HABLANDO DEL CORAZÓN: A PHENOMENOLOGICAL EXPLORATION OF IMMIGRANT LATINA WOMEN’S EXPERIENCES IN MENTAL HEALTH GROUPS by DARIEN T. COMBS A DISSERTATION Presented to the Department of Counseling Psychology and Human Services and the Division of Graduate Studies of the University of Oregon in partial fulfillment of the requirements for the degree of Doctor of Philosophy September 2021 DISSERTATION APPROVAL PAGE Student: Darien T. Combs Title: Hablando del Corazón: A Phenomenological Exploration of Immigrant Latina Women’s Experiences in Mental Health Groups This dissertation has been accepted and approved in partial fulfillment of the requirements for the Doctor of Philosophy degree in the Department of Counseling Psychology and Human Services by: Dr. Ellen H. McWhirter Chairperson Dr. Krista M. Chronister Core Member Dr. Bertranna Muruthi Core Member Dr. Lynn Stephen Institutional Representative and Dr. Andy Karduna Interim Vice Provost of the Graduate School Original approval signatures are on file with the University of Oregon Division of Graduate Studies Degree awarded September 2021 ii © 2021 Darien T. Combs ii i DISSERTATION ABSTRACT Darien T. Combs Doctor of Philosophy Department of Counseling Psychology and Human Services September 2021 Title: Hablando del Corazón: A Phenomenological Exploration of Immigrant Latina Women’s Experiences in Mental Health Groups The purpose of the present study was to acquire knowledge of Latina immigrant women’s psychological experiences of participating in mental health groups through exploration of the actual situation, as lived through and experienced by the women. The present study aimed to gain an understanding of women’s experiences, women’s relational experiences with others, and the meaning of the women’s experiences in mental health groups. The central phenomenological question guiding this study is, What is the lived psychological meaning of Latina immigrant women’s experiences in mental health groups with other Latina immigrant women? In order to explore and understand the phenomenon under investigation, a descriptive phenomenological qualitative analysis (Giorgi et al., 2017) was utilized for the research design and overall methodology to understand the meaning that the group members place on the group (Patton, 2002) and to determine the essence of their lived experiences (Creswell et al., 2007). For data collection, I sought voluntary participation of women who were at the time or previously engaged in a mental health group for Latina immigrant women. I, as the primary researcher, and two colleagues, as research assistants, conducted individual semi-structured, in-person, in-depth interviews with each of the volunteer participants. All ten recordings were transcribed verbatim using iv professional online transcription services in the original language used by the participant and interviewer (Spanish, English, or a combination of both). As a research team, we analyzed the data according to the descriptive phenomenological methods outlined by Giorgi et al. (2017). Results revealed four psychological structures of the experience of participating in a mental health group: disconnection and isolation, relational liberation, healing from adversity, and group logistics and future recommendations. This study illuminates the experiences of Latina immigrant women in mental health groups in a largely majority White area of the country including processes that made it safe to share, shifts in relating to others and to themselves, and mental health changes. The findings from this study have important implications for improving culturally responsive mental health group services with Latina immigrant women, and for highlighting the importance of their contributions and their ideas of what is best for their own healing and empowerment. v CURRICULUM VITAE NAME OF AUTHOR: Darien T. Combs GRADUATE AND UNDERGRADUATE SCHOOLS ATTENDED: University of Oregon, Eugene, OR Wesleyan University, Middletown, CT DEGREES AWARDED: Doctor of Philosophy, Counseling Psychology, Anticipated 2021, University of Oregon Master of Science, Counseling, Family and Human Services, 2019, University of Oregon Master of Education, Counseling, Family and Human Services, 2016, University of Oregon Bachelor of Arts, Psychology, 2011, Wesleyan University AREAS OF SPECIAL INTEREST: Spanish Language Psychological Services and Research Specialization PROFESSIONAL EXPERIENCE: Bilingual Psychology Doctoral Intern, Aurora Mental Health Center, Aurora, Colorado, 2020-2021 Psychology Trainee, Oregon State Hospital – Junction City, Junction City, Oregon, 2019-2020 Ongoing Support Counselor, Graduate Employee, Accessible Education Center, University of Oregon, Eugene, Oregon, 2017-2020 Bilingual Group Co-Facilitator, Trauma Healing Project, Eugene, Oregon, 2018- 2019 Bilingual Qualified Mental Health Professional, Centro Latino Americano, Eugene, Oregon, 2018-2019 v i Child/Family Practicum Intern, Child and Family Center, Eugene, Oregon, 2018- 2019 Adult Practicum Intern Therapist, University Counseling Center, University of Oregon, Eugene, Oregon, 2017-2018 University Supervisor, Graduate Employee, University of Oregon, Eugene, Oregon, 2016-2017 Intervention Facilitator and Research Assistant, Advocating for Latinx Achievement in Schools Intervention, University of Oregon, Eugene, Oregon 2016- 2019 Research Assistant, Intersectional Justice in Guatemala Project, University of Oregon, Eugene, Oregon, 2015-2019 Spanish Coach Consultant, Fisher Stress, Neurobiology, and Prevention Lab, University of Oregon, Eugene, Oregon, 2016 Research Assistant, Sexual Violence Prevention and Education, Office of Student Life, University of Oregon, Eugene, Oregon, 2015-2016 Research Assistant, Cognitive Development Lab, Wesleyan University, Middletown, Connecticut, 2010 GRANTS, AWARDS, AND HONORS: College of Education Doctoral Research Award, University of Oregon, 2020 Lorraine Moe Davis Scholarship College of Education Scholarship, University of Oregon, 2019, 2020 General University Scholarship, University of Oregon, 2017, 2018, 2019, 2020 Jean Twohig Scholarship, College of Education, University of Oregon, 2019 Edward Farrell Rust Scholarship, College of Education, University of Oregon, 2019 Helen Martin Scholarship, College of Education, University of Oregon, 2019 Doctoral Research Travel Award Scholarship, University of Oregon, 2018, 2019 Clare Wilkins Chamberlain Memorial Research Award Scholarship, College of Education, University of Oregon, 2018 vi i College of Education Alumni Scholarship, College of Education, University of Oregon, 2017 Departmental Honors in Psychology, Wesleyan University, 2011 Psi Chi, International Honor Society in Psychology, 2011 PUBLICATIONS: Kerewsky, S., Combs, D., & Mather, N. (Chapter accepted). Rewrite the script: A call for more queer and inclusive relationship enrichment programs In J. J. Bigner and J. L. Wetchler (Eds.), Handbook of LGBT-affirmative couple and family therapy, 2nd Edition. New York: Routledge. Kennedy, A., Kuperman, K., & Combs, D. (Summer 2020). Hablar es sanar: Reflections on a trauma healing and wellness group for Latina women. Division 56 Trauma Psychology News, American Psychological Association, 15, 12-15. McWhirter, E., Rojas-Araúz, B., Ortega, R., Combs, D., Cendejas, C., & McWhirter, B. (2019). ALAS: An intervention to promote career development among Latina/o immigrant high school students, Journal of Career Development, 46(6), 608–622. https://doi.org/10.1177/0894845319828543 Combs, D. (2011). Unwillingly revealed: Registered sex offenders’ attitudes toward the sex offender registry. Honors thesis published on WesScholar. https://wesscholar.wesleyan.edu/etd_hon_theses/632/ vi ii ACKNOWLEDGEMENTS First and foremost, I wish to express my profound gratitude to my doctoral advisor, Dr. Ellen H. McWhirter. Thank you for believing in me, for your guidance, for supporting me to follow my heart with this dissertation, and for your encouragement at every step of this doctoral journey. To my committee members, Dr. Lynn Stephen, Dr. Krista Chronister, and Dr. Bertranna Muruthi, thank you for your willingness to share your time, expertise, and support throughout this process. Special thanks to Lynn for your inspirational mentorship throughout my program. I could not have completed this project without my wonderful research team, Samantha Martinez and Yahaira Garcia. Thank you for your dedication, your support, and your immense contributions to this study. I want to express my deep gratitude to the participants for honoring us with your stories. It has been an honor and a privilege to work and learn with all of you. I would also like to thank the College of Education for funding this research. To my family, friends, DocSem, and colleagues, thank you from the bottom of my heart for accompanying me on this journey. To my partner, Bryan Rojas-Araúz, thank you for your unconditional love, support, and partnership, without which I would not have made it. Tú eres mi otro yo. To Jay, Mom, Dad, Dev, Hunter, Courtney, Minni, and Khalua, thank you for your unconditional love and support through the most difficult times and reminding me of who I am. Bobby Ortega and Kelsey Kuperman, thank you for your unwavering support, for encouraging me to pursue my passions, and for never letting me give up. A Margarita, Yeni, Joan, Oscar, Diego, Hellen, Megan, José y mi comunidad en Costa Rica, gracias por su amor, amistad, y apoyo continuo. Without all of you as my community of support, this project would not have been possible. ix Dedicated to the ten courageous women who shared your stories and experiences with us. And to all immigrant Latina women, may this work challenge the mental health field to better serve you. x TABLE OF CONTENTS Chapter Page I. INTRODUCTION AND RESEARCH PROBLEM ........................................................ 1 Background and Context ................................................................................................. 1 Problem Statement ........................................................................................................... 2 Purpose of Study and Research Questions ...................................................................... 3 Research Approach and Design Overview ...................................................................... 4 Assumptions .................................................................................................................... 5 The Researchers ............................................................................................................... 7 Rationale and Significance .............................................................................................. 9 Language Use Conventions ........................................................................................... 10 II. LITERATURE REVIEW AND CONCEPTUAL FRAMEWORK OVERVIEW ....... 11 Immigration and Immigrant Latina Women’s Mental Health ....................................... 12 Psychosocial Stressors of Immigration ..................................................................... 12 Immigrant Latina Women’s Mental Health .............................................................. 14 Social Isolation .............................................................................................................. 16 Social Support ............................................................................................................... 18 Mental Health Groups ................................................................................................... 21 Barriers to Mental Health Care .................................................................................. 21 Group Psychotherapy ................................................................................................ 22 Latinx Values in Mental Health Groups .................................................................... 23 Latina Women’s Experiences in Mental Health Groups ........................................... 23 Calls for Research .......................................................................................................... 25 Theoretical Framework ................................................................................................. 26 Relational-Cultural Theory ........................................................................................ 27 x i Chapter Page Testimonio ................................................................................................................. 28 A Psychological Radical Healing Framework .......................................................... 30 Summary of Literature Review ..................................................................................... 31 Purpose of the Present Study ......................................................................................... 32 III. METHODS .................................................................................................................. 33 Rationale for Phenomenology ....................................................................................... 33 Social Constructivist Paradigm ................................................................................. 38 Research Sampling and Participants ............................................................................. 38 Context ...................................................................................................................... 39 Participants ................................................................................................................ 40 Participant Demographic and Descriptive Data ........................................................ 41 Research Design Overview ........................................................................................... 43 Methods of Data Collection ........................................................................................... 44 Semi-Structured Interviews ....................................................................................... 47 Methods for Data Analysis ............................................................................................ 51 Descriptive Phenomenological Data Analysis .......................................................... 52 Ethical Considerations ................................................................................................... 56 Reliability and Validity ................................................................................................. 57 Chapter Summary .......................................................................................................... 58 IV. RESULTS .................................................................................................................... 59 Descriptive Phenomenological Analysis ....................................................................... 59 Structure 1. Disconnection and Isolation ................................................................... 62 Structure 2. Relational Liberation ............................................................................. 66 Structure 3. Healing from Adversity ......................................................................... 85 xi i Chapter Page Structure 4. Group Logistics and Future Recommendations ..................................... 90 Summary of Psychological Structures ....................................................................... 97 V. DISCUSSION, RECOMMENDATIONS, AND IMPLICATIONS ............................ 98 Overview of Findings .................................................................................................... 99 Structure 1. Disconnection and Isolation ................................................................... 99 Structure 2. Relational Liberation ........................................................................... 100 Structure 3. Healing from Adversity ....................................................................... 105 Structure 4. Group Logistics and Future Recommendations ................................... 106 Summary .................................................................................................................. 107 Strengths and Limitations of the Study ....................................................................... 108 COVID-19 Benefits and Challenges ....................................................................... 111 Recommendations and Implications ............................................................................ 112 Implications for Research ........................................................................................ 113 Summary and Conclusion ............................................................................................ 114 APPENDIX A ................................................................................................................. 117 APPENDIX B .................................................................................................................. 118 APPENDIX C .................................................................................................................. 120 APPENDIX D ................................................................................................................. 122 REFERENCES CITED ................................................................................................... 134 xi ii LIST OF TABLES Table Page 1. Participant Contextual Information....................................................................... 42 2. Psychological Structures and Constituent Elements............................................. 61 xi v CHAPTER I INTRODUCTION AND RESEARCH PROBLEM The purpose of this study was to explore Latina immigrant women’s psychological experiences in mental health groups by examining the essence of the phenomenon (Giorgi et al., 2017), as lived through and experienced by the women. Knowledge acquired from this study includes insights from women’s experiences that can inform community members and leaders, mental health providers, and policy makers regarding provision of meaningful and culturally responsive mental health group services for Latina immigrant women. This chapter commences with a brief overview of the background and context for this inquiry. The problem statement and the central research question are then introduced followed by the research design and overview, assumptions of the primary researcher, and the role of the three researchers. Finally, the rationale and significance of the study are stated. Background and Context Leaving one’s homeland and coming to live in a new country is rife with major challenges and stressors, among them potentially traumatic experiences and major losses (Goodman et al., 2017). Immigrants are the fastest growing population in the United States, with more than half of the 44 million foreign-born residents and 11 million undocumented immigrants being from Latin America (Manuel Krogstad et al., 2019; Radford & Noe-Bustamente, 2019). Many Latinx immigrants have survived war-related trauma, political and gendered violence, and encountered life-threatening situations during the migration journey to the United States (Martínez, 2014; Vogt, 2013) 1 Immigration can include loss of familiar physical, social, and cultural environments in addition to loss of language, identity, belief system, socioeconomic status, and social support (Berger, 2013). Due to socioeconomic- and immigration-related stressors, Latina immigrant women in the United States are at a higher risk of poor mental health outcomes (Rios Casas et al., 2020). Problem Statement The loss of emotional and instrumental support is a common challenge for immigrants. Once in the Unites States, Latina immigrant women often report isolation, loneliness, and difficulty creating trustworthy and supportive relationships (Hurtado-de- Mendoza et al., 2014b). Social isolation, or lack of social support, is a powerful contributing factor to poor mental health outcomes (Hurtado-de-Mendoza et al., 2014a; Menjívar, 2000). For Latina immigrant women, support from interpersonal relationships and social networks are critical for enhancing resilience (Goodman et al., 2017), protecting against depression (Hovey, 2000), and reducing the negative effects of economic and social stressors on mental health (Ornelas et al., 2009). Furthermore, a strong sense of community may buffer against the stressors of being an immigrant (Hombrados-Mendieta et al., 2013). Mental health groups can create spaces to relieve feelings of isolation and loneliness; however, Latina immigrant women have been found to endorse preference for individual therapy over group therapy due to worries about confidentiality and fear of judgement by others (Kaltman et al., 2016). Additionally, the cost of mental health services, particularly individual therapy, has been shown to be a primary logistical barrier influencing help-seeking among Latina immigrant women (Kaltman et al., 2016). Past 2 research on changes in social support in a mental health group with Latina immigrant women did not find significant changes in support and found that quantitative measures of social support did not adequately capture changes (Kaltman et al., 2016). The researchers called for future interventions and research to examine specific techniques and skills to enhance social support networks for Latina immigrant women. Latinx immigrants engage in culturally specific processes to cope with and heal from distressing events in their lives (Abraído-Lanza et al., 2004); however, factors that contribute to healthy psychological functioning among Latina immigrants have often been ignored in the psychology literature (Ruiz, 2002). As Latina immigrant women come from more collectivist cultures highly valuing collective interests and connectedness to others (Comas-Díaz, 2006), the erosion of support networks that occurs with migration makes it important to explore and understand the meaning of their experiences in spaces designed for connection and support. Currently, there is a lack of research designed to explore and understand the psychological experiences of Latina immigrant women in mental health groups. Research that addresses the unique stories and experiences of Latina immigrant women in a mental health groups is critical to affecting systemic changes that could result in more supportive, culturally responsive, and affordable mental health services for these women. Purpose of Study and Research Questions The purpose of the present study was to acquire knowledge of Latina immigrant women’s psychological experiences of participating in a mental health group through exploration of the actual situation, as lived through and experienced by the women. The present study aims to gain an understanding of women’s experiences, women’s 3 experiences with others, and the meaning of the women’s experiences in mental health groups. Furthermore, based on the acquired knowledge from this study, I present implications and recommendations for community members and leaders, mental health service providers, and policymakers. In order to explore and gain insight into the phenomenon under investigation, the central question guiding this study is, What is the lived psychological meaning of Latina immigrant women’s experiences in mental health groups with other Latina immigrant women? Research Approach and Design Overview This study was conducted with the approval of the University of Oregon’s Institutional Review Board. A descriptive phenomenological qualitative analysis (Giorgi et al., 2017) was utilized for the research design and overall methodology due to the nature of the research question. Phenomenology was used to understand the meaning that the group members place on the group and the context of the group in their lives. This methodology is a “way of understanding the actor’s frame of reference” (Deutscher, 1973, p. 12) and has been historically utilized to find the essential meaning of a phenomenon. Phenomenology allows for exploration of the meaning, structure, and lived experiences for a phenomenon (Patton, 2002) and helps to determine the essence of a lived experience (Creswell et al., 2007). Previous research on Latina immigrant women’s mental health groups has called for research to more adequately capture changes and experiences in these groups where quantitative measures fall short (Kaltman et al., 2016). For this study, I engaged in purposeful sampling and sought voluntary participation of women who are currently or were previously engaged in a mental health group for Latina immigrant women. Mental health groups included groups for Latina 4 immigrant women centered around specific themes such as intimate partner violence, sexual violence survivor support, parenting, support for support professionals, specific mental health support (trauma, depression, etc.) and overall wellbeing. I, as the primary researcher, and two colleagues, as research assistants, conducted individual semi- structured, in-person, in-depth interviews with each of the volunteer participants. All ten recordings were transcribed verbatim using professional online transcription services in the original language used by the participant and interviewer (Spanish, English, or a combination of both). As a research team, we analyzed the data according to the descriptive phenomenological methods outlined by (Giorgi et al., 2017). Briefly, this analysis entails reading the data, bracketing out assumptions and past knowledge, reducing the data to “psychological meaning units,” organizing and expressing the data using free imaginative variation from a psychological perspective, and synthesizing and describing the psychological structures of the experience. Elaboration of each step of this process is found in Chapter III. Finally, I discuss the findings of this study in context of the theoretical frameworks and concepts, past literature, and highlight the unique contributions of this study. Assumptions A requirement of the scientific phenomenological reduction involves researchers, to the best of their ability, “bracketing out,” or suspending assumptions and previous knowledge of the phenomenon under investigation in order to better describe the participants’ experiences while limiting the researcher bias as much as possible (Wertz, 5 2005). After these assumptions are bracketed out, they can then be reintroduced when data is synthesized and summarized. Based on my experiences as a therapist and researcher in the community, I had three assumptions during the development of the design of this study. First, most of the Latina immigrant women living in the vastly White community from which data was collected may feel isolated, lonely and/or experience increased language or ethnic discrimination due to the small percentage of Latinx community members. This assumption was based on clinical work in the community. Second, I assumed Latinos/as are a heterogenous group, richly diverse in differences in race, ethnicity, nationality, generational status, socioeconomic status, degree of acculturation, and languages. Acculturation refers to the cultural and psychological change processes that occurs after contact between cultural groups and members (Berry, 2005). Although Latinx communities are diverse and speak many languages, they are unified by a history of colonization and the majority utilize a common language, Spanish (Chavez-Dueñas et al., 2014). Additionally, many Latinx communities are united by traditional cultural values emphasize interdependence, collectivism, and family unity (Santiago-Rivera et al., 2002). There might be both divergence and convergence of participants responses and experiences of groups depending on their diverse cultural backgrounds and experiences. Third, I assumed that due to their therapeutic intent, that mental health groups would generally produce positive experiences and improved mental health outcomes for Latina immigrant women. Group psychotherapeutic treatment has special curative factors such as the instillation of hope, universality, imparting information, development of 6 socializing techniques, interpersonal learning, group cohesiveness, and catharsis, among others (Yalom, 1970). These assumptions were bracketed out and they were then reintroduced when data was synthesized and summarized. The Researchers As clinicians and researchers engaging in this phenomenological research, we felt it critical to be reflexive throughout the research process. As the primary researcher of this dissertation study (Researcher A), I identify as White from a European American background. I have worked with Latinx communities for the past fifteen years including living in Latin America for two years, and I am a second-language Spanish speaker. As a doctoral student in counseling psychology, my research and clinical work focus on integrated trauma healing, mental health impacts of immigration policy, and critical consciousness. I have also provided clinical services with Spanish-speaking immigrant clients for three years, including co-facilitating a women’s mental health and wellbeing group with Latina immigrant women. The first research assistant (Researcher B) identifies as Mexican-American, with ties to her indigenous Mexican heritage through her maternal lineage, as a heritage- language Spanish speaker, and as a first-generation doctoral student in counseling psychology She has worked intimately with Latinx immigrant communities since early adulthood and characterized her pursuit for higher education as largely motivated by a desire to give back to the community that raised her. She has worked as a bilingual, Spanish-speaking clinician in Oregon and Pennsylvania for six years and currently facilitates several groups for mono- and bilingual immigrants, as well as works 7 individually with bilingual, bicultural clients through a local community mental health organization. The second research assistant (Researcher C) identifies a Mexican-American woman and first-generation scholar. She is a native-Spanish speaker and a doctoral student in counseling psychology. Her research has focused on addressing health and educational disparities among Latinx communities for over six years. She is a clinician who has worked with Spanish-speaking and bilingual clients through various mental health organizations. In order to deal with our biases and assumptions that come from our own life experiences, we approached all phases of the research endeavor reflexively. As the primary investigator, I acknowledge that I do not share multiple points of identity with participants including racial/ethnic background, native language, possible socioeconomic status, possible motherhood status, and possible level of education. Differences in our identities made it even more important for us as the researchers to critically reflect at every step of the process. I kept a self-reflective journal of ongoing experiences throughout the research process. These self-understandings can then be examined and set aside to some extent or purposefully incorporated into the analysis (Morrow, 2005). Another reflexive strategy we engaged in as a research team was to consult each other as peer debriefers and serve as mirrors reflecting our responses throughout the research process (Morrow & Smith, 2000). We worked together and consulted throughout each step of the research process including processing thoughts and emotions during the process of interviewing, reducing the data to “psychological meaning units,” and organizing and expressing the data from a psychological perspective. At each 8 research meeting, we checked-in about overall interpretations, impressions, and topics that stood out amongst the data. As the primary researcher, I consulted with multiple counseling psychology bicultural and/or bilingual researchers, some of whom identify as Latinx, and others who identify as allies, in order to review for cultural relevance and appropriateness of the interview questions, data analysis, and of the research process in general. At the outset of this research process, I consulted with group members in a mental health group for Latina immigrant women on their thoughts and ideas about additional research questions and the research process in general. I committed to conducting research that addresses social injustices and structural inequalities and integrates a sanctuary research framework in which Chavez-Dueñas et al. (2019) suggest the voices and expert opinions of the people who have survived and resisted immigration policies are integrated into all phases of research. Rationale and Significance The rationale for this study, elaborated in Chapter II, derived from the call for future research to better understand Latina immigrant women’s psychological experiences of participating in mental health groups. The literature examining immigrant Latina women’s experiences of participation in mental health groups is minimal. At the time this study was proposed and throughout the research process, a review of the literature yielded no published studies examining this phenomenon using a descriptive phenomenological design and analysis. A more in-depth description of the literature search is found in Chapter II. 9 Latina immigrant women’s experiences in mental health groups and their interactions with others in the group could have important impacts on their mental health. Thus, exploring these experiences might provide valuable insight into improving mental health services for these women. Furthermore, findings generated from this study could aid mental health professionals and policy makers to work towards providing more equitable, culturally relevant, and culturally responsive mental health services. Language Use Conventions Although there are critiques and contention of the use of “Latinx,” in this study, the term “Latinx” will be used as a gender-inclusive term to encompass Latina/o/x populations (Guidotti-Hernández, 2017). In Chapters IV and V, the use of “the group” will be used to discuss either one participant’s experiences in a particular mental health group or to the experience of participating in groups in general, not a specific mental health group. 10 CHAPTER II LITERATURE REVIEW AND CONCEPTUAL FRAMEWORK OVERVIEW The purpose of this study was to explore Latina immigrant women’s psychological experiences of participating in a mental health group. The present study aims to gain an understanding of women’s experiences, women’s experiences with others, and the meaning of the women’s experiences in mental health groups. Throughout this study, “psychological experiences” refers to the participants’ subjective descriptions of their lived experiences (Giorgi, 2012). Emphasis in this study is on participants’ descriptions of their internal experiences (thoughts and emotions) and how they make meaning from those experiences. The literature review examines Latina immigrant women’s experiences of mental health and utilizing mental health group services. Four major research areas of research were explored: (a) Effects of immigration and subsequent mental health impacts on Latina immigrant women; (b) Social isolation and repercussions on mental health; (c) Social support and influences on mental health; (d) Mental health group service utilization by Latina immigrant women. To conduct this literature review, I used multiple information sources including peer-reviewed journal articles, books, and dissertations. From PsycNet’s database, a search for “Immigrant Latina women mental health group” yielded 4 results. In order to expand the search, using the same search terms on GoogleScholar yielded 43,700 results. The following key terms were added in different combinations to narrow down the results: Latina, immigrant, mental health, mental health group, social support, isolation, trauma, PTSD, depression, therapy, relational cultural theory, radical healing, and testimonio. Additionally, a search was conducted in Spanish 1 1 on GoogleScholar using terms “Latina inmigrante grupo salud mental” [Latina immigrant mental health group,” which resulted in 20 results. Additional terms were added in different combinations to expand the results: apoyo mutuo [mutual support], apoyo social [social support], and mujeres inmigrantes [immigrant women]. To narrow down results, I focused on studies on Latina immigrant women’s mental health, group psychotherapy studies, mental health outcome studies, and qualitative studies on mental health groups. A review of the literature covers Latina immigrant women’s experiences of the psychosocial stressors of immigration, mental health, social isolation, social support, and mental health group utilization. These areas are reviewed in order to provide an understanding of the context, barriers, and challenges women experience to obtain access to mental health groups. Additionally, the review of this literature contributes to knowledge of the multifaceted factors that may contribute to women’s experiences in mental health groups. Next, calls for research in this area are presented. Then the theoretical framework for this study is introduced. Finally, this chapter concludes with a summary of the literature providing the basis for this study and how past research and the conceptual framework contributed to the ongoing development of this study. Immigration and Immigrant Latina Women’s Mental Health Psychosocial Stressors of Immigration Multiple immigration-related stressors influence the mental health of Latina immigrant women. Many immigrants from Central America, South America, and Mexico have experienced war-related trauma, political violence, and other forms of trauma and violence (Martínez, 2014). Martín-Baró stressed that the types of repression 1 2 in the political conflicts in Latin America, including rape, torture, disappearance, and massacres, contributed to not only the traumatization of families, but of society. These events create a “psychosocial” trauma in which there is a “traumatic crystallization in persons and groups of inhuman social relations” (Martín-Baró, 1988, p. 138). The trauma resulting from these experiences extends beyond the individual to the social fabric of society (Herman, 1997). Additionally, increasing numbers of women from Central America, South America, and Mexico are migrating independently as primary providers for themselves and their transnational families due to the economic shifts of globalization and the displacement of men as the primary providers (Petrozziello, 2013), a concept known as the feminization of migration (Gabaccia, 2016). The potential experience of traumas at each stage of migration includes premigration traumas in the home country, traumas in transit to the new country, the process of asylum-seeking and resettlement, and the oftentimes hostile context in the new country (Foster, 2001). Additionally, these phases can include stressors and traumas of extended transit, multiple attempts to cross borders, and multiple detentions (Levers & Hyatt‐Burkhart, 2012; Martínez, 2014). Once in the United States, immigrant women who believed that they would experience a sense of safety and help in the United States often experience institutional betrayal, or wrongdoings of institutions meant to protect them, due to the lack of government and social support (Goodman et al., 2017). Immigrants with undocumented legal status can be further traumatized by “legal violence,” through criminalization, fear of immigration raids, family separation, and anti-immigrant environments. This “crimmigration,” or intersection between criminalization and immigration laws (Stumpf, 13 2006) further marginalizes Latinx immigrants and undermines feelings of stability predictability, and hope (Chavez-Dueñas et al., 2019). Although recently arrived immigrants may face an array of stressors and risks, they do fare better than their counterparts who remain in their country of origin, as well as in comparison with second-generation immigrants, in regard to some physical and mental health outcomes (Alegría et al., 2008; Coll & Marks, 2012). However, despite faring better on some outcomes, it is important to consider the numerous challenges immigrants face. The impacts of these adversities on immigrant women’s mental health are now presented. Immigrant Latina Women’s Mental Health Trauma, Post-Traumatic Stress Disorder (PTSD), and Depression Trauma has often been understood in relation to the definition from the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) of PTSD which includes a history of exposure to (directly experiencing or witnessing) an actual or threatened death, serious injury, or sexual violence. Labelling the impacts of complex trauma or gender-related violence as a “disease” or “disorder” removes the political, social, and economic forces that have given rise to the trauma, whereas women who experience psychological trauma from conflict situations are victims of a political agenda intended to harm (Leslie, 2001). Scholars have advocated for an ecosystemic perspective of trauma to help researchers and counselors to identify and address the multifaced sources of trauma that do not align within the DSM-5 definition (Burstow, 2003; Goodman, 2013). 1 4 Latina immigrant women are at a high risk for exposure to trauma. Prevalence rates have been shown to be 75% (Fortuna et al., 2008; Kaltman et al., 2010). In a study with immigrant and refugee women, three types of trauma were identified: trauma related to the sociopolitical contexts from which women flee, status-based trauma, such as trauma related to their immigration status, and postmigration trauma (experienced in the United States) (Goodman et al., 2017). Latina immigrant women are also at-risk of developing depression and PTSD. A survey of 100 Latina immigrant women at primary care clinic found that 93% reported exposure to trauma, 22.8% met criteria for depression, and 18.8% met criteria for PTSD (Kaltman et al., 2016). Other studies have found rates of depression up to 47.6% for Latina immigrant women (Fox & Kim-Godwin, 2011). Several risk factors for these adverse mental health outcomes include difficulty being away from family, immigration status, fewer years in country, nonmarried marital status, and having experienced four or more types of traumatic events (Fox & Kim-Godwin, 2011; Kaltman et al., 2010). Ethno-Racial Trauma Additionally, Latinx immigrants in the United States often experience systemic oppression and ethno-racial trauma, defined as individual or collective psychological distress and fear in response to experiencing or witnessing discrimination, threats, or intimidation aimed at ethno-racial minority groups (Chavez-Dueñas et al., 2019). Perceiving ethnic discrimination can also have adverse effects on overall health. In a study examining perceptions of language-based and ethnic discrimination among Mexican and Dominican immigrant women, both perceived ethnic discrimination and 1 5 perceived language discrimination were associated with higher levels of psychological distress and lower levels of physical health (Halim et al., 2017). Furthermore, for those who are undocumented, fear and anxiety of the possibility of being forcefully removed or deported from the United States can also contribute to a decreased sense of psychological trust, and safety, and feelings of isolation, powerlessness, frustration fear, stress, and chronic trauma for Latinx immigrants (Rojas- Flores et al., 2016; Salas et al., 2013). This psychological distress and fear have a significantly negative impact on overall health and wellbeing. All of these stressors can exacerbate previous trauma for immigrants and their families, often without social or other support (Capps et al., 2007). As Latina immigrant women come from more collectivist cultures highly valuing collective interests and connectedness to others, the breaking up of support networks that occurs with migration makes it critical to examine the potential implications of social isolation on mental health. Next, the impact of social isolation on mental health is discussed, following with the beneficial components of social support. Social Isolation The loss of emotional and instrumental support is a common challenge for immigrants. Latina immigrant women, especially those from Central America, have lower levels of social support, report feeling lonely and isolated, and experience difficulties creating trustworthy and supportive relationships in their host country (Hurtado-de-Mendoza et al., 2014a; Menjívar, 2000). Social isolation, or lack of social support, is a powerful contributing factor to poor mental health outcomes (Hurtado-de- Mendoza et al., 2014a; Menjívar, 2000). 1 6 Feelings of loneliness and isolation are due to family separation and other barriers to developing and maintaining relationships and support networks. In a study of immigrant Latina women and social support, participants used the word “encerrada” (closed-in or trapped) when describing their lack of opportunity to spend time with others outside of the home (Hurtado de Mendoza, et al., 2014a). Women in the study described socioeconomic (pressures to work), environmental (lack of transportation and weather), and psychosocial (difficulties establishing trust, mental health such as depression, and relationships with controlling others) barriers to establishing social support in the United States (Hurtado de Mendoza, et al., 2014a). Perceived lack of social support among immigrant women has been described as feeling that they do not have anyone to listen to them, to help them to feel secure, to discuss about the local context, to ask for help, or to seek a ride (Parrado et al., 2005). Furthermore, women who have immigrated are less likely than men to work outside of the home, meaning forming social bonds is more difficult, and they may be more likely to depend on their husbands following migration (Parrado et al., 2005). Despite some studies that have highlighted the existence and value of immigrant informal support networks, especially in urban areas (L. A. Leslie, 1992), even immigrant and refugee women who live in immigrant communities and enclaves experience feelings of isolation (Goodman et al., 2017). This isolation can arise from financial barriers and some women limiting or disconnecting ties with family rather than endure the hardship of maintaining them (Goodman et al., 2017). Additionally, trauma exposure has also been demonstrated to correlate with lower perceptions of social support (Schumm et al., 2006) and PTSD can impair a person’s ability to cultivate and sustain supportive networks 17 (Olatunji et al., 2007). Other barriers to creating relationships and emotional connection that have been identified in other studies include discrimination experiences (Negi, 2013), competition, envy, racism and/or classism among Latinx communities (Bathum & Baumann, 2007; Menjívar, 2000). Although familismo, a cultural value of strong family attachment, can lead to reliance on family and friend support networks (Callister et al., 2011), practitioners with stereotypic beliefs that Latinx clients are socially connected may disregard the possibilities that they feel socially isolated (Barrio et al., 2008). Furthermore, when abuse occurs in some Latinx families, the cultural saying, la ropia sucia se lava en casa, (“the dirty laundry is washed at home”) identifies that matters that happen within the home stay within the home and are shameful to discuss with others outside (Edelson et al., 2007, p. 2). Social isolation and lack of social support are significant challenges to mental health and healing among immigrant Latinx communities. Social Support Humans are social beings whose interwoven interpersonal relationships and networks have implications for both mental and physical health (Berkman et al., 2000). Social networks can act as a means of providing social support, social influence, social engagement, and interpersonal contact, all of which have been shown to impact overall health (Berkman et al., 2000). Social support has many meanings. For the purposes of this study, social support is defined as affirming interactions with social networks or professionals that promote coping by offering tangible resources and/or emotional guidance (Stewart & Langille, 2000). These supports can become crucial during major life transitions, such as moving to a new country. 1 8 Social support has the ability to buffer the impacts of stressors on mental health concerns. For immigrant women, support from family and friends can reduce the effect of economic and social stressors on emotional health by helping individuals to cope with challenges, organize resources, and share their burden of stress (Ornelas et al., 2009). Another study among Central American immigrants found that effective family and social support was also protective against depression during acculturation (Hovey, 2000). Social support can play a major role in buffering the impact of trauma. High levels of social support moderate the impact of trauma and decrease likelihood of developing depression or PTSD due to increased resources to cope (Charuvastra & Cloitre, 2008; Ibarra-Rovillard & Kuiper, 2011). In a meta-analysis of 77 studies, lack of social support after trauma was one of the strongest predictors of developing posttraumatic stress disorder (Brewin et al., 2000). One study demonstrated that for Sudanese refugees in Australia, perceived social support, particularly from their own ethnic community, played a significant role in predicting more positive mental health outcomes (Schweitzer et al., 2006). Among women who experienced intimate partner violence, higher social support was associated with improved mental health including lower anxiety, depression, PTSD symptoms, and suicide attempts (Schweitzer et al., 2006). For immigrant and refugee women, social support and interpersonal relationships have been shown to be key to developing resilience, which is a process of adaptation to circumstances in one’s life (Masten, 2001). For Mexican women using health centers, those who perceived social support from their family networks reported less suffering than those who felt more alone (Juárez-Ramírez et al., 2015). Furthermore, spending time 19 and sharing with others from one’s country of origin and language offer valuable opportunities for support and friendship (Goodman et al., 2017). Social support also has the potential to impact self-esteem. In a study on factors contributing to self-esteem among Central American/South American, and Mexican immigrant women, social support was the most consistent explanatory variable of higher self-esteem (Flaskerud & Uman, 1996). An important aspect of social support, sense of community, has been found to moderate the effects of acculturation stress that immigrants experience in a new country. A strong sense of community may buffer against the stressors of being an immigrant (Hombrados-Mendieta et al., 2013). McMillan and Chavis (1986) write, a “sense of community is a feeling that members have of belonging, a feeling that members matter to one another and to the group, and a shared faith that members’ needs will be met through their commitment to be together” (p. 9). Central to feeling a sense of community is emotional safety, a sense of belonging to, and identification with a larger community (Hombrados-Mendieta et al., 2013). Community belonging is experienced as a process that is relational, dynamic, and creative, driven by interpersonal networks that could be accessed in times of need (Hudson, 2015). For Latinx communities, two of seven particular psychological strengths that have helped Latinxs to survive and thrive despite challenges and barriers in the United States, include connectedness to others and collective emotional expression (Adames & Chavez- Dueñas, 2016). Connectedness to others is the value of being emotionally, physically, and spiritually connected to others through sharing and bearing witness to each other’s pain and joy. Collective emotional expression is the ability and need to share strong emotions 20 in community, whether through spoken word, music, dance, art, spiritual rituals, art, literature, and sporting events (Adames & Chavez-Dueñas, 2016). Mental health groups are one avenue for creating social support, sense of community, connectedness to others, and a venue for collective emotional expression. Mental Health Groups Latinx immigrants in the United States experience significant mental health disparities related to access to care, quality of care, and socioeconomic- and immigration- related stressors (Rios Casas et al., 2020). Due to the high rates of exposure to trauma, depression, and PTSD (Fortuna et al., 2008; Fox & Kim-Godwin, 2011; Kaltman et al., 2010; Kaltman, et al., 2016) and the lower likelihood of seeking treatment (Alvidrez, 1999), the mental health needs of immigrant Latinxs from Central and South America are of particular concern. Barriers to Mental Health Care Barriers to care for Latinx communities include concern about cost and lack of insurance (Kaltman et al., 2016), stigma and norms about mental health (Nadeem et al., 2009), lack of ethnic/racial matching between clients and clinicians (Olfson et al., 2009), lack of services provided in Spanish, mistrust of clients toward the health care system, and insufficient training and tailoring of treatment to the cultural background of the family (Alegría et al., 2008). Currently, fear and anxiety among immigrant communities may serve as barriers to seeking mental health services due to concerns about the ramifications of discussing their immigration status with mental health providers (French et al., 2020). 2 1 Latinxs who seek psychotherapeutic support often encounter Eurocentric-based services that are not sensitive to their cultural and spiritual experiences (Atkinson et al., 2001). Additionally, many clinicians lack cultural sensitivity (Sue & Sue, 1999) resulting in some Latinxs feeling that the dominant culture is using the techniques and goals of mainstream psychotherapy as an acculturation tool (Ramirez, 1991). Another potential contributor to challenges to accessing mental health care for Latina women in particular are cultural priorities such as family responsibilities over self- care (D’Alonzo, 2012). Women may place family needs and concerns first before their own and be more likely to seek services for family members (e.g., children) rather than for themselves (Becerra & Michael-Makri, 2012). Therefore, the extent to which Latinas internalize or feel pressure to embody idealized cultural identities may possibly serve as a vehicle of additional stress (Mahalingam et al., 2009), which may also adversely impact mental health. Group Psychotherapy Group psychotherapeutic treatment has special characteristics and curative factors (Foy et al., 2000; Klein & Schermer, 2000). Yalom’s Curative Factors (1970) include the instillation of hope, universality (the notion that group members are not alone), sharing information, development of socializing techniques, interpersonal learning, group cohesiveness, and catharsis, among others. Some of the goals of mental health groups include establishing safety, reducing isolation and alienation, and helping group members to connect with others who have had similar experiences and may share similar identities (Foy et al., 2000; Klein & Schermer, 2000). Participation in a mental health group can foster healing via cohesion, normalization, and containment, which support group 22 members to cope with physical, cognitive, and emotional reactions to trauma (Foy et al., 2000; Klein & Schermer, 2000). These characteristics of group therapy seem like a good match for Latina immigrant women’s concerns; however, less is known about their experiences in mental health groups. Latinx Values in Mental Health Groups Although mainstream psychotherapy promotes the values of dominant culture such as that the ideal self is unique and independent from others, people from collectivist cultures understand themselves through others and value family, social, and emotional bonds and prioritize communal goals over individual ones (Comas-Diaz, 2006). As isolation is a powerful effect of trauma and depression, groups that provide support and reconnection for group members is especially important (Ulman, 2004). Confianza (trust), is a value that is central to Latinx culture, and means that individuals are dedicated to mutually trusting relationships. Confianza is demonstrated when someone expresses their deepest and innermost feelings to a trusted group and signifies that each person in the relationship has the other’s best interests at heart (Bracero, 1998). This makes it critical for group psychotherapy to honor the Latinx values of personalismo (an inclination for warm yet formal relationships), confianza (trust), and respeto (respect) (Sue & Sue, 2015) in order to create a space of confidentiality and free of judgment. Latina Women’s Experiences in Mental Health Groups A review of the findings on mental health groups for Latina women suggested that group psychotherapy for Latinas with bilingual and bicultural staff has been found to be effective especially with women over 50 years of age who more commonly report feeling isolated or lacking in social support (Vargas-Willis & Cervantes, 1987). The 23 authors also noted that groups for this population can be helpful for the development of support networks, relief of mental health symptoms, and development of a sense of cultural connectedness and identification (Vargas-Willis & Cervantes, 1987). Group therapy for Latina women who have experienced domestic violence has been found to be supportive in a variety of ways. Immigrant Latina women in a culturally specific psychoeducational group, Sí, Yo Puedo, reported improved self-esteem, understanding of healthy relationship dynamics, and experienced empowerment due to listening to and supporting one another (Marrs Fuchsel, 2014). For Latina women in their country of origin who have experienced domestic violence, participating in group psychotherapy can result in feelings accepted and understood by other group members (Castro, 2009). Reduction in mental health symptoms has been demonstrated in various groups for Latina women. Cognitive behavioral group therapy has been found effect for treatment of certain mental health disorders with Latina clients, such as depression (Comas-Diaz, 1985). Mexican mothers who have experienced domestic violence have been found to have a reduction in PTSD experiences after participation in a mothers’ empowerment program (Galano et al., 2017). Latinas Saludables [Healthy Latinas], a mental health individual and group session intervention for trauma-exposed Latina immigrant women in primary care resulted reduction in depression and PTSD symptoms (Kaltman et al., 2016). It is important to keep in mind that no single treatment method is the best for all Latina immigrant women and women will respond differently to various approaches depending on the presenting problem (Vargas-Willis & Cervantes, 1987) and their 2 4 background and context. Literature has primarily focused on Latina women’s mental health outcomes in mental health groups addressing specific topics such as domestic violence or depression, but research studies have not explored the meaning of immigrant Latina women’s participation, interactions, and relationships with each other in mental health groups specifically within a predominantly White community. Calls for Research The literature examining immigrant Latina women’s experiences of participation in mental health groups and social support is minimal. Although there have been previous studies examining Latina immigrant women’s experiences in specific mental health support groups, findings often focus on quantifiable mental health outcomes (Comas- Diaz, 1985; Galano, et al., 2017; Kaltman et al., 2016). Few studies explore immigrant Latina women’s interactions with others and relational experiences in mental health groups (Castro, 2009; Marrs Fuchsel, 2014; Vargas-Willis & Cervantes, 1987). At the time I commenced my literature review, and in a more recent search for new findings, there were no published studies examining Latina immigrant women’s psychological experiences in mental health groups with other Latina immigrant women in a vastly majority White community using a descriptive phenomenological design and analysis. Phenomenology supports exploration of the meaning, structure, and lived experiences for a phenomenon (Patton, 2002). In previous research on Latina immigrant women’s mental health groups, scholars have called for research to more adequately capture changes and experiences in these groups where quantitative measures fall short (Kaltman et al., 2016). Cultural competence and cultural humility include attending to perspectives on healing that are based on the culture of the clients (Mosher et al., 2017). Scholars have 25 called for understanding the potential benefits of increased access to mental health care and community-based programs to connect immigrant Latina women to resources (Rios Casas et al., 2020) such as analyzing interventions that target barriers to building and maintaining supportive networks among trauma-exposed immigrant Latinas (Hurtado-de- Mendoza et al., 2016) and the effectiveness of depression-care programs for Latina women (Nicolaidis et al., 2011). Scholars have also called for research on the pathways to resilience and wellness for immigrants (Salas et al., 2013), culture-centered mental health services (Goodman et al., 2017), and how to increase community connections and resource sharing to create communities of resistance (Watkins & Shulman, 2008). Increased attention to diversity and cultural competence has led to greater sensitivity and cultural adaptations in individual and group therapy (Bernal & Domenech Rodríguez, 2012), and the present study aims to further contribute cultural adaptations in group therapy specific to immigrant Latina women. Additionally, French et al. (2020) have requested research focusing on relational liberation and exploring contexts in which people who experience oppression come together in solidarity and compassion. The purpose of the present study is to explore the psychological experiences and the meaning of those experiences of Latina immigrant women who participated in mental health groups. Theoretical Framework Relational-cultural theory (RCT), testimonio, and elements of psychological radical healing framework are now presented as the frameworks and conceptual tools utilized to guide this study. 2 6 Relational-Cultural Theory Relational-cultural theory (RCT) is a comprehensive feminist theory of counseling and development that evolved from the idea that traditional models of human development and psychotherapy do not accurately address the experiences of women and individuals from marginalized cultural groups (Comstock et al., 2002). RCT provides an inclusive model of relational development across the lifespan that is grounded in the idea that healing occurs in the context of mutually empathic, growth-fostering relationships. RCT’s focus on interdependence and contextualism is aligned with more collectivist values (Frey, 2013). The context of relational development is inextricably connected to racial, cultural, and social identities. RCT assumes that experiences of cultural oppression, social exclusion and isolation, and other forms of social injustices all contribute to the pain and trauma that marginalized individuals experience in their lives (Birrell & Freyd, 2006). RCT posits how individuals can be silenced from sharing their experiences due to power differentials, gender role socialization, race, culture, sex orientation and all of the various “isms” (Dooley & Fedele, 1999; Hartling et al., 2000; Miller et al., 1999; Walker, 2001). RCT theorists posit that all individuals yearn for connection, belonging, and social inclusion (Comstock et al., 2008). However, despite desires for connection, people commonly demonstrate a paradox in which feelings of vulnerability, fear, shame, suspicion, and mistrust result in further disconnection and isolation (Comstock et al., 2008). Although groups can create spaces to relieve feelings of isolation and loneliness, Latina immigrant women have expressed preferences for individual over group therapy 2 7 due to worries about confidentiality and fear of judgement by others (Kaltman et al., 2016). From a multicultural/social justice perspective, many marginalized groups are subjected to various forms of structural violence (racism, sexism, classism, nationalism, etc.), which perpetuate fear and psychological disconnections with others. When people acknowledge these relational fears and concerns about disconnections, they need others to empathically resonate and identify with their vulnerabilities (Comstock et al., 2008). RCT expands Carl Rogers’s one-way concept of empathy (Rogers, 1975) to a two-way process called mutual empathy, which serves as a key to healing and relational transformation in therapy (Comstock et al., 2008). Research calls for additional studies of RCT in the field, particularly application of the theoretical framework with diverse individuals in community-settings (Frey, 2013). RCT informed the design and analysis of this study via interview questions assessing how participants experienced mutually empathic, growth-fostering relationships and/or disconnections in the mental health groups. For example, two interview questions were, “What were your experiences with other group members?” and “What was similar or different with your relationships or experiences with group members and/or friends or family members outside of the group?” Testimonio Aligned with RCT is testimonio, a form of sharing originating in Latin America, which is defined as sharing personal accounts of struggle in order to inform, show solidarity, or to cast light on oppression (Elenes, 2000). A ‘conspiracy of silence’ can create situations in which women feel disempowered and unworthy of telling their stories 2 8 to others (Leslie, 2001). Testimoniar (to give testimony) is the act of uncovering previous experiences that have been silenced or untold and weaving them into a narrative of one’s personal, political, and social realities. Testimoniando, or telling one’s personal testimonio, can be powerful and healing because of the collective identification that emerges when sharing struggles with others who hold a shared understanding (Elenes, 2013; Huber, 2009). A safe space is critical for giving testimony, especially for women, who might feel responsible for the violence or traumatic events they have experienced (Leslie, 2001). Testimonio has been found to be socially therapeutic in group counseling to desahogarse (to vent or literally to undrown one’s self) and to be experienced as healing and empowering (Cervantes et al., 2019). By the nature of a speaker sharing in front of listeners, testimoniar is a relational and interactional process, which in and of itself can be healing. Testimonio has been described as a verbal healing journey into a painful past, an account of a person’s traumatic experiences and how these affect the individual, family, and community (Cienfuegos & Monelli, 1983). Mainstream psychotherapy testimony differs from testimonio because the latter takes into account both the individual and communal effects of trauma (Comas-Díaz, 2006). The process of healing can be facilitated via testimonio by reflecting, recounting, and remembering the past (Delgado Bernal et al., 2012). Testimonio is used as a conceptual tool to understand the healing processes within RCT in study because the study seeks to explore the women’s experiences of sharing in community with other women with overlapping identities and experiences of migration. 2 9 A Psychological Radical Healing Framework Additionally, elements of a psychological radical healing framework for communities of color (French et al., 2020) are utilized as another conceptual frame. Radical healing refers to a process by which People of Color and Indigenous individuals (POCI) come together as a community to heal. It involves acknowledging the pain of oppression while also resisting and building hope for justice and freedom. Collectivism can create spaces for radical healing in which authenticity and comradery can offer support in the context of continual oppression. In this way, radical healing also includes sharing one’s story as a way of testifying and building solidarity with others (French, et al., 2020). Although clinicians are taught to acknowledge and inform interventions with the cultural background of their clients, they sometimes invalidate clients’ experiences by questioning the validity of the POCI’s experiences of racism and discrimination (Sue, 2015). Coming together as a community to talk about experiences of racism and discrimination allows for validation from others with similar experiences. Emancipation circles, developed by the Association of Black Psychologists, are healing spaces that center the voices of community members as they share and validate their experiences of intersectional discrimination and identify their own culturally informed healing practices (Grills et al., 2016). A sense of psychological strength can occur when POCI have a healthy sense of self and cultural authenticity and come together to work to reduce barriers to wellness and healing from adversity (French, et al., 2020). Relational liberation is manifested through acts of solidarity and compassion with others who suffer from oppression, coming together to talk about experiences (French, et al., 2020). In this 30 sense, a model of radical healing illuminates the possible mechanisms at work as women come together to heal including collectivism, women defining their own healing, telling their own stories, and enacting solidarity as they listen to and discuss experiences of adversity. Using a framework of RCT, testimonio, and collectivism from the model of radical healing, this study explored immigrant Latina women’s experiences in mental health groups with other Latina immigrant women. Rather than proposing a process and testing whether this in fact aligns with the women’s experiences in the groups, I sought to explore the meaning for immigrant Latina women of sharing about life experiences together in a mental health group of women with diverse and shared identities and experiences. Summary of Literature Review Multiple immigration-related stressors influence the mental health of Latina immigrant women. Latina immigrant women are at a high risk for exposure to trauma (Fortuna et al., 2008; Kaltman et al., 2010) and of developing depression and PTSD (Fox & Kim-Godwin, 2011; Kaltman et al., 2016). The loss of emotional and instrumental support is a common challenge for immigrants. Social support has the ability to buffer the impacts of stressors on mental health concerns (Brewin et al., 2000; Charuvastra & Cloitre, 2008; Ibarra-Rovillard & Kuiper 2011; Ornelas et al., 2009; Schweitzer et al., 2006). Mental health groups are an avenue for creating social support, sense of community, connectedness to others, and a venue for collective emotional expression. Although groups can create spaces to relieve feelings of isolation and loneliness, Latina 3 1 immigrant women prefer individual therapy over group therapy due to privacy and judgment concerns (Kaltman et al., 2016). Developing a clearer understanding of immigrant Latina women’s experiences in mental health groups may inform efforts to increase the effectiveness of such groups in reducing social isolation, psychological distress, and promoting healing with others. Next, I present the purpose of this study. Purpose of the Present Study The purpose of the present study was to acquire knowledge of Latina immigrant women’s psychological experiences of participating in a mental health group through exploration of the actual situation, as lived through and experienced by the women. The present study aimed to gain an understanding of women’s experiences, women’s relational experiences with others, and the meaning of the women’s experiences in mental health groups. Furthermore, the acquired knowledge from this study led to implications and recommendations for community members and leaders, mental health service providers, and policymakers. In order to explore and understand the phenomenon under investigation, I utilized a descriptive phenomenological design and analysis (Giorgi et al., 2017). The central phenomenological question guiding this study is, What is the lived psychological meaning of Latina immigrant women’s experiences in mental health groups with other Latina immigrant women? In Chapter III, the descriptive phenomenological design and analysis are discussed in detail. 32 CHAPTER III METHODS This chapter describes the research methodology of this study including: (a) rationale for a phenomenological research design, (b) description of the research sample, (c) overview of the research study design, (d) methods and data collection, (e) data analysis, and (f) ethical considerations of this study. The chapter concludes with a brief overall summary. Rationale for Phenomenology Descriptive phenomenology (Giorgi et al., 2017; Moustakas, 1994) is used for the research design and overall methodology. Phenomenology is used to understand the meaning that participants place on their experiences in the mental health groups, their interactions with others in the group, their experiences of testimonio, and the context of the group in their lives. This methodology is a “way of understanding the actor’s frame of reference” (Deutscher, 1973, p. 12) and helps to determine the essence of a lived experience (Creswell et al., 2007). Phenomenology is a type of qualitative research that was originally developed by philosopher Edmund Husserl, who expanded the methods of modern science to include the study of consciousness and created scientific research methods to support psychological researchers study human experience and behavior (Wertz, 2005). The phenomenological movement made the most critical impact on psychology in the area of mental health (Spiegelberg, 1972). By valuing the distinctive characteristics of human behavior and first-person experience, phenomenology was a protest against the 33 dehumanization that can occur in other methods of theory and research in psychology (Wertz, 2005). Husserl’s phenomenology uses a common methodological principle that scientific research begins with an unbiased description of the subject. In order to strive for an unbiased description, Husserl proposes two procedures called epochés. The first epoché helps the researcher come to the subject matter freshly, as it exists before and independent of scientific knowledge. This involves the researcher acknowledging and bracketing out prior theories, assumptions, and conceptualizations of the subject (Husserl, 1913/1962). This process of bracketing allows the researcher to put aside prior scientific assumptions to gain access to what Husserl would say, “to the things themselves (Sachen selbst)!” This gives the researcher access to the “natural attitude” in the prescientific life- world, that is, an unreflective experience of the world as it is lived in everyday life (Husserl, 1939/1954, p. 148-150). The second epoché involves the researcher suspending belief in the existence of what presents itself in the life-world. Rather, the researcher shifts focus from what presents itself to the lived psychological meanings and subjective performances of human experiences. This is the attitude of the phenomenological psychological reduction. Human experiences are “bracketed” in order to transfer focus from what is presented in a straightforward manner to a reflection on the psychological meanings of how the life- world presents itself (Wertz, 2005). These two epochés as procedures allow the researcher to collect data from people who have experienced a phenomenon and to develop a composite description of the essence of the experience for all individuals – what they experienced and how they 34 experienced it (Moustakas, 1994). Researchers report how individuals in the study view their experiences differently (Moustakas, 1994). This method allows for description of what all participants have in common as they experience a phenomenon and reduces these experiences to a description of the universal essence (a “grasp of the very nature of the thing”; van Manen, 1990, p. 177). Phenomenological research design in counseling psychology begins with identifying a psychological topic in the life-world. The researcher conducts a thorough review of the literature and determines the gap between knowledge and reality that requires a qualitative knowledge and understanding of what occurs (Wertz, 2005). The research project is then designed and constructed to fill in the gap. In phenomenological research design, interviews are a common method of data collection “when the phenomenon of study is complex in structure, extensive in scope, or subtle in features that participants may not likely offer in response to questions at the outset” (p. 171, Wertz, 2005). After designing the study, the researcher then utilizes the first epoché to come to the subject matter freshly by bracketing out prior theories, assumptions, and conceptualizations of the subject before conducting data collection. Following in the phenomenological design, after data collection, is the analysis. Descriptive phenomenological analysis have been outlined by Amadeo Giorgi, influenced by the work of Husserl. Giorgi et al. (2017) outline five steps of the descriptive phenomenological process of analyzing descriptions provided by research participants: (1) read the entire description in order to grasp and understand the whole; (2) assume the attitude of the psychological phenomenological reduction; (3) reread the description and note shifts in “psychological meaning units” in the text, with a psychologically sensitive 35 curiosity to the phenomenon of interest; (4) reflect on each “psychological meaning unit” to understand what each unit reveals about the phenomenon and transform participants’ expressions into expressions that highlight the psychological meanings lived by participants; and (5) synthesize these reflections and expressions into a statement that describes the psychological structure(s) of the experience (Giorgi, 2012; Giorgi et al., 2017). An important note about research attitudes is that the first epoché and “natural attitude” is sufficient for the first step of analysis. For the remaining steps of the analysis (2-5), the researcher must engage in the second epoché, and adopt the attitude of the phenomenological psychological reduction. This attitude allows the researcher to shift focus from the descriptions of participants’ experiences in the data collected to the lived psychological meanings and subjective performances of the participants’ experiences. For steps 4 and 5, Giorgi et al. (2017) also encourage employing what is deemed, “free imaginative variation.” Giorgi (2007) defined the process of utilizing free imaginative variation as the researcher imaginatively varies different aspects of the phenomenon in order to determine which aspects are essential to the phenomenon, and which are contingent. For example, if the researcher imagines the elimination of an aspect and the phenomenon collapses, then that aspect is essential. However, if the researcher imagines the variation of an aspect and it barely changes what is presented, that aspect is not essential (Giorgi, 2007). For clarity, the terms utilized in descriptive phenomenological analysis are elucidated. Because descriptions of experience can be long, they need to be broken into parts for proper analysis. Phenomenological analyses are concerned with discriminating meanings and separating them into parts; the researcher must carefully reread the 36 participant’s description and intentionally distinguish whenever she experiences a difference in meaning. The researcher then marks this as, a “psychological meaning unit,” which is a unit of meaning of the participant’s emotional or cognitive experience. Once the psychological meaning units are determined, the researcher then transforms the meanings in the description in phenomenologically and psychologically sensitive ways. The transformations are meant to express meanings more directly in relation to the psychology of participating in a mental health group (in this case) and to generalize the meanings so that they can be integrated with other descriptions from other participants (Giorgi et al., 2017). During step 5, the researcher then reviews all the transformed expressions and determines the essential ones. This process requires eidetic reduction in which the researcher examines a phenomenon and then systematically varies it in order to determine its essence, essentially determining what the key meanings are and if they relate to the whole description or not (Giorgi et al., 2017). These transformations are then grouped together to form constituent elements of a larger psychological structure. Each constituent is defined as part of an interconnected structure in which each part must be both nonredundant and present for the whole structure to be preserved. The resulting general psychological structures of the overall phenomenon consist of both the essential constituent meanings as well as the relationship among the meanings. Determining these structures involves a reflective process with the goal of deciding what is essential to each description (Giorgi et al., 2017). In the advanced phase of the analysis, the researcher can deliberately discontinue the epoché and examine the situation with previous concepts and theories as guides for knowledge. When phenomenologically useful, preconceptions may 37 evince aspects of the description that were not previously evident (Wertz, 2005). This process is elaborated on with examples in the Methods of Data Analysis section following in this chapter. Social Constructivist Paradigm Phenomenology is rooted in the constructivist philosophical paradigm. This study uses a social constructivist paradigm in which we, as the researchers, utilized open-ended questions in order to listen carefully to what people say or do in their life setting (Creswell & Creswell, 2017). Constructivist researchers often focus on the “processes” of interactions among people and focus on the specific contexts in which people live and work and the historical and cultural settings of participants (Creswell & Creswell, 2017). We, as researchers, recognized that our own backgrounds shaped our interpretations and we “positioned ourselves” in the research to acknowledge that the interpretation is also influenced by our own personal, cultural, and historical experiences. Our intent was to understand the meanings the participants have about the world. Next, the research sample is presented followed by methods of data collection and methods of data analysis. Research Sampling and Participants A purposive sampling procedure was utilized to select this study’s sample, which is consistent with Strauss and Corbin (1998) theoretical sampling, used to choose individuals who can contribute to an evolving conceptual framework. A total of ten Spanish-speaking Latina women who have immigrated from Latin America were recruited from local organizations and nonprofits that currently or in the recent past conducted mental health groups specifically for Latina immigrant women in a predominantly White community in the Pacific Northwest. 3 8 Context In order to understand the context in which the participants lived, it is important to provide some information and history of the city and state. To protect the identities of participants, I will not disclose the name of the city or state because of the small city where the research was conducted. This study took place in a majority White city in which the population is 78% non-Latinx White and 10% Latinx (US Census Bureau, 2019). The state has had long racial exclusionary laws, which prohibited Black people from living in the state until 1926 (Harris et al., 2009) and beginning in the 1920s, the city had an active chapter of the Ku Klux Klan (Dennis & Reis-Dennis, 2019). Racially biased crimes are rising in the city and the state (Campbell et al., 2018) and according to a 2019 report on hate and bias crimes in the city, race was the leading motivating factor of hate crimes (Office of Human Rights and Neighborhood Involvement, 2020). Two major factors that have exacerbated the problem are a perceived anti-immigrant climate encouraged by President Donald Trump and fears of reporting to authorities, especially due to fears of deportation among undocumented immigrants (Campbell et al., 2018). Additionally, during the time period of this study, the U.S. President openly expressed antagonism for immigrants of color. His administration enacted hundreds of policies designed to decrease the number of immigrants accessing and remaining in the United States, such as “zero tolerance” policies aimed at Mexican and Central American noncitizens (Pierce & Bolter, 2020; Villazor & Johnson, 2019). Legal scholars argue that this “war against immigration diversity” facilitated the Administration’s overarching goal of restoring pre-1965 immigration policies designed to preserve a “White nation” (Villazor & Johnson, 2019). Understanding the time in history, the demographics, bias, 39 and discrimination stressors of the city and state in which this research study took place provides important context for the lived experiences of the participants as Latinx immigrant women. Participants The participants involved in this study were engaged in various mental health groups specifically for immigrant Spanish-speaking Latina women in the community. The groups were focused around varied themes pertinent to immigrant Latina women including intimate partner violence, sexual violence survivor support, parenting, support for support professionals, specific mental health support (trauma, depression, etc.) and overall wellbeing. Two of the groups that participants had been involved in included non- immigrant Latina women. Including participants from various kinds of mental health groups allows for consideration of whether elements of RCT, Radical Healing, and testimonio were present or important across the different kinds of groups. Participant inclusion criteria were specified to increase consistency across participants’ experiences, in order to better understand the phenomenon of participation in a women’s mental health group. Study participants were required to be over the age of 18, Spanish-speaking, and to have participated in a minimum of five sessions in a women’s mental health group for Latina immigrant women, which is the number of sessions used in previous research to assess experiences of social support in a mental health group (Kaltman et al., 2016). Due to the nature of qualitative research, the number of participants could not be determined mechanically beforehand. Scholars argue that qualitative inquiry has no rules for sample size, but rather sample size is relative to the goals of the research (Patton, 4 0 2002). The sufficiency of the data rather than the numbers is the most important in the selection process (Morrow, 2005). In order to reach adequate sample size in qualitative research, it is important to assess for data saturation both in occurrence of themes and the meaning of issues. Data saturation signifies when a there is a redundancy of findings that fulfill the aims of the research (Wertz, 2005). In phenomenological analysis, saturation may be reached after a few interviews by providing an outline to the main topics of inquiry, however further data may be needed to provide depth, richness, and complexities in data that have important meaning for understanding the phenomena of interest (Wertz, 2005). I continued to add participants as needed until I reached code and meaning saturation with ten participants. Following, participant demographic and descriptive data are presented. Participant Demographic and Descriptive Data Demographic and descriptive data for the full sample of interviewed participants (n = 10) and their participation in mental health groups are presented in Table 1. Participants ranged in age from 34 to 77 years old (M = 45.2, SD = 11.6) and had lived in the United States from 1.5 to 29 years (M = 14.5, SD = 9.8). Five participants were from Mexico (50%), three from Guatemala (30%), and two were from Perú (20%). Nine participants identified as heterosexual (90%) and one preferred not to respond (10%). Five participants were married (50%), one was in a free union (10%), two were separated (20%), and two were divorced (20%). Participants had 0 to 4 children (M = 2.2, SD = 1.1), and their children ranged in age from 1 to 37 years old (M = 13.1, SD = 9.0). 4 1 Table 1. Participant Demographic Information Pseudonym Age Years in Groups Group Sessions United States Attended Attended Sofía 42 27 3 64 Isabella 34 4 3 54 Valentina 44 6 4 127 Alma 37 3 2 16 Thalia 77 13 3 34 Maite 52 20 4 143 Xochitl 43 21 2 6 Camila 42 29 1 108 Eva 43 20 2 118 Lola 38 1.5 1 21 In terms of education, one participant had no formal schooling (10%), two had completed elementary school (20%), one had some high school (10%), one had completed high school (10%), two had completed some college (20%), two had completed college (20%), and one had a master’s degree (10%). Participants held occupations in diverse fields; two participants were homemakers (20%), one participant engaged in agricultural work (10%), one in childcare (10%), two in the service industry (20%), one in education (10%), one in a non-profit (10%), one in reception (10%), and one in employment training (10%). Annual incomes ranged from between $0 – 19,000 to $110,000 to support households of 1 to 5 people (M = 3.2, SD = 1.5). Participants had attended between 1 and 4 different mental health groups in the community for Latina 4 2 immigrant women (M = 2.5, SD = 1.0), attending approximately 6 to 143 sessions total (M = 69.1, SD = 48.3). Next, an overview of the research design is presented. Research Design Overview The following steps were utilized to engage in the descriptive phenomenological method. After this list is a more in-depth description of each of these steps. 1. I consulted with multiple counseling psychology bicultural and/or bilingual researchers, immigrant Latina women involved in a mental health group, and counseling psychology faculty members to create culturally appropriate and open- ended interview questions for this phenomenological inquiry. 2. I secured University of Oregon Institutional Review Board approval to conduct this study. 3. I sought and received the College of Education Doctoral Research Awards for the purpose of funding participant incentives, professional transcription services, recording devices, and a stipend for research assistants. 4. I emailed study fliers and study emails to local community liaisons and organizations which have facilitated or were currently facilitating mental health groups for immigrant Latina women. 5. I engaged in purposeful sampling for semi-structured interviews by seeking voluntary participation of women who are currently or previously engaged in a Latina immigrant women’s mental health group and have attended at least five sessions. 6. I and two colleagues, as research assistants, conducted individual semi- structured, in-person, in-depth interviews with each of the volunteer participants 4 3 in the order that they had volunteered. Due to COVID-19 restrictions, interviews occurred over Zoom or the phone and were audio recorded. 7. All ten recordings were transcribed verbatim using professional online transcription services through the technological and research services company, DataGain, which provided the transcripts in the original language used by the participant and interviewer (Spanish, English, or a combination of both). 8. We analyzed the data according to the descriptive phenomenological methods outlined by Giorgi et al. (2017). 9. As a final step included in the IRB-approved consent forms that is not a formal part of the dissertation project, I will share findings with the participants, community agencies, and other interested community partners through a link to a website with a summary of the study findings. Methods of Data Collection The steps of the methods of data collection are now explained in more depth. For the first step of the research design, the interview questions were designed to address gaps in the literature of the meaning of Latina immigrant women’s experiences in mental health groups. Developing culturally appropriate questions requires in-depth knowledge of the population and consulting with cultural experts (Ojeda et al., 2011). At the outset of this research process, I consulted with group members in a mental health group for Latina immigrant women on their thoughts and ideas about research questions and the research process in general, in commitment to a sanctuary research framework (Chavez- Dueñas et al., 2019). Group members responded that connections with other group members and receiving mutual support were essential to their group experiences, thus, 4 4 specific questions were developed around group connections and types of support (Weinberg et al., 2005). Next, I designed the open-ended questions to elicit what it is like specifically to be in a group with other Latina immigrant women to understand their experiences in context, the relational processes of interactions and relationships, and the meaning of their experiences. I consulted with multiple counseling psychology students and faculty researchers, some of whom identify as immigrant, some as Latinx, and others who identify as allies, in order to review and edit the questions for cultural relevance and appropriateness of the interview questions in English and Spanish. Additionally, with feedback from my dissertation committee, I further broadened the open-ended questions in order to elicit participants’ experiences. This enabled me to continue in the first epoché and to avoid any leading questions that might support a particular theory such as RCT or the psychological radical healing framework. Before recruitment efforts commenced, approval for the research project was granted from the University of Oregon Institutional Review Board. (Please see Appendix A for UO IRB approval of this study.) Following IRB approval, I sought and received the College of Education Doctoral Research Awards for the purpose of funding participant incentives, professional transcription services, recording devices, and a stipend for research assistants. Next, participants were recruited through flyers posted at local non-profits and centers and emails to providers within the community. As the primary researcher, I conducted all recruitment efforts and scheduled interviews. I emailed study fliers and study emails to local community liaisons and organizations which have facilitated or 45 were currently facilitating mental health groups for immigrant Latina women. Mental health groups focused on specific themes such as intimate partner violence, sexual violence survivor support, parenting, support for support professionals, specific mental health support (trauma, depression, etc.) and overall wellbeing. (The recruitment and flyer and email in English and Spanish are included in Appendix B and Appendix C.) Interested participants were screened over the phone to ensure that they met the pre- established study criteria. After the screening process, I invited participants who met the study criteria to an interview time and date with one of the three researchers. As it is a small community in which the research took place and all three researchers are involved in clinical work within this community, care was taken to ensure that each participant was not known to the researcher who was interviewing them. Specifically, I verified with each researcher (including myself) that we did not know and had not had prior interactions with each participant with whom we interviewed. Participants were informed the interview duration would be between 60-90 minutes via phone or Zoom with the possibility of a follow-up via phone. A majority of the participants preferred Zoom interviews, though some requested phone. In order to provide consistency across interviews, only audio without video was utilized. The participants were emailed or texted a link to the consent form. (The consent form in English and Spanish is included in Appendix D.) At the time of the interview, interviewers reviewed the consent form verbally with the participants and the participants were encouraged to ask any questions they had throughout. Before commencing the interview, the participants were reminded of (a) the purpose of the research, (b) the potential minimal risks including loss of confidentiality or 46 psychological risk, (c) the potential benefits of participating in the research, and (d) their right to terminate the interview at any point. Participants were reassured that due to their experiences attending mental health groups, the risk to participating in the interview was not greater than participating in one of these groups. Participants were additionally informed that the primary researcher would send the incentive ($30 Visa gift card) via email or mail and provide community resource referrals for individual therapy and mental health groups in the community. Finally, participants were requested to provide verbal consent prior to the interview prior to recording and again after recording had begun. All interviews were conducted in whatever language the participant preferred, in either Spanish or English, or a combination of the two. As the researchers, we first collected demographic information (more detail on the information collected follows in the measures section and demographic questions are listed in Appendix E) and we then conducted the semi-structured interviews (the questions are listed in the measures section that follows). The audio recordings from the interviews were filed on two secure drives until transcription. All identifying information was removed from interview transcriptions. Semi-Structured Interviews The primary method for data collection in this study were semi-structured interviews. This method was chosen because of the potential to capture an individual’s perspective of an experience in order to best understand the individual’s psychological experiences (Creswell, 1994). Interviews typically begin with open-ended questions, and then the researcher may follow-up with questions to complete the description if not spontaneously addressed (Wertz, 2005). The respondents are encouraged to use their own 47 language to describe their experiences, but the researcher must be careful not to reinforce only certain responses; for example, making sure not to only follow-up on answers that fit the researcher’s assumptions (Wang, 2007). As Polkinghorne (2005) writes, “although the produced account is affected by the researcher, it is important that the participant remain the author of the description” (p. 143). Researchers also may need to do follow-up interviews because new insights about the phenomenon, and therefore possible additional questions, may emerge as more participants are interviewed (Wang, 2007). Although counselors are well-trained in asking questions and there are many similarities between the counseling interview and the qualitative research interview, there are different goals and skills required of a research interview (Polkinghorne, 2005). We, as the researchers and interviewers, have previously worked in therapeutic context in the role of therapists, it was important for us to focus on the goal of understanding the experience of the participants rather than engaging in therapeutic actions (Wang, 2007). Prior to conducting the interviews, as the three researchers/interviewers, we engaged in the first epoché meaning we bracketed out our previous knowledge and assumptions with this topic in order to prevent previous experiences and conceptualizations from influencing the research findings. Conducting the literature review as the primary researcher was part of my bracketing process as I learned more about the topic, and gained knowledge on possible theoretical frameworks, such as RCT and a psychological framework of radical healing. This consolidated my learning in a way that better enabled me to suspend this knowledge during research question development, conducting interviews, and the initial phases of data analysis. Giorgi et al. 48 (2017) write, “The ability to reflect on one’s own experience opens up dimensions of the lived experiences that would otherwise be inaccessible” (p. 178). Additionally, as a research team, we discussed our intersecting identities in relation to this topic and our previous knowledge on the topic as researchers, as facilitators of groups, as therapists providing services, as students in a Spanish Specialization, and as individuals with family members who had participated in similar groups. We suspended our judgments and all prior knowledge of the topic under investigation during the data collection and data analysis until the final stages of data analysis. In order to engage in this process, we put forth conscious effort to mindfully empty our thoughts and focus on the description in front of us to allow “what is directly given to consciousness” using “a pure consciousness …that in no way is shared with empirical reality” (Giorgi et al., 2017, p. 178). Furthermore, utilizing this same mindfulness of emptying our thoughts, to corroborate the meanings that had emerged, we viewed and discussed each other’s psychological meaning units and two different researchers engaged in the transformation of life-world expressions to phrases highlighting the psychological meanings lived by participants. More detail on each of these steps follows in the “Descriptive Phenomenological Data Analysis” section. To gather data, we interviewed participants and obtained their description of the phenomenon under investigation. The participants’ descriptions were from the perspective of the life-world, or the world as it is lived and encountered every day. In other words, the participants answered questions from their own lived experiences. Following are the measures used to collect demographic data and the semi-structured interview questions. 49 Measures The measures we used included a demographic measure and a list of semi- structured interview questions. Demographic Data We collected demographic information with open-ended questions for age, country of origin, length of time in the United States, number of children and their ages, occupation, number of family members/people in the home, number of groups attended, and number of sessions attended in each group. We utilized questions with multiple response options and read these response options to participants for gender, racial/ethnic group, sexual orientation, marital status, years of schooling completed, and annual estimated household income. (Demographic items and options are presented in Appendix D.) Next, I present the questions that comprised the semi-structured interviews followed by the methods for data analysis. Semistructured Interview Questions How would you describe your experience in the group(s)? 1. Why did you join a mental health or mutual support group(s)? a. Why did you continue with or leave the group(s)? 2. What have been your experiences in the group(s)? a. What happened in the group? b. What was the group structure? c. Was there a typical format? 3. How did this group meet or not meet your needs? What other needs do you have? 4. How were you able to share or not able to share your experiences in the group(s)? a. Are there experiences you shared in the group(s) that you have not shared with your outside support (family, friends)? If so, how were you able to share? b. Have you had any difficulty sharing your experiences in this group? If so, why? 5. How would you change the group? a. Would you add anything to the group? b. Would you take away anything from the group? How would you describe your experience with others in the group(s)? 50 1. What were your experiences with other group members? a. What was similar or different with your relationships or experiences with group members and/or friends or family members outside of the group? 2. How did you feel with other women in the group? a. How was it similar or different to how you feel with your friends and family outside of the group? b. Can you describe moments in which you felt most supported by (an)other group member(s)? c. Can you describe moments in which you felt the least supported by (an)other group member(s), disconnected, or isolated from others in the group? d. Are there any ways that you supported other women in the group? Can you describe moments in which you felt you were most supportive to another group member(s)? 3. Did you know some group members before the group(s)? a. If so, how did this affect your experience of the group(s)? 4. What were your experiences with the facilitator(s) of the group? 5. Did your relationships with group members change over time in or outside of the group(s) and if so, how? How would you describe the meaning of your experience in the group(s)? 6. Have there been experiences in the group(s) that have been more meaningful to you? 7. Have there been more difficult or challenging experiences in the group? 8. How do you see yourself differently now than before you participated in this group? 9. Is participating in a group similar to or different from healing practices you engage in? 10. What did you learn about yourself in the group(s)? a. Did you or your family members notice anything different about you? b. Did your relationships with others outside of the group change or remain the same? 11. If you were to design a healing space for Latina immigrant women, what would it look like? a. What themes would be discussed? b. What would you need? c. Where would it be located? d. How would it be facilitated? Methods for Data Analysis Following the ten interviews, all ten recordings were transcribed verbatim using professional online transcription services through the technological and research services company, DataGain, which provided the transcripts in the original language used by the 51 participant and interviewer (Spanish, English, or a combination of both). Next, the methods of descriptive phenomenological data analysis are described in detail. Descriptive Phenomenological Data Analysis We, the two research assistants and I (Researcher A, Researcher B, and Researcher C), analyzed the data according to the descriptive phenomenological methods outlined by Giorgi et al. (2017). First, we read the entire transcription in order to obtain a basic sense of the entire description. Second, we engaged in the second epoché and assumed the attitude of the phenomenological psychological reduction. This attitude allowed us as researchers to shift focus from the descriptions of participants’ experiences in the data collected to the lived psychological meanings of the participants’ experiences. Third, we used qualitative software, MAXQDA, to analyze the data. Within the attitude of the phenomenological psychological reduction, we separated the interview into parts by noting psychological meaning units whenever we experienced a transition in meaning. A psychological meaning unit was determined whenever we, as researchers, using a psychological perspective and keeping the research question in mind, noted a transition in meaning. For example, in Interview 2, “Pues sabes, con la familia da pena, contar lo que le pasa a uno. Y con las personas que uno no conoce puede uno confiar más, porque es lo que me ha pasado a mi.” [Well, you know, with the family it is embarrassing, telling what happens to you. And with people you don’t know you can trust more, because that’s what happened to me.] The first sentence was identified with the psychological meaning unit, “Shame Sharing with Family,” whereas, the second sentence was identified with the psychological meaning unit, “Ability to Share.” We labelled these psychological meaning units in MAXQDA. 52 Researcher A, Researcher B, and Researcher C each independently read, identified, and labelled psychological meaning units for Interviews 1, 2, and 3. We came together and compared our meaning units for the first three interviews to determine intercoder agreement (Padgett, 2016). Having found similar psychological meaning units in the first three transcripts, we then developed a list of the most common psychological meaning units as codes to utilize for the remainder of the interviews. We had the option of creating additional psychological meaning unit codes as needed. Each researcher separated the interviews into parts using the list of psychological meaning unit codes. Researcher A coded Interviews 5 and 7, Researcher B coded Interviews 4 and 8, and Researcher C coded Interviews 6, 9, and 10. We engaged in peer debriefing throughout in order to check for validity by checking for bias of the meanings and interpretations of the psychological meaning units (Padgett, 2008). As a research team, we employed the use of MAXQDA to help us code, write memos, and listen to audio from the interviews. For the first read-through and code, we were able to use MAXQDA to help us immerse ourselves in the data and in the life-world of the participants. However, we found that we needed to both zoom in on data and the particular and zoom out in to get a wide angle view for interpretation. Davidson and Di Gregorio (2011) wrote, “all tools have limitations and ... tools for research are in constant flux and development. Therefore, researchers must engage in an active dialogue between methodology and technology in order to craft the appropriate fit for their work” (p. 633). As a research team, we decided that in order to engage in dialogue with our data, it was more practical to have a live Excel document in which we could each complete the third and fourth steps of the phenomenological reduction. This allowed us to more 53 effectively view and engage with the psychological meaning units from each researcher’s analysis of each interview. We used both forms of technology at different phases of the research process in order to prevent limiting ourselves in the phenomenological research process (Sohn, 2017). Fourth, remaining within the attitude of phenomenological psychological reduction, we then intuited and transformed participants’ life-world expressions into phrases that highlighted the psychological meanings lived by participants. The researcher who had coded with the psychological meaning units completed the first transformation. For example, continuing with the previous example, Researcher A determined the psychological meaning units, “Shame Sharing with Family,” and “Ability to Share.” Researcher A completed the first transformation which was, “With family, there might be shame and embarrassment to share what one has experienced, but one may be able to confide more safely with others in an anonymous space.” Researcher B engaged in the second transformation, “Family relationships often include embarrassment and guilt and sometimes include people that cannot be trusted.” As the primary researcher, I then engaged in “free imaginative variation” (Giorgi, 2007; Giorgi et al., 2017) and imaginatively varied different aspects of the phenomenon in order to determine which aspects were essential to the phenomenon, and which were contingent. For example, “Shame Sharing with Family,” and “Ability to Share,” were both essential to two different psychological structures. Without both of these constitutent elements, the overall phenomenon of the meaning of women’s experiences in mental health groups collapses. 5 4 Finally, for step 5, as the primary researcher, I reviewed all the transformed expressions and determined the essential ones. I continued to use free imaginative variation. I also utilized eidetic reduction, a form of imaginative variation, in which I examined the phenomenon of women’s participation in a mental health group and then systematically varied it in order to determine its essence, essentially determining what the key meanings are and if they relate to the whole description or not (Giorgi et al., 2017). I then used these transformations and key meanings and grouped them together to form constituent elements of a larger psychological structure. Each constituent was a part of an interconnected structure in which each part must be both nonredundant and present for the whole structure to be preserved. Every participant’s life-world description is unique; however, it is possible to find coherence and commonalities in the psychological meanings. This allowed me as the researcher to incorporate the descriptions from multiple participants into general structures with essential constituents. At this advanced phase of the analysis, I purposely discontinued the epoché and examined the structures using RCT, testimonio, and radical healing frameworks as guides for knowledge (Wertz, 2005). For example, “Ability to Share” was essential to the essence of the phenomenon of women’s participation in a mental health group and the “Relational Liberation” that women experienced in the group. Preconceptions of relational liberation me helped to better understand the overall aspects of the second psychological structure that was previously less evident (Wertz, 2005). The resulting four psychological structures of the overall phenomenon consisted of both the essential constituent meanings as well as the relationship among the meanings. The details of these psychological structures and 55 essential constituents are discussed in Chapter III. Next, I review the ethical considerations of this research project. Ethical Considerations Integrating Latinx cultural values, beliefs, customs, and traditions is essential in conducting culturally competent qualitative research with Latinx immigrants (Ojeda et al., 2011). These values include demonstrating respect of the cultural value of personalismo (personal engagement) by plática (small talk) during the interview and scheduling the interview. As a research team, we discussed this before conducting the interviews, and we worked to use personalismo and plática during the scheduling process, the consent process, and the interviews in order to develop rapport with participants to increase their level of comfort and confianza (trust). These three factors have been deemed crucial to provide a positive research participation experience for Latinx immigrants (Ojeda et al., 2011). In their analysis of conducting qualitative research with Latinx immigrants, Ojeda et al. (2011) suggest that researchers should compensate participants for their time as this is consistent with the belief of “giving back” to participants for their research involvement, since many individuals from underresearched and marginalized groups do not have the luxury of “free” time. I provided financial compensation research participation incentives in the form of $30 Visa gift cards to each interview participant for participation in the interviews. As a research team, we shared with potential participants about the research process, how the data would be used, and their rights as research participants, as recommended for culturally competent researchers (Haverkamp, 2005). We followed 5 6 appropriate informed consent procedures, which is critical especially in work with Latinx immigrants, as their participation in research can place them in a vulnerable position (Ojeda et al., 2011). We did not ask about any information pertaining to participants’ immigration status and made this clear in the informed consent process. Additionally, we explained that data would be anonymous, meaning participants’ names would not be associated with any data (the data would be stored separately from consent forms and would not be linked in any way to identifying information). Reliability and Validity Compared to the criteria used by quantitative researchers for evaluating a quantitative study (internal validity, external validity/generalizability, reliability, and objectivity) (Wang, 2007), different sets of criteria have been proposed to evaluate the validation of qualitative phenomenological descriptive research (methodological integrity, fidelity in the subject matter, and utility in achieving goals). Methodological integrity is the aim of making decisions to most effectively support the application of methods, as evaluated in relation to the qualities of each study (Levitt et al., 2017). Research designs and procedures supported research goals, my approaches to inquiry, and were tailored to the characteristics of the subject matter and researcher (Levitt et al., 2017). Throughout, we engaged in peer debriefing throughout in order to ensure validity by checking for bias of the meanings and interpretations of the psychological meaning units (Padgett, 2008). We compared our meaning units for the first three interviews to determine intercoder agreement (Padgett, 2008). Fidelity to the subject matter is described as researchers having an intimate connection with the phenomenon under study. As a research team, we all had conducted research and clinical work in this area. 57 Finally, the research design and methods had a synergistic relationship in achieving both study goals and answering questions (Levitt et al., 2017). Although some argue that participants can verify phenomenological findings, Giorgi (2008) recommends that participants are not consulted about the results of the analysis for three reasons: (1) the phenomenological attitude that is employed can only be checked by phenomenological procedures, not necessarily verification by someone not familiar with the procedures; (2) the purpose of the research is to understand the experience of the phenomenon rather than to clarify the experience of each individual; and, (3) participants are the experts in their experience, but not necessarily the meaning of their experience. For these reasons, participants were not consulted on verification of phenomenological findings. Chapter Summary In summary, this chapter provided a detailed description of the methodology utilized in this study. A descriptive phenomenological design and analysis was employed to explore the meaning that participants place on their experiences in the mental health groups, their interactions with others in the group, their experiences of testimonio, and the context of the group in their lives. For data collection, ten participants engaged in semi- structured interviews. The data was analyzed and synthesized according to Giorgi et al. (2017)’s five steps of the descriptive phenomenological process. Validity and reliability were accounted through methodological integrity, fidelity in the subject matter (Levitt et al., 2017), intercoder agreement, and peer debriefing (Padgett, 2008). 5 8 CHAPTER IV RESULTS In this chapter, the results of the phenomenological analyses are presented for the central research questions, sub-questions, and ideal group recommendations questions. First, I detail the results of the phenomenological analysis of the data collected from this study. Throughout the chapter, participants’ quotes are shared to honor their stories, their voices, and to illuminate the lived meaning of their experiences. All participant quotes are verbatim, except for removal of filler words for clarity, and in the original language that the participant used. From interview transcriptions, all identifying information was removed. In order to provide increased clarity to findings and to humanize the research process, names were replaced with pseudonyms. Descriptive Phenomenological Analysis Through the descriptive phenomenological analysis, data was reduced to the essential components, or constituents, that comprised four general structures of the participants’ shared experience in mental health groups. Each constituent is defined as part of an interconnected structure in which each part must be both nonredundant and present for the whole structure to be preserved (Giorgi, 2009). The general structures consist of both the essential constituent meanings as well as the relationship among the meanings. Wherein the general structures of the shared experience focus on participants’ emotional and cognitive responses and experiences, the analysis was conducted from a psychological perspective. Primary research question: What is the lived psychological meaning of Latina immigrant women’s experiences in mental health groups with other Latina 5 9 immigrant women? Data collected from all ten participants (P) from the phenomenological interviews were combined into four general psychological structures of the experience using the methods described in the prior chapter. Four psychological structures comprised the overall P experience. Within each of these four psychological structures of P’s experience, essential constituents, which are integral parts of each interrelated structure, emerged from participants’ experiences of engaging in mental health groups. The psychological structures and constituent elements are listed in Table 2. The remainder of the results chapter is organized as follows. The first psychological structure of P’s experience is introduced and described. Next the constituent elements of that psychological structure are presented with in-depth descriptions and illustrative quotes. Following, the second psychological structure of P’s experience is introduced and described along with the constituent elements of that psychological structure, and so forth. Finally, I present a summary of the four psychological structures. 6 0 Table 2 Psychological Structures and Constituent Elements Psychological Structure Constituent Element 1. Yo No Lo Había Compartido Con Nadie [I Had Not Shared with Anyone] 1. Disconnection and Isolation 2. Barriers to Sharing in the Group - No es fácil platicar nuestras experiencias vividas [It is not easy to talk about our lived experiences] 1. Ability to Share Testimonio - Poder yo expresar lo que tenía guardado en mí misma [To be able to express what I had kept guarded within myself] 2. The Nature of Group Support - Se siente uno apoyada [One feels supported] 3. Relationship Building - Conexiones profundas y amistades verdaderas [Deep connections and true friendships] 2. Relational Liberation 4. Strengthened by Collective Identification - Their struggles are my struggles, y nos echamos porras mutuamente [and we cheered each other on] 5. Cultural Appreciation and Strengths - Me ha traído otra vez el orgullo de mi cultura [It has brought back my cultural pride] 1. Psychological Changes 3. Healing from Adversity 2. Social Changes 1. Facilitators’ Impact on the Group 2. Group Structure 4. Logistics and Recommendations 3. COVID-19 Changes 4. Ideal Group - Todas unidas para mejorar [All united to improve] 61 Structure 1. Disconnection and Isolation The general structure encompassing P’s essential common features related to the first structure were as follows: P felt alone and isolated in her experiences and lacked support from others in whom she could confide. Participation in the group began with experiences and/or awareness of isolation or dissatisfaction in P’s life, leading P to seek out resources or mutual support. Once participating in a group, P continued to encounter barriers to sharing her experiences with others. These barriers included timidness, shame, lack of anonymity, cultural barriers, and partners or others prohibiting her from sharing. The following constituents comprised the general structure: 1. Yo No Lo Habia Compartido Con Nadie [I Had Not Shared with Anyone] 2. Barriers to Sharing in the Group - No es fácil platicar nuestras experiencias vividas [It is not easy to talk about our lived experiences] Constitiuent 1. Yo No Lo Había Compartido Con Nadie [I Had Not Shared with Anyone] Prior to group participation, the majority of the participants expressed that there were barriers to sharing difficult experiences and mental health challenges with others in their lives. They described how they felt alone and isolated in their suffering. Some participants noted that there were experiences that they had not yet shared with anyone. As Lola described, Yo no había compartido, por lo menos todo lo que yo había sufrido, verdad, todo lo que yo había pasado, todo eso yo no lo había compartido con nadie. [I had not shared, at least everything that I had suffered, right, everything that I had gone through, all that, I had not shared with anyone.] Maite shared that she had felt alone since living in the United States because she was not with her family. 62 Yo siempre he estado sola, mi familia no ha estado cerca durante estos últimos años, así que lo he vivido yo sola. [I have always been alone, my family has not been close during these last years, so I have lived it alone.] Others discussed immigrating alone to the United States and lacking a support system, as Lola shared, Cuando yo me vine aquí a este país, yo venía muy desesperada, con tantas cosas que a mí me habían pasado. Y ya cuando tenía como dos meses de estar en este país, conocí a un grupo. [When I came here to this country, I came very desperate, with so many things that had happened to me. And when I had been in this country for about two months, I started a group.] Sofía noted that to survive, she had pretended things were okay and that she did not need help. Yo pienso que, I guess some of my background is “fake it until you make it,” and then you kind of don’t express your feelings or frustration or things like that. Entonces pasamos la vida pretendiendo que cosas están bien, pero en realidad sí necesitas ayuda. [I think that, I guess some of my background is “fake it until you make it,” and then you kind of don’t express your feelings or frustration or things like that. So we spend our lives pretending that things are okay, but you really do need help.] Prior to attending the groups, many participants shared how they had felt isolated and alone in their suffering. Xochitl explained how Latina immigrant women who do not attend these groups may feel like victims, that they are the only ones suffering alone, and like there is no solution. Inmigrantes hispanas que están en sus casas y que no van a estos grupos se sienten como que son víctimas o como que son las únicas o como que solamente ellas están sufriendo y como que no hay solución. [Hispanic immigrants who are in their homes and who do not go to these groups feel like they are victims or that they are the only ones or that only they are suffering and there is no solution.] Some participants described feeling unsure of who they could confide in. Participants described their fears of worrying their families if they disclosed their experiences or fear 63 of judgment from others. As Sofía elucidated, “There are things that you cannot share with your family, porque [because] you would worry them.” Thalia explained she had been in individual therapy previously, which had supported her mental health, but over time, she continued to experience mental health symptoms. She shared, Anteriormente yo estaba asistiendo por mucho tiempo a terapias psicológicas. Por mucho tiempo estuve yendo, y la doctora ya me dio de alta después, porque ya me sentía bien. Y yo también pensé que me sentía bien, pero después de un tiempo otra vez como que… de recordar esas cosas, ciertas vivencias, me sentí un poco mal. [Previously I was attending therapy for a long time. I went for a long time and the doctor had already discharged me, because I was already feeling fine. And I also thought that I felt good, but after a while again like… remembering those things, certain experiences, I felt a little bad.] Prior to attending groups, the majority of participants felt isolated and without a space to share about how they were doing in authentic ways. Constituent 2. Barriers to Sharing in the Group In addition to feeling isolated in their experiences, for the majority of the participants, there were barriers to sharing their stories and experiences with others. For some participants, it was initially difficult to share in a group setting. Barriers to sharing included timidity, embarrassment, shame, lack of anonymity, cultural barriers, difficulty verbalizing experiences, fear of mental health perceptions, and control tactics from others outside of the group. One participant shared how the name of the place was a barrier to attending the group and made her embarrassed because the name included “trauma,” and she was worried that others would assume that she had experienced traumatic events. For some participants, it took time to become comfortable with sharing in the group. Some felt embarrassed or ashamed before sharing with a group, as Isabella noted, 64 Porque al principio no tenía confianza, pero me daba pena. Pero después yo agarré confianza y pude platicar ya más y contar todo lo que me había pasado. [Because at first, I didn’t have trust, but I was embarrassed. But later I gained trust and I was able to talk more and tell about everything that had happened to me.] Alma discussed how she felt uncomfortable speaking in front of others because of the lack of anonymity due to previous relationships with group participants outside of the group, Había personas en el grupo que yo conocía fuera del grupo, entonces por eso siempre me quedaba callada. [There were people in the group that I knew outside of the group, so that’s why I always kept quiet.] The lack of anonymity made it feel less safe to share. Multiple participants noted how women do not speak about their suffering and trauma due to various religious, cultural, and individual reasons. Maite described the difficulty in sharing experiences due to a lack of words to describe experiences, Y a veces no es fácil platicar nuestras experiencias vividas, porque nos falta aprender a hablar, a decir. [And sometimes it is not easy to talk about our lived experiences, because we need to learn to speak, to tell.] Camila expressed a fear of disclosure about mental health perceptions and how overcoming her fear allowed her access to help and support, “Yeah, I was really scared to share that because I thought maybe they’ll take my kids away, what if they think I'm crazy.” She reflected on cultural barriers to sharing including barriers of silence and needing safe space to disclose without fear, shame, guilt: When you come from another country, any other place in Mexico or another, I don't know Columbia or whatever, you at some point, we have been raped at some point, that's my opinion. It's not physically, probably mentally, probably verbally as a Latina, as a culture because we are a machista culture. We come from too many prejudice, too much things that are in silence that you don't talk about those things because it's a sin, because of the religion, because of too many 65 stuffs going on in our cultures. And I think we need a safe space to talk, we need a safe space that we can come in and disclose whatever we want to disclose and feel free and don’t feel shame and don’t feel guilty, like we’re out of the line. We need a space like that, we always need it, more in these times right now that is too much craziness, we need a safe place to talk. She reflected on cultural barriers, due to her identity as Latina, her gender, and religion, as barriers to creating a safe space to come together to discuss mental health challenges and difficult experiences. Camila also shared about the cultural stigma of speaking with a mental health provider and the importance of sharing with other women that it is okay to speak to someone. It's okay if you don't know what to do and you try to find answers with a professional provider and break that stigma because as a Latina, I mean, in our culture it's not like let's just go talk to the counselor, nah, I'm not crazy I'm not going to do that, that's a very cultural part of it, but definitely give them more, like thumbs up, like, yeah, you can talk to somebody and you'll feel much better to talk to somebody. Another barrier to sharing in groups was overcoming partners or others telling participants they were not allowed to share, which made initial confiding in the group difficult. Eva explained, Antes no me sentía cómoda, por supuesto, porque me decía el papá de mis hijos que yo no podía estar comentando lo que estábamos pasando. [Before, I didn’t feel comfortable, of course, because my children's father told me that I couldn’t be commenting on what we were going through.] She was overcoming experiences of concurrent abuse and control tactics, and those dynamics contributed to her fear of sharing her experiences with others. Structure 2. Relational Liberation Relational liberation emerged as its own psychological structure as the participants shared about coming together in solidarity and compassion with others to discuss their experiences of oppression. The general structure encompassing P’s essential 66 common features related to the second structure were as follows: once in the group, P recounted various processes of the group that allowed her to feel safe to share testimonio, including group norms to create a safe and nonjudgmental space, developing rapport, and facilitators, to structure and guide conversation. With this safety, ways of expressing themselves were redefined and new patterns of communication were established, enabling P to experience relational liberation and be strengthened by the support and collective identification with other women in the group. Relationships were formed through compassion and solidarity, which held a distinct meaning from relationships outside the group. Finally, P experienced restorative connections to her cultural identities and cultural strengths. The following constituents comprised the general structure: 1. 1. Ability to Share Testimonio - Poder yo expresar lo que tenía guardado en mí misma [To be able to express what I had kept guarded within myself] 2. The Nature of Group Support - Se siente uno apoyada [One feels supported] 3. Relationship Building - Conexiones profundas y amistades verdaderas [Deep connections and true friendships] 4. Strengthened by Collective Identification - Their struggles are my struggles, y nos echamos porras mutuamente [and we cheered each other on] 5. Cultural Appreciation and Strengths - Me ha traído otra vez el orgullo de mi cultura [It has brought back my cultural pride] Next, I describe the constituent elements of relational liberation. 6 7 Constituent 1. Ability to Share Testimonio Most participants described that the ability to share in the group depended on multiple factors including the group norms, how the facilitators created the space, the size of the group, trusting the confidentiality of the space, and/or their comfort in the group over time. Multiple participants detailed how they were able to share in the group what they had never shared with anyone before, including family. Participants recounted differences between sharing with family and sharing with others in the groups. Group norms helped create a safe space to share that was confidential and free of judgment, as Sofía shared, Todos nos abrazábamos y como siempre ellas decían, ‘Pues todo lo que hacemos aquí, de aquí no sale nada. No se cuenta a nadie y tengámonos confianza. [We all hugged and as always they said, “Well everything we do here, stays here. Don’t tell anything to anyone and let’s trust each other.”] Xochitl shared about how the group space was set up as a space free of judgment and prejudice, “Ahí podríamos hablar libremente sin ningún prejuicio.” [There we could speak freely without any judgment.] Some participants shared a fear about lack of confidentiality within the group. As Alma expressed, A veces, eran muy pocos los casos, que me daba un poco de temor por el tema de la confidencialidad, porque algunas compañeras a veces comentaban que les contaban a sus parejas acerca de la clase. [Sometimes, there were very few times, which made me a little fearful due to the issue of confidentiality, because some colleagues sometimes commented that they told their partners about the class.] Some participants shared that the group facilitators played a vital role in creating a particular type of space in which it was comfortable and safe to share things that had never been shared before. Valentina described this feeling of safety and trust, 68 Ellas saben muy bien sobrellevarnos y te dan tal confianza que tú puedes desahogarte de cualquier cosa. No sé si las demás pero yo sí en su momento hubo pláticas que jamás las había tenido con nadie. [They know very well how to help us cope and they are so trustworthy that you can vent about anything. I don’t know about the others in the group but at the time there were conversations that I had never had with anyone.] The group was a genuine space in which facilitators were there not out of obligation to a job but rather, to listen in authentic, caring, and culturally congruent ways. Camila noted, “I think that no matter what is your style, if you’re genuine, people can feel that. I think that’s the key. If you don’t have that, and that is not something that you learn in school.” Feelings of safety and trust with facilitators and other group members gave them confidence to share their testimony. For some topics, it took time for women to gain trust and comfort with one another. Timing and pacing were important to the development of relationships, rapport, and ability to discuss certain topics over time. As Camila shared, “We could start having conversations about domestic violence, after a year and a half.” Participants reflected that depending on the topic and their identities, they felt more or less able to relate or to share. Alma noted that she did not identify as a mother and would not participate in conversations about parenting, Pero cuando era por ejemplo un tema de relación de pareja o de que algunas personas se sentían discriminadas por el idioma, yo sentía que podía dar mi opinion. Yo sentía que me escuchaban. [But when it was for example a relationship issue or that some people felt discriminated against because of the language, I felt that I could give my opinion. I felt that they listened to me.] Group dynamics between group members and facilitators and group size made it more or less comfortable for others to share. Whereas some people felt comfortable sharing about how they related to or were impacted by all of the topics, others divulged 69 less or did not feel secure about contributing. Some participants discussed how the size of the group mattered to their comfort in sharing. A smaller group allowed for more time to share, process, and “desahogarnos” [vent]. Due to knowing the people in the group better, small group settings helped participants create more trust, experience more comfort, and have more freedom for expression. Sofía described how people behave differently in various groups due to their comfort, trust, and ability to take up space: Pues es que dependiendo del grupo, te comportas diferente. Es un nivel de confianza, pues, entonces si no sientes el apoyo, o ves que alguien está like overpowering the conversation y taking over, y no te da espacio para compartir, a veces eso es frustrante. [Well, depending on the group, you behave differently. It is a level of trust, well, so if you don't feel supported, or you see that someone is like overpowering the conversation and taking over, and does not give you space to share, sometimes that is frustrating.] Despite these challenges to sharing in the group, the majority of participants described how participation in groups helped them to overcome obstacles and barriers to sharing and to be more open with others over time. Sofía shared that although she was not initially expressive and was timid, she later felt she could not be quiet, Donde yo en realidad no era tan expresiva, y ahora siento que no me puedo callar. [Whereas I was not really that expressive, now I feel like I can’t shut up.] Like, I feel like somebody freed me or allowed me to talk, and now I just expose all my thoughts. Others discussed feeling safer and more confident to participate with trust gained, as Thalia shared, Ahora sí puedo conversar. Cuando empecé a ir a los grupos no hablaba mucho, no participaba, mejor dicho. Pero ya después tuve un poco más de confianza. [Now I can talk. When I started going to the groups, I didn’t speak much, rather, I didn’t participate. But afterwards I had a little more confidence.] Eva shared that she initially felt uncomfortable but experienced a transition to the ability to share her thoughts and anxieties over time, 70 Al principio sí, pero ahorita me siento cómoda. Y siento que es un lugar donde yo puedo expresar lo que está pasando y poder como liberarme de la angustia de lo que estoy pasando. [At first yes, but right now I feel comfortable. And I feel that it is a place where I can express what is happening and be able to free myself from the anguish of what I am going through.] Group spaces allowed for older members to model how to share and for newer members to learn. Eva noted other women’s courage to share enabled her to share, Al principio, cuando empecé a ir a las primeras sesiones no hablaba. Lo que me dió el valor de hablar fue escuchar a otras mujeres que estaban asistiendo al grupo y compartiendo sus experiencias. Entonces enseguida fue que me dió el valor o no sé cómo expresar, el poder hablar, el poder compartir lo que yo estaba pasando. [At first, when I started going to the first sessions, I didn’t speak. What gave me the courage to speak was to listen to other women who were attending the group and sharing their experiences. That immediately gave me the courage or I don’t know how to describe it, the power to speak, to be able to share what I was going through.] Groups offered a safe space to share things that had not been shared previously. Valentina explained that participating in a group helped her to break cycles of silence and create confidence and trust to share, Hubo temas que jamás los había hablado con nadie. Y, sin embargo, ese espacio me brindó la confianza para hacerlo. [There were topics that I had never discussed with anyone. And yet, that space gave me the confidence to do it.] Thalia shared how she was able to get to know others and felt comfortable sharing what she had kept guarded inside. Muy gratas, en compartir y conocer a otras personas; y poder yo expresar lo que sentía, de repente, que es lo que tenía guardado en mí misma. [Very pleasant, in sharing and meeting other people; and to be able to express what I felt, suddenly, which is what I had kept guarded within myself.] The spaces that were created in groups were different from those within family systems. Women shared feeling different about the space that was created with other 71 women that enabled them to share in ways they may not have been able to share with family or friends outside the group. Thalia noted, Con alguna familia, con algunas amistades, yo no había compartido estas cosas. No sé, no vi esa confianza suficiente. [With some family, with some friends, I had not shared these things. I don’t know, I didn’t see enough trust.] Others shared the ease they felt in sharing with group members rather than family, such as Maite, “Para mí es más fácil compartirlo con las personas del grupo que con mi familia.” [It is easier for me to share it with the people in the group than with my family.] The confidentiality and lack of judgment made it easier for some women to share in groups rather than with their families. Additionally, some women spoke to how they did not want to hurt or burden their families with their challenges as Xochitl noted, Era un grupo tan confidencial y tan abierto y tan sin juzgar y todos hablaban muy abiertamente. Entonces para mí, era fácil compartir cosas que puede a veces uno no comparte aún ni siquiera con su familia porque uno no quiere dañar la familia. [It was such a confidential group and so open and so nonjudgmental and they all spoke very openly. So for me, it was easy to share things that you can sometimes not share even with your family because you don't want to harm the family.] Others shared that they felt their family would not support them or that there would be judgment. As Sofía explained, Pues con la familia, pienso que hay más judgement. Si las cosas no están yendo bien, la sociedad o tu familia te critica. [Well with the family, I think there is more judgment. If things are not going well, society or your family criticizes you.] Some participants referred to the shame, embarrassment, and potential lack of support that can occur when sharing with family, whereas there is a safety and openness relative to the anonymity in the group. Women spoke to the differences they experienced their group interactions as compared to in their families as Valentina noted, 72 Yo siento que no soy juzgada en el grupo y a veces acá afuera soy juzgada por mis familiares o por mis amigos. [I feel that I am not judged in the group and sometimes out here, I am judged by my family or my friends.] Constituent 2. The Nature of Group Support All of the participants interviewed discussed their feeling of being supported within the group and receiving mutual support from the others in the group. Support was provided in forms of emotional support, informational support through sharing resources, and material support outside of the group. Most participants shared that they did not experience times in the groups in which they did not feel supported. Participants described the support they felt in the group as distinct from others outside of the group, including friends and family. Support from other Latina women was also noted to be different than support from White friends or colleagues. Participants described how just by showing up to the group, they experienced a sense of support. Thalia described how attending the group was at times challenging due to low energy after a full day of work, but that once she arrived, she felt better. Groups provided support without needing to speak. Being a part of the group as an active listener and holding space for others allowed participants to provide support as Eva recounted, Con el simple hecho de estar ahí, con el hecho de llegar ahí aunque yo no platique con nadie, me siento libre. Se siente uno apoyada por las personas que están ahí hablando. [With the simple fact of being there, with the fact of getting there even though I don’t talk to anyone, I feel free. One feels supported by the people who are there talking.] Listening, sharing, supporting were each valued as fundamental skills. In some groups, there was an emphasis on being listened to without unsolicited advice or guidance, which felt more supportive, as Thalia expressed, 73 No es que te aconseje, que te diga lo que hay que hacer, sino que cada uno cuenta su experiencia, y yo me sentía… el solo hecho de que te escuchen, ya uno se siente más apoyada. [It is not that they advise you, that they tell you what to do, but that everyone tells their experience, and I felt ... the mere fact that they listen to you, already one feels more supported.] One type of support described was access to resources and cultural capital. Participants described how facilitators and women in the group have access to resources that were previously inaccessible or unknown to them, especially as immigrants learning to navigate a new country, culture, and systems. Participants described feeling supportive by sharing about experiences and resources with others. As Sofía noted, And the things we could help each other, like people that were newcomers, like how to… you know, kind of teach them about the system, the DMV, how to open an account, how to… just mostly integrate them into the society. Participants also described sharing with each other access to resources and knowledge such as paying bills, parenting resources and groups, information about mandatory reporting, immigration resources, divorce resources, and financial support. There was an emphasis on needing to make sure resources were culturally competent before referring people. The mutual support from the group extended beyond the group setting to outside the group. Group members provided tangible support to each other outside of the group, by providing each other rides and support with transportation. The women in the group would call one another to check in and see if anyone needed anything, which some commented has been helpful to their mental and emotional wellness. Another participant noted how she always felt supported by the group, even when she could not attend, because the women in the group would check in on her and make sure she was okay. 74 Constituent 3. Relationship Building in the Group Participants reflected on the relationships they created in the group, their previously established relationships with group members prior to joining the group, and how those relationships remained the same or changed over time. Women described a shift from being critical and judgmental to becoming more open, understanding, and respectful due in part to perspective-taking of others in the group. Some described how their relationships were closer in depth than relationships outside of the group due to the nature of conversations and the themes discussed. The majority of the women in this study shared that they felt the relationships they created in the group were strong or even stronger than relationships that they had outside of the group. The warmth of group spaces and sharing laughter helped some participants come together and form relationships. Group relationships sometimes surpassed the intimacy of outside relationships because of shared understanding, mutual empathy, safety, the themes discussed, shared emotional expression, and depth of processing. One participant described how the women in the group felt like family or even closer due to the intimacy of what was shared. Thalia described how by gaining trust with women in the group, she felt, Con el grupo agarraba más confianza, de ver que una no está sola, que siempre hay alguien que te puede escuchar, que siempre te da su hombro para que puedas sentirte mejor. [With the group I gained more confidence, to see that one is not alone, that there is always someone who can listen to you, who always gives you her shoulder so you can feel better.] Others described how they got to know women who had been acquaintances outside of the group on a deeper level, enabling shifts in their perspectives and understanding of 75 each other. The relating in the space of the group was crucial to forming these relationships. Constituent 4. Strengthened by Collective Identification Participants reflected that a collective identification emerged from engaging in mental health groups with other Spanish-speaking Latina immigrant women. For the majority of participants, their experiences were normalized and they found that they were not alone in their suffering. For some, they found strength from others’ sharing and resilience, while for others, they felt that by comparison, their problems were not as bad as others’ problems. Participants discussed how through hearing others’ experiences, that they could better understand themselves. Being in a group allowed women to feel supported by the fact that they are not suffering alone. Having a gender-based sharing was important; women could share about their emotions and the problems they were facing in a safe place with a guide in which they could confront their life situations as women. Camila shared, “Just to know that somebody has the same issue that you have or even worse that makes me feel more human. That makes me feel that it's just a stigma, break the stigma around the topic.” Groups provided a process through which to eradicate stigma and other barriers to communication around a topic. Groups were spaces for women where they do have a voice, as Eva noted, Wow, yo era la que no podía hablar, no solamente era yo la que estaba en ese agujero. Otras personas estaban igual que yo, sufriendo muchos años, no sabiendo que hay grupos de apoyo, entonces nos pueden ayudar. Hay lugares donde nuestra voz es válida. [Wow, I was the one who couldn't speak, it wasn't just me who was in that hole. Other people were like me, suffering for many years, not knowing that there are support groups, that they can help us. There are places where our voice is valid.] 76 The sense of community from the group of being in a space with other immigrant Latina women was integral to the sense of a collective experience. Group members became accomplices and companions in life because of the similar things they had gone through. Women shared about topics that they perceived only group members could understand due to their identities as Latina immigrant women in the United States, such as experiencing discrimination and learning English. As Alma expressed, Yo vivo aquí sola…entonces a mi sí me ayudó poder compartir y expresar mi sentir respecto a… no sé si fue discriminación, pero por el tema del idioma, del inglés, de que a veces yo me sentía mal porque no podía comunicarme. Y eso es algo que solamente aquí me pueden entender. Si yo lo cuento con una amiga en [country of origin], no me va a entender, pero si yo lo contaba en el grupo, muchas, por no decir todas, pasábamos por la misma situación de que nos sentíamos avergonzadas de que no hablábamos el idioma, que nos daba pena. Y en ese sentido yo sí me sentí apoyada. [I live here alone ... so it helped me to be able to share and express my feelings about ... I don’t know if it was discrimination, but because of the language, English, sometimes I felt bad because I couldn’t communicate. And that is something that only here they can understand me. If I tell it to a friend in [country of origin], she will not understand, but if I told it in the group, many, if not all, we have gone through the same situation in which we felt embarrassed that we did not speak the language, that we felt ashamed. And in that sense, I did feel supported.] Women shared about how they gained insight from others’ experiences and learned from them. Lola expressed, Fuera bonito, pues, un grupo donde podemos también seguir compartiendo nuestras experiencias y todo y también contar cómo uno ha salido adelante y todo y sí estuviera bonito. Pues la verdad, hacer un grupo así y todo, apoya. Hay muchas mujeres que necesitamos el apoyo de otras personas. [It was nice, then, a group where we can also continue to share our experiences and everything and also share how one has overcome things, and yes, it was beautiful. Well the truth, to do a group like this and everything, supports. There are many women who need the support of other people.] 77 There was solidarity, strength, and learning through hearing about others’ lived experiences. Participants recognized each other's pain and describe a sense of collective opportunity for growth and strength. As Eva recounted, Es triste y es interesante, porque cuentan sus experiencias y me doy cuenta que no soy la única persona que he pasado por problemas así tan feos, tan difíciles. Entonces, al escucharlas a ellas, a veces pienso que es más grande lo que han pasado ellas que lo mío, y es triste. Pero no sé, como que nos ayuda escuchar el testimonio de otras personas para ser más fuertes. [It’s sad and it’s interesting, because they tell about their experiences and I realize that I’m not the only person who has gone through such ugly, difficult problems. So, when listening to them, sometimes I think that what they have gone through is harder than what I have been through, and it is sad. But I don’t know, it is as if it helps us to listen to the testimony of other people to be stronger.] Participants reflected how listening to others’ stories put things into perspective for them, made them feel stronger with a sense of mutual resilience. If others can overcome challenging and traumatic experiences, there was a sense that they could too. Participating in the group impacted the way women perceived themselves, activated their advocacy, and their motivation. Camila shared how the group created a sense of communal empowerment: Support groups are 100%, because you do this and like in the old times when people would get together and talk about business, and when women get together, I mean that’s amazing, when we stop our prejudice and all those things and we just sit there with our hearts on the table and talking, I mean, we can accomplish anything, we can change so many things in life. And I think it’s a need… doing that kind of stuff makes us closer, it makes us more powerful as women, yeah. Differences in lived experiences of women in the groups (i.e., country of origin, immigration stories) were identified by participants as crucial to expanding their understanding of others’ experiences and increasing their skill sets. Regardless of cultural differences, they shared a group space and while the people or circumstances were different, the problems were shared. Thalia elucidated, 78 Bueno, como son de culturas diferentes, personas de México, de Perú y de otros países también, diferentes costumbres en algunos casos, pero siempre el fondo era el mismo, de todas nuestras compañeras en el grupo. Al final era el mismo, pero diferentes tipos de problemas; a veces con los hijos, a veces con el esposo, a veces con la familia. [Well, as they are from different cultures, people from Mexico, Peru, and other countries as well, different customs in some cases, but at the bottom it was all the same for all of the group members. In the end, it was the same, but different kinds of problems; sometimes with the children, sometimes with the husband, sometimes with the family.] Through sharing similar struggles, they felt increased trust and felt that they were no longer alone, which was part of the power of the group. Although they were from different cultural backgrounds, various countries, and had immigrated at different times, participants discussed how the essence of their experiences as immigrant Latina women were similar, despite distinct challenges. Distinctions existed between the support that women received from other Latina immigrant women in the groups and help received from others, outside of the groups. Sofía described the difference between being supported by her White colleagues in the community and Latina women in the group, It’s not that they don’t care. They do support you, but it’s just like, at a different level. Y con los Latinos, yo siento que [And with the Latinos, I feel that] we are on the same boat. Their struggles are my struggles, y nos echamos porras mutuamente [and we cheer each other on]. She described how due to the collective identification and similar struggles and challenges, the support from other Latina women was felt on a different level. Women saw themselves in each other’s struggles and resiliency. Participants described their experiences of having empathy for one another due to their shared collective identification with each other’s testimonio and experiences. Others shared feeling comfortable that no one would judge them and appreciated the mutual 79 empathy that came from sharing. Isabella commented about the collective identification between the women helped them to support each other through difficult times, Una a la otra nos apoyábamos como si algo le pasó a ella mal, entonces le decíamos, ‘No te preocupes, esto tiene solución, esto me pasó a mí.’ Entonces es como lo que me ha pasado a mí yo puedo contarle a otra persona para que ella también se pueda mejorar. [We supported one another whenever hard things happened, and we said, ‘Don't worry, this has a solution, this happened to me.’ So it’s like what happened to me I can tell another person so that she too can get better.] Despite their diverse backgrounds, due to a sense of collective identification, the women understood each other and could put themselves in each other’s shoes. As Valentina described, Aunque todas tenemos cosas diferentes, vidas bien diferentes, todas nos entendemos y no sé si nos comprendemos pero es como si somos empáticas, todas. Todas nos ponemos en los zapatos de la compañera y yo creo que sufrimos igual que ellas. [Although we all have different things, very different lives, we all understand each other and I don’t know if we understand each other but it is as if we are empathetic, all of us. We all put ourselves in our peer’s shoes and I think we suffer just like them.] Groups helped remove cultural barriers of judgment, competition, and emphasis on external features. Xochitl described how participation in the groups shifted cultural perceptions and created a space where women could see each other as a community rather than individuals competing with one another. The emphasis on the internal world created a space for deep connections and true friendships. As Xochitl elaborated, Lamentablemente en nuestra cultura latina se dice de que una mujer no puede ver ojos bonitos en otra, entonces… Pero al estar en nuestros grupos esa barrera pienso que se quita y ya puedes ver mucho más el interior de la persona porque esa persona está hablando del corazón acerca de sus experiencias. Entonces ya esa barrera lamentablemente… ‘Ay, mira cómo, si el pelo, ay, no, si está delgada si tiene un cuerpazo.’ Ya como que hay como que envidia. ¿No? En cambio, acá en estos grupos es del interior más que el exterior. Entonces es súper importante eso porque logras hacer conexiones profundas y amistades verdaderas. 80 [Unfortunately in our Latin culture it is said that a woman cannot see beautiful eyes in another...But being in our groups that barrier I think is removed and you can see much more inside the person because that person, she is speaking from the heart about her experiences. So now that barrier unfortunately…“Oh, look how, if the hair, oh, no, if she is thin if she has a great body.” It’s like there is something like envy, right? On the other hand, here in these groups it is from the inside more than the outside. So that is super important because you manage to make deep connections and true friendships.] Along with building this profound sense of companionship, some discussed how they could see other women in the group as past and future versions of themselves. Camila shared, When they share, when they open like genuinely, you feel like, “I was there too. I was there in the same shoes, 10 years ago, 6 years ago, 5 months ago, and I feel the same way that she is talking about. And now look at her, where is she right now, how has she accomplished that? How much pain did she have to go through for that? How much things did she need to be done in order to be there and look at that, how she made it happen, that’s amazing. I want to be there, I want to keep working, I want to keep coming, I want to keep moving on.” Valentina described how she felt that she was supporting others when she could identify with their experiences at one point in her life. Entonces siempre que ella platicaba algo que se asemejaba a lo que yo había vivido entonces ahí era cuando yo le decía a ella, yo sé cómo te sientes…y entonces eran las veces en que yo podía apoyar cuando yo me sentía identificada con alguien en lo que está viviendo o lo que vivió. [So whenever she talked about something that was similar to what I had experienced then that was when I said to her, ‘I know how you feel ...’ and then those were the times when I could support when I felt identified with someone in what she is living or what she had lived.] The group space was one in which women both saw themselves in each other’s experiences and inspired each other to grow. For all participants who had participated in individual therapy, distinctions arose between individual therapy and participating in a mental health group. Whereas individual therapy is a space where one narrates their own experiences, participants noted 81 how the group setting provided support by sharing with others, learning, and coming together united. Valentina remarked, Individual es una sola y en el grupo somos más, son pláticas más… conocer otras personas más, conversar con otras personas, hacer amigas. Porque ahí me ayudaron para relajarme o para conversar, unirnos como mujeres. [Individual is one person alone and in the group, we are more people, there are more conversations… meeting other people more, talking with other people, making friends. Because there they helped me to relax or to talk, to unite as women.] Reflections on group therapy compared to individual indicate a group may be a beneficial introduction to mental health services and help to combat stigma. Group therapy differed from individual therapy due to the collective identification and collective resilience. As Thalia explained, Y con el grupo, me hacía sentir más en confianza en el aspecto de que no soy yo sola la que está pasando este tipo de problemas; que también hay más personas. Y entre las mismas compañeras uno se da ánimo en decir que sí, ‘Podemos salir adelante.’ [And with the group, it made me feel more confident in the aspect that it is not me alone who is going through these kinds of problems; that there are also more people. And among the group members, we would encourage each other and say that, “We can overcome.”] One participant recommended trying a group before individual therapy due to developing confidence as part of a team to then confront one’s own monsters in individual therapy. The group provided a space of shared power in unity, shared accomplishment, and communal empowerment. Constituent 5. Cultural Appreciation and Strengths Participants found renewed sense of ties to their culture and strengths of being an immigrant through participation in groups with other Latina immigrant women. Constituent 5 shares similarities with Constituent 4, however, Constituent 4 is set apart by inclusion of the experiences of empowerment and refuge with other Latina immigrant 82 women. Even being from different countries and Latinx cultures, being able to speak their native language was a source of comfort and empowerment. Participating in the group helped to facilitate cultural sharing of immigration stories and created opportunities for women to appreciate cultural resilience and strength. Despite coming from different countries and having varied trauma histories and immigration stories, women felt “at home” in the group with one another. As Valentina described, Pero aún así me doy cuenta de que somos muy fuertes al tener el valor de salir de nuestros países para tratar de buscar una estabilidad mejor. Entonces sí es fuerte pero también te sientes como en casa, también que hablen tu mismo idioma y que conozcan más o menos sus costumbres que varían un poco, pero a final de todo todas hablamos el mismo idioma; es reconfortante estar fuera de nuestros países de origen y estar en un país diferente, pero estando juntas también es confortable. [But still I realize that we are very strong in having the courage to leave our countries to try to seek a better life. So it is intense but you also feel at home, also that they speak your same language and that they know more or less your customs that vary a little, but in the end, we all speak the same language; it is comforting because we are outside of our countries of origin and are in a different country, so being together is comforting.] When living in a part of the country in which the majority of the population is White, it was a sanctuary space for participants to discuss feelings, traditions, and ways of communicating. As Xochitl described, En nuestros trabajos no había eso…la mayoría de los lugares son totalmente blancos entonces como que no entendían nuestros sentimientos, nuestras tradiciones nuestra manera de hablar, entonces es muy bueno poder llegar a estos lugares porque es como un lugar de un refugio. [In our jobs there was not that…most of the places, they are totally White so they did not understand our feelings, our traditions our way of speaking, so it is very good to be able to get to these places because it is like a place of refuge.] Further, Xochitl explained it was beautiful to be in a space in which women speak the same language, feel supported, feel they can talk about similar things as immigrants, as Hispanic, and the things they faced. “Ay muy bonito porque sentíamos que hablábamos el mismo idioma, nos sentíamos apoyadas, sentíamos que muchas veces hablamos acerca 83 de las cosas que sentíamos al ser inmigrantes, ser hispanas y las cosas que we faced.” [Oh, very nice because we felt that we spoke the same language, we felt supported, we felt that many times we talked about the things we felt being immigrants, being Hispanic and the things we faced.] The therapeutic practice and catharsis of sharing within the Latinx community helped Alma to feel that she was back her in her country of origin: Siento que para mí ha sido terapéutico, no sé si esta es la palabra o curative. Me ha ayudado a hacer catarsis, a poder hablar, a sentirme escuchada y estar en una comunidad hispana en un país que no es mío, me sentía a ratos como si estuviera en [country] otra vez, cuando estaba en el grupo. [I feel that for me it has been therapeutic, I do not know if this is the word or healing. It has helped me cathartically, to be able to speak, to feel heard and to be in a Hispanic community in a country that is not mine, at times I felt like I was in [country] again, when I was in the group.] Creating a cultural community in particular was salient, especially for women who had immigrated alone or felt isolated due to being in primarily White spaces. Sofía shared that there are more similarities among Latinxs than those who identify as White and noted how participating in a group with Latinas helped to renew her sense of connection with her cultural heritage: Me encanta, porque yo desde que me mudé a [estado], todas mis compañeras, la mayoría, siempre han sido caucasian, entonces, es como que empecé a adoptar esos comportamientos y formas de pensar, pero en realidad me fui separando de mi cultura y de las cosas que yo aprecio en mi cultura. Pero luego el estar con latinos, y mirar y apreciar de dónde venimos y las cosas buenas que temenos; entonces, eso me ha traído otra vez el orgullo de mi cultura. [I love it, because since I moved to [state], all my colleagues, most of them, have always been Caucasian, so, it's like I started to adopt those behaviors and ways of thinking, but in reality, I was separating from my culture and from the things that I appreciate in my culture. But then being with Latinos and looking and appreciating where we come from and the good things that we have, that has brought back my cultural pride.] 84 After participating in a support group with White women conducted in English, Camila felt motivation to start her own group due to her awareness of the benefits for her and wanting to bring that to others in Spanish. I think support groups changed my life so much. I got inspired to just not go back and say, you know I was a part of my support group once. This has inspired me so much to be aware of, this is something that is a need, it is something that needs to exist for my culture, too, for my people who do not speak the language. Structure 3. Healing from Adversity The general structure encompassing P’s essential common features related to the third structure were as follows: P’s experience of healing through group participation involved concrete skill-building, which could then be employed outside of the group. After experiencing support from the group, group support emerged in P’s consciousness as a different manner of existing in the world. Thus, the search for group support was also a search for new ways for P to express herself in the world, which could lead her to feelings of greater self-confidence, self-compassion, improved mental health, skills to manage mental health, mutual resilience, and inner strength to continue forward. The following constituents comprised the general structure: 1. Psychological Changes - Skill-Building and Mental Health Changes 2. Social Changes Constituent 1. Psychological Changes Skill-Building. Participants reflected how groups were a space in which they learned skills to support themselves in living healthier lives. Acquisition of new skills included stress management, relaxation strategies, mindfulness, emotion identification and regulation, parenting, creating and maintaining boundaries, and time management. Participants 85 discussed learning concrete skills such as parenting skills or interview skills, which they could then share with others outside of the groups. Further, group facilitated positive changes that improved family relationships, such as patience with children and partners. One participant discussed how learning her own self-regulation strategies then helped her to be more empathetic and co-regulate with her children. Critical to skill-building was learning cultural differences in these skills such as navigating parenting and childrearing in the United States. The group process allowed group members to honor that not everyone is in the same place and is on their own learning continuum with each topic. Mental Health Changes. Participants commented on a multitude of mental health changes they experienced over time that coincided with their group participation. Participants described how group participation first helped them to be vulnerable and admit a need for help. Group support corresponded with reduced mental health symptoms including reduced symptoms of depression and anxiety. As Isabella explained, Pues la necesidad que tenía era de que estaba muy deprimida, me daba ansiedad, y ahí pues me ayudó a quitar bastante… Me siento mejor, más animada a participar y seguir adelante. [Well, the need I had was that I was very depressed, it gave me anxiety, and there, well, it helped me to decrease my symptoms a lot …I feel better, more encouraged to participate and carry on.] Participants discussed how sharing their histories and testimonio with others helped them to let go of the past, spend less time reminiscing, and put more energy into their futures. Various psychological resiliencies and strengths shifted through engagement in groups including confidence to overcome depression, learning how to not be a victim, hope for the future, optimism, acceptance, patience, resilience and strength, and valuing time and life. Further, participants noted how their relationships with themselves evolved 86 over time in the group including reduced egocentricity, and increased humility, self- confidence, personal growth, self-knowledge and introspection skills, perception of self- value, and self-love and compassion. As Sofía shared, Dedicarnos un tiempo para nosotras mismas, para que sintamos que nosotros también nos queremos un poco, lo propio, porque es algo que sí nos va a ayudar bastante. [Dedicating some time for ourselves, so that we feel that we also love ourselves a little, the same, because it is something that will help us a lot.] Sofía described the power of awareness and knowledge that she gathered from group participation, Awareness is powerful, entonces cuando te empiezas a darte cuenta de cosas, a cambiar hábitos, te vas conociendo a ti misma. Y knowledge is power; entonces pienso que el saber te hace ser más abierta, o darte la oportunidad de conocer otras cosas más y con eso you can relate to more people. [Awareness is powerful, so when you start to realize things, to change habits, you get to know yourself. And knowledge is power; I think that knowing makes you more open or gives you the opportunity to know other things and with that you can relate to more people.] Valentina shared how the group was an escape from daily life and she noted the mental health changes she experienced through group participation, Sin embargo, saco lo que yo no pensé que tuviera que es paciencia y ahora la tengo. Yo que pensé que yo no era tan fuerte y esto me hizo saber que sí lo soy. Me hizo saber y valorar más el tiempo, valoro más la vida, o sea, ya me quejo menos, ya lloro menos, ya me enojo menos y ya sonrío más. Pero la verdad es que a mí sí me cambió mucho, por eso seguí ahí y seguía ahí porque me hacía sentir muy bien. [However, I draw out from within what I didn’t think I had which is patience, and now I have it. I thought that I was not that strong and this made me know that I am. It made me know and value time more, I value life more, that is, I complain less, I cry less, I get angry less and already smile more. But the truth is that it did change me a lot, that’s why I was still there, and I was still there because it made me feel very good.] Alma noted how she gained humility and openness to the diverse experiences of others, Considero que soy una persona más humilde y más abierta, más receptiva a personas que no tienen mi mismo pasado o background. 87 [I consider myself a more humble and open person, more receptive to people who do not have the same past or background.] Additionally, with increased self-love and value, participants shared feeling more confident saying “no,” setting and maintaining boundaries, making autonomous decisions, and being alone. Women noted changes from being more submissive to growing more assertive and having restorative experiences to gain trust with others. After experiencing intimate partner violence, Eva shared she learned that she could be her own person, make mistakes, feel what she wanted to feel, and felt free, Yo soy libre, no porque yo me haya casado o tenga un esposo quiere decir que el esposo va a dirigir mi vida de todo a todo. [I am free, just because I got married or have a husband does not mean that my husband is going to direct all the things in my life.] Valentina noted being open to sharing more with others, “Sí, como ser más compartida con los demás.” [Yes, how to be more open to sharing with others.] Not only did participation in groups help to normalize and validate mental health challenges, but some participants discussed how engaging in a group helped them to be an example for others within the same culture in order to normalize and validate mental health experiences and participation in groups. Camila described, If talking about the same culture of people to be aware, to be an example and like, wow, what are you talking about, yeah, well, that happened to me when I had my kid like six years ago, but I didn't know that it was a post-partum depression, nobody told me, you know, when you're talking to someone, like wow, and I'm talking to friends, because I don't have family here, but to friends it's like, wow if I had known about those kind of groups I would have probably done it but I didn't know about it. Participants described the group as an opportunity not only to overcome feelings of embarrassment and shame, but to share with others that there are avenues for them to do the same. 88 Two participants commented on how support groups are similar and different from other healing practices such as attending church. Whereas support groups are more for emotional help and discussing lived experiences and trauma, church is spiritual help with support from the community. In mental health groups, one may be more likely to learn from others with different ways of thinking, diverse beliefs and alternative points of views. In contrast, church usually involves people with similar beliefs. Constituent 2. Social Changes Group participation facilitated positive changes that had the potential to improve family and social relationships. Additionally, family members and others noticed that participants had changed with their experiences in the group. For some, sharing difficult or traumatic experiences in a group then allowed them to share and discuss difficult topics outside of the group with family members, friends, and community networks for the first time. As Eva described, Fue donde empecé a compartir los abusos que estaba llevando en mi hogar, y mis papás no lo sabían. Ahora, ya basado a que he estado en grupo de apoyo, eso me ha permitido sentirme con más confianza de poder expresarme y compartir con mis padres y recibir el apoyo. [It was where I began to share about the abuse that I was experiencing at home, and my parents did not know it. Now, based on having been in a support group, it has allowed me to feel more confident to be able to express myself and share with my parents and receive support.] Participants described how their family members and others had noticed changes in them coinciding with group participation. Some described their families noticing that they were more independent, more willing to go out by themselves, more open to engage in conversation, smiled more, and overall, had an improved quality of life. For Lola, the group had changed her quality of life and her family and teachers noticed changes in her that she smiles more and goes out independently. 89 Es que me daba fuerzas de andar con alguien y ya podía salir así sola, aunque sea en el bus y ya me llevo a mi hijo y allá voy. O con las maestras también, las maestras muy buenas, platicábamos de todo un poco, ellas me dicen, “Tú ahora ya eres diferente.” [It’s that it gave me the strength to walk with someone, and I could go out like that alone, even if it's on the bus, I take my son with me and there I go. Or with the teachers too, the very good teachers, we talked about everything a little, they tell me, “Now you are different.”] Valentina described her experience of her husband noticing changes in her and wanting support of his own, Pero él se ha dado cuenta que yo he cambiado tanto y que he sido tan paciente, bueno, con los niños, cuando no lo era. Que hasta el mismo me dijo, ‘Yo también quiero ir, búscame un apoyo, unas clases de eso.’ Y le digo, ‘Sí, sí, sí te voy a buscar,’ porque la verdad es que a mí me ayudaron tanto que yo sé que a mi marido también lo van a ayudar demasiado. [But he has realized that I have changed so much and that I have been so patient, well, with the children, when I wasn’t before. He even told me, ‘I also want to go, find me a support, some classes like that.’ And I say to him, ‘Yes, yes, yes, I'm going to look for you,’ because the truth is that they helped me so much that I know that they will also help my husband so much.] Others discussed how people had noticed their own personal growth. Camila’s family noticed differences and changes: When I talked to my mama again she said, ‘You changed your mind, you’re a different person, you are not the same person, what happened to you?’ Yeah. I learned a lot of things and not just learned, it’s just that you become more human. You become more aware of too many things, whatever the topic is because like I did with postpartum depression but now that I’m doing this with domestic violence, sexual assault, I mean you change, you change, people change you, experiences in life that others share, this changes your life. Structure 4. Group Logistics and Future Recommendations The general structure encompassing P’s essential common features relating to the fourth structure were as follows: The facilitators were essential to creating the space of the group and impacted P’s ability to share and their experience of the group. The structure of the group provided the foundation for the group work. Due to COVID-19, P 90 experienced changes to group format or a loss of connection with the group. With all of her experiences, P made suggestions for envisioning an ideal group including location, logistics, group norms, facilitators, structures, themes, and adaptations. The following constituents comprised the general structure: 1. Facilitators’ Impact on the Group 2. Structure 3. COVID-19 Changes 4. Ideal Group Constituent 1. Facilitators’ Impact on the Group Participants described the facilitators as being both helpful in creating a safe space and at times, challenging to that space. The ways in which facilitators supported the group included setting the atmosphere with platica and personalismo, facilitating check- ins, monitoring responses, offering real skills and ways to resolve difficulties to overcome barriers, and having authentic care for participants. Lola shared about the support, confidence, and hope the facilitators afforded her when she joined the group, “Vas a ser una buena persona, y todo lo que traes aquí en tu corazón todo va a quedar por un lado y vas a ser nueva; vas a ser diferente compartiendo todas tus experiencias. Tu sufrimiento y todas las mujeres que están aquí, todas pasamos por algo y por eso estamos aquí.” [“You are going to be a good person, and everything that you bring here in your heart will all be left aside and you will be new; you will be different by sharing all your experiences. Your suffering and all the women who are here, we have all been through something and that is why we are here.”] Relationships and level of comfort and intimacy differed between participants and different facilitators and this impacted participants’ experiences and level of comfort participating in the groups. Maite shared how due to the facilitators she did not feel comfortable or prepared to share in the group at first, 91 Al principio cuando entré, la persona que estaba dando la clase, no me sentía tan capaz de hablar porque no me sentía preparada para escuchar y dar consejos. [At first when I entered, the person who was teaching the class, I did not feel as capable of speaking because I did not feel ready to listen and give advice.] Facilitators’ professionalism, cultural responsivity, and inclusivity of diverse identities also mattered to creating a safe and comfortable space. When facilitators did not do this, it created challenging experiences as Xochitl explained, Lo único que no me gustó es que la que estaba dirigiendo el grupo es una persona que es atea. Entonces sí, por algunos momentos ella recalcaba mucho que ella no creía en Dios y se reía y como que forzaba al grupo a reírse de sus creencias sin ser totalmente profesional en pensar en que las demás personas pues podrían tener otro tipo pues de creencia o religión. Y eso sí fue lo que vi malo y pues para mí en lo personal que soy una persona que cree en Dios, para mí fue muy ofensivo. [The only thing I didn’t like is that the one who was leading the group is an atheist. So yes, for some moments she stressed a lot that she did not believe in God and laughed and it was as if she forced the group to laugh at their beliefs without being totally professional in thinking that other people could have another type of belief or religion. And that was what I saw as bad and well, for me personally, I am a person who believes in God, for me it was very offensive.] Depending on how they facilitated the space, group facilitators had the potential to create a comfortable and inclusive space or a space in which women did not feel understood or supported. Constituent 2. Group Structure Constituent 2 denotes how the structure and the logistics of the group were critical elements to group engagement. Group structure included group norms such as maintaining confidentiality and check-ins. Due to the diversity of groups participants in this study had engaged in, activities and resources spanned a range of topics including crafting, movement and activities for physical nourishment, dancing, singing, games and various relaxation exercises. Participants reflected how these activities contributed to 92 their group engagement. Lola identified how the inclusion of diverse dynamic activities helped her to bring to light challenges she was experiencing, Bueno, sí, teníamos conversaciones con todas las mujeres y hacíamos muchas, cómo le dijera… dinámicas, bailábamos, cantábamos, muchas cosas para relajarse uno, para tratar uno de olvidar todo lo que uno sentía, lo que uno tenía, compartiendo nuestras experiencias y todo. Era, pues algo que para mí fue algo que sí me ayudó bastante porque así yo pude y más que todo sacar todo lo que yo tenía. [Well, yes, we had conversations with all the women and we did many, how could I say ...engaging activities, we danced, we sang, many things to help us relax, to help us forget problems we felt, sharing our experiences and everything. It was, something that really helped me a lot, because that way more than anything I was able to bring out what was going on for me.] Constituent 3. COVID-19 Changes Although it was not specifically addressed in the research or interview questions, many participants brought up the changes that had occurred to the groups or for them in their personal lives due to COVID-19. Overall, the participants who had their groups cancelled due to COVID-19 described the loss of the group and the loss of connection with other women. Groups facilitate interpersonal growth and a lack of access to these connections made that growth challenging to sustain. As Isabella put it, Pues ha cambiado bastante porque ya no veo a nadie de mis amigas, ya no nos podemos reunir, hablamos por teléfono, es muy difícil ahorita. [Well, it has changed a lot because I no longer see any of my friends, we can no longer meet, we talk on the phone, it is very difficult right now.] Even with online platforms to host the groups virtually via internet or phone, some described barriers to attending a virtual group such as needing to attend to their children. Three participants described how despite not attending the group, they maintained contact and positive relationships with other group members and a mutual understanding due to experiencing the same struggles socially due to COVID-19. As Sofía shared, “Todas 93 estamos en el mismo bote y podemos entendernos.” [We are all in the same boat and we can understand each other.] Constituent 4. Ideal Group Recommendations A range of suggestions and considerations were made for envisioning future groups. Participants discussed ideal locations, logistics, structure, facilitators, themes, and adaptations for groups serving immigrant Latina women. Location According to participants, the ideal location for a mental health group would be in an activity center or an open space like a garden, in a central location that serves the community, and would have beautiful and non-distracting decorations. The title of the group would be something that does not say “mental health” but is well-received, like “Hablar es Sanar” [Speaking is Healing], or “Free,” “Relieve,” or something about releasing one’s problems. Logistics Logistics of the group, such as providing a meal and childcare, were critical to some participants’ ability to access and engage in the group and were deemed essential to the sustainability of future groups. One recommendation to reduce barriers to attendance included flexible group days and times. To increase accessibility, it was suggested that materials be created with awareness of differing levels of education and literacy. Economic support and resources were suggested be available to women during emergencies, such as paying for an ambulance bill following an IPV incident. 94 Group Norms Participants expressed that group norms are important to create a safe and respectful group. Group norms that were deemed crucial included confidentiality, mutual respect for each other and differing opinions, assumptions that every group member is doing their best at any given moment, active listening, and cultural humility. Facilitators Participants recommended that group facilitators identify what kind of support group they are conducting and who the target population is. For example, it may be difficult to have various generations of Latinas in the same group due to differences in experiences and potential difficulties relating to each other’s experiences. Facilitators for an ideal group should have cultural competency education and cultural humility. For example, facilitators must engage in outreach and develop trust within the community, take into consideration the space, the potential impacts of more formal or more casual clothing, and how they use language and approach different topics in culturally responsive ways. For example, Camila shared, So, it’s the manner in which you approach, it’s very important, you have to be aware of how you approach any individual… some people don’t know how to read, some people don’t know how to write, and they’re not going to say anything because people feel very ashamed about it. It was also recommended that facilitators should have specialty treatment for support women through specific experiences like DV, substance use, trauma, etc. One participant recommended that a facilitator should share identities (race/ethnicity, gender, parenting status) and background with participants to better identify with their concerns. Additionally, ideal facilitators would manage the length of sharing, and empower and encourage all group members to share. 95 Group Structure An ideal group would continue to be a place where group members share testimonio, provide mutual support, and learn from each other how to overcome difficult situations. Additional suggestions included arts and crafts for alternative forms of collective emotional expression, movement for empowerment and motivation, and role plays to gain confidence in applying skills. Specific skill building recommendations for immigrants included using technology and literacy. Isabella shared how she believed more groups could help more women and others due to collective unity. Unirse con el grupo de mujeres es muy importante, porque de verdad nos ayuda bastante. Como hacer otro grupo para que otras personas más que lo ocupan, puedan llegar y hacerlo para poder ayudar y trabajar todos juntos, todos unidos para mejorar. [Joining the women’s group is very important because it helps us a lot. How to make another group so that other people who need it, can come and do it, to be able to help and work all together, all united to improve.] Group Themes Ideal group themes and topics covered mental health, social justice, and providing resources. Suggestions for mental health topics spanned overcoming fears, helping others, self-love, self-esteem, abusive relationships, parenting throughout the lifespan, child discipline practices, communication with children, cultural sharing, and goals and challenges living as an immigrant in the United States. Themes related to social justice included a focus on autonomy and human rights and processing what is contextually occurring, such as the current sociopolitical climate, Black Lives Matter, and impacts and overlaps focused on being an immigrant woman in the United States. Ideas for resource and career support included professional support, support with English and American customs, and book recommendations. 96 Summary of Psychological Structures The analysis of the results led to four distinct psychological structures of the experience with two to five constituent elements per structure. In summary of all four psychological structures, P felt alone and isolated in her experiences and lacked support from others in whom she could confide, leading P to seek out support. Once participating in a group, P continued to encounter barriers to sharing her experiences with others. Various aspects and processes of the group that allowed P to feel safe to share testimonio included group norms to create a safe and nonjudgmental space, and facilitators to structure and guide conversation. With this safety, ways of expressing herself were redefined and new patterns of communication were established, enabling P to experience relational liberation and feel strengthened by the collective identification with other women in the group. Support and relationships acquired different and more profound meanings in the context of the group. P experienced restorative connections to her cultural identities and cultural strengths. P’s experience of healing through group participation involved skill-building, improved mental health, and feelings of greater self- confidence, self-compassion, and strength to continue forward. Group facilitators, structure, and COVID-19 all had impacts on P’s experiences in groups. P envisioned an ideal group and made suggestions from her lived experiences, expertise, and innovation. 97 CHAPTER V DISCUSSION, RECOMMENDATIONS, AND IMPLICATIONS The purpose of the present study was to explore the psychological experiences and the meaning of the experiences of Latina immigrant women who had participated in mental health groups. The goal of the descriptive phenomenological analysis was to derive the meaning that participants place on their experiences in mental health groups with other Latina immigrant women, in order to determine the essence of their lived experience (Creswell, 2007). Four psychological structures of the experience of participating in mental health groups emerged from the findings. Participants experienced disconnection and isolation prior to attending groups. Group participation was hindered by various barriers to sharing with others and multiple processes supported in facilitating safety to share. Participants established new patterns of communication, gained relationships and support from the group, renewed ties to their cultural identities, and experienced improved mental health outcomes. Participants made suggestions for ideal groups for Latina immigrant women. In this chapter, the results are discussed in the context of the existing literature and in relation to the key frameworks and processes of RCT, a psychological framework for radical healing, and the conceptual tool of testimonio. RCT proposes that fear, shame, and mistrust lead to disconnection and isolation while healing happens within mutually empathic relationships that promote growth (Comstock et al., 2002). The psychological framework of radical healing honors the relational liberation process of POCI coming together in community to offer support and solidarity for healing from oppression and increasing hope for justice and freedom (French et al., 2020). Furthermore, testimonio 98 highlights the potential healing power of sharing struggles with others with mutual identification and understanding (Elenes, 2000). Throughout this discussion, I will highlight the novel contributions of this study to the literature. Later in this chapter, I discuss the strengths and limitations of this research. I then share the recommendations and implications for practice with Latina immigrant women and make suggestions for future research. The chapter concludes with an overall summary of the study and findings. Overview of Findings Four distinct psychological structures of the phenomenon emerged from the results with two to five constituent elements per structure. Structure 1. Disconnection and Isolation Disconnection and isolation from a RCT perspective stems from cultural oppression and social exclusion (Birrell & Freyd, 2006; Comstock et al., 2008) and although many forms of oppression are enacted at institutional levels, the resulting harm is often at an interpersonal level (Birrell & Freyd, 2006). The majority of the women in the present study endorsed feeling lonely and isolated prior to joining mental health groups, whether or not they had family members and friends in the United States. These findings are consistent with previous research with immigrant Latina women in which they described feeling encerradas or “closed in” due to lack of familiarity with the U.S and difficulty connecting with others (Hurtado de Mendoza et al., 2014). In RCT, condemned isolation is “being locked out of the possibility of human connection” (Miller & Stiver, 1997, p. 72) and women in the present study described that some women may feel isolated and disconnected alone in their homes without support. 9 9 Furthermore, participants discussed their hesitations about sharing their mental health challenges, traumatic experiences, and/or experiences of discrimination with family members or friends. Women experienced the RCT relational paradaox of both desiring connection and feeling disconnected and isolated from others (Comstock et al., 2008) due to fears of judgment from others and the potential to burden or even harm others by needing their support or sharing their struggles. Disconnection can involve a lack of clarity and confusion regarding self and other, decreased self-worth, and isolation from relationships, (Jordan & Dooley, 2000), which can result in a deep sense of shame. Participants felt embarrassed or ashamed, due to various cultural barriers, such the indignity of discussing family abuse or problems with others outside of the home (Edelson et al., 2007). This study took place in a predominantly White area with a small Latinx population, Latina immigrant women might be more likely to hear about each other or interact with each other at the few community gatherings conducted in Spanish, which might be another reason for women’s hesitancy to share openly with one another. Additionally, due to stigma and norms about mental health (Nadeem et al., 2009), adding to previous research, participants emphasized the importance of sharing with others the acceptability of therapy in order to break stigma regarding mental health service utilization. Structure 2. Relational Liberation Establishing safety through a supported vulnerability, in which is it safe to share is a critical component of the relational cultural model (Comstock et al., 2002). For some participants, it was a process to feel comfortable and safe to share in the group, such as 10 0 the processes for engaging in group formation as the first stage in which participants develop a sense of trust with the others (Yalom, 1970). An important contribution to the existing literature is support for the underlying mechanisms of establishing safety in the group for immigrant Latina women, including group norms, developing rapport over time, learning from modeling of group members who had attended the group longer, and a smaller more intimate group. Some of these factors have been identified as important for group safety with various populations (Foy et al., 2000; Klein & Schermer, 2000) but less research has addressed this with Latinx immigrants, and particularly in predominantly White communities. Furthermore, the intentionality of the facilitators creating and monitoring the space and honoring Latinx values of confianza, personalismo, and respeto (Sue & Sue, 2015) made a difference in participants’ abilities to share and engage in the group, in line with cultural perspectives of healing based on the culture of the clients (Mosher et al., 2017). Additionally adding to the literature, multiple participants described how they were able to share in testimonio in the group what they had never shared with anyone before, including family. Previous research has found sharing testimonio in group therapy as healing and empowering (Cervantes et al., 2019). Women were able to share experiences that had previously been silenced, or guarded with a sense of shame, and may have engaged in processes of healing through reflecting on and recounting the past (Delgado Bernal et al., 2012). In this study, participants described the emotional support they felt in the group as distinct from support outside of the group due to mutuality, which is described as a mutual exchange in which one both extends oneself emotionally out to the other and is emotionally receptive to the impact of the other (Jordan, 1986). Constituent 4, 10 1 Relationship Building in the Group adds to the literature in that relationships in the group at times felt stronger than family or friends due to the nature of the group and themes discussed, confidentiality, non-judgment, and listening without giving feedback. Contrary to previous findings that fear of judgment from others led Latina immigrant women to endorse preference for individual therapy over group therapy (Kaltman et al., 2016), participants in this study described a shift from being critical and judgmental to becoming more open, understanding, and respectful due in part to perspective-taking of others in the group. These processes of mutual empathy were critical to eliminate barriers in order to identify with others’ vulnerabilities and ultimately helped women to transform ways of relating to others (Comstock et al., 2008). From a neuropsychological perspective, positive connections with others helps to rewire the brain’s circuitry and vagus nerve, which helps the brain assess safety, trust, and belonging in new situations. Furthermore, when a person hears someone’s experience and conveys empathy, mirror neurons (brain cells that respond equally when we a perform an action and observe the same action by another person) in the brain register the signals from others that one is seen, accepted, and understood. These mirror neurons create more flexibility in the brain and can increase a sense of ease and wellbeing in relating to other people and in navigating the world in general (Graham, 2013). Not only were women able to grow in the processes of relating to others which has been demonstrated in previous research (Castro, 2009; Marrs Fuchsel, 2014; Vargas- Willis & Cervantes, 1987), but participants in this study were strengthened and bolstered by the normalization and collective identification of their experiences of being Latina immigrant women in a majority White community. Constituent 2. Strengthened by 10 2 Collective Identification extends previous research in that support from other Latina immigrant women was described as different than support from White friends or colleagues, due to this collective identification of experiences. A psychological radical healing framework highlights the possible mechanisms at work as women come together to heal. Through sharing and listening to their life experiences and testimonio, women in the groups became life accomplices to each other gaining insight, solidarity, and strength from others’ experiences of adversity and discrimination. Agency and power were fostered through shared identities and experiences. There was the Mayan notion of “In La’Kech Ala K’In, “You are my other me,”1 (Valdez, 1973) reflected in how women felt empathy for each other and how they saw themselves in each other’s struggles and resiliency. Groups provided a space in which women were able set aside preconceptions based on exteriors, and access interior worlds of one another by listening and speaking from the heart. Furthermore, adding to the literature on immigrant Latina women in mental health groups, the group space provided access to experiences that supported positive ethnic identity development, offering women an alternative psychosocial space to affirm their sense of self in a social structure in which they are often marginalized (Viruell-Fuentes, 2006). Despite coming from various cultural backgrounds and having varied trauma histories and immigration stories, women came to feel “at home” in the group with one another. Although participation in mental health groups with members of diverse cultural and racial/ethnic backgrounds could foster common identities as women, the collective 1 In Lak’Ech is a Mayan saying that Chicano playwright, Luíz Valdez, incorporated into a larger poem called “Pensamiento Serpentino.” The meaning of the phrase draws from the Mayan definition of the human being or “vibrant being,” meaning humans are all part of the same universal vibration. 10 3 identification as immigrants and as Latinas was especially important in the context of a time of anti-immigrant policies and living in a vastly White majority city with high rates of racially-motivated hate crimes in the state. Enhancing previous research, the group space in this study was similar to a sanctuary space created to offer protection, affirmation, and validation to immigrant communities (Chavez-Dueñas et al., 2019). Listening and sharing testimonio with other Latina immigrant women helped to reaffirm connections to culture and of being an immigrant. Being able to speak their native language together was a unifying source of comfort and empowerment across their diverse national and ethnic cultures. Women were able to engage with each other, learn from each other, and reconnect to their cultural identities and cultural strengths. The more connected one is to their culture and has a foundation in their identity development, the better one can understand the limitations to universally accepted truths and define their own reality (Gallardo et al., 2011). Adding to the literature on Latina imimigrant women’s experienced in mental health groups, this study found that through connecting with others of similar cultural backgrounds or identities, participants were able to better analyze different perspectives and choose for themselves how to move forward in their own reality. Findings from this study highlight the potential for mental health groups among Latina immigrant women to reduce isolation, enhance feelings of safety and normalization, increase collective identification, and provide a space to affirm cultural and ethnic identities in ways individual therapy could not. 10 4 Structure 3. Healing from Adversity In this study, participants described various psychological changes that they attributed to participating in a group including reduced depression and anxiety, confidence to overcome depression, learning how to not be a victim, hope for the future, optimism, acceptance, patience, resilience and strength, and valuing time and life. Although these benefits are consistent with previous literature (Charuvastra & Cloitre, 2008; Hovey, 2000; Katlman et al., 2014; Ornelas et al., 2009; Ulman, 2004), Constituent 1. Skill-Building and Mental Health Changes demonstrated how participants’ relationships with themselves evolved over time in the group. In this study, through relating more authentically and empathically, group members started to view themselves more clearly and noted how their relationships with themselves evolved over time in the group including reduced egocentricity, increased humility, self-confidence, and self- compassion. These are powerful and empowering outcomes of group participation because clarity of self can enhance relational capacities and relational confidence (Comstock et al., 2002), enhancing individual, collective, and familial wellbeing. Constituent 2. Social Changes, adds to the literature in finding that after participating in groups, women experienced positive changes that had the potential to improve family and social relationships. Not only did women experience transformations within themselves, but family members and others noticed, and participants attributed these changes to their experiences in the group. Sharing with group members and experiencing mutually empathic relationships gave some participants confidence to risk being vulnerable in other relationships and seek mutually empathic relationships with family members or friends, therefore strengthening their outside support networks of 10 5 support. RCT in group therapy notes how with increased relational confidence, group members become more flexible in deciding with whom to establish relationships and become more open to exploring patterns of disconnection (Comstock et al., 2002). These enhanced social networks and women’s increased willingness to share can create additional space for connectedness to others and collective emotional expression. Again, though prior investigations have demonstrated these outcomes of group therapy with other populations, far less attention has been given to Latina immigrant women. Structure 4. Group Logistics and Future Recommendations Consistent with previous research, participants described the facilitators as being both helpful in creating a safe space and at times, challenging to that space. Participants shared that the structure of the group was critical to the running of the group. Group structure included maintaining confidentiality about group membership and other's experience outside of the group. Past research on mental health support groups with Latina immigrant women have suggested the provision of childcare and even transportation as essential to women’s participation in the group (Shattell et al., 2010). Constituent 3. COVID-19 Changes add to a nascent telehealth literature because it has only been one year (as of this writing) since the beginning of the worldwide coronavirus pandemic (Nicholas et al., 2021). Overall, the participants who had their groups cancelled due to COVID-19 or experienced barriers to attending a virtual group, such as attending to their children, described the loss of the group and the loss of connection with other women. Groups helped to facilitate interpersonal growth, and a lack of access to these connections made that growth challenging to sustain. Recent research on COVID-19 and teletherapy has highlighted the challenges of creating the 10 6 therapeutic alliance via teletherapy in online groups; the quality of the therapeutic relationship is in question and is an area of future study (Weinberg, 2020). Some participants noted they maintained contact with other group members outside of group and had a shared current context and mutual understanding due to all experiencing COVID-19 restrictions. In this study, Latina immigrant women were surveyed about their notions of ideal group psychotherapy for women in their communities, which allows for another unique contribution to the literature. Their suggestions included giving overt attention to establishing group norms of cultural humility. Some participants proposed that group facilitators should share identities and backgrounds with the participants in the group, whereas others highlighted that the most important qualities of a facilitator are cultural competency, experience, listening skills, and ability to monitor and manage group dynamics. Recommendations for structure included dynamic activities such as crafts, role plays, and movement in addition to discussion. The inclusion of movement could be an important component to take into consideration to enhance mental health support group groups with Latina immigrant women. The somatization of psychological or emotional distress in one’s body is culturally normed and more commonly reported among minority racial/ethnic groups than U.S.-born Whites (Kirmayer & Young, 1998) and physical movement been shown to facilitate trauma healing (Dieterich-Hartwell, 2017). Summary This study illuminates the experiences of mental health groups that made the group a safe supportive space that promoted relational liberation and affirmed the identities and common struggles women experienced. Participating in a mental health 10 7 group with other Latina immigrant women addressed social isolation in a way that individual therapy could not. The safety of the confidential and monitored space by facilitators allowed participants to share experiences that they could not or at least would not share with family or friends. Sharing with and learning from each other created a sense of community and collective identification with one another consistent Latinx psychological strengths of connectedness to others and collective emotional expression (Adames & Chavez-Dueñas, 2016). These experiences helped to nurture greater agency, self-esteem, and self-compassion. Participants noted improved mental health, personal growth, and increased vulnerability to reach out to others to create mutually empathic relationships and strengthen support networks. Strengths and Limitations of the Study Study strengths and limitations are presented followed by benefits and challenges due to COVID-19 changes. Strengths of this study include responding to calls for research, consulting about interview questions, eliciting testimonio from participants, affirming the importance of participants’ experiences and perspectives, and helping participants to integrate their group experiences further into their life narrative. First, this study responds to calls for more research on the experiences of social cohesion and connection between Latina immigrant women in mental health support groups (Kaltman et al., 2016; Hurtado-de-Mendoza et al., 2016). Second, the design and interview questions of this study were derived in consultation with Latina immigrant women who were participating in a mental health group on their ideas for questions to be used in the study. Additional consultation was sought from a team of bilingual and/or bicultural graduate student participants in a 10 8 Spanish specialization program who engage in clinical work with Latinx communities. This consultation process reflects best practices of integrating Latinx cultural values, beliefs, and traditions in conducting culturally competent qualitative research with Latinx immigrants (Ojeda et al., 2011). Furthermore, it is consistent with a sanctuary research framework in that it is part of infusing the expert opinions of people who are directly connected to and have experienced the processes that are the focus on the study (Chavez- Dueñas et al., 2019). Third, by engaging in these interviews, participants were able to further share testimonio about their experiences in mental health groups, which affirmed the value and importance of their experiences and perspectives. Through this sharing and reflecting on their experiences, they may have been better able to integrate their group experiences in into their life-narrative. Making meaning of life events can lead to some degree of “narrative integration,” or integrating the meaning of one’s experiences into one’s life story, thus increasing the experienced quality of life (Hartog et al., 2020). Fourth, Constituent 4. Ideal Group brings a focus to the agency and autonomy of the participants in the study of defining their own healing process, which is not always present in other research. Participants were positioned as experts on the elements and processes of groups that they found to be most supportive and conducive to healing. Space was created for them to innovate and imagine an ideal mental health group experience, and they understood that their perspectives would be utilized for the purpose of enhancing practice, to the benefit others in their community. As with all research studies, there are several important study limitations to consider when interpreting the findings of this study. Limitations include purposive 10 9 sampling, limited generalizability, and researcher subjectivity. First, this study utilized purposive sampling, which is often used in qualitative research in order to identify individuals who are especially knowledgeable about a phenomenon of interest (Creswell et al., 2007). For this study, I recruited participants from local organizations and nonprofits who currently have or have held mental health groups for Latina immigrant women in the Pacific Northwest. Second, as a qualitative study, the generalizability of these findings is limited by the nonrandom selection of study participants (Heppner et al., 2007). Giorgi (2008) writes that using the psychological phenomenological reduction, the researcher can describe essential findings that are intrinsically general. The researcher must employ methods of eidetic reduction in which they examine a phenomenon and then systematically varies it in order to determine its essence, essentially determining what the key meanings are and if they relate to the whole description or not (Giorgi et al., 2017). However, it remains the case that the structures and constituent elements generated in this study could have been different had participants included Latina immigrant women living in other geographic regions (more urban, more rural, higher or lower percentages of Latinx community members), with different political climates, who identify as indigenous, and/or for whom Spanish is not their first language. For this phenomenological research study, it was important to reduce the research bias of interpretation of the data and results. In order to reduce researcher bias, although the primary researcher and two research assistants reflexively bracketed out our experiences and identities and background with the topic, and continuously engaged in critical self-reflection, openly acknowledging our biases and having debriefing and 11 0 reflective discussions, it is still possible that researcher biases influenced our analysis and conclusions in a way that was outside of our awareness. The analysis was ultimately within our thinking and choices and the write-up rested within my thinking and choices, as the primary researcher, meaning this study was limited by researcher subjectivity. COVID-19 Benefits and Challenges As a result of COVID-19, there were a few benefits and challenges of conducting this study due to altered interview formats. The format of conducting interviews for data collection was altered after this study was proposed, to online and phone interviews. Video was not used, recorded, or analyzed because not all participants had access to the same technology and to reduce bias. Engaging in phone interviews presented both benefits and challenges. One benefit was that participants did not have to arrange for transport to a venue for the interview. One challenge of phone interviews was that some participants with young children had to find their own childcare or take care of children during the interviews. Childcare would have been provided during the interviews if they had occurred in-person. Although research has shown some benefits to face-to-face interviews such as the observation of nonverbal data in addition to verbal data (Hiller & Diluzio, 2004), phone interviews have been shown to reduce interviewer effects by allowing for increased interviewer uniformity in delivery and standardization of questions (Shuy, 2003). Despite some possible disadvantages to phone interviews, this study benefitted from phone interviews due to increased access for participants and increased uniformity for researchers. 11 1 Recommendations and Implications Implications derived from the results of this study could enhance services provided by mental health professionals, service providers, and community organizations working with Latina immigrant women. Results highlighted recommendations from Latina immigrant women on how to improve mental health groups. The majority of the literature examining Latina immigrant women’s experiences in specific mental health support groups is conceptual (non-empirical) or is focused on quantifiable mental health outcomes (Comas-Diaz, 1985; Galano, et al., 2017; Kaltman et al., 2016). Few studies explore immigrant Latina women’s interactions with others and relational experiences in mental health groups (Castro, 2009; Marrs Fuchsel, 2014; Vargas-Willis & Cervantes, 1987). There is scant research on the meaning of Latina immigrant women’s experiences in mental health groups with other Latina immigrant women in a predominantly White community. Although immigrant Latina women have been demonstrated to express preference for individual therapy (Kaltman et al., 2016), there were multiple distinct elements of group psychotherapy that cannot be replicated in individual therapy. Groups may be an effective introduction to therapy for some Latina immigrant women. In this study, modeling and witnessing other women share their testimonio made it feel safer to share. Aligned with a psychological radical healing framework, mental health groups for only Latina immigrant women were important spaces due to the mutual empathy and collective identification that arose from Latina immigrant women’s unique and diverse experiences of disconnection and isolation, trauma, and discrimination. It is recommended that mental health groups are intentionally created with and for these 11 2 communities particularly in the context of a White majority areas and in the current sociopolitical climate of anti-immigration rhetoric and “crimmigration” policies (Stumpf, 2006) that can further marginalize and undermine stability and emotional wellness of Latinx immigrants (Chavez-Dueñas et al., 2019). Additionally, Spanish-speaking and culturally competent and humble facilitators were critical to creating safe spaces to share. Group facilitators need training in and understanding of immigration-related psychosocial stressors, barriers to mental health access, and effects of discrimination and trauma on mental health for immigrant women. Furthermore, facilitators should not only help in monitoring group members responses but should also be trained in trauma containment and emotion regulation strategies to reduce potential further re-traumatization or vicarious trauma through sharing of one’s testimonio. Previous research on mental health support groups for Latina immigrant women called for providers to be creative in incorporating service preferences for Latinxs in cost- efficient interventions (Kaltman et al., 2016). This study highlights that groups may serve as a viable and cost-efficient therapeutic intervention for Latina immigrant women. Policy makers could provide funding for initiatives to serve the mental health needs of Latina immigrant women through culturally competent and responsive mental health group services. Implications for Research Findings from the present study indicate the potential value of future research to explore the meaning of Latina immigrant women’s experiences in mental health groups in different demographic and geographic areas. Research should examine when Latina 11 3 immigrant women are most at-risk and needing social support and could most benefit from mental health group services. Additionally, researchers could examine differences in experiences in mental health groups for women depending on length of time they have been residing in the United States. It would also be important to take into account transnational connections and how often women are communicating and interacting with people in their countries of origin for social support (Viruell-Fuentes & Schulz, 2009). Research could include development of a measure reflecting the qualities of the groups that participants found effective (e.g., establishing safety with group norms, reflecting on cultural strengths, etc.) and examine if mental health groups characterized by these elements and experiences generate more benefits than those that are missing these elements. Scholars should continue to explore differences between groups and individual therapy for Latina immigrant women as group services could be a beneficial and viable alternative when agencies lack resources for individual therapy. Finally, findings from this study could aid policymakers with considerations of how to better support the mental health and wellbeing of Latina immigrant women through culturally responsive supports and services. Summary and Conclusion Immigrating to a new country presents with major challenges and stressors, among them potentially traumatic experiences and losses (Goodman et al., 2017). The loss of emotional and instrumental support is a common challenge for immigrants (Berger, 2013). Social isolation, or lack of social support, therefore, is a powerful contributing factor to poor mental health outcomes (Hurtado de Mendoza, et al., 2014; Menjívar, 2000). Latina immigrant women, especially those from Central America, have 11 4 lower levels of social support, report feeling lonely and isolated, and experience difficulties creating trustworthy and supportive relationships in their host country (Hurtado de Mendoza, et al., 2014; Menjívar, 2000). The available literature on Latina immigrant women accessing mental health groups is mainly focused on quantifiable outcomes. This study illuminates the experiences of Latina immigrant women in mental health groups in a largely majority White area of the country. This study contributes to a small but growing body of research about Latina women’s experiences in mental health groups. Unique contributions of this study include an understanding of the mechanisms and processes that made it safe to share in the group including developing rapport over time, learning from modeling by other group members, and a smaller more intimate group. Additionally, women experienced normalization and validation due to the collective identification of sharing testimonio with others of similar backgrounds, identities, and/or language in the groups, which although has been found in previous relational studies with immigrant Latina women (Vargas-Willis & Cervantes, 1987), is critical because of the context of living in a vastly majority White community and state. Another finding that adds to the minimal literature on Latina immigrant women’s patterns of relating to each other in mental health groups is that experiencing mutually empathic relationships provided participants with confidence to risk vulnerability in other relationships, strengthening outside support networks of support. Finally, this study brought a focus to the agency and autonomy of the participants in the study of defining their own healing process. 11 5 The findings from this study have important implications for improving culturally responsive mental health group services with Latina immigrant women, and for highlighting the importance of their contributions and their ideas of what is best for their own healing and empowerment. This dissertation study demonstrates the complex experiences of Latina immigrant women in mental health groups and illustrates the ways in which they can experience improved mental health outcomes, forge deep, meaningful, and growth-inducing relationships with others and with themselves, and engage in processes of healing. 11 6 APPENDIX A UNIVERSITY OF OREGON INSITUTIONAL REVIEW BOARD APPROVAL DATE: May 06, 2020 IRB Protocol Number: 04132020.014 TO: Darien Combs, Principal Investigator Department of UGS Accessible Education Center RE: Protocol entitled, “A Phenomenological Exploration of Immigrant Latina Women’s Experiences in Mental Health and Mutual Support Groups” Notice of Review and Exempt Determination The above protocol has been reviewed and determined to qualify for exemption. The research is approved to be conducted as described in the attached materials. Any change to this research will need to be assessed to ensure the study continues to qualify for exemption, therefore an amendment will need to be submitted for verification prior to initiating proposed changes. For this research, the following determinations have been made: • This study has been reviewed under the 2018 Common Rule and determined to qualify for exemption under Title 45 CFR 46.104(d)(2). Limited IRB review criteria were additionally determined to be satisfied. Contingencies: • Effective March 23, 2020, face-to-face interactions with human subjects are restricted unless a request is made by the investigator and approved by the UO Institutional Review Board (IRB) and the Office of the Vice President for Research (OVPRI). Investigators are permitted to conduct only those activities that can be facilitated remotely once the restriction takes effect. This restriction is in effect until changes are communicated by the OVPRI. See the OVPRI COVID-19 FAQs for Human Subject Research for the most up to date information and guidance for research teams and staying compliant during the current public health event. • The Spanish translated version of the consent form must be provided to RCS prior to use with subjects. Approval period: May 06, 2020 - May 31, 2021 If you anticipate the research will continue beyond the approval period, you must submit a Progress Report at least 45-days in advance of the study expiration. Without continued approval, the protocol will expire on May 31, 2021 and human subject research activities must cease. A closure report must be submitted once human subject research activities are complete. Failure to maintain current approval or properly close the protocol constitutes non-compliance. You are responsible for the conduct of this research and adhering to the Investigator Agreement as reiterated below. You must maintain oversight of all research personnel to ensure compliance with the approved protocol. The University of Oregon and Research Compliance Services appreciate your commitment to the ethical and responsible conduct of research with human subjects. Sincerely, Lizzy Utterback Research Compliance Administrator COMMITTEE FOR THE PROTECTION OF HUMAN SUBJECTS ● RESEARCH COMPLIANCE SERVICES 677 E. 12th Ave., Suite 500, 5237 University of Oregon, Eugene OR 97401-5237 T 541-346-2510 F 541-346-5138 http://rcs.uoregon.edu An equal-opportunity, affirmative-action institution committed to cultural diversity and compliance with the Americans with Disabilities Act 11 7 APPENDIX B RECRUITMENT FLYER IN ENGLISH AND SPANISH Have you participated in a women’s group in the community? Are you interested in sharing about your experience? ___________________________________________ The Meaning of Women's Groups ________________________ The purpose of this research study at the University of Oregon is to learn ways to better serve Latina immigrant women in mental health or support groups.        You are eligible to participate in this study if: You are at least 18 years old You identify as a woman who has immigrated from Latin America You have participated in a women's mental health or support group You are willing to participate in a 1.5 hour interview (via phone or Zoom)       For participation in the interview, you will receive a $30 gift card for your time. _______________________________________________ To learn more about the study, verify your criteria, and to make an appointment, please contact: Darien Combs (774) 343-1185 (Call or Text) dcombs@uoregon.edu 11 8 ¿Ha participado en un grupo de mujeres en la comunidad? ¿Le gustaría compartir acerca sus experiencias en el grupo? El Significado de Grupos de Mujeres ________________________ El objetivo de este investigación de la Universidad de Oregón es aprender modos para mejorar servicios de salud mental grupal para Latinas inmigrantes hispano hablantes. Usted califica para participar en la investigación si:      Usted tiene por lo menos 18 años. Usted se identifica como inmigrante Latina hispano hablante. Usted ha participado en un grupo de salud mental o de apoyo mutuo. Usted está dispuesta a participar en una entrevista de 1.5 horas (por teléfono o por Zoom).  *Para participar en la entrevista, se le dará una tarjeta de regalo de $30.00 como forma de agradecimiento. ____________________________________________ Para aprender más sobre la investigación, verificar su elegibilidad, y para hacer una cita, por favor llamé o mandé un mensaje a: Darien Combs (774) 343-1185 dcombs@uoregon.edu 11 9 APPENDIX C RECRUITMENT EMAIL IN ENGLISH AND SPANISH Greetings, My name is Darien Combs and I am a doctoral candidate in Counseling Psychology and the Spanish Language Psychological Services and Research Specialization at the University of Oregon. I previously co-led a women’s mental health support group at the Trauma Healing Project called Hablar es Sanar. I am writing to invite you or someone you know to participate in a study in which we will be discussing ways to better serve Latina immigrant women in mental health groups. Our aim is to explore and understand the experiences of Latina Spanish-speaking immigrant women who have participated in a mental health or mutual support groups. The research study seeks to understand: (a) your experience in mental health support group(s), (b) your experience with others in the group(s), and (c) the meaning of your experience in the group(s). You are eligible to participate in this study if you are at least 18 years old, you identify as a woman who has immigrated from Latin America, and you have participated in a mental health or mutual support group in the Eugene/Springfield community. If you decide to participate, you will be asked to participate in one 1.5 hour interview, which will be a conversation with me to discuss your experiences and suggestions. I will ask a series of questions and you will be encouraged to share your opinions. Due to COVID-19 safety regulations and the CDC’s recommendations, in order to protect your safety, interviews will occur over the phone or over Zoom depending on your access and preference. The interview will be audio recorded and transcribed, and we are taking the steps necessary to protect your confidentiality. I am happy to discuss and answer any questions you may have. If you decide to participate in this study, you will be provided with a $30.00 gift card. If you would like to participate or have any questions about the study, you can email me (dcombs@uoregon.edu) or call or text me at (774) 343-1185. Thank you and I hope you are taking care during this time! Warmly, Darien -- Darien Combs Doctoral Candidate in Counseling Psychology M.S., M.Ed. in Counseling, Family, and Human Services University of Oregon dcombs@uoregon.edu (774) 343-1185 Pronouns: she, her, hers 12 0 Saludos, Mi nombre es Darien Combs y soy una candidata doctoral en Consejería Psicológica con una Especialización de Servicios y Estudios Psicológicos en Español de la Universidad de Oregón. Anteriormente, yo co-facilité un grupo de apoyo y salud mental de mujeres en la organización del Proyecto de Sanar del Trauma (Trauma Healing Project) que se llamaba Hablar es Sanar. Estoy escribiéndole para invitarla a usted o alguien que le conoce a participar en una investigación en que vamos a discutir modos para mejorar servicios de salud mental grupal para Latinas inmigrantes hispano hablantes. Nuestro objetivo es explorar y entender las experiencias de Latinas inmigrantes hispano hablantes que hayan participado en un grupo de mujeres de salud mental o apoyo mutuo. La investigación va a explorar: (a) su experiencia en grupos de salud mental, (b) su experiencia con otros miembros del (los) grupo(s), y (c) el significado de su experiencia en el (los) grupo(s). Usted califica para participar en la investigación si usted es mayor de edad, usted se identifica como una mujer que ha inmigrado de América Latina, es hispano hablante, y ha participado en un grupo de salud mental o en un grupo apoyo mutuo en la comunidad de Eugene/Springfield. Si usted decide participar, usted tomará parte en una entrevista de 1.5 horas, que va a ser una conversación conmigo o con una otra investigadora para discutir sus experiencias y sugerencias. Por las regulaciones de seguridad y las recomendaciones del CDC, y para proteger su salud, las entrevistas serán por teléfono o por Zoom, dependiendo de su acceso y preferencia. La entrevista va a ser audio grabado y transcrito. Vamos a tomar los pasos necesarios para proteger su confidencialidad. Estoy feliz de hablar con usted y contestar cualquier pregunta que tenga. Si usted decide participar en el estudio, se le dará una tarjeta de regalo de $30.00 como forma de agradecimiento. Si usted le gustaría participar o si tiene preguntas sobre la investigación, puede mandarme un correo electrónico (dcombs@uoregon.edu) o llamarme o mandarme un mensaje al (774) 343-1185. Gracias y espero que se encuentren bien durante estos tiempos. Sinceramente, Darien Combs -- Darien Combs Candidata Doctoral en Consejería Psicológica M.S., M.Ed. en Servicios Consejerías de Familias y Humanos Universidad de Oregón dcombs@uoregon.edu (774) 343-1185 Pronombre: ella 12 1 APPENDIX D CONSENT FORM IN ENGLISH Consent for Research Participation Title: An Exploration of Immigrant Latina Women’s Experiences in Mental Health Support Groups Researcher(s): Darien Combs, M.S., M.Ed., University of Oregon Ellen H. McWhirter, Ph.D., University of Oregon Researcher Contact Info: 774.343.1185 dcombs@uoregon.edu You are being asked to participate in a research study. The box below highlights key information about this research for you to consider when making a decision whether or not to participate. Carefully consider this information and the more detailed information provided below the box. Please ask questions about any of the information you do not understand before you decide whether to participate. Key Information for You to Consider • Voluntary Consent. You are being asked to volunteer for a research study. It is up to you whether you choose to participate or not. There will be no penalty or loss of benefits to which you are otherwise entitled if you choose not to participate or discontinue participation. • Purpose. The purpose of this research is to address ways to better serve Latina immigrant women in mental health groups. This study seeks to explore and understand the experiences of Latina Spanish-speaking immigrant women who have participated in a mental health or mutual support groups. The research study seeks to understand: (a) your experience in mental health support group(s), (b) your experience with others in the group(s), and (c) the meaning of your experience in the group(s). • Duration. It is expected that your participation will last between sixty and ninety minutes for one interview. It is possible that we may contact you to answer follow-up questions via phone call. • Procedures and Activities. You will be asked to answer questions about what groups you have participated in, what you experiences have been in the group(s), what your experiences have been with others in the group(s), and the meaning of your experiences in the group(s). • Risks. Some of the foreseeable risks or discomforts of your participation include: o Loss of confidentiality (MINIMAL): We will minimize the risk of violation of confidentiality by using an ID number to mask identifiable information. All data will be maintained in locked storage and password protected storage so that risk of violation of confidentiality is minimal. 12 2 o Psychological risk (MINIMAL): You will be asked to share your experience in mental health support group(s), your experience with others in the group(s), your experience sharing with others in the group(s), and the meaning of your experience in the group(s). As a participant in this study, you have already attended mental health support groups. The risk to participating in this study is not greater than participating in one of these groups. • Benefits. You may or may not benefit from participating in this research. There are three possible research benefits to the participants including: (1) potential catharsis of reflecting on your experiences in mental health support groups, (2) being involved in identifying ways to better serve the needs of Latina immigrant women in mental health groups, and (3) receiving detailed information about all of the local nonprofit mental health support groups that currently serve Latina immigrant women. • Alternatives. Participation is voluntary and the only alternative is to not participate. Who is conducting this research? The researchers Darien Combs and Dr. Ellen H. McWhirter from the University of Oregon are asking for your consent to this research. Who is eligible? You are eligible to participate in this study if you are at least 18 years old, you identify as a woman who has immigrated from Latin America, and you have participated in a mental health or mutual support group in the community. Eligibility also requires that you are able participate in one semi-structured interviews. Eligibility also requires that you be willing to be audiotaped during the interview. About ten people will take part in this research. What happens if I agree to participate in this research? Your participation will include an interview with one of the researchers or research assistants about what groups you have participated in, what your experiences have been in the group(s), what your experiences have been with others in the group(s), and the meaning of your experiences in the group(s). In addition to your answers, we will ask you for demographic information such as your age, gender, country of origin, length of time in the United States, number of children, and annual estimated household income. Your participation in this research is voluntary. You can skip any question that makes you uncomfortable and you can stop the interview at any time. Interview questions will include questions such as: • What have been your experiences in the group(s)? • What were your experiences with other group members? • Have there been experiences in the group(s) that have been more meaningful to you? Due to COVID-19 safety regulations and the CDC’s recommendations, in order to protect your safety, interviews will occur over the phone or over Zoom depending on 12 3 your access and preference. All interviews will be audio recorded and transcribed. We may contact you to answer follow-up or clarification questions via a brief phone call. Research results will be available to you in the form of a report write-up and a brief summary of the research at http://tinyurl.com/gruposmujeres. You will be notified via text message once the results are available. Additionally, you will receive a $30 gift card at the end of the interview for participation in the research study. What happens to the information collected for this research? Information collected for this research will be used for a dissertation study and for possible publication. Identifiable information, such as your name, will not be included in any information at any time. How will my privacy and data confidentiality be protected? We will take measures to protect your privacy including conducting the interviews over the phone or Zoom in a confidential location. Despite taking steps to protect your privacy, we can never fully guarantee your privacy will be protected. This consent form will be provided at the beginning of the semi-structured interview via http://tinyurl.com/gruposmujeres. The semi-structured interview facilitator will review each section of the consent forms and answer any questions. If you agree to participate in the study, you will be asked to provide verbal consent. Audio recording will not begin until you have reviewed the informed consent and verbally consented to participate. The investigators will take measures to protect the security of all participants’ personal information including audio recordings and semi-structured interview notes. Investigators will ensure that the audio recordings and interview notes will have their ID code on them. The ID code list will not contain any participant names. ID numbers will be assigned to each participant and used in the transcripts in place of any real names used. The ID number will be connected to the semi-structured interview audio files, demographic data collected via a brief phone questionnaire, and any notes associated with the interview. For purposes of sending the gift card, you will be asked your preferred method (via email, text message, or mail), which will not be linked to your data. All data will be secured on a password-protected hard drive belonging to the PI. All written consent forms (if applicable) and any written notes will be store in a locked filing cabinet under double-lock. Despite these precautions to protect the confidentiality of your information, we can never fully guarantee confidentiality of all study information. The Institutional Review Board that monitors this research may be permitted access to and inspect the research records. This may include access to your private information. We protect your information from disclosure to others to the extent required by law. We cannot promise complete secrecy. You should understand that the researcher is not prevented from taking steps, including reporting to authorities, to prevent serious harm of yourself or others. The research team includes individuals who are mandatory reporters. If the research team has reasonable cause to suspect abuse or neglect of a child or adult, or that you may do 12 4 serious harm to yourself or others, a report may be required under Oregon State Law. In such a case, the research team may be obligated to breach confidentiality and may be required to disclose personal information. What if I want to stop participating in this research? Your participation in this study is voluntary. You can change your mind and stop at any time without penalty or loss of benefits to which you are otherwise entitled. Your decision whether or not to participate will not affect your relationship with the researchers or the University of Oregon. Will it cost me money to take part in this research? There is no financial cost to take part in this research. Will I be paid for participating in this research? For taking part in this research, you will be paid a total of $30 compensation in the form of a gift card at the end of the semi-structured interview. This may be considered taxable income. You will be provided this gift card via text, email, or mailing, depending on your preference. Who can answer my questions about this research? If you have questions, concerns, or have experienced a research related injury, contact: Darien Combs, M.S., M.Ed., University of Oregon 774.343.1185 (Text or Call in Spanish or English) dcombs@uoregon.edu An Institutional Review Board (“IRB”) is overseeing this research. An IRB is a group of people who perform independent review of research studies to ensure the rights and welfare of participants are protected. UO Research Compliance Services is the office that supports the IRB. If you have questions about your rights or wish to speak with someone other than the research team, you may contact: Research Compliance Services 5237 University of Oregon Eugene, OR 97403-5237 (541) 346-2510 STATEMENT OF CONSENT I have had the opportunity to read and consider the information in this form. I have asked any questions necessary to make a decision about my participation. I understand that I can ask additional questions throughout my participation. I understand that with my oral consent, I volunteer to participate in this research. I understand that I am not waiving any legal rights. I have been provided with a copy of this consent form through the website link provided to me and can be mailed a paper copy if I prefer. I understand that if my ability to consent or assent for myself changes, either I or my legal representative may be asked to reconsent prior to my continued participation in this study. As described above, you will be audio recorded while performing the activities described above. Recordings will be used for data analysis only and for inclusion of quotes in written materials. 12 5 • Please verbally consent if you consent to the use of audio recording as described. ________ Adult participant has verbally agreed to the use of audio recording. • Please verbally consent if you consent to participate in the interview. ________ Adult participant has verbally agreed to participation in the interview. • Once the recording has begun, please verbally state your consent if you consent to participating in this interview. ________ Adult participant has verbally re-stated agreement to participate in the interview. Researcher Signature (to be completed at time of informed consent) I have explained the research to the participant and answered all of his/her questions. I believe that he/she understands the information described in this consent form and freely consents to participate. Name of Research Team Member Signature of Research Team Member Date 12 6 CONSENT FORM IN SPANISH Consentimiento para participar en la investigación Título: Una exploración de las experiencias de mujeres inmigrantes latinas en grupos de apoyo de salud mental Investigadoras: Darien Combs, M.S., M.Ed., University of Oregon Ellen H. McWhirter, Ph.D., University of Oregon Información para contactar las investigadoras: 774.343.1185 dcombs@uoregon.edu Se le pide que participe en un estudio de investigación. El cuadro a continuación destaca la información clave sobre este estudio para que la tome en cuenta al tomar la decisión de participar o no. Considere esta información y la información más detallada que se proporciona debajo del cuadro. Haga preguntas sobre cualquier información que no comprenda antes de decidir si desea participar. Información clave para considerar • Consentimiento voluntario. Se le pide que sea voluntaria para un estudio de investigación. Depende de usted si elige participar o no. No habrá penalidad o pérdida de los beneficios, a los que tiene derecho, si elige no participar o suspender la participación. • Propósito. El propósito de esta investigación es identificar formas de mejorar servicios de salud mental grupal para mujeres inmigrantes Latinas. Este estudio busca explorar y comprender las experiencias de mujeres inmigrantes latinas hispano hablantes que han participado en grupos de salud mental o de apoyo mutuo. El estudio de investigación busca comprender: (a) su experiencia en grupos de apoyo de salud mental, (b) su experiencia con otras mujeres en el grupo, y (c) el significado de su experiencia en el grupo. • Duración. Se espera que su participación dure entre sesenta y noventa minutos para una entrevista. Es posible que nos comuniquemos con usted para responder preguntas de seguimiento a través de una llamada telefónica. • Procedimientos y actividades. Se le pedirá que responda a preguntas sobre en qué grupos ha participado, qué experiencias ha tenido en los grupos, cuáles han sido sus experiencias con otros en el grupo y el significado de sus experiencias en el grupo. • Riesgos. Algunos de los riesgos posibles de su participación incluyen: o Pérdida de confidencialidad (MÍNIMA): minimizaremos el riesgo de violación de la confidencialidad mediante el uso de un número de identificación para enmascarar la información identificable. Todos los datos se mantendrán en un 12 7 almacenamiento bloqueado y protegido con contraseña para que el riesgo de violación de la confidencialidad sea mínima. o Riesgo psicológico (MÍNIMO): se le pedirá que comparta su experiencia en grupos de apoyo de salud mental, su experiencia con otras mujeres en el grupo, su experiencia compartiendo con otras mujeres en el grupo y el significado de su experiencia en el grupo. Como participante en este estudio, usted ya asistió a grupos de apoyo de salud mental. El riesgo de participar en este estudio no es mayor que participar en uno de estos grupos. • Beneficios. Puede o no beneficiarse de participar en esta investigación. Hay tres beneficios posibles de la investigación para las participantes que incluyen: (1) catarsis potencial de reflexionar sobre sus experiencias en grupos de apoyo de salud mental, (2) participar en la identificación de formas de atender mejor las necesidades de las mujeres inmigrantes latinas en grupos de salud mental, y (3) recibir información detallada sobre todos los grupos locales de apoyo de salud mental sin fines de lucro que actualmente atienden a mujeres inmigrantes Latinas. • Alternativas. La participación es voluntaria y la única alternativa es no participar. ¿Quién está llevando a cabo esta investigación? Las investigadoras Darien Combs y la Dra. Ellen H. McWhirter de la Universidad de Oregón solicitan su consentimiento para esta investigación. ¿Quién está calificada? Usted es calificada para participar en esta investigación si tiene al menos 18 años, se identifica como una mujer que ha inmigrado de América Latina y ha participado en un grupo de salud mental o de apoyo mutuo en la comunidad. También requerimos que pueda participar en una entrevista semiestructurada y que esté dispuesta a ser audio grabada durante la entrevista. Alrededor de diez personas participarán en esta investigación. ¿Qué sucede si acepto participar en esta investigación? Su participación incluirá una entrevista con una de las investigadoras o asistentes de investigación las cuales le harán preguntas acerca de grupos que a participado, sus experiencias en los grupos, sus experiencias con otras personas en los grupos y el significado de sus experiencias en el grupo. Además de sus respuestas, le pediremos información demográfica como su edad, genero, país de origen, tiempo en los Estados Unidos, número de hijos, e ingresos familiares anuales estimados. Su participación en esta investigación es voluntaria. Puede omitir cualquier pregunta que la incomode y puede parar la entrevista en cualquier momento. Las preguntas de la entrevista incluirán preguntas como: • ¿Cuáles han sido sus experiencias en los grupos? • ¿Cuáles fueron sus experiencias con otras mujeres del grupo? • ¿Ha habido experiencias en los grupos que han sido más impactantes para usted? 12 8 Debido a las regulaciones de seguridad de COVID-19 y las recomendaciones del CDC, para proteger su seguridad, se realizarán entrevistas por teléfono o por Zoom, según su acceso y preferencia. Todas las entrevistas serán audio grabadas y transcritas. Pueda que después de la entrevista, le contactemos a través de una breve llamada telefónica para clarificar dudas o dar seguimiento a respuestas previamente dadas. Los resultados de la investigación estarán disponibles para usted en forma de un informe escrito y un breve resumen de la investigación en http://tinyurl.com/gruposmujeres. Se le notificará por mensaje de texto una vez que los resultados estén disponibles. Además, recibirá una tarjeta de regalo de $30.00 al final de la entrevista como un gesto de agradecimiento por su participación en el estudio de investigación. ¿Qué sucede con la información recogida para esta investigación? La información recogida para esta investigación se utilizará para un estudio de tesis y para una posible publicación. La información identificable, como su nombre, no se incluirá en ninguna información en ningún momento. ¿Cómo se protegerá mi privacidad y confidencialidad de datos? Tomaremos medidas para proteger su privacidad, incluyendo la acumulación de entrevistas por teléfono o Zoom en una ubicación confidencial. A pesar de tomar medidas para proteger su privacidad, nunca podemos garantizar por completo que su privacidad estará protegida. Este formulario de consentimiento se le dará al comienzo de la entrevista semiestructurada a través de http://tinyurl.com/gruposmujeres. La facilitadora de la entrevista semiestructurada revisará cada sección de los formularios de consentimiento y responderá cualquier pregunta. Si acepta participar en el estudio, se le pedirá que brinde su consentimiento oral. La grabación de audio no comenzará hasta que haya revisado el consentimiento informado y haya aceptado verbalmente participar. Las investigadoras tomarán medidas para proteger la seguridad de la información personal de todos los participantes, incluidas grabaciones de audio y apuntes de entrevistas semiestructuradas. Se asignarán números de identificación a cada participante y se utilizarán en las transcripciones en lugar de utilizar los nombres reales. Las investigadoras se asegurarán de que las grabaciones de audio y las notas de la entrevista tengan su código de identificación. La lista de códigos de identificación no contendrá ningún nombre de participantes. El número de identificación se conectará a los archivos de audio de la entrevista semiestructurada, los datos demográficos recopilados a través de un cuestionario breve telefónico y cualquier apunte asociada con la entrevista. Para enviar la tarjeta de regalo, se le preguntará cuál es su método preferido (por correo electrónico, mensaje de texto o correo), que no estará vinculado a sus datos. Todos los datos estarán protegidos en un disco duro protegido por contraseña que pertenece al PI. Todos los formularios de consentimiento por escrito (si corresponde) y las notas escritas se almacenarán en un archivador cerrado con doble candado. La Junta de Revisión Institucional (IRB) que monitorea esta investigación puede tener acceso e inspeccionar los registros de la investigación. Esto puede incluir el acceso a su 12 9 información privada. Protegemos su información de la divulgación a otros en la medida requerida por la ley. No podemos prometer un secreto completo. Debe comprender que no se impide que el investigador tome medidas, incluida la presentación de informes a las autoridades, para evitar daños graves a usted u otros. El equipo de investigación incluye individuas que son denunciantes obligatorios de abusos a menores y personas mayores. Si el equipo de investigación tiene una causa razonable para sospechar abuso o negligencia de un niño o un adulto mayor, o si usted puede hacerse un daño grave a usted misma o a otros, es posible que se requiera un informe según la Ley del Estado de Oregón. En tal caso, el equipo de investigación puede estar obligado a violar la confidencialidad y puede ser obligado a revelar información personal. ¿Qué pasa si quiero dejar de participar en esta investigación? Su participación en este estudio es voluntaria. Puede cambiar de opinión y parar en cualquier momento sin penalización o pérdida de los beneficios a los que tiene derecho. Su decisión de participar o no, no afectará su relación con las investigadoras o la Universidad de Oregón. ¿Me costará dinero participar en esta investigación? No hay ningún costo financiero para participar en esta investigación. ¿Me pagarán por participar en esta investigación? Por participar en esta investigación, se le pagará un total de $30.00 de compensación en forma de una tarjeta de regalo al final de la entrevista semiestructurada. Esto puede considerarse ingreso imponible. Se le proporcionará esta tarjeta de regalo por mensaje de texto, correo electrónico o correo postal, según su preferencia. ¿Quién puede responder mis preguntas sobre esta investigación? Si tiene preguntas, inquietudes o una experiencia negativa relacionada con la investigación, comuníquese con: Darien Combs, M.S., M.Ed., University of Oregon (774) 343-1185 (Llamadas o mensajes de texto en español o en inglés) dcombs@uoregon.edu Una Junta de Revisión Institucional ("IRB") está supervisando esta investigación. Un IRB es un grupo de personas que realiza una revisión independiente de los estudios de investigación para garantizar la protección de los derechos y el bienestar de los participantes. UO Research Compliance Services es la oficina que respalda al IRB. Si tiene preguntas sobre sus derechos o desea hablar con alguien que no sea el equipo de investigación, puede comunicarse con: Research Compliance Services 5237 University of Oregon Eugene, OR 97403-5237 (541) 346-2510 13 0 DECLARACIÓN DE CONSENTIMIENTO He tenido la oportunidad de leer y considerar la información en este formulario. He hecho las preguntas necesarias para tomar una decisión. Entiendo que puedo hacer preguntas adicionales durante mi participación. Entiendo que con mi consentimiento oral, soy voluntaria para participar en este estudio. Entiendo que no renuncio a ningún derecho legal. Se me ha proporcionado una copia de este formulario de consentimiento a través del enlace del sitio web que se me proporcionó y se me puede enviar una copia en papel si lo prefiero. Entiendo que si mi capacidad de consentir o asentir por mí mismo cambia, se me puede pedir a mí o a mi representante legal que se retiren antes de continuar participando en este estudio. Como se describió anteriormente, las entrevistas serán audio grabadas. Las grabaciones se utilizarán solo para el análisis de datos y para la inclusión de sus respuestas directas en materiales escritos. • Por favor, consienta verbalmente si consiente al uso de la grabación de audio y participación como se describe. ________ La participante ha aceptado verbalmente el uso de la grabación de audio. • Por favor, consienta verbalmente su consentimiento si acepta participar en esta entrevista. ________ La participante ha aceptado verbalmente a participar en la entrevista. • Una vez que la grabación ha comenzado, declare verbalmente su consentimiento si acepta participar en esta entrevista. ________ La participante ha expresado otra vez verbalmente su consentimiento para participar en la entrevista. Firma del investigador (debe completarse en el momento del consentimiento informado) Le expliqué la investigación al participante y respondí a todas sus preguntas. Creo que ella entiende la información descrita en este formulario de consentimiento y acepta libremente participar. Nombre del miembro del equipo de investigación Firma del miembro del equipo de investigación Fecha 13 1 APPENDIX E DEMOGRAPHIC INFORMATION QUESTIONAIRE Demographic Information 1. How do you identify your gender? o Female o Male o Additional gender category/identity (ex: Trans woman, Nonbinary Twospirited): please specify ___________________________ o Prefer not to disclose 2. What is your age? 3. How do you identify your race and ethnicity? o Latina/x o White o Black or African descent o Indigenous/Native o Asian o Two or more o An identity not listed (ex: Afro-Latinx): please specify ____________________________ 4. How do you identify your sexual orientation? o Heterosexual (straight) o Gay o Bisexual o Lesbian o Queer o Questioning or unsure o An identity not listed: please specify ____________________________ o Prefer not to disclose 5. What is your country of origin? 6. How long have you lived in the United States? 7. What is your current or most recent occupations? 8. What is your marital status? o Single o Married o Divorced o Widowed 13 2 o Other:__________ 9. Do you have children? If so, how many? What are their ages? 10. How many years of schooling did you complete in or outside of the United States? o Primary or less o Secondary o Bachelor’s degree o Master’s degree o PhD 11. What is your annual estimated household income? o 0,000 -19,000 o 19,001- 25,000 o 25,001- 50,000 o 50,000 – 75,000 o 75,000 or more 12. How many people live in your home or are supported by this income? 13. Which women’s mental health or mutual support groups in the community have you participated in? When and for how long (about how many sessions) did you attend each group? o [Group Name 1] o [Group Name 2] o [Group Name 3] o [Group Name 4] o Other group in other location or in country of origin: please specify________ 13 3 REFERENCES CITED Abraído-Lanza, A. F., Vásquez, E., & Echeverría, S. E. (2004). En las manos de dios [in God’s hands]: Religious and other forms of coping among Latinos with arthritis. Journal of Consulting and Clinical Psychology, 72(1), 91–102. https://doi.org/10.1037/0022-006X.72.1.91 Adames, H. Y., & Chavez-Dueñas, N. Y. (2016). Cultural foundations and interventions in Latino/a mental health: History, theory and within group differences. Routledge. Alegría, M., Chatterji, P., Wells, K., Cao, Z., Chen, C., Takeuchi, D., Jackson, J., & Meng, X.-L. (2008). Disparity in depression treatment among racial and ethnic minority populations in the United States. Psychiatric Services, 59(11), 1264– 1272. https://doi.org/10.1176/ps.2008.59.11.1264 Alvidrez, J. (1999). 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