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IDENTIFYING INFORMATION (NAMES AND AFFILIATIONS, AUTHOR NOTE)
Fortalezas Familiares Program: Building sociocultural and family strengths in Latina women with
depression and their families.
Carmen R. Valdez, Jessica Abegglen, and Claire T. Hauser
University of Wisconsin‐Madison
Carmen R. Valdez, Jessica Abegglen, and Claire T. Hauser, Department of Counseling Psychology,
University of Wisconsin‐Madison. Correspondence concerning this article should be addressed to
Carmen R. Valdez, Department of Counseling Psychology, University of Wisconsin, Madison, 301
Education Building, 1000 Bascom Mall, Madison, WI 53706. Telephone: 608‐263‐4493. Fax: 607‐265‐
3347. Email: email@example.com
We thank Stephen Quintana for reviewing earlier drafts of this article.
The project described was supported by the University of Wisconsin Morgridge Center for Public
Service; and the Clinical and Translational Science Award (CTSA) program, previously through the
National Center for Research Resources (NCRR) grant 1UL1RR025011, and now by the National Center
for Advancing Translational Sciences (NCATS), grant 9U54TR000021. The content is solely the
responsibility of the authors and does not necessarily represent the official views of the NIH.
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The purpose of this article is to describe Fortalezas Familiares (FF; Family Strengths), a
community-based prevention program designed to address relational family processes and
promote wellbeing among Latino families when a mother has depression. Although depression in
Latina women is becoming increasingly recognized, risk and protective mechanisms associated
with children’s outcomes when a mother has depression are not well understood for Latino
families. We begin by reviewing the literature on risk and protective psychosocial mechanisms
by which maternal depression may affect Latino youth, using family systems theory and a
developmental psychopathology framework with an emphasis on sociocultural factors shaping
family processes. Next, we describe the theoretical basis and development of the FF program, a
community-based 12-week intervention for Latina immigrant women with depression, other
caregivers, and their children. Throughout this article, we use a case study to illustrate a Latina
mother’s vulnerability to depression and the family’s response to the FF program.
Recommendations for future research and practice include consideration of sociocultural
processes in shaping both outcomes of Latino families and their response to interventions.
Keywords: maternal depression, Latinos, immigrants, child mental health, family intervention
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There is an acute need for family based interventions when mothers have depression
(Beardslee, 2002). Over 25 years of research shows that children of mothers with depression are
more likely to develop social impairment and mental health problems (i.e., major depression,
anxiety disorders, and substance dependence), as well as physical disability and medical
conditions that persist into adulthood, compared to children of mothers without depression
(Timko et al., 2009; Weissman et al., 2006). Because the majority of this research has been
conducted with predominantly White populations, researchers and practitioners have been
limited in their ability to address the needs of socioeconomically disadvantaged families, where
rates of depression are particularly elevated (Cardemil, Kim, Pinedo, & Miller, 2005). Thus,
understanding the relationship between maternal depression and family functioning among
minority families, such as Latino immigrant families, and the associated sociocultural pathways
to risk and resilience, therefore, should be a priority for researchers who are interested in
developing culturally-appropriate interventions for this vulnerable population. Although
depression varies by severity and timing of onset, in this article, we focus on mothers who
experience moderate to severe symptoms of depression during their child’s pre-adolescent or
adolescent years, to highlight the association of these symptoms with other family processes, and
their impact on a particularly vulnerable stage of child development.
Keeping Families Strong (Author et al., 2008), an evidence-derived family based
intervention developed for White and African American families, has now been adapted for
Latino families in response to the growing literature on depression in Latina women. The
adapted intervention, Fortalezas Familiares (FF; Family Strengths) was piloted over three
administrations in a community-based, multi-family group setting. We discuss how this
intervention addresses the needs of Latino families and their response to the intervention.
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Despite research showing that many newly arrived Latino immigrants have lower rates of
depression, their risk for depression increases the longer they live in the United States (Alegría et
al., 2007). In addition, when immigrant mothers succumb to depression, they have a more
chronic course of depression compared to White women (Breslau, Kendler, Su, Gaxiola-Aguilar,
& Kessler, 2005), and coping may be less effective in a foreign culture, where traditional support
systems may not be in place (Busch, Bohon, & Kim, 2010). Because family cohesion and
interdependence are highly valued by many Latino families (Falicov, 2003), maternal depression
has significant implications for the wellbeing of children of immigrant parents.
Factors contributing to depression among Latina women include family separation,
exposure to traumatic experiences, acculturative stress, racism and discrimination, and poverty
(Heilemann, Coffey-Love, & Frutos, 2004). Relational factors and patterns are mutually
influential in Latina depression as well, and include marital dissatisfaction, parent-child conflict,
and coping with interpersonal losses and transitions both in the country of origin and the host
country (Falicov, 2003). These factors are illustrated in the following case study of Mariana1, a
33 year-old Mexican mother and wife:
Mariana first experienced depression when she was 11 years old, after being sexually
abused by a neighbor while her single mother worked outside the home. At the age of
20, Mariana migrated to the United States alone in search of better economic
opportunities, but she struggled to adapt to her new environment without her mother’s
support. Three years later, her boyfriend abandoned her after discovering that she was
pregnant. Soon after Antonio was born, she married Joaquín, a kind man who lovingly
raised her son. Mariana and Joaquín have experienced a series of financial and marital
1 All names and some details have been changed to protect the identities of the individuals
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stressors, and in the past two years, Mariana’s mother passed away in Mexico, and
Antonio’s biological father returned to start a relationship with his, now, 10 year-old son.
Mariana’s regret over leaving her mother in Mexico, and fear of having to disclose the
truth to Antonio about his biological father, intensified her depression. Joaquín could not
understand why she was increasingly withdrawing from the family, and he responded in
turn by being critical and distant. Interactions grew tense between Joaquín and Mariana,
and the children grew angry and worried as they watched their family fall apart. In one
attempt to get her mother’s attention, Amanda, her 7 year-old daughter, wrote a poem to
Mariana but was saddened when her gesture went unacknowledged for days.
Although research is beginning to reveal why Latina women, like Mariana, are vulnerable
to depression, mechanisms of risk and resilience for children with a mother with depression are
less well understood for Latinos, relative to Whites (Corona, Lekfowitz, Sigman, & Romo,
2005). Consequently, theory- and culturally- driven interventions for these families are scarce.
Our conceptual framework of maternal depression is informed by systems theory and
developmental psychopathology. Systems theory is founded on the premise that persistent
change or stress in the family will prompt family members to reorganize in order to adapt. The
family’s adaptability to these changes will in turn affect the level of change or stress, so that rigid
family patterns will accelerate undesirable changes, and flexible family patterns will decelerate
these changes (Baker, Seltzer, & Greenberg, 2011; Nichols & Schwartz, 2008). In addition, our
work on Latino families is guided by developmental psychopathology, which examines negative
and positive adjustment as a consequence of the dynamic interplay among risk and protective
factors over time (Cummings, Davies, & Campbell, 2000). We focus on sociocultural risk and
protective factors affecting family processes for Latino children, given the centrality of family
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life in Latino culture (Corona et al., 2005) and the vulnerability of family life when parental and
family stressors are present (Beardslee, 2002; Author et al., 2008). We focus on pre-adolescents
and adolescents because of their (a) increased risk for internalizing symptoms, particularly for
girls (Cicchetti & Toth, 2008); and (b) heightened sensitivity to the needs of the family (Crean,
2008; Prado et al., 2008; Zayas, Lester, Cabassa, & Fortuna, 2005).
Sociocultural Mechanisms of Risk in Maternal Depression
Sociocultural processes affecting the family system, such as differential acculturation
pace between parents and children, cultural emphasis on family obligation and cohesion, and
parenting practices that are dissonant with the host culture, among others, shape the resources
that families have to cope with maternal depression. These processes exacerbate risk factors
associated with maternal depression—family conflict, inconsistent routines, and isolation—or
enhance protective factors associated with resilience in children when a mother has depression—
family cohesion and involvement, cultural traditions and bicultural orientation, and strong social
ties—and are described within each one of these family risk and protective factors (see Figure 1).
Conflict in the parent-child and marital relationship is often a consequence (i.e., way of
coping) and a contributing force of maternal depression. Empirical evidence with 101 low-
income, Puerto Rican and Dominican women with children in Head Start suggests that mothers
with depression are more irritable and praise their children less and criticize them more,
compared to mothers without depression (Plano, Zayas, & Busch-Rossnagel, 2005). Conversely,
research with 111 low income, Mexican and Central American mothers in the United States and
their adolescent children shows that mothers with depression report being less satisfied with their
family interactions than Latina mothers without depression, in turn decreasing warmth and
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nurturance and increasing conflict (Corona et al., 2005). These studies suggest circular relational
patterns with maternal depression, with family relations both increasing risk for maternal
depression and increasing risk for children’s adjustment when a mother has depression.
Family conflict may be particularly burdensome for Latino immigrant families because
many of these families value cohesion and children’s dependence on their mother (Corona et al.,
2005). In a study of 329 Latino adolescents of predominant Mexican descent in the southwestern
United States, adolescents were found to experience more negative effects from family conflict,
including internalizing and externalizing symptoms, than non-Latino adolescents (Crean, 2008;
Prado et al., 2008). In a review of the literature on Latino youth suicidality, Zayas and colleagues
(2005) described Latina adolescents who attempt suicide as being more likely to attribute their
attempts to family problems rather than peer problems, relative to non-Latina youth.
Although intergenerational conflict is assumed to be normative, and to increase when a
mother has depression, it can be exacerbated in immigrant families in which adolescents attempt
to individuate as a result of greater acculturation to U.S. norms and expectations, relative to their
parents (Chapman & Perreira, 2005). As children internalize the values of the host culture at a
faster pace than their parents, family conflict may increase, parental authority may decrease, and
children may increasingly express disconnection over parents’ ways (Portes & Rumbaut, 2006).
In addition, immigrant parents who once relied on their children for language and cultural
brokering may handle the resulting role reversal by attempting to curtail children’s growing
independence (Prado et al., 2008). Thus, acculturative stress is associated with family stress in
immigrant families (Falicov, 2003), and may heighten conflict and maternal depression.
Another type of family conflict powerfully connected with maternal depression is marital
conflict. Although a significant number of adult immigrants are in a married or partnered
SOCIOCULTURAL PROCESSES 8
relationship (Falicov, 2003), marital dissatisfaction may be high due to acculturative stress,
financial burden, and unanticipated changes to traditional gender norms (Busch et al., 2010). In a
literature review of adaptation among Latino and Asian immigrant families in the United States,
Busch and colleagues (2010) described the role of acculturation in marital conflict, explained by
women acculturating more rapidly than men into U.S. society and often gaining economic power
when they join the workforce to support the family’s income. Conflict ensues, and the mother’s
stress increases, when the father perceives that her increasing independence comes at the expense
of her caretaking responsibilities (Busch et al., 2010; Sarmiento & Cardemil, 2009).
As illustrated in our case study, family conflict can undermine the marital relationship,
exacerbate the mother’s depression, and strain the family’s resources to cope with changes in the
family. Family conflict decreases parents’ responsiveness to their children’s needs, and increases
children’s perceived responsibility for the wellbeing of the family (Beardslee, 2002). Further,
family conflict can reduce family conversations about day-to-day events, family problems, and
about the mother’s depression. Moreover, cultural norms may restrict children’s role in difficult
family conversations (Falicov, 2003), further preventing children from expressing concerns
about their mother’s depression and the family (Author et al., 2008). Language differences
between parents and children can also limit family communication, as when parents are largely
Spanish-dominant and their children are largely English-dominant. As a consequence, family
members lack a framework to understand the mother’s depression and related family stressors
and cope on their own with their sorrow, anger, fear, and confusion (Author et al., 2008).
Parenting Practices and Family Routines
Depressive symptoms and negative family patterns can undermine the mother’s
confidence in her ability to parent her children, that is, to establish rules and expectations for
SOCIOCULTURAL PROCESSES 9
their children’s behavior (Author et al., 2008). Latina mothers with depression may feel even less
secure in their parenting skills because their standards of acceptable discipline (i.e., spanking)
may be incompatible with those of U.S. society (Falicov, 2003). Further, immigrant parents may
experience a loss of authority when their children serve as brokers of U.S. culture. Thus, when
parents are not able to manage their children’s behavior consistently, they lack the authority to
enforce stable routines (e.g., meals, bedtime) and activities for the family. Research shows that
inconsistent parenting and routines associated with maternal depression have been linked with
higher risk for substance abuse in Latino children (Corona et al., 2005).
While some children respond to their mothers’ inconsistent parenting by not complying
with rules, others assume significant family obligations. Although in general, family obligations
are considered protective for Latino children because they elevate children’s place within the
family (Fuligni, Tseng, & Lam, 1999), a stressful emotional climate coupled with a motivation to
restore the family’s wellbeing can make these obligations burdensome (Jurkovic et al., 2004).
Family stress and isolation
As illustrated in our case study, family stress can strain already limited resources for the
family when a mother has depression, including time for caregiving, monitoring, supervision,
and engaging in everyday family routines (Author et al., 2008). For example, many immigrant
parents work multiple, low-paying, and unstable jobs to manage financially (Jurkovic et al.,
2004). Mothers are also now more likely to work outside of the home than they did in their
country of origin (Falicov, 2003). Thus, economic stressors on Latino families may limit parents’
involvement in their children’s lives (Jurkovic et al., 2004).
Economic disadvantage is particularly elevated for families affected by other social
stressors, such as increasingly restrictive immigration policies in the United States. Intimidation,
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detention, and deportation have led to limited employment opportunities, loss of a parent’s
income, and financial stress, as well as family separation (Author et al., 2012). In addition, racial
and ethnic discrimination has been associated with higher levels of stress and depression for
Latino children (Cardemil et al., 2005). However, because many immigrant Latino parents did
not grow up experiencing ethnic discrimination in their native country, they may not know how
to help their children cope with this type of discrimination (Hughes, 2003).
Social isolation can deprive children from positive role models and activities outside the
family, which are known to protect families during times of stress (Author, 2008). Among Latino
immigrant families, decreased public exposure and social participation may derive from fear of
deportation and intimidation (Jurkovic et al., 2004; Author et al., 2012), and also from parents’
perception that their values and expectations are at odds with those of the host culture (Prado et
al., 2008). Alarming is that as children move closer to the host culture, their isolated parents
become less involved in their children’s lives and in their peer relationships (Prado et al., 2008).
Building Family Resilience
Resilience can be achieved in spite of the risks reviewed in this article, by drawing upon
the family and cultural strengths and assets that may already exist but that families may not know
how to access (see Figure 1). These include family cohesion, nuclear and extended family
involvement, cultural traditions, bicultural orientation, and community supports.
In general, family cohesion and involvement are important sources of resilience for
Latino children facing disruptions in family functioning and parental depression. Familism,
defined as “the emotional bonding that family members have towards one another” (Rivera et al.,
2008, p. 258), is related to feelings of reciprocity, loyalty, and cohesion, which in turn are related
to lower levels of psychological distress among Latinos (Chapman & Perreira, 2005). The
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positive emotional bond associated with familism can be strengthened through family activities
and routines that connect parents with depression and their children.
Similarly, parental involvement, in the form of warmth, communication, and monitoring,
prepares children to cope with their mother’s depression, negative family interactions, and other
stressors, such as discrimination (Hughes, 2003), and can help to mitigate children’s risk for
internalizing symptoms, as well as exposure to deviant peers (Berger Cardoso & Thompson,
2010). Involvement can also come from extended family members (Falicov, 2003), and can help
Latino children develop more positive attitudes towards family life (Chapman & Perreira, 2005).
In addition to family cohesion and involvement, cultural traditions can be a significant
resource for Latino immigrant families (Berger Cardoso & Thompson, 2010). Participation in
spiritual, folk, and cultural rituals and traditions that reinforce families’ cultural heritage and
connect family members through their shared immigration history can strengthen loyalty and
weaken the effects of emotional and societal stressors (Berger Cardoso & Thompson, 2010;
Chapman & Perreira, 2005; Imber-Black & Roberts, 1998). In fact, D’Angelo and colleagues
(2009) found in their intervention with Puerto Rican and Dominican mothers with depression in
the United States that cultural rituals, such as religious coping or faith, can help Latino
immigrant families cope with maternal depression and loss by providing meaning to their
experience and a source of comfort.
Similarly, bicultural identity can protect children facing adversity by allowing them to
draw upon the resources and supportive outlets of the two cultures (Smokowski & Bacallao,
2011). Biculturalism has been linked with optimal functioning for children, including lower
depression and better academic and interpersonal adjustment (Berger Cardoso & Thompson,
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2010). Notably, when both youth and parents are bicultural there is greater family cohesion,
adaptability, and loyalty, compared to when only youth are bicultural (Portes & Rumbaut, 2006).
Finally, Latino immigrants in the United States generally have strong social ties within
their ethnic enclaves that facilitate the procurement of employment, housing, and other resources
(Portes & Rumbaut, 2006). These ties have been associated with parental monitoring, norm
socialization, and children’s academic success (Prado et al., 2008), and have the potential to
decrease social isolation and to promote children’s efficacy when a mother has depression.
Addressing Family Processes Associated with Maternal Depression
Because maternal depression is interpersonal in nature and is both shaped by and shapes
family interactions, interventions should be developed at the family level and should incorporate
the theorized sociocultural processes that influence Latino families’ functioning in the context of
maternal depression. First, to create change at the level of the family, the whole family needs to
be part of the intervention. Second, psychoeducation about depression and associated family
processes needs to be an integral part of any intervention so that family members have a
framework for recognizing and understanding the family interactions contributing to the
mother’s emotional response, and the emerging family interactions attempting to manage that
response (Author et al., 2008). Similarly, a family intervention should build family members’
skills and confidence in conflict-resolution, problem-solving and communication, so family
members can share their concerns and plan for recovery.
Third, increasing parental involvement and parenting confidence can restore positive
interactions, positive emotional bonds, and meet children’s needs for consistency and stable
routines. Thus, an intervention needs to help families recognize the value of positive family
experiences, and provide the tools to plan and carry out fun activities that increase emotional
SOCIOCULTURAL PROCESSES 13
connection and positive family exchanges. Fourth, because of the acculturative and social
stressors affecting many Latinos in the United States, a family intervention needs to educate
immigrant parents and youth about acculturative stress and youth experiences of discrimination
in the United States, and to enhance family members’ comfort with family conversations about
discrimination. Fifth, interventions for maternal depression should also aim to strengthen social
ties and support to reduce family isolation. Thus, a multi-family intervention including nuclear
and extended family members would be ideally positioned to strengthen parental support, as well
as children’s access to supportive and positive role models and development of friendships.
Interventions for Latino Families
Unfortunately, many Latino immigrant families have limited access to culturally and
linguistically appropriate mental health services (Cardemil et al., 2005; Sarmiento & Cardemil,
2009). In addition, only two programs specifically designed for Latina mothers with depression
have been published to date, Cardemil and colleagues’ (2005) Family Coping Skills Program
(FCSP), and D’Angelo and colleagues’ (2008) adapted version of the Preventive Intervention
Program for Depression (PIP; Beardslee, Gladstone, Wright, & Cooper, 2003). These time-
limited programs primarily use psychoeducation to help mothers deal with negative emotions
and decrease stigma (Cardemil et al., 2005), and to increase the family’s shared understanding of
depression (D’Angelo et al., 2008). However, FCSP does not include children, and PIP includes
only one child in some but not all modules. Thus, interventions that promote children’s resilience
and that involve children’s full participation are needed.
We set out to develop Keeping Families Strong (KFS), a clinic-based 10-week multi-
family group program for low-income mothers in treatment for depression, other adult
caregivers, and all children ages 9-16 (Author et al., 2008; Author et al., 2011). This age range
SOCIOCULTURAL PROCESSES 14
was chosen because of the high risk for the onset of depression in adolescence, and because
process-oriented and psychoeducation programs are more effective during this development
stage than in younger childhood (Cicchetti & Toth, 2008; Author et al., 2008). Results from a
KFS pilot of six White and four African-American predominantly low-income families shows
that the program met its goals, with standardized self-report measures of parent, child, and
family functioning reporting participants’ (a) greater understanding of depression among family
members, (b) enhanced communication, (c) strengthened parenting skills and confidence, (d)
effective children’s coping skills, and (e) increased interpersonal warmth and family cohesion.
The KFS program was designed for predominantly low-income, English-speaking
families, but did not account for the unique mechanisms associated with outcomes in Latino
immigrant families, reviewed in this article. With research showing improved outcomes for
Latino families when interventions are adapted for cultural relevance (Cardemil et al., 2005;
D’Angelo et al., 2009; Parra Cardona et al., 2012), it was, therefore, critical to culturally and
linguistically adapt KFS to increase its effectiveness and acceptability for these families.
The Fortalezas Familiares Program
The adapted program, Fortalezas Familiares (FF; Family Strengths) is composed of 12
concurrent meetings for mothers with depression and other caregivers, and all youth ages 9-18.
In addition to the goals of KFS described above, FF aims to promote Latino families’
understanding of (a) the effects of acculturative and immigration stressors on family life, (b) the
importance of parental involvement in and monitoring of children’s activities outside the home,
and (c) ways to strengthen children’s coping through involvement in cultural traditions, support
from extended family, and engagement in ethnic socialization (i.e., cultural pride and coping
with discrimination). In addition to a new meeting on these sociocultural processes, FF dedicates
SOCIOCULTURAL PROCESSES 15
a meeting to marital stress because of the large majority of immigrant families involving a
married or partnered relationship. Finally, FF is held in a community agency, rather than a
mental health clinic, to facilitate family members’ comfort with and access to the program.
Because many low-income women experience a chronic course of depression, it was important
for FF, and KFS, to be adjunct to their ongoing outpatient treatment of depression.
Program Structure and Format
The FF program was designed to be delivered in a multi-family group format (3-6
families) to create social support across the families, to normalize the experience of depression
and reduce stigma, and to enhance learning and problem solving through collaboration (Author
et al., 2011). At the beginning of every meeting, families sit around a table and participate in a
culturally-representative meal intended to build group cohesion and trust, as well as to promote
social support, family engagement, and cultural pride. Finally, a raffle at the end of the night
provides positive interactions among family members after their therapeutic meetings.
Members of each family are divided into parent/caregiver and youth groups. The
parent/caregiver group includes the mother with depression and another adult caregiver who has
regular contact with the family. In FF, 80% of mothers participating to date brought a spouse,
and a few also brought their children’s grandmother, aunt, or an adult sibling. Additionally, we
expanded the age from 16 to 18 in FF because many older Latino youth live with their parents.
Depending on the number and age span of youth in a cycle, the youth group is broken down into
two separate groups to address the different developmental needs of younger and older youth.
Similar to KFS, children under nine years of age are provided with childcare. Unlike
KFS, however, FF includes programming that was adapted for young children’s learning
capabilities. The programmatic focus in the young child groups is on identifying feelings and
SOCIOCULTURAL PROCESSES 16
stressful situations through developmentally appropriate activities such as drawing, acting,
reading children’s stories, and relaxation. The young child group varies widely in terms of
developmental level and engagement with the therapeutic materials. Thus, this group is not
considered to be an active program component.
The parent/caregiver groups are facilitated by mental health providers who are native
Spanish speakers with substantial knowledge of Latino culture. For the youth group, facilitators
are bilingual in English and Spanish, and all materials are available in both languages to reflect
the heterogeneity of language dominance and cultural identification of the youth group.
Theoretically, FF is guided by a developmental psychopathology framework in that it
aims to target the mechanisms of risk and resilience that interact during critical periods of
development, such as adolescence, and that are potentially malleable by a family intervention.
The FF Program is also guided by family systems in that the target of change is the family
processes that both lead to and are exacerbated by maternal depression. Thus, inclusion of
multiple family members is crucial in working through these processes. Therapeutically, FF uses
interpersonal and group process, cognitive-behavioral, and narrative models to integrate
psychoeducation with meaning-making, self-reflection, and life stories to target risk and
protective processes (Author et al., 2008). These combined approaches are adjusted in
accordance with the varying developmental needs of each family member. Family systems
theory is incorporated throughout the program in a number of ways. First, education and group
discussions about depression are couched in the context of family processes. Second, metaphors
and a “family circle” activity are used widely to describe how changes in family members’
feelings and in their family relationships lead to family difficulties that are greater than the sum
SOCIOCULTURAL PROCESSES 17
of their parts. Third, and finally, once foundational understanding, skills, and confidence have
been developed the program incorporates individual family sessions towards the end of the
program and in the booster meetings. These family sessions are intended for families to address
their relational patterns and set goals for the future.
In addition, in FF we use action-oriented learning activities to facilitate perspective-
taking by participants of different ages and acculturation levels (Smokowski & Bacallao, 2011).
We ask participants in the parent and youth groups to create five scenes representative of the
experience of Latino parents/youth in the United States, and to act these scenes in front of the
other group (M. Bacallao, personal communication, January 31, 2011). One of the scenes created
by parents was of a parent being subjected to abuse in the workplace by a Latino supervisor with
“papers”; a scene created by youth was being teased at school for having an accent. Afterwards,
participants share with the opposite group, and later with their own group, what they learned
from the scenes, and how they connected their new understanding to their family experiences.
Program meetings are sequenced to move group members from self-awareness to
understanding of depression, and from coping, to competence and cohesion (see Table 1). During
the first two meetings, group members share their family experiences and personal hardships and
learn about the relationship between maternal depression and family functioning. Children in
particular learn new coping mechanisms such as challenging negative thoughts, seeking support
from a trusted person, and engaging in perspective-taking (meeting 2). In meeting 3, group
members learn about risk and protective factors for youth in multi-stressed families. Meeting 4
introduces them to the challenges of adolescence for many Latino youth, including negative peer
influences, acculturative stress, parent-child cultural separation, and discrimination at school.
SOCIOCULTURAL PROCESSES 18
Over the next four meetings, group members work towards changes in order to attain
enhanced wellbeing, including engaging in pleasant family activities, more stable family
routines, open communication, conflict resolution, and strengthening of the marital relationship.
In meeting 10, a family meeting is conducted with individual families so they can achieve a new
and shared understanding of depression and their family goals. Meetings 11 and 12 allow group
members to process their family meeting in their separate groups, learn about how to plan more
family meetings, and reflect on the growth of their families during the course of the program.
Youth also create a video of their experiences in the program, which families view at a
celebratory post-intervention meeting. Two monthly booster meetings include brief family
meetings and reinforce the awareness and skills learned and problem solve any concerns that
may have arisen since the program.
A Case Study of Fortalezas Familiares
Mariana’s initial depression scores were in the clinical range. During the first FF
meetings, Joaquín described at length his confusion about and frustration with Mariana’s lack of
interest in family life and persistent irritability. Psychoeducation and group process helped
Mariana understand how her cognitions, emotions, and behaviors were connected, and how these
were linked to her life story, but her engagement and commitment to change were low. In spite
of other group members’ encouragement, Mariana refused to consider medication treatment.
It wasn’t until meeting 3 that Mariana discussed in great detail and with intense emotion
her chronic history of trauma, poverty, and loss. She described her grief as God’s punishment for
leaving her mother in Mexico. Although facilitators honored her belief, they explored how she
could seek comfort in God for the adversity in her life. In addition, many group members
reassured Mariana that God wouldn’t want to punish her, but rather for her to do well in her life
SOCIOCULTURAL PROCESSES 19
as a way to honor her mother’s memory. Facilitators followed up on this suggested shift from her
past to her present by connecting Mariana’s longing for her mother with her children’s longing
for connection with her. Perspective-taking allowed Mariana to understand and commit to her
family’s needs, and allowed Joaquín to become more empathetic of Mariana’s life story.
Meanwhile in the youth group, Antonio was able to express confusion, concern, and guilt about
his mother’s depression and the frequent arguments between his parents for the first time in
meeting 3. He learned to identify and use positive coping skills during this time.
In meeting 4, focused on culture, Mariana and Joaquín shared their concerns about what
they perceived to be Antonio’s rebellious behavior as he enters adolescence, and learned about
acculturative risks on children in the United States. In the group they practiced conversations
they can have as a family about discrimination and about remaining close in spite of diverging
cultural expectations. After the family participated in the action-oriented activities, Antonio
evidenced a new perspective on the sacrifices made by his parents to provide him with a better
life than they had in Mexico. As families shared ways of remaining connected to their cultural
traditions, for example, by participating in “posadas” (religious ritual) during the holidays, they
learned about the value of these traditions in further strengthening family bonds.
During meetings 5 and 6, Mariana’s affect was visibly more positive than before and she
became more engaged in group discussion and activities. For example, she and Joaquín became
more planful about carrying out family activities and about supporting each other’s new
strengths with their children. During meeting 6, Mariana and Joaquín disclosed to group
members about Antonio’s biological father. In the youth meeting, Antonio spoke in more detail
about his family’s difficulties. After learning about the family cycle, he was able to offer
SOCIOCULTURAL PROCESSES 20
examples of ways that he could turn negative interactions with his family into positive ones. He
reported spending more time with his parents and noticing improvement in his mother’s mood.
In spite of this progress, an argument between Mariana and her sister-in-law, in which the
latter alleged to having an affair with Joaquín (to which she later confessed to be false), gave
way to a setback in the family during the week of meeting 7. With great shame, Mariana told the
group that while confronting Joaquín about her sister-in-law’s allegations, she pulled out a
kitchen knife and threatened him in front of the children. Although no one was hurt, she felt
deeply ashamed about her actions. Sobbing in front of the group, she apologized to Joaquín and
reassured him that she has since then sought medication treatment. He also apologized to her for
not paying enough attention to her needs. This situation prompted Mariana and Joaquín to
commit to bringing back trust to their relationship and sparked conversations among others about
their own vulnerable relationships. Mariana sought advice from the group as to how she could
talk about this incident with her children. Concurrently, Antonio shared this story with the youth
group, and he was able to relate those struggles directly back to how it was affecting him.
During meeting 8 about marital conflict resolution, Mariana and Joaquín updated the
group on the events of the previous week. They both noticed improvement in the way they
related to one another, and in turn, noticed that the children were more relaxed at home, which
they also attributed to her improved mood. They learned other ways of feeling more connected as
a couple. In the 8th youth meeting, Antonio shared his ideas about conflict resolution and was a
group leader in offering examples in regards to using “I” statements to resolve conflict.
The family meeting two weeks later was highly successful. With reassurance and
assistance from the facilitators and his parents, Antonio was able to ask Mariana about her
depression and about the recent “knife” incident. Mariana managed her emotions well during this
SOCIOCULTURAL PROCESSES 21
conversation, validated his concerns and learned that what Antonio feared the most was that she
and Joaquín would divorce. Joaquín held her hand and reinforced her position as a parent during
this conversation. They communicated to Antonio changes they are making to improve family
life, such as her medication treatment and working on communication and family time together.
Over the final weeks of the program, Mariana, Joaquín, Antonio, and Amanda had two
family meetings on their own that they described to be successful in helping the family feel
connected and to set goals for the family. Mariana appeared radiant during the final meetings, as
she paid more attention to her appearance and dress, and her affect was more positive. She and
Joaquín evidenced a renewed understanding of their relationship vulnerabilities and strengths.
Between the two booster meetings, Mariana and Joaquín had a family meeting with Antonio and
they used the communication skills learned in the FF program to disclose the identity of
Antonio’s biological father. Much to their surprise, Antonio remained calm and told them that he
would always see Joaquín as his father, but that he was glad he knew. At the final youth booster
meeting, Antonio reported feeling closer to his parents than he had ever felt to them before. He
also reported that overall his family was able to communicate better, resolve conflict quicker and
in a calmer manner, and was spending more quality time together. At the post-assessment and up
to a final, 8-month follow-up, Mariana’s depression scores fell below the clinical range, and the
family reported improvements in their communication, routines, and cohesion. The family
maintained regular contact with the other participating families.
Summary of Program Outcomes
We conducted a pilot study of the FF program with 16 adult female clients with a major
depressive disorder and their families. Thirteen families were from Mexico and three were from
Central and South America. Of the 16 participating families, 13 completed the program (81%),
SOCIOCULTURAL PROCESSES 22
including 13 mothers, 9 fathers, 1 grandmother, and 18 adolescents. Participants completed pre-
and post-intervention measures about parent and child coping and mental health, family
functioning, and acculturative stressors. All mothers experienced a decrease in depressive
symptoms from pre-test to post-test. Further, four mothers scored in the clinical range on a
measure of psychological symptoms at pre-test, and only one mother, whose husband did not
participate in the program due to substance abuse issues, remained in the clinical range at post-
test. This mother was offered referrals and she continued to meet with her clinician. Caregivers
also reported lower levels of depressive and anxiety symptoms at post-test, and one father who
had scored in the clinical range at pre-test, no longer did at post. Parents and caregivers reported
improvement in youth internalizing and externalizing symptoms, and youth reported increased
use of positive coping strategies. Mothers and caregivers reported a significant increase in social
support and improvement in family functioning (i.e., routines, communication, cohesion,
parenting skills) were reported by all participants. Measures were selected for their wide use with
Latinos, availability in Spanish, and adequate psychometric properties. Detailed information
about the study measures and outcome data, including an 8-month follow-up, as well as
qualitative data from interviews and focus groups are presented elsewhere (Author et al. 2012).
Conclusions and Future Directions
Sociocultural and family processes shaping immigrant Latino families’ adjustment in the
context of maternal depression, need to be understood to address risk and promote resilience
among children. A developmental psychopathology framework was useful in understanding the
dynamic interplay between family and sociocultural risk and resilience processes. However,
sociocultural processes have been largely understudied, even in the developmental
psychopathology literature (Cicchetti & Toth 2008). Our work shows that a deeper
SOCIOCULTURAL PROCESSES 23
understanding of how sociocultural processes, such as acculturative stress and cultural values,
shape family relational patterns and personal adjustment, and can serve as a foundation for the
development of clinically effective and culturally acceptable interventions.
A family systems framework was useful in addressing relational patterns within the
family. Families’ understanding of their relational patterns was critical to their engagement in the
program, as many mothers with depression believed until that point that they were able to “hide”
their symptoms and not affect the family. Similarly, many spouses and children until that point
lacked adequate understanding of how these symptoms were connected to other changes in the
family. Later in the program, individual family meetings were powerful because the family came
together for the first time to listen to and address each other’s concerns in a supportive
environment. Increased understanding and competence was likely conducive to a positive marital
relationship, stronger coparenting, warmer and more consistent parent-child interactions, and
stable family activities and routines, all of which, have been associated with wellbeing in Latino
families (Sotomayor-Peterson, Figueredo, Christensen, & Taylor, 2012). Perhaps the significant
changes in family functioning noted after the family meetings suggest the need to anchor the
intervention more in a family systems framework, relative to our other frameworks. Although
our family meetings were successful in part because family members had their own space in their
previous meetings to grieve losses, understand and reframe their family patterns, and learn new
skills to improve family life, in future implementations of FF we will consider the value of
incorporating more family meetings earlier in the program.
The FF program addressed the general risk and protective mechanisms that shape
children’s outcomes when a mother has depression, accounting for specific sociocultural
processes that are salient to Latino immigrant families. In FF, we discussed immigration history
SOCIOCULTURAL PROCESSES 24
and losses, acculturative adjustment of parents and children, and experiences of discrimination
and other social challenges often common in this population. There were also many protective
factors among these families that were incorporated, such as cultural traditions (e.g., family
rituals and religious traditions) for bonding the family, family cohesion and interdependence,
large extended family networks to increase support, and optimism for the future, among others.
In addition to using culturally and socially congruent examples and concepts, we relied
on action-oriented techniques (e.g., acting) to facilitate family engagement and perspective-
taking between parents and youth. Moreover, the program infused greater focus on marital
relationships given that the majority of women in the program had a spouse/partner who also
participated. These program modifications, the linguistic customization of the program, and
attention to the facilitators’ language and culture, were found to increase the family’s
acceptability of the program.
To the best of our knowledge, the FF program is the only intervention for Latino families
facing maternal depression that involves the full and equal participation of mothers, caregivers,
and all pre-adolescent and adolescent children in each meeting. Young children also participate
in programmatic activities as part of a childcare group. By including the whole family, fathers—
who are typically a difficult group to engage— become more involved in the program and in the
family’s recovery, potentially amplifying the effects of the program. Thus, the design, feasibility,
acceptability, and preliminary outcomes of the FF program suggest that it is meeting the needs of
Latino immigrant families when a mother has depression. The efficacy of the FF program needs
to be ascertained and we are currently planning to evaluate it using a randomized design.
The FF program targets Latino families with pre-adolescent and adolescent children but
the program may have greater impact with younger children, who have yet to experience
SOCIOCULTURAL PROCESSES 25
dissonant acculturative stressors. A few of the parents reported being monolingual in Spanish,
and their adolescent children, in contrast, had very low levels of Spanish fluency. Thus, reaching
families prior to the marked acculturative parent-child dissonance that is more common in
adolescence could potentially strengthen family outcomes and children’s coping with family and
community stressors. We are currently working to develop a program for children ages 4 to 8 to
accompany the youth and parent/caregiver groups.
Research and social policy play an important role in making family programs more
effective and accessible to immigrant families. Policymakers need to recognize the role of family
and sociocultural contexts in the health and illness of individuals (Doherty, 2002). When a
mother experiences depression, the cost to the children can be significant. And when the family
faces poverty, discrimination, and restrictive immigration policy, as in the case of many
immigrant families, recovering from and coping with the illness and its associated family
relational patterns may be even more difficult. Thus, professionals are charged to offer effective
and culturally congruent interventions that can address the family processes and sociocultural
risks and strengths of Latino immigrant families.
SOCIOCULTURAL PROCESSES 26
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SOCIOCULTURAL PROCESSES 30 Download full-text
Table 1 Content of FF Parent/Caregiver and Youth Groups
Meeting Parent Program Youth Program
1 Introduction and family sharing
Identifying hopes and goals
Introduction and family sharing
Identifying strengths, hopes and goals
2 Understanding depression
Depression, thoughts and feelings
Helpful and hurtful thoughts
3 Effects of depression on the family
Resilience in children
Family stress and strengths
Effects of depression on the family
4 Growing up in the United States
Integrating two cultures
Growing up in the United States
Integrating two cultures
5 Creating positive family experiences
Family activities and using praise
Creating positive family experiences
Changing kids’ and families’ worlds
6 Building positive communication
Listening, Responding, “I” Statements
Building positive communication
Positive statements/“I” Statements
7 Managing children’s behavior
Clear, calm, and consistent strategies
8 Conflict resolution
Working through marital conflict
Negotiating conflict in a different culture
9 Preparing for family meeting Preparing for family meeting
10 Family meeting Family meeting
11 Processing the family meeting and preparing
for future meetings
Processing the family meeting and
preparing for future meetings
12 Review of program progress and goals Review of program progress and goals
Boosters Family updates and check-ins Family Updates and check-ins