Cultural Competence Mental Health
Southern Region Summit XVIII
The Intersection of Evidence- Based
Practices and Cultural Adaptations of
Mental Health Interventions
Sergio Aguilar-Gaxiola, MD, PhD
Director, Center for Reducing Health Disparities
UC Davis School of Medicine
San Diego, CA
December 7, 2012
Overview

Types of practices

Definitions of Evidence-Base Practices (EBPs)

Types of studies and levels of evidence

Who is represented in EBPs and key concerns

Cultural adaptations of EBTs

EBTs vs. Practice-based Evidence vs.
Community-defined Evidence

Recommendations
“Strength is in our culture,
but let us show you our
success, not use your
measurements of
success…”
“We are developing our
own workforce, but not
getting recognition
because you use your
measurements to
measure us…”
“We can’t only treat
children, we have to
treat the whole family”
NA Community Leader
“There is a way you talk to people in our
communities…You have to know
how to talk to black people.”
Dr. Vanessa Siddle Walker, 2010
Source: Kindly Provided by Forrest Toms, 2010.
4
Ways of Knowing

Clearly, there are differences in ways of knowing
among cultures.

What counts as “evidence” is defined differently
from group to group.

There is a cultural gap between a “scientific way
of knowing” and clinicians’ professional ways of
knowing

There is an even wider gap between “scientific
ways of knowing” and community, cultural ways
of knowing.
Source: Blasé & Fixsen, 2003, National Implementation Research Network, Louie de la Parte Florida Mental Health
Institute, Consensus Statement on Evidence-Based Programs and Cultural Competence.
How Communities Perceive
Research Centers…
How Communities Perceive
Scientists…
Evidence?

What do we mean by “the best evidence
available?”

What are the dangers/advantages of focusing so
much on outcomes?

How does the debate and dialogue about
“evidence” interact with issues of culture, race,
and ethnicity?

In what ways do you consider culture, race and
ethnicity, sexual orientation when assessing the fit
between an evidence-based program and a
potential implementation site?
Source: Blasé & Fixsen, 2003, National Implementation Research Network, Louie de la Parte Florida Mental Health
Institute, Consensus Statement on Evidence-Based Programs and Cultural Competence.
Three Types of Practices
1. Research Validated Best Practice
2. Field Tested Best Practice
3. Promising Practice
Source: Compassion Capital Fund National Resource Center, Identifying and Promoting Promising Practices
http://www.acf.hhs.gov/programs/ocs/ccf/about_ccf/gbk_pdf/pp_gbk.pdf.
Three Types of Practices
1. Research Validated Best Practice
A program, activity or strategy that has the
highest degree of proven effectiveness
supported by objective and comprehensive
research and evaluation.
Source: Compassion Capital Fund National Resource Center, Identifying and Promoting Promising Practices
http://www.acf.hhs.gov/programs/ocs/ccf/about_ccf/gbk_pdf/pp_gbk.pdf.
Three Types of Practices
2. Field Tested Best Practice
A program, activity or strategy that has been
shown to work effectively and produce
successful outcomes and is supported to some
degree by subjective and objective data
sources.
Source: Compassion Capital Fund National Resource Center, Identifying and Promoting Promising Practices
http://www.acf.hhs.gov/programs/ocs/ccf/about_ccf/gbk_pdf/pp_gbk.pdf.
Three Types of Practices
3. Promising Practice
A program, activity or strategy that has worked
within one organization and shows promise
during its early stages for becoming a best
practice with long term sustainable impact. A
promising practice must have some objective
basis for claiming effectiveness and must have
the potential for replication among other
organizations.
Source: Compassion Capital Fund National Resource Center, Identifying and Promoting Promising Practices
http://www.acf.hhs.gov/programs/ocs/ccf/about_ccf/gbk_pdf/pp_gbk.pdf.
What is Evidence-Based Practice?

“…interventions for which there is scientific
evidence consistently showing that they improve
client outcomes.”
Source: Drake et al., 2001

“The integration of the best available research
with clinical expertise in the context of patient
characteristics, culture, and preferences.”
Source: APA Presidential Task Force on EBPinP, 2005
Types of Studies


“Efficacy Studies”

Gold Standard scientifically to show if a drug or
intervention works for a particular narrowly defined
problem in carefully controlled populations and
conditions.

Randomized Controlled Clinical Trial
“Effectiveness Studies”

Less scientific power, but more socially relevant.
What happens when the drug or intervention is used
in the general population under ordinary care
conditions.

Follow-up studies
Levels of Evidence

Efficacious -- achieves child/family outcomes, based
on controlled research (random assignment), with
independent replication in controlled settings

Effective -- achieves consumer outcomes, based on
controlled research (random assignment), with
independent replication in usual care settings

Not effective -- significant evidence of a negative or
harmful effect

Promising -- some positive research evidence, quasiexperimental, of success and/or expert consensus

Emerging -- recognizable as a distinct practice with
“face” validity or common sense test
Source: Carter, 2005
What are Promising Practices?
“A ‘promising model’ is defined as one with
at least preliminary evidence of effectiveness
in small-scale interventions or for which there
is potential for generating data that will be
useful for making decisions about taking the
intervention to scale and generalizing the
results to diverse populations and settings.”
Source: Department of Health and Human Services Administration for Children and Families Program
Announcement. Federal Register, Vol. 68, No. 131, (July 2003), p. 40974
What is Community-Defined Evidence
“A set of practices that communities have
used and determined to yield positive results
as determined by community consensus
over time and which may or may not have
been measured empirically but have
reached a level of acceptance by the
community.”
Source: CDEP Working Group, 2007)
Status of EBTs

Little research related to evidence-based
programs has been conducted with diverse,
underserved populations.

Most EBTs are conducted with white, educated,
verbal, and middle class patients and may not
generalize to ethnic minority communities.

This makes it difficult to ascertain whether
currently identified evidence-based programs
are, in fact, best practices models for specific
racial, ethnic, and cultural communities.
Source: Blasé & Fixsen, 2004; Bernal & Scharrón-del Río, 2001.
Who is Represented by the Evidence?

Minority Supplement to Surgeon General’s Report
(2001)



Limited science base on racial/ethnic minority mental
health
Clinical trials from 1986-1994 documented absence of
racial/ethnic minority participants
This has begun to change under impetus from
NIMH


For example, grant applications must specify minority
inclusion goals
However, great variability in whether and how research
questions and design address issues of culture (and
language)
Whose Evidence?

Most studies reporting findings for racial and
ethnic minorities had small samples and were
not randomized controlled trials.

The research used to generate professional
treatment guidelines for most health and
mental health interventions does not include
or report large enough samples of racial and
ethnic minorities to allow group specific
determinations of efficacy.
Source: Blasé & Fixsen, 2004, National Implementation Research Network, Louie de la Parte Florida Mental Health
Institute, Consensus Statement on Evidence-Based Programs and Cultural Competence.
Concerns with EBPs

Lack of ethnic/racial groups participation in the
efficacy studies that determine the evidence (Surgeon
General Report, 2001).

Between 1986 and 2001:

Out of 9,266 participants in randomized controlled trials
evaluating the efficacy of interventions for bipolar disorder,
schizophrenia, depression, and ADHD:

561 African Americans (6 percent)

99 Latinos (1 percent)

11 Asian Americans/Pacific Islanders (0.1 percent)

0 American Indians/Alaska Natives identified

Not a single study analyzed the efficacy of the treatment by
ethnicity.
Source: “Mental Health: Culture, Race, and Ethnicity” A Supplement to Mental Health:
A Report of the Surgeon General, 2001 (p. 35)
Minority Recruitment and Diversity:
Clinical Research – Minority Enrollment
Percent
Extramural Grants Clinical Trials: Percent Achieving 80% of Minority
Enrollment Goal by Final Year for Studies Ending or with No Cost
Extensions in FY 2003
Source: Figure 8 of NAMHC Report on Treatment Research in Mental Illness: Improving the Nation’s Public Mental
Health Care through NIMH Funded Interventions Research, September 2004.
Key Concerns Regarding EBPs


Lack of consideration of context:

EBP’s have typically been normed or standardized
irrespective of cultural context and socioeconomic
realities

Models are sweepingly applied to all people, regardless
of their history, race/ethnicity, and environmental
context
Lack of demonstrated generalizability:

The generalizability of EBP’s to diverse communities
has not been substantially or systematically
demonstrated especially in terms of their
appropriateness, relevance, and applicability to Latinos,
Asian-Pacific Islanders, and Native Americans
Aisenberg, 2005
Key Concerns Regarding EBPs

Lack of description on how EBPs will ensure
fidelity to their treatment model when engaging
communities of color and in different contexts

Blurring of definition of what constitutes an EBP

EBPs are not necessarily developed to address
existing disparities in access and utilization of
services

Costs incurred by community-based agencies and
sustainability of EBPs
Aisenberg, 2005
Underlying Assumptions of EBPs

Since EBPs have demonstrated evidence
of successful implementation and effective
outcomes they are to be trusted with
funding across and throughout the country.

Since EBPs have documented evidence of
effectiveness with certain populations they
will be equally effective with all ethnic
populations upon which they are yet to be
tested.
Source: Aisenberg, 2005.
One Size Fits All?

Embedded in the suggestion that EBPs be used without
formal adaptations to culture, language, and context is
the notion that the same treatment (manual or protocol)
should work with all patients.

“Standard” interventions (e.g., CBT, IPT) should be
delivered as designed and tested to different groups with
only minor “tailoring” of the intervention to clinical
characteristics.

Some agencies (e.g., SAMHSA, CDC) are now requiring
that funded programs document the use of EBPs.

Thus, clinicians and administrators are presented with
the problem of having to “fit” the existing EBPs to their
patients with little guidance on standards for adaptation
for culture, language, and context.
Source: Bernal, 2006.
Basic Assumption
Culture and language are important variables in
determining how people (consumers and
their families, staff and providers) see
and interpret (know) the world
around them and the basis
of how they make
decisions.
Evidence-Based Programs and
Cultural Competence: What we
Know and Do not Know

Evidence suggests that culturally-oriented
interventions are more effective than usual care
at reducing dropout rates for underserved
populations receiving mental health services.

Because stigma and help-seeking behaviors
are two culturally determined factors in service
use, research is needed on how to change
attitudes and improve utilization of mental
services.
Source: Blasé & Fixsen, 2004, National Implementation Research Network, Louie de la Parte Florida Mental Health
Institute, Consensus Statement on Evidence-Based Programs and Cultural Competence.
Evidence-Based Programs and
Cultural Competence: What we
Know and Do not Know

We know more about effective practices and
programs than what is reflected through
research done using randomized clinical trials.

There are practices and interventions that
consumers and practitioners have found to be
helpful in addressing their problems (“PracticeBased Evidence”) and achieving their goals but
for which the evidence base has not been fully
established.
Source: Blasé & Fixsen, 2004, National Implementation Research Network, Louie de la Parte Florida Mental Health
Institute, Consensus Statement on Evidence-Based Programs and Cultural Competence.
Current Status of EBP

Currently we don’t know whether and what
types of adaptations and modifications of an
evidence-based program are needed to
ensure that its implementation does not
create or exacerbate disparities across
diverse groups.
Source: Blasé & Fixsen, 2004, National Implementation Research Network, Louie de la Parte Florida Mental Health
Institute, Consensus Statement on Evidence-Based Programs and Cultural Competence.
Intersection of EBPs and Cultural
and Linguistic Considerations

EBPs are given much attention but they need
to be viewed within a larger context, that of
the host community---EBPs cannot stand
alone;

EBPs must be viewed within a Cultural and
Linguistic Competence frame, tailored and
individualized for a particular community and
population at a give time.
EBP
C & L Adaptations
PBE
Source: Echo-Hawk, Hernández, Huang & Isaacs, 2006
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
What are Adaptations?

Changes to treatment content or process
that include:
 Additions,
enhancements, or deletions
 Alterations
 Changes
 Cultural
to the treatment components
in the intensity of the treatment
or other contextual modifications
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.
Source: Bernal, Jiménez-Chafey, & Domenech Rodríguez, 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, &
Vásquez, 1999; Trimble & Mohatt, 2002)
Arguments Against and
in Support of Cultural Adaptation
Against adaptation:



Universality among groups (“they probably work”)
Need to have fidelity to make sure it works
Feasibility issues
In support of adaptation:



Treatment must fit the community
Adaptation can prevent diagnostic and treatment errors
Adaptation will foster adherence to treatment
Source: Bernal, 2006
Ecological Validity Model
Language
Context
Methods
Persons
Culturally
Sensitive
Elements
Metaphors
Content
Goals
Concepts
Source: Bernal, 2006
Elements/dimensions of treatment and criteria for
evaluating cultural sensitivity in clinical interventions
Elements
Criteria for Cultural Sensitivity
Language
Do consumers understand language, idioms,
and words used?
Culturally syntonic
Persons
Ethnic/racial similarities &
differences client & therapist
Metaphors
Symbols & concepts shared
Content
Cultural, social, economic,
historical, & political
knowledge (e.g., values,
traditions)
Is the consumer comfortable with the similarity
(or difference) in the ethnicity of the
therapists?
Are sayings or “dichos” common to ethnic
group part of the intervention?
Does the consumer feel understood by the
therapist? Does the consumer feel that the
therapist respects his/her cultural values (e.g.,
familismo, respect, personalismo, gender
roles)?
Source: Bernal, 2006
Elements/dimensions of treatment and criteria for
evaluating cultural sensitivity in clinical interventions
Elements
Concepts
Treatment concepts
consonant with culture &
context (dependence vs.
independence)
Criteria for Cultural Sensitivity
• Are treatment concepts framed within cultural
values?
• Does the patient feel understood by the
therapist?
• Is the patient in agreement with the definition
of the problem & the specific treatment?
Goals
Transmission of positive
adaptive cultural values;
support of adaptive values
from culture of origin
• Are treatment goals framed within adaptive
cultural values of the patient?
• Are treatment goals consonant with cultural
expectations of therapy?
• Does the patient agree with the goals of
treatment?
Source: Bernal, 2006
Elements/dimensions of treatment and criteria for
evaluating cultural sensitivity in clinical interventions
Elements
Criteria for Cultural Sensitivity
Methods
Development and cultural
adaptation of treatment
methods.
•Are the treatment methods framed within adaptive
cultural values of the consumer?
•Does the consumer agree with the methods of
treatment?
Context
Consideration of changing
contexts in assessment during
treatment or intervention:
acculturative stress, phase of
migration, social supports and
relationship to country of
origin, economic & social
context of intervention.
•Does the intervention consider contextual issues such
as migration and acculturation stress, social supports,
family relationships in country of origin, and barriers to
treatment common to Latinos?
•Do patients view therapists caring about their social
and economic situation?
Source: Bernal, 2006
Language
Interventions conducted in the consumer’s native language
were twice as effective (Griner & Smith 2006).

Rosselló and Bernal
 Manual translated in Spanish
 Tú utilized when addressing adolescents usted to
address parent
 Edited for clarity and simplicity



I am Worthless = Soy una nulidad = No sirvo para nada
Therapy administered in Spanish
Lau
 Language adaptations eliminate the word praise (biao
yan kan) instead emphasize the preferred concept of
encouraging your children (li kan)
Top Priority: Empowering Consumers
“The direct participation of consumers and
families in developing a range of
community-based, recovery-oriented
treatment and support services is a priority.”
“Health care systems must:

Respect patients’ values, preferences and
expressed needs

Coordinate and integrate care across
boundaries of the system

Provide the information, communication, and
education that people need and want…”
So what is Consumer-centered EBPs?

Focusing on the consumer’s problems

Taking a consumer’s perspective

Accommodating of the consumer’s preferences

Allowing consumer participation

Building upon consumer/provider partnerships

Empowering the consumer to improve their
health.
Source: Bridges, 2007
Patient-Focused Questions

What information do I trust?

Who is making decisions about
my care?

How does the use of “Evidence”
affect my treatment/care?

Does the “Evidence” answer
questions that matter to me?

What decisions can be made with
limited evidence?
Source: The National Working Group for Evidence-Base Health care, 2008
Is good evidence an effective practice?

There is good evidence that shows some
programs are harmful and good evidence that
shows some programs are ineffective.

In spite of this evidence, public funding is
available for these programs year after year.

Thus, the public funding and policy debates
should not be about the relative merits of more or
less evidence or about the type of evidence that
should define an evidence-based program.
Source: Blasé & Fixsen, 2003, National Implementation Research Network, Louie de la Parte Florida Mental Health
Institute, Consensus Statement on Evidence-Based Programs and Cultural Competence.
Questions about public funding of EBTs

Why public funds are being used to support
evidence-based programs in which the target
populations were not used to develop the
evidence?

Why public funds are being used to support
programs which have been demonstrated to be
ineffective or harmful programs instead of
programs that have at least some evidence to
support their effectiveness.

We need to educate legislators, legislative staffs,
and the public about the evidence available to
support better policy and funding decisions.
Source: Blasé & Fixsen, 2003, National Implementation Research Network, Louie de la Parte Florida Mental Health
Institute, Consensus Statement on Evidence-Based Programs and Cultural Competence.
The Consumer as THE Center of EBPs

Design studies to answer clinical questions relevant to the consumer
and their treating provider.

Include consumers and families in defining outcomes and
evaluating decisions based on evidence.

Test and develop tools with consumers.

Transparent communication about how new learning will be
adapted to practice and policy.

Disseminate information and resources where consumers are and
with information that reflects values for home, work and community.

Measure outcomes and evaluate policies with consumer-designed
metrics.

Empower consumers to ask questions, seek knowledge and demand
the best from the healthcare system.
Source: Modified from The National Working Group for Evidence-Base Health Care, 2007
Recommendations

Include diverse communities in the development of EBPs.

Development and testing of EBPs should be carried out in
diverse communities.

Cultural and linguistic competence should be incorporated
into the development and implementation of EBPs.

Cultural adaptations should be done in EBPs.

PBEs and CDEs may be effective so they need to be
further funded, tested and documented.

The process of implementing CDEs in diverse communities
and their effectiveness should be supported with
resources.
Source: Carrazco, 2008
Words of Wisdom
“The most basic of all human needs is the
need to understand and be understood.
The best way to understand people
is to listen to them.”
Ralph Nichols