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Using Cuento to Support the Behavioral Health Needs of Hispanic/Latinos

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Date: July 28, 2022

July is National Minority Mental Health Awareness Month. To bring awareness to the health disparities and unique struggles that racial and ethnic minority communities face in this country, there will be a series of three blogs published in July: Coping with Community Violence Together; Addressing Disparities by Diversifying Behavioral Health Research; and Using Cuento to Support the Behavioral Health Needs of Hispanic/Latinos. Read below to learn more about the behavioral health needs of Hispanic/Latinos.

According to the 2020 National Survey on Drug Use and Health (NSDUH), nearly eight million (18.4 percent) Hispanic/Latino adults reported having a mental illness. Among those with a mental illness, 1.9 million (24.4 percent) had a serious mental illness, or a mental illness that impacted their ability to function.

Though the prevalence of a major depressive episode (MDE) was lower in Hispanic/Latino youth, a larger proportion of those with MDE reported suicidal ideation compared to non-Hispanic White youth. In 2020, 18.7 percent non-Hispanic White and 15.7 percent Hispanic/Latino youth reported MDE. In non-Hispanic White youth with MDE, the proportion of those with suicidal ideation decreased from 71.6 percent in 2019 to 69.4 percent in 2020. In contrast, the proportion increased for Hispanic/Latino youth – 67.1 percent in 2019 to 72.1 percent in 2020.

The data shows that efforts towards eliminating behavioral health disparities must continue. This blog will highlight additional data, showcase culturally appropriate approaches, and provide a framework for doing so.

Treatment Gaps

In addition to disparities in prevalence, it is important to consider disparities in treatment. For MDE, non-Hispanic White youth received treatment at rates 12-13 percentage points higher than Hispanic/Latino youth. In the 2019 NSDUH, nearly half of non-Hispanic White youth with MDE did not receive treatment compared to 63.2 percent Hispanic/Latino youth. This remained relatively unchanged in 2020 with 49.1 percent non-Hispanic White youth and 37.0 percent Hispanic/Latino youth. Additionally, in 2019, 18 percent of Hispanic/Latino females aged 12 to 17 with MDE had severe impairment (PDF | 4.2 MB), a sharp increase from 11.5 percent in 2016.

Treatment gaps for Hispanic/Latino youth with MDE worsened for those with suicidal ideation. Serious treatment gaps exist for Hispanic/Latino youth with MDE. In 2020, 57.3 percent of non-Hispanic White youth with MDE and suicidal ideation received treatment. However, only 39.6 percent of Hispanic/Latino youth received treatment, a gap of nearly 18 percentage points.

Suicidal Behavior in Youth

A closer look at suicidal behaviors reveal a concerning trend in Hispanic/Latino female youth. Between 1991 and 2015, Latinas outpaced other adolescent girls in rates of suicide attempts. In 2019, 18.8 percent of youth reported suicidal ideation compared to 17.2 percent Hispanic/Latino youth. However, 22.7 percent Hispanic/Latino female youth reported suicidal ideation, nearly four percentage points higher than the overall sample. Similarly, 2.5 percent of youth reported suicide attempts resulting in injury compared to three percent Hispanic/Latino youth and, more specifically, 3.6 percent Hispanic/Latino female youth.

Understanding suicidal behaviors in Hispanic/Latino youth requires a cultural lens. It is important to consider the cultural characteristics, beliefs, and values that can be risk or protective factors for suicidal behavior. Cultural factors like greater acculturation, greater exposure to the mainstream United States culture, and racial/ethnic discrimination have been associated with increased suicide risk.

Gaps in Evidence-Based Practices and Treatments

Evidence-based practices and treatments (EBPs and EBTs) are considered the gold standard of behavioral healthcare service delivery. EBPs/EBTs have gone through rigorous evaluation and clinical trials and are replicable. Utilizing EBPs/EBTs supports countless individuals in accessing lifesaving behavioral health services. However, gaps in equitable service for diverse and hard to reach communities persist.

Many EBPs/EBTs rely on a Western medical model which may not reflect perceptions of health across diverse cultures. Culturally adapted EBPs/EBTs for Hispanic/Latino populations tend to add cultural elements like personalismo and familismo to existing mainstream treatment modalities. In contrast, culturally defined interventions are developed and delivered with culture integrated in specific and intentional ways. Culturally defined treatment concepts utilize the therapeutic value inherently embedded within Hispanic/Latino cultural practices.

Latinos often rely on cultural context to understand and address their health needs. This may include assessing progress in psychotherapy by the improvement in relationship instead of internal or individual growth. Understanding relational or collectivistic needs within Latino culture is important for effective and equitable behavioral health care.

Understanding and Encouraging Storytelling

Many Latinos use cuento, or storytelling, to answer questions in a narrative form. Storytelling preserves a collective memory and shares historical knowledge. Through cuento, Latinos can find healing through the intersections of their culture and personal stories. Storytelling allows people to learn about, share, and better understand each other’s culture. When leveraged correctly, storytelling is beneficial to behavioral health wellbeing, treatment, and recovery. Digital storytelling, or the use of images to describe experience, has been effective for several diverse communities, including peers in recovery, Indigenous youth, and immigrant/refugee community members. In Latinas, fotonovelas, or images of soap opera narratives, have been effective as a health education tool to reduce stigma related to accessing treatment. For more culturally appropriate strategies, providers should consider integrating storytelling into all aspects of care for Latinos.

Utilizing the Cultural Formulation Interview

A clinical tool to encourage storytelling is the Cultural Formulation Interview (CFI). The CFI evolved from years of research focusing on culture and its relationship to behavioral health. The tool is intended to garner nuanced information based on an individual’s experiences and understanding of their culture. Clinicians can also use the informant CFI (I-CFI) to gain cultural insight from those close to the patient. There are additional CFIs for even more unique experiences based on subcultures such as older or younger patients. Most health assessments ask generalized, close-ended questions. In contrast, the CFI blends general and probing questions allowing the provider and patient to explore deeper issues.

Support for Implementation

It is important to understand the positive impact of culturally responsive tools, like CFI, on achieving behavioral health equity for Latinos. However, this understanding is only the first step. Behavioral health practitioners serving Latinos must take meaningful, actionable steps toward providing culturally, and linguistically tailored care. Beyond a one-time assessment, the use of tools, such as CFI, should be a requirement for all patients throughout the entire care continuum of service delivery. Ensuring these culturally responsive changes are sustained will require a sense of urgency and broad support from behavioral health leadership and policymakers.

Organizational leaders and decision-makers are urged to adopt the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care. Integrating tools like the CFI into behavioral health practice achieves CLAS Standard #4: “Educate and train governance, leadership, and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis.” To ensure sustainability, behavioral health leaders must advocate for increased accountability, continued training, and provider incentives for leveraging culturally and linguistically responsive care.

Challenge for Change

EBPs/EBTs are not “one-size fits all.” Equitable, patient-centered care requires behavioral health providers to consider community-defined evidence (CDE). CDE is an evidence base that uses cultural and/or community indices to define successful practices. Utilizing the CFI and other culturally responsive assessment tools can help providers learn what might best serve the unique needs of an individual, their family, and their community. The use of such culturally centered strategies provides a better understanding of the experiences and origins of distress. They also allow individuals to draw strength from culturally protective elements on their own.

For providers, the challenge is a continued commitment to learning how an individual’s cultural experiences shape their behavioral health. However, real change happens at the system level. Behavioral health leaders can replace antiquated, discriminatory organizational values, and policies with those that reflect and honor diversity, equity, inclusion, and accessibility.

When everyone accepts these challenges, we will eliminate behavioral health disparities like those impacting young Latinas. We will create a behavioral health system that has a genuine interest in the Latino experience and achieving the long-lasting positive outcomes they have chosen.