Adapting Behavioural Activation to the Values of Latino Clients

1. Adapting Behavioural Activation to the Values of Latino Clients Jonathan Kanter, Ph.D.

2. Latinos in the United States 4.2 million Puerto Ricans 30.7 million Mexicans 1.6 million Cubans Central and South Americans

3. My story

4. Latinos in the United States: • Largest minority group • Currently 14% of population • By 2050, 30% of population By 2050, Caucasians = 47% of population

5. FACTS ABOUT LATINO DEPRESSION Immigrate to U.S.A.? Depression = 13%

6. FACTS ABOUT LATINO DEPRESSION Immigrant Paradox Born in U.S.A.? Depression = 19% NOT TRUE for Puerto Ricans TRUE for Mexicans Immigrate to U.S.A.? Depression = 13%

7. FACTS ABOUT LATINO DEPRESSION Distress vs. Disorder? Symptoms Improved Coping Focus on family and social support Expression of emotional distress rather than suppression Active religious coping versus passive coping Less tendency toward avoidance coping through drugs/alcohol Latinas tend to show higher rates of depressive symptoms Latinas do NOT show higher rates of depressive disorders

8. Conclusion 1 Traditional Latino cultural values are protective against depression My country’s values are depressing…

9. FACTS ABOUT LATINO DEPRESSION Preferences: Psychotherapy over medication Engagement: Lower than Caucasians Retention: Lower than Caucasians Quality: Lower than Caucasians Clear health disparity for Latinos with depression Cooper et al., 2003; Fernandez y Garcia et al., 2010

10. Conclusion 2 We need treatments for depression that emphasize traditional Latino cultural values to improve treatment engagement, retention, and outcomes

11. Behavioural Activation What are your goals and values? I will use my expertise to help you get as active as possible with respect to your goals and values We will be very concrete and come up with specific action plans each time we meet.

12. Behavioural Activation What are your goals and values? I will use my expertise to help you get as active as possible with respect to your goals and values We will be very concrete and come up with specific action plans each time we meet.

13. The goal is to help you engage in concrete actions related to your life goals each week, regardless of how you are feeling

14. Values Assessment

15. Let’s pick five goals for you for this week. We will schedule each one and talk about how to make sure you do them. I understand – if we could change how you feel on the inside then changing your behavior on the outside would be so much easier. But I feel so depressed. I just want to feel better. I feel like such a failure. Help me with that, then I could do what you’re asking. But I want to help you get active without waiting for your feelings to get better. Have you ever been able to act even if you haven’t felt like it? Act from “outside-in” rather than “inside-out”

16. What, when, where, with whom?

17. What is Depression? Negative Life Events: Will vary depending on cultural background Daily stress/hassles Unemployment and poverty Homelessness Trauma, violence Physical/medical conditions Harassment, racism, discrimination Losses, separation from loved ones and family Intergenerational acculturation conflicts “Presencios,” “curses” and similar events Eventos Negativos

18. What is Depression? Feeling sad, down, depressed Loss of interest or pleasure in things Stress, headaches, pain, fatigue, anger, irritability Spiritual questioning/doubts Guilt and shame Changes in sleep and appetite Difficulties with concentration and memory Reacción Use clients’ descriptions No need to educate about “symptoms” of depression Eventos Negativos

19. What is Depression? Escape and avoidance patterns Shut down, give up Staying in bed all day Calling in sick to work Withdrawing from friends/family/church Stopping doing housework Stopping looking for work Pretending to look for work Drinking too much Filling every minute of the day to avoid facing problems Stopping activities related to cultural roots Trying to kill yourself Reacción Patrones de escape Eventos Negativos

20. What is Depression? Reacción Patrones de escape Eventos Negativos

21. What is Depression? Reacción Patrones de escape Eventos Negativos

22. What is Depression? Reacción Patrones de escape Eventos Negativos

23. What is Depression? Reacción Patrones de escape Eventos Negativos

24. What is Depression? Reacción Patrones de escape la depresión Eventos Negativos

25. Reacción Patrones de escape Instead of reacting to your problems with poor coping and avoidance… Eventos Negativos

26. Reacción Pasos de acción Use your strengths and social support to stay active, reengage in life, solve problems Activate religious coping as appropriate Incorporate family in activation Free, low cost activities Use community resources Eventos Negativos

28. Pilot Study Intake Evaluation Week 20 Evaluation BA (N=10) 12 sessions max. TAU (N=10) 12 sessions max. • 2 BA therapists • 2 Treatment as Usual (TAU) therapists • Brief BA training provided • Weekly consultation meetings for BA • No restrictions on medication referrals 28

29. Treatment of Latino Depression Kanter, J. W., Santiago-Rivera, A., Rusch, L. C., Busch, A. M., & West, P. (2010). Initial outcomes of a culturally adapted behavioral activation for Latinas diagnosed with depression at a community clinic. Behavior Modification, 34, 120-144.

30. Treatment of Latino Depression Percent of TAU sessions in which specific techniques occurred Not BA BA Kanter, J. W., Santiago-Rivera, A., Rusch, L. C., Busch, A. M., & West, P. (2010). Initial outcomes of a culturally adapted behavioral activation for Latinas diagnosed with depression at a community clinic. Behavior Modification, 34, 120-144.

31. Treatment of Latino Depression Percent of BA sessions in which specific techniques occurred Not BA BA Kanter, J. W., Santiago-Rivera, A., Rusch, L. C., Busch, A. M., & West, P. (2010). Initial outcomes of a culturally adapted behavioral activation for Latinas diagnosed with depression at a community clinic. Behavior Modification, 34, 120-144.

32. Treatment of Latino Depression Activities scheduled in BA sessions • Dancing, walking, exercising, playing sports • Listening to favorite Latin music • Community center activities, relaxation group, stress management group • Attending a community fiesta • Go to museum, seasonal free concerts, library • Church activities and events • Visit friends, play with children/grandchildren • Reading Spanish language magazines • Preparing a traditional family meal • Cleaning house, knitting • Employment seeking • Medical appointments and care, diabetes care • Call family and friends in country of origin • Social service agency problems • Asking others for help, saying no to requests • Spend time with family • English-language, computer classes • Asking others for help • Maintaining personal hygiene • Talking with husband about parenting issues

33. Treatment of Latino Depression Total Number of Sessions Mean = 4.8 Median = 4 Mean = 7.6 Median = 10 TAU BA

34. Treatment of Latino Depression Total Number of Sessions Mean = 4.8 Median = 4 Mean = 7.6 Median = 10 TAU Found employment BA No reasons given

35. Treatment of Latino Depression BDI Session by Session % of clients no longer depressed at the end of treatment: TAU = 20% BA = 57% TAU BA

36. Future Directions 1 Many BA studies currently ongoing

37. BA Meta-Analyses Ekers, Richards & Gilbody. (2007). Psychological Medicine Cuijpers, van Straten & Warmerdam. (2007). Clinical Psychology Review Mazzucchelli, Kane & Rees. (2009). Clinical Psychology: Science and Practice

38. Current BA investigations

39. Current BA investigations

40. Future Directions 1 3 Many BA studies currently ongoing 2 Developing model of BA to maximize efficient cross-cultural adaptation Developing technology for rapid and effective training in BA skills, including multi-cultural competency

41. Thank You