The rehabilitation of Hispanics experiencing acculturative stress: implications for practice.

The Rehabilitation of Hispanics(1) Experiencing Acculturative Stress: Implications for Practice

An ever-increasing number of Hispanics, particularly Mexicans, are immigrating to the United States. Rehabilitation agencies are being called upon to assist these newcomers in adjusting to life in this country. Demographic statistics give an indication of the magnitude of these needs. Davis (1990), in her compassionate and insightful collection of oral histories of Mexican immigration to the U.S., provided insight into these immigration patterns. She stated:

What began as a trickle over a century ago with a few people trekking north has, through the decades, ebbed and flowed as a shifting tide over our southern border, swelling to a great tsunami at times of stress such as the economic crisis Mexico now faces. From a quiet beginning has grown the greatest migration of people in the history of humanity.

Many of these newcomers will have disabilities and require rehabilitation services in order to fully participate in the social and economic life of the United States. Recent estimates (Thomas & Murr, 1993) placed the number of legal, illegal, and amnestied aliens who have come to the United States since 1970 at 19.3 million. The majority of these immigrants are from Mexico. The cost of government services utilized by these newcomers during 1992 was estimated to be $50.8 billion, $30.6 billion more than was collected in taxes from this group (Thomas & Murr, 1993). This plight is made worse by the fact that recent immigrants have fewer job skills and a lower educational level than those who came to the United States before 1970 (McCarthy & Valdez, 1985; Thomas & Murr, 1993).

As the world evolves toward a global economy, the U.S. will be required to compete in world-wide markets. An increasingly efficient and productive work force will be necessary to maintain a healthy American economy. It is therefore clear that rehabilitation services will be required to respond to the needs of Hispanics with disabilities.

The passage of the Americans with Disabilities Act (ADA) adds a legal mandate to the movement for greater productivity and employment participation by all. This combination of legal, economic, and social forces will place increasing demands upon rehabilitation services to provide for the needs of Hispanics with disabilities. This article will define the concept of acculturative stress and will list and discuss implications for assisting Hispanics who are experiencing acculturative stress.

Acculturative Stress

Stress is created when environmental or internal demands tax one's ability to cope and adapt. Acculturation, the process of adapting to the rules and behavioral characteristics of another group of people, brings many challenges (Smart & Smart, 1993b). Acculturative stress varies depending upon how different the two cultures which must be bridged are.

For Hispanics who come to the U.S., there are a number of significant stressors which are likely to be pervasive, intense, and life-long. Smart and Smart (in press) listed six unique factors which set the immigration experience of Hispanics apart from the immigration experience of northern Europeans. These factors are (a) the tendency of mainstream Americans to quickly and superficially dichotomize and discriminate against people based on their color, (b) the greater emphasis by Hispanics upon social and family ties and the consequent greater loss of social support when immigrating, (c) the stress and risks of illegal immigration, (d) the geographic proximity of the mother country, (e) a legacy of armed conflict in Central American countries, and (f) a historical reliance on physical labor. These unique characteristics work to intensify and prolong acculturative stress and add to the existing stress of a disability.

The experience of coping with loss is central to acculturation of most Hispanics because immigration to the U.S. means leaving behind a way of life which is familiar. Acculturation also means adjusting to the possibility (and reality) of unfulfilled wishes and dreams which do not materialize in the U.S.

It is worth noting that "immigration" is included in the Diagnostic and Statistical Manual of Mental Disorders (third edition, revised) (American Psychiatric Association, 1987) as an example of a psychosocial stressor to be included in the diagnostic Axis IV, severity of psychosocial stressors. Inclusion of immigration as an example is evidence of recognition that the experience of moving to a new culture may be stressful and may be seen as a "predominantly enduring circumstance" which is "more likely to predispose children to develop mental disorders than predominantly acute events" (American Psychiatric Association, 1987, p. 19). The term "acculturative stress," as used in this article, is meant to incorporate all of the possible demands which one faces in adapting to the life styles and culture of the U.S.

Acculturative stress has many potentially negative effects upon the rehabilitation process. Smart and Smart (1993b) listed these adverse influences: (a) impairment of physical health and recovery from illness and injury, (b) impairment of decision making, (c) impairment of occupational functioning, (d) solidifying role entrapment, (e) impairment of adaptation to and acceptance of disability, and (f) impeding the counselor-client relationship.

Meeting the Rehabilitation Needs of Hispanics with Disabilities Who are Experiencing Acculturative Stress

I. Family, Group, and Community-based Interventions

Numerous scholars (Alvirez, Bean, & Williams, 1981; Cervantes & Castro, 1985; Gomez, 1987; Keefe, 1980; Marin & Marin, 1990; Marin, Otero-Sabogal, Marin, & Perez-Stable, 1987; Mikawa, Morones, Gomez, Case, Olsen, & Gonzalez-Huss, 1992; Rogler, Malgady, Costantino, & Blumenthal, 1987) have described Hispanic culture as one which is oriented toward strong personal, family, and community ties. Hispanics rely heavily on close interpersonal relations and are accustomed to face-to-face relationships rather than the more distant and formal contacts which characterize much of Anglo interaction. Elements of trust, personal involvement, and care permeate Hispanic relationships and are a key to successful rehabilitation interventions. Loss of the social support which is characteristic of Hispanic culture places Hispanic rehabilitation clients at risk for high levels of acculturative stress. It is for this reason that rehabilitation work must be based upon family, group, and community ties.

Family. Whereas Anglos are likely to turn to friends and professional help in time of need, Hispanics turn to the family (Keefe, 1980). Fifty-four percent of Hispanic households consist of four or more persons, while only 28 percent of Anglo households are that large (U.S. Bureau of the Census, 1988). Not only is the Hispanic nuclear family larger than the Anglo, so also is the extended family. The resulting kinship network encompasses a deep sense of obligation by its members to each other for economic assistance, emotional support, and even personal correction. Thus, the Hispanic family is a problem-solving unit and serves as a retreat and protection from the outside world. Relationships are intense and frequent and deep mutual obligations are felt.

Marin, Marin, and Perez-Stable (1989) showed how the use of Hispanic values enhanced the acceptability of a "stop-smoking" behavior change message and improved its therapeutic effectiveness. A significant proportion of the intervention was based on the value of the family and nonsmokers were utilized as co-interveners with their relatives who smoked. "Stop-smoking" messages emphasized familial reasons for quitting smoking, such as providing a good example for children, facilitating better health for all members of the household, and saving family income.

Cousins, Rubovits, Dunn, Reeves, Ramirez, and Foreyt (1992) have shown that the implementation of a weight-loss program which emphasizes family values--losing weight for family members--was more effective than a similar program that utilized bilingual materials and bicultural therapists. The fact that the appeal to the best interests of the family was a more powerful intervention technique than the use of bilingual, bicultural therapists demonstrates the powerful effect of the family as a component of the rehabilitation process.

Group interventions. Various scholars and therapists (Acosta, 1979; Boulette, 1976; Cervantes, Salgado de Snyder, & Padilla, 1989; Comas-Diaz, 1981, 1986, 1990; Salgado de Snyder, 1987) have acknowledged the importance of the group setting as a supportive and therapeutic medium in the treatment of Hispanics. Group therapies aid Hispanics in overcoming isolation and alienation resulting from migration. Delgado (1983) identified group interventions as important in assisting Hispanics in the development of control over their lives, while Acosta (1979) viewed groups as providing opportunities for dialogue with other Hispanics on topics of adaptation to a new society and as antidotes to family breakdown.

In a study by Griffith and Villavicencio (1985), it was empirically demonstrated that the number of friends and neighbors viewed as providers of social support by Hispanics was positively correlated with level of acculturation. That is to say, more highly acculturated participants reported a larger social support network than did less acculturated Hispanics. This may be due to the simple fact that recent immigrants often have few friends or family members in the United States. This lack of social support also suggests high levels of acculturative stress for newcomers.

Rehabilitationists have long known the value of group support and have made great use of the power of self-help groups. Perhaps most widely used have been the techniques of the 12-step process, made popular by Alcoholics Anonymous, and its modifications.

Research supports the view that group therapy is highly effective for Hispanics who need help in ameliorating personal problems, expanding personal awareness, clarifying personal values, improving listening skills, focusing feelings, and learning relaxation and contracting techniques (Boulette, 1976; Espin, 1987; Romero, 1981).

The concept of universality--the recognition that one's life experience is similar to that of others--also appears to be an important therapeutic intervention for Hispanics. By sharing the universal effects of migration, the sense of isolation and stigmatization can be overcome. The use of groups can give Hispanics the all-important sense of social support which is such a deeply ingrained part of Hispanic culture.

Community-based intervention. Another long tradition for rehabilitation workers is their commitment to the principle of community-based service. In order to put this principle into practice, the rehabilitation worker must be knowledgeable about a wide range of community services and able to make referrals to appropriate helping agencies. The incorporation of various medical, psychological, and job support services into the rehabilitation plan encourages a multidisciplinary approach which is often needed to address the full range of immigrant needs.

In providing such community-based services, counselors must be able to advocate for their clients. An active advocacy is important because many Hispanic immigrants lack the knowledge and experience to negotiate complex and often disjointed U.S. service systems. Consistent and appropriate use of support services can be frustrating even for sophisticated clients because of such ordinary bureaucratic practices as limited hours, scattered service locations, limited availability of Spanish, and the understandable degree of intimidation that naturally accompanies the meeting of unknown service providers in unfamiliar settings (Garcia, 1985).

II. Client-Counselor Relationships

The importance of building an adequate level of trust and rapport in the client-counselor relationship cannot be overemphasized. Rehabilitation counselors must be prepared to conduct a preliminary rapport-building phase in which they work to reduce the social distance between themselves and their clients. During the rapport-building phase of the rehabilitation intervention, care must be taken not to bring inaccurate biases and stereotypes into the relationship. In particular, implicit and explicit blame of the culture must be avoided. The rehabilitation worker must also realize that the professional literature may reflect ethnocentric biases which view Hispanics and persons with disabilities as deviant and pathological.

De la Cancela and Martinez (1983) surveyed Hispanics who used the services of curanderos(as) (native folk healers), asking why they liked these services instead of medical doctors. Among the reasons cited were the following.

(1) The curanderos tolerated unacceptable, negative emotions, such as anger, frustration, shame, and guilt. The individual did not have to mask, hide, or minimize these feelings.

(2) These individuals felt little social status differentiation between the curanderos and themselves. When using conventional medical services, they felt themselves to be in an inferior position.

(3) These individuals felt that the curanderos knew them, their families, and their histories and thus accorded them respect and dignity.

(4) These individuals had expectations that something active and positive would be done to solve their problem. They were often given immediate treatment and not required to wait for services which had to be scheduled into the routine of a bureaucratic system.

(5) Often their emotional or psychological problems were given physical etiologies, thus eliminating any personal responsibility or guilt and also providing some form of therapy.

(6) There was no overwhelming bureaucracy to negotiate before services could be received.

Open communication about prejudice and discrimination is appropriate so as to gain a better understanding of the client and to let the client know that the counselor takes the counseling relationship seriously and is willing to be honest and forthright. Such open communication also helps the client become engaged and assertive in his or her own rehabilitation program. Active participation is important because otherwise unacculturated Hispanics may present as overly polite, passive, and compliant. Such a veneer of cooperation may, in fact, conceal attitudes of disagreement or confusion. Wodarski (1992) also pointed out that Hispanics who are accustomed to more directive and authoritarian culture may expect the rehabilitation counselor to be directive and "solve all their problems".

Intensive insight-oriented psychotherapy may be of limited value and may, in fact, exacerbate acculturative stress by creating expectations for personality modification that overtax an already stressed capacity to cope. "Deep," insight-oriented psychotherapy should not be confused with an appropriate long-term supportive relationship provided by a rehabilitation counselor who can do much to guide and mentor Hispanic immigrants with disabilities.

III. Language Issues

As a greater and greater proportion of Americans come from Hispanic backgrounds, language will become more of an issue in the provision of culturally sensitive rehabilitation services. In a statement that underlines this point, Weyr (1988) estimated that by the year 2000 Spanish will be as common as English in the U.S.

Wodarski (1992) has also observed, "it should be acknowledged that some of the more vulnerable segments of the Hispanic population, such as the elderly and new immigrants, are likely to speak only Spanish, therefore, they have the most need for bilingual services". This observation therefore suggests that immigrant Hispanics with disabilities may be more likely to be monolingual Spanish speaking.

The fact that many monolingual Hispanics are and will be in need of rehabilitation services is increasing the need for interpreters, or for rehabilitation professionals to become bilingual. The use of interpreters, in turn, raises issues regarding the therapeutic relationship. In some cases, use of an interpreter may inadvertently lead to the development of a dual relationship within the help setting--one relationship with the therapist and one with the interpreter. Such a dual relationship is more likely when the client chooses his or her own interpreter. If clients choose their own interpreters, they may be trying to protect themselves from the practitioner, particularly if the practitioner lacks cultural understanding. Whatever the client's choice is, it may signal a measure of bonding or trust which exists apart from the therapeutic relationship. If the client seeks out the interpreter/translator after the interview, this is evidence that the rehabilitation counselor needs to strengthen his or her relationship by establishing greater cultural and linguistic comfort. It may be somewhat disconcerting to the rehabilitation counselor to realize that the client feels more linguistic and cultural comfort with the interpreter than the counselor, but this must be taken in stride and dealt with by continued efforts to strengthen the relationship.

The linguistic and cultural needs of clients place a responsibility upon the counselor to go beyond the superficial understanding of the mere words and phrases of the counseling interchange. The counselor must also understand the concepts which lie at a deeper level. This is particularly demanding when subtle colloquial meanings are in danger of being lost in translation and when the affective tones and nonverbal cues convey a unique richness for each person. One answer to these challenges is to take more time in order to insure accurate communication. Success of the rehabilitation process also requires good interpretation which is based upon intimate and detailed knowledge of the language and culture.

Good interpretation requires (a) a working knowledge of the rehabilitation system including medical terminology, status codes, and other basic rehabilitation technical terms; (b) good knowledge of the culture; the interpreter must have some grasp of typical or normal behavior within the culture; and (c) fluency in Spanish and English so as to grasp and accurately translate literal as well as idiomatic expressions.

It is a good idea to also include other family members in the rehabilitation process. This is likely to help with the translation/interpretation process as well as to serve the purpose of including family members in the treatment plan. Inclusion of the family is likely to be a stabilizing factor and will reduce the acculturative stress which would otherwise be experienced. Rehabilitation should encourage the maintenance of the original culture while adding the North American culture. Monolingual Spanish speaking clients should also be encouraged to learn English in order to facilitate job placement.

It has been said that change is not easy. Indeed, the Spanish saying "La vida es dura" (life is hard) forcefully captures this concept. Rehabilitation workers must recognize the acculturative stress which many Hispanics with disabilities encounter and must be prepared to ameliorate its effects. In so doing, a more satisfying and productive life is opened to these citizens who have had the courage and tenacity to assume the challenges of acculturation into the mainstream North American society.

1 Currently there is divided opinion regarding preference of the words Hispanic or Latino. There appears to be a growing use of the term Latino, yet the term Hispanic has a history of use by the U.S. Census Bureau and other government agencies in designating peoples who share the common language of Spanish and whose roots and culture trace back to Spain. The authors acknowledge the divided preference of these two terms but have chosen to use the term Hispanic which at this point is more embedded in the professional literature of rehabilitation. Also to be noted are the great differences among the various subgroups (i.e., Mexican Americans, Cuban Americans, Puerto Ricans, Americans from Central and South America, and Americans from Spain).

References

Acosta, F. X. (1979). Barriers between mental health services and Mexican Americans: An examination of a paradox. American Journal of Community Psychology, 7, 503-520.

Alvirez, D., Bean, F. D., & Williams, D. (1981). The Mexican American family. In C. H. Mindel & R. W. Habenstein (Eds.), Ethnic families in America: Patterns and variations (2nd ed., 269-292). New York: Elsevier.

American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author.

Boulette, T. (1976). Assertive training with low income Mexican American women. In M. R. Miranda (Ed.), Psychotherapy with the Spanish-speaking: Issues in research and service delivery (67-72). Los Angeles: University of California, Spanish Speaking Mental Health Research Center.

Cervantes, R. C., & Castro, F. G. (1985). Stress, coping and Mexican American health: A systematic review. Hispanic Journal of Behavioral Sciences, 7, 1-73.

Cervantes, R. C., Salgado de Snyder, V. N., & Padilla, A. M. (1989). Post-traumatic stress disorder among immigrants from Central America and Mexico. Hospital and Community Psychiatry, 49, 621-632.

Comas-Diaz, L. (1981). Effects of cognitive and behavioral group treatment in the depressive symptomatology of Puerto Rican women. Journal of Consulting and Clinical Psychology, 49, 627-632.

Comas-Diaz, L. (1986). Puerto Rican alcoholic women: Treatment considerations. Alcoholism Treatment Quarterly, 3, 47-57.

Comas-Diaz, L. (1990). Hispanic/Latino communities: Psychological implications. The Journal of Training and Practice in Professional Psychology, 4, 14-35.

Cousins, J. H., Rubovits, D. S., Dunn, J. K., Reeves, R. S., Ramirez, A. G., & Foreyt, J. P. (1992). Family versus individually oriented intervention for weight loss in Mexican American women. Public Health Reports, 107, 549-555.

Davis, M. P. (1990). Mexican dreams/Mexican voices. New York: Henry Holt.

de la Cancela, V., & Martinez, I. Z. (1983). An analysis of culturalism in Latino mental health: Folk medicine as a case in point. Hispanic Journal of Behavioral Sciences, 7, 273-284.

Delgado, M. (1983). Alcoholism treatment and Hispanic youth. Journal of Drug Issues, 18, 59-68.

Espin, O. M. (1987). Psychological impact of migration of Latinas: Implications for psychotherapeutic practice. Psychology of Women Quarterly, 11, 489-503.

Garcia, P. I. (1984). Stress response among physically injured Spanish-speaking/surnamed workers. Hispanic Journal of Behavioral Sciences, 6, 225-246.

Gomez, E. A. (1987). Hispanic Americans: Ethnic shared values and traditional treatments. The American Journal of Social Psychiatry, 8, 215-219.

Griffith, J., & Villavicencio, S. (1985). Relationships among acculturation, sociodemographic characteristics and social supports in Mexican American adults. Hispanic Journal of Behavioral Sciences, 7, 75-92.

Keefe, S. E. (1980). Personal communities in the city: Support networks among Mexican Americans and Anglo Americans. Urban Anthropology, 9, 51-74.

Marin, G., & Marin, B. V. (1990). Perceived credibility of channels and sources of AIDS information among Hispanics. AIDS Education and Prevention, 2, 156-163.

Marin, G., Marin, B. V., & Perez-Stable, E. J. (1989). Cigarette smoking among San Francisco Hispanics. American Journal of Public Health, 79, 196-199.

Marin, G., Otero-Sabogal, R., Marin, V. A., & Perez-Stable, E. J. (1987). Hispanic familism and acculturation--What changes and what doesn't? Hispanic Journal of Behavioral Sciences, 11, 178-189.

McCarthy, K. F., & Valdez, R. B. (1985). Current and future effects of Mexican immigration in California - Executive summary. Santa Monica, CA: Rand.

Mikawa, J. K., Morones, P. A., Gomez, A., Case, H. L., Olsen, D., & Gonzalez-Huss, M. J. (1992). Cultural practices of Hispanics: Implications for the prevention of AIDS. Hispanic Journal of Behavioral Sciences, 14, 421-433.

Rogler, L. H., Malgady, R. G., Costantino, G., & Blumenthal, R. (1987). What do culturally sensitive mental health services mean? American Psychologist, 24, 565-570.

Romero, M. (1981). Multicultural reality: The pain of growth. Personnel and Guidance Journal, 6, 384-386.

Salgado de Snyder, V. N. (1987). Factors associated with acculturative stress and depressive symptomatology among married Mexican immigrant women. Psychology of Women Quarterly, 11, 475-488.

Smart, J. F., & Smart, D. W. (1991). Acceptance of disability and the Mexican American culture. Rehabilitation Counseling Bulletin, 34, 357-367.

Smart, J. F., & Smart, D. W. (1992). Cultural issues in the rehabilitation of Hispanics. Journal of Rehabilitation, 58, 29-37.

Smart, J. F., & Smart, D. W. (in press). Acculturative stress of Hispanics: Loss and challenge. Journal of Counseling and Development.

Smart, J. F., & Smart, D. W. (1993a). The costs of acculturative stress: The experience of the Hispanic immigrant. Manuscript submitted for publication.

Smart, J. F., & Smart, D. W. (1993b). Acculturation, biculturalism, and the rehabilitation of Mexican Americans. Journal of Applied Rehabilitation Counseling, 24, 46-51.

Thomas, R., & Murr, A. (1993, August 9). The economic cost of immigration. Newsweek, pp. 18-19.

U.S. Bureau of the Census. (1988). The Hispanic population in the United States: Marth 1988. Current Population Reports, 431.

Weyr, T. (1988). Hispanic USA: Breaking the melting pot. New York: Harper & Row.

Wodarski, J. S. (1992). Social work practice with Hispanic Americans. In D. F. Harrison, J. S. Wodarski, & B. A. Thyer (Eds.), Cultural diversity in social work (pp. 71-105). Monterey, CA: Brooks/Cole.