As used in the U.S. Census, Americans of "Hispanic origin" can be of any race. For example, the 22.4 million Americans of Hispanic origin reported in the 1990 Census includes 20.4 million Whites, 1.2 million Blacks, 0.3 million American Indian, Eskimo, or Aleutian, 0.5 million Asians and Pacific Islanders (U.S. Bureau of the Census, 1997). The three major groups of Americans of Hispanic origin identified in the Census are Mexican, Puerto Rican, and Cuban, with Mexican Americans being by far the largest, making up about 64% of the Hispanic American population (Paniagua, 1998). The term "Other Hispanic" encompasses 13 other groups under the subcategories of Dominican, Central American, and South American, plus an additional "all other Hispanic origin." Outside of Census definitions, language, family name, or ancestry are usually the determinants for the label of Hispanic (Paniagua, 1998). In the literature and mass media, the term Hispanic is often used interchangeably with Latino. However, there are some who prefer the term Latino, feeling that Hispanic carries colonial connotations. While acknowledging their preference, the term Hispanic is used here in order to be consistent with the language used in the Census data.
Approaching the issue from the perspective of culture rather than races or countries of origin, Robinson (1998) identified 17 major Hispanic subcultures among Hispanics residing in the United States. In California, four major groups are immigrant Mexicans, middle-class Mexicans, barrio dwellers, and Central Americans of Pico Union. In Texas, Mexican Americans distinguish themselves from the California Mexicans, with the largest Latino population living in South Texas. In Houston, Mexican and Central Americans make up 28% of the population, and Mayan Indians of Guatemala stand out as a separate subculture. Robinson (1998) indicates that Chicago Hispanics are more diverse in representation than in New York or Los Angeles, with the largest groups being Mexican and Puerto Rican followed by Ecuadorans, Guatemalans, and Cubans. In Miami, Cubans, Nicaraguans, and other South Americans make up about 60% of the population and carry strong political and economic influence. "Neoyorqui-
nos" are the Puerto Rican, Dominican, and Columbian groups that form the majority of the Latino population in New York. Finally, Robinson (1998) identifies the descendants of the original Spanish conquistadors living in New Mexico and the migrant workers in United States farming communities as distinct subcultures among Hispanic Americans.
In addition to the above differentiation in cultures and subcultures among Hispanics in the United States, mental health professionals who want to be culturally competent with Hispanic American clients must also recognize the importance of age, gender, socioeconomic class, religion, generational status, immigration, and acculturation. In particular, skin color is a significant factor, as darker skinned Hispanics are more likely to experience racism than lighter skinned Hispanics within mainstream White American, as well as within Hispanic American settings (Comas-Diaz, 1998).
The extensive heterogeneity coupled with the definite apparent commonalities within the Hispanic population again highlight the need of our integrated approach utilizing both the etic and emic perspectives. In introducing the topic of Hispanic American mental health services, we can start by identifying the major groups covered by the generic label Hispanic Americans, and discuss their distribution in various parts of the United States. While acknowledging and reviewing the diversity among the Hispanic American population, the discussion can focus more on the larger groups such as Mexican, Puerto Rican, and Cuban Americans, along with groups that students and trainees are most likely to encounter in their geographical region. The major cultural elements common to many Hispanic groups can then be discussed in general, along with the precautions on differences based on countries of .origin, socioeconomic considerations, and degree of acculturation to mainstream United States society, among others. In general, there are a number of sociocultural factors concerning Hispanic American clients that we can discuss with students and trainees. Some of these factors are common for working with any ethnic group where diversity exists in English language acquisition and level of acculturation into mainstream U.S. society. Within Hispanic groups, it is also important for clinicians to be prepared to work with the clients' religious and folk beliefs. The clinician who dismisses the role of the folk healer presents an example of the limitations of insight into the emic perspective, and therefore fails to understand the client's support system.
Students and trainees are not expected to understand the total belief systems within the Mexican, Puerto Rican, Cuban, or Dominican cultures. What is important, however, is to recognize that clients will have personal backgrounds enriched with a wide variety of spiritual beliefs that should not be severed from the clinical protocol. Likewise, students and trainees should be informed of culturally embedded concepts such as machismo (physical strength, masculinity, aggressiveness),familismo (family), and ataques de nervios (nervousattacks)
versus being loco (crazy) (Paniagua, 1998). Furthermore, they need to be prepared to face the dilemma they will encounter when dealing with specific clinical issues in the context of cultural values. For example, suppose a man who has migrated to the United States from a Latin American country experiences symptoms associated with posttraumatic stress disorder. Suppose further that the client was a victim of natural disaster such as severe flooding. The clinician must take into account the personal and cultural belief systems held by the client and avoid addressing the problem solely as a reaction to flooding. It is quite possible the client may not view the natural disaster as random and unprovoked by his own behavior. In this case, a clinician who is open and willing to address the client's recurrent feelings of distress in the context of a spiritual belief system will likely be more effective in helping the client. Furthermore, the client might also be blaming himself for failing to take care of his family in this disaster. Such feelings must also be understood and addressed within his cultural context.
Understanding the general sociocultural factors common to many Hispanic American groups will give students and trainees the foundation to go deeper into specific groups as warranted by their professional work. Again, they can be instructed to read or research further on issues relating to particular Hispanic American groups in which they are personally interested, or with whom they anticipate working. The training can also cover specific groups in greater detail, depending on the needs of the trainees or the nature or purpose of the training program. In this manner, the combined etic and emic approach will help to make the subject matter more attainable and less overwhelming for students and trainees.
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