Clinical Gerontologist
ISSN: 0731-7115 (Print) 1545-2301 (Online) Journal homepage: https://www.tandfonline.com/loi/wcli20
Vida Calma: CBT for Anxiety with a SpanishSpeaking Hispanic Adult
Katherine Ramos, Jose Cortes, Nancy Wilson, Mark E. Kunik & Melinda A.
Stanley
To cite this article: Katherine Ramos, Jose Cortes, Nancy Wilson, Mark E. Kunik & Melinda A.
Stanley (2017) Vida Calma: CBT for Anxiety with a Spanish-Speaking Hispanic Adult, Clinical
Gerontologist, 40:3, 213-219, DOI: 10.1080/07317115.2017.1292978
To link to this article: https://doi.org/10.1080/07317115.2017.1292978
Published online: 03 Mar 2017.
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CLINICAL GERONTOLOGIST
2017, VOL. 40, NO. 3, 213–219
http://dx.doi.org/10.1080/07317115.2017.1292978
NEW AND EMERGING PROFESSIONALS
Vida Calma: CBT for Anxiety with a Spanish-Speaking Hispanic Adult
Katherine Ramos, PhDa,b, Jose Cortes, BAc,d, Nancy Wilson, MA, MSWc,d, Mark E. Kunik, MD, MPHd,c,e,
and Melinda A. Stanley, PhDd,c,e
a
Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA; bDuke University,
Durham, North Carolina, USA; cBaylor College of Medicine, Houston, Texas, USA; dMichael E. DeBakey VA Medical Center, Houston, Texas,
USA; eVA South Central Mental Illness Research, Education and Clinical Center, USA
ABSTRACT
KEYWORDS
Background: Hispanic adults aged 55 years and older are the fastest growing ethnic minority group
in the United States facing significant mental health disparities. Barriers in accessing care have been
attributed to low income, poor education, language barriers, and stigma. Cultural adaptations to
existing evidence-based treatments have been encouraged to improve access. However, little is
known about mental health treatments translated from English to Spanish targeting anxiety among
this Hispanic age group.
Objctive: This case study offers an example of how an established, manualized, cognitive-behavioral
treatment for adults 55 years and older with generalized anxiety disorder (known as “Calmer Life”) was
translated to Spanish (“Vida Calma”) and delivered to a monolingual, Hispanic 55-year-old woman.
Results: Pre- and post-treatment measures showed improvements in symptoms of anxiety, depression, and life satisfaction.
Conclusion: Findings suggest Vida Calma is a feasible treatment to use with a 55-year-old Spanishspeaking adult woman.
Clinical Implications: Vida Calma, a Spanish language version of Calmer Life, was acceptable and
feasible to deliver with a 55-year-old participant with GAD. Treatment outcomes demonstrate that
Vida Calma improved the participant’s anxiety, depression, and life satisfaction.
Anxiety; case reports; cognitive-behavior therapy;
Hispanic adults
Introduction
Hispanic adults (aged 55 years and older) are the
fastest growing ethnic minority group in the United
States, with fewer than 24% initiating mental health
treatment when needed (Jimenez, Cook, Bartels, &
Alegría, 2013). Low mental health care access and
utilization in this population presents a significant
health disparity (Barrio et al., 2008). Contributors to
limited access include low income, poor education,
language barriers, and cultural stigma (Aranda &
Lincoln, 2011; Hansen & Aranda, 2012). Limited
English proficiency, in particular, is associated with
poorer access to healthcare (DuBard & Gizlice, 2008)
and increased risk for psychological distress (Kim
et al., 2011).
Hispanic adults who are 55 years old or older,
second to non-Hispanic whites, have the highest lifetime prevalence for mood (13.9%) or anxiety disorders (15.2%) compared with other minority groups
(Woodward et al., 2012). One-year prevalence data
show similar trends; for example, among Hispanic (in
the age category of 55+) having a past-year mood
disorder is 9.48% and for an anxiety disorder it is
13.59%
(Reynolds,
Pietrzak,
El-Gabalawy,
Mackenzie, & Sareen, 2015). Generalized anxiety disorder (GAD) is the most common psychiatric condition among Hispanics over 55 years of age, with a
lifetime prevalence of 6.2% (Woodward et al., 2012).
Interventions designed to improve mental health
access for Hispanic adults over 55 have targeted
depression (Areán et al., 2005; Ell et al., 2010;
Hinton & Areán, 2008), but interventions have yet
to address anxiety in this age group. In a randomized
control trial across four different clinic sites,
Cognitive-behavioral therapy (CBT) was found effective for younger Hispanic adults with panic disorder,
GAD, social anxiety disorder or posttraumatic disorder (PTSD) (Chavira et al., 2014); although treatment
was most effective for individuals who are primarily
English-speaking and more acculturated.
CONTACT Katherine Ramos, PhD
Katherine.Ramos@va.gov
GRECC (182), Durham VA Medical Center, 508 Fulton Street, Durham, NC 27705, USA.
Color versions of the figure in the article can be found online at www.tandfonline.com/wcli.
This article is not subject to U. S. copyright law.
214
K. RAMOS ET AL.
Among adults aged 55 years and older with GAD,
CBT demonstrates significant reductions in anxiety
symptoms relative to waitlist conditions or usual care
(Gonçalves & Byrne, 2012; Gould, Coulson, &
Howard, 2012, 2014; Stanley et al., 2009; Thorp
et al., 2009). CBT for late-life GAD showed positive
effects (e.g., improvement in GAD severity and
reduced symptoms of depression) among ethnic and
racial minorities, mostly African Americans (Stanley
et al., 2016), but research has yet to examine outcomes
with Spanish-speaking Hispanic adults over 55 years
of age. This case study describes the implementation
of an established manualized CBT for GAD known as
“Calmer Life” for a Spanish-speaking 55-year old
adult woman. The Spanish-language version of the
intervention is called “Vida Calma.” Outcomes of
interest included generalized anxiety, depression,
insomnia, and life satisfaction. Exit interview feedback, number of sessions and completed home practice assignments were used to evaluate feasibility and
acceptability of treatment.
Case Study
Calmer Life Program Overview and Spanish
Adaptation
Calmer life is a 3-month (up to 12 sessions) modular
CBT targeting GAD symptoms. Delivery method is
flexible, with the first two to three sessions completed
in-person and the remainder delivered either in-person or by telephone. Three initial sessions address
anxiety awareness, diaphragmatic breathing, and use
of calming statements. Participants subsequently
select five elective modules covering exposure, behavioral activation, relaxation skills, problem solving and
cognitive re-structuring. Community resources to
address basic needs/personal care are offered and discussed with the participant. Unique to this intervention is the option to include religious/spiritual (R/S)
beliefs. Previous participants have expressed satisfaction with attention to R/S beliefs in treatment, and
preliminary outcomes from the English-language version are positive (Shrestha et al., 2012; Stanley et al.,
2016).
Translation of Calmer Life to Vida Calma involved
a three-stage process. First, a professional translation
service was used to translate two treatment manuals
(one R/S-based, the other secular) and a provider
manual. The primary author (KR), fluent in Spanish,
worked closely with the service. Of note, session content of the English version of Calmer Life is at an 8th
grade reading level. However, for Vida Calma, session
content was translated to a sixth-grade reading level to
align with state data and education-level guidelines
among the Hispanic community living in an urban
city in the Southern U.S. (Department of Health and
Human Services, and Hispanic Health Coalition,
2013). Second, upon receipt of translated materials,
the first author (KR), together with a bilingual consumer and bilingual Master’s-level provider (who
subsequently served as an independent evaluator for
pre- and post-intervention measures), reviewed treatment content and addressed discrepancies in language use. Third, (KR) secured Spanish versions of
diagnostic and pre- and post-treatment measures,
including the Structured Diagnostic Interview for
the Diagnostic Statistical Manual of Mental
Disorders, Fourth Edition (SCID; American
Psychiatric Association, 1994), Generalized Anxiety
Disorder scale (GAD-7; García-Campayo et al.,
2010; Spitzer, Kroenke, Williams, & Löwe, 2006),
Patient Health Questionnaire (PHQ-8; Kroenke
et al., 2009), Insomnia Severity Index (ISI;
Fernandez-Mendoza et al., 2012; Morin, 1993),
and the Satisfaction with Life scale (SWLS;
Diener, Emmons, Larsen, & Griffin, 1985). The
lead author translated an exit interview used in
prior English-language studies (Shrestha et al.,
2012; Stanley et al., 2016), and trained the
Master’s-level provider to deliver baseline and
posttreatment measures. The exit interview contained detailed questions comprising four main
areas: (a) personal experiences about participating in the program (e.g., having the option to
add R/S to the Vida Calma skills; helpful and
least useful components of the program, satisfaction with number of sessions received, and suggestions to improve the program), (b) personal
use of the Vida Calma skills, (c) satisfaction with
service delivery locale or format (e.g., having
sessions offered at home, a partner site or via
telephone), and (d) general experiences with the
Vida Calma provider, overall satisfaction with
the program, and confidence in continued used
of the Vida Calma skills.
CLINICAL GERONTOLOGIST
Participant Demographic Information
Initial Assessment
Lucia was friendly and pleasant but presented with
an anxious disposition. She reported experiencing
anxiety all her life, with worsened symptoms in the
last 2 years. Lucia denied specific precipitating factors, although she endorsed continued arduous work
hours and changes in physical health and stamina as
contributing factors to her worry. Her baseline
symptoms met criteria for GAD and Major
Depressive Disorder (MDD), as assessed by the
SCID. She denied needing resources for basic
needs. In the past 6 months, she reported feeling
restless, irritable, and tense. She often tired easily
and had difficulty focusing, and trouble falling and
staying asleep. She endorsed moderate symptoms of
worry and anxiety regarding minor matters, work,
finances, social relationships, and personal health.
Lucia worried about her financial stability (subsequently perpetuating low mood), her declining physical health (e.g., chronic pain, reduced mobility for
heavy lifting and undesired weight gain), and feeling
overwhelmed by daily errands/tasks. At the start of
treatment, she also expressed sadness, tearfulness,
decreased interest in previously enjoyed activities,
and worry over her friend’s terminal illness.
During the pretreatment assessment, Lucia scored
in the moderately severe to severe range on measures
of anxiety (GAD-7 = 15) and depression (PHQ8 = 16). She scored in the subthreshold range for
35
30
25
Scores
Lucia was a 55-year-old Hispanic female native of
South America who immigrated to the United States
in her thirties. She was living with her only adult son
during participation. She was divorced for the last
15 years from a verbally and physically abusive exhusband who she reported suffered from severe
alcohol abuse. Lucia worked fulltime as a housemaid
and provided weekend caregiving to older adults as a
volunteer. She also ran a support group for victims of
domestic violence at her local church. Lucia denied
any prior anxiety treatment (and denied clinically
significant symptoms of PTSD related to previous
abuse). She was not taking any medications. Lucia
self-referred to the intervention after attending a
community outreach presentation.
215
20
Baseline
15
3 Month
10
5
0
GAD
PHQ
ISI
SWLS
Assessment Measures
Figure 1. Treatment outcome scores. This figure illustrates
Assessment scores of anxiety, depression insomnia, and life satisfaction at baseline and three-month follow-up. (Generalized
Anxiety Disorder Scale [GAD-7; Range 0–21]), depression (Patient
Health Questionnaire-8 [PHQ-8; Range 0–24]), sleep (Insomnia
Severity Index [ISI; Range 0–28]), and life satisfaction
(Satisfaction With Life Scale [SWLS; Range 5–35]). Note, higher
scores for GAD, PHQ, and ISI = higher severity in symptoms. Higher
scores in SWLS = higher life satisfaction.
insomnia (ISI = 14) and in the average range for life
satisfaction (SWL = 22) (see Figure 1).
Module Selection
The therapist provided appropriate recommendations for CBT modules, using a protocol algorithm
based on the English version of Vida Calma
(Shrestha et al., 2012). This algorithm used baseline
scores to guide provider recommendations and collaborative decision-making about elective skills.
Lucia began treatment with core skills addressing
anxiety awareness, deep breathing, and calming
thoughts. Lucia then chose the following elective
skills: changing behavior to manage depression, problem solving and learning to relax (this last skill
could not be completed due to participant time constraints). To accommodate Lucia’s schedule and
access to treatment, she completed all sessions
(except two) by phone.
Inclusion of Religious Affiliation Into Treatment
Lucia identified as Catholic. She grew up with a
strong religious faith and belief in a higher power.
She was active in her church community and often
used her religion as a source of comfort. Lucia chose
to include her religious beliefs in treatment.
216
K. RAMOS ET AL.
Session Descriptions and Treatment
Sessions 1 and 2
Session 1 focused on anxiety awareness and a discussion of Lucia’s life values, treatment goals, and motivation for change. Her life values included being a
good person (e.g., caring for a friend diagnosed with
cancer), caring for her health and well-being, having
financial stability, and good quality of life. The first
session provided psychoeducation around anxietyrelated thoughts, behaviors and physical symptoms,
and the option of including spirituality in treatment.
A list of community resources was also provided.
Session 2 included assessment of Lucia’s beliefs
about Catholicism. She exhibited a strong belief in
God and viewed the Catholic church as a safe haven
from difficult life circumstances. From her R/S perspective, it was also important that Lucia treat others
with compassion and empathic understanding.
Lucia, active in her church, attended weekly service
and prayed daily. She consistently prayed to God for
“help and bravery” to overcome difficult obstacles in
her life related to her health concerns (e.g., reducing
pain and losing weight) and financial security. Lucia
enjoyed reading the Bible with selected verses that
she perceived help answer her prayers.
During Session 2, Lucia learned diaphragmatic
breathing. She was encouraged to focus on a spiritual word or image while practicing. Lucia chose the
words Dios Mio!, meaning “My God!” in English.
This phrasing aligned with Lucia’s special connection and relationship with a higher power. She
found this skill helpful when she worried about
her friend’s declining health and as another source
of connecting to God.
Session 3
Lucia was introduced to calming statements to
decrease the effects of anxiety. In this skill, participants can choose a combination of both spiritual
and nonspiritual statements. Lucia identified the
following statements: “I can do what I have to do
in spite of my worry or stress,” and “My worry or
stress won’t hurt me.” A specific spiritual statement chosen by Lucia was: “I am thankful to God
for this opportunity to grow for myself.”
Lucia’s friend passed away the week prior, and
she used breathing techniques for comfort while
attending the funeral. As she practiced calming
statements in session, she also offered examples
of when she could utilize the skill. For example,
Lucia later described using calming statements to
reduce anxiety when organizing church events and
when needing to assert her opinions on personally
important matters.
Sessions 4 and 5
These two sessions addressed behavioral activation
for depression. Lucia experienced greater severity in
depressive symptoms as her financial situation worsened. Given her need to secure additional jobs,
self-care became increasingly limited. She worried
about having time to accomplish daily tasks and
hobbies. Additionally, Lucia often wondered
whether seeking treatment was “too self-focused
and selfish.” These anxieties increased her depression, fatigue, sleep disturbance, and social isolation.
Lucia also had decreased appetite, discontinued
social gatherings (e.g., eating with friends, music
concerts), and found less pleasure in previously
enjoyed hobbies. The therapist and Lucia discussed
the link between her lower mood and decreased
frequency of pleasant activities. Afterward, Lucia
was encouraged to consider activities she could
pursue to improve her mood. Illustratively, she
was encouraged to attend church and community
events. When she followed through, she noticed
improvements in her mood and anxiety.
During Session 5, Lucia reported cooking for herself, attending church more frequently and walking
for exercise and relaxation. She also began discussions about life-meaning and her future. For example, Lucia discussed having interest in completing
her GED and wanting to prioritize her time to feel
better. She initiated reading the Bible with greater
frequency, practicing yoga, and eating out with
friends. Lucia found behavioral activation skills helpful. Her participation in pleasant events subsequently
translated to improvements in her time management
and boundary-setting with work and church commitments. Lucia shared relying on calming statements and diaphragmatic breathing while
envisioning images of “God” or “Jesus” as motivators
for behavior change.
Sessions 6 and 7
Session 6 focused on problem solving. In this session, Lucia learned about the effects of stress,
CLINICAL GERONTOLOGIST
worry and anxiety on her ability to identify/solve
problems in daily-living. She also learned steps to
identify a problem, consider all viable solutions,
and then decide and choose a course of action.
Lucia identified household activities (gardening)
she was unable to complete due to time constraints. She listed possible solutions such as asking someone for help and/or paying for gardening
services. For each possible solution, Lucia offered
examples of advantages and disadvantages.
Regarding gardening, Lucia decided to take time
after work to plant flowers she always wanted in
her backyard. She developed action plans with
times, days of the week, and frequency that she
could dedicate to her efforts. She also desired to
keep her home cleaner than its current state, and
she decided to prioritize the rooms she would like
cleaned first and created an organized chore list to
maintain her efforts. Throughout, Lucia presented
with a determined and resourceful outlook. Lucia
was also encouraged to consider using previously
learned skills as coping resources in her problemsolving activities.
Session 7 served as a summary and review of
completed Vida Calma skills. This session also
provided Lucia with opportunities to discuss
future anxiety-provoking situations and the skills
she would use to reduce her anxiety. Examples
included use of deep breathing during social
events with large crowds and calming statements
when feeling financially stressed.
217
perceiving others noticing her sleep difficulties were
impairing her quality of life (2-point increase). A
possible explanation for an increase in insomnia
symptoms could be her continued anxiety about
finances. During her participation in treatment, financial stability was a consistent source of anxiety that
may have worsened for Lucia due to unanticipated
work shift changes and pay cuts. Overall, however,
Lucia experienced and recognized positive changes in
her life and her ability to self-soothe when anxious or
distressed.
Exit Interview
Lucia highly regarded her participation with Vida
Calma. In particular, she deeply appreciated including her R/S beliefs in treatment. She also expressed
that continued practice of the Vida Calma skills
afforded her personal growth (e.g., efficacy and
patience in making better decisions around work–
life balance), and relaxation by using deep breathing
and calming statements, in addition to flexibility in
daily living by using her problem-solving skills (e.g.,
managing her time for self-care while also completing needed household responsibilities). Moreover,
by engaging in pleasant events (i.e., behavioral activation), her overall mood improved and feelings of
depression significantly decreased. In her own
words, Lucia rated the program as “very helpful”
and mentioned feeling “very sure” that she would
continue to use the skills in the future.
Assessment and Outcomes
Discussion
At 3 months, Lucia responded to the same baseline
measures. Lucia’s assessment scores are presented in
Figure 1. By 3 months, Lucia reported meaningful
improvements in anxiety and depression.
Specifically, her symptoms were below the clinical
threshold for mild anxiety (GAD-7 = 5); her depression symptoms (PHQ-8 = 5); decreased from severeto-mild severity levels. Lucia also reported improved
life satisfaction (SWLS = 30), though she endorsed an
increase in insomnia symptoms (ISI = 19, raw change
of 4+ points from pre- to post-intervention). Upon
further review, specific symptoms that led an increase
in pre- to post-treatment scores on the ISI included:
waking up too early (1-point increase), dissatisfaction
with current sleep patterns (2-point increase), and
This case study describes successful implementation
of Vida Calma, a manualized intervention for the
treatment of GAD for a 55-year-old Spanish-speaking adult. The intervention was well received, and
treatment outcomes indicated improvement in anxiety, depression, and life satisfaction. Previous studies
have demonstrated positive outcomes in the delivery
of mental health treatments for depression among
Hispanic adults aged 55 years and older. However,
none have examined treatment outcomes of those
who are monolingual and have a diagnosable anxiety
disorder. Despite promising results, including
Lucia’s positive reception of Vida Calma, she did
not complete one last elective module that could
have influenced improved symptom reduction at
218
K. RAMOS ET AL.
the end of treatment. Additional study limitations to
be addressed in future studies include: improving
translation equivalence via backward translation
methods and performing post-intervention followup assessments to address maintained gains from
program participation. Further study is needed to
address treatment efficacy and effectiveness.
Additionally, research detailing implementation of
this treatment with nonreligious Hispanic adults
may also offer further insights about treatment feasibility. Given the obvious and yet unmet mental
health needs of Hispanic adults over the age of 55
(Barrio et al., 2008), the hope of this study is to offer
an initial suggestion of the acceptability and feasibility of delivering the Calmer Life intervention translated to Spanish and titled: Vida Calma.
Clinical Implications
● Vida Calma, a Spanish language version
of Calmer Life, was acceptable and feasible to deliver with a 55-year-old participant with GAD.
● Treatment outcomes demonstrate that
Vida Calma improved the participant’s
anxiety, depression, and life satisfaction.
Funding
This material is the result of work supported by the use and
resources of the Houston VA HSR&D Center for Innovations
in Quality, Effectiveness and Safety (CIN 13-413). The opinions expressed are those of the authors and not necessarily
those of the Department of Veterans Affairs, the U.S. government or Baylor College of Medicine.
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