Mexican American Women’s Perspectives on a Culturally Adapted Cognitive-Behavioral Therapy Guided Self-Help Program for Binge Eating

Abstract

The prevalence of bulimia nervosa (BN) and binge eating disorder (BED) among Latinas is comparable to those of the general population; however, few interventions and treatment trial research have focused on this group. Cognitive-behavioral therapy (CBT) is the treatment of choice for binge eating related disorders. CBT-based guided self-help (CBTgsh)—a low-cost minimal intervention—has also been shown effective in improving binge eating related symptom, but the effectiveness of the CBTgsh among ethnic minority women is not well understood. Cultural adaptation of evidence-based treatments can be an important step for promoting treatment accessibility and engagement among underserved groups. This qualitative study was part of a larger investigation that examined the feasibility and efficacy of a culturally adapted CBTgsh program among Mexican American women with binge eating disorders. Post-treatment focus groups were conducted with 12 Mexican American women with BN or BED who participated in the intervention. Data were analyzed with the grounded theory methodology (Corbin & Strauss, 2008). Three themes emerged from the data: 1) eating behavior and body ideals are socially and culturally constructed, 2) multifaceted support system is crucial to Mexican American women’s treatment engagement and success, and 3) the culturally adapted CBTgsh program is feasible and relevant to Mexican American women’s experience, but it can be strengthened with increased family and peer support. The findings provide suggestions for further adaptation and refinement of the CBTgsh, and implications for future research as well as early intervention for disordered eating in organized care settings.

Research in the last decade has underscored the importance of examining binge eating disorders, such as Bulimia Nervosa (BN) and Binge Eating Disorder (BED), among Latinas (e.g., Alegria et al., 2007; Cachelin et al., 2001; Cachelin, & Striegel-Moore 2006; Chamarro & Flores-Ortiz, 2000). BN includes symptoms such as recurrent binge eating, inappropriate compensatory behavior, and over-valuation of body shape and weight (American Psychiatric Association, 2011). BED is characterized by recurrent binge eating without inappropriate compensatory behaviors, and is associated with behavioral indicators of a sense of loss of control over binge eating such as eating when not hungry or feeling extremely distressed over binge eating behavior (American Psychiatric Association, 2011). Both Bulimia Nervosa (BN) and Binge Eating Disorder (BED) have been associated with severe medical and psychiatric problems, including obesity (Wonderlich, Gordon, Mitchell, Crosby, & Engel, 2009). The prevalence of BN and BED among Latinas is comparable to the estimates found in White women (Alegria et al., 2007; Granillo, Jones-Rodriguez, & Carvajal, 2005). However, Latinas—especially those from socioeconomically disadvantaged background— continue to be underrepresented in eating disorder treatment and treatment trial research (Garvin & Striegel-Moore, 2001; Rosen, Tolman, & Warner, 2007). The disparities are in part due to their poor utilization of psychological services. Cultural and institutional-level barriers such as a lack of culturally sensitive treatment, poverty, stigma, and logistical constraints (e.g., no childcare) may have contributed to Latino/as’ challenges in seeking professional help for mental health issues (Cachelin et al., 2001; Cawthorne, 2008; Kouyoumdjian, Zamboanga, & Hansen, 2003; Nadeem et al., 2007; U.S. Department of Health and Human Services, 2001).

Cognitive behavioral therapy (CBT) is one of the most effective treatments for binge eating disorders (Wilson, Grilo, & Vitousek, 2007). CBT model targets maladaptive cognition and behavior associated with binge eating, such as negative over-concern with body shape and weight, dysfunctional dieting, and unhealthy weight-control behaviors (e.g., purging). The treatment is designed to reconstruct one’s rigid thinking and concern with body shape and weight, replace dysfunctional dieting and weight-control behaviors with more regular and healthy pattern of eating, and help clients develop strategies to prevent relapse (Grilo, 2006). However, CBT can be costly to implement due to the extensive training and expertise required of the therapists. Cognitive behavioral based guided self-help (CBTgsh) was developed as a low-cost alternative and is recommended as a first-line minimal treatment for binge eating related problems (Striegel-Moore et al., 2010; Wilson & Zandberg, 2012). Efficacy trials suggest that CBTgsh is effective in reducing binge eating and vomiting, mitigating excessive weight and shape concerns, and improving depression and self-esteem (Grilo & Masheb, 2005; Striegel-Moore et al., 2010; Sysko & Walsh, 2008). Nonetheless, these research studies have been conducted on predominantly White (European/European American) women (Miller, 2004), thereby limiting the generalizability of their findings to ethnically and culturally diverse groups.

As part of the efforts to eliminate mental health disparities (U.S. Department of Health & Human Services, 2001), there has been a call to integrate the best available clinical research and practice, such as evidence based treatments (EBTs), and the needs and characteristics of racial/ethnic minority clients (American Psychological Association Presidential Task Force on Evidence-Based Practice, 2006, p. 273; Miranda, Nakamura, & Bernal, 2003). Case studies and empirical findings have supported the theoretical and pragmatic importance of incorporating culturally and contextually relevant factors and features (e.g., values, beliefs, immigration and acculturation experience, literacy level) into treatment (Vega et al., 2007; Shea, & Leong 2013). Culturally tailored practice tends to promote service utilization and treatment engagement among ethnic minority groups (Falicov, 2009; Interian, Martinez, Rios, Krejci, & Guarnaccia, 2010; Bernal & Domench-Rodriguez, 2012).

The current study was part of a larger project that examined the feasibility and preliminary efficacy of a culturally adapted CBTgsh program to treat binge eating related problems among Mexican American women. We focused specifically on second or later generations of Mexican Americans because they are the largest Latino group in the U.S. (Lopez, Gonzalez-Barrera, & Cuddington, 2013) and to control for within-group variability due to different nationalities, sociopolitical histories, cultures and acculturation levels. The quantitative results of our efficacy study were reported in a separate paper (Cachelin et al., 2014). In addition to the quantitative evaluation, we intended to qualitatively assess Mexican American women’s experience with the culturally adapted CBTgsh program using a focus group methodology to better understand the key components for future program development and adaptation. This paper reports the qualitative findings from the post-treatment focus groups.

There are several benefits of conducting post-treatment focus groups. First, qualitative method from the focus groups are useful for enlightening a particular group’s perspectives, describing complex sociocultural phenomena, elaborating and complementing quantitative findings, and generating new research inquiries (Bernal & Scharró-del-Río, 2001; Morgan, 1998; Pyett, 2003). Second, focus groups provide a safe place to bring forward the voices of those women who have been underrepresented: to validate their everyday experiences, to highlight commonalities, and to enrich each other’s ideas (Wilkinson, 1998). Lastly, there has been an increasing trend for using focus groups as a part of cultural adaptation process and treatment program evaluation (e.g., Blonstein et al., 2013; Grau et al., 2013). Prior to implementing the CBTgsh program, we have conducted preliminary focus groups with a group of Mexican American women diagnosed with binge eating disorders and solicited their feedback on the cultural components that need to be adapted (Shea et al., 2012). Findings from the current study can be used to corroborate findings from the preliminary focus groups, serving the purpose of data triangulation and illuminating the utility of focus group in informing cultural adaptation and program evaluation research.

In the following, we provide the backdrop to the current study: the CBTgsh program for binge eating problems and the cultural adaptations that were implemented. We then describe the process of conducting post-treatment focus groups and discuss the participants’ responses to the culturally adapted CBTgsh program.

CBTgsh and Cultural Adaptation

Similar to CBT, the core components of CBTgsh address maladaptive and irrational thinking (e.g., “I have to be in complete control of my diet plan or I will just give up and start binging”) and problematic behavior or coping (e.g., “I use binging to relieve my stress”). Unlike CBT, which is typically conducted by a trained specialist in a clinical setting, the CBTgsh program allows participants to follow a self-help manual and receive regular but limited guidance/support sessions from a “supporter” or “coach,” who may or may not have received specialized training in CBT. The sessions can be conducted over the phone or in person. Thus, CBTgsh is less costly to implement, less stigmatizing, and more accessible compared to traditional CBT. Fairburn (1995)’s self-help book, Overcoming Binge Eating, is the most frequently evaluated CBTgsh program (Wilson & Zandberg, 2012). Participants follow six steps of the self-help book and receive eight brief guidance/support sessions (25 minutes) over a 12-week period with more sessions clustered in the earlier phase (see a detailed description of the CBTgsh program and a case study by Cachelin et al., 2013).

Following the recommended guidelines on cultural adaptation (Bernal & Domench-Rodriguez, 2012; Napoles-Springer & Stewart, 2006; Rounsaville, Carroll, & Onken, 2001), we conducted preliminary focus groups to evaluate the acceptability of CBTgsh among Mexican American women and to elicit cultural themes that would be pertinent to our adaptation. Based on the participants’ feedback, we made a few adaptations (see Shea et al., 2012), which include: (1) creating an ethnic specific food guide for Mexican Americans, (2) developing and role-playing vignettes that portray common family and cultural dynamics in Mexican American households during an initial orientation session, and (3) providing ongoing supervision to the supporters with an emphasis on multicultural competency. We retain the core structure and features of the CBTgsh and did not alter any of the contents of the self-help book.

Method

Participants

Approval was received from the Institutional Review Board to recruit Mexican American women with binge eating disorders in the greater Los Angeles area. Twelve Mexican American women (M_age = 30.82, SD = 6.42, range = 22–40) who had completed a culturally adapted CBTgsh intervention for binge eating disorders (Shea et al., 2012) were invited to participate in two semi-structured focus groups at post-treatment. Each group consisted of six participants. This sample came from the original study that examined the feasibility and effectiveness of a culturally adapted CBTgsh program, which included 31 participants (see inclusion and exclusion criteria in Cachelin et al., 2014). Of the 31 participants, 11 dropped out of the program at some point, 20 completed the program. Of the 20 completers, 12 expressed willingness to participate in the post-treatment focus group interview to share their experiences. The majority of the participants were of second or later generation of Mexican immigrants and all of them were English speaking (see other demographic and diagnostic information in Table 1). The sample size of 12 is consistent with the number reported in other focus group studies and the guidelines for conducting focus groups (Krueger, 2009; Onwuegbuzie, Dickinson, Leech, & Zoran, 2009).

Table 1.

Focus Group Participants’ Demographic and Diagnostic Information

Total number of participants		N =12
Generation status	1st generation	3
	2nd generation	7
	3rd generation or above	2
Relationship status	Married	4
	Single	8
Have children	Yes	3
	No	9
Education Level	Some college	4
	4-year college graduate	8
Employment Status	Employed	7
	Unemployed	4
	Not disclosed	1
Eating Disorder	Bulimia Nervosa	2
	Binge Eating Disorder	7
	Recurrent Binge Eating	3

Semistructured Interview Guide

The semistructured focus groups were conducted in English and began with an introduction of the study purpose and the interview process. Group discussions were first elicited by asking participants an open-ended question: “What do you think of the CBTgsh intervention program and book?” Based on the participants’ initial responses, the group facilitator prompted the participants for more specific details about their responses, such as: “What was most/least helpful about the program?” (See Appendix I for sample questions).

Procedure

We followed established guidelines for conducting focus groups (e.g., Shea et al., 2012; Yeh, Kim, Pituc, & Atkins, 2008). A trained research assistant facilitated the focus groups, while a note taker recorded detailed notes of the session content and non-verbal behavior during the discussion. The 90-minute focus group session was audio recorded with participants’ permission. The transcription procedure was rigorous. Two raters, who were not the group facilitator or the note taker, independently checked the transcripts against the original audiotapes. They then discussed any discrepancies until consensus was reached. The two raters were not involved in the cultural adaptation phase or any of our previous studies; therefore they were blinded to the study purpose.

Data Analysis

Grounded theory approach was used to facilitate participants’ insights and discovery of meanings of their subjective experience within relevant sociocultural context (Corbin & Strauss, 2008). This approach goes beyond simple descriptions of themes; rather it creates a thematic schema (a “story”) that illuminates the process, interaction, and action shaped by the participants. Grounded theory method can also help generate future research questions and hypotheses about binge eating disorders and treatment engagement among Mexican American women.

Data analysis followed systematic steps and is characterized by constant comparison (Corbin & Strauss, 2008). First, open coding was used to code the data. The two raters read the transcripts several times and then labeled the smallest unit of meaning as “concept.” Then, during the axial coding stage, constant comparison was utilized where these units of meaning (concepts) were grouped together under various categories or themes (Corbin & Strauss, 2008). Finally, selective coding was utilized to outline the interrelationships of the categories and themes. This step helps create a coherent story line (i.e., emerging theory) that captures the most poignant aspects of the data (Fassinger, 2005).

Establishing Trustworthiness of Data

Previous research utilizing grounded theory approach suggested several methods for increasing the authenticity and credibility of researchers’ interpretations grounded in the data (Yeh et al., 2008, Pyett, 2003). Our research team consisted of the two researchers (the first two authors), the group facilitator, the note taker, and the two raters. First, the second author and the group facilitator had prolonged engagement with the Mexican American community. Over a decade, the second author and her research group had been involved in a women’s health project that examined disordered eating among ethnic minority women— specifically Mexican American women of low-income background. Many of the participants were willing to take part in the follow-up studies years later due to the established trust and respect toward the second author. In this study, the second author contributed her ideas to the recruitment and engagement of Mexican American participants in treatment outcome research. The group facilitator is a bilingual (Spanish, English) behavioral therapist who works with Latino/a clients in her daily work. Her bicultural and bilingual competency helped facilitate a sense of confianza (trust) during the interview process, which made the participants feel at ease discussing their thoughts and emotions. Second, a trail of research activities and processes was carefully maintained. The team met regularly to discuss their questions, concerns, and potential biases with regards to the interview process and data analysis. All transcripts and notes were checked against the original audiotapes. In addition, the first author, who has expertise in ethnic minority and immigrant mental health, did an independent review of the concepts, categories, and themes. Third, the research team engaged in member checking. After the analysis, a participant of the focus group was invited to read the list of the themes and categories as a stability check (Swagler & Ellis, 2003). Her feedback was incorporated into the final version. Finally, the two raters kept notes of their thoughts and reactions while doing the data coding—a process known as reflexivity—in an attempt to understand how their worldviews, biases and assumptions may inform their interpretations of the data (Patton, 2002). Examples of their self-reflection are shown in Appendix II.

Results

Three main themes emerged from the data: 1) eating behavior and body ideals are socially and culturally constructed, 2) multifaceted support system is crucial to Mexican American women’s treatment engagement and success, and 3) the culturally adapted CBTgsh program is feasible and relevant to Mexican American women’s experience, but it can be strengthened with increased family and peer support.

Socially and Culturally Constructed Eating Behavior and Body Ideals

Participants expressed that the ethnic- or culture-specific influences on eating and meaning of food, financial constraints, and the Western cultural ideal of thinness may precipitate their overeating and present challenges to their help seeking or treatment engagement. Many participants mentioned that their family members dislike the taste of low-fat, low-calories foods (e.g., vegetables, yogurt) and were not used to healthier preparations (e.g., steaming and boiling as opposed to deep frying). One participant said, “My mom tried to cook with little salt and seasonings. But they (family members) loathed the dishes my mom brought in. They tasted it and immediately said ‘Oh no, esto no tiene sabor (the food has no taste)!’ and would refuse to eat it.” Several participants suggested that serving and eating food together is congruent with their cultural expectations and family traditions. The ritual of preparing, sharing, and providing food to the younger family members (e.g., grandchildren) symbolizes love, nurturance, abundance, and hospitality in Mexican culture, especially among women, (Harris & Franklin, 2003; Shea et al., 2012). One woman recalled, “My mom always asks me ‘Mija, do you want more? You want more?’ That’s the only part I remember growing up because that is so true (typical) of my culture.” Another woman said, “Well my family especially my mom shows her love through food, through cooking. She just loves to overwhelm us with food.”

Many participants reported that it was difficult and impractical for them to make individual choices about their diets and food preparations since they live with others. In Mexican culture, women were expected to take care of and prioritize other family members’ needs above their own (Arredondo, Elder, Ayala, Slymen, & Campbell, 2006; Bautista, Reininger, Gay, Barroso, & Mccormick, 2011), and thus the participants felt wary of drawing criticism from their family for trying to eat differently:

Basically all the sacrifices we women make, part of that is a big duty, and part of that is to keep the family traditions of how things are prepared… it is an overwhelming feeling. Conformity! It becomes part of who we are.

Financial and social factors also underlie Mexican American women’s ambivalence toward seeking help for their eating problems. A few women noted the costs of healthy eating. For example, they said, “It’s expensive, you know, it’s like… a big issue to eat healthy. You have to pay for it.” “It is not because your parents don’t want you to eat healthy, but sometimes they cannot afford to buy healthy food. You know, especially when there are a lot of kids… They buy lard instead of olive oil because lard is less expensive, even though they know olive oil is very good for you. Where I grow up, you know, you are eating things to fill up your stomach not so much to care about the nutritional value, you eat just so you don’t go to bed starving.”

Several participants mentioned that the mainstream cultural expectation and emphasis of thinness in women had led them to engage in relentless self-deprecation of not being “good enough.” “You know, you’re supposed to be thin. You’re supposed to look like the models in the magazines." “You draw a lot of parallels with those out there… I mean you’re being bombarded with these ideal images.” Some women said the thin ideal is so pervasive that even their own mothers and the prominent public female figures (e.g., Miss Universe) emulate that. As a result, these women felt overcome by a sense of despair and loss of control, and would resort to overeating. One participant shared:

My mom is really picky about what she’ll eat or what we’ll eat. She’s even thinner than I am. And she’s very critical of what I eat. I think it makes me self-conscious and then I feel depressed. So then I want to eat more because I can’t get to where she wants me to be. I just gave up! She wants me to be more ideal (thinner) and I don’t think that she knows she’s putting a lot of pressure on me. I don’t think she has ever known that she has done it to me throughout.

The pervasive cultural norms governing women’s ideal body image, eating behavior such as dieting, and certain ethnic- or generation-specific view toward food (e.g., “Food is sacred, you don’t waste that.”) may leave the participants feeling conflicted and powerless to make changes, and become doubtful of the utility of professional help. As a result, they may feel locked in a cycle of self-criticism, shame, and secrecy, which further escalates the risk of maladaptive eating and other psychological problems such as anxiety and depression (American Psychiatric Association, 2013; Shea et al., 2012).

Multifaceted Support System

Participants unequivocally stated that the supporters were instrumental to their success in completing the GSH intervention. One participant said, “My supporter was very helpful. When you were working through the issues, they never made you feel bad for anything that you had done or needed to work on. They were always so encouraging.” Nevertheless, participants acknowledge that individual commitment and support from other sources were equally important in their motivation for engaging in the treatment. One woman summarizes her view toward the GSH program:

The person really needs to commit to it (GSH program) as a lifestyle change and not just sees it as a weight loss program. Because weight loss programs are to be used for a certain amount of time and then you move on. This is not something that you are going to do for a while or that you are supposed to move on from. This is something that is supposed to help you like, change the way you are, change the way you think, change the way you eat, you know.

Eating, like many other social behaviors, is susceptible to social context influences such as the choice or amount of food consumed by others (Robinson, Blissett, & Higgs, 2013). One woman stated that her partner regularly eats a large meal of fast food late at night. His eating habit often triggered her overeating. Another woman shared:

I know one of my issues was trying to keep everyone, like myself and my kids, on track. For my kids it was easy but trying to keep my husband on the same track… ah that was a little hard. Because he doesn’t understand… I mean I’ll try to get him to follow the meal plan, but he won’t. He’ll eat like two big meals a day. He is like that. So trying to get him to incorporate the GSH program into his life style would help. It’s like a family thing.

Participants expressed that—on a broader level—there are not many programs or resources that are geared toward Mexican American women. Several participants said the commercial weight loss programs were “too expensive” for them and not contextually appropriate. For instance, one participant said, “There are a lot of young single mothers in our community, you know. Young single mothers need tips on how to cook, what to cook, and what kind of food they can make at home that is inexpensive and easy-to-make. They need specific suggestions and guidance for that."

Feasibility and Cultural Relevance of the CBT-GSH

Overall, participants responded favorably to the culturally adapted CBT-GSH program. The pragmatic approach of the book allows the participants to accept their eating problem without feeling negatively or ashamed, and the step-by-step instructions make it easy for them to maintain their focus on short-term goals and follow through with their plans. Many women said they would recommend this treatment to those who have similar issues.

The core elements of the intervention—such as developing self-awareness of binge triggers (cognition), maintaining regular eating through meal planning, and engaging in problem solving to reduce psychological distress (behavioral management)—as well as the self-help emphasis were deemed most helpful. One woman said, “The program helps you identify patterns. Our triggers are not just about food. It’s about other (emotional) issues.” Another said, “The program is straightforward, to the point. The book gives you examples. It is easy to understand. You can implement it right away.”

With regards to the cultural adaptations, participants found the program to be generally congruent with and relevant to their experience. They appreciated the ethnic specific food guide and their supporters’ cultural sensitivity. For example, one participant said her supporter understood the context of her problems and helped her unravel the triggers of her binging:

I noticed that in Mexican culture—well I think Latin culture in general—we are not encouraged to express anger, especially with parents or with family. You’re like, oh no, girls are supposed to be pretty and pleasant all the time and she’s not supposed to be angry. And that just eats me up! When I realized that (through identifying the triggers), that was like a very big revelation to me. Oh my god this is the way I’ve been raised most of my life and this is what my culture has taught me. But they (supporters) gave you permission to express yourself out loud. It’s like having someone acknowledge and validate your feelings.

In spite of the role-playing exercise, many participants felt underprepared for coping with family conflicts or family interferences with their treatment. They suggested that the program could be strengthened with increased family and peer involvement. One participant said, “Yeah, the program can talk about how to get them (family) on your side, as opposed to making you feel ostracized. I mean I don't have those tools, I don't know how to go about doing that. If they can provide us with suggestions, that will be very helpful.” Another participant highlighted the importance of involving spouses or significant others in a Mexican household:

I would definitely recommend it (the GSH program) to the partners of the females who are in the program, because they need to understand how hard it is for us. You know…for her (pointing to another participant), they’re married so they have to eat together. I think the males should be more supportive… so they can understand what we are going through. They can also try to participate in healthy eating.

To combat the sense of isolation and loneliness that often result from the secrecy and shame associated with disordered eating, participants suggested that the program could provide them with an opportunity to connect with other women in the CBTgsh program. For example, one participant said, “Knowing you are not by yourself, that there are other people who are doing the same thing. Maybe getting to know each other helps. When I am about to binge, oh my god, help me out! Then we have not just the support of your supporters, but also the support of the people who are doing the program.” Other women agreed that having a peer support network could strengthen the self-help aspect of the program:

If you are able to meet twice a month and build a support group, having the actual face-to-face contact with other women in the program, you wouldn't really need a supporter to call you all the time. It would be a little bit more like doing it on your own, like taking ownership of this (program) rather than having the guidance. I think it’s more empowering to be able to know how to do it yourself and having a group of people going through it with you.

Discussion

Our findings provide a contextualized view of Mexican American women’s eating problems and challenges in treatment seeking and engagement. The three themes reveal a narrative about Mexican American immigrant women’s vulnerabilities and strengths. Eating may have emerged as a way of coping for the problems participants face in a rapidly changing acculturative context. At the same time, disordered eating became a precipitating and perpetuating factor for their emotional distress and family tensions. Despite their feelings of loneliness in their recovery process, participants remained hopeful and stayed engaged in a treatment that empowers them to work toward self-acceptance.

Mexican American women in our study—many of whom are second generation immigrants and living with family members—encounter competing messages about their body image and eating. Previous research suggests that ethnic minority women in the U.S. are not immune to the Western feminine ideals including thinness due to the frequent exposure to the mainstream standards (Cachelin et al., 1998; Gordon, Perez, & Joiner, 2002; Mahalik et al., 2005). The pressure to live up to the thin ideal may be especially intense among our participants who tend to be college-educated, employed, and more acculturated. On the one hand, acculturation to the mainstream norms and practices including beauty standards helps Mexican American women adapt to the changing environment outside of their home. On the other hand, the expectation to navigate between two sets of worldviews and cultural standards can leave them feeling distressed and alone. Research suggests that second-generation Mexican American women may be at greater risk for developing disordered eating (Alegria et al., 2007; Swanson et al., 2012), in part due to the interpersonal stress brought on by acculturation gaps and divergent intergenerational ideals on weight and body shape (Chamorro & Flores-Ortiz, 2000). Findings from our previous studies also suggest that a lack of understanding toward eating disorders among family members, coupled with traditional gender role demands, may contribute to ongoing family interferences and criticisms toward Mexican American women’s treatment decision and behavioral change, which render them vulnerable for treatment disengagement and dropout (Cachelin et al., 2014; Shea et al., 2012).

Participants’ retention in the program and their own reports of treatment acceptability present evidence for the ecological validity of the culturally adapted CBTgsh program. Similar to what we found in other studies that examine the feasibility and efficacy of the CBTgsh program (Shea et al., 2014; Shea et al., 2012), Mexican American women described the core components (i.e., intervention of problematic cognitions and behaviors) and the self-help feature as the most helpful and empowering aspect of the treatment. The systematic approach of the book and the flexibility of the program structure may be especially appealing to a population who would not otherwise seek professional psychological services due to a myriad of cultural, financial, and intuitional barriers (Cachelin et al., 2006; Cawthorne, 2008). The low-cost, self-help feature provides an alternative to participating in more expensive commercial weight loss programs. Furthermore, participants’ positive response toward their supporters suggests that disseminating an evidence-based treatment with non-specialists is feasible as a first-step minimal intervention for Mexican American women with binge eating disorders.

In terms of therapist effect, researchers who specialize in cultural adaptation posit that multiculturally competent clinicians can augment the effect of a thoughtfully adapted intervention (Bernal & Domenech-Rodriguez, 2012). Our findings seem to support this contention: The supporters’ understanding and sensitivity toward Mexican American women’s contextual and cultural challenges (e.g., not having access to a private computer to update their food logs, having difficulty in expressing negative emotions toward family members), and their efforts to follow up after missed appointments were instrumental in establishing a strong therapeutic alliance and in keeping the participants engaged in the treatment.

Consistent with previous findings (Shea et al., 2012; Lindberg & Stevens, 2007), culture, family, and economic factors play an important role in shaping Mexican American women’s eating behavior, perceived meaning of food, and attitudes toward seeking treatment. Some of the participants acknowledged that their family’s limited income, dietary choices and lack of knowledge toward eating disorders had undermined their treatment efforts; however, they were reluctant to address these issues with their family so as to avoid interpersonal conflicts. The family vignette role-playing exercise was intended to help participants cope with potential family conflicts related to their eating. Nevertheless, the brevity of the exercise (20 minutes) and the timing of which was offered (during the very first session) may have compromised its effectiveness, as the participants had not had the opportunity to reflect upon or to anticipate potential family conflicts. It is also possible that the vignettes did not fully capture the participants’ real life experiences or dilemmas; such as their financial hardship and interpersonal difficulty in convincing or helping their families buy and use healthy, tasty and affordable ingredients in their meals.

While some of the ethnic and cultural influences on food choices and preparations (e.g., large portions) may contribute to overeating, it is important for clients and practitioners to capitalize on the cultural assess for behavioral change and treatment success. For example, familismo—a sense of interdependence and a commitment to participation and mutual support within nuclear and extended family networks—tends to be a strong characteristic of Mexican American families (Falicov, 2014). Family members may be encouraged to provide emotional and practical support, such as caretaking of children, problem solving, and sharing of household responsibilities, to the participants while they pursue treatment.

Many women in our groups, in fact, longed for increased family and peer support; they also wanted to connect with other women who were struggling with similar issues and going through the CBTgsh program. This is not a surprising result given that family and peer support, or the lack thereof, could influence Latina/o’s treatment engagement and process of change (Erwin, et al, 2007; Interian et al., 2010; Shea et al., 2012). Traditional and mainstream psychotherapy—including cognitive-behavioral intervention and assertiveness training—tend to overemphasize individualistic values, thereby placing the “problem” or responsibility of change within the individual (D’Andrea et al., 2001; Sue & Sue, 2012). However, such an approach may be antithetical to the collectivist worldviews and coping strategies (Yeh, Arora, & Wu, 2006), which tend to value interconnectedness and collaboration (Markus & Kitayama, 1991).

Future adaptation and refinement of the CBTgsh program for ethnic minority women should continue to acknowledge and incorporate minority women’s worldviews, contextual challenges, and unique experiences associated with being a woman (Shea et al., 2014), including those experiences related to the impact of feminine ideologies and patriarchy (Hill & Ballou, 2005). In addition, researchers and clinicians can explore varied modalities of treatment such as parallel intervention and psychoeducation for significant others and family members (Guadalupe-Rodriguez, Reyes-Rodriguez, & Bulik, 2011; Mier, Ory, & Medina, 2010), and a combination of in-person- and telephone-based meetings (Wilcox, Sharpe, Parra-Medina, Granner, & Hutto, 2011).

Study Limitations

There are several limitations to this study. First, since not all of the participants who were enrolled in the CBTgsh took part in the post-treatment focus groups, there may be a response bias. It is possible that those who chose not to participate in the focus groups have a less favorable view toward the culturally adapted CBTgsh program or did not feel as strongly connected to their supporters. Nevertheless, the data we gathered from the participants who dropped out of the program may help provide a balanced view toward the strengths and limitations associated with the CBTgsh intervention (Shea et al., 2014). Second, findings from our current study were based on participants’ initial responses upon their completion of the program and only provided a snapshot of their experience at that time. Therefore our understanding of the prolonged effect of the CBTgsh program on Mexican American women’s disordered eating is limited. Future studies could be enhanced with 6-month or one-year follow-up interviews. Last, there are diverse nationalities, cultures, socioeconomic classes, and political histories among Latinas in the U.S. (Andres-Hyman, Ortiz, Anez, Paris, & Davidson, 2006), hence the generalizability of our findings—which are primarily based on second-generation Mexican American women living in Southern California—to other groups of Latina/os and ethnic minorities must be viewed with caution.

Implications for Practice, Prevention and Intervention

The present study examined Mexican American women’s experience with and perspectives on a culturally adapted evidence-based treatment. Their narratives of challenges and empowerment through self-help provide several implications for the refinement of the CBTgsh program as well as the prevention and intervention of eating disorders among ethnic minority women. In terms of program refinement, treatment providers may consider including optional psychoeducation or parallel intervention for family members or significant others on the risk and protective factors of disordered eating (Erwin et al., 2007; Kuba & Harris, 2001; Swanson et al., 2012), as well as the effect of social support on Mexican Americans’ treatment utilization and engagement. Second, the ethnic specific food guide could be expanded to include resources for diverse cooking preparation methods and recipes, accessibility to affordable fresh produce, and sample meal plans that are palatable and acceptable to Mexican American families. Third, a pre-treatment in-person orientation session and a post-treatment termination session may be added to the CBTgsh program. These prolonged group engagement sessions could provide an opportunity for the supporters and the participants to address or review any issues and behaviors that may interfere with the treatment, to discuss and learn about effective coping strategies, and to establish a sense of community with other Mexican American women who struggle with disordered eating.

On a broader level, the rise of disordered eating among ethnic minority females (Swanson et al., 2011) and the under-utilization of mental services in this group (U.S. Department of Health and Human Services, 2001) call for more concerted efforts to develop and deliver culturally sensitive and accessible prevention and intervention programs. Since the primary care and school counseling settings are often the first point of contact for racial and ethnic minority clients (Chapa, 2004), training on eating disorders intervention and multicultural competency should be systematically provided for primary care physicians and school-based counselors, so that they could more effectively direct clients to available resources, including the low-intensity self-help intervention. Furthermore, utilizing screening tools such as the Eating Disorder Examination Questionnaire (EDE-Q; Fairburn & Beglin, 2008) in healthcare settings can help identify high-risk groups and facilitate differential diagnosis.

The use of technology such as smartphone and social networking sites has the potential to reach large number of clients in a cost-effective way (Luxton et al., 2011). Smartphone apps could augment the utility of the CBTgsh program. For example, linguistically and culturally appropriate behavioral health information (e.g., nutrition) and psychoeducation can be disseminated via podcasts, guided support session can be recorded for clients to review later, and appointments, homework assignments, and food logs can be tracked and updated instantly.

Future Research Directions

The three themes evolved from our data suggest that Mexican American women’s disordered eating and treatment engagement are mediated by a complex interaction of sociocultural factors and interpersonal processes, which generate potential research questions. First, future studies could explore how Mexican American women’s racial/ethnic identity, adherence to mainstream feminine norms and ideologies, and acculturative stress may affect their development of disordered eating—either as a stress response or as a coping mechanism. Second, researchers could examine how the differential family acculturation, intergenerational conflicts, and social support may moderate Mexican American women’s help-seeking attitudes and treatment engagement. Third, Latinas of diverse nationalities, generation statuses, educational and socioeconomic backgrounds can be included to test the interactions between the CBTgsh intervention and participant characteristics. Since all of our supporters were bilingual bicultural Latinas, it would be interesting to compare the effect of the therapist-client ethnicity and sex matching vis-à-vis the therapist’s multicultural competence on client outcomes in future cultural adaptation studies.

Overall, the themes and issues described in this study are very similar to those reported in the preliminary focus group study (Shea et al., 2012): (1) the CBTgsh is a feasible and acceptable treatment for Mexican American women with binge eating disorders; (2) eating behavior, meaning of food, and treatment utilization are influenced and mediated by sociocultural and familial factors, and (3) adaptation and implementation of the CBTgsh for Mexican American women should incorporate their bicultural experience and daily stressors, as well as family and peer support. The overlaps in findings between the preliminary and post-treatment focus groups also demonstrate that focus groups can be an effective and reliable tool for gathering feedback and opinions from relevant stakeholders prior to the cultural adaptation. In addition, the qualitative data from the post-treatment group nicely elaborate and complement the quantitative results (Shea et al., 2014), which illuminate our understanding of the unique experience and challenges faced by Mexican American women with a debilitating disorder and help fine-tune the delivery of the CBTgsh to underserved groups. Finally, this study suggests that strong therapeutic alliance is crucial to keeping the participants motivated and engaged in treatment (Norcross & Wampold, 2011), underscoring the role of therapists or coaches. Future research may compare the benefits of a supporter-facilitated culturally adapted intervention with those of a completely self-led culturally adapted intervention.

Appendix I

Sample Focus Group Questions

Open-ended Questions:

• 1)What do you think of the Cognitive Behavioral Therapy Guided Self-Help program and the book?
• 2)What culturally relevant themes or components should have been incorporated into the CBTgsh program?

Probing Questions:

• 3)What was most helpful about the program and the book?
• 4)What is most helpful about (each specific step)? Why?
• 5)What is least helpful about (each specific step)? Why?
• 6)What changes or improvements would you make to the program?
• 7)Would you recommend this program to others who have binge eating problems or concerns? Why or why not?

Appendix II

Examples of the Two Raters’ Reflection

SW is a Taiwanese American master student in psychology. SW often felt ostracized in her home country and had witnessed the negative effects of patriarchy in the more traditional society. As a result, she quickly assimilated to the mainstream culture after she immigrated to the U.S. and became an ardent supporter of feminism. During the initial phase of data analysis, SW was especially mindful of the participants’ discussions about their experience with systemic oppression, such as differential treatments and unfair standards. However, she tended to overlook the reality and importance of collectivism in participants' narratives, and to interpret the participants’ desire for family involvement in their treatment as a sign of weakness or fear of changes. Through reflective discussion with the research team, SW recognized that the sense of connectedness and social support may be an imperative part of these women’s coping and recovery process, as many of them struggle with disordered eating alone and in secrecy.

As a 1.5 generation Mexican American immigrant, GG felt she could readily relate to the bicultural experience and stress described by the participants in several ways. First, growing up, she herself did not have an open communication with her “overprotective” parents and was not allowed to give her opinions or question her parents’ decisions. Second, being Latina, she was expected to assume certain gender-specific roles and responsibilities such as living with her family until she gets married and taking care of household chores. All in all, she felt that there were more limits and rules imposed on her because of her female gender. Third, her acculturation to the American values, which emphasize independence and self-reliance, conflicts with her parents’ expectations of her. She constantly had to negotiate and balance her own goals (e.g., pursuing new academic and career endeavors) with her family’s restrictions and demands. On the other hand, GG found herself to be different from the participants in that she did not care as much about appearance, body image or fashion. In Mexico, she was raised to believe that working hard and focusing on education (as a way to fight poverty) was the priority. And food was never used as a symptom expression or coping mechanism.