CULTURAL ADAPTATION OF PSYCHOTHERAPY

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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.
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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

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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.

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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).

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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

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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.

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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

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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 _at_ week - to 1 session _at_ week
• Structure
• From Individual to Group, to Family, Couples,
  Networks
• Adaptations respond to changing socio-cultural
  context

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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, Jiménez-Chafey, Domenech Rodríguez, in
  press)

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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)

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Reasons for Culturally Adapting Interventions

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

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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)

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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)

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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

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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)

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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).

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Feasibility-Practicality Argument
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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

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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.

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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.

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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

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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.

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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)

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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.

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Frameworks for Culturally Adapting Interventions
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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)

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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

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Cultural Adaptation Process Model(Domenech-Rodrig
uez 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.

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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

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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

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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

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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.

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Applications of Frameworks for Culturally
Adapting Interventions
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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).

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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

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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)

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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)

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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?

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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.

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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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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.