Treatment Outcomes for Latinos and Non-Hispanic White Victims of Crime: An Effectiveness Study

Abstract

This was a record review study. Data from all cases seen (N = 121) at the Victims of Crime Treatment Center over a 7-year period were examined to collect demographic information and determine diagnoses, the intervention that was used, and whether or not the client successfully completed treatment. Results from a logistic regression revealed that ethnicity was not a predictor of treatment success in this sample. Treatment outcomes for empirically supported treatments were comparable for Latinx and non-Latinx White (NLW) victims of interpersonal violence (with 77% of Latinxs successfully completing treatment compared to 69% of NLWs). The results from this study indicate promising treatment implications for Latinx victims of interpersonal violence.

Keywords

trauma treatment outcome Latinxs empirically supported treatments effectiveness research interpersonal violence

The Latinx population is the largest minority group in the United States (approximately 17% of the total population) and is significantly impacted by interpersonal violence in terms of rate and sequelae (Cuevas, Sabina, & Milloshi, 2012; Lipsky & Caetano, 2007). While psychological interventions exist to treat the psychological sequelae of victimization, there is limited research on how effective these treatments are with Latinxs (Benuto & O’Donohue, 2015).

Psychological treatments are classified as efficacious or possibly efficacious based on their evaluation by randomized clinical trials (RCTs) and/or single-subject experimental designs (Chambless & Hollon, 1998). The Society of Clinical Psychology (2016) classified the empirically supported treatment status of cognitive behavioral therapy (CBT) for depression and anxiety as having strong research support. Despite the large body of literature focused on empirically supported treatments, the inherent limitations of determining the overall value of a treatment via research that supports its ability to produce change under highly controlled conditions have been noted. Indeed, efficacy versus effectiveness involves tradeoffs between maximizing internal versus external validity (Chambless & Hollon, 1998). Despite Chambless et al.’s seminal papers promoting the use of empirically supported treatments (Chambless & Hollon, 1998; Chambless & Ollendick, 2001), criticism of empirically supported treatments has persisted (e.g., Gartlehner, Hansen, Nissman, Lohr, & Carey, 2006). Effectiveness research has been advanced as one mechanism of establishing the degree to which results from RCTs generalize to actual conditions of treatment (Seligman, 1995). Efficacy RCTs have been noted to involve narrowly defined patient populations and do not provide sufficient information for clinical or policy decision-making (Gartlehner et al., 2006), whereas effectiveness research allows for the examination of interventions under real-world conditions, including the use of interventions with ethnic minorities. The extent to which findings from RCTs on empirically supported treatments generalize to ethnic minorities has been questioned because the cultural values and assumptions in these therapies may not be representative of the values and assumptions held by ethnic minorities (Benish, Quintana, & Wampold, 2011) and because ethnic minorities have been underrepresented in clinical trials (Bernal & Scharró del Río, 2001).

Latinxs in the United States: Treatment Needs

Approximately 54 million Latinxs reside in the United States (U.S. Census Bureau, 2015), and nearly two-thirds of the Latinx population experiences anxiety and depression in their lifetime (Wassertheil-Smoller et al., 2014). Despite that both anxiety and depression are considered to be highly treatable disorders via the use of empirically supported treatments, outcome research on the effectiveness of CBT with Latinxs is surprisingly sparse. CBT has been noted to be effective with this population in studies with small sample sizes (Gelman, López, & Foster, 2005 [N = 5]; Aguilera, Garza, & Muñoz, 2010 [N = 14]) as well as in case studies (e.g., Benuto & Bennett, 2015).

A limitation to the research discussed above is that none of these works have expressly focused on Latinx victims of interpersonal violence. While there is some limited research focused on post-traumatic stress disorder (PTSD) treatment for Latinxs (Vera et al., 2011), there are only two case studies focused on the treatment of the psychological sequelae that Latinx victims of interpersonal violence experience (Benuto & Bennett, 2015, 2019). The Benuto and Bennett (2015) case study illustrated the unique challenges that Latinx victims of interpersonal violence experience, which highlights the need for understanding how this population fairs in treatment.

An Effectiveness Study With Latinxs

One means of determining the degree to which the findings from RCTs on empirically supported treatments generalize to other populations is via effectiveness research with ethnic minority clients. The purpose of the current (uncontrolled effectiveness) study was to investigate the degree to which Latinx victims of interpersonal violence experience treatment success when they are treated with empirically supported treatments at a specialized clinic that treats victims of interpersonal violence (i.e., sexual assault). The specific research questions that were addressed by this study were as follows:

What are the treatment success rates (using empirically supported treatments) for Latinxs versus non-Latinx Whites (NLWs)?

What are the treatment success rates for Latinxs in a real-world clinic that utilizes empirically supported treatments and makes efforts to reduce some barriers to treatment?

Method

For the past 20 years, the Victims of Crime Treatment Center (VCTC) has provided psychological services to primary victims (individuals directly impacted by the crime) and secondary victims (individuals who are indirectly impacted by sexual abuse or assault, that is, a child’s parent or the partner of a sexual assault victim) of sexual abuse or assault. The VCTC has been supported by a grant from the Victims of Crime Act administered by the National Institute of Justice and the Attorney General’s Office in a rural, western state. Over the 7-year review period for which data from the VCTC were reviewed, therapists consisted of doctoral clinical trainees, master’s-level therapists, a post-doctoral scholar, and a licensed clinical psychologist.

All victims who are seen at the VCTC receive an intake and assessment process to establish the presenting problem, diagnoses, and treatment goals. Due to the grant focus (i.e., crime victims), the clients seen at the center most typically present with an anxiety (most often PTSD) or mood disorder [most often Major Depressive Disorder]), and CBT is the most frequently used intervention. The VCTC aims to follow empirically supported treatment protocols (e.g., treatment manuals such as Prolonged Exposure Therapy; Foa, Hembree, & Rothbaum, 2007), but congruent with real-world practice, there is flexibility in terms of the number of sessions a client can be seen and therapists also have the flexibility of adjusting treatment based on the client’s needs. For example, if a client presents with symptoms of anxiety (i.e., PTSD) and the treatment being implemented is Prolonged Exposure Therapy (Foa et al., 2007), but the client also presents with depressed mood, behavioral activation (Martell, Dimidjian, & Herman-Dunn, 2010) may be used to augment treatment. While treatments are not formally tailored on account of the client’s cultural background, the VCTC makes efforts to reduce barriers to treatment. Services are free as they are grant supported, hours are flexible, and clients who require assistance with transportation are provided with a bus pass so that they can travel to and from their appointment.

Procedures

After obtaining institutional review board (IRB) approval, a list of all therapy records from the clinic was generated from a database that houses client information. From this list, all records were reviewed, and data were entered into a database. These data included ethnicity, therapist, victim status (primary victim vs. secondary victim), crime the client was a victim of, sex, age, scores on any assessments that were administered, primary diagnosis, primary treatment used, and then whether or not the client met diagnostic criteria for a mental health disorder the last time they were seen. Two independent raters rated each case based on the criteria described above, and inter-rater reliability was noted to be adequate (there was a 93% agreement rate across the two raters).

Data from all cases seen (N = 189) at the VCTC over a 7-year period were reviewed to identify cases that met inclusion criteria. Inclusion criteria were that the client be NLW or Latinx (24 cases were omitted because they did not meet this inclusion criterion) and that the client met criteria for a Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000) diagnosis (15 clients were only seen for intake and they did not meet criteria for a DSM-IV-TR diagnosis and were determined to not need treatment). Clients who were actively suicidal (as the clinic does not have 24-hour availability) or who required an intervention that the clinic does not provide (e.g., Dialectical Behavioral Therapy) was provided with a community referral, and thus, this constitutes exclusion criteria for this study. Twenty-nine cases met these exclusion criteria and were thus excluded from data analysis.

Participants

After all cases that did not meet inclusion criteria and those that met exclusion criteria were omitted from the data set, 121 cases remained. Participants consisted of 30 Latinx and 91 NLW clients. The majority of the sample was female (88%), a direct victim of a sexual crime (97%), and had been diagnosed with PTSD (65%). Over half (54%) of the sample had a co-morbid presentation with the majority of co-morbidity being accounted for by depression and anxiety. Co-morbid presentation was approximately equally distributed across the two ethnic groups: 50% of the Latinxs in the study had co-morbid diagnoses compared to 55% of NLWs. Participants ranged in age from 4 to 58 years. The mean age across all participants was 22.54 (SD = 10.93) years. While Latinxs (M = 20.45 years; SD = 11.30 years) were slightly younger than NLWs (M = 23.25 years; SD = 10.77 years), this difference was not statistically significant. Across the sample, 74 (61%) clients were noted to have successfully completed treatment; this was defined by the client no longer meeting diagnostic criteria in the last session that they were seen at the VCTC.

General CBT was the most commonly used treatment. General CBT consisted of the use of cognitive therapy including the use of techniques such as attribution change, behavioral activation, response chaining, cognitive diffusion, cognitive restructuring, problem-solving skills training, and the incorporation of relaxation exercises (O’Donohue & Fisher, 2008). In terms of frequency of use, general CBT was followed by more specific forms of CBT including prolonged exposure therapy (Foa et al., 2007) and trauma-focused CBT (TF-CBT; Cohen, Mannarino, & Deblinger, 2006). A small minority of the sample (4%) were children who presented with Oppositional Defiant Disorder. In these cases, the parenting component of TF-CBT was used to address behavioral problems, and as such, the intervention was labeled as Behavioral Management. This includes the delivery of psychoeducation to parents about how problem behaviors are learned, an examination of antecedents and consequences of problem behaviors (i.e., a functional analysis), and the implementation of basic behavior management principles (Pollio, Glickman, Behl, & Deblinger, 2013). On average, clients attended 7.43 sessions (SD = 6.33). While Latinxs attended slightly more sessions (M = 8.40; SD = 7.61) than NLWs (M = 7.20; SD = 6.33), this difference was not statistically significant.

The outcome variable was a categorical variable: treatment success. Participants were categorized as either having experienced treatment success or not. The majority of the sample (61%) experienced treatment success. Of the 47 participants who did not experience treatment success, the majority (78%) dropped out of treatment. The remaining 22% of participants (who did not experience treatments success) simply did not experience a reduction in symptoms over the course of the time that they were seen at the VCTC. These cases were eventually terminated and provided with a referral. Given the categorical nature of the outcome variable, logistic regression was used in the data analysis. See Table 1 for additional details of client characteristics.

Table 1.

Client Characteristics (N = 121).

Variable	All participants	Latinx	NLW
Sex
Female	106	20	86
Male	15	10	5
Victim status
Child victim	44	16	28
Adult victim	42	4	38
Adult survivor	31	9	22
Secondary victim	4	1	3
Diagnosis
PTSD	79	18	61
Depression	12	2	10
Anxiety disorder NOS	23	9	14
ODD	5	1	1
Adjustment disorder	2	0	2
Treatment used
General CBT	58	11	47
PE	39	9	30
TF-CBT	19	9	10
Behavior management	5	1	4
Treatment success
Yes	74	23	51
No	47	7	40

Note. NLW = non-Latinx White; PTSD = post-traumatic stress disorder; NOS = not otherwise specified; ODD = oppositional defiant disorder; CBT = cognitive behavioral therapy; PE = premature ejaculation; TF = trauma-focused.

Results

Variables That Were Not Significantly Related to the Outcome Variable

There were several variables that were examined for their relationship to the outcome variable that had the potential to act as confounds. Sex χ²(1) = 2.559, p = .110; victim status (primary adult victim, child victims, and secondary victims) χ²(3) = 2.713, p = .438; primary diagnosis χ²(4) = 6.113, p = .191; co-morbid diagnosis χ²(1) = .218, p = .640; therapist χ²(3) = 1.883, p = .597; client-therapist ethnic match χ²(1) = 2.393, p = .64; language χ²(1) = 2.935, p = .087; and age t(113.466) = .662, p = .509 were not related to the outcome variable (treatment success).

There was a significant mean difference in the number of sessions attended on the basis of treatment success, t(118.691) = 6.422, p < .001, with the no-treatment-success group attending less sessions (M = 3.72) than the treatment-success group (M = 9.77). In addition, there was a significant association existed between treatment success and type of treatment used, χ²(3) = 12.651, p = .005. Behavior management had the highest success rate (80%) closely followed by TF-CBT (79%) and PE (74%). General CBT had a substantially lower treatment success rate (55%). With any nominal (categorical and unranked) variable, one category needs to be selected and removed from the analysis as the comparison category. The results of all remaining categories are then compared to the omitted comparison category. In this case, CBT was selected to act as the comparison category.

Logistic Regression Model

In the logistic regression analysis conducted, the predictors included in the analysis consisted of ethnicity, which was a dummy variable representing Latinx respondents versus NLW respondents, and the two significant controls, which consisted of treatment type and the number of sessions attended. With regard to treatment type, the variables included in the analysis consisted of dummy variables representing behavior therapy, prolonged exposure therapy, and TF-CBT, with CBT omitted from the analysis as the comparison category. The number of sessions attended was included in the analysis as a continuous measure.

Table 2 summarizes the results of this logistic regression analysis. As shown, respondent ethnicity was not found to achieve statistical significance. Nonetheless, the odds ratio (OR) value was substantial suggesting that statistical significance was not achieved as a result of the modest sample size. Per the OR value, Latinxs had odds of treatment success that were increased by a factor of 2.759 as compared with NLWs. Treatment type was not found to achieve statistical significance, while with regard to the number of sessions attended, each additional session attended was found to be associated with odds of treatment success that were increased by a factor of 1.420. Overall, this logistic regression model was found to correctly predict cases 80.2% of the time, while the regression model, overall, was found to achieve statistical significance. In addition, this regression model achieved a Cox and Snell R² of .336, along with the Nagelkerke R² of .455.

Table 2.

Logistic Regression Analysis With Treatment Success.

Variable	B	SE	Wald χ²	df	p	OR
Latinx	1.015	0.579	3.073	1	.080	2.759
BI	0.844	1.228	0.472	1	.492	2.325
PE	0.215	0.567	0.144	1	.704	1.240
TF-CBT	0.920	0.714	1.659	1	.198	2.509
No sessions attended	0.351	0.079	19.916	1	.000	1.420
Constant	−2.074	0.491	17.814	1	.000	0.126

Note. χ²(5) = 49.480, p < .001; Cox & Snell R² = .336, Nagelkerke R² = .455. BI = Behavioral Intervention; OR = odds ratio; TF-CBT = trauma-focused cognitive behavioral therapy.

Discussion

Treatment Success

The results from this study indicated that Latinxs experienced comparable treatment success rates compared to NLWs. While the clinicians in this study employed standard (i.e., nonculturally adapted or tailored) renditions of empirically supported treatments, it is possible that some modifications (to noncore components of treatment) were made to enhance the compatibility of the intervention with cultural values and beliefs within the context of service delivery. Indeed, Chu and Leino (2017) noted that in the majority of cases, cultural adaptations do not involve changes to core treatment components. For example, when the interventions were delivered in Spanish, cultural idioms and other cultural similarities might have occurred. Moreover, the VCTC is well networked with the community and specifically marketed as having resources available for Latinxs. Thus, clients are often referred to services based on their individual needs (i.e., if a client requires assistance with completing U-Visa paperwork, they are provided with a referral to an immigration attorney). While arguably when ethnic match occurs between a client and therapist, the client may be more likely to receive informal cultural adaptations to treatment (given the presumed shared cultural values). However, it is interesting that the cultural matching variable failed to reach significance in this study.

It is important to note that the VCTC (by design) attempts to reduce barriers to treatment. Services are free, hours are flexible, clients may receive assistance with transportation (via a bus pass), and services are available in Spanish. However, with the exception of services being available in Spanish, all these adaptations could benefit both Latinx and NLW clients. The literature has indicated that clinic procedures designed to reduce traditional barriers do improve service utilization rates (Organista, Muñoz, & González, 1994).

Dropout Rates

Hans and Hiller (2013) noted that it is essential that authors exactly describe the extent of dropout to help interpret effect sizes of completers-only analyses, as these are likely to be upwardly biased when those patients systematically drop out or do not benefit or deteriorate from treatment. Dropout rates were available for review. In this study, the dropout rate for Latinxs was 20% and 34% for NLWs. Across studies published in the extant literature, the dropout rate for CBT has been noted to be 26.2% and RCT dropout rates did not differ significantly from non-RCTs in dropout rates (Fernandez, Salem, Swift, & Ramtahal, 2015); in an effectiveness study on CBT for depression, the dropout rate was noted to be 24.6% (Hans & Hiller, 2013). The dropout rates of Latinxs are much higher in the published literature. For example, in a naturalistic treatment study, the dropout rate was noted to be 58% (Organista et al., 1994) and inconsistent attendance has been noted to occur among this group (Aguilera et al., 2010). Studies have indicated that almost 70% of Latinxs who access mental health care services do not return after their first visit, thus indicating a possible lack of trust in the mental health care system (Aguilar-Gaxiola, 2005). It is peculiar that the dropout rates from this study were substantially lower than what has been observed in the extant literature specific to Latinxs. It is possible that the clinic procedures aimed at reducing external barriers to service, the availability of Spanish-speaking therapists, and the fact that the VCTC is well networked with the community and specifically marketed, as having resources available for Latinxs may have reduced the dropout rate of Latinxs in our sample. An additional point to consider is the reason for dropout. The records did not reflect why clients dropped out of treatment and arguably clients may have dropped out for a host of different reasons (i.e., they gained what they were seeking, the treatment was aversive, they were not making treatment gains, etc.).

Implications for Effectiveness Research

The data analyzed in this study were collected from a real-world clinic outside the parameters of a RCT. While there is inherent value in conducting a study under tightly controlled parameters, there is also an inherent limitation with regard to generalizability. While the results from effectiveness research may have lower internal validity, it has higher external validity than research conducted under tightly controlled parameters. The participants in this study had co-morbid conditions and represent a sample drawn from a population that accurately represents the majority of clients who will seek treatment. In addition, the clinicians in this study represent clinicians from a real-world practice outside the confines of an RCT. The results from this study support that in real-world clinical practice, empirically supported treatments are likely to result in comparable treatment gains for Latinxs and NLWs.

Limitations

There are several limitations to note in the current study. First, the small sample size examined indicates the need to interpret the results with caution. Second, the fact that records were reviewed from a real-world clinic that was not necessarily designed to collect data for purposes of research analysis means that certain variables were not measured. For example, although interrater reliability was adequate, the utilized definition of treatment success (i.e., two raters categorized the cases based on documentation in the client record at termination that the client no longer met diagnostic criteria for a mental health condition that they were initially diagnosed) may be considered a vague or subjective notion of treatment success, although arguably it may be the criterion that many clinicians in real-world clinics utilize. However, given that this study was conducted as a record review, this operational definition of treatment success was the most objective definition that could be applied to the data. Because how clients respond to assessment questions may vary by ethnicity (Benuto, 2013a, 2013b), it would have been useful if standardized assessment measures had been used. Furthermore, given that this study was not randomized nor controlled, it was impossible to compare the treatment outcomes of clients to those in a control group. Thus, the data do not account for possible cases of spontaneous remission and reasons for dropout are not known. It is also important to note that this study was conducted with a very specific sample of outpatients (i.e., victims of sexual crime) and it is unknown whether the findings generalize to other types of outpatient populations. Finally, this study did not account for socioeconomic and other factors that could contribute to underutilization of services and/or clinical outcomes, that is, lack of child care, cultural factors including the presence or absence of familial support, characteristics, and stigma (which has been noted to mediate the relationship between ethnicity and utilization of services; Benuto, Gonzalez, & Reinosa Segovia, 2019).

Future Directions

The findings of the current study will need to be replicated with larger samples across different client populations. Future researchers may be able to more directly examine the questions of interest in this study through designing a randomized-controlled trial that would be able to account for variables such as spontaneous remission, as well as purposely assigning clients to conditions to examine pertinent variables of interest rather than controlling for such variables post hoc. In addition, more objective measures of treatment success (e.g., scores on standardized assessments or behavioral observation of clients) and reasons for dropout may be utilized to gain a more accurate understanding of the differences in treatment outcome between groups. As indicated above, it is difficult to ascertain whether or not informal modifications were made to enhance the compatibility of the intervention with cultural values and beliefs within the context of service delivery. Future researchers should also examine the extent to which clinicians change service delivery to ethnic minority clients to enhance the compatibility of the intervention with cultural values and beliefs.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Lorraine T. Benuto, PhD in psychology, the University of Nevada, Reno. She aims to answer research questions regarding the behavioral health of minorities. Her secondary research involves examining risk factors in the development of behavioral health issues in the aftermath of trauma from interpersonal violence and identifying gold standards for the treatment of the common sequelae from interpersonal violence. She also conducts research on secondary traumatic stress (STS) including research on the prevalence of STS, the associated risk and protective factors, and interventions for frontline health professionals who are experiencing STS.

William O’Donohue, PhD in Psychology, University of Nevada, Reno. He is interested in the philosophy of science and how insights from philosophy can improve the progress of psychology. Additional interests include child sexual abuse, forensic interviewing, adult sexual assault treatment and prevention, evidence-based assessment and treatment, sexually violent predator assessments, PTSD, integrated care, and quality improvement.

Natalie Bennett, MA in Psychology, University of Nevada, Reno. She is interested in research regarding the treatment of individuals who have experienced interpersonal trauma. Specifically, she is interested in examining the sequelae of sexual abuse and assault and how symptoms respond to evidence-based treatment. In addition, she conducts research on the prevention of sexual abuse.

Jena Casas, MA, University of Nevada, Reno. She aims to answer research questions regarding psychological well-being and psychopathology of women and children post-victimization. Her secondary research interest is to examine the impact culture in this same context. Currently, she is researching various aspects of cultural sensitivity and evidence-based interventions for Latina victims of IPV and sexual assault.

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