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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 ... – PowerPoint PPT presentation

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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
  • 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
  • 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
  • Some suggest that we develop a new therapy for
    each and every patient.

What are Adaptations?
  • Changes to treatment content or process that
  • 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
  • Setting
  • From the couch to the chair to the phone and the
  • Intensity
  • 4-5 session _at_ week - to 1 session _at_ week
  • Structure
  • From Individual to Group, to Family, Couples,
  • Adaptations respond to changing socio-cultural

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

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)

Reasons for Culturally Adapting Interventions
  • 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
  • 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)

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
  • (Bernal Scharrón-del Río, 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.
  • (Alegría McGuire, 2003)

Evidentiary Argument
  • Little empirical evidence that EBTs are effective
    with minority populations (Hall, 2001 Sue,
  • Few efficacy studies to guide treatment and
    research with ethnic minorities (Miranda et al.,
  • 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).

Feasibility-Practicality Argument
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
  • 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

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
  • 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
  • Interventions conducted in the Pts native
    language were twice as effective.

Huey Polo Meta-analysis (2008)
  • Reviewed research on EBTs for ethnic minority
  • Probably efficacious and possibly efficacious
  • 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-Rodríguez Wieling, 2004)
  • Psychotherapy Adaptation and Modification
  • (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-Rodrig
uez Wieling, 2004)
  • Expanded on the Ecological Validity Model
  • Three general phases and ten specific target
  • Phase 1 Change Agent (researcher) and a
    Community Opinion Leader collaborate to find a
    balance between community needs and scientific
  • 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
  • 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
  • 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
  • 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 González-Castro
  • 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

Applications of Frameworks for Culturally
Adapting Interventions
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,

Ecological Validity Model
  • Used to adapt Parent-Child Interaction Therapy
    (PCIT) with Puerto Rican children and families
    (Matos, Torres, Santiago, Jurado, Rodríguez,
  • Pilot study 9 families culturally adapted PCIT
  • Results
  • high parental levels of satisfaction with the
  • reduced parental stress
  • improved parenting practices
  • significant reductions in child externalizing

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)

Psychotherapy Adaptation and Modification
  • 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
  • (Hwang, Wood, Lin, Cheung, 2006)

Limits of Adaptations
  • Balancing fidelity and fit
  • Do adaptations change the theoretical
    propositional model or the implied theory of
  • 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 socio-economic status,
    gender, and preferences.
  • Adaptations that are well documented, systematic,
    and tested can advance research and inform
  • 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
  • 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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