Una Familia Unida

1 Theoretical and Research Basis for Treatment

Adolescent and young adult Latinas are at elevated risk of poor mental health outcomes including depression, body dissatisfaction, and disordered eating behaviors (Alegria et al., 2007; U.S. Department of Health and Human Services, 2001). Latina adolescents also have higher rates of suicidal ideation and attempts compared with their African American and White American peers (Centers for Disease Control and Prevention, 2013). Despite these risk factors, young Latinas are less likely to be referred to or present for mental health treatment (cf. Hochhausen, Le, & Perry, 2011; Perez, Fang, Inkelas, Kuo, & Ortega, 2009).

Researchers have drawn attention to a variety of barriers to treatment, such as stigma, limited access to transportation and affordable services, and lack of culturally and linguistically relevant care (Franko et al., 2012; Granillo, Jones-Rodriguez, & Carvajal, 2005). Clinicians providing services to this unique population may also face barriers to providing high quality services, such as limited linguistic or cultural competency and a lack of assessment instruments and research literature to assist in guiding treatment (cf. Bernal & Roselló, 2008; Franko et al., 2012). In this article, we will review the case of a Mexican American family who presented for outpatient treatment due to their adolescent daughter’s binge-purge cycles and recent suicide attempt. We will specifically discuss how family-based treatment (FBT) was modified along multiple dimensions as suggested by Bernal, Bonilla, and Bellido (1995) to address the presenting concerns, track progress, and target complicating factors in a manner that was sensitive to the family’s language, culture, and context (Bernal, Jimenez-Chafey, & Domenech Rodríguez, 2009). We will also review data that suggest that treatment helped reduce symptoms, and also describe some of the strengths and weaknesses of the treatment approach. Finally, we will review treatment implications and outline recommendations.

In selecting a treatment approach, we wanted to honor the family’s request for FBT while also attending to the targeted behaviors for intervention and the relationships which had been disrupted as a result of the depression and eating disorder symptoms. The idea of enhancing family relationships as a way to reduce depression and eating disorder symptoms is consistent with Latino cultural values of familismo and respeto.

Consequently, FBT of eating disorders (LeGrange, Crosby, Rathouz, & Leventhal, 2007; LeGrange & Lock, 2010) was selected for the treatment of this Latina adolescent. FBT for Bulimia Nervosa (FBT-BN) is a three-phase symptom-focused treatment protocol that aims to empower parents and adolescents to regulate food intake, disrupt problematic eating patterns, and strengthen the parent–adolescent relationship (e.g., increase adolescent autonomy, enhance family boundaries). Strategies include the family meal, psychoeducation, weekly binge/purge monitoring, externalizing the illness, exploring family patterns around eating, and encouraging low-pressure and consistent meals. This approach requires the clinician to collaborate with interdisciplinary peers, particularly given some of the possible negative physiological and psychological effects of binge/purge behaviors (e.g., hypokalemia, esophageal irritation, gastric rupture, periodontal disease, menstrual problems, electrolyte imbalance, irritability). As described by LeGrange and colleagues (2007), in FBT-BN, the parents are utilized as part of the team to help support their teen in overcoming problematic eating behaviors so as to better negotiate adolescence and young adulthood.

2 Case Introduction

The family described in this article presented for treatment at an outpatient community mental health clinic providing low-cost services. “Elena S ¹ ” was a 17-year-old Mexican American young woman who presented at intake with both parents for family therapy subsequent to a suicide attempt and an emergent “obsession” with her weight. Her parents reported that they were greatly concerned about Elena’s depressed mood and had recently discovered that Elena was intentionally vomiting following family meals. Although Elena was bilingual and identified her preferred language as English, both parents were monolingual Spanish-speaking; as such, treatment was conducted bilingually.

3 Presenting Complaints

Elena’s mother and father reported that they were quite worried about their daughter’s “obsession” over food as well as her general unhappiness. They reported that their most pressing concern was their daughter’s safety. Several months prior to intake, Elena had reportedly ingested a bottle of iron pills following a disagreement over social privileges. Elena’s parents also reported that Elena had been making superficial cuts on her arms for several months, and she appeared sad, fatigued, and irritable as well as overly concerned about her weight for about 6 months.

With respect to eating behaviors, Elena’s parents estimated that she had lost about 40 pounds in the past 3 months, following a yearly physical in which Elena was told she was overweight. Elena’s parents both reported that Elena would refuse to eat breakfast or dinner, and shared that she often verbalized concerns about the caloric content of various foods, many of which were available in a local grocery store owned by extended family. They acknowledged great sadness about Elena’s mood and were perplexed about why she would refuse even healthy food (e.g., fruits, vegetables) that was available to the family. Both parents reported a desire to participate in family therapy to become “una familia unida” (a united family) and to help Elena overcome her fear of eating as well as improve her mood.

Elena shared that she had felt “depressed” on and off since middle school, but had never considered suicide nor felt quite as unhappy and unmotivated until the past few months prior to intake. She reported that she had researched depression and she came to treatment prepared with a list of symptoms that fit hers including guilt, hopelessness, worthlessness, daily tearfulness, as well as sadness about her weight and the lack of time she was able to spend with her family due to her parents’ work schedule. She acknowledged a sharp increase in depressive symptoms several months prior to intake, and although she was unaware of any obvious antecedent, she reported some worry and apprehension about possibly transitioning out of the family home to attend college or start a career after graduating.

In regard to risk, Elena also shared that for the past 4 months, she had occasionally made shallow cuts in her arm with a pencil sharpener when she felt sad, guilty, or anxious; she estimated that she cut herself approximately once per week. Elena then became tearful while disclosing that she had consumed a bottle of iron pills after a disagreement with her parents. When asked about her intent, she stated that she had been trying to kill herself, as she believed she was a disappointment to her family and was failing in her role as the eldest daughter. While she was hopeful that family therapy could help bring her closer to her family as well as alleviate some of the pain she was feeling, she also felt “selfish” about using the family’s time and finances to attend therapy.

In regard to eating behaviors, Elena acknowledged that she began having “eating disorder thoughts” in middle school. She related that she had been generally unhappy about her weight for several years and had started intentionally vomiting after being told at her yearly physical exam a few months prior to intake that she needed to lose weight. Elena stated she limited her food consumption during the day and then purged in the bathroom at school. This occurred approximately once or twice per day. She denied engaging in excessive exercise or other compensatory strategies, but eventually revealed through an assessment survey that she had used laxatives on a few occasions. She also acknowledged that on several days per week, after arriving home, she often ate large amounts of chips or bread in private. Elena reported that she felt “out of control” during these episodes, after which she tended to force herself to throw up.

Elena and her family presented with several significant strengths. Both of Elena’s parents described her as intelligent, respectful, and responsible. Each parent reported a sense of pride in Elena’s academic achievements and work ethic, and shared great concern about her mood, stating that they were willing to do anything for her bienestar (well-being). Furthermore, Elena’s parents each described an awareness of intergenerational differences (e.g., differences with respect to social culture, acculturation), and related a desire to continue teaching Elena about cultural and family values while also balancing this with her emerging young adulthood. In addition to being bilingual, Elena excelled in school. She described pride in some of her academic achievements as well as her interest in music. She also related pride in her parents’ work ethic and ability to provide for her and her brothers while also working full-time. She provided several examples of the positive qualities she admired and respected in each of her parents, and described a desire to spend more time as a family, as well as work on their communication with each other. Finally, all members of the family easily named several previously enjoyed family activities (e.g., cooking, watching television, going to a nearby lake), which had been reduced in the past several months due to long work hours and limited finances.

4 History

History was provided by Elena as well as both parents. Elena was the first of four siblings and was born about 5 weeks early in Mexico. She moved with both parents to the United States several months after her birth. Elena’s parents described their immigration experience as positive, stating that they had relied on spirituality, extended family living in the United States, and consejos (advice) provided by family in Mexico to cope with financial and acculturative stress. All family members were documented.

On the whole, Elena’s parents described her childhood in positive terms, stating that she experienced no major educational, medical, or social difficulties. Elena denied abusive experiences and related that she felt safe and accepted in the community and at home. She had some brief struggles with self-esteem during late elementary school as she began the process of puberty slightly ahead of most of her age peers.

At the time of the evaluation, Elena resided with both parents as well as her four younger siblings. She attended a nearby high school and was performing well in school, achieving straight As while taking honors classes and participating in several extracurricular activities. She reported having several close friends; though her best friend had recently moved to a distant city, Elena and her family attended a local Catholic church and she enjoyed writing and playing music. Elena reported that she was not dating or pursuing a romantic relationship, stating that she was not allowed to spend much time out of the home. The family reported that although they had all been saddened by the death of Elena’s grandmother approximately 1 year prior to the intake, they had not experienced any other major stressors aside from financial difficulties. Elena’s parents related that this was the family’s first experience with mental health treatment. They were unaware of any family history of substance abuse or mental health concerns, including depression, suicide, or eating disorders.

With regard to psychosocial stressors, Elena’s parents acknowledged financial stress as well as limited time to spend with their children due to long work hours. Both parents reported that they felt welcome in the community; however, they also disclosed experiences of racism. For example, Elena’s mother noted that at times, White American teens and young adults would enter the family store and pretend that they were immigration officials or loudly allude to calling “ICE” (Immigrations and Customs Enforcement) should desired produce not be made available to them at a reduced price. Elena also described some experiences with microaggressions in her peer group (e.g., asking her to bring salsa to school so that they could “celebrate Cinco de Mayo”) and at school (e.g., teachers expressing concern about her speaking Spanish in the hallway). She also noted that most of her friends were White American and shared that she believed they had different “body types” than members of her ethnic and racial community.

5 Assessment

In addition to an individual interview and interviews with both of her parents, Elena participated in a brief assessment to obtain additional information about her presenting concerns. The clinician considered Elena’s language history, proficiency, and preferences, level of acculturation, and educational history prior to selecting test instruments and engaging in testing (Benuto, 2013; Fernandez, Boccacini, & Noland, 2007). Prior to testing, the clinician also explained the rationale and methods for assessment to both Elena and her parents to increase their buy-in and obtain permission for testing (Cofresi & Gorman, 2004). Elena completed self-report questionnaires and was administered a cognitive screen in English, her preferred language and the language of her educational experience. Multiple additional factors were considered prior, during, and after the assessment process (see section “Cultural Adaptations to Treatment”).

Elena completed the Children’s Depression Inventory–Second Edition (CDI-2; Kovacs, 2011) as a self-report measure of symptoms in the domain of depression. On this measure, Elena endorsed suicidal ideation (i.e., “I think about killing myself but would not do it”), as well as several items related to feelings of guilt and self-criticism (i.e., “I do everything wrong”; “All bad things are my fault”; “I can never be as good as other kids”; “I look ugly”) and social concerns (i.e., “My family is better off without me”; “I feel alone many times”; “I am not sure if anybody loves me”). Her total score fell within the Very Elevated range, which is consistent with the presence of multiple depressive symptoms. All subdomains (Emotional Problems, Negative Mood/Physical Symptoms, Negative Self-Esteem, Functional Problems, Ineffectiveness, Interpersonal Problems) were also clinically elevated.

Elena completed the Eating Disorder Examination Questionnaire (EDE-Q 6.0; Fairburn & Beglin, 2008), a self-report questionnaire used to obtain information about eating behaviors. The EDE-Q also provides information about attitudes toward eating as well as specific problematic behaviors and their accompanying frequencies. At the time of treatment, norms were available for young adolescent girls ages 12 to 14 (Carter, Stewart, & Fairburn, 2001) and young adult women ages 18 to 42 from Australia (Mond, Hay, Rodgers, & Owen, 2006). As the clinician was unable to find norms for older adolescents Elena’s age (cf. Penelo, Negrete, Portell, & Raich, 2013, for urban adolescent Mexican male/female norms), this measure was not scored. However, a qualitative review of the EDE-Q revealed that in addition to having tried over-the-counter laxatives to purge, Elena had also missed her last period. Her body mass index (BMI) as calculated by data she provided on the EDE-Q was within the normal range. She was referred to her primary care physician for follow-up shortly after the initial intake, at which time it was discovered that she had indeed lost 40 pounds, placing her at an average BMI.

Elena was administered the Weschler Abbreviated Scale of Intelligence–Second Edition (WASI-II; Wechsler, 2011) to obtain an estimate of her general cognitive functioning. The WASI-II is a brief, standardized measure of cognitive intelligence and was normed on 2,300 individuals ages 6 to 90; according to test developers, the ethnic and racial background of the standardization sample was consistent with population-based representation from the 2008 Census data. Her performance across all four subtests was within the High Average range, yielding an estimate of her full-scale IQ as also High Average. This performance was consistent with her report of feeling confident about her academic abilities.

6 Case Conceptualization

After obtaining information from interviews, assessment measures, and data from Elena’s initial and follow-up appointments with her primary care physician, Elena was diagnosed with major depressive disorder (MDD), single episode, moderate, as well as bulimia nervosa (Diagnostic and Statistical Manual of Mental Disorders [4th ed., text rev.; DSM-IV-TR]; American Psychiatric Association, 2000). At the time of treatment, DSM-IV-TR was used, as the DSM-5 had not yet been published. Diagnoses including recurrent major depressive disorder and early onset dysthymia (persistent depressive disorder) were also selected as relevant rule-outs pending additional information about the timeline behind her depressive symptoms.

In considering a conceptualization approach, the authors utilized an integrative model (Garcia Coll et al., 1996). The integrative model highlights important societal, family, and child factors, which influence the development of children of color (Perreira, Chapman, & Stein, 2006). Thus, we aimed to consider Elena’s symptoms of depression and bulimia in the context of these interactive factors.

Societal factors include intersecting variables such as race, class, gender, experiences of marginalization, and systemic environments (e.g., neighborhoods, health care, schools; Perreira et al., 2006). Salient variables considered in Elena’s case included the larger national context as well as the state where she was living and how this affected her symptoms and overall development. For instance, one in five children in the United States is an immigrant or a child of an immigrant; 62% of these children are Latino/a (Perreira et al., 2006). Although Elena was living in the Northwest Section of the United States where the population of Latinos was similar to that of the overall United States (i.e., less than 15% of the state’s population, U.S. Census Bureau, 2010), we were also aware of the fact that she was living in an area which was generally not receptive to immigrants and/or Latino families, and in which access to affordable linguistically and culturally sensitive medical and mental health care was limited (Kliman, 2010).

Family factors include variables such as values, beliefs, structures/hierarchies, roles, and resources (Perreira et al., 2006). For Elena, this meant consideration of her family’s hope that family-based work could assist them in becoming more united (“una familia unida”) as well as being mindful of the family’s values around parenting and mental health, and the structure and hierarchy of the family (e.g., respeto). Finally, child factors include variables such as gender, temperament, age, health status, and physical characteristics (Perreira et al., 2006). Thus, it was important for us to consider what it meant for Elena to be an emerging young woman of color within the context of both her family and community.

In selecting a treatment approach for Elena’s family, our goal was to provide services which were linguistically and culturally relevant as well as sensitive to the family’s values and presenting concerns. For this reason, as discussed in more detail above, we selected FBT-BN as the intervention to support the family in reducing negative family interactions and strengthening family bonds to salir adelante (move forward). Working within the family context also allowed us to work in a way that was consistent with the Latino cultural value of familismo.

7 Cultural Adaptations to Treatment

Treatment was modified across eight major domains, as per the ecological validity and cultural sensitivity model proposed by Bernal et al. (1995). This model offers a framework consisting of eight major domains in which interventions can be developed and/or modified from an existing treatment to provide culturally sensitive treatment, which is contextualized based on the client’s cultural values, language, socioeconomic status, and other variables (Bernal et al., 2009).

8 Course of Treatment and Assessment of Progress

The family attended five outpatient therapy visits over the course of approximately 3 months. After the intake session, which predominantly focused on risk assessment and collaborative safety planning (in addition to urging the family to visit Elena’s primary care provider (PCP) ), the second visit included administration of the WASI-II and EDE-Q as well as a renewed risk assessment, at which time Elena revealed that she had not experienced a recurrence in either cutting or suicidal ideation. The majority of this session was spent discussing treatment options and reviewing psychoeducation about both depression and binge/purge and restrictive eating behaviors. For instance, we reviewed the dangerousness of purging behaviors (i.e., increased risk of electrolyte imbalance, dental problems, and cardiac arrhythmias) and the impact of dietary changes (i.e., food restriction) on mood and cognitive ability. The third and fourth sessions focused heavily on leveraging family strengths and using narrative strategies to create a “family story.”

Elena completed the CDI-2 at the second and fourth session, as well as provided a report of her weekly binge and/or purge cycles. Elena’s mom was also asked to provide qualitative feedback on Elena’s mood as well as how many family meals they had shared. Elena’s self-report of depressive symptoms on the CDI-2 dropped to the normal range across all domains for both the second and fourth session. These scores were consistent with Elena’s mother’s report; Elena’s mom reported that Elena seemed “happier” and more willing to participate in school and church activities. Thus, it seemed as though treatment had been helpful in reducing anhedonia as well as fatigue. Elena’s mom also reported that she had neither heard Elena vomiting nor found vomit in the toilet, and both agreed that the family had been able to eat dinner together twice per week between the first and fourth session. In terms of risk, Elena denied the return of suicidal ideation after the first session; she also denied any recurrence of cutting behaviors.

In addition to the narrative strategies mentioned in the previous section, the clinician utilized behavioral strategies including (a) encouraging the family to set aside time weekly to cook or eat a family meal and (b) modeling the provision of positive reinforcement for Elena’s participation in sessions and achieving treatment goals. We also spent time each session discussing new coping skills (e.g., controlled breathing, journaling) which the family could integrate into their existing routine. The aforementioned behavioral strategies are consistent with the goals of Phase I in FBT-BN, in which the focus is on supporting the adolescent and parents on reestablishing healthy eating patterns, providing psychoeducation about eating disorders, externalizing the problem, and inviting the family to collaborate as a team in addressing disrupted eating behaviors (LeGrange, 2010).

9 Complicating Factors

Although Elena’s symptoms responded to family intervention (based on self and family report), there were multiple factors that affected the family’s treatment and progress. Some of the most salient complicating factors included access to care, dual diagnosis of MDD and bulimia, and power and privilege issues.

Elena’s comorbid depressive and bulimia symptoms were a complication that required discussion in session. For example, the majority of the first session was spent collaboratively safety planning and engaging in a risk assessment to ensure that Elena did not present with imminent risk of harming herself given her previous suicide attempt. We also spent a great deal of time discussing risk reduction and coping alternatives to cutting behaviors, as these obviously presented not only a safety risk but were also mutually influenced by Elena’s feelings of guilt about eating and fears of gaining weight. We also discussed the possibility of having Elena evaluated for the appropriateness of medication management for depression; however, Elena expressed a desire to participate in therapy first, as she was concerned that in addition to being unaffordable (as the family was without insurance), antidepressants may cause her to gain weight.

There was also the potential for power and privilege to serve as complicating factors on this case. For example, in addition to being in a power position as a mental health professional, the clinician also had privilege in domains such as race, immigration status, education, and language. It was important for the clinician to be aware of the intersections of power and privilege variables on the family’s experience in the community as well as in the therapy room. For instance, we discussed what it was like for Elena to live in a community with some hostile attitudes toward Latino/a immigrants. We also explored her experience being bilingual, and how this affected conversations with her parents as well as how the family navigated the community. As mentioned previously, the intersection of language and education also affected the therapeutic relationship, with Elena’s mother noting how the clinician’s language use differed from her own. Furthermore, Elena shared awareness of how her body shape and skin color differed from those of her White American friends and many of the women she saw on TV, and we used this disclosure as a starting point to look for women of color she could use as role models. The family’s experiences of discrimination based on race and skin color came up frequently in our sessions, and it was important that the clinician, who is multiracial with White privilege, to hold space for these conversations without becoming defensive or dismissive.

10 Access and Barriers to Care

Several factors related to access and barriers to care are worth mentioning in this case. First, access to care was a challenge for the family, as evidenced by Elena’s mom report that she had only been able to locate the clinic’s information after her daughter performed a Google search on the Internet. Thus, visibility of the clinic was an area of challenge, and the family may not have been able to locate the clinic had Elena not been motivated to look for help online and assist her mother in understanding the English-language format of the clinic’s webpage. In addition, treatment in this case was available on a sliding-scale fee at a location that did not accept third-party (insurance) payment. Elena’s family did not have health insurance; however, the sliding-scale fee available to them presented a major barrier in their ability to attend sessions regularly.

Finances colluded with time constraints to contribute to yet another barrier to care. Although the family did have access to a car and child care through extended family members, they often had to decide between paying for sessions or other necessities, such as gasoline, school supplies, clothing, and rent.

Barriers to care including time constraints and financial limitations also significantly affected the length of our treatment and our ability to maintain fidelity to the FBT-BN treatment model. In traditional FBT-BN, treatment progresses through three major phases, weekly, and for about 20 sessions (LeGrange, 2010). Therapy with Elena’s family was five sessions over the course of 3 months. Although we were able to address many of the components of Phase I (Reestablishing healthy eating for the adolescent), the limited duration of treatment resulted in us not being able to address components of Phase II (Return control over eating to the adolescent) and Phase III (Adolescent developmental issues and termination).

While there were many issues that served as barriers to care, there were also some that facilitated access to care. First, the outpatient clinic in which the family received treatment was conveniently located near both public transportation and a low-cost medical clinic. As a result, Elena and her parents were able to access both services as well as receive coordinated care, which may not always be possible in all outpatient settings.

One final issue that promoted access to care for this client had to do with the clinician’s access to a pediatric psychologist with specialized training in adolescent eating disorders, as well as multiple peers with training and interest in cross-cultural care and cultural humility. In addition to being able to consult with this psychologist, the clinician was also able to receive bilingual supervision with an emphasis on multicultural competencies (e.g., knowledge, skills, awareness, cultural humility). As a result, the clinician also had a space to discuss variables such as countertransference, personal biases, and how the intersections of the clinician, supervisor’s, and family’s marginalized and privileged identities may be affecting the treatment (Kliman, 2010). Such supervision and consultation are luxuries that may not be available to all clinicians, particularly those practicing in rural or private practice settings.

11 Follow-Up

During the fifth session, both Elena and her mother expressed a concern that therapy may need to be put on hold due to financial and time constraints. For instance, Elena was entering into a time in the school year in which pre-college admissions tests (ACT, SAT) were about to begin. One of her Elena’s extracurricular activities, which was also a major expense and one of their favorite activities to attend as a family, was about to start again. Both Elena and her mother reported that they were hopeful that Elena’s symptoms would not return and shared that they had found therapy to be especially helpful in terms of becoming better listeners of each other’s stories. The family was encouraged to return for treatment when possible, and we also discussed “red flags” signaling the need for immediate intervention or use of the safety plan. They did not return after this session. A follow-up call with Elena’s mother approximately 1 month after the fifth session yielded the report that Elena’s mood continued to remain stable and she had started participating in after-school activities as well as her church community.

12 Treatment Implications of the Case

This case adds to the existing literature by highlighting gaps in available research as well as highlighting the importance of flexibility and peer support when modifying treatments to be more culturally responsive. First, at the time of treatment, the clinician was unable to locate any available assessment screens for eating disordered behaviors, which were appropriate for older Mexican American adolescents (rather than adults or college samples). There is also limited research addressing how to adapt FBT for communities of color. For instance, much of the available depression research to date focuses on individual treatment of primarily White American older adolescents and college-aged women. This case study also highlights the need for additional research on how families can be utilized as strengths in the treatment of comorbid depression and eating disorders. Finally, the brief nature of this treatment episode underscores the importance of addressing barriers to care, such as finances, transportation, and eliciting beliefs about the length of treatment (and how these may differ between the clinician and family) early on. In addition, research is needed focusing on the effectiveness of brief treatment models for families of color.

Multiple authors have spoken to the importance of receiving and maintaining formal training in the domains of assessment and intervention with Latino/as (Acevedo-Polakovich et al., 2007). At the time of treatment, the clinician was able to receive ongoing supervision as well as peer consultation, which enabled her to become aware of and address how some of her own biases and experiences could affect the family’s care. Supervision and peer consultation also opened up space for attention to intersectionality, and the impact of the family’s and clinician’s interacting marginalized and oppressed identities on the therapeutic relationship (Kliman, 2010). Additional research is needed addressing how intersectionality can be used to highlight strengths as well as address power and privilege in the therapy room.

Finally, this case adds to the literature by highlighting that in the absence of specific treatments for Mexican American youth, ambitious clinicians can still deliver culturally and linguistically informed treatment. Some of the key steps to effective care highlighted in this case included (a) taking a stance of cultural humility (Tervalon & Murray-García, 1998) through openness and awareness to variables such as power and privilege; (b) listening to and learning from the family’s narratives; (c) cultural adaptations to treatment, attention to family strengths; and (d) access to culturally and linguistically informed colleagues and supervisors.

13 Recommendations to Clinicians and Students

In addition to utilizing supervision and/or peer consultation so as to remain vigilant about the impact of cultural variables on treatment, this case reflects the importance of the clinician continually monitoring the impact of their own marginalized and privileged identities on treatment. For instance, multiple authors (cf. Cofresi & Gorman, 2004) have spoken to the importance of addressing preconceptions based on cultural judgments; these include attention to within-group differences in value adherence and expression (Añez, Silva, Paris, & Bedregal, 2008). While modifying evidence-based treatments (EBTs) to be more culturally responsive, clinicians should also be attuned to the possibility of making Type I or II cultural errors during both intervention and before, during, and after assessment or test selection (cf. Acevedo-Polakovich, et al., 2007; Fernandez et al., 2007). Bernal et al. (1995) describe cultural errors as problems including stereotyping, or assuming there are cultural factors at play when in fact this is false (Type I cultural error), and/or not considering cultural factors when they are relevant (Type II cultural error).

Many authors have described strategies for modifying parent training programs to support parents and families discuss bicultural coping skills, including coping with racism and discrimination, acculturative differences, and strategies for achieving success at work and school (cf. Perreira et al., 2006). The protective influence of biculturalism, or “learning to live between two cultures” (Parra Cardona et al., 2012, p. 68) was highlighted in this case, as both Elena and her parents were able to leverage personal and family resources to target depressive symptoms and eating disruption. Family meetings also allowed a space to discuss experiences of oppression, including at school or within the health care system. Clinicians working with families may benefit from exploring with all members of the family their level of involvement in cultures of origin as well as the dominant culture in which they live; this also includes an examination of the intersections between various salient identities, such as the impact of class, gender, age, and language proficiency within various settings (e.g., home, school, work, health care system, larger community).

A weakness of the treatment approach described in this case was the fact that the family’s ideas around the length of treatment were not addressed early on. For instance, although the clinician and family did discuss treatment barriers (e.g., time constraints, transportation, finances), it is possible that the clinician’s lens of what constitutes stabilization or improvement was influenced by Western ideas of treatment procedures (e.g., research supporting the idea of even 10-20 sessions as “brief” therapy, reduction in symptoms as measured by assessment instruments) as well as her own areas of privilege (e.g., access to health care, financial resources). Discussing early on and throughout therapy how the family was measuring treatment progress would likely have assisted in providing more effective and time-limited care. Furthermore, utilizing culturally responsive role induction by coming to a mutual understanding of the roles of each member of the family in therapy and therapy’s likely course may have also aided in strengthening our rapport as well as improving long-term outcomes, addressing relapse issues (consistent with Phase III of FBT-BN), and perhaps exploring possible community resources which may have supported the family in attending treatment more frequently.

Finally, clinicians and students alike should consider publishing or disseminating their research on cultural adaptations of EBTs. Such research will aid in acting as what Bernal and colleagues (2009) describe as a “bridge” (p. 366) between the literature on multiculturalism and the literature on EBTs, thus decreasing the gap between what is known about how cultural factors affect the efficacy of interventions (Martinez & Eddy, 2005). Additional research will also serve to highlight how culturally modified interventions engage target communities as well as affect outcomes (Mendez & Westerberg, 2012).