a brief(200 word APA style) description of the natural disaster or terrorist activity you selected. Then explain the scope of the impact of the disaster in YOUR community, including who and what might be impacted in YOUR community and how. Be specific.

Latina Mothers' Perceptions of Mental Health and Mental Health Promotion

Elizabeth M. Vera and Wendy Conner

Latina mothers' perceptions of mental health and factors that promote/restore mental health were explored in this qualitative study. Participants discussed the importance of community, safety, and financial stability in addition to conventional factors that are related to mental health. Implications for working with urban Latinas and their families are discussed.

En este estudio cualitativo se exploraron las percepciones de las madres Latinas sobre Salud Mental y los factores que la fomentan/restablecen. Las participantes discutieron acerca de la importancia de la comunidad, la se- guridad y la estabilidad financiera además de otros factores convencionales relacionados con la salud mental. Se discuten las implicaciones para el trabajo con Latinas residentes en núcleos urbanos y sus familias.

T he underutilization of mental health services by people of color has been well documented (Akutsu, Snowden, & Organista, 1996; Padgett, Patrick, Burns, & Schlesinger, 1994; Pumariega, Glover, Hölzer, &

Nguyen, 1998). Although availability of mental health services undoubtedly affects utilization, rates of utilization differ among ethnic groups even when access to services is similar across ethnic groups (Alvidrez, 1999). One aspect of understanding the causes of underutilization is examining the cultural ap- propriateness of available services. This contention is supported by policies such as the Multicultural Counseling Competencies (Roysircar, Arredondo, Fuertes, Ponterotto, & Toporek, 2003) and the Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists (American Psychological Association, 2003), which offer recommendations for adapting services to meet the needs of diverse constituents.

Understanding cultural beliefs and values of ethnic groups is important to the development of treatment approaches that are culturally congruent. In the case of Latino clients, much has been written about the cultural characteristics of this population. For example. Marin and Marin (1991) characterized Latinos as (a) group oriented, (b) valuing harmonious interpersonal relationships, (c) loyal to family, (d) deferent to authority figures or revered relatives, and (e) valuing traditional gender roles. On the basis of this information, group and family-based modalities of counseling might be viewed as culturally ap- propriate for Latino clients (Falicov, 1996), primarily because of the systemic nature of conceptualizations that may appeal to members of collectivist or interdependent cultures (Triandis, 1988). Although such treatment approaches

Elizabeth M. Vera, School of Education, and Wendy Conner, Department of Counseling Psychology, both at Loyola University Chicago. Correspondence concerning this article should be addressed to Elizabeth M. Vera, School of Education, 820 N. Michigan Avenue, Loyola University Chicago, Chicago, IL 60611 (e-mail: [email protected]).

© 2007 American Counseling Association. All rights reserved.

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may be effective with this population. Latino clients' perceptions of whether counseling is a culturally appropriate option is directly related to their utiliza- tion rates. This issue may be particularly relevant to tailoring mental health services to meet the needs of Latina women. Given that women often attend to the emotional needs of the families, understanding their perceptions of mental health and help-seeking behaviors are important to understanding treatment decisions of Latino families.

pnrpnsp of tbp stnHy Increasing the field's knowledge of how women of color in general, and those who are mothers in particular, conceptualize mental health and its maintenance may be informative to the development of culturally relevant individual and family mental health promotion and remediation efforts. Because mothers are often the "monitors" of their children's emotional needs, their perceptions of mental health and related interventions would have implications for working with Latinas and their families. It is not assumed that being a mother, per se, would affect the mental health beliefs and experiences of service provisions of Latinas. However, given the powerful role that many Latina mothers have in protecting the mental health of their families, this population was the focus of the present investigation. This study was guided by an interest in the participants' beliefs about the following issues: (a) How is mental health understood or conceptualized by urban Latina mothers? (b) What factors affect mental health, both positively and negatively? and (c) What formal and informal methods of help seeking are used for the mental health needs of Latina mothers and their family members?

rpipvant litpratnrp In comparison with the amount of literature on Latina women, a relatively larger body of research exists on women of color in general and their deci- sions to use mental health services. Several recent studies have examined the help-seeking attitudes, explanations of psychological disorders, and coping strategies of women of color (Alvidrez, 1999; Brodsky, 1996). Alvidrez found that, for low-income women of color, the likelihood of making an appoint- ment to see a mental health professional was predicted by problem type, beliefs about the origin of mental health problems, and having a friend or family member who had sought services. In her sample, stigma regarding psychological problems and preference for informal means of help seeking were not found to be relevant predictors of seeing a mental health profes- sional. Alvidrez's study was very helpful in clarifying some of the factors that lead women of color to seek the assistance of mental health professionals, but it did not explore a wide range of precipitating events that might result

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in a woman seeking services in the first place. Additionally, the role of larger systemic factors such as poverty or community in jeopardizing the mental health of women was not explored.

Brodsky (1996) examined the role of poverty and community factors in the mental health and resiliency of low-income African American women. Resiliency is defined as the ability to persevere in the face of obstacles (Mas- ten, 2001). Brodsky found that, for women who see the community as a burden as opposed to a resource, distancing from the community was seen as a coping mechanism that enhanced resiliency and mental health. Her findings challenged the extant literature that found community involvement and belonging to be related to positive mental health for women of color (McMillan & Chavis, 1986). Yet the findings could have been a function of social class rather than the ethnicity of the participants. In other words, Brodsky's participants' residence in an impoverished neighborhood, not their ethnic backgrounds, was most likely what influenced their perceptions of the neighborhood as unsafe. The most distinctive aspect of Brodsky's study is that it is one of the only investigations in which women of color were interviewed about the relevance of community and neighborhood factors in relation to mental health and resiliency.

Other than the aforementioned studies, there has been relatively little re- search done on mothers' perceptions of mental health, barriers to treatment, or mental health promotion. We found even less research on Latina mothers' perceptions of mental health. One recent study (Christie-Mizell, Steelman, & Stewart, 2003) focused on ethnic differences in perceptions of maternal distress and neighborhood disorder in a nonclinical sample of mothers. That study found that Mexican American and African American mothers perceived higher levels of neighborhood disorder than did their White counterparts and that perceived neighborhood disorder was significantly predictive of ma- ternal distress (a finding that was exacerbated for African American mothers by number of children).

However, the majority of extant research on Latina mothers has focused on mothers whose children have identified psychological or behavioral disorders or on the mental health problems of the mothers themselves (Ainsenberg, 2001; La Roche, Turner, & Kalick, 1995; Pavuluri, Luk, & McGee, 1996; Raviv, Raviv, Propper, & Fink, 2003). In general, this research has used survey re- search that limits responses to predetermined categories of mental health problems and resources. This is problematic because women of color often have alternative conceptualizations of mental health problems and appropriate responses to such problems (Alvidrez, 1999). The paucity of more discovery- oriented research underscores the need for additional empirical studies that address Latina mothers' general perceptions of mental health barriers and attitudes toward help seeking. A qualitative research approach was selected for this study to generate such discovery-oriented data.

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This study used narrative inquiry (Guba & Lincoln, 1985) as a qualitative methodology to investigate perceptions of and attitudes toward mental health in a sample of resilient, urban Latina mothers. In narrative inquiry, first-person accounts of experience form the narrative text of this research approach (Mer- riam, 2002). The goal of narrative inquiry is to make sense of experience by communicating and constructing meaning (Chase, 1995). The interpretation of narrative data involves the identification of thematic categories that are descriptive (vs. interpretive) and are allowed to emerge from the data using an open-coding process (Miles & Huberman, 1994; Strauss & Corbin, 1990). Narrative inquiry differs from other approaches to qualitative research, such as grounded theory, in that it aims to describe experience as opposed to de- velop and provisionally verify theory contained in the data (Merriam, 2002). Given the limited research on Latina mothers' perceptions of mental health, it would be premature to construct theory. Narrative inquiry is appropriate when discovery of phenomena is the goal of the study.

Whereas past studies (Alvidrez, 1999; Landrine & Klonoff, 1994) have largely used quantitative approaches to understanding mental health conceptual- ization and patterns of service utilization in women of color (e.g., symptom and resource checklists), existing surveys often fail to incorporate protective factors or processes that may promote mental health, not jeopardize it. The decision to use a qualitative, discovery-oriented approach was also based on the anticipation of illuminating protective factors or factors that are important to maintaining mental health.

metboH PARTICIPANTS

Participants in this study were 10 Latina mothers who resided in a low-income neighborhood in a large, midwestern, urban community. Participants were nominated by their children's school administrators, by community leaders, and by other parents whose children attended the local public elementary school. The criteria for nomination were women who were perceived as suc- cessful in overcoming challenges of raising healthy children (i.e., an example of resiliency) and living in a low-income environment. The 10 mothers who were selected for participation, then, were not thought to be representative of parents in general or Latina mothers as a group, but rather were thought to be potentially effective spokespersons for resilient Latina mothers in the community. This participant selection procedure has been used in other studies (e.g., Brodsky, 1996).

Mothers ranged in age from 30 to 43 years. Six were first-generation Mexican immigrants who had lived in the United States for more than 10 years (rang- ing from 10 to 18 years). Of the remaining four participants, three were born in the continental United States and were of Argentinian, Puerto Rican, and

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multiracial ethnic backgrounds. One mother was born on the island of Puerto Rico. All mothers had worked outside their homes in positions that ranged from paid employment as secretaries to volunteer work as teacher's aides or crosswalk guards. No specific data were gathered on the incomes earned by the participants because it was determined through consultation with leaders in the community that such a question would be viewed as culturally inap- propriate. Seven of the mothers were married to the fathers of at least one of their children, and three were in nonmarital, cohabitating relationships. The number of participants' children ranged from one to three. The ages of the children ranged from 18 months to 12 years.

The mothers were invited to participate in the study by the primary investi- gator (first author) at a time that was convenient for them in their children's school setting. Mothers who were employed by or volunteered at the school received permission from the principal to participate in the interviews during their workdays. Informed consent was obtained prior to the beginning of the interviews, and the participants were assured that the information gathered was anonymous and that pseudonyms would be used in the description of the findings. After the interviews were completed, gift certificates to a local grocery store were offered to participants as tokens of gratitude. No incentive was offered to mothers when they were invited to participate.

PROCEDURE

Individual interviews were conducted for this study by a bilingual, doctoral- level psychologist (first author) in English, or Spanish, or both languages, depending on the preferences of the participants. Interviews lasted approxi- mately 30 minutes and were guided by the following open-ended questions, derived from a review of previous literature: (a) "How do you understand the term mental health?" with a follow-up probe, "For example, what would be some of the characteristics of people who have good mental health?" (b) "What are the kinds of things that help people to stay mentally healthy?" (c) "What are the kinds of things that can damage or threaten mental health?" (d) "What would be acceptable ways to address a mental health problem in your com- munity?" (e) "What is available to people in the community right now that helps promote and maintain mental health?" and (f) "What are things that are not available right now but would be beneficial in promoting and main- taining mental health for people in the community?"

DATA ANALYSIS

Individual interviews were transcribed from audiotapes, and the transcripts were initially reviewed by the participants for accuracy. Secondary interviews were scheduled with the participants after the narrative data had been ana- lyzed and categorized by the coders. At the time of the follow-up interviews.

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participants were able to comment on the extent to which the categorization of their individual responses appeared appropriate and to elaborate on their initial responses. This process was used to enhance the credibility and validity of the data obtained. Additionally, in an effort to minimize personal bias, the interviewer kept field notes, which were later compared against the results of the final analysis.

Two independent coders identified emergent descriptive themes from the transcribed interviews in this study. One of the coders was a White, female graduate student who had previous clinical and research experience working with Latinos, and the other was a Latina professor. The themes were then compared and integrated into an initial list of coding categories. Once a final list of themes was constructed, two additional coders tested the reliability of the coding scheme. These secondary coders were White, female graduate stu- dents. Each coder had been trained in qualitative research and data analysis in the course of their studies, and neither was involved in the planning of this study. The decision to use these additional coders was part of a strategy to increase the relative objectivity of the data analysis and to prevent researcher bias from influencing the results. The secondary coders categorized samples of the data into the existing schema with a 90% success rate. Discrepancies in categorization were discussed until consensus was achieved. Narrative samples were then selected from the interviews to illustrate themes. Illustrative sample responses were attributed to participants using only pseudonyms and brief demographic descriptors.

results WHAT DEFINES MENTAL HEALTH?

Participants described a variety of characteristics of mentally healthy people, such as stability and happiness. One repeating theme in all 10 interviews was the interpersonal nature of mental health. Harmonious relationships within the family, providing support to others, and fostering interdependence were associated with positive mental health. Every participant talked about the connection between parental and child mental health. Parents were viewed as role models who "taught" their children how to be healthy people. To quote one of our participants, "happy parents make happy children."

Interpersonal components of mental health were not discussed to the exclu- sion of individual factors. Hope and optimism were identified as components of positive mental health. Daria, a 30-year-old mother of two, stated,

I give my kids a hard time. I tell them that if you have a bad attitude, you are going to have a bad day. Everything is in your mind. If you expect [to have] a good day, look forward to going to school, then you will have a good day. It is up to you. No one else determines this.

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WHAT PROMOTES MENTAL HEALTH?

Environmental influences on mental health constituted another category of factors that promoted mental health. Having access to tangible, economic, and social resources was seen by eight participants as critical influences on the mental health of families in the community. Participants recounted sto- ries of families who lost their homes because of fires or who were forced to move in with other families because of unexpected job loss. Although these events were associated with threatening mental health, the social resources provided by neighbors were cited as "protective." Cristina, a 43-year-old mother of three, stated.

Lots of families struggle here, and if they recover, it is because someone was there for them. Most of the time, it is other families that step in to be there. But when families reach out to neighbors who [have] stumbled, amazing things can happen.

Not only were a lack of financial resources a concern for participants, but also the availability of community-sponsored resources were concidered an important protective factor for half of the participants. The availability of re- sources such as safe recreational areas was seen as a factor promoting mental health for families. Jacinia, a 34-year-old mother of two, stated.

What promotes mental health? To me, it's day care centers, a close-by job, park district programs. (Interviewer. How do these help promote mental health?) When you can provide for your kids and don't feel guilty about not being with them or wonder if they are safe, you have peace of mind. Knowing your kids are safe is having mental health.

On a similar note, neighborhood factors such as affordable housing were linked to maintaining mental health. Carolina, a 30-year-old mother of two, told a story about a family that had become homeless because of gentrification in the neighborhood, which had prompted local landlords to raise rents. She concluded that "if you lose your home, everything is up for grabs. You go to a shelter, you move in with another family, but everything changes. This is why parents have to come together to fight gentrification and other threats."

Using community resources on a regular basis was viewed as an avenue to promoting mental health for Latina women in the community in particular. Linda, a 30-year-old mother of two, stated.

Especially for Latinas, we don't need to sit home alone in the house. If you can't get a job, while your kids are in school, you need to stay active, involved with people, caring for your kids, yes, but also going to church, exercising, volunteering, whatever you can get yourself into.

Community-sponsored programs for families and youth were mentioned by half the participants as resources that can protect mental health. Yet one participant, Linda, a 30-year-old mother of two, expressed a concern that

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there were misperceptions of some of the existing programs that affected how much they were used by the community members:

A lot of parents see the rec[reation] centers and aren't sure if they are really good for their kids. They think, "What if this is where the gang bangers hang out?" even if it is not true. It is really important for parents to know that it is safe for your kids here.

Mistrust due to perceived community dangers was mentioned as an issue that prevented some members of the community from taking advantage of available programs, although such problems have the potential to enhance family mental health. These responses reflected an awareness of formal mental health services in the community but underscored the importance of such resources being trustworthy and safe.

WHAT THREATENS MENTAL HEALTH?

Many conventional threats to mental health were identified in response to this question. All participants listed divorce, drugs, conflict, neglect, illness, and abuse as life events that are highly disruptive to one's mental health. Half of the participants gave equal emphasis to lack of resources and negative community influences. For example, a lack of opportunities to "stay busy" with one's family was mentioned as a threat to mental health. Additionally, gangs and related violence in the community were listed as factors threatening mental health in families. Cristina, a 43-year-old mother of three, stated.

Some of the things in the street that families are exposed to . . . that kind of negativity is a hard thing to overcome. You take the little ones to the park and sometimes you get nervous 'cause of who else is there. Maybe something is about to go down, you don't know. But having to worry about what you don't expect, that is a problem.

In addition to safety, direct family influences were seen as affecting the mental health of children. Seven participants discussed concerns about the community's number of teenage parents viewed as being ill-equipped to provide for their children's emotional needs. For parents in general, not spending time with one's family was identified as contributing to a climate that threatens mental health. In some cases, the reasons for this were economic. Three participants discussed situations in which parents worked two or three jobs and were never physically present when their children were home. All participants described the Stressors of being single parents that compromise one's ability to be emotionally present in the family. Linda, a 30-year-old mother of two, stated.

Lots of parents in this community are literally not there for their kids. The kids go home to an empty house every day. Others start out being there but can't handle all the pres- sure of being alone with the kids and fall through the cracks. You are hanging in there, holding a job, paying rent, and one day it gets to be too much and it all falls apart.

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Whether absence was defined as physical or emotional, being unavailable to one's family members was viewed as an important threat to mental health.

WHAT ARE ACCEPTABLE WAYS TO RESTORE MENTAL HEALTH?

Many informal and formal mechanisms for addressing mental health prob- lems were discussed by the participants. The importance of consulting with trusted individuals, such as family, friends, clergy, or peers in the community, was discussed by eight participants. Five of these participants described such individuals as "mentors," or people who have different perspectives on situ- ations whose advice would be valuable and welcomed.

The general issue of trustworthiness was mentioned in all of the conversa- tions. Given that the problems discussed by the participants were of a more personal nature (i.e., family problems), participants stressed the importance of finding someone who could protect their privacy. The theme of trustwor- thiness extended to the participants' openness to formal sources of support as well. In terms of formal strategies to address mental health problems, participants listed counselors, social workers, and psychologists as being good resources, especially if they were "known quantities." School counselors and psychologists affiliated with the participants' children's schools were seen as potential resources. All participants seemed knowledgeable about the clinics in the community that offered mental health services and mentioned several by name. The formal sources of support were identified as preferred over informal resources only when the problem was of a large enough magnitude and informal resources were insufficient.

WHAT RESOURCES ARE AVAILABLE AND WHAT ARE NEEDED?

None of the participants reported concerns about the overall quality of the resources currently available to the community, but half reported that the quantity and availability of such resources could be greatly expanded. The existing community resources appeared to be underutilized by families either because of safety concerns or because parents lacked the initiative to locate such resources. Claudia, a 35-year-old mother of one, stated.

There are opportuniues for families to get help when they need it and to stay involved in things that are good for them, but you have to look for those things. They are not everywhere or delivered on a plate to you. You have to check things out and get it.

This Statement illustrates the participants' sentiments that it was up to par- ents not only to be aware of what is available but also to be active in pursuing and evaluating the quality of resources for their families.

In addition to community programs, four participants expressed a desire for mental health professionals to be active members of the community. The importance of mental health professionals knowing the strengths and needs

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of the community, as opposed to intervening only when problems arise, was discussed. Cristina, a 43-year-old mother of three, stated.

If counselors could be a part of the community, part of an effort to prevent problems from the beginning, walking in the shoes of the community, it would be better than waiting to step in until it is too late to do much. We need partners to walk with us.

disrnssinn The results of this investigation are consistent with several other studies that have found mental health to be perceived as influenced by individual, family, and environmental factors, specifically by women of color and Latinas in par- ticular (Christie-Mizell et al., 2003; Jenkins & Cofresi, 1998). However, these data suggest that several types of individual, family, and community resources are viewed as assets that promote mental health for Latinas and their families. Participants in the study were family and community focused in how they conceptualized mental health and which preventative resources they viewed as related to the maintenance of mental health. There were several occasions when individual psychological resources (e.g., positive attitude) were men- tioned as important determinants of mental health, but the themes identified from the data reflect a distinct focus on family and community influences. This may because, as mothers, these Latina participants were more oriented to aspects of family and parenting than would be women without children. Participants' ethnic heritages may also shape their worldviews to be more collective, regardless of whether they were parents (Marin & Marin, 1991; McNeill et al., 2001). The low-income status of the neighborhood combined with the collective orientation of the participants may have exacerbated the importance of community, as was found in Brodsky's (1996) study.

These narratives support the past work of feminist theorists (Mattis, 2002) documenting that worldviews of women in general are relational in nature. The implications for psychologists and counselors working with urban Latina mothers and their families, especially those who reside in low-income, urban communities, are multiple. First, adopting a systemic, relational focus in the delivery of mental health services is supported by these data and past literature (Falicov, 1996; i.e., family and group-based interventions). Second, attending to the larger social context in the provision of services (e.g., community resources, family income needs, public spaces in which families can spend time together) as it affects mental health and well-being is supported by these data and other studies (Rosado & Elias, 1993). Third, a focus on preventive interventions and connecting families with community resources may be an important supplement to more traditional service delivery (i.e., therapy; Vera & Speight, 2003). In ad- dition, informal support services within community institutions (e.g., support groups) may also be viewed favorably by Latina mothers, a finding supported by previous literature (Rhodes, Contreras, & Mangelsdorf, 1994).

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Fourth, the ahility to form ongoing, collahorative relationships within the community may he a key to decreasing the underutilization of services hy Latina mothers and their families. Participants in this study empha- sized the importance of trustworthiness and familiarity in the utilization of formal community services. Although many service providers may work in agencies or schools that are located within the communities, the extent to which they are viewed as insiders versus outsiders may he an important issue influencing decisions to seek services. It may he that the issue of trust is exacerhated hy acculturation in that more accultur- ated participants would have preferred the use of services by unknown professionals, as is more typical of traditional therapeutic services. This interpretation may he supported hy flndings from another study of La- tina mothers, which found that private psychologists were preferred to school-hased psychologists in seeking treatment for their children (Raviv et al., 2003). However, Raviv et al. suggested that their flndings reflected their participants' strong distrust in puhlic systems. Thus, trust was a consistent theme in hoth sets of findings. Outreach into the community through involvement in local schools, places of worship, or community organizations may enhance the trustworthiness and credibility of service providers with populations that historically have underutilized formal services. These recommendations are supported by existing literature (Vera & Speight, 2003). The implications of this study must be tempered in that the participants were

spokespersons of a unique community. Philosophically, qualitative data are not intended to be generalizable. However, when discussing recommendations to mental health practitioners, it is important to consider the opinions of the participants as part of an emerging picture of perspectives on mental health from historically underserved constituents. In this instance, the perspectives were those of urban Latina mothers residing in a low-income neighborhood. Their perspectives may diverge from those of other urban women or other women of color. It is important to keep these considerations in mind when evaluating the validity of the data.

These data contribute to the dialogue of how to make counseling services more culturally relevant. Future research should focus on clarifying the interaction of ethnicity and socioeconomic status as they affect mothers' perceptions of mental health and service provision. Also, it would be valuable to systematically study the impact of a variety of community- based services (e.g., prevention programs, family recreation) on the overall mental health and functioning of low-income Latino families and other families of color. In the quest of professionals in the field for answers to these questions, larger problems of the underutilization of psychological services by people of color and racial disparities in mental health problems might be better understood.

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