(p. 310) Tailoring Treatment to the Patient’s Race and Ethnicity
There is strong consensus at present that ethnic minorities have been underserved in mental health. To address these health disparities, scholars have been asked to address cultural competence of practitioners and the applicability of evidence-based treatments. Cultural adaptations pertain to treatments yet require practitioners to be culturally competent. We define cultural adaptations as “the systematic modification of an evidence-based treatment (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, Jimenéz-Chafey, & Domenech Rodríguez, 2009, p. 362). We review the rationale, conceptual frameworks, and evidence supporting the use of cultural adaptation models. We also provide guidelines for cultural adaptations and recommendation for future directions.
There are solid reasons rooted in science and practice to utilize cultural adaptations in implementing EBTs. From a science perspective, EBTs are presumed to be ecologically valid for the groups on which they were developed and tested but may not be for other racial and ethnic groups. A careful conceptualization of commonalities across theories of psychotherapy (Ford & Urban, 1998) reveals three primary components that can be understood as underlying assumptions, mechanisms of change, and intervention techniques associated with a theory. There is ample evidence of differences in worldviews, values, beliefs about health and illness, and specific behaviors across cultural groups that could call into question any or all of the three common components of psychotherapies. In the absence of evidence supporting the use of EBTs across ethnic and cultural groups, we advocate for the use of “the best available evidence” (American Psychological Association [APA], 2006) in engaging cultural adaptations, which can in turn be documented and tested to establish the much-needed verification of treatment utility.
From a practice perspective, psychotherapy is assumed to be a cultural phenomenon that emerged in a particular historical context and has evolved over time. Psychotherapy has been adapted since it was born in the late 19th century, morphing in structure (couch, chair, phone, Internet), format (individual, groups, family, networks), intensity (multiple times per week, weekly, biweekly; changes to the 60-minute hour), and in content (e.g., from an id-based to ego-base psychology as psychoanalysis crossed the Atlantic). In the United States, Carl Rogers Americanized psychoanalysis by retaining key (p. 311) elements (e.g., focus on the therapy relationship) but adapting others to be more culturally attuned to middle-class US values (e.g., present oriented, focused on personal growth and actualization). A historical perspective would suggest that we have been adapting psychotherapy since its inception (see Chapter 1, Bernal & Domenech Rodríguez, 2012).
Early clinical experiences documented by ethnic minority psychologists led to questions regarding the utility of contemporary psychotherapy models with diverse populations. The challenges of engagement, retention, and outcomes led to calls on the need for “sensitivity,” “relevance,” and later “competence” in working with clients of a different race and ethnicity. The emergence of an ethnic minority psychology, later a multicultural psychology in the United States, the changing demographics of the population, and the lack of treatment outcome studies on diverse populations coalesced to further question the generalizability of the efficacy studies with racial and ethnic groups. These findings were of tremendous relevance given the literature on common factors (Norcross, 2011). These show that the psychotherapeutic relationship is critical to success regardless of underlying assumptions, stated theories, and specific techniques of a treatment.
In its most current form, evidence-based psychological practice calls for combining the best research evidence with competent expertise in delivering treatments, in the context of patient characteristics (APA, 2006). As such, cultural adaptations work to thoughtfully and systematically transport conventional models of EBTs to other cultural and linguistic groups, taking into account research approaches (e.g., gathering observations) and the most up-to-date findings in treatment application to ethnic and culturally diverse populations, while acknowledging the critical importance of clinician characteristics (e.g., cultural competence).
There are 12 published cultural adaptation models identified in a systematic review (see Chapter 2, Bernal & Domenech Rodríguez, 2012) with more models surely waiting to be identified. Cultural adaptation models published since the mid-1990s appear to have been developed in relative isolation. For example, 8 of the 12 models were published between 2004 and 2006, suggesting that authors were working in parallel to help define their needs in attempting to reach racial and ethnic minorities. This body of work now provides us with the opportunity to cull the commonality in recommendations from these experts. There are a number of similarities across models that lend credibility to the recommendations for cultural adaptations. Chief among the recommendations, stated or implied in the models, is to follow a systematic and rigorous process that includes documentation and evaluation of the cultural adaptations. Most of these models also share two important attributes; they advocate for the use of multiple/flexible methods to gather information, and they specify that the cultural adaptation process is iterative, that is, adjustments are to be expected in the process of making adaptations.
The systematic procedures laid out across models vary in the way they prioritize particular actions; however, there is a great deal of consensus on the importance of learning from important stakeholders in treatment delivery. These stakeholders can be key community members, agency leaders, or specific individuals (e.g., clients, treatment providers). In addition, authors call for maximizing existing knowledge, pointing to the particular importance of culturally relevant variables (e.g., acculturative stress, discrimination, immigration, spirituality, cultural values) that may be, or may exert their influence upon, predictors, mediators/moderators, and outcomes. Indeed, cultural adaptations models are broadly concerned with modifications to the process and content of treatments that can support increased engagement, acceptability, and/or outcomes of treatments.
Many of the cultural adaptation models advance the need for addressing ecological validity of EBTs, that is, the alignment of the treatment with the client’s cultural (p. 312) experience, language, and context. To that effect, some models point to common roots in Bronfenbrenner’s ecological systems theory and Roger’s diffusion of innovation theory. Many also consider treatment provider characteristics as central to the success of the cultural adaptation process. What specific characteristics are explicitly stated within models vary (e.g., collaborative approach, ethnic or language matching).
There is now strong evidence for the benefits of culturally adapting treatments. Several narrative reviews and four meta-analyses on the effectiveness of cultural adaptations have been published. Here we review the most recent reports published in 2011. In one study of 65 clinical trials with 8,620 clients, cultural adaptations were superior to the treatments that did not explicitly incorporate culture (Smith, Domenech Rodríguez, & Bernal, 2011). A medium effect size (d = .46) showed that clients receiving culturally adapted treatments had better outcomes. Those treatments that included a variety of cultural adaptations tended to be more effective than those with fewer adaptations, and those treatments that were attuned to client outcome goals and those that involved cultural metaphors tended to be more effective in contrast to other treatments. Another meta-analysis of 59 clinical trials with 1,242 clients directly compared culturally adapted to an unadapted or conventional psychotherapy (Benish, Quintana, & Wampold, 2011). An effect size (d = .32) showed that culturally adapted treatments were again superior to the unadapted ones. Outcome differences for the culturally adapted treatments were moderated by the explanatory model of the illness myth that is fundamentally cultural.
Cultural Adaptation Guidelines
We advance the thesis that the cultural adaptation process begins with the selection of a treatment. A treatment is selected based on relevance to the presenting concern and the fit of the underlying assumptions, stated theory, and associated techniques with the values, beliefs, and practices of the ethnic and cultural group population for which it is needed. Once a treatment is selected, the next question is: Are cultural adaptations needed? Answers will vary depending on whether the EBT (1) targets the appropriate mechanisms for good outcomes in the population of interest, (2) is itself acceptable to the population of interest, (3) has acceptable related treatment procedures (e.g., evaluation procedures), and (4) is sufficiently flexible to coordinate “fidelity” and “fit.” In addition to these considerations and during this initial phase, it is critical to examine the availability of the EBT to practitioners in the field. Some EBTs require intense training to reach competent delivery standards and the time and financial resources required place them out of practical reach for treatment providers.
If cultural adaptations are warranted, we recommend that a systematic framework be followed, that all adaptations are carefully documented, and that outcomes are evaluated as much as possible. More specifically, we recommend involving the target population as much as possible. There are exemplars in the literature for how to do this, such as giving potential clients the manual procedures and gathering their impressions of their utility, acceptability, and relevance. We also recommend involving treatment providers with expertise in the particular ethnic and cultural group. The existing literature is rich and decade reviews and meta-analyses can be useful ways for practitioners in particular to get the most up-to-date findings in a manageable time frame. We advocate for thoughtful planning incorporating all these sources of knowledge prior to delivering a culturally adapted intervention. We also advocate for frequent checks on the impact of the treatment. In research this can be done by way of pilot tests prior to a large trial. In private practice this can be achieved via frequent and brief evaluations (e.g., peer observations, self-report, client reports). (p. 313) Finally, we recommend those engaging in cultural adaptations of EBTs to carefully consider specific details of delivery such as format (e.g., group, individual), participants (i.e., Who should participate in treatment?), packaging (e.g., psychoeducation, psychotherapy), and location (e.g., school, therapy office, home visit). Other sources of support may also help in the evaluation process and associated iterations, such as regular peer consultation groups or a community advisory board.
There is a strong rationale for adaptations, models to follow, and evidence of positive impact. We are in an excellent position to take the next “big steps” to advance the field. The commonalities across models suggest an opportunity for convergence so that efforts can be directed at testing the cultural adaptation process (e.g., Which parts of the process yield the most powerful information?), types (e.g., Which adaptations yield the most benefit?), and utility (e.g., How can researchers and practitioners make cultural adaptation models more relevant for use in applied practice?). Another pressing need in the literature now concerns examples of culturally adapted treatments wherein researchers and practitioners alike can observe examples of the recommendations put into practice (e.g., What is an example of a “context” adaptation to an EBT?).
References and Readings
American Psychological Association. (2006). Evidence-based practice in psychology. American Psychologist, 61, 271–285.Find this resource:
Benish, S. G., Quintana, S., & Wampold, B. E. (2011). Culturally adapted psychotherapy and the legitimacy of myth: A direct-comparison meta-analysis. Journal of Counseling Psychology, 58, 279–289.Find this resource:
Bernal, G., Jiménez-Chafey, M. I., & Domenech Rodríguez, M. M. (2009). Cultural adaptation of treatments: A resource for considering culture in evidence-based practice. Professional Psychology: Research and Practice, 40, 361–368.Find this resource:
Bernal, G., & Domenech Rodríguez, M. M. (2012). Cultural adaptations: Tools for evidence-based practice with diverse populations. Washington, DC: American Psychological Association.Find this resource:
Ford, D. H., & Urban, H. B. (1998). Contemporary models of psychotherapy: A comparative analysis (2nd ed.). Hoboken, NJ: Wiley.Find this resource:
Norcross, J. C. (2011). Psychotherapy relationships that work: Evidence-based responsiveness (2nd ed.). New York & London: Oxford University Press.Find this resource:
Smith, T. D., Domenech Rodríguez, M. M., & Bernal, G. (2011). Culture. Journal of Clinical Psychology, 67, 166–175.Find this resource:
Whaley, A. L., & Davis, K. E. (2007). Cultural competence and evidence-based practice in mental health services: A complementary perspective. American Psychologist, 62, 563–574.Find this resource: