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The Schema Therapy Bulletin

The Official Publication of the 

International Society of Schema Therapy

Schema Therapy and Latino Patients… A Cultural Approach
by Carlos Rojas (USA)

A primary challenge in working with patients from different cultural backgrounds is being able to use cultural generalizations appropriately without losing sight of the individual patient. To succeed in this challenge, clinicians must keep in mind that variations occur between cultural subgroups just as individuals subscribe to group norms to varying degrees.  Consideration of culture is essential in the process of diagnosis and treatment of culturally diverse patients.  In the past decade the consideration of cultural factors has gained recognition in a variety of disciplines.  In this article you will find a discussion of Latino cultural factors that are influential in the development of early maladaptive schemas (as defined within the Schema Therapy Model) and the propensity for specific schemas to develop within Latinos as a cultural group.


Overall, the Latino community does not talk about mental health issues. There is little information about this topic.   Many Latinos do not seek treatment because they don't recognize the signs and symptoms of mental health conditions or know where to find help. This lack of information also increases the stigma associated with mental health issues. Many Latinos do not seek treatment for fear of being labeled as “locos” (crazy) or as having a mental health condition because this may cause shame.  One in 5 people is affected by mental illness.   Among Latinos cultural beliefs often influence mental health issues, el dicho "la ropa sucia se lava en casa” (similar to “don’t air your dirty laundry in public”). Latinos as a group tend to be very private and often do not want to talk in public about challenges at home. Cultural differences may lead to misdiagnosis among Latinos. For instance, Latinos may describe the symptoms of depression as “nervios” (nervousness), tiredness or a physical ailment. These symptoms are consistent with depression, but mental health providers who are not aware of how culture influences mental health may not recognize that these could be signs of depression.


While Latino communities show similar susceptibility to mental illness as the general population, unfortunately, they experience disparities in access to treatment and in the quality of treatment they receive. This inequality puts Latinos at a higher risk for more severe and persistent forms of mental health conditions.  As a community, Latinos are less likely to seek mental health treatment. A 2001 Surgeon General’s report found that only 20% of Latinos with symptoms of a psychological disorder talk to a doctor about their concerns. Only 10% contact a mental health specialist. Yet, without treatment, certain mental health conditions can worsen and become disabling.


Failure to understand and respond appropriately to the normative cultural values of patients can have a variety of adverse clinical consequences.  Latinos tend to be highly group-oriented. A strong emphasis is placed on family as the major source of one’s identity and protection against the hardships of life. This sense of family belonging is intense and limited to family and close friends. People who are not family or close friends are often slow to be given trust. The family model is an extended one; grandparents, aunts, cousins, and even people who are not biologically related may be considered part of the immediate family. The term Latinos use to describe their supreme collective loyalty to extended family is familismo. Financial support of the family by the individual and vice versa is important and expected. The decisions and behavior of each individual in the extended family are based largely on pleasing the family; decisions are not to be made by the individual without consulting the family.  In Latin American cultures, people tend to expect status differences between members of a society which is very different from U.S. American culture. Latinos place a high value on demonstrating respecto in interactions with others, which literally translates into respect. Respecto means that each person is expected to defer to those who are in a position of authority because of age, gender, social position, title, economic status, etc. Healthcare providers, and doctors especially, are viewed as authority figures. Thus, Latino patients/parents will tend to demonstrate respecto in healthcare encounters. They may be hesitant to ask questions or raise concerns about a doctor’s recommendations, being fearful that doing so might be perceived as disrespectful. They may nod to demonstrate careful listening and respect when a doctor is talking, rather than agreement about treatment.  Respecto is also expected on a reciprocal basis by Latinos when dealing with healthcare professionals. This is especially the case when a young doctor is treating an older Latino patient. It is important to approach Latino patients/parents in a somewhat formal manner, using appropriate titles of respect (Senor [Mr.] and Senora [Mrs.] and appropriate greetings [good morning or good afternoon]. This is especially true with older Latinos.


Latino families are often stratified based on age and sex. Generational hierarchy is expected – grandparent, child, grandchild. The oldest male (direct relative) holds the greatest power in most families and may make health decisions for others in the family. Latino men traditionally follow the ideal of machismo. They are expected to be providers who maintain the integrity of the family unit and uphold the honor of family members. Many Latino females, at least publicly, are expected to manifest respect and even submission to their husbands, though this compliance varies by individual and is affected by acculturation in the U.S. Women follow the ideal of marianismo which refers to the high value Latino women place on being dedicated, loving and supportive wives and mothers. They are responsible for teaching Latino children culture and religion and for being ready to help those in need both in the family and community. It bears repeating that upward mobility, education and other societal factors are changing the above, but in isolated communities and among new immigrants, little has changed.


ST has demonstrated relatively low levels of attrition (e.g. Giesen-Bloo et al., 2006) with populations who may otherwise struggle to engage in therapy, making it a promising approach for Latinos. Because the ST model assumes that all people develop schemas in childhood (Arntz & van Genderen, 2009), an explicit focus is put on schema development, often involving family relationships. Strategies are employed to defuse dysfunctional, self-defeating patterns fueled by early maladaptive schemas that formed due to unmet needs (Young et al., 2003). The ST focus on interpersonal and family relationships makes it particularly relevant to Latinos because of the cultural value of familism, a deep sense of loyalty, solidarity, and reciprocity among Latino family members (Sabogal, Marin, Otero-Sabogal, Marin, & Perez-Stable, 1987). A careful understanding of familism is considered crucial for successfully recruiting and retaining Latinos in psychotherapy research (Miranda et al., 1996) but the topic is complex. Adherence to familism can bring benefits that are protective (Gallo, Penedo, Espinosa de los Monteros, & Arguelles, 2009) such as family cohesion and support (Sabogal et al., 1987), but it can also present challenges. Overt or covert cultural expectations regarding obligations or gender roles in the family starting in childhood can create emotional conflict with potential to influence adult relationships (Gil & Vazquez, 1996). The focus on schemas allows a way to deal with familism within ST.


It has been my experience that as a result of these cultural phenomenon Latinos are characterized by particular schema profiles.  One must be careful not generalize or jump to conclusion as each individual carries unique characteristics, however cultural factors play a major role in the development of certain schemas among Latinos.  Below I will present a short discussion on schemas and the Latino Cultural factors that influence their development and maintenance.  This is by no means an exhaustive or comprehensive list; it serves a perspective for further discussion and to raise awareness on the topic.


Young describes the maladaptive schema category of “Impaired Autonomy and Performance” as: The expectation of an individual’s ability to separate, survive, function independently and/or perform successfully away from their environment is impaired.  The schema of dependence/incompetence can be found in this category and is characterized by: The expectation that an individual’s ability to separate, survive, function independently and/or perform successfully away from their environment is impaired.  People with this schema often rely on others excessively for help in areas such as decision-making and initiating new tasks. Among Latinos this schema is influenced by the concept of familismo which requires individuals to make decisions and behave in ways that please the family rather than address his or her individual needs. The concepts of machismo and marianismo also influence this schema as they require men to focus their attention on the financial and protection needs of the family and women to place a greater enfaces on the physical and developmental needs of the family which often sacrifices their own needs.  This approach does not encourage individuals to act independently and develop confidence in their ability to take care of themselves. But rather it sends the individual the message that their individual happiness will come as a result of focusing on the needs and loyalty to the family.   Among Latino patients this schema is often characterized by feelings of dependence and impaired autonomy.  Patients are often report feelings of enmeshment and often experience some level of impairment in making life through different life stages.


Young describes the maladaptive schema category of “other directedness” as: The individual is overly invested on the desires, feelings, and responses of others at the expense of their own needs; in order to gain love and approval and maintain their sense of connection or avoid retaliation.  The schema of self-sacrifice can be found in this category and is characterized by: the excessive sacrifice of one’s own needs in order to help others.  Among Latinos this schema is promoted by the concepts of respeto, which expects the individual to often sacrifice their own needs and defer to the needs of those in charge or the needs of family and/or community. The concepts of machismo and marianismo also influence this schema as they require men to focus their attention  strength and women to place a greater enfaces on the needs of the family which often sacrifices their own needs.  This approach sends the individual the message that their individual happiness will come as a result of placing the needs of others above those of their own.   Among Latino patients this schema is often characterized by feelings of guilt and resentment.  Patients are often left feeling that their intimate relationships will only work if they are overly invested in the needs of others.  That in order to gain love, approval and maintain a sense of connection they need to place the needs of others above their own.


Young describes the maladaptive schema category of ”Overvigilance and Inhibition” as: The individual has an excessive emphasis on suppressing spontaneous feelings, impulses, and choices or meeting rigid, internalized rules and expectations about performance and ethical behavior, often at the expense of happiness, self-expression, close relationships, or health.  The schema of Emotional Inhibition can be found in this category and is characterized by: the belief that you must suppress spontaneous emotions and impulses, especially anger, because any expression of feelings would harm others or lead to loss of self-esteem, embarrassment, retaliation or abandonment.  Among Latinos this schema is promoted by the concepts of respeto, which expects the individual to defer to individuals in a position of power often sacrificing the needs of the individual for the needs of those in charge.  The concepts of machismo and marianismo further influence this schema as they require men to be strong and maintain the integrity of the family and the later concept requires women to place the needs of the family above all else.  Among Latino patients this schema is often characterized by feelings disconnection and isolation.  Patients are often left feeling that their intimate relationships will not adequately meet their needs for empathy, nurturance or protection.

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