International Journal of Mental Health & PsychiatryISSN: 2471-4372

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Research Article, Int J Ment Health Psychiatry Vol: 1 Issue: 3

Cuento Therapy: Cultural Attunement in a Spanish-Speaking Alcohol and Drug Recovery Treatment Program: A Qualitative Case Study

Isaac Carreon*
School of Cultural and Family Psychology, Pacific Oaks College, USA
Corresponding author : Isaac Carreon
LMFT, School of Cultural and Family Psychology, Pacific Oaks College, USA
E-mail: [email protected]
Received: October 20, 2015 Accepted: December 14, 2015 Published: December 17, 2015
Citation: Carreon I (2015) Cuento Therapy: Cultural Attunement in a Spanish-Speaking Alcohol and Drug Recovery Treatment Program: A Qualitative Case Study. Int J Ment Health Psychiatry 1:3. doi:10.4172/2471-4372.1000112

Abstract

The Latina/o population is the fastest growing ethnic minority in the United States, yet the population faces barriers to access mental health services due to a number of reasons. This qualitative case study was undertaken to address barriers to mental health for Spanish-speaking clients by implementing Cuento (folktales) Therapy, first introduced by Costantino, Malgady, and Rogler. The current study was adapted from the original intervention with (n=10) adult Latina/o clients in an alcohol and drug outpatient recovery program in Los Angeles, California. Group members read culturally relevant folktales during a 6-month period. A pre and post-test was used to assess participants’ experiences in the alcohol and drug outpatient recovery program conducted in English and the adapted Spanish cuentos group. An Acculturation Scale was used to assess participants’ level of acculturation and language. Results of the study support that cultural attunement is important when working with Latina/o clients. Therefore, three themes emerged: (1) cuentos were experienced as a culturally relevant therapeutic modality, (2) the Cuento Therapy intervention also created a comfortable nonthreatening environment, and (3) the cuentos group facilitated participation in therapy of all group members.

Keywords: Cuento therapy; Alcohol; Drug recovery

Keywords

Cuento therapy; Alcohol; Drug recovery

Introduction

The US Census reported that there are approximately 40 million immigrants in the United States with at least 11 million of those here illegally [1]. The percentage of immigrants living in the United States is approximately 13%. From 1970 to 2013 the number of immigrants in the United States has increased from 9.6 million to 41.3 million [2]. Mexicanborn immigrants comprise 28% (11.6 million) of the total number of immigrants in the U.S., while Central American-born immigrants comprise 8% (3.1 million) [2]. In 2013, 46% of the total immigrant population in the United States was reported to be of Hispanic or Latino origin [2]. Out of the 140 million that comprises the total workforce of the U.S., 22.5 million are immigrants [2]. Dillon, de La Rosa, Ibanez, and Sastre [3] reported that the Latino population will account for more than half of the nation’s population by the year 2050.
Barriers to mental health
Latina/o immigrants face political, legal, cultural, and personal challenges [4] yet those challenges such as acculturation, struggle to maintain cultural values, economic struggles, oppression, and language are associated with barriers to accessing mental health [5]. August, Nguyen, Ham, Ngo-Metzger, and Sorkin [6] found that individuals who discuss mental health needs with their physicians depended on race or ethnicity and the degree to which they spoke the same language as their physicians. There are also institutional barriers when faced with access to medical and mental health care including the high cost of medical care, lack of bilingual and bicultural staff, low socio-economic status, racism, discrimination, and immigration laws [4]. Keyes et al. [7] conducted a study of 6,359 Latina/o participants in order to examine their utilization of mental health, which indicated that ethnic identity and Spanish language predicted lower accessibility of mental health services. Oftentimes, when Latinas/os receive services they are often substandard in quality and low clinical outcomes [8]. Kaltman et al. [8], found economic reasons force many Latina/o immigrant families to only receive treatment from their primary care doctors and not from mental health clinicians who are better trained to provide these services.
Globalization of psychology
Psychology in general is interested in universals, but for psychology to be considered culturally competent, one should examine different cultures if one is to make claims of universality [9]. Psychology only samples a very tiny fraction of the 7 billion people in the world. The population where the US draws their research constitutes less than 5% of the world’s population [10]. The problem in the field of psychology is that most psychological research and knowledge is based on nonethnic minority participants. From 2003-2009, only 2% of research analysis in English peer-reviewed PsycINFO addressed cross-cultural issues [11]. Other first-tier journals only published 2-14% of research on cross-cultural issues. Also, PsycINFO only addressed 4% of ethnic minority issues. In addition, Hartmann et al. [11] argued that most of the cross-cultural and ethnic minority issues are presented in specialty journals such as Hispanic Journal of Behavioral Sciences and others.
Cultural attunement
In order to address health care and mental health disparities with ethnic minorities, researchers and clinicians implement cultural adaptation in their interventions. Cultural adaptation has been described by Bernal, Jimenez-Chaffey, and Domenech-Rodriguez [12] as the systemic adaptation of Evidenced-Based Treatments (EBTs) incorporating language, culture, and context that are compatible with the person’s cultural patterns, meanings, and values. Falicov [13] described cultural attunement as the addition of evidencebased treatments to boost engagement and retention in subcultural groups. Examples of additions include providing services in the person’s native language, utilizing bicultural staff, and incorporating familiar cultural traditions [14]. Costantino et al. [15] described three approaches to the delivery of culturally sensitive services:
• Increasing bilingual and bicultural staff into mental health facilities.
• Therapy should be congruent with the client’s culture or therapies should be modified to include cultural variables.
• Modification of traditional therapeutic approaches to fit the Latina/o client’s cultural values.
The first approach leads to less resistance and attrition by Latina/o clients. The second approach incorporates Latina/o values such as familismo (familism) in order to demonstrate respect for the client’s culture. The third approach facilitates the integration of cultural adaptation and cultural attunement into traditional modalities.
La Cultura Cura (Culture Cures)
Brucato [16] conducted a study to examine ethnic identity among incarcerated gang-involved youth. Brucato [16] hypothesized that Latina/o youth face many challenges as well as negative self-images, stereotypes, and omissions of positive attributions. Brucato also hypothesized that Latina/o adolescents internalize these negative images leading towards unhealthy development and behaviours. Brucato’s interventions included allowing for Latina/o history, culture, and contributions to American society to be presented via didactic presentation, films, bibliotherapy, guest speakers, and holiday celebrations. Culturally relevant food, calendars depicting Latina/o art and others were used as rewards for completion of homework that was given during the study. Although the study did not demonstrate that the incarcerated youth were able to initiate positive social behaviours as a result of the interventions, the results show that the youth can become engaged in the group therapy as a result of cultural themes in the intervention.
Chavarria [17] coined the term “la cultura cura”, which literally translates into “the culture cures”. Chavarria’s theory is that culture can provide protection from involvement in unhealthy behaviours. Thus, the use of cuentos in a cultural perspective can foster a caring, healthy, supportive, safe environment, building inner strengths within individuals and groups so they can resist negative influences [17]. To accentuate this phenomenon, Seeley [18] argued that psychotherapists should illuminate issues that usually occur in intercultural treatments. These cultural issues warrant further investigation. Also, psychotherapists should recognize profound ways in which culture shapes psychologies. Listening for cultural issues has significance not only for clinical practice but also for research [18]. Costantino and Malgady [19] saw the value in the effects that culturally adapted cuentos had on children and adapted the development of a similar approach when working with adolescents. The modality was based on the theory that adolescents of Puerto Rican descent needed adult role models rather than folkloric heroes. Costantino and Malgady [19] coined the term Hero/Heroine Therapy when working with at risk youth. Because adolescence is a critical period in the psychological development of most individuals, current literature suggests that ethnic minorities are at a higher risk of mental disorders due to their experience of inequality, social exclusion, including racial discrimination, poor socio-economic status, and unemployment [20].
The use of dichos
Aviera [21] implemented a culturally sensitive intervention using Dichos (Spanish proverbs and first introduced by Zuniga, [22,23]) with patients in an inpatient setting. The use of dichos was used as a way to engage patients into a wide range of discussions about different topics. Dichos worked where other traditional interventions failed because of the cultural relevance. Aviera [21] found that the use of dichos with the Latina/o population facilitates rapport building, decreasing defensiveness, enhancing motivation in therapy, improving self-esteem, assisting in the development of insight, and exploring cultural values and identity. For example, the dicho“A caballo regalado, no hay que mirarle el diente” (“One should never look at a gift horse in the mouth”) allowed a patient named Mario who was quiet and reluctant to share in group therapy become more involved and led to sharing. Mario received a short sleeve shirt for Christmas from a unit worker but stated he would have preferred a long sleeve shirt because it would cover his tattoos. Through the dicho, Mario was able to share “feelings about his many tattoos, which symbolized his painful and self-destructive choices made in the past that continue to have a legacy in the present” [21].
The power of stories in Psychology
For centuries, storytelling has been a method of educating the young. In the Latina/o community, cuentos (folktales) have been an integral part of the culture. Cuentos produce a manifestation of the vision of the world and the way of life. Therefore, the Latina/o narratives have an aesthetic, historical, literary, philosophical, and cultural value being that they are a product of humanity. Willis [24] argued that storytelling and metaphors have long been part of human culture. Native American children who engage in traditional practices do so because of a long history of relying on the oral tradition [25]. Stories have always “played an important role in education and in the development of wisdom…infusing life with purpose, worth, meaning, and value” [21]. Cuentos can foster education and personality development. Tsethlikai and Rogoff [25] argued that before a formal education system, Native American tribal elders told children stories. Children learned through listening to the elders’ experiences, myths, and stories handed down through generations [25]. Stories are used to educate the tribal children about cultural norms, Gods, war, illnesses, evil spirits, and other perils that may threat its people [15]. Referring to folktales, Joseph Campbell wrote that there is instruction in lying, and in all forms of guile: in magic and in violence [26]. Campbell asserted that storytellers had to entertain as well as instruct. The goal of fairytales was to communicate “instructive wonder,” which is a subtle kind of wisdom that permeates the soul [26]. Campbell added that folktales are the primer of the picture-language of the soul [26].
In psychology, researchers have “likened psychopathology to an incoherent story with a wrong ending and psychotherapy as a process of retelling coherent stories with right endings” [15]. Storytelling in psychology has three essential elements: identification, catharsis, and insight [27,28].
Bibliotherapy has been used since the 1930s as a method of fostering personal growth and development [29]. This is achieved by reading stories that facilitate insight into personal concern. In therapeutic settings, the use of cuentos have been used to address a myriad issues and concerns such as social skills, emotional intelligence, anxiety, bereavement, child abuse, separation of parents due to divorce, and aggression [29].
Historically, the power of generational storytelling has high significance. Cuentos can transcend cultural morals and values like familismo (familism), language, food, celebrations, customs, and many aspects that contribute to the self. For example, black slaves used folktales to keep their identity intact under the domination of slave masters and horrible conditions [15]. Black slaves found consolation from inhumane treatment by chanting folk tunes from their motherland [15].
In the original work by Costantino et al. [15], they empirically tested a culture-specific modality using folktales and storytelling. The basis for their approach was based on empirical evidence that storytelling can have lessons on cultural values, enhance ethnic identity, simplify the communication of a complex message, adapt stories to the realities of the culture, reinforce achievement and motivation, and can be an effective medium to promote moral development. To test their hypothesis, Costantino et al. compared three therapeutic modalities: (1) cuentos from Puerto Rican culture, (2) art/play therapy and (3) no therapy. The researchers identified 210 children who were having maladaptive behaviours, along with their mothers. The children and mother pair were randomly assigned to either one of the therapeutic modalities. In the cuento group the therapist and the mother read the cultural cuentos to the children. Afterwards, the therapist engaged the dyads in a discussion about the characters in the stories. They also discussed the morals of the stories. Results of the use of folktales with Puerto Rican children demonstrated reduction of anxiety and aggression as well as enhancement of social skills among children and adolescents [30]. The narratives found in folktales reflect the values of the cultural group, which transmitted the story. Accepting the story and gradually internalizing the characteristics or value of the culture are a major function of folktales. From this viewpoint, folktales are a medium for the transmission of societal values and cultural traditions [15]. Also, the transmission of cultural values can have a powerful effect in the healthy development of an individual.

Methods

A qualitative case study design was selected in order to explore and understand the meaning the participants ascribed the AOD program when they were in a combined group and also when they participated in the cuentos group. A qualitative design focuses on individual meaning, and the importance of rendering the complexity of a situation [31]. A qualitative case study was utilized in order to develop an in-depth analysis of the implementation of a program to a number of individuals [31]. This approach helps this researcher develop in-depth analysis of the implementation of the cuentos group of Latina/o clients in mental health settings.
Setting
Los Angeles, California is one of the most diverse cities in the United States and Latinas/os make up 48.3% of the population in Los Angeles County [32]. Latinas/os represent people from Mexico, Central, and South America. They also represent people from Cuba, Puerto Rico, and the Caribbean. Over a 6-month period this researcher conducted a cuentos group in an outpatient alcohol and drug recovery program (AOD) in Los Angeles, California. Prior to the start of the cuentos group, participants were attending the AOD program with other English-speaking members. During the combined group therapy sessions, Spanish-speaking group members sat in the group quietly. A case manager served as the translator to the Spanish-speaking group members. The English-speaking clients dominated the two-hour group. The group met three days a week. When the cuentos group was introduced, Spanish-speaking clients were excited to take part in the group. The group was an open group; however, nine of ten group members started at the beginning and completed the 6-month program. One group member joined the group after the third week.
Participants
Group members consisted of 10 Spanish-Speaking clients enrolled in the AOD program. Group members were born outside the United States including in Mexico (n=5), El Salvador (n=1), Honduras (n=1), Guatemala (n=1), Puerto Rico (n=1), and Cuba (n=1). Participants’ ages ranged from 19-40 years old. Some group members worked, while others were on General Relief (GR), or disability. The majority of the participants (8 out of 10) were mandated to attend the AOD group by the courts. In addition, some participants (3 out of 10) were mandated to attend parenting classes and individual therapy. They all were also required to be randomly drug tested.
Instruments
In order to collect the data for this study, group members were provided with a pre-test questionnaire developed by this researcher (Spanish version) that asked questions regarding their participation in the AOD group. The questionnaire is a Likert scale raging from (1) Strongly Disagree to (5) Strongly Agree. The purpose of this questionnaire was to get a baseline of their thoughts of the combined English and Spanish AOD group. Questions included the following: How much trust do you have with the group members and with the therapist? How motivated do you feel in participating in group therapy? How much has the group therapy taken your culture into consideration? How helpful has the group therapy been for you? A post-test was also administered at the end of the 6-month cuentos group to measure the participants’ attitudes, experience, and feelings towards the group after being in the Spanish-speaking cuentos group. Group members were also administered an acculturation scale in order to establish their primary language and level of acculturation and assimilation to the dominant culture [33]. The acculturation scale by Hazuda et al. [33] has an excellent reliability (Cronbach’s alpha coefficient development sample was 0.75 and the replication sample was 0.77). The acculturation scale assesses a person’s childhood experience with the English and Spanish language, their proficiency in English and Spanish, their values placed on preserving their Mexican or Latina/o cultural origin, attitudes towards traditional family structure and sex-role organization, and structural assimilation described by Hazuda et al. [33] as childhood and adulthood interaction with members of mainstream society. Researchers recognize that acculturation should be considered in the evaluation and development of mental health programs [34].
Procedure
Group members met once a week for two hours during each Cuento Group. For the first 15-minutes group members checked in to discuss any crisis issues. After the initial check in, group members were given a copy of the day’s cuento. The guidelines for the cuento group were adopted from [21]. The cuentos were selected for the group members. The cuentos selected were brief in length. This allowed for maximum engagement. Each week different group members selfselected to read the cuento. This is an important concept of Cuento Therapy. By having the group members read the cuento, this provided group members to be more engaged in the process and also to take ownership of their group [21]. Group members processed themes and topics. Therapist asked for first impressions, general thoughts, and reactions of the cuento. Participants were also asked whether they identified with the main or other characters in the cuento. Also, participants were asked if they could think of any similar dilemmas or problems they had faced in their life and to develop insight about the moral or lesson of the cuento.
Data analysis
The process of the qualitative data included analyzing and coding any themes that came out from audio recording the weekly cuentos group and careful note taking. The themes in the data analysis supported the responses given in the Likert scale questionnaire. There were three themes that came out as a result of the data analysis (See results section). The Acculturation Scale was also scored. Researcher followed the recommendations from Hazuda et al. [33] on scoring the level of acculturation for each participant.

Results

The acculturation scale by Hazuda et al. [33] was utilized for its multidimensionality. That is, it measures not only dimensions of assimilation of Mexicans and other Latina/os in the United States but also it measures dimensions of structural assimilation. Structural assimilation [33] is described as a person’s interaction with other members of the mainstream society both during childhood and adulthood. The measurement of acculturation aids clinicians to develop appropriate interventions catered to the patients’ language and cultural background. The acculturation and assimilation scale results show that 8 out of 10 participants in the cuentos group identified themselves as placing a value on preserving their Latina/o culture. Two of the participants who grew up in Los Angeles scored moderate -high on the acculturation scale. Both identified themselves as fully bilingual (English and Spanish), placed a lower value on preserving the Latina/o culture, and also were prescribed as having a high interaction with the mainstream society both in childhood and adulthood (Table 1).
Table 1: Acculturation Scale.
Themes
Over the course of the cuento group, the participants were able to engage more, participate by reading the cuentos, identify with some of the characters in the cuentos, and also elicit emotions, feelings, and circumstances that led them to use alcohol or drugs. The pre and post-test Likert scale questionnaire indicated that the use of cuentos with Latina/o clients was experienced as a culturally relevant therapeutic modality (Theme 1). The Cuento Therapy intervention also created a comfortable non-threatening environment (Theme 2), and facilitated participation in therapy of all group members (Theme 3). The latter was a notable observation as prior to the implementation of the cuentos group, participants simply sat quietly listening to the English-speaking group members. The use of cuentos as a therapeutic intervention also helped participants build rapport with each other and with the therapist, facilitated emotional exploration, helped participants in articulating their feelings, and helped them develop insight about their use of alcohol or drugs. Of notable significance was the post-test result of the Cuento Therapy. All 10 participants noted that the Cuento Therapy intervention took their culture into consideration and that they had been given an opportunity to express their family’s cultural experience.
Theme 1: Cuentos were experienced as a culturally relevant therapeutic modality: During the fifth week a popular folktale in the Mexican culture was read: The cuento of “La Virgen de Guadalupe” (The Virgin Mary) [35]. “La Virgen de Guadalupe” is a folktale about a character named Juan Diego who on his way to church saw an apparition of the Virgin Mary. The Virgin Mary reassured Juan Diego and asked him not to be scared. The Virgin Mary asked Juan Diego to tell the bishop to build a church at that very spot where he has the apparition. Juan Diego went to church and told the bishop but the bishop didn’t believe him. The next day Juan Diego brought the bishop proof. He brought him roses that didn’t grow in that region of Mexico and the Virgin Mary saved the life of Juan Diego’s uncle. The bishop finally believed Juan Diego.
Immediately after the cuento, one of the participants reported that he had thoughts of using and relapsing, but instead had chosen to go to church. He reported that when he was at church, he felt as though the topics being discussed by the priest were directed towards him. After church, he reported that he did not use alcohol or drugs because he felt shame and the power of God. He became convinced that his belief in God had prevented him from using drugs over the weekend. Although some of the participants did not identify themselves as catholic, they all reported that Catholicism had been part of their upbringing and family culture. Moreover, a number of participants recognized the cuento regardless of their country of origin. One of the participants reported that her mother would tell her this cuento when she was growing up. Both of her parents were catholic and would go to church in Guatemala.
Theme 2: Cuentos create a comfortable non-threatening environment: Scores in the post-test questionnaire show that after participants participated in the cuentos group, they felt that they were able to trust the other group members and the therapist. This was illustrated during week 6 and the reading of a popular cuentofrom Guatemala called “El Canto del Chiquirrin” [36]. El Canto del Chiquirrin is about an insect called chiquirrin who sings day and night looking for love but feels no one loves him. The moon talks to him and tells him to find someone with big a heart like his. The sun joins in and tries to find him a partner. The chiquirrin finally meets a female chiquirrin with a big heart and who loves to sing as well, and he decided to marry her. However, other insects from the jungle including a spider and a butterfly try to impede the wedding by preventing the female chiquirrin from joining the male chiqurrin on their wedding day. The spider builds a trap with its web and catches the female chiquirrin. The singing chiquirrin saw that she was not coming to their wedding and began to sing and call for her. He called for her so loud until his body exploded and died.
A participant from Guatemala recognized the folktale and so did the participant from Honduras. The participant from Guatemala began to share that the cuento reminds her of her mother-in-law who tried to impede her marrying her husband. She stated that her mother-in-law never liked her for some reason, and she started to cry as she recalled the painful event of when her mother-in-law kicked her in the stomach when she was pregnant with her first child. She lost her child as a result of her mother-in-law’s assault. The group was supportive to her as she cried. She stated that she had never shared this with anyone but felt comfortable to share it with the group. The use of the cuento had given her the space for her to process her trauma and have a sense of catharsis.
Theme 3: Cuentos facilitated participation in therapy of all group members: As stated before, prior to the start of the cuentos group, Spanish-speaking group members very seldom shared anything because the English-speaking group members dominated group therapy. From the start of the cuentos group, all Spanishspeaking group members participated. During week 4, the cuento of “La Llorona” (The Weeping Woman) [37] was read. The general legend of La Llorona is that there was a beautiful young Native American girl. A handsome came riding into town and ended up marrying her despite her grandmotheradvising her to marry an honest and good man rather than a handsome man. She married despite the warnings of her beloved grandmother. She had two children. Her husband was abusive and sometimes would leave for days and not come back until he felt like. The husband would bring other women with him. When her husband left her she threw her children into the river out of madness. When she realized what she had done she ran after her children. The next day she was found dead on the riverbank. They buried her, but that night they heard a shrieking cry of “AIIEEE mis hijos” which means “Oh my children. After hearing this cuento, a participant from Mexico who rarely spoke before shared that she had been a victim of domestic violence. She described her abuse as being one of the most painful experiences of her life. This allowed her with the opportunity to process her abuse for the first time. Others in the group also joined and described their experience with being witness to domestic violence when they were growing up. Others identified with the cuento of La Llorona by saying that their parents would scare them when they were growing up by telling them to come home early before darkness or La Llorona would get them (Table 2).
Table 2: Pre-test and post test of the original group and cuentos group experience.

Discussion

The purpose of this qualitative case study was to develop an indepth analysis of cuento therapy as a group therapy process when working with Latina/o clients. Three themes emerged as a result of the study. The first theme is that Cuentos were experienced as a culturally relevant therapeutic modality and that highly acculturated clients benefit from cultural interventions in the same way than lower acculturated clients. Similarly to the work by Costantino et al. [15,19] the use of cuentos has shown to be a culturally sensitive modality with Latina/o clients regardless of their acculturation. Aviera [21] also found that his work with Dichos Therapy is applicable to Latina/os across a range of acculturation. Similar to the present study, Aviera [21] found that the client’s fluency in Spanish was less important than the strength of their emotional connection to the Latina/o culture. Comas-Dias [30] has also used Latino ethnic psychology to designate cuentos as an application of cultural traditions and practices into healing and liberation.
The second theme is that Cuento Therapy as a psychotherapeutic intervention creates a comfortable non-threatening environment. Prior to the implementation of the cuentos group, clients were part of a larger group that included monolingual English speakers. The lead therapist was English-speaking. The two peer-counselors were also English speaking. They also had a case manager who served as a translator. The Spanish-speaking clients rarely shared and had difficulty understanding what others in the group shared as well as the therapeutic interventions given by the therapist and the peercounselors. As the results of the post-test showed, soon after the implementation of the cuentos group, the Spanish-speaking clients became more comfortable and increased the therapeutic alliance with this researcher. Participants in the group also felt more comfortable with each other and provided support to each other.
The third theme is that Cuento Therapy fosters the therapeutic environment in a non-threatening collaborative manner to facilitate emotional exploration, build rapport between the clients and between the therapist and the clients. The use of cuentos was a straight-forward approach to help clients engage in therapy, examine their problems, thinking, behaviors, and the process of change. For example, during the cuento of “La Llorona” (The Weeping Woman), a client who was highly acculturated was fully engaged in the discussion of domestic violence, although he had never heard of the cuento. The cuento had an impact on this client because he was able to recognize the cultural themes in the cuento. The client described how “Mexican grandmothers always know best”. In the cuento, the grandmother of the main character had advised her not to marry the man because he was no good for her. The client then described how his grandmother always gave him good advice. He wishes now that he would have listened to her.
The three themes from this study support the need for clinicians to have cultural attunement. As illustrated, cuentos therapy as a culturally relevant intervention addressed the tenets of cultural attunement. Cultural attunement is about providing services in the person’s native language, utilizing bicultural staff, and incorporating familiar cultural traditions [13,14]. Costantino et al. [15] also support the practice of cultural attunement when working with Latina/o clients. Cultural attunement may address the Latina/o clients’ barriers to mental health. Because some of the barriers include not having bilingual and bicultural staff, increasing bilingual and bicultural staff into mental health facilities has the potential to address this barrier. In addition, the cultural attunement described in this study proposes and supports Costantino et al. [15] in that therapy should be congruent with the client’s culture or therapies should be modified to include cultural variables and that modification of traditional therapeutic approaches to fit the Latina/o client’s cultural values.

Limitations and Recommendations

This case study was conducted in an outpatient alcohol and drug recovery program. Validity strategies were implemented in order to ensure accuracy of the findings. Triangulation [31] was used in order to verify the use of different data sources of information that outlined the themes reported in the results. The acculturation scale, the pre and post-test, and the audio recordings of the sessions were used to ensure accuracy of the findings. In addition, participants were interviewed to determine accuracy of the findings and verify the themes of the study. Most of the participants (80%) in the study were mandated to be in the program. Participants were not voluntary and not randomized. Also, control groups were not utilized. Therefore, this case study design was utilized as a way to form inquiry about cuentos therapy and not to generalize findings to individuals, sites, or places outside of those under study [31].
Although cuento therapy has demonstrated to be a culturally appropriate when working with Latinos, a distinction should be made between a treating it as a therapeutic tool and not a philosophy of treatment. Cuento therapy should be utilized as a way to facilitate the exploration of issues compounding the Latina/o community. Cuento therapy does not replace therapeutic orientations. The use of appropriate therapeutic orientations such as Cognitive Behavioral Therapy (CBT), Motivational Interviewing (MI), Narrative Therapy, or Psychodynamic Therapy should be incorporated when using Cuento Therapy.
With the growth of the Latina/o population in the U.S., it is more than likely that Psychologists, Marriage Family Therapists, Clinical Social Workers, and other clinicians will be treating this segment of the population. Therefore, it is imperative that clinicians develop and become familiar with evidence-based practices and culturally specific therapies to meet the unique socio-cultural reality of minority groups. This calling is not just for bilingual and bicultural Latina/o therapists, but also for non-Latina/o therapists. Non-Latina/o therapists should be willing to keep an open mind to have cultural attunement of the Latina/o worldviews, community structures, family dynamics, immigration issues, values, beliefs, and client’s culture.

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