). This signifies not just the absence of a singular male parent but the absence of all patterns of social interaction enmeshing the father role. Puerto Rican adolescents in such families lack comprehensive parental role models with whom to identify and, therefore, may be denied adaptive values and behaviors to emulate as they mature toward adulthood. Thus, the hero/heroine modeling intervention uses biographical stories about prominent Puerto Rican historical figures as a therapeutic vehicle not only to bridge a cultural gap
470
R. MALGADY, L. ROGLER, AND G. COSTANTINO
experienced by adolescents, but also to provide for their need for adaptive role models. Method
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.
Participants All Puerto Rican eighth and ninth graders (N = 418) at a public school in Brooklyn, New \brk were screened for behavior problems by their homeroom teachers using the Conners Teacher Rating Scale (Trites, Blouin, & Laprade, 1982). Students presenting the most severe behavior problems (below the median teacher rating) were solicited for the study, and 110 who were not undergoing mental health treatment volunteered to participate with parental consent. Students were randomly assigned to an intervention group (n = 70) and a control group (n = 40),' but 9 intervention members (13%) and 11 control members (27%) dropped out. The 90 students who completed the study ranged in age from 12 to 15 years (M = 13.67, SD = 0.79); all were U.S. born and English-dominant; 50 were eighth graders (29 male, 21 female) and 40 ninth graders (11 male, 29 female). Seventy-one percent of the students' households were female-headed, and 64% were receiving welfare benefits. Employed mothers and fathers were in the three lowest SES occupations (menial service and unskilled and semiskilled workers) on the Hollingshead Index of Social Position.
Intervention The hero/heroine intervention was based on a social learning, modeling approach to treatment. The rationale was to expose adolescents to successful adult role models, often lacking in their own environment, with whom they could identify by virtue of ethnic and cultural similarity; to focus adolescents' attention, first, on the similarity of their own stressful experiences to the models' experiences and then on how the models coped adaptively with stress; and to reinforce adolescents' behavior that was consistent with the models' by discussion and imitative role-playing exercises. The content of the intervention targeted cultural conflicts, emphasizing the need for a strong sense of personal and ethnic identity, and ways of overcoming stressful life circumstances. The intervention was conceived as preventive rather than actively therapeutic because although the adolescents were socioeconomically and demographically defined as a high-risk population and were already experiencing behavior problems in school, they were not diagnosed as psychiatrically disordered. The target outcomes of the intervention were to increase ethnic identity and self-concept and to reduce stress and its symptoms. In this sense, the intervention did not target specific DSM-IH-R disorders of childhood and adolescence but rather presumed antecedents of psychopathology. A panel of Puerto Rican psychologists, educators, and sociologists and a specialist in Puerto Rican literature and history selected "heroic" role models for the intervention on the basis of their significant achievements and adaptive coping to overcome adversities such as poverty, sickness, and prejudice. Biographies were compiled on nine male and nine female models in diverse areas of achievement (e.g., sports, education, art, and politics), sampling Puerto Rican history from the 16th century to the present time. The intervention sessions were conducted in small groups of 3-5 students led by a schoolteacher and a graduate psychology intern (under supervision of Robert G. Malgady, Lloyd H. Rogler, and Giuseppe Costantino). After rapport was established, each group member read aloud a portion of the biography, and the group leaders analyzed selected anecdotes taken from the biography, identifying the source of stress and the behavior reflecting ethnic pride, positive self-concept, and adaptive coping strengths. The group leaders then asked a series of
questions of the group members designed to focus attention on the model's concerns, feelings, obstacles faced, and the resources used to surmount them. The ensuing discussion prompted members to volunteer similar experiences from their own lives, which were compared with those of the model through another series of questions (e.g., The person faced poverty. How have you faced this problem?) in order to reinforce identification with the model. The discussion evoked examples of positive and negative experiences, feelings, and behaviors; the group leaders intervened to verbally reinforce members' self-reported behavior that was consistent with the model's and explored alternatives to reports of behavior they judged as maladaptive. Sessions ended with unstructured role playing in which members enacted an open-ended skit that was based on the story they discussed. The group leaders closed the session by verbally reinforcing adaptive resolutions of the skit's conflict or seeking alternatives to maladaptive resolutions.
Procedure An introductory intervention session was conducted to present an overview of the history of Puerto Rico and some of the famous people the members would be learning about. The intervention was portrayed as an educational program about famous men and women in the history of Puerto Rico. Eighteen 90-min modeling sessions were conducted in the school on a weekly basis, with a male or female biography presented alternately. One group leader was male and one female in each intervention session. Regardless of students' sex, they were exposed to male and female biographies, as opposed to same-sex modeling, because a significant degree of diversity would have been lost by creating separate male and female intervention protocols. The sequence of biographies was arranged chronologically in order to provide historic continuity to the intervention. Eight 90-min control group meetings were conducted for comparability with the intervention group and to maintain student interest in order to minimize attrition at the posttest. The control group also met in small groups with a psychology intern and a teacher (one male and one female) leading group discussions of current events, school activities, and topics of student interest. Control group meetings were held at the testing sessions and on a monthly basis between testings. Students were paid $7 per session for their participation. Different group leaders conducted the intervention and control group sessions. The students in both groups were formed into single-sex groups because pilot work indicated that groups of mixed-sex adolescents were distracted by members of the opposite sex and were more likely to misbehave, resulting in interference with the intervention. By conducting single-sex group sessions, the leaders were better abie to manage students' behavior and focus their attention on the biography, discussion, and role-playing themes at hand. The comparability of the intervention and control groups is shown in Table 1. The students in the two groups were distributed very similarly by grade level, age, father presence/absence in the household, and welfare status. However, a notable source of discrepancy was amount of contact. There were more than twice as many intervention sessions as control sessions, and the attendance rate was much higher in the control group (M= 84%) than in the intervention group (M= 68%).
Outcome Measures In order to assess the effects of the intervention, participants were pretested and posttested with a battery of instruments to measure 1
By design, the intervention and control groups had unequal samples sizes to accommodate the participating public school officials who wanted as many students as possible to participate in the intervention.
471
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HERO/HEROINE MODELING ethnic identity, self-concept, trait anxiety, and symptom distress. These measures were chosen for several reasons. First, the models to be emulated demonstrated a positive self and ethnic image, and the intervention was specifically targeted toward enhancing the participants' ethnic identify and self-concept. Second, because the biographies to be modeled and the criteria for reinforcing imitative behavior emphasized adaptive coping with stress, an effect on indicators of stress (anxiety and symptom distress) was expected. Third, the instruments selected have acceptable reliability with Puerto Rican examinees. Ethnic identity was measured by a 17-item version of the Cuellar, Harris, and Jasso (1980) acculturation scale for Mexican-Americans, which was adapted to measure identification with Puerto Rican versus Anglo-American ethnicity. Items composing the scale referred to behavior and feelings associated with pride in being Puerto Rican (e.g., not proud at all to extreme pride), ethnic affiliation (e.g., Anglo-American to Puerto Rican), language preference in family, peer, and media interactions (e.g., English only to Spanish only), and ethnic self-classification (e.g, very American to very Puerto Rican). Items were rated on a 5-point scale such that low scores reflected high Puerto Rican identity and high scores, high Anglo identity, whereas intermediate scores reflected a bicultural identity. Self-concept was measured by the 80-item Piers-Harris Self-Concept Scale. Items were rated dichotomously ind icating endorsement (or not) of statements indicative of positive or negative self-concept. The scale was scored such that high scores reflected a positive self-concept. Trait anxiety was measured by Spielberger's 20-item trait scale of the
Table 1 Comparison of Intervention and Control Groups by Grade, Father in Household, Welfare, Age, and Attendance Group Variable Grade Eighth n Percentage Ninth n Percentage Father presence Present n Percentage Absent n Percentage Welfare n Yes n Percentage No n Percentage Age M SD Total sessions Attendance M Percentage SD
Intervention (n=61)
Control (» = 29)
34 56
16 55
27 44
13 45
18 30
8 28
43 70
21 72
38 62
20 69
23 38
9 31
13.61 0.63
13.79 0.64
19 12.93
68 2.27
Table 2 Internal Consistency (Alpha) Reliability of Outcome Measures Outcome measure
No. of items
Pretest alpha
Posttest alpha
Ethnic identity Self-concept Trait anxiety Symptom distress
17 80 20 88
.76 .91 .89 .97
.84 .93 .92 .98
State-Trait Anxiety Inventory for Children. Items were rated on a 3point scale representing frequency with which a given anxiety symptom was felt: 0 (hardly ever), 1 (sometimes), 2 (often), and were scored such that high scores reflected high trait anxiety. Symptom distress was measured by the 90-item Symptom Check List (SCL-90-R; Derogatis, 1983), which is appropriate for adolescent nonpatient populations.2 Symptoms were rated on a 5-point distress scale from 0 (no symptom distress) to 4 (extreme distress). The Global Severity Index, a measure of overall distress across nine symptom dimensions, was used in the data analysis. Although raw scores on some of the outcome measures can be converted to norm-referenced scores, scaled scores were not used in the data analysis because the norms were not established for Puerto Rican adolescents. Because of occasional missing data on some items, mean item scores were used in the data analysis. All students were tested in small groups by bilingual psychology students before and after the 19-week intervention period in two 1-hr sessions for each administration. Internal consistency (alpha) reliability estimates of the pretests and posttests are reported in Table 2. As Table 2 shows, all instruments demonstrated an acceptable level of internal consistency reliability.
Results The data were analyzed by three-way multivariate analysis of covariance of posttest scores (anxiety, identity, self-concept, distress), with the corresponding pretests serving as the covariates. The independent variable of main interest was treatment group; sex, grade level, and father presence/absence were of interest as potential qualifiers of treatment effects. However, a four-way analysis could not be conducted because of small cell sizes. Therefore, 2 three-way analyses were conducted: Treatment X Sex x Grade Level and Treatment X Sex X Father Presence/Absence. In both versions of the multivariate analysis, Box's M test was not significant (ps > .15), indicating that the within-group variance-covariance matrices were homogeneous. Significant multivariate effects were due to Treatment, F(4, 75) = 2.99, p < .025; Treatment X Grade, F(4, 75) = 2.53, p < .05; and Treatment X Sex X Father Presence/Absence, F(4, 75) = 3.29, p < .025. The multivariate analysis was followed by univariate analyses of covariance for each outcome measure. In each univariate analysis, homogeneity of variance and of within-group regression of posttests on pretests were satisfied (ps > .20). There was no significant main effect of treatment, nor interactions involving treatment, in the analysis of the
8 6.74
84 0.86
2 Two items on the SCL-90-R were deleted, at the request of school officials, because of their reference to sexual behavior.
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R. MALGADY, L. ROGLER, AND G. COSTANTINO
Table 3 Adjusted Posttest Ethnic Identity and Self-Concept Means and Standard Deviations of Intervention and Control Groups as a Function of Sex and Father Presence in Household Father present
Father absent
Outcome group
Male
Female
Male
Female
Identity Intervention M SD
2.19 0.36
2.15 0.27
2.14 0.46
2.10 0.47
2.15 0.41
2.51 0.46
2.61 0.48
2.19 0.28
0.73 0.14
0.67 0.17
0.73 0.13
0.76 0.13
0.72 0.18
0.85 0.17
0.67 0.17
0.68 0.16
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Control
M SD Self-concept Intervention At SD Control
M SD
symptom distress.3 A significant main effect of treatment was found on ethnic identity, F= (\, 81) = 3.96, p < .05. The intervention group had significantly greater Puerto Rican identity (M= 2.14) than the control group (M = 2.36). The mean difference between groups represented a moderate standardized effect size (Cohen, 1977) of 0.54 SD units (pooled within-group SD = 0.41). Another covariance analysis conducted on a global rating of pride in being Puerto Rican, from 1 (not at all proud) to 5 (extremely proud), revealed a significant main effect of treatment, F(l, 81) = 4.23, p < .05, and a significant Treatment X Grade interaction, F([, 81) = 4.36, p < .05. Overall, the two groups had high mean ratings, but the intervention group expressed significantly more pride (M= 4.75) than the control group (M = 4.48), corresponding to a moderate effect size of 0.45 SD units (SD = 0.60). Tests of simple main effects indicated no significant difference at Grade 8, F(l, 81) < 1, and a significant difference at Grade 9, F(l, 81) = 12.19, p < .001. The mean rating of the intervention group (4.81) was significantly higher than the mean of the control group (4.23), which corresponded to a large-effect size of 0.97 SD units. The analysis of trait anxiety revealed a significant Treatment X Grade interaction, .F(l, 81) = 4.37, p < .05. Tests of simple main effects within grade levels revealed no significant difference between the intervention and control groups at Grade 9, F(l, 81) < 1, and a significant difference at Grade 8, F(l, 81) = 4.98, p < .05. At Grade 8, the intervention group had significantly lower trait anxiety (M = 0.54) than the control group (M = 0.65), representing a small-to-moderate effect size of 0.39 SD units (SD = 0.28). The significant multivariate Treatment X Sex X Father Presence/Absence interaction was evident in the univariate analyses of ethnic identity, F(l, 81) = 4.14, p < .05, and self-concept, F(\, 81) = 5.96, p < .025. Table 3 shows the ethnic identity and self-concept means and standard deviations of the treatment groups as a function of sex and father presence. Tests of simple interaction effects revealed significant twoway (Treatment X Sex) interaction effects within father-present
and father-absent families for ethnic identity and self-concept (.01 < all ps < .05), except for father-absent families in the self-concept analysis. These interactions are illustrated in Figures 1 and 2. Analysis of simple main effects on ethnic identity indicated that treatment was not significant for girls in father-absent families nor for boys in father-present families, Fs(l, 81) < 1. However, there was a strong treatment effect for boys in father-absent families, F(l, 81) = 14.34, p < .001, and for girls in fatherpresent families, F(l, 81) = 11.91, p < .001. Figure 1 shows that the intervention group had greater Puerto Rican identity, corresponding to a large effect size of 1.15 SD units in the father-absent group (boys only) and 0.87 SD units in the father-present group (girls only). Analysis of simple main effects on self-concept revealed a significant treatment effect for boys, F(l, 81) = 4.01, p < .05, and girls, F(l, 81) = 5.44, p < .025, in father-absent families, and for girls in father-present families, F(l, 81) = 14.06, p < .001. Treatment was not significant for boys in father-present families, F(\, 81) < 1. Figure 2 shows that boys and girls in father-absent families had a higher self-concept in the intervention group, corresponding to a small-to-moderate effect size of 0.36 SD units (within-group SD = 0.14) and a moderate effect size of 0.56 SD units, respectively. On the other hand, girls in father-present families had a lower self-concept in the intervention group. This negative treatment effect was large, corresponding to 1.29 SD units.
Discussion A culturally sensitive modality that was based on modeling heroic Puerto Rican biographies was evaluated as a mental health intervention for high-risk Puerto Rican adolescents. Features from the client's culture were incorporated into the intervention in compliance with one approach to cultural sensitivity discussed by Rogler et al. (1987). A more rigorous test of cultural sensitivity, however, would be a demonstration that the intervention enhances the functioning of Puerto Ricans more than non-Puerto Ricans. For example, biographies of Black Puerto Rican role models also may be relevant to Blacks and other ethnic groups who face stress induced by poverty, discrimination, and inner-city life. The effect of the intervention on anxiety, specific to grade level, is consistent with our earlier findings with young Puerto Rican children (Costantino et al, 1985,1986), but we know of no similar studies that have treated Hispanics' ethnic identity or self-concept. When the role of anxiety as a precursor in the development of psychopathology is considered along with the importance of ethnic identity and self-concept in psychosocial development during the adolescent years, these outcomes testify on behalf of the secondary preventive mental health value of the hero/heroine intervention. Although the adolescents did 3
In addition to scoring the SCL-90-R on the Global Severity Index,
two other global indices were examined: (a) the Positive Symptom Total, a count of positive symptoms, and (b) the Positive Symptom Distress Index, a ratio of severity/number of symptoms. However, scoring
distress for severity, number, or severity/number of symptoms did not alter this finding.
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