Professional Documents
Culture Documents
Overview
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
Intensity
4-5 session @ week - to 1 session @ week
Structure
From Individual to Group, to Family, Couples, Networks
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)
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)
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)
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
Demographics
Racial and ethnic minorities will soon be the numerical majority Engagement
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
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.
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.
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)
Originally conceptualized for Latino populations Consists of eight elements for adaptation: Language Persons Metaphors Content Concepts Goals Methods Context
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.
Six domains: Dynamic Issues Cultural Complexities Orientation Cultural beliefs Client-therapist relationship Cultural differences in expression and communication Cultural issues of salience
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
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.
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)
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?
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.
References
Alegria, M., & McGuire, T. (2003). Rethinking a universal framework in the psychiatric symptom-disorder relationship. Journal of Health and Social Behavior, 44(3), 257-274. Barrera, M., & Gonzlez-Castro, F. (2006). A Heuristic framework for the cultural adaptation of interventions. Clinical Psychology: Science and Practice, 13, 311-316. Bernal, G., Bonilla, J., & Bellido, C. (1995). Ecological validity and cultural sensitivity for outcome research: Issues for cultural adaptation and development of psychosocial treatments with Hispanics. Journal of Abnormal Child Psychology, 2367-82. Bernal, G., Domenech Rodriguez, M. (2009). Advances in Latino Family Research: Cultural Adaptations of Evidence-Based Interventions. Family Process, 48, 2,169-178. Bernal,G., Jimnez-Chafey, Domenech Rodrguez, M. (in press) Cultural Adaptation of Evidence-based Treatments for Ethno-cultural Youth, Professional Psychology: Research and Practice. Domenech-Rodrguez, M., & Weiling, E. (2004). Developing culturally appropriate, Evidence-Based Treatments for interventions with ethnic minority populations. In M. Rastogin & E. Weiling (Eds.), Voices of Color: First person accounts of ethnic minority therapists. (pp. 313-333). Thousand Oaks: Sage Publications. Domenech Rodrguez, M. Oldham, & Baumann, (in press). Cultural adaptation of an empirically supported intervention: From theory to practice in a Latino/a community context, American Journal of Community Psychology. Griner, D. Smith, T. (2006) Culturally adapted mental health intervention: A meta-analytic review. Psychotherapy: Theory, Research, Practice, Training, 43(4),531-548. Hall, G. C. N. (2001). Psychotherapy research with ethnic minorities: Empirical, ethical, and conceptual issues. Journal of Consulting and Clinical Psychology, 69, 502-510. Huey, S. J., & Polo, A. J. (2008). Evidence-based psychosocial treatments for ethnic minority youth: A review and meta-analysis. Journal of Clinical Child and Adolescent Psychology, 37, 262-301. Hwang, W. (2006). The Psychotherapy Adaptation and Modification Framework: Application to Asian Americans. American Psychologist, 61, 702-715. Hwang, W., Wood, J. J., Lin, K., & Cheung, F. (2006). Cognitive-Behavioral Therapy with Chinese Americans: Research, theory, and clinical practice. Cognitive and Behavioral Practice, 13, 293-303. Lau, A. S. (2006). Making the case for selective and directed cultural adaptations of evidence-based treatments: Examples from parent training. Clinical Psychology: Science and Practice, 13, 295-310. Matos, M., Torres, R., Santiago, R., Jurado, M., & Rodriguez, I. (2006). Adaptation of Parent-Child Interaction Therapy for Puerto Rican families: A preliminary study. Family Process, 45, 205-222. Rossell, J., & Bernal, G. (1999). The efficacy of cognitive-behavioral and interpersonal treatments for depression in Puerto Rican adolescents. Journal of Consulting and Clinical Psychology, 67, 734-745. Rossell, J., & Bernal, G. (2005). New Developments in Cognitive-Behavioral and Interpersonal Treatments for Depressed Puerto Rican Adolescents. In E. D. Hibbs & P. S. Jensen (Eds.), Psychosocial treatments for child and adolescent disorders: Empirically based strategies for clinical practice (2nd ed.). (pp. 187-217). Washington, DC, US: American Psychological Association. Rossell, J., Bernal, G., & Rivera, C. (2008). Randomized trial of CBT and IPT in individual and group format for depression in Puerto Rican adolescents. Cultural Diversity and Ethnic Minority Psychology, 14, 234-245.