Trials point to culturally competent therapy as a way to improve suicide rates among Latino teens

PHOENIX ㅡ The suicide rate among young Americans is on the rise. Because Latino youth are the most vulnerable, some researchers are calling for a culturally informed approach to treatment.

In ethnic communities, family, culture and social expectations significantly influence identity and mental health. Dr. Jovanska Duarte-Velez, associate professor of psychiatry and human behavior at Brown University, developed the first culturally tailored treatment for suicidal Latino and Hispanic adolescents.

“As part of adolescent development, identity is an important component in which we take into account different aspects of the individual, such as their ethnicity, their cultural values, their beliefs and how they see themselves and their family,” said Duarte- Veles.

Imagine an onion, said the researcher, who has written extensively about ethnically diverse teenagers with suicidal ideation and how to tailor treatment to them. In the Onion, “youth are at the center and surrounded by the family, the context as well as the environment, and then the broader cultural values and system,” Duarte-Vélez said.

Duarte-Vélez Social-Cognitive-Behavioral Therapy for Suicidal Behavior (SCBT-SB) looks at every layer of the onion. It builds on traditional cognitive-behavioral therapy (CBT), focusing not only on overcoming and changing negative thoughts and attitudes, but also on how family communication, social interactions, trauma, actions, and substance use can influence on these thoughts and behaviors.

In a recent trial of a small sample of 46 Hispanic/Latino youth and at least one of their caregivers, the results showed that the therapy was more effective in reducing suicide attempts and depressive symptoms compared to conventional therapy. “There may be other clinicians who … take cultural aspects into account — and that’s great — but … we have to make sure that the protocol we’re testing is incorporated in a standardized way,” Duarte-Velez said.

Providing quality medical care to a rapidly diversifying population has been a challenge for the health care system. Although no law requires every provider to be culturally sensitive, some recent federal initiatives address cultural competency.

The Centers for Medicare and Medicaid Services (CMS) has expanded the list of people to whom a Medicare Advantage plan must provide culturally diverse services. The list includes ethnic, cultural, racial and religious minorities; people with limited knowledge of the English language; LGBTQ+; villagers; and others affected by inequality. In addition, the optional disclosure of cultural and linguistic knowledge and experience of providers must now be clearly stated in the handbooks.

Cultural competence in health care has no legal definition. However, under Title IV of the Civil Rights Act of 1964, its absence can be considered a form of discrimination on the basis of nationality. This term has various interpretations: The American Hospital Association defines cultural competence as the ability to provide personalized care to patients with different values, beliefs, and behaviors.

Other federal laws and policies protecting nondiscrimination in health care are Section 1557 of the Patient Protection and Affordable Care Act and the Americans with Disabilities Act. Arizona Health Care Cost Containment System (AHCCCS) ACOM 405, Cultural Competence and Family Member Care, mandates that providers meet cultural competency standards that are consistent with federal regulations.

Some practitioners say that proper therapy includes this cultural sensitivity by default. Kelly Zaragoza, a Latino counselor in Phoenix, primarily practices CBT, a standard type of therapy, but emphasizes the importance of culture and identity when working with clients.

“I hope that most therapists … (have) the cultural competency to understand that we need to include family members,” Zaragoza said. “Understanding … cultural biases that they may experience, gender roles that may exist.”

Almost half of Hispanic adults living in the United States were born in another country. After Puerto Rico, the Southwest region has the highest concentration of Hispanic population by proportion, and nearly half of all Arizona K-12 students are Hispanic. Zaragoza said it’s critical to consider identity and lived experience: “The pieces of acculturation, assimilation, depending on whether they’re first generation … having those conversations and giving them an opportunity to talk about what that looks like in their lives.”

Cynthia Ramos, a bilingual Hispanic therapist in Scottsdale, uses cultural sensitivity through a type of therapy called Acceptance and Commitment, emphasizing to her young Latina clients the importance of embracing their values without labeling them. Ramos said therapy based on Western values of individualism may resonate less with Latino caregivers, who prefer cooperation and interdependence.

“There are no good or bad values. We do not classify them. … We have pride and respect for our elders, the family team, right? And these values can be adopted in the same way as individual values,” Ramos said. “Sometimes it can be a little bit stressful, especially for Gen X.”

Duarte-Velez said second-generation Latinos often grow up in two worlds: “(They have) a Latino perspective, and then they go to school and have a more Americanized way of seeing the world. So it can be a bit more difficult for clinicians to help (young people and their carers) navigate these differences and understand each other.”

Both Ramos and Duarte-Velez call family involvement in culturally appropriate interventions critical. “Teenagers are forming their identity and autonomy, and that’s normal development,” Ramos said. “So (we’re) helping parents do psychological education … to facilitate communication, to help reduce conflict and to help them understand each other, to create a supportive environment for that teenager.”

Profound barriers arise when families view mental health as a private matter. This can contribute to increased levels of depression and suicidal tendencies among young people.

“Even as a Latino provider … sometimes I really want to go out in front of the community and talk to them about mental health because I know (that) there’s still a stigma,” Zaragoza said.

In her trials, Duarte-Vélez saw greater involvement and attributed it to a different phase of the crisis.

“When we bring families together in this model, they’ve already had a suicidal crisis and … no matter what they do, it doesn’t work,” Duarte-Velez said. “Then they see that we are Latin Americans, we have common values, we speak the language. So one way to overcome the stigma around mental health is to show (families) that we’re here to support and respect them.”

Family rejection of their adolescent’s identity can also hinder therapy and delay healing for the young adult and caregivers. This is especially true for LGBTQ+ teenagers, who often feel stifled by their families’ expectations. A 2023 survey by The Trevor Project found that among LGBTQ+ Latino teens and young adults, 42% had thought about suicide and 15% had attempted suicide.

“Over the years of working with this community, we’ve seen that cisgender boys are harder to get into treatment (and) they’re reluctant to see the benefit of therapy,” Duarte-Velez said. “Girls are more encouraged to express their feelings and talk about what’s bothering them (so) they’re easier to talk to. In general, it is more difficult to communicate with trans youth. The main challenge here is working with family dynamics, (other) acceptance of their identity and working with social rejection.”

With a grant from the American Foundation for Suicide Prevention in 2023, Duarte-Vélez will launch the largest trial to date of culturally informed therapy for Latinos. In partnership with the National Institute of Mental Health at a hospital in Mexico City, 114 participants will participate.

This study will involve community health workers to examine how the environment and other social factors affect mental health.

“Community health workers support families in what we call the social determinants of health: food, transportation, living conditions, work, language learning and various social aspects,” said Duarte-Velez. “We think families have needs that go beyond what therapy does, but … you have to test it to know.”

Although SCBT-SB is not yet widely integrated into mental health practice, more and more researchers, therapists, and counselors are emphasizing the importance of deeper cultural awareness and a more nuanced approach in psychotherapy.

“I’ve worked in a lot of different environments, and there were (some) where there was a lack of cultural sensitivity and awareness,” Ramos said. “(Awareness) doesn’t mean you have to know everything about every culture, but it does mean you approach it with caution, more curiosity and a humble heart.”