CULTURAL ADAPTATION OF PSYCHOTHERAPY

1. CULTURAL ADAPTATION OF PSYCHOTHERAPY 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.

2. 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

3. 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.

4. 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).

5. 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

6. 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.

7. 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

8. History of Psychotherapy Adaptations • Psychotherapy has a long history of adaptations • Setting • From the couch to the chair to the phone and the Web • Intensity • 4-5 session @ week - to 1 session @ week • Structure • From Individual to Group, to Family, Couples, Networks • Adaptations respond to changing socio-cultural context

9. 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 client’s cultural patterns, meanings, and values. (Bernal, Jiménez-Chafey, & Domenech Rodríguez, in press)

10. 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, & Vásquez, 1999; Trimble & Mohatt, 2002)

11. Reasons for Culturally Adapting Interventions • Singularity - Specificity Argument • Ecological Validity Argument • Evidentiary Argument • Feasibility-Practicality Argument • Science Argument • Ethical Argument

12. 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 (Alegría & McGuire, 2003; Canino & Alegría, 2008; Comas-Díaz, 2006) • Three common constructs found to differentiate ethnic minority from majority persons in the US: • inter-dependence, spirituality, discrimination (Hall, 2001)

13. 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 & Scharrón-del Río, 2001)

14. 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

15. 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….” (Alegría & McGuire, 2003)

16. 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 Río, 2001).

17. Feasibility-Practicality Argument

18. 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

19. APA Ethics Code 2002 PRINCIPLE E: RESPECT FOR PEOPLE’S 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.

20. 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.

21. 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

22. 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 Pt’s native language were twice as effective.

23. Huey & Polo Meta-analysis (2008) • Reviewed research on EBTs for ethnic minority youth • Probably efficacious and possibly efficacious treatments • Studies met either Nathan and Gorman’s (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)

24. 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.

25. Frameworks for Culturally Adapting Interventions

26. Frameworks for Cultural Adaptations • Ecological Validity Model • (Bernal, Bonilla & Bellido, 1995) • Cultural Adaptation Process Model • (Domenech-Rodríguez & Wieling, 2004) • Psychotherapy Adaptation and Modification Framework • (Hwang, 2006) • Selective Adaptation Model • (Lau, 2006)

27. 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

28. 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.

29. 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

30. 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

31. 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

32. Heuristic Framework(Barrera & González-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.

33. Applications of Frameworks for Culturally Adapting Interventions

34. Ecological Validity Model • Rosselló and Bernal conducted two RCTs to examine the efficacy of adapted CBT and IPT for Puerto Rican adolescents with depression (Rosselló & Bernal, 1999; Rosselló, Bernal, & Rivera, 2008). • In the first RCT, 82% of adolescents in IPT and 59% in CBT were within the functional range after treatment (Rosselló & 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 (Rosselló, Bernal, & Rivera, 2008).

35. Ecological Validity Model • Used to adapt Parent-Child Interaction Therapy (PCIT) with Puerto Rican children and families (Matos, Torres, Santiago, Jurado, & Rodríguez, 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

36. 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 Rodríguez, 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 Rodríguez, 2008)

37. 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)

38. 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?

39. 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 socio-economic 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.

40. 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)

41. 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., & González-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., Jiménez-Chafey, Domenech Rodríguez, M. (in press) Cultural Adaptation of Evidence-based Treatments for Ethno-cultural Youth, Professional Psychology: Research and Practice. Domenech-Rodríguez, 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 Rodríguez, 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. Rosselló, 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. Rosselló, 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. Rosselló, 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.