Applying a Process-Oriented Model of Cultural Competence to Behavioral Activation for Depression.

Efforts to integrate cultural competence and evidence-based treatments (EBTs) typically take the form of cultural adaptations of EBTs, characterized by modifications to the existing treatment based on presumed cultural notions of a given race or ethnic group. Much less attention has been given to ways EBTs can integrate a process model of cultural competence, which focuses on what clinicians do in-session to identify and integrate key cultural factors for a given individual in the treatment. Our objective is to consider how a process model of cultural competence (Shifting Cultural Lenses) can be integrated with an EBT (Behavioral Activation). We present a theoretical rationale for integrating the SCL model with BA and illustrate this integration, which clinician provides an additional approach to bringing culture to treatments and shows promise for identifying clinicians' in-session behaviors that reflect cultural competence.

Recovery From Schizophrenia: The Case of Mexican-Origin Consumers and Family Caregivers.

This study examined the views about the future of persons with schizophrenia and their caregivers to understand what is at stake in engaging in recovery. The views of 60 Mexican-origin consumer-caregiver dyads were coded by three independent raters using a recovery literature-based coding system of recovery components: social relations, caregiving burden relief, independence, self-responsibility, and empowerment. General recovery expectations were also rated. Interrater reliability, component frequency, and congruence between the consumers and caregivers' expectations were statistically examined. Dominant recovery components for consumers and caregivers were independence (72.5%), general expectations for recovery (51%), and social relations (43%). Relatives differed in two important ways. Consumers held significantly greater expectations for independence (p < 0.01), whereas caregivers focused more on general recovery (p < 0.001). What matters for recovery for this sample of Mexican-origin consumers and caregivers differs. Addressing differences in views may facilitate person-centered treatment that considers the views of consumers and caregivers.

Caregiver criticism, help-giving, and the burden of schizophrenia among Mexican American families.

OBJECTIVES: This study tested an attribution model of help-giving in family caregivers of persons with schizophrenia as it relates to caregivers' reported burden. We hypothesized (a) that caregivers' attributions of their ill relatives' responsibility for their symptoms would be associated with more negative and less positive affective reactions, (b) that affective reactions would be related to perceptions of administered support, and (c) that support would in turn predict greater burden. METHODS: We examined 60 family caregivers of Mexican origin living in Southern California. Mexican Americans were chosen because of their high degree of contact with their ill relative, thereby facilitating the examination of help-giving and burden. Contrary to past studies, caregivers' attributions and affective stance were assessed independently, the former based on self-report and the latter based on codes drawn from the Camberwell Family Interview. Caregiver burden was assessed at baseline and one year later. RESULTS: Path analyses showed partial support for the attribution model of help-giving. Specifically, attributions of responsibility negatively predicted caregiver's warmth, which in turn predicted more administered support. Contrary to hypotheses, attributions were not associated with caregiver criticism, and criticism was positively related to administered support. In addition, caregiver support was not related to burden at either baseline or a year later. Criticism was a significant predictor of burden at follow-up through burden at baseline. CONCLUSION: The emotional stance of caregivers predicts burden independent of the help they provide. Caregiver criticism not only predicts negative patient outcomes but can predict negative caregiver outcomes as well. PRACTITIONER POINTS: Positive clinical implications In family treatment, it is important to address caregiver criticism not only because of its relationship to poor clinical outcomes of ill relatives but also because of its relationship to greater caregiver burden. Integrating a balanced rationale for family interventions - to improve ill relatives' and caregivers' outcomes - may promote further engagement of both parties as some caregivers may be additionally motivated to improve their own well-being, and some ill relatives may appreciate more equitably distributing the treatment focus. Limitations The caregiver sample was in general low in criticism; therefore, the findings may not be generalizable to families with a higher degree of criticism. There was a 35% sample attrition at the one-year follow-up.

Using a Narrative Film to Increase Knowledge and Interpersonal Communication About Psychosis Among Latinos.

Narrative communication is effective in increasing public awareness while generating dialogue about varied health topics. The current study utilized narrative communication in the form of a 15-minute motivational film titled La CLAve to help Latinos recognize symptoms of psychosis and begin a discussion about serious mental illness. The study aimed to explore the participants' response to the film and whether the film led to further dialogue about psychosis. Four focus groups were conducted with 40 Spanish-speaking participants, mostly foreign-born Latinas, with a mean age of 49 years. Results indicate that participants engaged with the film as reflected in their ability to recall the storyline in detail. Reports of psychosis knowledge gains included recognition of key symptoms, such as hallucinations and disorganized speech. Participants attributed symptoms of psychosis, observed in a film character, to social stressors and other previously constructed views of mental illness. Many participants discussed the content of the film within their immediate social networks. Other findings include discussions of key barriers and facilitators to seeking mental health treatment among Latino families, such as denial and family support. Results suggest that narrative films offer a promising strategy to stimulate dialogue about serious mental illness among Latinos.

Cultural pathways to psychosis care: Patient and caregiver narratives from Puebla, Mexico.

The current study used the McGill Illness Narrative Interview (MINI) to explore patients' (n = 6) and caregivers' (n = 3) narratives about how they identified and sought care for psychosis. Participants were recruited from an outpatient clinic at the Hospital Psiquiátrico Dr. Rafael Serrano, a public psychiatric hospital in Puebla, Mexico. All participants consented to complete semi-structured interviews in Spanish. Thematic analyses were used to inductively identify common themes in participants' narratives. The results indicated that during the initial symptom onset, most participants noticed the presence of hallucinations but did not seek help for this hallmark symptom. Participants described seeking care only when they or their ill relative exhibited escalating aggressive behaviors or physical symptoms that were interpreted as common medical problems. As participants became connected to specialty mental health services, they began to develop a conceptualization of psychosis as a disorder of aggression. For some participants, this conceptualization of psychosis as an illness of aggression contributed to their ambivalence about the diagnosis. These results can be understood using a cultural scripts framework, which suggests that cultural norms are influenced by collective understandings of normalcy and valorization of behaviors. Implications for community campaigns are discussed.

Perceptions of efficacy, expressed emotion, and the course of schizophrenia: the case of emotional overinvolvement.

Although it is clear that expressed emotion (EE) is associated with the course of schizophrenia, proposed models for this association have struggled to account for the relationship between the EE index of emotional overinvolvement (EOI) and relapse. To expand our understanding of the EOI-relapse association, we first attempted to replicate the finding that the EOI-relapse association is curvilinear among 55 Mexican-Americans with schizophrenia and their caregiving relatives. Second, we evaluated whether the caregivers' perception of their ill relative's efficacy may account for the EOI-relapse association. Our results comport with past findings with regard to the curvilinear nature of the EOI-relapse association among Mexican-Americans and suggest that EOI may only seem to be a risk factor of relapse because of its strong association with a true risk factor for relapse (i.e., caregivers' perception of their ill relative's efficacy).

Acculturation stress and drinking problems among urban heavy drinking Latinos in the Northeast.

This study investigates the relationship between the level of acculturation and acculturation stress and the extent to which each predicts problems related to drinking. Hispanics who met criteria for hazardous drinking completed measures of acculturation, acculturation stress, and drinking problems. Sequential multiple regression was used to determine whether the levels of self-reported acculturation stress predicted concurrent alcohol problems after controlling for the predictive value of the acculturation level. Acculturation stress accounted for a significant variance in drinking problems, while adjusting for acculturation, income, and education. Choosing to drink in response to acculturation stress should be an intervention target with Hispanic heavy drinkers.

Culturally adapted motivational interviewing for Latino heavy drinkers: results from a randomized clinical trial.

A randomized clinical trial of culturally adapted and unadapted motivational interviewing to reduce drinking and related problems among heavy drinking Latinos assessed 57 participants at baseline and at 2 (86% retention) and 6 months (84% retention) after treatment. Significant decreases across both treatments were found in heavy drinking days per month and drinking consequences (p < .001), with greater reductions for drinking consequences for culturally adapted motivational interviewing at 2 months (p = .009) and continuing reductions in culturally adapted motivational interviewing at 6 months. Findings provide preliminary support for the value of cultural adaptation to enhance the efficacy of motivational interviewing with Latino heavy drinkers.

Evaluation of an Audio-Visual Novela to Improve COVID-19 Knowledge and Safe Practices Among Spanish-Speaking Individuals with Schizophrenia.

In the United States, the health and economic consequences of the COVID-19 pandemic have disproportionately affected the Latinx community. Within the Latinx community, people with schizophrenia-spectrum disorders are more susceptible to exposure to the virus. Given their increased risk of contracting and getting sick from the virus, efforts targeting the Latinx population should focus on increasing knowledge and safe practices associated with COVID-19. We developed a 10 min animated, Spanish-language audio-visual novela designed to improve knowledge, attitudes, and behaviors regarding COVID-19. Latinx adults with schizophrenia (N = 100) at a community mental health center in Los Angeles were randomly assigned to watch the novela or a non-COVID video (control group). Participants completed surveys immediately before and one month after viewing the material. One month after watching the audio-visual novela, subjects endorsed a greater likelihood of seeking a COVID-19 vaccine than control subjects. No other significant differences were observed between the two conditions. The findings of this study suggest that the presentation of health information in a relevant, engaging, and appealing manner may be useful way to improving salutary health behaviors of Latinx people with schizophrenia-spectrum disorders.

The Impacts of the COVID-19 Pandemic on Therapy Utilization Among Racially/Ethnically and Socio-Economically Diverse Autistic Children.

PURPOSE: The purpose of current study was to evaluate change in hours of Applied Behavior Analysis (ABA) therapy utilization for autistic children during the year prior to the COVID-19 pandemic, the first three months of the pandemic (crisis phase), and the following 9 months of the pandemic (mitigation phase). Additionally, this study aimed to evaluate if change in therapy utilization differed based on child race, ethnicity, and primary payer of services. Finally, we aimed to identify potential mechanisms of ABA therapy disruption by interpreting findings using an extended version of Donabedian's structure-process-outcome model. METHODS: Retrospective clinical data on client demographics and therapy utilization (n = 283) were collected from ABA clinics in California and analyzed with four piecewise growth multi-level models. RESULTS: We found that therapy utilization dropped during the first three months of the pandemic (-10.65 h/month; p < .001) and increased during the following 9 months (2.39 h/month; p < .001). Moderator analyses revelated that Asian, Non-Latinx and school-district funded children had significantly different trajectories of change in therapy utilization compared to white, non-Latinx participants and private insurance funded participants, respectively. CONCLUSION: Findings suggest that utilization of ABA therapy was disrupted for a full year following the onset of the COVID-19 pandemic and that child race/ethnicity and primary payer influenced the degree to which autistic children were impacted by service disruption. These findings have implications for autistic children who lost therapy access during key developmental periods and for the ABA care delivery system.

Reorienting the focus from an individual to a community-level lens to improve the pathways through care for early psychosis in the United States.

The implementation of coordinated specialty care in the U.S. over the past decade has led to the improvements of clinical and functional outcomes among individuals in the early stages of psychosis. While there have been advancements in the delivery of early intervention services for psychosis, it has almost exclusively focused on short-term change at the individual level. In light of these advancements, research has identified gaps in access to care and delivery of services that are driven by different levels of determinants and have the biggest impact on historically excluded groups (e.g., ethnoracial minoritized communities). Interventions or efforts that place an emphasis on community level (structural or sociocultural) factors and how they may influence pathways to care and through care, specifically for those who have been historically excluded, have largely been missing from the design, dissemination and implementation of early psychosis services. The present paper uses a structural violence framework to review current evidence related to pathways to care for early psychosis and the physical/built environment and conditions (e.g., urbanicity, residential instability) and formal and informal community resources. Suggestions on future directions are also provided, that focus on enriching communities and creating sustainable change that spans from pathways leading to care to 'recovery.' In all, this lays the groundwork for a proposed paradigm shift in research and practice that encompasses the need for an emphasis on structural competency and community-driven approaches.

Development and Evaluation of a Measure of Drinking Behavior in Response to Acculturation Stressors for Latinx Adults Entering Alcohol Treatment.

Introduction: The current study presents the development of a scale to assess drinking behavior in response to acculturation and immigration stress. Methods: The 19-item Measure of Immigration and Acculturation Stressors (MIAS) and a parallel assessment, a Measure of Drinking in Response to Immigration and Acculturation Stressors (MDRIAS), were administered at baseline, 6 months, and 12 months in a completed randomized controlled trial testing culturally adapted motivational interviewing to reduce heavy drinking and related problems in Latinx individuals who met criteria for heavy drinking (n=149). Results: Exploratory factor analysis of the MIAS showed best fit for a four-factor solution (Relational Stress, Perceived Ethnic Discrimination, Attenuated Aspirations, and Sense of Alienation) with 15 items. The MIAS subscales and the four corresponding MDRIAS subscales were shown to have good reliability (i.e., internal consistency, intercorrelations, and test-retest) and criterion-related validity (i.e., concurrent, convergent, and predictive). Conclusions: These findings suggest that the MIAS can be used to assess different types of immigration and acculturation stressors for Latinx adults and the MDRIAS can be used to assess drinking in response to those experiences. The MIAS and MDRIAS could be used in the future to adapt alcohol interventions to relevant stressors that contribute to Latinx adults' alcohol use.

Psychosocial factors associated with the risk of developing psychosis in a Mexican general population sample.

Epidemiological evidence has linked an array of sociodemographic and psychosocial factors with an increased risk of developing psychosis. However, research in samples from low- and middle-income countries is still scarce. This study used a Mexican sample to explore (i) sociodemographic and psychosocial differences between individuals with and without a positive screen for Clinical High-Risk for psychosis (CHR), and (ii) sociodemographic and psychosocial factors associated with screening positive for CHR. The sample consisted of 822 individuals from the general population who completed an online survey. Of the participants, 17.3% (n = 142) met the CHR screening criteria. Comparisons between those who screened positive (CHR-positive group) and those who did not (Non-CHR group) showed that participants in the CHR-positive group were younger, had a lower educational level, and reported more mental health problems than the Non-CHR group. Furthermore, relative to the Non-CHR group, the CHR-positive group had a greater prevalence of medium/high risk associated with cannabis use, a higher prevalence of adverse experiences (bullying, intimate partner violence, and experiencing a violent or unexpected death of a relative or friend), as well as higher levels of childhood maltreatment, poorer family functioning, and more distress associated with the COVID-19 pandemic. Groups did not differ in sex, marital/relationship status, occupation, and socio-economic status. Finally, when examined in multivariate analyses, the variables associated with screening positive for CHR were: having an unhealthy family functioning (OR = 2.75, 95%CI 1.69-4.46), a higher risk associated with cannabis use (OR = 2.75, 95%CI 1.63-4.64), a lower level of education (OR = 1.55, 95%CI 1.003-2.54), having experienced a major natural disaster (OR = 1.94, 95%CI 1.18-3.16), having experienced a violent or unexpected death of a relative or friend (OR = 1.85, 95%CI 1.22-2.81), higher levels of childhood emotional abuse (OR = 1.88, 95%CI 1.09-3.25), physical neglect (OR = 1.68, 95%CI 1.08-2.61), and physical abuse (OR = 1.66, 95%CI 1.05-2.61), and higher COVID-related distress (OR = 1.10, 95%CI 1.01-1.20). An older age was a protective factor for screening positive for CHR (OR = 0.96, 95%CI 0.92-0.99). Overall, the findings highlight the importance of examining potential psychosocial contributors to psychosis vulnerability across different sociocultural contexts to delineate risk and protective processes relevant to specific populations and better target preventive intervention efforts.

Evaluating the message of an ongoing communication campaign to reduce the duration of untreated psychosis in a Latinx community in the United States.

AIM: Initiatives aimed at reducing the duration of untreated psychosis (DUP) attempt to increase the community's level of psychosis literacy. Most of these efforts, however, have failed to reduce DUP. One plausible explanation is that the campaigns do not actually increase psychosis literacy. To date, there have been few efforts to assess whether the campaign messaging does indeed increase psychosis literacy prior to or during the campaign. This study evaluated whether the message of the La CLAve DUP reduction program delivered during the campaign increased the psychosis literacy of a U.S. Latinx community. METHODS: The sample consisted of 81 Latinx community residents aged 15-84. Two community health educators of the La CLAve campaign facilitated workshops using a narrative film to initiate a conversation in the community about the signs of psychosis and the importance of professional help-seeking early in the illness course. Psychosis literacy was assessed via questionnaires pertaining to a hypothetical vignette administered before and after the workshops. RESULTS: The psychosis literacy of participants increased after the workshops in several domains. Participants' knowledge of multiple psychotic symptoms, self-efficacy in their ability to recognize psychosis in others, and correct attributions of a hypothetical vignette's psychotic symptoms significantly increased. No changes were observed in recommendations for professional help-seeking. CONCLUSIONS: These findings provide support for the effectiveness of the La CLAve messaging in increasing psychosis literacy of U.S. Latinx community residents. Evidence-based campaign messaging is needed to increase the success of DUP reduction programs especially among underserved communities.

Further development of a scale of perceived expressed emotion and its evaluation in a sample of patients with eating disorders.

High expressed emotion (EE) as measured by the Camberwell Family Interview (CFI) predicts the course of eating disorders (ED). Despite its important contribution to the field, the CFI has two major limitations; it is time-consuming and it does not consider the patient's perspective. Obtaining the patient's view may help shed light on the dyadic nature of caregiver's EE and the patient's illness course. The objectives of our study of 77 patients with ED were to develop further a brief measure to assess the patients' perceptions of their caregivers' EE, the patient version of the Brief Dyadic Scale of Expressed Emotion (BDSEE), and to evaluate its psychometric properties. Three clearly separate factors were identified: perceived criticism, perceived emotional overinvolvement, and perceived warmth. The BDSEE also demonstrated good levels of reliability and construct validity. The BDSEE subscales are significantly related to other measures of the perceived family emotional climate and to the CFI, the gold standard in the field of EE. The clinical implications of the ED patients' perceptions of their caregivers' EE are discussed. Findings support the utility of the expanded BDSEE for both research and clinical practise in assessing the perspective of patients with ED.

Dyadic view of expressed emotion, stress, and eating disorder psychopathology.

Prevailing models of the association between expressed emotion (EE) and relapse conceptualize EE as a form of stress for patients. In eating disorders (ED), there is no research addressed to evaluate the degree to which patients feel stress due to their relatives' EE. It has been neither investigated how the EE and the subsequent stress relate to disordered behaviours and attitudes neither. Using a sample of 77 inpatients with ED, this study aimed to: (1) evaluate patients' reported level of stress as it relates to their caregivers' EE, particularly as associated with carer's criticism, emotional overinvolvement and warmth; (2) examine the associations of stress with the patients' perceptions (self-reported) and the caregivers' perspective (assessed by the Camberwell Family Interview) of the EE; and (3) study how the two views of EE (patients' and caregivers') and the stress due to EE relate to the ED symptoms. The findings indicate that patients judged their carers' critical stance as the most stressful, followed by emotional overinvolvement. Secondly, patients' perceptions of EE, whereas none of the interview indices focused on the caregivers' perspective, were associated to the stress and to the ED symptomatology. Additionally, the patients' stress due to criticism was positively related to the ED symptoms, while the stress associated with emotional overinvolvement and warmth was not. Clinical and research implications are discussed. Findings suggest attention to the ED patients' view of their family environment and support the utility of assessing their appraisals of EE.

A cultural adaptation of motivational interviewing to address heavy drinking among Hispanics.

Although the need for cultural adaptations is often noted in addiction research, there are few templates to guide the process. The rationale for a social contextual framework to culturally adapt motivational interviewing for an immigrant heavy drinking Latino population in the U.S. Northeast is presented. The aim of the pilot study was to obtain data on acceptability of this approach. Participant responses to the adaptation were examined qualitatively and quantitatively in a preliminary study. Participants recruited from the community met criteria for risky drinking (men, ≥5 drinks/occasion or ≥14 drinks/week; women, ≥4 drinks/occasion or ≥7 drinks/week). Participants (n = 25) who completed baseline assessments and a culturally adapted brief motivational interview (CAMI) were asked to complete a qualitative exit interview to give feedback on their interview experience. Participants reported being highly engaged with treatment (M = 3.58 on a scale of 1-4, SD = .50), and felt very satisfied with treatment (M = 3.58 on a scale of 1-4, SD = .93). Nearly all (95%) reported that understanding their culture was important to understanding their drinking behavior. Results support the acceptability and relevance of this adaptation from participants' perspectives.

Expressed emotion and health outcomes among Mexican-Americans with schizophrenia and their caregiving relatives.

Past studies have demonstrated a clear relationship between expressed emotion (EE) and relapse for individuals with schizophrenia. However, little attention has been directed toward exploring whether EE may have negative health consequences for caregivers as well. We recruited 60 Mexican-American family caregivers of individuals with schizophrenia and examined whether EE predicted the health of caregivers and ill relatives approximately 13 months later. For caregiving relatives, the EE indices of emotional over-involvement and warmth were predictive of worse mental health among caregivers at follow-up. There was no association between EE and health outcome among individuals with schizophrenia. Our findings suggest that, among Mexican-Americans, family factors may be associated with health outcomes among individuals with schizophrenia and their caregiving relatives.

What do health providers and patients tweet about schizophrenia?

AIM: Twitter is the most commonly used social media forum in public health and is considered the radio of the internet. Many health providers utilize this media to disseminate health information. Patient use of social media for mental health topics encourages providers to disseminate quality information and to develop virtual collaborative learning environments. This study explored trends in health information exchanged by patients, doctors and health organizations about schizophrenia through analyses of tweets posted using the #schizophrenia. METHODS: The likelihood that the information distributed by each user type was scholarly was assessed via qualitative and logistic regression analyses. Specifically, a sequential exploratory multimethod of data analysis guided this study with a sample of 981 tweets. RESULTS: Most tweets focused on the improvement of schizophrenia literacy (n = 366) followed by personal experiences/motivational stories (n = 207) and biological explanations of the disorder (n = 158). Logistic regression results indicated that compared to doctors, patients were less likely to tweet with a scholarly source (OR = 0.481, CI = 0.311, .744; P < .001). All users were less likely to include a scholarly source when tweeting about schizophrenia literacy, personal/motivational experiences, campaign/organizational events or illness management in comparison to those who tweeted about biological explanations of schizophrenia. CONCLUSION: Results suggest all users disseminated beneficial information that can increase public schizophrenia literacy and illness management, while connecting individuals to organizational events targeting this debilitating disorder. Health providers are encouraged to establish a presence on social media to share scholarly work with patients and promote prompt treatment for schizophrenia.

Emotional over-involvement can be deleterious for caregivers' health: Mexican Americans caring for a relative with schizophrenia.

UNLABELLED: The study of emotional over-involvement (EOI) has focused primarily on its relationship with patients' course of illness. We know little about the predictors and possible consequences of EOI for caregivers. Based on past research, we tested the hypotheses that EOI is associated with worse physical and psychological health among caregivers and examined whether caregiver burden and social support may mediate this relationship. METHOD: In a sample of 37 Mexican American caregivers and their ill relatives recruited from two outpatient clinics, we examined the relationships between EOI, caregiver burden, caregivers' level of social support, and caregivers' health. Additionally, we examined whether caregiver burden and social support may mediate the relationship between EOI and caregivers' health. Cross-sectional analysis indicates that at baseline EOI was not associated with caregiver burden or social support, but was related to worse current health. Longitudinal analysis, however, indicates that EOI at baseline was associated with greater burden, less instrumental support, and worse health among caregivers at follow-up. Moreover, objective burden and instrumental support mediated the relationship between EOI and several health outcomes. Consequently, EOI may be a marker of poor current health status and predicts worse future health among Mexican-American caregiving relatives of individuals with schizophrenia. Moreover, changes in burden and social support associated with EOI appear to mediate the relationship between EOI and several health outcomes among caregivers. These findings suggest that it might be important for family interventions to not only address the functioning of individuals with schizophrenia but also their caregiving relatives.