A Silver Lining in the Dark Clouds of Treatment for Minorities

"...understanding of traditional counseling theory. Although the Eurocentric nature of traditional counseling theory has been criticized [1], each theory has aspects that contribute to best practice in counseling. Therefore it is important that the foundation of counseling practice lay down by pioneering thinkers and practitioners such as is incorporated into culturally diverse ways of thinking and approaches to helping" [2].

Critics are right in pointing out the inappropriate use of traditional counseling (individual-centered, intimate in nature, and geared towards verbal communication) for clients from many cultures. It should not be surprising, then, that minority clients often prematurely drop out of treatment and generally benefit less from counseling or psychotherapy. The corollaries are unmet needs, affecting quality of life (QOL) for minorities. Minorities are overrepresented in unemployment and tend to have a high rate of health-related issues [3]. This dark cloud of treatment (or traditional-based treatment) is evident for minorities (e.g., Hispanics with diabetes and individuals with intellectual disabilities with depression) [4,5].

Diabetes

The greatest challenge associated with diabetes, for example, is that despite significant evidence that prevention strategies like changing diet and developing exercise habits can reduce diabetes-related death and disability [6], diabetes among Hispanics is on the rise. This may be due to the lack of culturally appropriate interventions for Hispanics. Popular diabetes prevention research falls primarily within a Eurocentric view resulting in a "one size fits all" approach. Of course, as one scholar puts it, what works for one group may not work for another group.

The education of and adherence to diet and exercise interventions is the dominant treatment for individuals with diabetes, including Hispanics. It is worth noting that education is crucial for preventing diabetes. Also, behavioral interventions such as adherence have been shown to be effective for treating and preventing health-related problems (e.g., diabetes) [7]. In fact, without sticking to a diet and exercise plan and medication, educational interventions are futile [8]. Preventative diabetes interventions that lack a component for adhering to treatments compromise the potential positive outcomes. Unfortunately, adherence strategies, in general, are confrontational, making them less appropriate, meaningful, and implementable for some cultures (e.g., Hispanics).

The Motivational Interview (MI) adherence strategy overcomes cultural barriers. MI is non-confrontational and mirrors Hispanic cultural values, and is therefore relevant for Hispanic populations. In fact, a core Hispanic value is "respeto" (respect for others) (Paderes, communication, 4, 16, 2014). A meta-analysis of MI showed moderate effect size (.25 to .57) [9]. Its effect on improving diet and exercise adherence among Hispanics with diabetes is positive. However, a deficiency of MI is its short term effectiveness. In a meta-analysis, MI showed a decreased effectiveness within one year [10]. MI also requires a substantial time investment and a greater frequency of visits ("CEBC"). Another problem is the lack of a key component in Hispanic culture: the family. Yet, positive outcome strategies are in line with the clients' cultural value [2].

Should these interventions be discarded? Or should we further investigate their silver linings? The latter makes more sense. As Lee noted (above), incorporating traditional views of counseling in helping culturally diverse clients is appropriate. Confrontational interventions can become non-confrontational ones like MI. Certainly; MI has shown general success among Hispanics. With the inclusion of a family component, MI can be even more effective and meaningful for Hispanics.

Not only would involving family increase adherence, it would also improve the short term effect of MI. Family, particularly in Hispanic communities, is a means of social support, and this has a positive effect on adherence by buffering stress and providing opportunities for and encouragement toward adherence. For instance, family presence may encourage an individual to control any behavior that would otherwise be counterproductive, thereby increasing the positive health outcomes [11]. Furthermore, meta-analysis suggests the importance of social support (with no conflict) to boost and improve adherence (DiMatteo): family members can be taught how to use MI to help their loved ones adhere to treatments and practices.

Incorporating family-involved MI (where conflict is avoided) for Hispanic individuals makes sense. The family unit (often including extended family) is critical in Hispanic culture but is missing in general MI intervention. Not enough can be said about the importance of the family in preventing and treating health issues for Hispanic individuals. Including the family as a treatment agent may mean long-term intervention and the possibility of long-term effects for MI intervention. However, there is a dearth of research investigating the effects of family inclusion in MI intervention; empirical study on MI family-based intervention for diabetes is largely neglected [6].

Depression

Compared to those without disabilities, the rate of depression is higher for individuals with intellectual disabilities (ID), a population that has problems learning [12,13]. Cognitive therapy (CT), an effective intervention for treating depression, appears unavailable for people with ID because the treatment requires individuals to call on their intellectual skills, including the ability to deal in abstractions, to report feelings and thoughts, and evaluate evidence [12]. However, there is a silver lining for this dark cloud.

CT can be modified by incorporating a life story approach to enable those with limited cognitive abilities to express their thoughts [12]. Modified cognitive interventions within a cognitive framework have been shown to improve depression for many with ID [14]. The life story approach makes it possible for counselors to change the false thoughts, attitudes, and beliefs that many individuals with ID have [15]. That is, life story employs clients' stories to correct false beliefs. For example, a therapist might help a person with negative false beliefs about his/her work ability recall positive memories of successful accomplishments by narrating those memories. As a result, the client can come to visualize his/her positive aspects or gains a more realistic evaluation of him/her [16]. In such case, the individual's positive story disempowers his/her previous false sense of self and empowers a more accurate and positive sense of self [17]. In the SPPRD model by Diallo et al. [15], clients "separate false from real thoughts" (S), "put these thoughts in perspective (PP), "retain healthy thinking" (R), and "discard faulty thinking" (D). In a current case study, a modified cognitive intervention (with life story, using the SPPRD mode) was effective in reducing a client's (with intellectual disability) depression.

Data suggests that Hispanics and other minority populations continue to grow, and that people with disabilities represent a substantial portion of the United States. Current treatments, however, are geared towards the majority and are not particularly relevant for many cultures [2]. However, modifying traditional counseling interventions based on Eurocentric views, rather than discarding them make sense. Many aspects of traditional interventions work for minorities. Also, traditional interventions already have frames to work from, making work less tedious and costly for future researchers and practitioners. Tailoring what we already have for minority population is not new; more effect with this approach benefit minorities. With the family included in diabetes preventive treatment for Hispanics and with life story used in CT interventions for individuals with intellectual disabilities in order to facilitate abstract thinking and communication, for example, Hispanics with diabetes and individuals with intellectual disabilities receive effective treatments. The silvers linings in the dark clouds of many traditional counseling interventions based on Eurocentric theories/models are definitely worth exploring for other treatments for minorities.

References

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