Daryl Fujii Ph.D., Honolulu
and the
Multicultural/Diversity Committee (2009-2010)
VA Psychology Training Council
Contact persons:
Daryl Fujii Ph.D., Honolulu (Daryl.Fujii@va.gov)
Rachael Guerra Ph.D., Palo Alto (Rachael.Guerra@va.gov)
Committee 2009-2010
Loretta E. Braxton Ph.D., Durham, (Co-Chair)
Linda R. Mona Ph.D., Long Beach (Co-Chair)
Lenora Brown Ph.D., St. Louis
Daryl Fujii Ph.D., Honolulu
Rachael Guerra Ph.D., Palo Alto
Jamylah Jackson Ph.D., North Texas
Tina Liu-Tom Ph.D., Honolulu
Monica Roy Ph.D., Boston
Miguel Ybarra Ph.D., San Antonio
Jay Morrison Ph.D., San Francisco (Postdoc)
Velma Barrios, Greater Los Angeles (Intern)
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Presentation will provide a brief overview of
literature on Evidence Based Practices (EBPs)
and ethnic minorities
Purposes
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Dispel the myth that there are no studies on EBPs
and ethnic minorities
Provide recommendations for modifying EBPs for
ethnic minorities
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APA Policy Statement on Evidence-Based
Practice (EBP) in Psychology (2006)
Literature review on EBP with ethnic
minorities
Justification of cultural adaptations
Types of cultural adaptations
Examples of recommendations for cultural
adaptations
Summary
Exercise
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Learn how APA position on EBPs are
consistent with culturally informed treatment
Learn how the emerging literature supports the
effectiveness of EBPs with ethnic minorities
Cultural adaptations incremental validity to
treatments
Learn strategies to adapt EBPs to improve
effectiveness with ethnic minority groups
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“Evidence-based practice in psychology
(EBPP) is the integration of the best
available research with clinical expertise
in the context of patient characteristics,
culture, and preferences.”
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Best Research Evidence
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Evidence should be based on systematic reviews,
reasonable effect sizes, statistical significance, and a
body of supporting evidence
Should not assume interventions that have not been
studied in controlled trials are ineffective
New developments should be rigorously evaluated
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Clinical Expertise
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“Important to integrate the best research evidence
with clinical data within the context of the patient’s
characteristics and preferences to deliver services
that have a high probability of achieving the goals of
treatment.”
Integral is “awareness of the limits of one’s
knowledge and skills and attention to the heuristics
and biases…that can affect clinical judgment.”
Understand how “own characteristics , values, and
context interact with those of the patient.”
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Patients Characteristics, Values, and Context
 Interventions “most effective when
responsive to the patient’s specific problem,
strengths, personality, sociocultural context,
and preference.”
 “A central goal of EBPP is to maximize
patient choice among effective alternative
interventions/”
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Clinician determines applicability of research
conclusions to individual patient.
A patient may require “decisions and
interventions not directly addressed by
available research.”
Application of research requires “probabilistic
inferences”
“Ongoing monitoring of patient progress and
adjustment of treatment as needed are
essential to EBP.”
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Miranda et al (2005)
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EBPs effective with different minority groups and
children and adults for a wide range of mental
disorders and problem behaviors (e.g. depression,
anxiety, family problems)
largest most rigorous literature support EBPs for
depression for African-Americans and Latinos with
size effects equal or greater to Whites
less data for Asians, however, findings promising
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Huey & Polo (2008)
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in children, EBP interventions produced positive
treatment effects of medium magnitude
no compelling evidence that cultural adaptations
promote better clinical outcomes for ethnic minority
youth
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Griner & Smith (2006) meta-analysis
found moderate size effect for culturally competent
interventions versus traditional mental health
interventions d=0.45
 findings provide support for incremental validity of
cultural competent interventions
 participant characteristics:
 older subjects had higher effect sizes than younger
 ethnicity of client did not moderate results
 Hispanics low levels of acculturation profited
greatly from culturally competent interventions
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Griner & Smith (2006) (cont.)
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type of adaptations:
 homogenous samples demonstrated stronger effect
sizes than mixed populations
 no matching of therapists had larger effect sizes
compared to those when matching attempted
 client matched on language (if other than English)
outcomes twice as effect than those that did not
match for language
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Given effectiveness of some EBPs with ethnic
minority samples, are cultural interventions
necessary?
Lau (2006)
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Cultural adaptations should be judiciously applied,
warranted if:
(a) clinical problem is unique to an ethnic group
(b) clients from a specific ethnic community are
found to respond poorly to an EBP approach
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APA Multicultural Guidelines (2003)
“Psychologists encouraged to:
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“acquire an understanding of the ways in which
experiences (e.g. ethnocentrism, racism, sexism,
ableism, homophobia) relate to presenting
psychological concerns…including…worldview”
“be aware of the role that culture may play in the
establishment and maintenance of a relationship
between the client and therapist.”
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“Multiculturally sensitive psychologist should:
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“recognize that culture-specific therapy (individual,
family, and group) may require nontraditional
interventions and should strive to apply this
knowledge in practice.”
“examine traditional psychotherapy practice
interventions for their cultural appropriateness… to
expand these interventions to include multicultural
awareness and culture-specific strategies.”
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Whaley & Davis (2007)
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Movement from efficacy to effectiveness studies can
be enhanced by using cultural adaptations
Therapeutic engagement and treatment retention
major challenges in delivery of evidence-based
practices, cultural competency may be a solution
Cultural adaptations consistent with need to
maximize external validity
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Method of delivery:
Language
 Varying interpersonal style (e.g. show respeto to
clinician)
 Providing a cultural context for interventions
(Andres-Hyman et al., 2006)
 (e.g. use of ethnic foods, blessing for the day, unity
circle, didactic orientation or classroom format to
reduce stigma)
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Involve generic applications that can
implemented across treatment modalities and
theoretical orientations
Method of delivery (goals):
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intended to make intervention more culturally
consistent
increase credibility of treatment provider
make treatment understandable to client
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Content:
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discussion of or dealing with cultural patterns,
immigration, minority status, racism, specific
cultural background experiences, in the intervention
Increase understandability and credibility of
intervention
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Developed a toolkit for modifying EBPS to
increase cultural competence
http://ssrdqst.rfmh.org/cecc/
Accommodations
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Modifying delivery of EBP so that it can be utilized
with a particular culture (e.g. language, interpreters)
Adaptation
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Changing structure of program to fit needs and
preferences of a culture
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View of Mental Illness
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Holistic health view
Attribution
Degree of stigma
Social Positioning
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Discrimination
Equality
Stereotypes
Acculturation
Formality
(Samuels et al. 2008)
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Lifestyle
Housing
 Education
 Social class
 Development through life
 Age
 Gender
 Dating
 Marriage/Divorce
 Sexual activity/sexual orientation
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(Samuels et al. 2008)
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Health
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Use of drugs and alcohol
Specific health problems
Family/kin relationships
Family constellation
 Disciplining children
 Power in relationships
 Communication
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(Samuels et al. 2008)
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World view
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Religion
Spirituality
Concepts of Self
Locus of Control
Outlook
Time Conceptualization
(Samuels et al. 2008)
Location
 Transportation
 Building
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(Samuels et al. 2008)
Hours
 Language
 Payor
 Provider
 Intervention-specific training and materials
 Who is included in treatment
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(Samuels et al. 2008)
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Open ended questions
Some cultures may prefer more directive approach
with clinician as “expert”
 Open-ended questions may feel too ambiguous and
people may not know how to answer
 Consider immigration status and how that might
impact questioning
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Affirmations
Some cultures may find affirmations embarrassing
 Affirmations may not feel appropriate if consumer is
somatizing illness
 It might be more affirming to praise the family,
spouse, or children
 Being genuine is critical
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Reflective listening
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May be important to offer directive approaches,
rather than simply repeating back information
presented
Might consider local and other culturally
appropriate reflective statements
Summarizing
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Summarizing may be confusing because it is too
linear
Circular approach like storytelling may be more
appropriate
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ADDRESSING (Hays, 2008)
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Age/Generational
Developmental Disabilities
Disabilities Acquired Later in Life
Religion and Spiritual Orientation
Ethnic and Racial Identity
Socioeconomic Status
Sexual Orientation
Indigenous Heritage
National Origin
Gender
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Assess the person’s and family’s needs with an
emphasis on culturally respectful behavior.
Identify culturally related strengths and supports.
Clarify what part of the problem is primarily
environmental and what part is cognitive with
attention to cultural influences.
For environmentally based problems, focus on
helping the client to make changes that minimize
stressors, increase personal strengths and supports,
and build skills for interacting more effectively with
the social and physical environment.
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Validate clients’ self-reported experiences of
oppression.
Emphasize collaboration over confrontation, with
attention to client-therapist differences.
With cognitive restructuring, question the
helpfulness (rather than the validity) of the thought
or belief.
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Do not challenge core cultural beliefs.
Use the client’s list of culturally related strengths
and supports to develop a list of helpful cognitions
to replace the unhelpful ones.
Develop weekly homework assignments with an
emphasis on cultural congruence and client
direction.
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APA clinical guidelines empowers clinicians to
use their judgment in determining the
effectiveness of EBP with ethnic minorities in
the absence of available research and to make
adaptations. When implementing such
adaptations, monitoring of progress is
essential.
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Current literature supports effectiveness of
some EBPS with ethnic minorities.
Literature also provides evidence for
incremental validity of cultural adaptation.
Cultural adaptations are most effective for
older, less acculturated clients who have poor
command of English.
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Cultural adaptations can target:
 method of delivery (e.g. language,
interpersonal style, cultural context)
 content (specific to client)
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Important cultural considerations include:
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Views of mental illness
Social positioning
Lifestyles
Common illnesses and health behaviors
Use of drugs and alcohol
Family/kin relationships
World view
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Components that affect access to
services
 structural components
 location, transportation, building
 process/operational components
 hours , language, pay
 provider, interventions
 who included in treatment
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Cultural adaptations increase credibility of
therapist and understandability/credibility of
the intervention
Clinicians should be familiar with growing
literature on EBPs in ethnic minorities,
particularly as it relates to their clientele and
interventions.
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Pick an Evidence Based Practice
Select an ethnic minority group (age and gender
optional)
What are the implicit values of the therapy and
how does this interface with values of the selected
ethnic minority?
What adaptations could be made in the delivery or
content of intervention?
What accommodations or adaptations could be
made to increase cultural competence?
Which aspects of Hays’ recommendations can be
applied to the cultural adaptation?
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Andres-Hyman et al. (2006): Culture and
clinical practice: Recommendations for
working with Puerto Ricans and other Latinas
in the United States
APA (2006): Evidence-based practice in
psychology
APA (2003): Guidelines for multicultural
education, training, research, practice, and
organizational change for psychologists
Beardsley & Wilson (2009): Introduction to
motivational interviewing (presentation)
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Griner & Smith (2006): Culturally adapted
mental health intervention: A meta-analytic
review
Hays (2009): Integrating evidence-based
practice, cognitive –behavioral therapy, and
multicultural therapy: Ten steps for culturally
competent practice
Huey & Polo (2008): Evidence-based
psychosocial treatments for ethnic minority
youth: A review and meta-analysis
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Lau (2006): Making the case for selective and
directed cultural adaptations of evidence-based
treatment: examples from parent training
Miranda et al. (2005): State of the science on
psychological interventions for ethnic
minorities
Samuels et al. (2008) Toolkit for modifying
evidence-based practices to increase cultural
competence http://ssrdqst.rfmh.org/cecc/
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Sue et al. (2009): The case for cultural
competency in psychotherapeutic interventions
Whaley & Davis (2007): Cultural competence
and evidence-based practice in mental health
services