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Guillermo Bernal, Ph.D. University of Puerto Rico

Race, Ethnicity, and Mental Health : Treatment Innovations and Cultural Adaptations of Evidence-based Interventions- 13th Annual Conference: Miami, Florida May 1, 2009. Work on this presentation was supported in part by NIH Research Grant R01-MH67893 funded by the NIMH, Division of Service & Intervention Research.

Case for culturally adapting interventions Review of literature on cultural adaptations Treatment development studies and clinical trials using culturally centered frameworks for adapting Evidence Based Treatments (EBT) for youth Limits of cultural adaptation and use of frameworks Recommendations for future work in research on EBTs with ethnic minorities

Public Policy Initiatives Promoting EBTs

State initiatives to provide incentives and require a list of treatments for Medicaid. NIMH and SAMHSA begin to promote EBTs in mental health and substance abuse centers in United States and U.S. Territories. Some agencies (e.g., SAMHSA, CDC) are now requiring that funded programs document the use of EBTs.

One Size Fits All?

Clinicians and administrators are presented with the problem of having to fit existing EBTs to their patients with little guidance on standards for adaptation for culture, language, and context. Achieving a balance between culturally competent practice and selection of interventions that are scientifically rigorous is especially challenging when delivering interventions to ethno-cultural groups (ECG).

Fitting the Data to the Model

Greek Mythology
Procrustean Fit Early example (fitting person to the model)

The reasonable alternative is to adapt, modify, or tailor the model

Fitting the Model to the Data

In the case of psychotherapy:
The adaptation should retain the essence (key theoretical constructs, theory of change, and basic procedures) of the model; yet the model of adaptation should take into consideration the unique characteristics of the population being served. Some suggest that we develop a new therapy for each and every patient.

What are Adaptations?

Changes to treatment content or process that include
Additions, enhancements, or deletions Alterations to the treatment components Changes in the intensity of the treatment Cultural or other contextual modifications

History of Psychotherapy Adaptations

Psychotherapy has a long history of adaptations
From the couch to the chair to the phone and the Web

4-5 session @ week - to 1 session @ week

From Individual to Group, to Family, Couples, Networks

Adaptations respond to changing socio-cultural context

Cultural Adaptation
The systematic modification of an EBT or intervention protocol to consider language, culture, and context in such a way that it is compatible with the clients cultural patterns, meanings, and values.
(Bernal, Jimnez-Chafey, & Domenech Rodrguez, in press)

Approach to Cultural Adaptations of EBTs

Some researchers suggest there should be flexibility with EBTs within a framework of fidelity so that adaptations may be made
(Kendall & Beidas, 2007)

Others have called for systematic adaptations to manuals and protocols such that culture, language, and socio-economic contexts are explicitly considered
(Hall, 2001; Sue, Bingham, Porche-Burke, & Vsquez, 1999; Trimble & Mohatt, 2002)

Reasons for Culturally Adapting Interventions

1. 2. 3. 4. 5. 6. Singularity - Specificity Argument Ecological Validity Argument Evidentiary Argument Feasibility-Practicality Argument Science Argument Ethical Argument

Singularity - Specificity Argument

Treatments need to be made specific to group culture
Values of subjective culture need to be considered in treatment of ethnic minorities
(Bernal, Bonilla & Bellido, 1995)

Culture and context influences almost every aspect of the diagnostic and treatment process (Alegra & McGuire,
2003; Canino & Alegra, 2008; Comas-Daz, 2006)

Three common constructs found to differentiate ethnic minority from majority persons in the US:
inter-dependence, spirituality, discrimination (Hall, 2001)

Ecological Validity Argument

External Validity
Is the environment as experienced by the patient/client the same as the therapist assumes it is experienced in treatment? Most EBTs are conducted with White, educated, verbal, and middle class patients and may not generalize to ethnic minority and Third World communities
(Bernal & Scharrn-del Ro, 2001)

Ecological Validity Argument

Social Validity
Acceptability and viability of the intervention by the community Evidence that some communities may respond poorly to EBP approaches (Lau, 2006)
Attrition Marginal participation Barriers to engagement

Evidentiary Argument
If there are systematic differences in the empirical connection between symptoms and disorders by race, ethnicity, or other factors, then failing to take these into account will result in more diagnostic and treatment referral errors for minority populations, contributing to disparities in services and in outcomes.
(Alegra & McGuire, 2003)

Evidentiary Argument
Little empirical evidence that EBTs are effective with minority populations (Hall, 2001; Sue, 1998).
Few efficacy studies to guide treatment and research with ethnic minorities (Miranda et al., 2005). Some literature suggests that EBT for Parent management training, ADHD, and depression care may generalize to Latino and African Americans (Miranda, et al. 2005).

Studies on service utilization, treatment preference, and health beliefs suggest that ethnic minorities may respond differently to psychotherapy (Bernal & Scharron del Ro, 2001).

Feasibility-Practicality Argument
Racial and ethnic minorities will soon be the numerical majority Engagement

Adapted EBTs are effective for engagement and retention


More likely if treatments were culturally congruent and community grounded

Relevance EBTs may not be relevant to minority patients

Science Argument
Ethnic science is good science Will enable tests of efficacy with other groups
Evaluate generalization of EBTs Test for moderators and mediators
A test of the theory itself

APA Ethics Code 2002

PRINCIPLE E: RESPECT FOR PEOPLES RIGHTS AND DIGNITY Psychologists are aware of and respect cultural, individual, and role differences, including those based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, and socioeconomic status and consider these factors when working with members of such groups. Psychologists try to eliminate the effect on their work of biases based on those factors, and they do not knowingly participate in or condone activities of others based upon such prejudices.

Ethical Argument
Psychotherapists have an ethical responsibility to offer the best possible treatment by taking into account the values, culture, and context of their patients (Trimble & Mohatt, 2002). Ethical considerations about beliefs and values of the members of the cultural groups being targeted for interventions are as powerful as questions related to science.

Meta-analytic Review of Culturally Adapted Mental Health Interventions

(Griner & Smith 2006) 76 studies
Most (84%) included cultural values and concepts into the intervention 61% employed ethnic matching 74% employed language matching 17% provided cultural sensitivity training for professional staff

Fewer efforts to involve the community

38% included collaboration or consultation with individuals familiar with the culture 29% provided outreach efforts to recruit underserved clients 24% provided extra services to remove barriers for attendance

Meta-analytic Review of Culturally Adapted Mental Health Interventions

(Griner & Smith 2006)

Random effects weighted average effect size was d = .45 indicating a moderately strong benefit of culturally adapted interventions. Interventions targeted to a specific cultural group were 4x more effective than interventions for groups consisting of a variety of cultural backgrounds. Interventions conducted in the Pts native language were twice as effective.

Huey & Polo Meta-analysis (2008)

Reviewed research on EBTs for ethnic minority youth
Probably efficacious and possibly efficacious treatments

Studies met either Nathan and Gormans (2002) Type 1 or Type 2 methodological criteria

Overall treatment effects of medium magnitude (d = .44) Effects were larger when compared to no treatment (d = .58) or psychological placebos (d = .51) versus treatment as usual (d = .22)

Huey & Polo Meta-analysis (2008)

Youth ethnicity (African American, Latino, mixed/other minority), problem type, clinical severity, diagnostic status, and culture-responsive treatment status did not moderate treatment outcome. With minority groups treated separately, several treatments met criteria for probably efficacious or possibly efficacious. Issues:
Most studies had low statistical power and poor representation of less acculturated youth. Few tests of cultural adaptation effects have been conducted. No treatments were well-established for ethnic minority youth.

Frameworks for Culturally Adapting Interventions

Frameworks for Cultural Adaptations

Ecological Validity Model
(Bernal, Bonilla & Bellido, 1995)

Cultural Adaptation Process Model

(Domenech-Rodrguez & Wieling, 2004)

Psychotherapy Adaptation and Modification Framework

(Hwang, 2006)

Selective Adaptation Model

(Lau, 2006)

Ecological Validity Model

(Bernal, Bonilla & Bellido, 1995)

Originally conceptualized for Latino populations Consists of eight elements for adaptation: Language Persons Metaphors Content Concepts Goals Methods Context

Cultural Adaptation Process Model

(Domenech-Rodriguez & Wieling, 2004)

Expanded on the Ecological Validity Model Three general phases and ten specific target areas
Phase 1: Change Agent (researcher) and a Community Opinion Leader collaborate to find a balance between community needs and scientific integrity. Phase 2: Evaluation measures are selected and adapted in a parallel process to the adaptation of the intervention. Phase 3: Integrating the observations and data gathered in phase two into a new packaged intervention.

Each phase consists of an on-going process of evaluation, revision, and reinvention.

Psychotherapy Adaptation and Modification Framework

(Hwang, 2006)

Six domains: Dynamic Issues Cultural Complexities Orientation Cultural beliefs Client-therapist relationship Cultural differences in expression and communication Cultural issues of salience

Psychotherapy Adaptation and Modification Framework

(Hwang, 2006)
Some of the principles of the PAMF for cultural adaptations are:

Establishing a goal for treatment congruent with family values Focusing on factors that would motivate the parents to take appropriate action based on their cultural beliefs Adapting therapy to accommodate patients lack of comfort in talking about their feelings with therapists that many Chinese clients may feel Becoming aware of the shame and stigma associated with mental illness

Selective Adaptation Model

(Lau, 2006)

Adaptation systematically guided by two types of evidence: Selective- adaptations done only if generalization of an EBT fails for a specific target group Directed- informed by data
Modifications to treatment procedures are empirically designed a posteriori

Heuristic Framework
(Barrera & Gonzlez-Castro 2006) Tripartite framework that compares two or more sub-cultural groups with subcomponents to evaluate the equivalence of engagement, of action theory (ability of treatments to change mediating variables) and of conceptual theory (relations between mediators and outcomes). Differences observed in each component could identify aspects of EBT content and implementation procedures that might require adaptation.

Applications of Frameworks for Culturally Adapting Interventions

Ecological Validity Model

Rossell and Bernal conducted two RCTs to examine the efficacy of adapted CBT and IPT for Puerto Rican adolescents with depression (Rossell & Bernal, 1999; Rossell, Bernal, & Rivera, 2008).
In the first RCT, 82% of adolescents in IPT and 59% in CBT were within the functional range after treatment (Rossell & Bernal, 1999). In the second RCT using variations in group and individual format for CBT and IPT, both group and individual formats of CBT and IPT produced positive outcomes (Rossell, Bernal, & Rivera, 2008).

Ecological Validity Model

Used to adapt Parent-Child Interaction Therapy (PCIT) with Puerto Rican children and families (Matos, Torres, Santiago, Jurado, & Rodrguez, 2006).
Pilot study: 9 families; culturally adapted PCIT Results:
high parental levels of satisfaction with the intervention reduced parental stress improved parenting practices significant reductions in child externalizing behaviors

Cultural Adaptation Process Model

Parent Management Training Oregon model (PMT-O) was adapted for Mexican American families with children who exhibit behavior problems (n = 87) (Domenech Rodrguez, Oldham, &
Baumann, in press)

Preliminary findings show good retention of parents into the intervention and steeper improvements in child outcomes in the treatment as compared to the control group (Domenech
Rodrguez, 2008)

Psychotherapy Adaptation and Modification Framework

Case study
Culturally adapted CBT used to successfully treat school phobia in 12-year-old Chinese American males who experienced drop attacks when confronted with school situations Somatic symptoms are a more culturally appropriate expression of anxiety in Chinese culture (less stigmatizing) and serve as an escape behavior when confronted with certain stressors (i.e., teasing). Pycho-educational information was presented using a cultural bridging technique to link Asian cartoon culture with Chinese culture and the connection between emotions and somatic experiences.
(Hwang, Wood, Lin, & Cheung, 2006)

Limits of Adaptations
Balancing fidelity and fit:
Do adaptations change the theoretical propositional model or the implied theory of change? Did the adaptation change the proposed core components and procedures to such an extent that what was adapted becomes a different treatment? Is change still a function of the therapeutic techniques that respond to a particular theoretical model? Or are there other mediating factors that might be due to the adaptation?

Summary and Conclusions

One size does not fit all
Through cultural adaptations it may be possible to go beyond the one-size-fits-all approach and move closer toward the ideal of providing effective psychotherapies for all individuals that is contextualized in terms of cultural values, language, and socioeconomic status, gender, and preferences.

Adaptations that are well documented, systematic, and tested can advance research and inform practice.
Psychotherapy adaptation models/frameworks are useful in guiding cultural adaptations. Research with ethnic minorities has shown that there are definite differences in responses to therapy, as well as in engagement and retention.

Ethnic science is not only good it is better science

Ethnicity should not be treated as a nuisance variable. Understanding ethnic differences is not only helpful to ethnic groups, it is good for science. The United States is one of the most diverse societies in the world. Why not take advantage of that fact by promoting external validity and by testing the generality of theories? (Sue, 1999)

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