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.
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
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 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
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.
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
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
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)
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
1.
2.
3.
4.
5.
6.
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
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)
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)
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, 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).
Feasibility-Practicality Argument
Demographics
• Racial and ethnic minorities will soon be the numerical majority
Engagement
• Adapted EBTs are effective for engagement and retention
Sustainability
• More likely if treatments were culturally congruent and
community grounded
Relevance
• EBTs may not be relevant to minority patients
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
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.
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
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–
–
–
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 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.
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)
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 Framework
– (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
•
•
•
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Concepts
Goals
Methods
Context
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.
Psychotherapy Adaptation and
Modification Framework
(Hwang, 2006)
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–
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–
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Six domains:
Dynamic Issues
Cultural Complexities
Orientation
Cultural beliefs
Client-therapist relationship
Cultural differences in expression
and communication
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 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
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.
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, 2008).
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:
•
•
•
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high parental levels of satisfaction with the intervention
reduced parental stress
improved parenting practices
significant reductions in child externalizing behaviors
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 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)
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?
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 socioeconomic 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.
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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