Considerations for Culturally Competent Cognitive-Behavioral Therapy for Depression with Hispanic Patients

www.elsevier.com/locate/cabpCognitive and Behavioral Practice 14 (2007) 84--97

Considerations for Culturally Competent Cognitive-Behavioral Therapy forDepression With Hispanic Patients

Alejandro Interian, Angélica M. Díaz-MartínezUMDNJ–Robert Wood Johnson Medical School, USA

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The purpose of this paper is to outline considerations for adapting cognitive-behavioral therapy (CBT) to Hispanic patients who haverecently immigrated, particularly those presenting with depressive symptoms. Culturally competent CBT is framed within a modeloriginally proposed by Rogler and his colleagues (1987). The considerations outlined by the model include ensuring that treatmentsprovide access, are selected based on compatibility with Hispanic culture, and are adapted to fit the culture. Recommendations forculturally adapting CBT include consideration of each patient’s unique ethnocultural background and their treatment expectations, aswell as culturally relevant interpersonal styles, values, and metaphors/language. In addition, specific strategies for conceptualizing andconducting CBT techniques are discussed.

IN 2002, Hispanics represented approximately 13% of thepopulation, becoming the largest U.S. minority group

(Ramirez & de la Cruz, 2003). The majority of Hispanicsin the U.S. were of Mexican origin (67%), followed byCentral and South Americans (14%), Puerto Ricans(9%), Cubans (4%), and “other Hispanics” (7%; Ramirez& de la Cruz, 2003). A Surgeon General’s reportconcluded that Hispanics, like other ethnic minorities,unfortunately experience disparate mental health carecompared to non-Hispanic Whites (Department ofHealth and Human Services [DHHS], 2001). Althoughprevalence rates differ according to levels of accultura-tion, mental disorders such as major depression aregenerally just as prevalent among Hispanics as amongnon-Hispanic Whites (Kessler et al., 2003; Vega, Sribney,Aguilar-Gaxiola, & Kolody, 2004). The impact of majordepression is a significant one, as it has been estimated tobe a leading cause of disability worldwide (Murray &Lopez, 1996). All of these points highlight the publichealth importance of ensuring quality treatments forHispanics with major depression.

Currently, a number of effective treatments exist formajor depression. The National Institute of MentalHealth’s Strategic Plan for Mood Disorders Research describedantidepressant medication and psychotherapy, cognitive-behavioral therapy (CBT) in particular, to be among the

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most effective treatments for major depression (NationalInstitute of Mental Health, 2003). Moreover, a number ofstudies have demonstrated that CBT is associated withfavorable results for Hispanic patients with major depres-sion (e.g., Miranda, Azocar, Organista, Dwyer, & Areane,2003; Miranda, Chung, et al., 2003; Organista, Muñoz, &Gonzalez, 1994; Rosello & Bernal, 1999). These studieshave examined culturally adapted CBT manuals, whichhave been tailored for working with Hispanic patients.Given the promising findings that are emerging with thesetailored approaches, it is important to outline whatconstitutes culturally competent CBT for Hispanic patients.

We are presenting CBT considerations for workingwith depressed Hispanic patients, particularly those whoare lower-income and/or have recently immigrated. Thevarious Hispanic groups we have been working withinclude primarily Mexican-origin patients, with theremainder evenly distributed between groups fromCentral America, South America, and the Caribbean.We have been piloting a 12-session, culturally adaptedCBT for Hispanics diagnosed with major depression,which has been used for individual psychotherapy in theprimary care setting. The treatment presented herein wasinformed by our clinical experience with Hispanicpatients and by cross-cultural approaches described inthe literature, including those described in a grouptreatment manual for Hispanic patients (e.g., Muñoz etal., 2000; Organista, 2000). The purpose of this paper isnot to describe the wide array of CBTapproaches, as theseare discussed elsewhere in far more detail (e.g., Beck,Rush, Shaw, & Emery, 1979; Persons, 1989; Young, Klosko,

85Considerations for Culturally Competent CBT

& Weishaar, 2003). Instead, the intent of this paper is togive serious attention to specific cultural adaptationsthat can complement these CBT approaches. It shouldbe noted that the cultural adaptations described beloware based not only on common Hispanic values, but alsoon issues associated with migration and many times withlower socioeconomic status.

Culturally Competent Psychotherapy for HispanicPopulations

What is culturally competent psychotherapy? Therecognition of cultural differences and the incorpora-tion of strategies to work with those differences inpsychotherapy are at the essence of some of the variousdescriptions of cultural competence. Nearly two decadesago, Rogler, Malgady, Constantino, and Blumenthal(1987) sought to describe what comprises culturallycompetent mental health treatment for Hispanics. Theyproposed that culturally competent interventionsshould provide the following components to Hispanicspatients: (a) ease of access; (b) strategies chosen basedon Hispanic culture; and (c) adaptation of traditionaltreatment approaches. These components of culturalcompetency remained relevant in a more recentdiscussion of culturally competent mental health treat-ments (Miranda, Nakamura, & Bernal, 2003). Also,Marín (1991) frames his discussion of cultural compe-tence around treatments that incorporate culturaldifferences in behaviors, attitudes, values, and treatmentpreferences. The sections that follow describe how CBTinterventions for treating depression among Hispanicscan be provided to maximize access, are compatible withHispanic culture, and can be adapted for working withHispanic populations. The approach is presented withinthe framework originally proposed by Rogler et al.(1987). Furthermore, domains of cultural differences(e.g., values, behaviors) discussed by Marín (1991) areintegrated within our discussion.

Maximizing Access

Access to treatment has been cited as a key variable inproviding culturally competent mental health services toHispanic patients (Miranda, Nakamura, et al., 2003;Rogler et al., 1987). Earlier findings showed thatHispanics, as a group, underutilized mental healthspecialty services (e.g., Hu, Snowden, Jerrell, & Nguyen,1991; Scheffler & Miller, 1989) and were more likely toseek mental health treatment in primary care settings(DHHS, 2001). Accordingly, improving access wouldinclude matching this general treatment utilizationpattern by providing CBT for depression in primary care.

Access to care is not only attained by providing servicesin commonly utilized settings (i.e., primary care). It alsorequires the availability of Spanish language services. As

noted by diverse Hispanic participants in a focus group,“Nosotros comoHispanos no tenemos donde recurrir. Y cuando nohablamos Inglés es otro obstáculo grandíssimo.” (“As Hispanicswe don’t have anywhere to turn to. And when we don’tspeak English it is another huge obstacle”; Guarnaccia &Martinez, 2003). Certainly, there should be languagecompatibility with the CBT therapist. However, thereshould also be language compatibility with the other staffwith whom patients come into contact (e.g., receptionist,program coordinator, etc.). In fact, these personnel areoften the first line of cultural competence, as patients maynot proceed beyond those initial contacts if culturalbarriers are perceived.

Delgado (1983) described the treatment setting thathas a “relationship with the Hispanic community” (p.509). In addition to being a setting that is bilingual, suchsettings should have track records of outreach within theHispanic community and have gained the trust of manyof its Hispanic community members. For example, wehave conducted psychotherapy with Hispanic patients ina primary care clinic in Central New Jersey. The clinicmakes coordinated efforts to reach out to the community.These efforts include home visits for chronically illpatients, community health fairs, and bilingual educa-tional programs (e.g., parenting classes, English, depres-sion, domestic violence, stress management). Moreover,this primary care clinic employs a large number ofSpanish-speaking clinical and support staff.

The issue of access to services is relevant not only fromthe standpoint of recruiting patients, but also from thestandpoint of patient retention. While culturally adaptedCBT treatments have demonstrated promising resultsamongHispanic populations (e.g.,Miranda, Azocar, et al.,2003; Miranda & Muñoz, 1994; Organista et al., 1994),many of these treatments are associated with significantdropout rates. Organista et al. (1994) reported dropoutrates of 58% and Rosello and Bernal (1999) reported that52% of Puerto Rican adolescent patients completed atleast 8 of 12CBTsessions. In amore recent study,Miranda,Chung, et al. (2003) showed that only 32% of low-incomeminority women (approximately half of whom wereHispanic) attended 6 or more sessions of an 8-sessionCBT intervention. In contrast, studies reviewed in a meta-analysis of CBT trials among non-Hispanics includedattrition rates that ranged from 5% to 27% (Hollon,Shelton, & Loosen, 1991). At this point, the reason for thisis unclear. However, a potential explanation stems fromthe fact that Hispanics have, until recently, not beenincluded in clinical research (DHHS, 2001; Miranda,Azocar, Organista, Muñoz, & Lieberman, 1996), adisparity in research participation that has likely limitedour treatment knowledge with this population.

Retention of Hispanic patients in psychotherapy islikely to require active efforts. Miranda and her colleagues

86 Interian & Díaz-Martínez

have applied efforts such as providing resources fortransportation and child care. We have focused ourefforts on being particularly encouraging of patients’ability to attend CBT sessions by using routine con-firmation calls prior to an appointment (often on theday of the appointment), a telephone call immediatelyafter a “no show” for an appointment, and considerableflexibility in terms of tardiness and rescheduling. Inaddition to these efforts, we believe that addressingtreatment retention will also require increased culturaladaptation of CBT, which is discussed below (“AdaptingCBT to Hispanic Culture”).

Treatments that Fit With Hispanic Culture

It has also been noted that culturally competentmental health care includes the selection of treatmentsthat fit with Hispanic culture (Marín, 1991; Miranda,Nakamura, et al., 2003). In this respect, is CBTcompatiblewith the needs and expectations of Hispanic patients? Webelieve so for a number of reasons.

First, in our clinical experience, many Hispanicpatients express a preference for psychotherapeuticapproaches over pharmacotherapies for treating depres-sion. These clinical observations are supported byempirical studies, which have shown Hispanics to have alower treatment adherence with pharmacotherapy, incomparison to non-Hispanic Whites (e.g., Cooper et al.,2003; Sanchez-Lacay et al., 2001; Wagner, Maguen, &Rabkin, 1998). Furthermore, some studies suggest thatHispanics prefer psychotherapy over pharmacotherapy(Alvidrez & Azocar, 1999; Cooper et al., 2003). Forexample, Cooper et al. showed that Hispanics preferredantidepressant medication significantly less than non-Hispanic Whites and preferred psychotherapy signifi-cantly more than non-Hispanic Whites and AfricanAmericans.

Second, among available psychotherapies, Rogleret al. (1987) posited that insight-oriented therapies(e.g., psychodynamic) might be incompatible with thetreatment needs of Hispanic patients. He argued thatthe self-exploratory nature of insight-oriented thera-pies offer greater long-term benefits that may seemincompatible with the more immediate symptomrelief desired by patients who experience the multiplestressors associated with recent immigration. Similarly,Sue and Sue (1990) suggest that Hispanic patientsexpect treatments that are problem-solving oriented,directive, and have more immediate effects. These arefeatures consistent with CBT.

Finally, one is left contemplating how to attaincompetency with the myriad of cultures that exist simplywithin the U.S. Miranda, Nakamura, et al. (2003) discussthis very issue in terms of selecting appropriate mentalhealth treatments. These authors note the practical

difficulty of developing culturally specific interventionsfor each culture and/or subculture without applyingexisting knowledge that is available from research withnonminority populations. Miranda and her colleaguespropose beginning with established empirical data onnonminority populations and with an assumption that the“critical ingredients” of effective treatments are similaracross populations. Culturally based hypotheses andtreatment studies can then highlight aspects of thetreatment that are effective, as well as those that areproblematic, allowing modifications of the treatmentstrategy to be implemented and further studied. Suchan effort is consistent with a culturally competent researchprogram that integrates universal and cultural perspec-tives (Bernal, Bonilla, & Bellido, 1995). Given theapproach proposed by Miranda and her colleagues,CBT presents a reasonable starting point for treatingdepression among Hispanic patients. The efficacy andeffectiveness of CBT for depression has been establishedamong nonminority populations (NIMH, 2003) andstudies with Hispanic patients have also supported itsefficacy (e.g., Miranda, Azocar, et al., 2003; Miranda,Chung, et al., 2003; Organista et al., 1994; Rosello &Bernal, 1999).

Do we know of any differences in the experience ofdepression among Hispanics, versus non-HispanicWhites, that preclude the use of CBT? A number ofstudies seem to indicate core similarities in majordepression between Hispanics and non-Hispanics.These similarities include comparable prevalence rates(Canino et al., 1987; Kessler et al., 2003), predominantsymptom profile (Weissman et al., 1996), and factoranalytic findings (Crockett, Randall, Shen, Russell, &Driscoll, 2005; Golding & Aneshensel, 1989; Guarnaccia,Angel, & Low Worobey, 1989; Radloff, 1977; Roberts,1980; Rubio-Stipec, Shrout, Bird, Canino, & Bravo,1989). While the factor structure of the Center forEpidemiological Studies–Depression Scale (NationalCenter for Health Statistics, 1985) was comparable,some ethnic differences emerged. The differencestypically involved the emergence of a single factor fornegative affect and somatization, whereas this dimen-sion represented two separate factors among samples ofnon-Hispanic Whites. Thus, many core aspects of majordepression appear to be similar among Hispanics, whichsupports the strategy of beginning with treatment that isalready known to be efficacious.

Other variations in the presentation of depressionamong Hispanics highlight the need to adapt CBT forworking with these populations. Numerous studies seemto point to somatization and its slightly higher role as anidiom of distress among some Hispanic groups, particu-larly those from the Caribbean (e.g., Canino et al., 1987;Guarnaccia et al., 1989; Koss-Chioino, 1999; Myers et al.,


2002). This difference provides yet another reason forproviding psychotherapy in primary care. It also high-lights the potential value of CBT approaches that havebeen adapted to work with patients who present withmedically unexplained symptoms (e.g., Allen, Woolfolk,Lehrer, Gara, & Escobar, 2001; Woolfolk & Allen,2006).

A perhaps more striking difference in the experienceof depression among Hispanics is the underutilization ofavailable treatments (e.g., Miranda & Cooper, 2004) andlower retention rates in treatment studies (e.g., Miranda,Chung, et al., 2003). While CBT seems to be efficaciousfor Hispanic patients with depression, the retentionproblem highlights the need for continued considera-tion of cultural competence. The benefit of improvingutilization and retention by increasing cultural compe-tency is exemplified in the results reported by Sue, Fujino,Hu, Takeuchi, and Zane (1991). Their results showed thatpatients whose therapists were ethnically similar andspoke their native language dropped out of treatment less,stayed in treatment longer, and experienced bettertreatment outcomes. The meaning of this study’s resultsextends beyond simple ethnic/language match betweentherapist and patient and likely points to the value ofcultural knowledge that was exercised by ethnically similartherapists. Thus, Sue et al.’s (1991) results may alsoindicate that it is appropriate for ethnically dissimilartherapists to acquire cultural knowledge. Given proposedframeworks of cultural competency (Miranda, Nakamura,et al., 2003; Rogler et al., 1987), as well as the resultsreported by Sue et al. (1991), we propose dedicatedattention to the cultural adaptation of CBT in an effort toimprove treatment retention and outcomes.

Adapting CBT to Hispanic Culture

A key dimension of cultural competency involvesadapting treatments so that they are compatible withHispanic culture (Miranda, Nakamura, et al., 2003;Rogler et al., 1987). Adjusting CBT for working withHispanics is much like other adjustments made topsychotherapy. Experienced clinicians adapt the man-ner in which CBT principles are applied based ongender, personality style, level of functioning, and otherrelevant considerations. Much like these variables,culture is a critical dimension that should inform thetailoring of treatments. The following cultural adapta-tions seek to summarize available literature, as well asincrement this knowledge with techniques we havefound useful in our own work with depressed Hispanics.

Ethnocultural assessment. The term Hispanic refers tomany cultures from the Spanish-speaking countries ofCentral and South America, as well as Mexico, theCaribbean, and Spain. The term refersmore to an ethnicclass that has some common attributes, but encompasses

diverse cultures that can vary considerably in terms ofpractices and values. Hispanic cultures also vary accord-ing to their sociopolitical histories, which are associatedwith varying migratory patterns and possibly differentialrisk for psychiatric illness (e.g., Lee, Markides, & Ray,1997; Moscicki, Rae, Regier, & Locke, 1987).

An additional consideration for differences is accul-turation, which refers to the process of adjusting to thehost culture (Balls Organista, Organista, & Kurasaki,2003). Results reported by Vega et al. (1998) exemplifythe clinical relevance of acculturation, particularly asrelated to psychiatric risk. Specifically, the prevalence ofDSM-III-R disorders among Mexican-origin participantsvaried according to level of acculturation. The lifetimeprevalence of any Axis I disorder among the variousgroups was as follows: (a) 18.4%, immigrants residing inless than 13 years in the U.S.; (b) 23.4%, Mexico Cityresidents; (c) 32.3%, immigrants residing in more than13 years in the U.S.; and (d) 48.7%, U.S.-born MexicanAmericans. In terms of acculturation, these groups likelydiffered in terms of dominant language, foreign versusU.S. education, and adoption of American values, toname just a few examples. Thus, given the range ofcultural contexts, it is critical to understand the specificcultural factors of individual patients.

Jacobsen (1988) described a model for conductingan ethnocultural assessment, which includes under-standing the patient’s specific ethnic heritage, focusingon his or her country of origin, as well as subculturalinformation. This can include understanding whetherpatients have rural or urban backgrounds and whetherheritage is indigenous, African, European, or mixed. Hismodel also includes questions regarding the migration,including reasons for emigrating (sociopolitical, eco-nomic), method of arriving to the U.S., and return visitsor stays in native country. Jacobsen also describes inquiryregarding the effect of the migration. Was the familygeographically reconfigured? How were familydynamics changed as a result of relatives residing indifferent countries or regions of the U.S.? How hasthe family faired as a result of the migration? Jacobsenalso described assessing the patient’s sense of his or hercultural adaptation and how his or her adaptationcompares with that of other family members.

In reality, the list of questions that provide this form ofethnocultural information is quite vast. In our experience,other domains that can be assessed include the patient’schange in social support or occupational status (somepatients were employed in higher status jobs in theirnative country). Also, what was the reaction of familymembers to the decision to migrate? Forming a cohesiveand comprehensive understanding of these dimensionscan be a considerable task that often requires an initialassessment that targets these variables, as well as ongoing


assessment of these issues throughout the therapy. Anethnocultural assessment should be integrated with aclinical interview, multiaxial diagnosis, and formalmeasures, provided that available measures are appro-priate for cross-cultural use.

Ethnocultural assessment facilitates the clinical pro-cess in a number of ways. First, it allows for beginningclinical work by discussing mundane aspects of patients’backgrounds. This can serve as a form of “small talk” orplatica, a recommended approach for beginning therapythat maintains personalismo and seeks to establishconfianza or rapport (Organista & Muñoz, 1996).Second, it allows the therapist to formulate reflectivestatements that are more accurate with regard tospecific cultural background. Third, an ethnoculturalassessment can also flag common areas of clinicalconcern among Hispanic patients. Organista (2000)reviewed a number of studies and concluded that familyand marriage conflicts are common problem areasamong Hispanic patients. Particularly, generational gapsbetween parents and children with regard to assimilat-ing to U.S. culture may result in differing value systemsthat clash and contribute to conflicts. Other problemsthat are more likely among Hispanic patients includestressful life events associated with the migrationprocess, reduction in support system due to family/social displacement, and feelings of separation andloneliness. Finally, a number of Hispanic values,normative behaviors, beliefs, and explanatory modelsof illness are likely to vary from individual to individual.For example, a highly educated, third-generationMexican-American patient is likely to demonstrate anumber of cultural differences in comparison with aMexican patient with a limited educational backgroundwho recently immigrated from a Mexican rural com-munity. In this respect, an ethnocultural assessmentprovides the detailed information pertaining to apatient’s cultural background that allows for appropri-ate hypothesis raising versus assumptions that are morebased on generalizations. The relevance of the culturaladaptations subsequently discussed are likely to varyaccording to the information obtained from an ethno-cultural assessment.

Interpersonal styles and values. The establishment of atherapeutic alliance is arguably a fundamental compo-nent of all psychotherapeutic approaches. It has beendemonstrated to be a key factor in predicting successfultreatment outcome among Hispanic psychotherapypatients (Bernal, Bonilla, Padilla-Cotto, Perez-Prado,1998). For over a decade, authors have discussed keyvalues among Hispanics (e.g., Delgado, 1984; Marín,1991; Triandis, Marín, Lisansky, & Betancourt, 1984).Embodying these values in the way we relate with Hispanicpatients will help engage Hispanic patients in the

treatment process and ultimately solidify therapeuticalliance.

Simpatia is a “permanent personal quality where anindividual is perceived as likeable, attractive, fun to bewith, and easy going … and seems to strive for harmony ininterpersonal relations” (Triandis et al., 1984, p. 1363).Although such a style may characterize many ther-apeutic interactions with non-Hispanics, simpatia withHispanic patients requires warmth and kindness of amore obvious and expressive quality. It includesavoiding a neutral, passive demeanor that may char-acterize some clinical stances. The consequence of notachieving simpatia can be significant, as focus groupswith Hispanic patients suggest that perceived coldnessamong practitioners is a barrier to treatment (Guar-naccia & Martinez, 2003). Simpatia also prescribes theemphasis on positive aspects of interaction and theavoidance of confrontational or negative interactions.Given that psychotherapy occasionally requires confron-tation or “limit-setting,” such encounters requirewarmth and an emphasis on positive aspects. For exam-ple, if a patient were to arrive late for appointmentsrepeatedly, a response with simpatia overtly expressesgladness for their arrival, concern for their having beendelayed (e.g., transportation difficulty), and apprecia-tion for their effort.

Authors have also discussed formalísmo, where acertain degree of formality characterizes interactions(e.g., Miranda et al., 1996). Notable examples involveaddressing patients as Señor (male patients) or Señora(female patients) followed by their last name, as well asuse of the word usted, which is a formal word for you. Asreviewed by Comas-Diaz and Duncan (1985), Hispanicculture prescribes a related value of respeto (respect)toward individuals who are older, in positions ofauthority, parents, and relatives, even toward malesand husbands (for women with traditional genderroles). Respeto together with formalismo are relevant interms of engaging the client because it helps todelineate the therapist’s role with the client and viceversa.

Personalismo involves personalized interactions withpatients. It is consistent with the value described byDelgado (1984), where Hispanic patients prefer tointeract with individuals versus institutions. For exam-ple, telephone calls to confirm or reschedule appoint-ments made personally by the clinician is one way toachieve this form of personal relating. Miranda et al.(1996) also suggest remembering the names ofchildren and family members and asking about themduring sessions. It is worth noting that interactions withHispanic patients should be characterized by a balanceof personalismo and formalismo, rather than an over-emphasis of one or the other.


Fatalismo has been described as the belief amongmanyHispanics that their problems are part of fate and cannotbe changed (Flores, 2000). Inmedicine, fatalismo is seen asunderlying adverse health behaviors, such as avoidance ofpreventative screening (e.g., Laws & Mayo, 1998). Thenotion that problems cannot be changed or affected is abarrier to CBT, a treatment that strives to help patientschange their cognitions, behaviors, moods, and evenenvironment. To overcome this barrier, a strong treat-ment alliance where rationales for behavioral or cognitivetasks are mutually understood is essential. Also, it is notuncommon for religion to play a role in fatalismo, whereHispanic patientsmay view their problems as part ofGod’swill. Organista (2000) has described effective techniquesfor working within patients’ belief in God’s will in order tomotivate active coping among religiously devout patients.

Familismo has also been described to be a strong valueof Hispanic culture (Sabogal, Marín, Otero-Sabogal,Marín, & Perez-Stable, 1987). It refers to a strong relianceon the family for meeting psychological, social, andsecurity needs. A strong orientation of familismo com-monly involves the secondary importance of individualneeds in order to meet those of the family (Comas-Diaz &Duncan, 1985), a value that is likely to influencemotivation and behavior. For example, Marín, Perez-Stable, Otero-Sabogal, Sabogal, andMarín (1989) showedthat Hispanic smokers, compared to non-HispanicWhite smokers, were more likely to cite the examplethey were setting for their children as a reason for smokingcessation. Thus, familismo provides information regardingpotential barriers to treatment, such as individualbehaviors that run counter to family needs. At the sametime, familismo provides a source of motivation that clini-cians can emphasize when advocating for behavioralchange.

The expectation of desahogo. When asked what is mostbeneficial about psychotherapy, many Hispanic patientsthat we have treated cited the opportunity for desahogo,which is similar to “getting things off one’s chest.” Thistreatment expectation has also been described in focusgroups with Hispanic patients (Guarnaccia & Martinez,2003). A potential barrier to desahogo may relate to thedirective and psychoeducational nature of CBT. Anessential component of CBT involves educating thepatient on depression and the rationales of cognitiveand behavioral principles (Beck et al., 1979). With CBT,and manualized treatments in particular, there is a risk ofbeing too directive or psychoeducation-oriented. Theseaspects of CBTmay have the unwanted effect of inhibitingdesahogo. Clinical judgment regarding the balancebetween applying directive techniques and elicitingopen expression is a common aspect of psychotherapy.However, when working with Hispanic patients, cliniciansare advised to sufficiently weigh desahogo in this balance.

CBT techniques, such as reviewing thought or activityrecords, may allow for desahogo if the patient is offered theopportunity to describe events/thoughts using theamount of detail that may be necessary for the patient.Incorporation of desahogo inCBTis consistent withMarín’s(1991) emphasis on responsiveness to expectations.

Dichos or refranes. Dichos or refranes respectively refer to“sayings” or “proverbs” used in Spanish language. Theyare generally interchangeable terms that refer to “a self-contained speech unit that expresses a truth or somebit offolk wisdom in language that is simple and invariablypicturesque” (Cobos, 1985, p. vii). Cobos (1985) has alsosuggested that Hispanics have an affinity towards dichos,stating that they are utilized in times of turmoil andcontain language that reveals the attitudes, feelings, andpsychology of [Hispanic culture]” (p. ix). In fact, the use ofdichos for enhancing psychotherapywithHispanic patientshas been suggested (Zuniga, 1991). Successful CBTtypically requires that patients be instructed on therationales for therapeutic techniques (Beck et al., 1979).For example, learning to change cognitions often requiresan understanding of what is a cognition, a cognitivedistortion, and even a schema.Dichos can be used to frameCBT principles in a manner that bridges the gap betweenthe language of a theory developed for working amongnonminority patients and the language of Hispanicculture.

The first author’s (AI) experience has been that dichosare often not effective as the sole vehicle for commu-nicating therapeutic concepts. Instead, dichos can beeffective when applied with timing and used to comple-ment these discussions. For example, the value ofbehavioral activity, versus inactivity, can be complemen-ted with Camaron que se duerme, se lo lleva la corriente (“Theshrimp that falls asleep gets taken by the tide”). A fairargument is that dichos may not precisely convey therationale of certain CBT principles. In fact, this is whythey are recommended for complementing discussion,not replacing it. When they are effective, patients mayreveal their own dichos, resulting in a discussion betweenthe therapist and patient that develops a conspicuouscongruency. For example, when one Mexican-Americanpatient began to engage in increased pleasurable andproductive activity, she reported that she felt distraida(“distracted”) from her problems. This writer respondedby stating that Ojos que no ven, corazón que no siente (“Eyesthat don’t see is a heart that doesn’t feel”). The patientresponded “Sí, y el que busca encuentra” (“Yes, and the onewho searches shall find”). Her dicho naturally led to adiscussion on behavioral activation, where her behaviorof leaving the house significantly enhanced her like-lihood of receiving positive reinforcement (Lewinsohn,Antonuccio, Steinmetz, & Teri, 1984). Table 1 provides abrief listing of dichos that may be utilized during CBT.


As a word of caution, Zuniga (1991) advises thatclinicians be familiar with the subtleties of dichos. Somedichosmay utilize language that is uncompassionate for usein psychotherapy. For example, depressed patients com-monly experience difficulty with initiating tasks. However,stating that El que deja para otro dia, de Dios desconfìa (“Hewhosaves things till tomorrow has no trust in God”) would not beconstructive or compassionate. In addition, patients’ levelof acculturation will likely determine how much reso-nance the dicho will have, where dichos are likely to be lessrelevant among individuals who retain less of theirHispanic culture of origin. This cultural adaptationprobably would be among the more difficult for non-Spanish-speaking therapists to learn, as it certainlyrequires a command of the Spanish language. To notfully understand the language of dichos and apply them in arule-basedmanner is likely to be ineffective. Thus, clinicaljudgment is certainly warranted, as is consultation withHispanic therapists (Zuniga, 1991).

Cognitive techniques. As described by Beck et al.(1979), psychopathology is seen as the result ofcognitions that are maladaptive. Although similar events

Table 1Dichos That Capture CBT Principles

Therapeutic Topic Dicho

Cognitions affect ourEmotions/behaviors

Todo es según el color del cristal conqué se mira.Everything is according to the color ofthe glass with which we view it.

Behavioral Activation El que busca, encuentra.One who searches shall find.

Camarón que se duerme, se lo lleva lacorriente.The shrimp that falls asleep getstaken by the tide.

Para nadar hay que tirarse en elagua.To swim, one must jump in thewater.

A quién madruga, Dios ayuda.God helps early risers.

Pleasurable activity asdistraction

Ojos que no ven, corazón que nosiente.Eyes that don't see, heart thatdoesn't feel.

Small incrementalbehaviors to resolvelarger problems

Grano a grano, la gallina llena elbuche.Grain by grain, the chicken gets amouthful.

Adaptive cognitions Dies aprieta pero no ahorca.God squeezes, but doesn't choke.

Communication/assertiveness

Hablando, la gente se entiende.People understand one another bytalking.

(e.g., job loss) could occur, individuals will differ in thecognitions they use to represent those events. A CBTclinician would view those cognitions as contributing tothe individual’s emotional and behavioral response.Among depressed patients, cognitions tend to representevents in ways that overemphasize negative aspects ofthe self, world, and future. Cognitive restructuring is anapproach that first helps patients recognize maladaptivecognitions and their negative effects on mood/behavior.Ultimately, patients are provided with techniques fordisputing maladaptive thoughts and forming morefunctional thoughts that lead to improved mood andbehavioral coping.

A relevant issue forHispanics is the higher likelihood ofexperiencing multiple psychosocial stressors. As a group,Hispanics are more likely to have a lower educationalattainment, a lower median annual income, and to beliving below the poverty line than Non-Hispanic Whites(Ramirez & de la Cruz, 2003). In addition, multiplestressors or negative life events associated with immigra-tion are more likely, including separation from family,cultural displacement, barriers associated with immigra-tion status, and not speaking the predominant language.Simply put, however, not all individuals who experiencemultiple stressors experience depression. A CBT viewwould predict that individuals who experience multiplestressors with more adaptive cognitions are less likely tosuffer from depressed mood. Therefore, CBT’s emphasison maladaptive thinking is likely to remain relevant forHispanic populations, provided that some adaptations areapplied, as described below.

In practice, teaching patients to modify their cogni-tions can be a difficult task. It requires that patientsdevelop some metacognitive awareness (Teasdale et al.,2002), where their negative thoughts are experienced as“passing events in the mind rather than as inherentaspects of self or as necessarily valid reflections of reality”(p. 285). Modifying cognitions also requires that patientsrecognize that distress is not solely connected to anegative event, but to the cognitions associated with thatevent (Beck et al., 1979).

Teaching these principles is a challenge with patientsof all cultural backgrounds. However, some challenges inteaching these skills may be particularly relevant forHispanic patients. Indeed, Organista and Muñoz (1996)have noted some obstacles to understanding cognitivedisputation among their Hispanic patients. As noted, onechallenge to learning these skills may be related to theincreased level of stressors that Hispanics are more likelyto face. When much of their distress can be easilyattributed to difficult realities, the task of helping thesepatients focus on the distress associated with maladaptivecognitions, rather than the event itself, may be morechallenging. A second possible challenge to learning


cognitive disputation involves the understanding ofcertain principles, such as a cognitive distortion or thevalidity of a cognition (Beck et al., 1979). These principlesmay be more difficult to acquire amongHispanic patientswith a more limited educational background. A thirdpossible challenge may involve the concept of fatalismo.Modifying cognitions is associated with changing one’sthinking about one’s problems, which may be at oddswith the spirit of acceptance that is associated withfatalismo.

These potential difficulties warrant special efforts inexplaining cognitive restructuring to patients. If thepatient is inadequately or hastily guided through therationale of cognitive restructuring, there is a risk thatthe therapist and patient will not achieve a mutualunderstanding of the skill, which is a factor associatedwith treatment response among Puerto Rican psy-chotherapy patients (Bernal et al., 1998).

There are a number of special efforts that can bemadefor instructing cognitive disputation more effectivelyamong Hispanic patients. First, we believe that simplyunderstanding the challenges of cognitive restructuringdescribed above would likely translate into better clinicaljudgment, which would lead to better implementation ofthe technique. As is the case with basic CBT, ongoingassessment should seek to understand patients’ level ofunderstanding of the skills, which can be combined withrepetition and modification of explanations when appro-priate. Also, CBT encourages capitalizing on naturalvariations in the intensity of cognitions to illustrate howdifferent thoughts are associated with varying levels ofdistress, thereby highlighting the utility of cognitiverestructuring (Beck et al., 1979). For example, whenpatients report a slight improvement in their mood, it ishelpful to inquire about the cognitions that are accom-panying theirmood. This often reveals cognitions that aremore adaptive and illustrates the connection betweenthoughts and mood. This process may be particularlyuseful among patients who cannot discern their ability tocontrol their moods, such as those who have viewed theirproblems through fatalismo.

Second, Organista and his colleagues (Organista &Muñoz, 1996) recommend simplifying the process ofteaching cognitive disputation when appropriate. Forexample, they have described the use of the si…, pero…technique (yes…, but…), which essentially seeks tocounteract the negative cognitive filter associated withdepression or anxiety. It does so by prompting patients toconsider other, less negative situational elements that arebeing filtered out. In our experience, the technique hasbeen very effective among patients who have difficultyunderstanding typical presentations of cognitive disputa-tion (e.g., identifying cognitive distortions). For example,one Guatemalan patient presenting with depressive

symptoms reported on several occasions that herboyfriend did not want to spend time with her becausehe was often busy when she visited his home. Using thetechnique, she reported that “yes, he is always busy whenI come over to his house, but he always invites me andthis is his way of saying he wants to be with me.” As aresult of this modified cognition, she later exploredevidence that was disconfirming of her negative beliefswith regard to this relationship. In fact, she eventuallyconcluded that her boyfriend was very affectionate andsupportive. Thus, the si … pero … technique can alsoprovide patients with early success when beginning tolearn cognitive disputation, which facilitates the subse-quent learning of cognitive disputation skills at moreadvanced levels. The patient described above eventuallybegan to discern the cognitive distortions that construedevents in ways that supported her maladaptive corebeliefs.

Third, Muñoz and his colleagues (Muñoz et al., 2000)described a technique called chaining. A chaining tech-nique involves identifying a cognition that is a responseto a situation. The therapist and patient then generate anumber of alternative cognitions for the same event thatvary in intensity and adaptiveness. This should includegenerating cognitions that are increasingly maladaptive,as the goal here is not necessarily to help the patientgenerate adaptive cognitions, but to recognize thevariation in adaptiveness. This allows for discussion onthe range of cognitions and the reactions associated witheach one. Usually, patients will correctly predict that themore adaptive thoughts will result in less distress andthat the more negative ones result in greater distress,thereby helping to illustrate the potential for controllingone’s cognitions.

Finally, as patients begin to acquire the skills, it isoften helpful to capture the technique with culturallyrelevant language by using a dicho. An example noted inTable 1, Todo es según el color del cristal con qué se mira(“Everything is according to the color of the glass withwhich it is viewed”), captures the skill of cognitivedisputation for some patients. If this dicho resonates withthe patient, discussion of cognitive disputation can beframed in terms of viewing the event/self through adifferent colored glass. Some patients have even useddichos as functional cognitions. For example, whileworking to cope adaptively with a stressor, one Colom-bian patient reported that she felt stronger knowing thatDios aprieta, pero no ahoga (“God squeezes, but does notchoke”). This helped her become cognizant of the factthat while prior stressors have been difficult for her, shehas always managed to resolve or survive them.

Behavioral techniques. Maladaptive behaviors are partof the cycle of psychopathology that is associated withnegative mood (Beck et al., 1979). Lack of behavioral


engagement, a common feature in depression, limitspatients’ opportunities for positive reinforcement andfurther decreases the probability that adaptive behaviorswill occur (Lewinsohn et al., 1984). Decreased activity,avoidance, and social withdrawal often characterize suchlack of behavioral engagement. These are behaviors thatcontribute to cognitions that are negative, maladaptive,and further perpetuate behavioral disengagement (Becket al., 1979). Behavioral activation approaches fordepression have sought to increase patients’ likelihoodfor positive reinforcement through increases in pleasur-able activity, social skills/assertiveness training, andgraded exposure to difficult tasks, to name a few(Jacobson et al., 1996).

In our experience, various challenges can also existin facilitating behavioral change among some Hispanicpatients, an observation that has been noted elsewhere(Comas-Diaz & Duncan, 1985; Organista, 2000).Although the clinical reality of implementing behavioralstrategies has its challenges with many cultural groups,some issues may particularly relate to Hispanics whenpursuing behavioral strategies. One relevant issue maypertain to mutually understanding the rationale ofbehavioral strategies. An additional issue is concernedwith generating strategies that are culturally compa-tible, given varying cultural backgrounds and levelsof assimilation. Moreover, when issues of lowersocioeconomic status are relevant, behavioral strate-gies must also be practical given patients’ financialand transportation means (Organista & Muñoz,1996).

In terms of explaining behavioral techniques, similarefforts as those suggested for presenting cognitivetechniques are recommended. These efforts can includerepetition of a behavioral technique’s rationale, as wellas using clinical judgment to modify the manner inwhich strategies are explained. For example, manyHispanic patients explain that a pleasurable or mean-ingful activity was helpful because it “distracted” themfrom their problems, an experience consistent withthose of other researchers (e.g., Organista, 2000).Discussing the benefits of distración illustrates thebenefits of some behavioral strategies using culturallyrelevant language. Additionally, in response to astressor/event, discussing a variety of behavioralresponses that range in adaptiveness can facilitate anunderstanding of the mood-behavior connection (Becket al., 1979), similar to the chaining technique forcognitions described by Muñoz et al. (2000). Patientsoften identify the behaviors that contribute to the mostadaptive emotional response, thereby illustrating howthey can influence their mood. Finally, dichos (Table 1)could also supplement discussion of these principleswith culturally relevant language.

It is also useful to be aware of cultural values that mayinteract with implementing behavioral strategies. Theexistence of these values is important, whether espousedby the patient, the patient’s family, or his or her socialenvironment. For example, behavioral techniques em-phasize influencing one’s mood or environment, whichcontrasts with the acceptance associated with fatalismo.When the value of fatalismo plays a relevant role,discussion can highlight examples where patients’ beha-viors have improved their mood, events, or outcomes,thereby illustrating controllability. For patients espousingreligious fate, discussion can focus on God’s will beingactualized through our actions (A quien madruga, Diosayuda or “God helps the early riser;” Organista, 2000).Accordingly, our experience indicates that many Hispanicpatients also value being able to poner de su parte (“dotheir part”), which seems to run counter to fatalismo.Being able to poner de su parte is a value that the firstauthor has often heard patients cite as a reason for notadhering to antidepressant treatment. Poner de su parte isalso a value that emerged during a focus group withHispanic participants on mental health treatment issues(Guarnaccia & Martinez, 2003). The value of doing one’spart can be invoked when framing the rationale ofbehavioral strategies. Specifically, behavioral assignmentscan be presented as an opportunity for patients to ponerde su parte in improving mood and functioning.

Comas-Diaz and Duncan (1985) discussed the impor-tance of considering cultural values when conductingassertiveness training with Hispanic women. The pursuitand expression of individual rights that characterizesassertiveness may be at odds with Hispanic values offamilismo and respeto. This may also be the case withtraditional gender roles, such as Marianismo, wherefemales are expected to be self-sacrificing for theirfamilies and to endure suffering in this sacrifice(Stevens, 1973). Familismo emphasizes family needsover individual needs and respeto prescribes respectfulbehavior toward authority figures, which may includeolder adults, parents, or husbands (for patients withtraditional female roles). An initial task in assertivenesstraining is to assess the degree to which assertivebehavior is acceptable within the patient’s family andsocial environment and the degree to which the patientaccepts these expectations of their role. Based on thisdetermination, traditional versus culturally adaptedassertiveness techniques can be applied. Comas-Diazand Duncan (1985) described culturally adapted asser-tiveness techniques that she applied with Puerto Ricanwomen. These techniques encourage assertive behaviorwhile acknowledging culturally relevant values. Table 2displays examples of assertive statements reported byComas-Diaz and Duncan (1985); Organista (2000). Thelast two statements listed in the table illustrate potential


responses that can be used when others react negatively topatients’ assertive behavior. The value of familismo maynot only interact with assertiveness, it may also runcounter to behavioral strategies that involve schedulingpleasurable activity. For some Hispanic patients, thenotion of “taking time out for oneself” may be difficultto accept when there are multiple pressing familyresponsibilities (Organista, 2000). When the value offamily priority inhibits patients’ engagement in individualbehavioral assignments (e.g., exercising, taking classes,visiting with a friend), Organista suggests emphasizingfamilismo as a rationale for engaging in the behavioralstrategy, whereby completion of the activity is likely toimprove mood and contribute to improved family rela-ionships. In addition, Organista (2000) suggests that tar-geting activities that involve family leisure is a helpfulmethod of working within familismo.

Behaviors targeted for increase through activity sche-duling should also be practical, given the means (e.g.,financial, transportation) and behavioral repertoires ofpatients. Organista (2000) advises clinicians to generate alist of local activities that cost little or no money. Marín(1991) also argues that interventions must prescribestrategies that are within the behavioral repertoire of thetargeted group. For example, we have found that manyrecently immigrated patients find a great deal ofreinforcement by enrolling in English or computerclasses. Also, while enrollment in a gymmay be financiallydifficult for some, many patients enjoy walking as anexercise. A useful resourcemay often include involvementwithin their church or local cultural agency, especially forstrategies that seek to increase social involvement andmeaningful activity (e.g., volunteering). One Mexicanpatient found significant pleasurable activity andincreased social support by volunteering with a localcultural agency, which later became a paid position.

In terms of generating behavioral strategies that arewithin patients’ repertoires and expectations, a certain

Table 2Culturally Compatible Assertive Statements

Value Statement

Respeto “With all the respect that you deserve, I feel/believethat…” *

Familismo “It is important for me to express my feelings andopinions. This will make me less nervous and betterable to help out my children. If I am nervous, I will notbe useful to my family.” *“I want to help you and I understand that I have a dutyas your relative to help you. I want to help you de buenagana [in good faith] but, right now I can't. I will be glad tohelp you out in the future if you ask me again.”*“Expressing my feelings make me feel less upset andbetter able to handle things” **

Note. *Comas-Diaz & Duncan (1985); **Organista (2000).

pitfall to avoid is stereotyping. While it is valuable to becognizant of common activities that tend to be enjoyedamongmembersof aparticularHispanic community, this issomething to be assessed and not assumed. The potentialactivities can be formulated via culturally adapted inquiry.Are there activities that they enjoyed in their native country,but in which they are no longer engaged? In what kind ofactivities do members of their family/friends engage? Arethere activities that they thought about pursuing prior toarriving in the U.S., but have never been able to begin?While the specific activities elicited by these questions maynot be always feasible, they will at least illustrate thedomains of activity that are important to the patient. Inturn, other activities that are within those domains can beexplored.

Given that recently immigrated Hispanics are likely toface more stressors, behavioral interventions will likelyneed to address practical strategies to manage theireveryday problems. With depression, it is not uncommonfor vegetative symptoms to result in task avoidance, whichcan impair functioning. Therefore, it is critical to also usebehavioral interventions as a means for solving actualproblems, instead of solely as a vehicle for restoringpleasurable/social activities. Techniques such as gradedtask assignment and problem-solving skills training (Becket al., 1979) can be used to increase behaviors that directlyconfront patients’ social realities (e.g., unemployment,lack of support). Accordingly, it is recommended thattherapists obtain information on resources for child care,vocational training/placement, legal assistance, notaryservices, and cultural agencies. Location of resources thatare bilingual and at little or no cost is critical and requiresfamiliarity with local services or coordination with socialor social workers or case workers (Organista & Muñoz,1996). Moreover, to the extent that is appropriate,personally working with the patient on obtaining andacting on this information, versus referring to a socialworker, is another way to maintain personalismo.

Finally, in adapting to the increased role that somaticsymptoms may play in depression among Hispanicpatients (e.g., Myers et al., 2002), behavioral interventionsthat target physical functioning are particularly indicated.These may include relaxation techniques (e.g., diaphrag-matic breathing), physical exercise, or distraction. Theseintervention techniques have been included in CBTtreatments for medically unexplained symptoms (e.g.,Allen et al., 2001; Woolfolk & Allen, 2006) and may helpreducephysical distress.Moreover, interventions that helppatients reduce autonomic arousal can be presented asways to cope with problems of nervios (nerves), which is apopular idiom of distress comprised of emotional andphysical symptoms among some Hispanic groups, parti-cularly those from the Caribbean (Guarnaccia, Lewis-Fernández, & Rivera Marano, 2003; Jenkins, 1997).


Problem complexity and the CBT case conceptualizationapproach. Problem complexity has been described as animportant dimension to consider when formulating apsychotherapy treatment plan (Beutler, Consoli, &Williams, 1995). The dimension characterizes patients’problems on a continuum: those that are multiple,recurrent, and thematic (high complexity) to those thatare more attributable to a singular event (low complex-ity). According to Beutler and his colleagues, clinicalpresentations that have a high level of problemcomplexity warrant a treatment approach that addressesrecurrent patterns. These include responses to recur-rent stressors that are part of the environment, as well asrecurrent behavioral and emotional themes. In contrast,clinical presentations with low problem complexity canbe treated with more symptom-focused approaches.

When conducting CBTwithHispanic patients, the issueof high problem complexity is more likely to be a relevantone. Hispanic populations in the U.S. may be more likelyto experience multiple stressors due to migration, thehigher likelihood of socio-economic difficulties, andperhaps even the difficult circumstances that promptedtheir emigration from their native countries.

Persons (1989) described a case-formulationapproach to CBT that appears well equipped to helppatients who present with a high degree of problemcomplexity. The approach distinguishes between overtdifficulties and underlying psychological mechanisms.Persons describes the overt difficulties as consisting of the“real life” problems (e.g., family conflict, occupationaldifficulties), whereas the underlying mechanisms includecognitive, behavioral, and mood patterns that are relatedto the overt difficulties. For example, overt difficulties,such as occupational barriers, may stem from cognitionsthat lack self-efficacy, avoidance of occupationally enrich-ing behaviors, and negative mood that is paired withwork-related stimuli. An assumption behind Persons’case conceptualization approach is that multiple overtdifficulties often share common underlying psychologicalmechanisms of cognitive, behavioral, and emotionalpatterns. This assumption of common underlyingmechanisms is consistent with formulations of underlyingassumptions, core beliefs, and schema (Beck et al., 1979;Young et al., 2003).

The case-conceptualization approach can addresshigh problem complexity by identifying and treating aunifying underlying psychological mechanism thatcontributes to an array of overt difficulties. Consideran example of a middle-aged Honduran woman whosought treatment for depression. Her overt difficultiesincluded obesity, high blood pressure, depression,economic difficulties, occupational stressors, andstrained family relationships. During the course ofCBT, she initially did not complete therapeutic home-

work assignments. Her overt difficulties could haveresulted in a number of CBT approaches, includingproblem-solving approaches, psychoeducation onhealth-related behaviors, increases in pleasurable activ-ities, and communication skills. Instead, all of theseovert difficulties were conceptualized by a core patternof neglecting her personal needs, including her healthand the business that she owned. The neglect con-tributed to dysphoria and anxiety regarding her life“being out of control,” which translated into irritabilitythat reduced the quality of her family relationships.Thus, a number of overt difficulties had the commonunderlying mechanism of a schema or core belief ofcognitions that equated her worth with being completelysubservient to others, behaviors that included failure toassert/attend to her needs, and feelings of despair. Thefocus on the underlying psychological mechanismsallowed for a more parsimonious approach, whichincluded examining her cognitions regarding the needto completely satisfy others. This was examined byemphasizing familismo and evaluating how her self-neglect contributed to strained family relationships, aswell as disputing the cognitions of negative self-worththat she experienced when not attending to others’needs. Behaviorally, treatment included assertivenesstraining to provide the skills necessary for her to engagein self-care.

Conclusions/Recommendations

For over two decades, the literature has addressedcultural adaptations to traditional psychotherapies, suchas CBT, for compatibility with Hispanic culture. Theseearly adaptations have included, as examples, under-standing common Hispanic interpersonal styles (e.g.,Triandis et al., 1984; simpatia) and group processes withHispanic patients (Delgado, 1983). Also, Comas-Díazand her colleagues described how assertiveness trainingcould be adapted according to common Hispanic values(Comas-Diaz & Duncan, 1985; Comas-Diaz & Greene,1994). More recently, Organista and his colleaguessynthesized the literature and described numerouscultural considerations, including adaptations devel-oped in their research group (Organista & Muñoz,1996). The result was a number of practical suggestionsfor enhancing CBT for Hispanic patients, includingsuggestions for simplifying cognitive disputation train-ing, working synergistically with religious values, andanticipating common problems among Hispanicpatients.

In the current paper, we have sought to furtheraugment available adaptations for increasing the compat-ibility of CBT for helping Hispanic patients. We havesought to further integrate adaptations described in theliterature (e.g., ethnocultural assessment) and further


augment thediscussion related to adaptations of cognitiveand behavioral techniques (e.g., potential problems withcognitive/behavioral techniques). Furthermore, we havealso attempted to describe values and language that can beused in CBT. This included describing some of the CBTprinciples that can be captured with dichos. In addition,being able to desahogarse and poner de su parte seems torepresent the language that many of our patients use todescribe valued methods of coping, which therapists, inturn, can integrate into the CBT process. Finally, we haveproposed the application of Persons’ (1989) case concep-tualization as a method for adapting to the problemcomplexity that a number ofHispanic patients are likely toface.

Progress has been made with regarding to applyingCBT for Hispanic patients. The effect of cultural com-petence was supported in a study showing that ethnicmatch between patient and therapist enhanced treatmentretention and outcome, providing support for the culturalresponsiveness hypothesis (Sue et al., 1991). Furthermore,emerging studies have supported the efficacy of CBT forHispanics with major depression (Miranda, Azocar, et al.,2003; Miranda, Chung, et al., 2003). This certainlyrepresents progress, as randomized clinical trials formental health treatments involving Hispanic participantswere unacceptably low prior to 2001. However, therecontinues to be room for improvement. Retention ratesappear to be lower among Hispanics in comparison tonon-Hispanic Whites (Miranda, Chung, et al., 2003;Hollon et al., 1991). Approaches for reducing thisdisparity will likely include improving service-relatedissues, such as minimizing finacial barriers. Consistentwith the cultural responsiveness hypothesis, otherapproaches should focus on furthering our ability toadapt CBT so that cultural competence is maximized.Such efforts can focus on identifying additional commonHispanic values that canbeused to frameCBT. In additionto desahogo and poniendo de su parte, it is necessary to identifyother common forms of language that Hispanics may useto frame strategies for coping, as well as outlining how theycan be incorporated into CBT. The goal is to develop theability to administer CBT in a way that resonates withpatients’ values, language, and modes of coping. Further-more, it will likely be necessary to develop strategies that,where appropriate, are specific to variousHispanic groups(e.g., Mexican-Americans, Cuban-Americans, etc.). Inpursuit of expanding our database of culturally competentadaptations, hypothesis-generating methodologies havebeen recommended (Bernal & Scharro-del-Rio, 2001).Such studies should initially involve qualitative dataregarding effective components of culturally competentCBT, which can perhaps be gathered with systematicobservation. In turn, these hypotheses can be evaluatedwith hypothesis-confirming methodologies.

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This work was supported, in part, by a grant from the NationalAlliance for Research on Schizophrenia and Depression (NARSAD).

Address correspondence to Alejandro Interian, Ph.D., UMDNJ-Robert Wood Johnson Medical School, Department of Psychiatry,675 Hoes Lane, D351, Piscataway, NJ 08854, USA; e-mail:[email protected].

Received: April 4, 2005Accepted: January 30, 2006Available online 12 December 2006

mailto:[email protected]

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Considerations for Culturally Competent Cognitive-Behavioral Therapy for Depression with Hispanic Patients