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1 EXPLORING THE EXPERIENCES OF LATINOS IN MENTAL HEALTH SERVICES By NATHANIEL LOPEZ A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS IN EDUCATION UNIVERSITY OF FLORIDA 2013
2 2013 Nathaniel Lopez
3 Para mi mama, los sacrificios que has hecho para mi me ayudaron ser la per sona que soy. Gracias por todo To all the friends and academic relationships I have had throughout the years. It is a culmination of those experiences that he lped me throughout this process
4 ACKNOWLEDGEMENTS I want to thank my committee members: Dr. Jacqueline Swank and Dr. Edil Torres Rivera for their support and help throughout this process. I would like to extend a special thanks for Dr. Swank who spent a lot of time guiding me through this endeavor and was instrumental for helping me complete it. It would have been much more difficult for me to do this without their doors and allowing me to collect data at their organization, they do really great work in the community. I want to thank my friends and c lassmates for their encouragement, especially when things got stressful. Additionally, thanks to my mother and family who were all incredibly supportive as they always have been. And lastly, a very special thanks to my longtime partner, Rebecca, for all he r support and patience through the long process of getting this completed. Thank you all sincerely, from the bottom of my heart.
5 TABLE OF CONTENTS Page ACKNOWLEDGEMENTS ... 4 ABSTRACT CHAPTER 1 INTRODUCTION ... 9 Overview .. . 9 Literature Review .. .10 Culture 13 Language .... 16 Immigration 18 2 METHODS 21 Research Design Participants Instrumentation Procedures Data Analysis Researcher Verification Procedures 3 RESULTS Finances Language Culture .... 26 Process of Seeking Services Helpfulness of Services .28 4 DISCUSSION Limitations of the S tudy 33 Implications Recommendations for Future Research Conclusion 36 APPENDIX A INFORMED CONSENT (ENGLI SH VERSION) B INFORMED CONSENT (SPANISH VERSION) C INTERVIEW QUESTIONS (ENGLISH VERSION)
6 D INTERVIEW QUESTIONS (SPANISH VERSION) E DEMOGRAPHIC QUESTIONNAIRE (ENGLISH VERSION) F DEMOGRAPHIC QUESTIONNAIRE (SPANISH VERSION) G IRB 02 APPROVAL LETTER REFERENCE LIST ..53 BIOGRAPHICAL SKETCH .56
7 Abstract of Thesis Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for t he Degree of Master of Arts in Education EXPLORING THE EXPERIENCES OF LATINOS IN MENTAL HEALTH SERVICES By Nathaniel Lopez December 2013 Chair: Dr. Jacqueline Swank Major: Mental Health Counseling OBJECTIVE: The Latino population in the United States is increasing more rapidly than any other racial or ethnic group in the country. Despite having comparable r ates of needing mental health services to non Latino groups, this increase in population has not been met with an increase in the literature researching Latinos in mental health services. This study is intended to explore the experiences of Latinos in ment al health services so there can be a better unde rstanding of how to serve this population more adequately The study will specifically focus on exploring preferences and barriers to mental health services that are unique to this ethnic group. RESEARCH DE SIGN AND METHODS: A phenomenological research design was used to conduct the present study. Ten semi struct ured interviews were conducted with self identified Latinos who were currently receiving or had received mental health services in the U.S. The inter views were examined for themes to highlight experiences with mental health services.
8 RESULTS: F ive themes emerged within the present study : ( a ) finances, ( b ) language, ( c ) culture, ( d ) the process of seeking treatment and ( e ) helpfulness of services The themes highlighted areas to consider in providing mental health services to Latinos.
9 CHAPTER 1 INTRODUCTION Overview The Latino population is the fastest growing group in the United States and has accounted for more than half of the total population growth experienced by the country over the past decade (Ennis, Rios Vargas, & Albert, 2011). There are currently over 50 million people of Latino origin living in the U.S. which equates to sixteen percent of the total population (En nis et al., 2011). With this rapidly increasing number of people there will likely be an increase in demand for mental health services. Latinos may also experience additional stressors not encountered by other group s including issues regarding citizenship status for themselves or family members, difficulties with acculturation, and language barriers (Keyes, Martins, Hatzenbuehler, Blanco, Bates, & Hasin, 2012). Despite these factors there has been a dearth of research in mental health fields regarding the L atino population. Florida currently holds the third largest percentage of Latino residents trailing only California and Texas; and the only county in the state with a Latino majority is Miami Dade County where more than fifty percent of the residents decl are themselves to be of Latino origin (Ennis et al. 2011). This study will focus on exploring the experiences of Latino clients who seek mental health services to examine potential barriers and improvements in the ir quality of care. Data collection will oc cur in South Florida due to the population demographics unique to that part of the state. It is likely that Latinos can encounter several deterrents to seeking mental health which may include financial constraints, language difficulties, and cultural disco uragers. The purpose of this qualitative research study is to give a voice to the clients receiving mental health services t o learn how to better serve the Latino population.
10 The term describe s individuals who associate with any culture or origin from Latin America which includes Central Ame rica, South America, and parts of the Caribbean. Latino is becoming the increasingly accepted vernacular in r eferring to individuals from the se cult ures instead of using the term Hispanic because it better encompasses the European and Native Ame rican origins experienced in the s e countries It is important to note that this is a term primarily constructed and used in the U.S., throughout Latin America individuals are identified by their country of origin rather than a pan ethnic term (Suarez Orozco & Paez, 2002). This serves as an important highlight to the cross national cultural differences found among Latinos. An example of these cross national diff erences can be seen between Brazilians and Argentinians. Both Brazil and Argentina are part of Latin America, they are geographic neighbors, share some common history, and have certain ethnic similarities. However, there are also several differences as wel l; including communicating in different languages due to being occupied by different European nations during the era of increasingly racialized and unifying term among p eople of Latin American descent. It can be argued that the prejudicial treatment of Latinos in the U.S. is the most salient commonality that they share as a group (Garcia & Sanchez, 2008). However, there are several other commonalities that define Latinos as a group such as certain aspects of culture, history in the U.S., and immigration. Literature Review Liang, Salcedo, Rivera, and Lopez (2009) conducted a content analysis on articles published between 1970 and 2005 involving Latino clients and found tha t the number of research articles increased from 0.88% to 4.4% during the 35 year period, indicating a substantial growth
11 However, the content of the research is not proportional to the mental health needs of Lati nos in the United States T he majority of the research articles focused on substance abuse within the Latino community or with comparing Latinos to White individuals (Liang et al., 2009) Furthermore, the analysis was completed on a limited number of scholarly journals, and was therefore not repre sentative of all mental health literature dur ing this time frame. However, the article does provide insight into the general trend of research regarding Latino clients. The lack of research on Latino clients is not correlated to a n absence of need for me ntal health services from the population. According to the U.S. Department of Health and Human Services (2001) there are no nationally representative statistics of Latinos with diagnosable mental health disorders but the rates of mental health diagnoses a re similar among Latinos and White Americans Despite comparable rates, l ess than 1 out of 11 Latino Americans with diagnosable mental health d isorders seek service s from mental health providers (National Institute of Mental Health, 2001) However despite having a low rate of utiliz ation Latin American women (Latinas) were more open to individual a nd group counseling and found it more helpful when compared to other U.S. ethnicities (Nadeem, Lange, & Miranda, 2008). Specifically, in the sample of low income women ( N =1,893), Nadeem and colleagues found that 63% of Latinas perceived group counseling as potentially helpful compared to 49% of White women. The results also showed that Latinas endorsed individual counseling at a higher rate than White women (Nadee m et al., 2008). However, it should be noted that this research was completed using a survey that primarily consisted of questions requiring a yes or no response which could have understanding expe riences and their preferences for mental health services
12 In studying the mental health preferences of Latino men C aba ssa (2007) found that participants ( N= 56) strongly preferred counseling (93%) over medications (54%) when treating mental health issues; however, this preference did not tra nslate to a higher usage of mental health services. Two li mitations of the study are its gene ralizability, due to the limited sample size and location, and the structured interview method of collecting responses Participants may not have been able to fully explain their circumstances or experiences during the interview process. Nonetheless, the literature reveals that while there is a currently established need for mental health services among the Latino populat ion it has not translated to a proportionate consumption of mental health services. The contradiction between an established need for mental health services and the lack of utilization of such services suggests that there must be widespread barriers to o btaining mental health services that are affecting the Latino population. Several studies have suggested that there are obstacles that are more unique to the Latino population when it comes to mental health services. These barriers include langua ge, immigration status, culture, and possibly other factors (Dupree, Herrera, Tyson, Jang, & King Kallimanis, 2010 ; Rastogi, Massey Hastings, & Wieling, 2012; Shattell, Hamilton, Star r, Jenkins, & Hinderliter, 2008 ). In analyzing the content of focus groups, R astogi et al. (2012), reported several themes related to barriers that were identified by participants ( N =18) as individual barriers, family barriers, cultural barriers, legal barriers and difficulties obtaining services Specifically, i ndividual barriers included a lack of knowledge, pride, denial, or embarrassment; while examples of family barriers included stigmatization and wanting to keep problems within the home ; c ultural barriers encompassed being able to only speak Spanish and machismo ( cultural clients from see king help The last two barriers in the study were described as issues with U.S.
13 citizenship status and financial c onstraints It should be noted that this study was conducted in the Midw est area of the United States with a non clinical sample; therefore, the results may not be as indicative of what Latinos who do seek treatment experience, especially in locations with a higher Latino population. However, a ll of these factors contribute t o the fact that Latinos seek mental health services at a lower rate than non Latinos in the United States (Keyes, Martins, Hatzenbuehler, Blanco, Bates, & Hasin, 2012). Culture One of the most all encompassing barriers to seeking mental health treatment for Latinos is culture. As mentioned previously, there is a wide and diverse definition of culture within the Latino population due to the subgroups that make up this po pulace. However, there are some commonalities among U.S. Latinos such as language (Span i Currently, Spanish is the second most common language in the U.S. due to the increasing Latino population (Shin & Kominski, 2007). Likewise, Catholicism has significantly increased in the U.S. along with the Latino population (Pew Research Hispanic Center, 2007). According to the Pew Research Hispanic Center (2007), around 68% of U.S. Latinos practice Catholicism wit h another 15% (the second largest religious affiliation) practicing evangelical Protestantism. The American Counseling Association (ACA) and the American Psychological Association (APA) both have guidelines on multicultural competencies to guide mental he alth providers. Some similarities found between both sets of guidelines include aware own biases and culture, becoming more knowledgeable about other cultures, and being able to apply that knowledge when providing mental health services. Howev er, these guidelines are not always represented in practice. Gushue, Constantine, and Sciarra (2008) found that Caucasian
14 marriage and family counselors ( N = 163) assessed the functioning level of cases differently solely on ethnicity. T he difference in assessments was most pronounced among White therapists who rated themselves as having a high multicultural knowledge (Gushue et al., 2008). It was example would mean the Latino clients were judged as being more functional than their White counterparts because they were being held to lower standards. However, one potential limitation is that the multicultural knowledge rating was established through self report. Noneth eless, it can be considered alarming that th e counselors who rate d themselves as multiculturally knowledg eable we re most prone to treating Latino clients differently than Caucasian clients in a setting w here all other factors were the same. Discriminatio n can have a sizeable role in the lives of Latinos living in the U.S Ayon, Marsiglia, and Bermudez Parsai (2010) found that discrimination had a measurable i mpact on mental health symptoms of participants ( N =150) particularl y when it came to Latino youth. The research ers hypothesized that Latino youth who were more acclimated to American culture did not have the same cu ltural tools as their parents in their coping with discrimination which could therefore manifest as psychological problems. The limitation s of this study include a purposive sample which is not representative of the Latino population in the U.S. A disproportionate number of respondents were of Mexican origin and female. Similarly, Perez, Fortuna, and Alegria ( 2008) found that percei ved discrimination varied among Latinos due to several factors. Using data collected from the National Latino and Asian American Study (NLAAS), Perez and her colleagues examined responses from 2,554 Latino respondents to determine if there was a correlation be tween the reported discrimination felt by the participants and other factors such as socioeconomic status, demographics, and culture.
15 While the overall rate of perceived discrimination was 30% among Latinos, there were several differences in the rates when other factors were included (Perez, et al., 2008). The study found that there was a statistically significant positive correlation between perceived discrimination and socioeconomic status and education, so that as schooling and income went up so did inci dents of perceived discrimination. Conversely, there was a negative correlation between perceived discrimina tion and strong ethnic identity. T he participants who reported a strong connection to their Latino identity felt the least discriminated. Perez and colleagues (2008) hypothesized this could be Latinos with a strong ethnic identity may not encounter discrimination from the majority group due to an inability to communicate in the same language at all or in a limited fashion. Another possibility that was not explored by the study could be that Latinos who felt the most discrimination became less tied to their Latino identity over time due to the perception that it was wrong or a bnormal compared to the majority culture. This could be indicative of a limitation in the study, related to analyzing a secondary dataset which may be further clarified through the use of a qualitative research design. Specifically, f uture research may fu rther explore the correlations, particularly how they affect the utilization rate of mental health services by Latinos. Despite the limitations these studies emphasize the importance of cultural competency when working with Latino clients. practitioner form a more effective relationship with the client (Mulva ney Day, Earl, Diaz Linhart, & Alegria, 2011). In exploring preferences for relational styles for different U.S. ethnicities, M ulvaney Day et al. found that a mong Latinos there was an emphasis on personalismo (friendly interpersonal interactions, being personable), being present in session by maintaining eye contact and using reflection questions instead of minimal encouragers (su ch as
16 profundizar (go deeper or more in depth) during sessions. This study focused on the relational prefere nces for U.S. ethnicities. Future research may explore other preferences La tinos may have when seeking mental health services. The language used to describe mental health problems may be another factor affecting Latinos seeking mental health services may lie in the names used to describe mental health problems Donlan and Lee ( 2010) interviewed Mexican immigrants ( N =179) about mental health problems by using the accepted vernacular for that population. They found that the three most common mental health problems were curaje (a type of anger which functioned as a symptom of stress), nervio s (anxiety), and susto (fear or panic). It should be noted that this study was conducted using Mexican participants who were all recent immigrants to the U.S. so it may not translate to all Latino clients. However, it does show how applying knowledge of culture to communicate problems with Latino clients can be effective. In summarizing the literature on culture, many researchers examined how culture can act as a barrier towards Latinos acces sing mental health services ; however, there is little research examining preferences that would lead to further utilization of mental health services. Language Besides having different names for mental health problems, many Latinos are bilingual or only speak Spanish. According to the U.S. census bureau there are at least 34.5 million Spanish speakers in the United States, over 10 million of which claimed to not be able to speak English at all or well (Shin & Kominski, 2007). Florida is one of the states with the highest Spanish speaking population with over 20% speakin g the language at home (Shin & Kominski, 2007). Speaking a different language can act as a barrier to seeking me ntal health services (August,
17 Nguyen, Ngo Metzger, and Sorkin, 2011). August a nd colleagues (2011), examined whether language concordance was a predicator of how patients discussed their mental health needs or concerns with their providers. Among the sample of Latinos and Asian and Pacific Islanders ( N =2,960) who were aged 55 or above and who had seen a primary health provider in the past 2 years August and colleagues found that Latinos who spoke the same language as their provider had no trouble reporting their perceived mental health needs This was in comparison to the respond ents who did not speak the same language as their providers which led to difficulty expressing their needs This literature serves as a highlight as to how language may be perceived as a more salient barrier than culture for Latinos. However, this researc h is also limited in generalizability because it was focused primarily on a geriatric population and the researchers were not able to control the interpersonal differences (e.g. personality) between the providers and their patients One common solution t o the language barrier is the utilization of interpreters. Searight and Armock (2013) examined research regarding the use of interpreters in providing mental health services and identified several common practical barriers; lack of officially trained interpreters (family members, non clinical staff), interpreter biases, non verbatim interpretation, and subtle nuances that get lost in the translation process. Searight and Armock suggested using training modules for the interpr eters and the practitioners on how to work together and meetings between the two before and after interacting with the patient to address these barriers They concluded that t hese suggestions have not been widely implemented and that there is no all inclus ive research that specifically focuses on interpreta tion in mental health settings. T he langua ge barrier appears to be a greater factor among recent Latino immigrants (Cook, Ale gria, Lin, and Guo, 2009). In examining ir
18 exposure to the United States ( N =2554), Cook et al. found that Latinos who h ad been born in the U.S. had a much higher English proficiency than immigrant Latinos (Cook et al., 2009). In addition, there was a correlation between the frequency of mental h ealth problems an d exposure to the U.S Immigrant Latinos who lived in the U.S. for 10 years or less had significantly lower rates of mental health issues than Latinos born in th e U.S. or had been living in the country for 11 years or more (Cook et al., 20 09). These results appeared contradictory to the lack of English being a barrier that may lead to more mental health issues T his is likely due to a limitation in the st udy that shows correlation, not causation However, i t does distinguish the difference between recently immigrated Latinos and Latinos who have lived in the U.S. for a prolonged period of time. Immigration There are many Latinos living in the U S that emigrated from their nation of origin. Latinos represent a l ittle over half of the 40 million foreign born population in the U.S. with 13% of that foreign born Latino pop ulation residing in Florida (Acosta & de la Cruz, 2010). In addi tion, it is estimated that only 32% of all foreign born Latinos are naturalized ci tizens (Acosta & de la Cruz, 2010). The added factor of immigration and legal status can add new barriers to seeking mental health treatment. Gee, Ryan, LaFlamme, and Holt (2006) examined the correlation between immigration, discrimination and mental health among 476 Latinos. They found that the longer Latinos lived in the U.S. the more discrimination they felt which contributed to an increased prev alence in mental health issues. The resea rchers also found a direct correlation between perceived discrimination when clients were seeking mental health care and an in crease in mental health symptoms Furthermore, the study found that the association between discrimination and mental health was m ore prevalent among Latinos who had resided in
19 the U.S. for a longer period of time than recent immigrants (Gee et al., 2006). This study helps demonstrate how immigrants Latinos are affected by a different set of factors than Latinos who were born in the U.S. or resided here for a longer period of time. However, i t should be noted that this study only took place in New Hampshire and the researchers reported that less than 5% There are several factors that make living in the U.S. different for Latino immigrants compared to t heir home countries. Fortuna, Porche, and Alegria (2008) examined trauma and political violence experienced by Latino immigrants ( N= 1630) be fore coming to the U.S Fortuna and colleagues found that 11% of Latino immigrants had experienced political violence before immigrating to the U.S. and 76% of that group had al so encountered traumatic events However, experiencing political violence or trauma did not co rrelate to seeking mental heal th services in the U.S. (Fortuna et al. 2008). The researchers discussed that being aware that Latinos may immigrate to this country for a variety of reasons can help mental health providers serve this populat ion better Like wise, the reasons for immigration may be due to unfavorable conditions that can lead to increased mental health symptomology (Fortuna et al. 2008). However, some limitations from this study included casual correlations between the phenomena studied and the use of a secondary dataset which do es not give the respondents an opportunity to further explain their stories. This is a recurrent limitation in several of the studies reviewed as many of them did not allow for the respondents to list their preferences f or mental health treatment. Likewise, several of the studies tend to be deficit oriented in contrast to strength based. According to Chung, Bemak, Ortiz, and Sandoval Perez (2008), immigration status can
20 become almost synonymous with people of Latino descent. In some cases, this has led to leg islature that specifically targets Latinos on the pretense that they might be illegal immigrants. One example is the Arizona S.B. 1070 law which allows law enforcement to detain a person who may be an illegal immigrant based on how they look or sound. The law also makes it a crime to transport anyone who is illegal in a vehicle. Since the law was passed in 2011, five other states have adopted similar laws to target the Latino community. Chung and his colleagues (2008) point out that systemic discrimination can have an adverse psychological effect on immigrants and their family members. In addition, immigration status can have practical impacts. A study conducted by Saechao and colleagues (2010) examined several first generation immigrants ( N= 30) and the bar riers/stressors that would prevent them from seeking mental health treatment. The research used focus groups comprised of immigrants from Cambodia, Eastern Europe, Iran, Iraq, Africa, and Vietnam The researchers found that there were several economic barr iers (e.g., lack of insurance, mental health costs being unaffordable, difficulty finding work due to education status attained in their country of origin not translating to U.S. standards) that were due to their immigrant status (Saechao et al., 2010). Ho wever, this study was limited by its small sample size that may have overrepresented socioeconomic status as being uniform among immigrants. Additionally, due to the various groups of immigrants studied these results may not be translatable to Latino immigrants as they were not included in the research study However, future research may want to explore the role of economic factors for Latinos seeking mental health services.
21 CHAPTER 2 METHODS Research Design This qua litative research study involved a phenomenological app roach. A phenomenological approach was chosen for this study due to the focus on experiences. This method emphasizes the lived experiences of th e participants which can help provide a greater understanding of the particular phenomenon Phenomenology focuses on the description of experiences rather than explanations by considering the perceptions of the participants as the primary source of informati on which cannot be doubted (Moustakas 1994 ). Due to the overall lack of research on Latino mental health treatment and the even smaller amount of research focused on the perspectives of Latino clients themselves, this study focused on exploring the expe riences of the Latinos with the mental health system to learn better ways to provide mental health services to this population. Participants The participants were individuals who identify as being of Latino origin or descent. A convenient sample was chos en It was not a requirement that potential participants are currently receiving mental health services; however it was necessary that they have experienced some type of mental health service in the U.S. at some period in their lives. As a phenomenological study, it was pivotal that the participants ha d first hand experience with mental health services, in order to provide descriptions of their experiences receiving mental health services. When collecting data, ten par ticipants chose to take part in the study. Most of the participants self gender section of their demographic questionnaire. The majority of the participants in this study self ide
22 most common response when it came to nationality or country of origin was an additional three participants identifying as such. The other two participants identified as 22 years old and the eldest participant being 61. The average age of the ten participants was 41.9. There was also a wide diversity of highest obtained educational status: one participant reported dropping out of school before reaching high school, an additional three participants completed high school or received their GED, four participants graduated from college, and the remaining two participants ha d This trend of diversity also continued with income. T he approximate annual income of the participants range d f rom no annual incomes earned to $55,000 per year. Instrumentation A semi structured interview format w as used in this study The questions were asked in English or Spanish depending on the preference of the participant. To maintain consistency in translation, accuracy was tested using a standard translation back translation format. This technique is widely p racticed in cross cultural studies and considered one of the best ways to maintain consiste ncy in such studies (Ozolins 2009) Utilizing this method, the questions were written in English then translated into Spanish. Afterwards, someone else who is litera te in both languages translate d it back to English. All questions were open ended with the exception of some demographic questions that addressed age, ethnicity, socioeconomic status, and education. Procedures This study was conducted in Miami Dade County in a community mental health agency Participants were recruited using pre established contacts with service providers in the community. The individuals who were contacts for the researcher were asked to speak to their
23 clients who meet the criteria and wh o they thought might be interested in participating in the study. Participants did not receive an incentive for participating in the study. Additionally, participants were accept ed on a voluntary basis and it was imperative to protect their confidentiality This was accomplished by not recording their names and not using their responses or demographic information for any other purposes except for the current study. The researcher receive d approval from the Institutional Review Board (IRB) prior to recruitin g participants for the study. Participants were given contact information to find out the results of the study after it was completed should they want such information. The interviews were conducted in a setting agreed upon by the participant They were re corded using a digital audio recording device which was explained thoroughly to the interviewee prior to beginning with additional information included in the consent form. Information was recorded verbatim. Furthermore, participants were asked for clarification when ambiguity arose during the interviews. Data Analysis Once the interviews were completed they were transcribed verbatim and coded into various themes that captured the experiences of the participa nts. This was accomplished by reviewing the transcribed interviews and clustering similar statements from different participants into categories named themes. When constructing the themes, verbatim examples were included to provide support for the theme. P rior to beginning the study it was important for th e researcher to bracket his assumptions and biases To bias, another individual also identified themes and consensus was sought between the researchers
24 Researcher I am a Latino male I have first hand experience with several issues that affect this population. While this may assist with communication with the participants and lead to further explor ation of their experiences it can also affect the validity of the study if personal bias is not controlled for in the design of the research. I am aware of this and will implement procedures (e. g., exploring m y biases with others prior to conducting the st udy, having additional researchers review the transcripts and identified themes) to enhance the trustworthiness of the study Verification Procedure The author employed verification strategies recommended by Creswell (2013) to augment the trustworthiness of this study. Prior to beginning the study, the author discussed his beliefs and assumptions about the Latino culture and the experiences of Latinos with in mental health services. Additionally, t he author had another researcher review the transcriptions and analyze the m Then, the author met with the other researcher to agree on themes present within the data. Finally, t he author met with others for debriefing.
25 CHAPTER 3 RESULTS The researcher found five overarching themes within the data. The themes were (a) finances, (b) language, (c) culture, (d ) the process of seeking out treatment and (e ) helpfulness of services These themes are discussed below in more detail to provide further insight int o the findings. Quota Finances Finances was the most common theme that emerged from the data. All of the participants identified money as a barrier to obtaining mental health treatment The majority of the seek mental health in stating However, ano ther individual discussed what happened to him when he had insurance, he reported recognized the lack of financ es for mental health treatment as a communal problem instead of being isolated to a specific individual. O ne participant indicated service they have to have insurance or find a place where they cou Another participant summed up the situation as follow ed We have so many people who are looking for services but there is no one who can provide services; Language Participants described the influence that language had on receiving mental health services. Specifically, participants described the necessity of having a counselor who could speak
26 Spanish in order to communicate effectively with each other. They reported that they were thankful that they found a counseling center with counselors who spoke Spanish. One participant the same language, so we understood each other. W e did not have any ot Furthermore, a participant reported that a counseling center that only offered counseling in English would not be an option for her because she would not be able to communicate effectively with the counselor. Culture Culture was a prevalent theme among participants though there were different opinions on how it a ffected their experiences with mental health services always been important, the culture part, because I am Latino, I looked for people who were more econd participant ] should not judge and understand that Asides from having practitioners from the same culture as a preference for some participants, others brought up the stigma of mental health services in their cultures. A particular same participant
27 n, another participant spoke ulture barriers and the whole stigma of looking for help because something is wrong with [Hispanic men] tend to believe that because the accept counseling, I feel that a lot of them would feel more comfortable with a man than having a woman as a counselor. Another male pa rticipant spoke of his own hesitancy when thinking of engaging in mental health you know However, several participants reported that they ignored cultural stigma or that it was not a factor for them at all. One One participant even spoke of her culture as being accepting of mental health treatment when she said Process of Seeking Services The p articipants in the study all shared their experiences with initially seeking mental health services. Many of them described being told about the services by other people in their e that they knew of
28 people who indicated they were good therapis referred to a service provider by someone they knew who had a positive experience was also that rapport right a n their reported experiences, several participants only engaged in mental health treatment when told about it by someone they knew or trusted. Helpfulness of S ervices Almost every participant discussed how the mental health services they received were hel pful to them. One participant described her experiences with her counselor by commenting, feel good. It relaxes me to talk and converse with them. And even though I finished the services and I keep coming back because I by reporting been also painful at times bu Some participants described specifically on how it was helpful; one participant reported discussed her experiences by com menting ee things how they really are, l ike putting aside your personal views and you see everything more
29 that it s more obj
30 CHAPTER 4 DISCUSSION This study was different from similar research conducted due to the location. Because Miami Dade County is the only county in Florida where Latinos are the majority of the population statistically speaking (Ennis et al., 2011), this study served to highlight some experiences encountered by this population that were differ ent but relatable to other parts of the country. Some of the themes that were described by the participants were consistent with the previous studies ( Dupree et al., 2010, Rastogi et al., 2012, and Shattell et al., 2008) that focused on barriers. However, potentially due to the unique demographics o f South Florida several of the barriers were also r efuted by the experiences of the participants in this study. The five th emes found in this study were (a) finances, (b) language, (c) culture, (d ) helpfulness of services, and (e ) the process of seeking out treatment. The first theme, finances, was identified as a barrier by every partici pant in the study. While previous research studies have focused on barriers, there were none found that focused solely on fina ncial barriers. Rastogi et al. (2012), reported that participants in their study discussed the lack of medical insurance as the m ain reason they did not seek mental health services. This was consistent with the participants in this study as the lack of insurance or finances was the main deterrent to receiving mental health services Several participants reported that if the services were not free then they would not have been able to pay for them. Other participants reported that they did have i nsurance but were not covered for mental health services ; and therefore they had to pay out of pocket for services, which was difficult. Based on what was reported by the participants in this study and in previous studies finances would seem to be a major contributing factor as to why Latinos seek mental health services at a lower rate than non Latinos in the United States (Keyes et al., 2012).
31 The second theme, language, yielded mixed results from the participants Some participants reported that having service providers who only spoke English was an obstacle to better understanding in mental health treatment. This was consistent with the findings of August et al. (2011) whose study reported that clients that spoke a different native language than that o f the services providers had more difficulties in communicating and would withhold certain information because they did not know how to express themselves. One participant in the current d what one another is saying language is Spanish. However, the majority of participants in this study reported that language was not a factor when receiving services Several of the participants who reported language not being a factor also mentioned that they received services in Spanish and requested the interview to be conducted in Spanish. The reason it was not a factor could be due to the fact that they received services from bilingual practitioners who were able to communicate with them in services. This could serve to show that Latinos and Latinas are willing communicators for their mental health needs when communicating with someone who speaks their language. The next theme, culture, was also confirming and contradictory to previous literature. A study conducted by Mulvaney Day et al. (2011) found that Latino clients had different relational preferences for the service providers. This was reflected in the responses of some of the participants in the current study, one such participant reported that what she liked most about her ich is concordant with the Latino cultural emphasis on friendliness (personalismo) described in Mulvaney Other participants described culture as being a barrier, particularly when it came to the
32 stigmatization of mental health in their respective cultures. Rastogi et al. (2012) described family as a barrier which was echoed by a participant in the current study who reported that she was r reported culture was not a factor in receiving services. Many explained that they saw mental health providers who were from the same culture so it was not difficult for them to feel understood. Anothe r participant reported culture as not being a factor when he was seeking mental health treatment because he had lived by Gee et al. (2006) that found a correla tion between the discrimination felt by Latinos and the longer they have resided in the U.S. since immigrating from their birth nation. These experiences serve to highlight that culture is a complex topic without many clear definitive answers, however, it did appear that the participants who worked with practitioners from similar cultures seemed to prefer it and felt more understood. The cultural barriers found i n the literature could be more evident of a relative lack of cultural awareness among practition ers or a lack of Latino/Latina practitioners. The fourth theme explored, process of seeking out treatment, was not really explored in any of the literature that was reviewed. A common situation described by participants in this theme was a lack of knowl edge about services. Many participants reported learning of services from friends or family members who had overheard or participated in services themselves. None of the literature expunged upon the experiences Latinos had learning about treatment. There c ould be several factors involved that affect knowledge of mental health treatment and where to find it, including socioeconomic status, educational level, proximity to service providers, etc. Some participants described having a positive experience when th ey were referred by someone
33 they knew to a service provider because it made them more co mfortable engaging in services. Participants also discussed a reliance on family members to help them find service providers who they could trust. This emphasis on fami ly is a part of Latino culture called familismo The last theme, helpfulness of services, was supported by previous literature. It was common among all participants to report the mental health services they received as being helpful and a positive experience. This is congruent with the research conducted by Nade em et al. (2008), who found that Latinas found counseling services to be useful at a higher rate than non Latinas. Specifically, several participants described mental health services as helpful an interesting phenomenon that may be explored further by future research. Among this vein of thinking, when participants were asked for alternatives to mental health treatment, some discussed their problems with family members. One participant described finding mental health treatment more helpful than just compared to her family. What is important to note from the experiences shared by the participants is that all o f them found mental health services helpful, furthering the notion that a lack of usage of mental health services among Latinos (National Institute of Mental Health, 2001) is not congruent with a lack of helpfulness. Limitations of the S tudy This study ha d several limitations that could be addressed in future research. One limitation is the sample size of the study. W hile it is a qualitative study the small number of participants made the sample non representative of the population at large. For example, t he nationalities, gender, and ages of the participants were not indicative of the population in South Florida or nationwide. In addition, all participants were recruited at the same community mental
34 health agency. The free services provided by the agency m ay have made the financial barriers to be overrepresented among a more diverse socioeconomic sample. While also a unique component of this study, it took place in South Florida which is not representative of the more demographically minority status held by Latinos in other parts of the nation. The location of the discrimination. Likewise, the study involved participants who were currently using services or who ha d receive d services in the past. Therefore the barriers facing those who chose not to ever receive services might be more telling of the factors that prevent Latinos from engaging in services. Finally, this study was intended to explore the genera l experiences of t he population. A more narrow study could potentially expunge upon the different themes in more detail. Implications There are several implications that can be made from this study. First, the results demonstrated that Latinos find mental health services to be helpful and are not being deterred by internal factors such as their own culture and stigmatization. Most of the barriers described were more relevant to external factors such as finances and finding services providers who were congruent with the client in regards to language and culture. This implies that the Latino population wants services ; however, there is a lack of supply to meet the demand. Another implication is that with adequate cultural training, non Latino service providers might be able to better relate and understand their Latino clients. The participants in this study described some of the cultural nuances described in Mulvaney ( 2011 ) study which means that they are importa nt to working with Latino clients. This is crucial to be aware of because due to the growing Latino population in the U.S., it is likely that there will be an increase in Latino s seeking mental health services. While none of the participants in this study
35 discussed a particular experience of not feeling understood by non Latino service providers, some participants discuss ed that they sought out Latino practitioners because they believed there would be a difference in cultural understanding from non Latino p roviders Additionally, the participants who were the least descriptive in their interviews all chose to conduct them in English; perhaps not speaking in their language of origin made it more difficult for those participants to go more in depth during the interviews. The final implication is that there seemed to be a barrier in learning about services. Many of the participants in the study described learning from the services from people they knew in their personal lives rather than advertisements or prof essional means of communication Improving advertisement and promotion of mental health treatment among Latino communities could help increase awareness about and access to mental health services for this population. Recommendations for Future R esearch F uture research may focus on studying Latinos who do not seek mental health treatment or who have difficulties engaging in it. This may be more indicative of barriers as all of the participants in this study overca me barriers and eventually receive d mental health services. Additionally, future research may include a more diverse socioeconomic sample. While Rastogi et al. (2012) noted that Latinos had lower rates of insurance than their non Latino counterparts, this sample was particularly representative of t his group because the sample was taken from a community agency that offers free mental health services As this study attempted to do, future research may also continue to focus on Latino samples that have more common barriers removed to examine the engagement in services for this group Researchers may conduct future studies to examine the cultural awareness of the Latino culture among non Latino practitioners. R esearch could also focus on examining the number of
36 Latino service providers in the me ntal health field. Thi s could potentially lead to follow up studies that examine the increasing or decreasing rate of Latinos entering the mental health field. Researchers may also want to continue offering the option of English or Spanish instrumentation. Based on the depth of the interviews in the current study, allowing the option for Spanish could yield more detailed results. Additional research with this population would continue to inform practice related to mental health services for Latinos. Conclusion The findings suggest that Latinos are willing participants in mental health services. Additionally, the Latinos in this study had preferences for mental health services that include d having service providers who (a) spoke the same language, (b) were from the same culture or had knowledge of Latino culture, and (c) had reasonable fees and availability. Service providers who want to improve their quality of care with Latinos should become more educated in Latino culture by continuing to increase t heir multicultural awareness This study included Latinos who had previously or were currently receiving counseling. Future research may focus on Latinos who were unable to access services to examine the barriers that affected them. Thus, future research may expand upon this study to assist counseling professionals in continuing to improve services to the Latino population, a crucial need as this population continues to increase in the United States.
37 APPENDIX A INFORMED CONSENT (ENGLISH VERSION)
38 Informed Consent Protocol Title : Exploring the experiences of Latinos and Latinas in mental health services. Please read this consent document carefully before you decide to participate in this study. Purpose of the research study : The purpose of the study is to explore the experiences of Latinos and Latinas who seek mental health services in South Florida so that better ways to provide those services may be considered. What you will be asked to do in the study : You will be asked to participate in a semi structured interview that should last between 10 to 30 minutes. The questions will be focused around your personal experiences with mental health services. This study only seeks your opi nions and is intended to give more voice to Latino and Latina clients. The interview will be completed in person and will be audio recorded. Time required : One interview lasting between 10 to 30 minutes. Risks and Benefits : You might be nervous about participating in the interview and being audio recorded. However, you may choose to not participate, stop participating at any time without consequence, or talk about this with me. It may be helpful to talk to someone about the benefits and consequences of seeking mental health services. This study will also help describe those experiences with the intention of seeking ways to improve them for Latinos and Latinas. Compensation : You will not receive any compensation for participating in this research. The re are no direct benefits to participating in this study. Confidentiality : Your identity will be kept confidential to the extent provided by law. Your name will not be used in the study at any point. I will be the only one who will listen to the recordi ngs and then I will erase them after I write the responses. Your responses might be quoted in a counseling article; however, your name will not be connected to the response. These responses may be direct quotes or paraphrases, but no information that could be directly tied to you would be included. The information and will not be associated directly with you. Voluntary participation : Your participation in this stud y is completely voluntary. There is no penalty for not participating. Right to withdraw from the study : You have the right to withdraw from the study at any time without consequence.
39 Whom to contact if you have questions about the study : Nathaniel Lopez, M.A.E./Ed.S candidate, University of Florida, School of Human Development and Organizational Studies in Education, phone: (786) 205 1906, email: firstname.lastname@example.org or my faculty advisor: Dr. Jacqueline Swank, University of Florida, School of Human Dev elopment and Organizational Studies in Education phone (352) 273 4326, email: email@example.com Whom to contact about your rights as a research participant in the study : IRB02 Office, Box 112250, University of Florida, Gainesville, FL 32611 2250; phon e 392 0433. Agreement : I have read the procedure described above. I voluntarily agree to participate in the procedure and I have received a copy of this description.
40 APPENDIX B INFORMED CONSENT (SPANISH VERSION)
41 Consentimiento informado Ttulo del estudio : Explorar las experiencias de los Latinos y Latinas en servicios de salud mental. Por favor lea este documento de consentimiento antes de decidirse a participar en este estudio. Propsito de la investigacin : El propsito del estudio es explorar las experiencias de los Latinos y Latinas que buscan servicios de salud mental en el sur de la Florida para que se considere mejores formas para ofrecer esos servicios. Qu t engo que hacer en el estudio? : Se le pedir participar en una entrevista semiestructurada que debe durar entre 10 a 30 minutos. Las preguntas se centrarn alrededor de sus experiencias personales con servicios de salud mental. Este estudio slo busca sus opiniones y se pretende dar ms voz a los clientes Latinos y Latinas. La entrevista se completar en persona y va hacer audio grabado. Tiempo requerido : Una entrevista dura entre 10 a 30 minutos. Riesgos y beneficios : Es posible que te sentirs nervi oso sobre la participacin en la entrevista y siendo audio grabado. Sin embargo, usted puede elegir no participar, dejar de participar en cualquier momento sin consecuencia, o hablar de esto conmigo. Puede ser til hablar con alguien sobre los beneficios y consecuencias de la bsqueda de servicios de salud mental. Este estudio tambin ayudar a describir esas experiencias con la intencin de buscar formas de mejorarlas para Latinos y Latinas. Compensacin : Usted no recibir compensacin alguna por partic ipar en esta investigacin. No hay ningn beneficio directo para participar en este estudio. Confidencialidad : Su identidad se mantendr confidencial en la medida de lo dispuesto por la ley. Su nombre no se utilizar en el estudio en cualquier momento. Yo ser el nico que se escucha las grabaciones y luego se borre despus de escribir las respuestas. Sus respuesta s podran citarse en un artculo de asesoramiento; sin embargo, su nombre no se conectar a la respuesta. Estas respuestas pueden ser citas directas o parfrasis, pero ninguna informacin que podra estar directamente conectada a usted va ser incluida. La informacin sobre el cuestionario demogrfico se compilar con informacin de los dems participantes y no se asocia directamente con usted. Participacin voluntaria : Su participacin en este estudio es totalmente voluntaria. No hay ninguna pena por no participar.
42 Derecho a retirarse : Usted tiene el derecho de retirarse del estudio en cualquier momento sin consecuencia. Quien puedo contactar si tengo preguntas acerca del estudio : Nathaniel Lopez, candidato M.A.E./Ed.S, University of Florida, Escue la de Desarrollo Humano y Estudios Organizacionales en Educacin, telfono: 786 205 1906, correo electrnico: firstname.lastname@example.org o mi asesor: Dr. Jacqueline Swank, University of Florida, escuela de desarrollo humano y estudios organizacionales en educacin, telfono (352) 273 4326, correo electrnico: email@example.com Quien puedo contactar acerca de mis derechos como participante de la investigacin en el estudio : IRB02 Oficina, caja 112250, University of Florida, Gainesville, FL 32611 2250; telfono 392 0433. Acuerdo : He ledo el procedimiento descrito anteriormente. Acepto voluntariamente participar en el procedimiento y he recibido una copia de esta descripcin.
4 3 APPENDIX C INTERVIEW QUESTIONS (ENGLISH VERSION)
44 Interview Questions 1. When did you start thinking about seeking mental health services? What steps did you have to take? 2. What qualities were important, if any, for the person you would be working with to have? 3. What role did your culture play in seeking mental health services? 4. Were there any potential problems to seeking mental health services? 5. If you are currently using mental health services; what is it about them that make you keep coming back? 6. If you are not currently using mental health services; what made you stop? 7. Are there any things you like about your mental health services? Things you dislike? 8. Did you think of any alternatives to mental health treatment? 9. How did you learn about these ment al health services? 10. What helped you seek out mental health services? 11. How did language play a role in receiving mental health services? If at all? 12. How did finances play a role in deciding to start/continue mental health services? If at all?
45 APPENDIX D INTERVIEW QUESTIONS (SPANISH VERSION)
46 Preguntas para la entrevista 1. Cundo empezaste a pensar en busca de servicios de salud mental? Qu pasos tenas que tomar? 2. Qu cualidades son importantes, si algunos, para la persona que estara trabajando con usted? 3. Qu componente tuvo su cultura en buscar servicios de salud mental? 4. Haba problemas potenciales en buscando servicios de salud mental? 5. Qu es lo que te hace seguir a volver a usar los servicios de salud mental? 6. Si no est usando actualmente los servicios de salud mental; que lo hizo parar? 7. Ay una cosa que le gusta de sus servicios de salud mental? Cosas que no te gustan? 8. Has pensado alguna alternativa para tratamiento de salud mental? 9. Cmo se enter acerca de estos servicios de salud mental? 10. Qu le ayud a buscar servicios de salud mental? 11. Cmo afecto tu lenguaje en la recepcin de servicios de salud mental? 12. Cunto componente tuv o las finanzas en decidir comenzar/continuar los servicios de salud mental?
47 APPENDIX E DEMOGRAPHIC QUESTIONNAIRE (ENGLISH VERSION)
48 Demographic Questionnaire Age: ______________________ Gender: Highest Education Obtained: ____________________ Approximate Annual Income: __________________________ Nationality/Country of Origin/Region: _____________________________ Thank you for completing this questionnaire! If you have any additional comments, you may include them below.
49 APPENDIX F DEMOGRAPHIC QUESTIONNAIRE (SPANISH VERSION)
50 Cuestionario demogrfico Edad: ______________________ Gnero: Educacin ms alto obtenido: ____________________________ Ingreso anual aproximado de: ____________________________ Nacionalidad y pas de origen o regin: ____________________ Gracias por completar este cuestionario! Si usted tiene algn comentario adicional, puede incluirlos siguientes.
51 APPENDIX G IRB 02 APPROVAL LETTER
53 LIST OF REFERENCES Acosta, Y. D., & de la Cruz, P. C. (2011). The Foreign Born From Latin America and the Caribbean: 2010 Retrieved from http://www.census.gov/prod/2011pubs/acsbr10 15.pdf Ayn, C., Marsiglia, F. F., & Bermudez Parsai, M. (2010). Latino family mental health: exploring the role of discrimination and familismo. Journal of Community Psychology, 38 (6), 742 756. Chung, R., Bemak, F., Ortiz, D. P., & Sandoval Perez, P. A. (2008). Promoting the Mental Health of Immigrants: A Multicultural/Social Justice Perspective. Journal of Counseling & Development, 86 (3), 310 317. Cook, B., Alegra, M., Lin, J. Y., & Guo, J. (2009). Pathways and Correlates Connecting Latinos' Mental Health with Exposure to the United Stat es. American Journal of Public Health, 99 (12), 2247 2254. Creswell, J. W. (2013). Qualitative inquiry & research design: Choosing among five approaches (3 rd ed.). Thousand Oaks, CA: Sage. Dupree, L. W., Herrera, J. R., Tyson, D., Jang, Y., & King Kallimanis, B. L. (2010). Age Group Differences in Mental Health Care Preferences and Barriers among Latinos: Implications for Research and Practice. Best Practice in Mental Health, 6 (1), 47 59. Ennis, S. R., Rios Vargas, M., & Albert, N. (2011) The Hispanic Population: 2010 Retrieved from http://www.census.gov/prod/cen2010/briefs/c2010br 04.pdf Fortuna, L. R., Porche, M. V., & Alegria, M. (2008). Political violence, psychosoc ial trauma, and the context of mental health services use among immigrant Latinos in the United States. Ethnicity & Health, 13 (5), 435 463. Garcia, F., & Sanchez, G. (2008). Hispanics and the U.S. Political System: Moving into the mainstream Upper Saddle River, NJ: Pearson Education, Inc. Gee, G. C., Ryan, A., Laflamme, D. J., & Holt, J. (2006). Self Reported Discrimination and Mental Health Status among African Descendants, Mexican Americans, and Other Latinos in the New Hampshire REACH 2010 Initiative: The Added Dimension of Immigration. American Journal of Public Health, 96 (10), 1821 1828. Keyes, K. K., Martins, S. S., Hatzenbuehler, M. M., Blanco, C. C., Bates, L. L., & Hasin, D. (2012). Mental health service utilization for psychiatric disorders amo ng Latinos living in the United States: the role of ethnic subgroup, ethnic identity, and language/social preferences. Social Psychiatry & Psychiatric Epidemiology, 47 (3), 383 394.
54 Mulvaney Day, N. E., Earl, T. R., Diaz Linhart, Y., & Alegra, M. (2011). P references for Relational Style with Mental Health Clinicians: A Qualitative Comparison of African American, Latino and Non Latino White Patients. Journal of Clinical Psychology, 67 (1), 31 44. Nadeem, E., Lange, J. M., & Miranda, J. (2008). Mental health care preferences among low income and minority women. Archives of Women's Mental Health, 11 (2), 93 102. Of fice of the Surgeon General ; Center for Mental Health Services ; National Institute of Mental Health (2001) Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General Rockville (MD): Substance Abuse and Mental Heal th Services Administration Chapter 6 Mental Health Care for Hisp anic Americans. Prez, D., Fortuna, L., & Alegra, M. (2008). Prevalence and correlates of everyday discrimination among U.S. Latinos. Journal of Community Psychology, 36 (4), 421 433. Rastogi, M., Massey Hastings, N., & Wieling, E. (2012). Barriers to Seeking Mental Health Services in the Lati no/a Community: A Qualitative Analysis. Journal of Systemic Therapies, 31 (4), 1 17. Saechao, F., Sharrock, S., Reicherter, D., Livingston, J. D., Aylward, A., Whisnant, J., & ... Kohli, S. (2012). Stressors and barriers to using mental health services amo ng diverse groups of first generation immigrants to the United States. Community Mental Health Journal, 48 (1), 98 106. Searight, H., & Armock, J. A. (2013). Foreign Language Interpreters in Mental Health: A Literature Review and Research Agenda. North Ame rican Journal of Psychology, 15 (1), 17 38. Shattell, M. M., Hamilton, D., Starr, S. S., Jenkins, C. J., & Hinderliter, N. (2008). Mental Health Service Needs of a Latino Population: A Community Based Participatory Research Project. Issues in Mental Health Nursing, 29 (4), 351 370. Shin, H. B., & Kominski, R. A. (2010). Language Use in the United States: 2007 Retrieved from http://www.census.gov/prod/2010pubs/acs 12.pdf Suarez Oroz co, & M., Paez, M. (2002) Latinos: Remaking America Berkeley, CA: University of California Press.
55 BIOGRAPHICAL SKETCH Nathaniel Lopez was born in Miami, FL. He graduated from the University of Florida in 2009 with a B.S. in psychology and a minor in history. Nathaniel began attending graduate school in the Counselor Education program at the University of Florida as a mast candidate in 2011. During the two years between undergraduate and graduate school, he worked in a community mental health agency with a forensic population. Nathaniel also has experience working with clients who have been involuntarily hosp italized as part of an internship experience with UF Health at Vista. He is looking forward to graduating in fall of 2013.