How much orientation towards the host culture is healthy? Acculturation style as risk enhancement for depressive symptoms in immigrants

Abstract

Aims:

As the specific acculturative tasks and challenges involved in the migration process can lead to an increased risk for depressive symptoms, the study was designed to gain further insight into the interrelation between acculturation styles and mental health.

Methods:

A total of n = 90 patients with different ethnic backgrounds from an outpatient consultation service for immigrants at the Hannover Medical School were investigated by the Hannover Migration and Mental Health Interview (HMMH), the Centre for Epidemiologic Studies Depression Scale (CES-D) and the Frankfurt Acculturation Scale (FRAKK).

Results:

The majority of the subjects (84.4%) had a clinically significant depression. The extent of depressive symptoms was determined by the selected acculturation style (1) (F = 3.29, p = .025): Subjects with integration as acculturation style showed less depressive symptoms than subjects with assimilation as acculturation style. Furthermore, subjects with segregation as acculturation style also showed less depressive symptoms than subjects with assimilation.

Conclusion:

The results suggest that even when undergoing extreme emotional distress, eventually leading to mental disorder, integration, as an acculturation style, seems to serve as a protective resource and possibly prevents further decline.

Keywords

Depressive symptoms acculturation style immigrants acculturation cultural identity

Introduction

Migration is known to be a multidimensional process and occurs in several stages, each of them involving specific acculturative tasks and a number of challenges (Berry, 1990, 1997; Bhugra & Jones, 2001). In this respect, acculturative tasks not only involve learning a new language or adapting to new values and customs but also coping with burdening losses or trauma. Beyond the requirements of everyday life, the psychological challenge for the individual may be considered equivalent to a new fundamental developmental task. Following the necessity to integrate two different cultures, fundamental changes in identity may occur, which are considered to be crucial for an increased risk for emotional vulnerability (Bhugra & Mastrogianni, 2004). Some studies (Borges et al., 2009; Hovey, 2000) have reported that acculturative stress leads to higher levels of depression. Other authors, however, could not show a significant impact of acculturation on depression (Ayers et al., 2009; Sin, Choe, Kim, Chae, & Jeon, 2010). In the United States, several studies have described even better health outcomes for Mexican (and other Latino) migrants compared to the general US native population. Since these migrant populations typically have lower socioeconomic status, education, income and greater barriers to access to care, this observation has been referred to as the ‘Hispanic Health Paradox’ (Vega & Sribney, 2011).

In general, however, data concerning the relationship between acculturation and mental health of migrants are heterogeneous and do not yet allow clear-cut conclusions about the predictability of risk factors. This is for several reasons: (1) the samples include individuals from different ethnic backgrounds, individuals with different motives for migration (i.e. asylum seekers vs labour migrants) and individuals with clinical versus non-clinical emotional conditions; (2) different host countries are themselves not comparable due to differences in immigration policies and attitudes of society concerning the integration of immigrants; (3) the concept of acculturation is multifold and thus operationalized in different ways (e.g. attitudes vs behaviour, time of residence) and based on one- or two-dimensional models (Matsudaira, 2006). Moreover, studies focusing on the testing of general risk factors (age, gender, social stress) or migration-related risk factors (ethnicity, discrimination, duration of residence, poor social integration) for depression in migrants have not revealed consistent results (Borges et al., 2009; Bursztein Lipsicas, & Mäkinen, 2010; Chandrasena, Beddage, & Fernando, 1991; Clarke, Colantoni, Rhodes, & Escobar, 2008; Van Bergen, Smit, Van Balkom, Van Ameijden, & Saharso, 2008; Zayas, Bright, Álvarez-Sánchez, & Cabassa, 2009).

A recognized, although not yet entirely unquestioned (Berry & Sabatier, 2011; Rudmin, 2009; Sayegh & Lasry, 1993; Snauwaert, Soenens, Vanbesselaere, & Boen, 2003), model of acculturation has been proposed by Berry (1997; see Figure 1). According to his theory, the adjustment to acculturative stress can be categorized by two different dimensions: (1) maintenance of relationship to the home culture is considered important (e.g. keeping in contact with members of the home country, preserving religious and/or cultural traditions, the mother tongue remaining the primary language, etc.) and (2) maintenance of relationship to the host culture is considered important (e.g. social support by members of the host country, use of media of the host country, openness to cultural values and traditions of the new society, etc.). Four different styles of acculturation are possible resulting from the combinations of these dimensions and their expressions. According to Berry (e.g. Hovey, 2000), the most adaptive style of acculturation for the emotional wellbeing of a migrant is integration, and the most devastating is marginalization. Presumably, the preference for a specific acculturation style is not necessarily an entirely conscious act on the part of the individual. In addition, details of daily life and conditions and immigration policies might have a considerable impact on coping strategies in terms of acculturation styles.

Figure 1.

Acculturation styles (adapted from Berry, 1997).

Following Berry’s model, we will focus on the intrapsychic process of identity adaptation and hypothesize that the balancing of the impacts of different cultures requires an enormous emotional effort and the necessity of constant emotional compensation of diverging tendencies and orientations (Akthar, 1999; Calliess, Bauer, & Behrens, 2012). Thus, emotional distress may increase temporarily (Hovey, Kim, & Seligman, 2005) and thereby lead to higher vulnerability for depressive symptoms (Grinberg & Grinberg, 1989). Individuals may tend to unconsciously alleviate this ambivalence by focusing exclusively either on their home culture or the host culture which may result in a ‘splitted self’ (Walsh & Shulman, 2007). To summarize, in our understanding, the above described emotional efforts and challenges constitute the acculturative stress.

Acknowledging these intrapsychic challenges in the acculturative process, the assessment of the degree of depressive symptoms is important for clinical work with migrants and defining preventive interventions. The aim of the study is therefore to gain further insight into the interrelation between acculturation styles and mental health.

Methodology

Subjects were recruited continuously from an interdisciplinary outpatient consultation service for immigrants (in a cooperation of the psychiatric and the psychosomatic unit) at a university hospital from January 2010 to November 2011. The service described offers culture competent assessment for immigrants from any ethnic background. The majority of the patients came from the city of Hannover, while in singular cases, patients were sent from smaller towns within a radius of 100 km. Immigrants of first and second generation with emotional distress and/or unclear physical complaints are seen for two to three elaborated diagnostic sessions with the aim of diagnosis and treatment recommendations.

Interviews and questionnaires (among others, the ones described below) are conducted with support of certified and psychologically trained interpreters in case of insufficient German language capacities. The questionnaires used had been translated by professional interpreters. The main object of the present study was to gain further insight into determinants for the development of mental disorders in immigrants.

The following questionnaires were applied in this study: Hannover Migration and Mental Health Interview (HMMH, see Calliess et al., 2009), Centre for Epidemiologic Studies Depression Scale (CES-D) (Radloff, 1977) and Frankfurt Acculturation Scale (FRAKK, see Bongard, Kelava, Sabic, Aazami-Gilan, & Kim, 2007).

This study was performed in accordance with the latest revision of the Declaration of Helsinki. Approval for this analysis was obtained from the Ethics Committee of Hannover Medical School (No. 607-2009).

HMMH

The HMMH was designed on the basis of theoretically funded criteria (Calliess et al., 2009). The interview is divided into four chapters. The first part of the interview focuses on the current level of integration into the host society (residence permit status including work permit, social support systems). In the second part of the interview, nationality, religion, ethnicity and native language are explored. After this, the interview deals with the analysis of the circumstances of the act of migration (date of the migration, alone vs with family, main motives of the migration, voluntary vs involuntary migration, handicaps on the way to the host country, traumatic experience).

The third part of the interview refers to the pre-migration phase, with the main focus on asking about losses and traumata. Afterwards, the patient is asked to draw a subjective balance of their migration with all its profits and negative aspects, including possible re-migration plans. The interview closes with a self-assessment by the patient and an assessment by the rater about a possible relationship between the experience of migration and the emotional distress of the patient.

Although the interview is orientated at the different migration phases according to Bhugra (2004), the order of questions is determined by clinical needs rather than chronological aspects. For the purpose of this study, the division of migration stages was neglected because of the small study sample. Validation studies of this instrument are at present underway.

CES-D

The German version of the CES-D (ADS-K; see Hautzinger & Bailer, 1993) was administered in a short version including 15 items. The CES-D is a self-rating instrument that identifies the presence of and the duration of impairment through depressed affect, physical complaints, motor inhibition and negative thought patterns. The depressive symptoms measured by the CES-D are insecurity, fatigue, hopelessness, feelings of worthlessness, dejection, feelings of isolation, sadness, lack of drive, crying, withdrawal, anxiety and others (the test assesses the symptoms of the patient over the past week). There are four possible answers: 0 = seldom or never (less than 1 day); 1 = sometimes (1–2 days); 2 = often (3–4 days); 3 = most or all of the time (5 days or more). The cut-off is a total score of more than 15 points. The CES-D has undergone numerous validation studies. The German version has been investigated by Lehr, Hillert, Schmitz, and Sosnowsky (2008).

FRAKK

The FRAKK (Bongard et al., 2007) conceptualizes acculturation as characteristic attitudes and everyday habits of an immigrant. It records two aspects of acculturation: ‘adoption of the host culture’ and ‘detachment from the culture of origin’ (e.g. reports of language and media use, attitude towards the country of origin and the host culture, ethnic background of social network).

There are seven possible answers: 0 = does not apply at all; 1 = applies seldom; 2 = applies less than half the time; 3 = applies about half the time; 4 = applies more than half the time; 5 = applies most of the time; 6 = applies all of the time. Two factors are to be calculated: Factor 1 identifies the ‘orientation towards the culture of origin’ (OC); Factor 2 identifies the ‘orientation towards the host culture’ (HC). So far there are no standard values for this scale. For a first orientation, however, there are tables available from a variety of samples (Bongard et al., 2007), but further validation is pending.

Statistical methods

This is an exploratory study, thus p-values are assessed descriptively and will be considered to be of relevance for p < .05. Univariate linear regression models and analyses of variance (ANOVAs) were performed to assess the impact on acculturation styles. In addition, secondary associations between cultural orientation and age groups were also examined using ANOVA.

Baseline characteristics

A total of 120 patients visited the outpatient consultation service for immigrants from January 2010 to November 2011. Full data sets were available from 90 of these patients and are analysed here. The high number of drop-outs (25%) was due to acute medical condition or study refusal. Mean age was 43.4 years (standard deviation (SD) = 12.9 years). For further analyses focusing on the life span developmental process intertwined with the migration process, subjects were divided into three age groups: (1) below or equal to 35 years (28.9%, N = 26), 36–50 years (46.7%, N = 42) and above 50 years (24.4%, N = 22). About two-thirds (67.8%, N = 61) of the sample were female. Most of the individuals (93%, N = 84) were first generation immigrants. Affective disorders (chapter F3 of the 10th Revision of the International Classification of Diseases (ICD-10) (Dilling, Mombour, & Schmidt, 2005); 40.8%, N = 33) and neurotic/somatoform disorders (chapter F4 of ICD-10; 53.8%, N = 43) were the most frequent main diagnoses.

In total, participants had lived a mean of 16.73 years (SD = 18.1 years) in Germany. Concerning the legal status, the majority of the sample (68.9%; N = 62) had an unlimited residence permit, of which 33.3% (N = 30) had German citizenship. The remaining cases had mostly either pending asylum court trials or limited residence permits.

Countries of origin of the patients are shown in Table 1.

Table 1.

Countries of origin in the study sample.

Country of origin	%	N
North Africa	6.7	6
Turkey	13.3	12
Commonwealth of Independent States (CIS)	56.7	51
European Union	3.3	3
Middle East	11.1	10
Latin America	1.1	1
Others	5.6	5
Missing values	2.2	2
Total	100%	90

The data described above have been included in the present article in order to illustrate the sample under investigation. Due to small cell sizes, however, no further analyses of countries of origin or diagnoses were made.

Results

The majority of the subjects (84.4%; N = 76) had a clinical depression according to the CES-D cut-off-score (greater than 15), which was to be expected due to the fact that the study sample is a clinical sample. Thus, the CES-D sum score was included into the analyses in order to represent the variance of depressive symptoms (Mean = 24.3; SD = 8.6; Min. = 4; Max. = 40, Median = 25).

Linear regression analyses initiated for the identification of risk factors for the degree of depressive symptoms in the migrant sample did not show significant effects for biological age, gender, voluntariness of the decision to migrate, orientation towards the home culture orientation, orientation towards the host culture or to emotional balance of the migration process (i.e. regret of the decision, re-migration intentions drawn from the HMMH).

In order to identify the possible impact of acculturation styles according to Berry (1997, see introduction), a median split was applied to the two dimensions, that is, orientation towards the culture of origin (OC; median = 36) versus orientation towards the host culture (HC; median = 37.0). The resulting frequencies are (1) Integration (culture of origin and host culture > median): 16.7% (N = 15); (2) Assimilation (culture of origin ≤ median and host culture > median): 27.8% (N = 25); (3) Segregation (culture of origin > median and host culture ≤ median): 26.7% (N = 24); (4) Marginalization (culture of origin and host culture ≤ median): 14.4% (N = 13); 13 individuals are missing (14.4%) (Figure 2).

Figure 2.

Scatter plot: displayed is the classification of the patients in the four different acculturation styles with respect to the model defined by Berry (1997).

An ANOVA was performed to examine the association between the acculturation styles described above and the degree of depressive symptoms.

The degree of depressive symptoms was determined by the selected acculturation style according to Berry (1997) (F = 3.29, p = .025; see Figure 3). Subjects with integration as acculturation style showed less depressive symptoms than subjects with assimilation as acculturation style. Furthermore, subjects with segregation as acculturation style also showed less depressive symptoms than subjects with assimilation.

Figure 3.

Impact of acculturation styles on the degree of depressive symptoms depicted by 95% confidence intervals of the mean of the general depression scale.

Moreover, subjects with marginalization as an acculturation style had a tendency to express more depressive symptoms (see Figure 4).

Figure 4.

Confidence interval plot. Displayed are 95% confidence intervals for the difference between the acculturation styles: Integration − Segregation (p = .5796); Integration − Assimilation (p = .0071); Integration − Marginalization (p = .2897); Segregation − Assimilation (p = .0138); Segregation − Marginalization (p = .5230); Assimilation − Marginalization (p = .1478).

Discussion

These findings are consistent with theory: integration, from a psychological point of view, has been described as the most adaptive acculturation style in Europe (e.g. Berry, 1997). The fact that even in a clinical sample subjects with an integrative acculturation style suffer least from depressive symptoms is remarkable. Even when undergoing extreme emotional distress eventually leading to mental disorder, integration as an acculturation style seems to serve as a protective resource. This acculturation style implies enough emotional openness and flexibility to bind with the host culture while not denying the culture of origin. Due to the fact that the results were drawn from a cross-sectional study, it remains unclear whether an integrative acculturation style in itself is sufficient to protect from further decompensation or whether primarily well-developed ego functions might be necessary to enable the individual to achieve an adequate emotional balance between two cultures.

In contrast, assimilation as an acculturation style, which is regarded by many people as highly desirable, has been found in our study to be associated with a high degree of depressive symptoms. While this acculturation style allows access to the host cultures (i.e. language, social network, etc.), the emotional roots of origin are predominantly denied. This may lead to conflictual identity crises and loss of a secure self-concept (Calliess et al., 2012) that eventually causes an increased vulnerability to depressive symptoms.

Subjects with segregation as acculturation style, in contrast, showed significantly less depressive symptoms. Consistent with theory, when choosing this acculturation style, the emotional distress becomes less salient because struggle with the host culture is mostly denied (Walsh & Shulman, 2007). This means that as a psychic compensation for instability and disorientation, the individual focuses on the culture of origin and its holding and familiar structures. This is what clinicians may experience in therapeutic settings, in which feelings of anger and depression may seem to be split off. The described phenomenon can also be found in the attitude of the immigrant patient towards the native therapist. However, this strategy of psychic stabilization can be assumed to be functional only for a limited period. Longitudinal studies investigating acculturation styles and their impact on mental health at various points of the migration process are necessary for an adequate interpretation of these first results.

While a segregative acculturation style involves at least an orientation towards the culture of origin, marginalization is characterized by a lack of any cultural orientation. Since cultural identity is essential for the structure of the self, marginalized subjects have substantially less favourable conditions for any emotional adaptation processes because of a lack of mature self-concepts involving, for example, continuity and intentionality. On being exposed to a host culture, subjects with marginalization as an acculturation style are confronted with fundamental diffusion, thus leading to high score of depressive symptoms.

This study involves several limitations and pitfalls: (1) First, the study sample refers to a clinical sample, that in itself represents patients under high emotional distress. (2) Due to this, there is a considerable missing data set because some of the cases were in a highly acute medical condition. The principal goal, however, was the clinical care of the patients, which is why this was always given priority over research aspects. This means that in cases of highly acute medical condition, neither thorough history taking in the clinical interview nor psychometric assessment was possible. (3) Further limitations are due to a relatively small sample size, which is moreover quite heterogeneous concerning countries of origin, age, gender and residence permission. (4) Since one of the therapists was of Russian origin, there are a considerable number of subjects from Commonwealth of Independent States (CIS), which reduces the representativity of the data. However, there was no theoretical foundation for a statistical split of the sample size into migrants originating from CIS versus non-CIS. (5) The cross-sectional design of this study allows interpretation of data only for the time of assessment of the patient, while acculturation can be regarded as a lifelong process. Therefore, it remains unanswered whether the adaptivity of different acculturation styles differs over the process of the acculturation. The present sample is characterized by a relatively long mean time of residence in Germany as the host country, which implies an advanced acculturation process. To analyse the relation between acculturation styles and depressive symptoms more thoroughly, for example, regarding the interdependence with self-concepts and ego functions, further longitudinal studies involving non-clinical subjects are required, especially since acculturation styles might differ in their adaptivity during the different stages of a migration process.

Conclusion

Following the aim of the study to gain further insight into the relation between acculturation and mental health, a clinical sample (N = 90 immigrants) was examined for depressive symptoms and Berry’s acculturation styles (Berry, 1997). Results revealed a high vulnerability of the study sample indicated by the fact that more than three quarters had a clinically relevant depression. Moreover, it was found that immigrants with integration as a preferred acculturation style according to theory scored less on the CES-D than the ones with assimilation as the prevailed acculturation style.

The present study suggests that certain styles of acculturation correlate with a higher burden of depressive symptoms. Thus, in treatment of immigrants, the prevailing style of acculturation should always be acknowledged and well recognized in clinical assessments. The different acculturation styles displayed on the societal surface are assumed to be accompanied by existential psychological identity formation and reformation processes. What seems to be adaptive at first glance in terms of assimilation turns out to involve higher risk for depression.

Footnotes

Acknowledgements

The entire team of the outpatient consultation service for immigrants at the departments of psychiatry and psychosomatic medicine of Medical School of Hannover, Germany, is acknowledged.

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

References

Akthar

(1999). Immigration and identity: Turmoil, treatment and transformation. Lanham, MD: Jason Aronson.

Ayers

J. W.

Hofstetter

C. R.

Usita

Irvin

V. L.

Kang

Hovell

M. F.

(2009). Sorting out the competing effects of acculturation, immigrant stress, and social support on depression. Journal of Nervous and Mental Disease, 197, 742–747.

Berry

J. W.

(1990). Psychology of acculturation: Understanding individuals moving between cultures. In Brislin

(Ed.), Applied cross-cultural psychology (pp. 232–253). Thousand Oaks, CA: SAGE.

Berry

J. W.

(1997). Immigration, acculturation and adaptation. Applied Psychology, 46, 5–68.

Berry

J.W.

Sabatier

(2011). Variations in the assessment of acculturation attitudes: Their relationships with psychological wellbeing. International Journal of Intercultural Relations, 35(5), 658–669.

Bhugra

(2004). Migration and mental health. Acta Psychiatrica Scandinavica, 109, 243–258.

Bhugra

Jones

(2001). Migration and mental illness. Advances in Psychiatric Treatment, 7, 216–222.

Bhugra

Mastrogianni

(2004). Globalisation and mental disorders. British Journal of Psychiatry, 184, 10–20.

Bongard

Kelava

Sabic

Aazami-Gilan

Kim

Y. B.

(2007). Akkulturation und gesundheitliche Beschwerden bei drei Migrantenstichproben in Deutschland [Acculturation and health condition in three migrant samples in Germany]. In Eschenbeck

Heim-Dreger

Kohlmann

C. W.

(Hrsg.), Beiträge zur Gesundheitspsychologie. Schwäbisch Gmünd: Gmünder Hochschulreihe Band 29, Germany, p. 53.

10.

Borges

Breslau

Miller

Medina-Mora

M. E.

Aguilar-Gaxiola

(2009). Immigration and suicidal behavior among Mexicans and Mexican Americans. American Journal of Public Health, 99, 728–733.

11.

Bursztein Lipsicas

Mäkinen

I. H.

(2010). Immigration and suicidality in the young. Canadian Journal of Psychiatry, 55, 273–281.

12.

Calliess

I. T.

Bauer

Behrens

(2012). Kultur-dynamisches Modell der bikulturellen Identität. Interkulturelle Psychotherapie unter Berücksichtigung der Struktur des Selbst [A dynamic model of bicultural identity. Intercultural psychotherapy under consideration of the strucure of the self]. Psychotherapeut, 57, 36–41.

13.

Calliess

I. T.

Ünlü

Neubauer

Hoy

Machleidt

Behrens

(2009). Hannover Interview ‘Migration, Akkulturation und seelische Gesundheit’ (HMMH). Ein innovatives Instrument zur systematischen Erfassung der Risiken und Ressourcen einzelner Migrationsphasen im Hinblick auf seelische Gesundheit [Hanover Interview “Migration, Acculturation, and Mental Health”. An innovative instrument for the systematic assessment of risks and resources for mental health in different migration phases]. Klinische Diagnostik und Evaluation, 2, 145–167.

14.

Chandrasena

Beddage

Fernando

M. L.

(1991). Suicide among immigrant psychiatric patients in Canada. British Journal of Psychiatry, 159, 707–709.

15.

Clarke

D. E.

Colantoni

Rhodes

A. E.

Escobar

(2008). Pathways to suicidality across ethnic groups in Canadian adults: The possible role of social stress. Psychological Medicine, 28, 419–431.

16.

Dilling

Mombour

Schmidt

M. H.

(2005). The ICD-10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines. Geneva, Switzerland: World Health Organization.

17.

Grinberg

(1989). Psychoanalytic perspectives on migration and exile. New Haven, CT: Yale University Press.

18.

Hautzinger

Bailer

(1993). Allgemeine Depressions Skala [General Depression Scale]. Göttingen, Germany: Beltz Test GmbH.

19.

Hovey

J. D.

(2000). Psychosocial predictors of acculturative stress in Mexican immigrants. Journal of Psychology, 134, 490–502.

20.

Hovey

J. D.

Kim

S. E.

Seligman

L. D.

(2005). The influences of cultural values, ethnic identity, and language use on the mental health of Korean American college students. Journal of Psychology, 140, 499–511.

21.

Lehr

Hillert

Schmitz

Sosnowsky

(2008). Screening depressiver Störungen mittels der Allgemeinen Depressionsskala (ADS-K). und dem State-Trait-Depressions-Test (STDS-T) [Screening of depressive disorders by means of the General Depression Scale and the State-Trait-Depression-Test]. Diagnostica, 54(2), 61–70.

22.

Matsudaira

(2006). Measures of psychological acculturation: A review. Transcultural Psychiatry, 43, 462–487.

23.

Radloff

L. S.

(1977). The CES-D scale: A self report depression scale for research in the general population. Applied Psychological Measurement, 1, 385–401.

24.

Rudmin

F.W.

(2009). Constructs, measurements and models of acculturation and acculturative stress. International Journal of Intercultural Relations, 33(2), 106–123.

25.

Sayegh

Lasry

J. C.

(1993). Immigrants’ adaptation in Canada: Assimilation, acculturation, and orthogonal cultural identification. Canadian Psychology, 34, 98–109.

26.

Sin

M. K.

Choe

M. A.

Kim

Chae

Y. R.

Jeon

M. Y.

(2010). Depressive symptoms in community-dwelling elderly Korean immigrants and elderly Koreans: Cross-culturalcomparison. Research in Gerontological Nursing, 3, 262–269.

27.

Snauwaert

Soenens

Vanbesselaere

Boen

(2003). When integrations does not necessarily imply integration: Different conceptualizations of acculturation orientations lead to different classifications. Journal of Cross Cultural Psychology, 34, 231–239.

28.

Van Bergen

D. D.

Smit

J. H.

Van Balkom

A. J. L. M.

Van Ameijden

Saharso

(2008). Suicidal ideation in ethnic minority and majority adolescents in Utrecht, The Netherlands. Crisis, 29, 202–208.

29.

Vega

W. A.

Sribney

W. M.

(2011). Understanding the Hispanic health paradox through a multi-generation lens: A focus on behavior disorders. Nebraska Symposium on Motivation, 57, 151–168.

30.

Walsh

S. D.

Shulman

(2007). Splits in the self following immigration: An adaptive defense or a pathological reaction? Psychoanalytic Psychology, 24, 355–372.

31.

Zayas

L. H.

Bright

C. L.

Álvarez-Sánchez

Cabassa

L. J.

(2009). Acculturation, familism and mother-daughter relations among suicidal and non-suicidal adolescent Latinas. Journal of Primary Prevention, 30, 351–369.