Translating Trauma Therapy for Hispanic and Latino Communities

“Have you ever watched a Puerto Rican novela?” Dr. Susana Rivera asked a room full of therapists and social workers. “I don’t know what they say to their therapists, but by the third visit, they always get committed. I tell my families, ‘We don’t do that.’”

Based on the work of Dr. Michael de Arrelleno of the National Crime Victims Research and Treatment Center at the Medical University of South Carolina, Rivera teaches practitioners how to adapt trauma-based cognitive behavioral therapy for families living in Hispanic and Latino communities. Her presentation to a packed room at the South Texas Trauma-Informed Care Conference in San Antonio on May 11 was an introduction to the work she does year-round in Laredo, Texas.

Before delving into the specifics of the approach she uses, Rivera described some lesser-known facts about immigrant families and the stress of their daily lives.

Many families are isolated, she said, because they fear being stopped by Immigration and Customs Enforcement (ICE). So they limit how often they leave their house, cramming all their errands and appointments for all family members into one day.

Living with constant fear impacts kids, too. “Children are anxious all day at school because they are worried that their family will be gone when they get home, that they’ll be taken away,” Rivera said.

Research has found that although Hispanic families are more likely to experience traumatic immigration-related events that aren’t often screened for, such as violence in one’s home country, they are also less likely to seek mental health services than other groups. When they do seek help, they are more likely to terminate mental health services prematurely, or not return at all after the initial session, Rivera said.

A number of factors drive these findings, according to Rivera: people are afraid to seek any kind of help if they (or any member of their family) are undocumented; there is a strong social stigma in Hispanic communities related to mental health; and there are long-standing traditions of turning to medical and spiritual leaders for such help.

Dr. Susana Rivera. Photo: The Children’s Shelter

But more than that are the larger cultural influences at play, Rivera said, especially the values of respeto and simpatia. Respeto, Rivera said, is about deference and showing respect to people of authority. In families, that may mean fathers and grandmothers, or whoever is considered the family leader. Simpatia, she said, means acting in a way that creates or promotes pleasant situations.

Seeking therapy may fly in the face of these two values, especially if a child was maltreated by an adult – an authority figure. Therefore, even talking about it is disrespectful, according to Rivera, and definitely not a pleasant interaction.

Rivera also described a handful of other values that complicate a family’s ability to seek mental health support, including machismo and marianismo.

Machismo is complex, Rivera said, and not what people often assume it is. Machismo refers to the male’s role in society and in the family, which is that of the provider. A father may not view his role as being inclusive of emotional support, and boys may be discouraged from talking about their feelings of fear or sadness.

What’s more, it may be considered disrespectful to discuss sex-related issues with fathers, making it difficult for family members to speak openly in cases involving sexual abuse or assault.

Marianismo is the belief that all women should be like the Catholic Virgin Mary, which further complicates a family’s ability to address sexual abuse or assault, in therapy or otherwise. Marianismo may also mean, for some families, that suffering and sacrificing for her family is part of a woman’s role.

Finally, practitioners have to contend with the belief that whatever happens to someone is fate, or God’s will, and that seeking therapy or help outside of a spiritual context somehow goes against that belief.

For Rivera, this means reframing the fact that the family came to her for help. “I tell them, ‘Maybe God sent you to the clinic,’” she said.

Other ways she adapts her approach include disclosing just enough personal information to establish a connection with the family at the beginning of each session, accepting food and gifts, and incorporating dichos and cuentos, or proverbs and folktales, into her work.

Rivera has also developed referral relationships with local spiritual leaders, including priests and curanderos – folk healers – which gives her and her practice greater credibility in the eyes of the families who might be in need of help.

The population in need of Rivera’s services is significant. According to Pew Research, Hispanics accounted for 18 percent of the U.S. population in 2016 and were the second fastest growing racial or ethnic group. In 2015, California had the highest population of Hispanic people but states like Georgia, Florida, Arizona and Texas saw the greatest increases in their Hispanic communities from 2000 to 2015.

Immigration statistics indicate more mothers and children are undertaking the often traumatic journey to the U.S. in recent years, despite the Trump administration’s stance on immigration. As of April 30, U.S. Customs and Border Protection had apprehended or turned away a total of 349,234 people seeking to enter the country legally or illegally in fiscal year 2018.

The violence and trauma experienced during immigration has been well documented by researchers, Amnesty International, the United Nations and others. A 2013 study on immigrant Latino adolescents found that “29 percent of foreign-born adolescents and 34 percent of foreign-born parents experienced trauma during the migration process.”

And trauma doesn’t end just because a person makes it across the border.

“Pre-migration poverty combined with clandestine entry into the U.S. increased the risk of trauma and the subsequent development of PTSD symptoms,” the study said.

Going forward, practitioners will be challenged with teaching Hispanic children and families how to protect themselves to prevent further trauma, Rivera said. This includes psychoeducation around sexual development and learning how to say no when it goes against the concept of simpatia, especially if the exchange is with a person of authority.

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