Cultural Adaptation of CBT for Mexican-American Women

A small study examines ways to
reduce cross cultural barriers to care.

Despite the risks, eating disorders go largely undetected and untreated among Mexican-American women and other Hispanics, who are rarely seen in eating disorder clinics and underrepresented in clinical trials. Results of a small study offer suggestions for improving diagnosis and treatment for these women.

Dr. Munyi Shea, from Cal State University-Los Angeles, and a team of researchers in California, North Carolina, Illinois, and New Jersey hypothesized that given the effectiveness of cognitive behavioral therapy (CBT)-based guided self-help (GSH), this treatment modality might appeal to Mexican American women with bulimia nervosa (BN) and binge eating disorder (BED).

The study explored the feasibility and cultural relevance of using a CBT-GSH program for Mexican-American women diagnosed with BN or BED. A secondary goal was to discuss which components, determined by Mexican-American women themselves after they had read the CBT-GSH manual, Overcoming Binge Eating (Fairburn, 1995), should be incorporated into a culturally adapted CBT-GSH program.

Focus groups offered helpful suggestions

Twelve Mexican-American women participated in 3 two-hour focus groups involving two English-speaking groups and one Spanish-speaking group. The mean age of the women was 32.8 years, and all English-speaking participants were second-generation immigrants. Most of these women were single and did not have children.  All but one of the Spanish-speaking participants were first-generation immigrants and all were married with children; 10 of 12 were employed. These women had participated in a previous study that examined treatment-seeking barriers among Latinas (Cachelin, Striegel-Moore, and Regan, 2006). All study participants met DSM-IV diagnostic criteria for BN or BED.

Before the focus group sessions, all participants received a packet containing a demographic form, a copy of the CBT-GSH manual, lists of focus group questions about the manual, and a list of local referral resources for eating disorder treatment. The women also had 30 days to receive and think about the manual but were not asked to participate in the program at this stage.

The sessions began with two open-ended questions for the women, asking what they thought of the program and manual and what themes or cultural components they would suggest adding.

Themes that emerged

Participants expressed tension and conflicts with others in their family, their community and within themselves about their eating problems, due to different cultural beliefs, values, and levels of acculturation. Family members, especially those from the older generations, were sometimes unable to identify with the participants’ experiences. Younger and more acculturated women tended to experience pressures to live up to the mainstream norms of body image, as portrayed on television and other media. As Mexican-American women, participants were often expected to adhere to traditional cultural roles, such as attending to others’ needs before their own. At the same time they tried to embrace new cultural norms and values that urged them to pursue personal interests and accomplishments.  The participants felt the CBT-GSH manual did not address how to negotiate these competing priorities and needs.

Cultural expectations was a large topic. For example, the women were concerned about being disrespectful to their family members and disrupting social harmony when they were trying to monitor their food intake. Food is central to social gatherings in Mexican communities food also carries symbolic meanings in interpersonal exchanges.

The women told the authors that their family members often had strong opinions about their weight and shape concerns. These attitudes could range from critical and overbearing to well-intentioned but misguided. For the most part parents and spouses were not well informed about eating disorders. In addition, the study participants were ambivalent about their family’s involvement in the CBT-GSH process

Most participants reacted favorably to the CBT-GSH manual.  However, participants indicated that the presentation and contents needed to be adapted to make it more culturally relevant to the Mexican-American community. For example, no Mexican foods were included. One woman said that that the manual didn’t offer enough alternative activities (to binge eating) that would be suitable for women living in low-income neighborhoods.

Suggestions for clinicians

The authors suggest that therapists and counselors invite their Mexican-American clients to explore how interpersonal and cultural factors affect their ability to cope, seek help, and participate in treatment.  The authors included interpersonal vignettes role-playing exercises as part of the CBT-GH program. They also advise counselors not to assume that most Latinas have a source of support from their family and community. For some women, involving family members in their recovery process would make them vulnerable to negative affect and relapses.

All therapists and counselors need to keep in mind that socioeconomic factors such as access to resources, financial pressures, and multiple responsibilities to family and work can vastly influence a Mexican-American woman’s motivation and ability to engage in treatment. Creative problem-solving and use of modern technology, such as cell phones may help clients make plans, monitor treatment progress, and organize priorities.

Finally, a key finding by Dr. Shea and colleagues was that the Mexican-American women had a positive attitude toward the CBT-GSH program and a desire to engage in it. For the most part the women found the manual to be well written, comprehensive and helpful.  The authors feel the results from their study can act as a model for developing self-help treatment for other mental health disorders among ethnic minority populations.