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When social worker Rachel Shapiro, LICSW, was hired by Children’s Hospital Boston in 1984, the Latino Team—an outpatient Psychiatry program that provides mental health services to Latino patients and their families—was in its infancy. Looking back, its creation was prescient: Since Shapiro joined the team 25 years ago, the number of Latinos in Massachusetts has more than tripled; now, 13 percent of Children’s patients are Latino (and the number of Spanish interpreters working at Children’s has swelled from three to 31).
Over the years, the team—made up of Shapiro and fellow Latina Roxana Llerena-Quinn, PhD, a psychologist—noticed a troubling trend as they counseled patients and families. “Although parents were requesting psychological services for their children, as we heard their stories—of immigration, domestic violence, the loss of family, poverty—we realized many were suffering from undiagnosed or untreated depression,” says Shapiro. “It became evident that we couldn’t address the children’s needs in isolation, and a family approach became the focal point of our work.”
Depression is especially high in immigrant Latinos, as many suffer from isolation due to language barriers, problems adjusting to unfamiliar cultural values and separation from their families. In addition to Shapiro and Llerena-Quinn’s concern for the parents, they worried about the impact of parents’ depression on their children. “By the time a child with a depressed parent reaches adolescence, there’s a 50 percent chance the child will be depressed too,” says Llerena-Quinn. “The greater the number of adversities they have in addition, like poverty and discrimination, the more their risk increases.”
The team had identified a clear problem, but it wasn’t until six years ago, when they attended a Grand Rounds by William Beardslee, MD, now the chairman emeritus of Psychiatry, that they saw a systematic way to address the issue. Llerena-Quinn and Shapiro knew about Beardslee’s Preventive Intervention Program (PIP) for depression, a family-centered program to prevent depression in children with a depressed parent, originally developed in 1989. Beardslee had recently adapted the program for the urban, predominantly black population of Dorchester, and talked about his enthusiasm to further adjust the program for widespread dissemination. “I was looking for more ways to make the program relevant for the cultures we work with in Boston,” says Beardslee. The clinicians saw the opportunity to collaborate: If his program was adapted for Latinos, who traditionally underutilize mental health services, it could be a powerful tool.
The family-based, story-telling aspects of Beardslee’s program impressed the two women. The intervention is made up of a series of conversations—some with parents, some with the children—with a focus on building on the existing strengths in each family. “It’s really about letting families tell their story, which was very similar to the work we were already doing,” says Shapiro. The program culminates in a family conversation, where family members can break the silence about the depression and its effects. “The key is helping people find their strengths, and helping them have a family conversation about what they are going through,” says Beardslee.
Eugene D’Angelo, PhD, chief of Psychology, was also interested in adapting Beardslee’s program for use with Latino patient families, so he approached the Substance Abuse Mental Health Services Administration to obtain funding to support the adaptation. For three years, Llerena-Quinn, Shapiro, Beardslee, D’Angelo and others met weekly for vigorous discussion on how to successfully modify the program while maintaining the original program’s core elements. “We educated each other,” says Llerena-Quinn.
In 2006, the group tested the adaptation in a study with nine predominantly low-income Latino patient families with a depressed parent. The adapted program included an increased focus on family history, and on the challenges of language barriers between family members. “We wanted to take into account the tensions created when you come from a different country, when your family is separated and when you speak a different language than your kids,“ says Llerena-Quinn. “One of the most striking things we noticed was the difficulty family members had communicating about the matters of the heart. Kids had trouble saying how they felt in Spanish, and the mothers didn’t have the words to speak about their depression in English,” she says. Taking extra time to develop trust, or confianza, between the parents and the clinicians was crucial.
In June of this year, the group published their findings in the journal Family Process. So far, the results are promising. “It appears to operate as safely and effectively as the original intervention did,” says D’Angelo, who was the principal investigator of the study. The team is contemplating starting a clinical trial.
Today, on Llerena-Quinn and Shapiro’s desks sit a copy of the manual for the adaptation, full of handwritten edits. They’re trying to reduce the page count and make it available for clinicians all over the United States—and the world—who work with Latinos. In fact, the government of Costa Rica has already taken the Latino adaptation and is refining it for use with Costa Rican families. Beardslee is thrilled that his original program, designed for white, middle-class families, is being used in so many ways. “Each time you do an adaptation well, it transforms the intervention and makes it even better,” he says. “You learn so much.”
For the Latino Team, it’s an accomplishment to create something of value for Latino families silently suffering with depression. “It’s such a gift for families to come together and feel heard and understood,” says Llerena-Quinn. “It’s not that one family conversation solves the problem. But if you learn to break the silence about one difficult topic, you can learn to break the silence about other difficult topics.”
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